Background Contrast-induced acute kidney injury (CI-AKI) is associated with increased morbidity and mortality following percutaneous coronary interventions (PCI) and is a patient safety objective of the National Quality Forum. However, no formal quality improvement program to prevent CI-AKI has been conducted. Therefore, we sought to determine if a six-year regional multi-center quality improvement intervention could reduce CI-AKI following PCI. Methods and Results We conducted a prospective multi-center quality improvement study to prevent CI-AKI (serum creatinine increase ≥0.3 mg/dL within 48 hours or ≥50% during hospitalization) among 21,067 non-emergent patients undergoing PCI at ten hospitals between 2007 and 2012. Six ‘intervention’ hospitals participated in the quality improvement intervention. Two hospitals with significantly lower baseline rates of CI-AKI, which served as “benchmark” sites and were used to develop the intervention and two hospitals not receiving the intervention were used as controls. Using time series analysis and multilevel poisson regression clustering to the hospital-level we calculated adjusted risk ratios (RR) for CI-AKI comparing the intervention period to baseline. Adjusted rates of CI-AKI were significantly reduced in hospitals receiving the intervention by 21% (RR 0.79; 95%CI: 0.67 to 0.93; p=0.005) for all patients and by 28% in patients with baseline eGFR<60 ml/min/1.73 m2 (RR 0.72; 95%CI: 0.56 to 0.91; p=0.007). Benchmark hospitals had no significant changes in CI-AKI. Key qualitative system factors associated with improvement included: multidisciplinary teams, limiting contrast volume, standardized fluid orders, intravenous fluid bolus, and patient education about oral hydration. Conclusions Simple cost-effective quality improvement interventions can prevent up to one in five CI-AKI events in patients with undergoing non-emergent PCI.

Background Risk factors for emergent readmissions or death after acute myocardial infarctions (AMI) are important to identifying patients at risk for major adverse events. However limited investigation in prospective clinical registries have been conducted to determine relevant risk factors. Methods Patients presenting with STEMI from 2006 to 2011 were prospectively enrolled in a STEMI registry (1,271). Thirty-day readmission was ascertained by administrative claims data. Death was determined by linking to the Social Security Death Master File. Univariate and stepwise multivariate logistic regression was conducted with Hosmer-Lemeshow goodness-of-fit statistics for model calibration and receiver operating characteristic curve for model discrimination. Results The combined endpoint of 30-day readmission or post discharge death included 135 patients (10.6%), including 109 emergent readmissions and 26 deaths. Factors associated with an increase risk of 30-day readmission or post discharge death age≥80 years, diabetes, chest pain or cardiac arrest at presentation and 3-vessel disease found at initial angiography. Factors associated with a decreased risk of 30-day readmission or post discharge death included transfer to the cath-lab from another emergency department, given during the procedure hypercholesterolemia, and receiving aspirin, beta-blockers, and ACE or ARB inhibitors at discharge. Index admission outcomes indicative of readmission or death post discharge only included a new diagnosis of congestive heart failure. The model discriminated well with an ROC of 0.71 (95%CI 0.66, 0.76). Conclusions Pre-hospitalization factors are overlooked and important factors to incorporate in routine risk prediction models for readmission or death within thirty days following an AMI.

Background: Therapeutic hypothermia improves survival for selected patients who remain comatose after cardiac arrest. Hypothermia triggers changes in electrocardiographic (ECG) parameters; however, the association of these changes to in-hospital mortality remains unclear. Hypothesis: QT interval changes induced by therapeutic hypothermia are not associated with in-hospital mortality. Methods:We retrospectively compared precooling ECG parameters to ECG parameters during hypothermia on all consecutive patients with available information who received hypothermia at our academic medical center between December 2006 and July 2012 (N = 101; 24% women). Paired 2-sample t test was used to compare precooling vs cooling ECG parameters. In-hospital mortality related to ECG parameter changes was compared using the Pearson χ 2 test. Results: Therapeutic hypothermia resulted in increases in PR and QTc intervals and decreases in heart rate and QRS intervals (P for all <0.02). During hospitalization, 45 of the 101 patients died. Survivors vs nonsurvivors did not differ in heart rate change (P = 0.74), PR change (P = 0.57), QRS change (P = 0.09), or QTc change (P = 0.67). Comparing patients who had reduced QTc intervals with hypothermia to those who had prolonged QTc with hypothermia, 14 out of 30 died in the former group, whereas 31 out of 71 died in the latter group (46.7% vs 43.7%, odds ratio [OR]: 1.13, 95% CI: 0.48-2.66). Patients presenting with right bundle branch block (RBBB) had a higher risk of in-hospital death compared to those without RBBB (72.2% vs 38.6%, OR: 4.14, 95% CI: 1.35-12.73). Conclusions: Therapeutic hypothermia prolonged QTc interval with no association to in-hospital mortality. Presence of RBBB on initial presentation was related to increased mortality.