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Forty-three patients with severe pump failure complicating acute myocardial infarction were treated with vasodilators (nitroprusside (40) and phentolamine (3)) for four hours to 27 days. Cardiac index, stroke volume index, and stroke work index (SWI) increased while the left ventricular filling pressure (LVFP) decreased during vasodilator therapy. Twenty-four of the 43 patients (56%) survived. Of patients with initial SWI between 11-20 gm-m/m2 and LVFP less than 15 mm Hg, 68% survived. In contrast only 18% of patients with SWI of 10 gm-m/m2 or less and LVFP greater than 15 mm Hg survived. Of the 17 patients with clinical shock, 8 (47%) survived. All 24 patients discharged from the hospital were followed for at least 12 months. Fourteen patients died one to 25 months (average 9.2 months) after discharge and the cause of death was pump failure in ten of them (71%). The ten survivors at last follow-up had been followed for 15 to 32 months (average 24 months). The cumulative survival at 24 months was 28%. Thus, despite improvement in short-term prognosis with vasodilator therapy in patients with severe pump failure complicating acute myocardial infarction, the prognosis for long term survival remains unfavorable, possibly due to severe intrinsic cardiac damage.

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To emerge from a significant quality crisis, hospital administration recognized the need for physician leadership to drive improvements. A framework is presented for a physician-led Quality Summit to select best practice initiatives for implementation over 1 year. Results demonstrated statistically significant reductions in ventilator-associated pneumonia, decreasing from the first quarter 2009 baseline of 8.34 per 1000 ventilator days to 3.32 per 1000 ventilator days in second quarter 2010 (P = .0055). During the same time frame, catheter-associated urinary tract infections decreased from 4.35 per 1000 catheter days to 0.98 per 1000 catheter days (P = .0438), and severe sepsis/septic shock mortality declined from 33% to 13% (P = .0084). The customized World Health Organization Surgical Safety Checklist was used in 93% of surgeries within 1 month of adoption. Venous thromboembolism screening for adults became routine. The annual Quality Summit cycle engages physicians to introduce and spread quality improvement.

Outpatient cardiac catheterization has become the standard in our laboratory. The only exclusion for outpatient study is current hospitalization for cardiac symptoms. Thus, any patient well enough to be at home is studied on an outpatient basis. We reviewed our experience on 4,094 diagnostic studies of which 3,537 (86%) were done on a same-day basis. The complication rates were generally lower than in published series with a mortality of 0.05%. There were no admissions for late bleeding. Ninety-seven percent of the procedures were done by the percutaneous technique utilizing 7-French catheters. Patients were heparinized, and protamine was not used. The low complication rate is to a large extent due to meticulous postoperative care by critical care nurses in an outpatient observation unit contiguous to the laboratory. Outpatient cardiac catheterization is a safe, cost-saving approach applicable to a large majority of cardiac patients.