MedStar Health Blog

Researchers from the Firefighters’ Burn and Surgical Research Laboratory at MedStar Washington Hospital Center evaluated wound cleansers to limit the effects of two strains of antibiotic-resistant bacteria.

Published in Advances in Skin and Wound Care, this study sought to identify the effectiveness of wound cleansers that may be used in both the setting of chronic wounds and in actue wounds such as burn injuries. The goal of “Disruption of Biofilms and Neutralization of Bacteria Using Hypochlorous Acid Solution: An In Vivo and In Vitro Evaluation” was to see which cleansers were most effective in stopping methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa, two infections that can impact patient outcomes.

The lead author on this was Anna Day. The study team included Abdulnaser Alkhalil, PharmD, Ph.D.; Bonnie C. Carney; Hilary N. Hoffman; Lauren T. Moffatt, Ph.D.; and Jeffrey W. Shupp, MD. The Burn Center at MedStar Washington Hospital Center is the only adult burn center in the region and the Burn Research Team here focuses on the study of surgical and chronic wounds and traumatic injuries, including wound healing, non-invasive imaging, and burn pathophysiology.

This study utilized collagen films with active bacterial cultures, which were treated with the wound cleanser, Vashe Wound Solution (VWS), 1% and 10% povidone-iodine, 0.05% chlorhexidine wound solution (CWS), or normal saline.

The films were then evaluated using multiple assays to assess bacterial cell death, and using traditional quantitative cultures. Each assay was performed in three times for each treatment group, and the experiment was done in duplicate for each bacterial strain. The cleanser was also tested for cytotoxicity in human skin cell cultures to evaluate for the potential cell toxicity to the host wound bed.

The MRSA films treated with the VWS were found to have a similar amount of live bacteria cells as the CWS-treated films. Both of these films were found to have a higher number of dead cells than live cells and both showed more dead cells than those films treated with the saline.

“These findings support the use of VWS in the treatment of wounds with biofilms,” the study concluded. “Ultimately, VWS had a similar effectiveness to CWS in eliminating bacteria but with lower cytotoxicity.”

Advances in Skin & Wound Care, 2017. DOI: 10.1097/01.ASW.0000526607.80113.66

As part of the MedStar Health commitment to research across the system, we are proud to announce the launch of PowerTrials within our electronic health record (EHR).

PowerTrials is a new module within MedConnect that integrates current research studies into clinical care through a unidirectional connection with OnCore, our clinical trial management system (CTMS). This connection allows for clinicians to access information about a patient’s participation in a MedStar Health or Georgetown clinical trial, as well as information about the study, in one location when in the EHR. The plans for this stage of integration was announced at the Fall 2017 MHRI Town Halls and has gone live as of February 1, 2018.

Key functionalities of PowerTrials, which enhance patient safety, include:

• Clinicians have awareness of their patient's research participation via an “on study” flag on the demographic Banner Bar
• Clinicians can view the research study description and recruitment information in PowerChart at the point of care and can take the study information into consideration when caring for the patient; while most patient participation in research does not overlap with their routine clinical care, any questions during the course of the patient’s treatment may be directed to the point of contact listed in the research study information, located in the Clinical Research tab
• Study contact information for the investigator and coordinator, which can be used in the Message Center, will enhance non-urgent communication between the clinical and research teams
• Automated alerts will be sent to the research team’s Message Center when a research patient comes into the Emergency Department or inpatient admission
• An auditor/monitor workflow is available to ensure HIPAA compliant access for study monitors and auditors

Thank you to all who have been a part of launching these new systems to help support research at MedStar. For more information about PowerTrials, please contact research@medstar.net.

It can be a shock to look down at the toilet paper after going to the bathroom and seeing bright red blood—a classic symptom of hemorrhoids. But hemorrhoids are no big deal, right? Just wait a few days, maybe pick up some cream from the pharmacy, and life will go back to normal. Unfortunately, it’s not that simple.

We are all born with small veins supplying the anus and rectum. However, over time, the tissue above the vein becomes weak and the veins enlarge and bulge. This is how a hemorrhoid develops. If something agitates them, they can cause symptoms such as rectal bleeding, soreness and itching. Hemorrhoid symptoms are similar to the symptoms of other conditions that are much more serious or can even endanger your life.

About 75 percent of adults will have symptomatic hemorrhoids to some degree in their lifetimes. Of these, only about one-third will need medical attention to treat the problem. So how do you know when to get medical help?

In 1988, MedStar Washington Hospital Center became one of the first four hospitals in the United States to implant a ventricular assist device, or VAD, in a patient with heart failure. Today, our Advanced Heart Failure Program uses left ventricular assist devices (LVADs) as a regular part of patients’ treatment plans. These amazing devices, implanted in the heart, can keep the heart pumping when medications are no longer enough.

When LVADs were first invented, it felt very much like how the Wright brothers must have felt in 1903, trying to prove humans could use technology to fly. The LVAD technology wasn’t practical to use for most patients, and it didn’t allow people to do anything but lie in bed. It’s fascinating to see how far we’ve come. In just three decades, LVADs have blossomed from a seemingly impossible technology to become an advanced treatment option that’s given thousands of patients their lives back during heart failure treatment.

How far LVADs have come

The first LVADs were huge, bulky contraptions. They had to be connected to pumps the size of a refrigerator to keep them running. The size of the internal components required lots of room under the belly muscles to squeeze blood through the body. That ruled LVADs out for just about any patient who wasn’t a man who weighed 200 pounds or more. Most women and smaller men just didn’t have the room in their bodies to accommodate the internal equipment. And to top it off, these machines were entirely hospital-based, so a patient with an LVAD couldn’t go home.

Our problem then was that we were trying to copy the natural human heart—an incredible machine. It fills with blood and pumps it out about 2.5 billion times in an average lifetime. So, of course, the first LVADs took this as the inspiration. But any “improvements” to the pumps just made them bigger or more complicated. For example, when the early air-powered pumps were changed to electric, that meant they had to have motors.

It’s no wonder we only were implanting about five LVADs per year before the mid-2000s. Most people chose hospice care instead or only used LVADs as a stopgap measure, hoping for a possible heart transplant.

The breakthrough and where we are today

By the late 1990s, we realized we had to get away from trying to mimic the filling/pumping action of the human heart. Enter continuous-flow technology. We found that a pump that constantly keeps blood flowing, rather than stopping and starting again and again, can be smaller and more efficient. Now, instead of a pump the size of a refrigerator, my colleagues and I were developing an LVAD called the HeartWare, which fits in the palm of a hand. For this device, only a cable, controller and small battery pack need to be outside the body.

In 2005, we finally got funding for the device, and one of my colleagues and I performed the first human surgery with our device at the University of Vienna. The first U.S. patient received their LVAD here at MedStar Washington Hospital Center in 2008. Today, we’re putting in 90 LVADs per year, of which the HeartWare is the most-often used, and our Advanced Heart Failure Program has grown to become one of the top five programs of its kind in the country.

One interesting note about continuous-flow LVADs: Patients who have one of these devices no longer have a pulse.

LVADs as an alternative to heart transplants

LVADs were first developed as a way to keep patients alive until they could get heart transplants. Today’s LVADs allow patients to do a lot more than just lie in a hospital bed and wait for a donor heart to become available. That’s good, because the D.C. area is one of the toughest in which to get a donor heart for a transplant. The chance that one of my LVAD patients will have a heart transplant within a year of receiving their LVAD is less than 20 percent.

In part, that’s because the number of available hearts for transplant has stayed virtually the same for the past decade, even as the number of people who need a heart has gone up. And even if a heart is available, that doesn’t mean it will be acceptable for a transplant. A 2015 study found that, out of more than 82,000 hearts available nationally, only 34 percent were accepted for use in transplantation surgeries.

The fact of the matter is that, without a huge increase in the number of donor hearts, most people with heart failure who could benefit from a heart transplant won’t get one. The LVAD has become the long-term solution for these patients.

The future of LVADs

LVADs have changed patients’ lives for the better in the last decade, and we continue to pursue advancements in the therapy and devices. Our next big challenge is to overcome the need for a power source and controller outside the body, which can limit what patients are able to do in their everyday lives.

We’re hard at work designing the next generation of LVAD technology. And we’re hopeful that the next LVADs can be completely implanted in a patient’s body with just a small scar on the chest as the only evidence of heart surgery. This future LVAD will work like an artificial heart, keeping blood flowing for hours off a single charge. Afterward, the patient would charge up the LVAD with a patch on their chest, like a wireless charging station can recharge the battery of a smartphone.

We also hope to get the word out to more people about how LVAD technology can help them. Only about 8 percent of the people who would benefit from an LVAD actually have one, compared to the 70 percent of people who can benefit from a defibrillator and have one. Many doctors don’t understand the advances we’ve made in the last 10 to 15 years, and that means patients aren’t learning about their options either.

LVADs started out almost as a curiosity rather than a practical treatment plan. Now, LVADs provide essential care for people worldwide with heart failure. Think about the advancements between the Wright brothers’ first flight and then, less than 70 years later, blasting a team of astronauts to the moon. I’m astonished at how far we’ve come in heart failure treatment in just three decades, and I can’t wait to see the new horizons in store for us and our patients.

As with any other workplace, MedStar Washington Hospital Center goes to great lengths to maintain a safe environment for physicians, staff and, of course, patients. Yet, even the most well-established and effective practices may have room for improvement. For example, refining procedures or layouts can cut treatment area risks even further, while addressing situational stressors can reduce the potential of miscommunication and mistakes.

For Kathryn M. Kellogg, MD, MPH, there’s no better place to put these best practices to the test than the Hospital Center’s Emergency Department, where she serves as an attending physician.

Unique research insights

“My clinical work feeds my research and administrative work,” explains Dr. Kellogg, who relishes emergency medicine’s rarity of routine days. “Along with being alert to how well our practices work across a wide variety of situations and patient presentations, I also get ideas for things to research, or barriers to effectiveness that need to be addressed.”

Dr. Kellogg’s interest in emergency medicine and human factors safety engineering was cultivated in medical school at the University of Rochester, under the guidance of her mentor, Rollin J. “Terry” Fairbanks, MD, MS, who later founded MedStar Health’s National Center for Human Factors in Healthcare, a safety engineering research center, and now serves as MedStar’s assistant vice president, Ambulatory Quality and Safety. The opportunity to again collaborate with Dr. Fairbanks brought Dr. Kellogg to the nation’s capital, after her residency in emergency medicine at Vanderbilt University Medical Center.

Since then, Dr. Kellogg’s work on patient safety, emergency care and avoidance of adverse events has been published in multiple peer-reviewed journals. Since starting at MedStar, Dr. Kellogg has been awarded more than $2 million in grants and contracts, to pursue her safety research. Her current research efforts include developing and testing a task management tool, to help emergency physicians reduce and mitigate interruptions during the course of treating patients.

“There’s a lot we can learn from other industries with similar stressors, including understanding their causes, and how we can better train staff to handle them,” she says.

A multi-faceted team member

Dr. Kellogg also works with other MedStar entities on improving safety and eliminating potential problems. In a new role as Associate Medical Director, Quality and Safety, she joins multi-disciplinary teams to investigate safety events, focusing on identifying and rectifying the root causes rather than simply how individuals responded, providing another parallel to her Emergency Department work.

“Effectively treating emergency patients on what is likely the worst day of their lives requires quickly gaining their trust and confidence,” Dr. Kellogg explains. “The same holds true when we’re talking with associates who may understandably feel anxious after being involved in a safety incident. It’s the only way we’ll get a full understanding of what happened and why, in order to make changes that will minimize the risk of it happening again.”

Outside the hospital

Appropriately for someone seemingly always on the go, Dr. Kellogg is an avid runner and plans to take part in the Rock n’ Roll Half Marathon this spring. She and her husband have three children, and true to her investigative nature, discovery is often on the fun time agenda.

“We love to travel, taking our kids to new places and helping them explore new things,” she says.

When a patient has a stroke, seconds and minutes can make the difference between life or death. Similar to someone who has had a gunshot wound or a serious car accident, a patient who’s had a stroke needs emergency care to save their life or prevent permanent, life-altering disabilities, such as paralysis or speech difficulties.

How do you know if your loved one has had a stroke?

Family members play a vital role in getting their loved ones stroke care as quickly as possible. But time after time, I see patients who have been delayed in getting care because their loved ones didn’t know the person was having a stroke.

It’s also possible for family members to simply not see that anything’s wrong. Stroke symptoms involve a decrease in the level of function or in the ability to communicate. If that happens to your loved one in the middle of a conversation, you’re more likely to tell. But I’ve seen cases in which the patient has a stroke while sitting quietly in a chair, and the family just thinks their loved one is sleeping.

• Are overweight or obese
• Don’t get enough exercise
• Have a cardiac rhythm disturbance such as atrial fibrillation
• Have a family history of strokes
• Have diabetes
• Have high blood pressure (hypertension)

• Face: Ask the person to smile. If they can’t, or if only one side of their face moves, it could be a sign of a stroke.
• Arms: Ask the person to raise their arms. A stroke can cause muscle weakness or paralysis, particularly on one side of the body.
• Speech: Ask the person to repeat a sentence. If they slur their words or have trouble speaking, they may be having a stroke.
• Time: Call 911 immediately. Don’t wait to see if the person gets better, and don’t try to take the person to the hospital yourself.

Where should your loved one go for stroke care?

Large vessel strokes should be treated with the same urgency and centralization as combat casualties are in war. Unfortunately, that’s not always the case. In our area, unnecessary delays have occurred when emergency medical services (EMS) personnel take patients having large vessel strokes to the nearest hospital that may lack the ability to perform lifesaving thrombectomies (catheter-based clot removals). Then, depending on that hospital’s affiliations or expertise, those patients end up getting transferred to facilities in Baltimore, or doctors rush from Baltimore to the patients. This wastes time that the patient may not have, and it just doesn’t make sense to me. In many cases, our Comprehensive Stroke Center and our sister hospital, MedStar Georgetown University Hospital, also a Comprehensive Stroke Center, are much closer than Baltimore to patients in Bethesda, Silver Spring, Rockville and many other communities.

While it may be tempting to rush a patient to a hospital that’s two miles from their house, it may not actually save the patient time in the long run. Our Comprehensive Stroke Center or MedStar Georgetown University Hospital may be 10 or 20 miles from the patient’s home, but the time saved in the initial decision of where to bring them can translate to saved brain function.

Especially for patients who need care for large-vessel occlusions, which are blockages in one of the large blood vessels bringing blood to the brain, treatment at a smaller hospital or one that doesn’t specialize in stroke care might not be enough. These patients may need a procedure called mechanical thrombectomy, a procedure to remove a stroke-causing blood clot that’s available only at specialized hospitals like ours.

How we streamline stroke care for our patients, and the vital role of EMS

We treat patients who are having a stroke with the same sort of urgency as patients who have had a traumatic injury. For patients who come directly to us, we mobilize the team immediately, so we can assess the patient and complete imaging studies within about 15 minutes, with treatment underway in less than an hour.

We’ve been working to bring our collaborative expertise from MedStar Washington Hospital Center and MedStar Georgetown University Hospital to hospitals that don’t specialize in endovascular stroke care through our regional telestroke program. When we identify a patient at one of these distant hospitals who needs emergency endovascular stroke care, we can help coordinate care there or bring the patient to us with emergency ground or air transportation. But that still can take precious minutes—time that might be saved if the patient were to get to us sooner.

I have talked to doctors and EMS personnel alike, so they know patients can get the advanced stroke care they need with us. Ultimately, though, it’s up to the EMS operators and fire stations in the district, as well as in the Maryland and northern Virginia counties in our area, to change the decision-making process for their services. Some states have avoided unnecessary delays by mandating that EMS bring these patients directly to centers with full-time and experienced neuroendovascular capabilities. EMS providers can access a process developed by the American Heart Association (AHA) and American Stroke Association (ASA) to determine what type of stroke a patient is having and which stroke center can best treat it. The process is available online as a PDF for EMS providers.

Ultimately, I’d like to see the AHA/ASA protocol become required at all levels—local, regional, state and national. Right now, there are no consequences for when the procedure isn’t followed, and families are left to pick up the pieces when their loved ones die or have their quality of life forever lowered because of strokes.

Having the most advanced tools and technology to treat strokes is a commitment we take seriously. Stroke care starts with the loved ones and first responders who have to make swift decisions about the patient’s care. It’s a lot of responsibility, but I’m hopeful that more patients can get timely emergency stroke care as more people learn what to do in this kind of emergency.