Valerie Danesh

Orlando VA Medical Center, Orlando, Florida, United States

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Publications (6)25.57 Total impact

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    ABSTRACT: Sedation management, delirium monitoring, and mobility programs have been addressed in evidence-based critical care guidelines and care bundles, yet implementation in the ICU remains variable. As critically ill patients occupy higher percentages of hospital beds in the United States and beyond, it is increasingly important to determine mechanisms to deliver better care. The Institute for Healthcare Improvement's Rethinking Critical Care (IHI-RCC) program was established to reduce harm of critically ill patients by decreasing sedation, increasing monitoring and management of delirium, and increasing patient mobility. Case studies of a convenience sample of five participating hospitals/health systems chosen in advance of the determination of their clinical outcomes are presented in terms of how they got started and process improvements in sedation management, delirium management, and mobility. The IHI-RCC program involved one live case study and five iterations of an in-person seminar in a 33-month period (March 2011-November 2013) that emphasized interdisciplinary teamwork and culture change. Qualitative descriptions of the changes tested at each of the five case study sites demonstrate improvements in teamwork, processes, and reliability of daily work. Improvement in ICU length of stay and length of stay on the ventilator between the pre- and postimplementation periods varied from slight to substantial. Changing critical care practices requires an interdisciplinary approach addressing cultural, psychological, and practical issues. The key lessons of the IHI-RCC program are as follows: the importance of testing changes on a small scale, feeding back data regularly and providing sufficient education, and building will through seeing the work in action.
    Joint Commission journal on quality and patient safety / Joint Commission Resources 02/2015; 41(2).
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    ABSTRACT: Enrollment of individual patients into more than one study has been poorly evaluated. The objective of this study was to describe the characteristics of patients, researchers and centers involved in coenrollment, studies precluding coenrollment, and the prevalence, patterns, predictors, and outcomes of coenrollment in a randomized clinical trial.
    Critical Care Medicine 11/2014; 43(2). DOI:10.1097/CCM.0000000000000692 · 6.15 Impact Factor
  • Orlando Ruiz-Rodriguez · Valerie Danesh · Edgar Jimenez
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    ABSTRACT: Introduction: The FDA cautions clinicians that the sensitivity (95% CI: 24-91%) and specificity (95% CI: 69-94%) of Rapid Flu A tests in adults are notoriously poor (FDA, 2013). This is the case of an 18-year-old male admitted from the Emergency Department with a negative Rapid Flu test for ARDS suspected as an inhalation injury (bleach inhalation versus illicit inhalant use). Patient presented with fever, cough, vomiting, diarrhea, headaches and tachypnea and was admitted to an intermediate critical care unit with subsequent ICU transfer for respiratory failure and intubation with a PF ratio of 54 and oxygenation index of 46 with groundglass opacities noted on CT. Extubated after a 16-day course of MV requiring heavy sedation for ventilator synchrony, including high-dose paralytic infusions required to achieve a train of four of 3/4. Large pneumomediastinum and pneumoperitoneum on HD 7 with extensive subcutaneous emphysema resolved without intervention on HD19. Flu A viral cultures from a miniBAL on HD 2 were resulted on HD 11 (variant subtyping not available) and treatment with oseltamivir was initiated. Encephalopathic process identified 2 days after extubation with tonic-clonic seizures with deterioration on HD 26 requiring reintubation for airway protection (2 days). MRI suspicious for acute demyelinating encephalomyelitis treated with IVIG. Patient complained of severe headaches on HD 31 with subsequent progressive left-sided weakness, pronator drift, dysmetria, nystagmus and partial visual field loss noted on HD 33 with a CT revealing 7mm right-to-left midline shift and intraparenchymal hemorrhage and edema. Patient is discharged from the hospital with mild cognitive impairment and left-sided neglect with rehabilitation treatment in progress. The clinical consequences of severe influenza-related infection, in this case an off-season case of untyped flu A, can be broad. In addition to severe respiratory compromise, severe CNS complications and sequelae are noted which are not widely reported in the medical literature. Reference: FDA. (2013). Cautions in using rapid tests for detecting Influenza A viruses. Retrieved August 1, 2013, from
    43rd Annual Critical Care Congress; 12/2013
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    ABSTRACT: ABSTRACT CONTEXT: Critically ill, morbidly obese patients, (BMI ≥40) are at high risk of respiratory failure requiring invasive mechanical ventilation (IMV). It is not clear if outcomes of critically ill obese patients are affected by obesity. Due to limited cardio-pulmonary reserve they may also have poor outcomes. However, literature to this effect is limited and conflicted. OBJECTIVE: We used Nationwide Inpatient Sample from 2004 to 2008 to examine the outcomes of morbidly obese persons receiving IMV and compared them to non-obese persons. We identified hospitalizations requiring IMV and morbid obesity using ICD9CM codes. Primary outcomes studied were in-hospital mortality, rates of prolonged mechanical ventilation (≥96hrs) and tracheostomy. Multivariable logistic regression was used to adjust for potential confounding variables. We also examined outcomes stratified by number of organs failing. RESULTS: Of all hospitalized morbidly obese persons, 2.9% underwent IMV. Mean age, co-morbidity score and severity of illness were lower in morbidly obese persons. The adjusted mortality was not significantly different in morbidly obese persons (OR 0.89; 95%CI: 0.74 to 1.06). When stratified by severity of disease, there was a stepwise increase in risk of mortality amongst morbidly obese persons - 0.77 (95% CI 0.58 to 1.01) for only respiratory failure to OR 4.14 (95% CI 1.11 to 15.3) for ≥4 organs failing. Rates of prolonged mechanical ventilation was similar, but rate of tracheostomy (OR 2.19; 95% CI 1.77 to 2.69) were significantly higher in the morbidly obese. CONCLUSION: Morbidly obese persons undergoing IMV have similar risk of death than non obese persons if only respiratory failure is present. When more organs fail, they have increased mortality.
    Chest 01/2013; 144(1). DOI:10.1378/chest.12-2310 · 7.13 Impact Factor
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    ABSTRACT: Deteriorating ward patients are at increased risk. Electronic automated advisory vital signs monitors may help identify such patients and improve their outcomes. A total of 349 beds, in 12 general wards in ten hospitals in the United States, Europe, and Australia. Cohort of 18,305 patients. Before-and-after controlled trial. We deployed electronic automated advisory vital signs monitors to assist in the acquisition of vital signs and calculation of early warning scores. We assessed their effect on frequency, type, and treatment of rapid response team calls; survival to hospital discharge or to 90 days for rapid response team call patients; overall type and number of serious adverse events and length of hospital stay. We studied 9,617 patients before (control) and 8,688 after (intervention) deployment of electronic automated advisory vital signs monitors. Among rapid response team call patients, intervention was associated with an increased proportion of calls secondary to abnormal respiratory vital signs (from 21% to 31%; difference [95% confidence interval] 9.9 [0.1-18.5]; p=.029). Survival immediately after rapid response team treatment and survival to hospital discharge or 90 days increased from 86% to 92% (difference [95% confidence interval] 6.3 [0.0-12.6]; p=.04). Intervention was also associated with a decrease in median length of hospital stay in all patients (unadjusted p<.0001; adjusted p=.09) and more so in U.S. patients (from 3.4 to 3.0 days; unadjusted p<.0001; adjusted ratio [95% confidence interval] 1.03 [1.00-1.06]; p=.026). The time required to complete and record a set of vital signs decreased from 4.1±1.3 mins to 2.5±0.5 mins (difference [95% confidence interval] 1.6 [1.4-1.8]; p<.0001). Deployment of electronic automated advisory vital signs monitors was associated with an improvement in the proportion of rapid response team-calls triggered by respiratory criteria, increased survival of patients receiving rapid response team calls, and decreased time required for vital signs measurement and recording (NCT01197326).
    Critical care medicine 08/2012; 40(8):2349-61. DOI:10.1097/CCM.0b013e318255d9a0 · 6.15 Impact Factor
  • Valerie C Danesh · Donna Malvey · Myron D Fottler
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    ABSTRACT: Violence in the health care workplace is occurring in a covert fashion; it is occurring at the patient bedside. However, data on workplace violence tend to be underreported and relatively scarce. This article identifies and examines the phenomenon of unreported and underreported workplace violence against nursing staff that is virtually hidden. Health care executives need to be attuned to this type of violence because it may significantly affect their ability to recruit and retain nursing staff. This article provides a synthesis of literature and data from health services administration and nursing and human resources, as well as the experience of the first author. Workplace violence in health care is a critical issue that must be addressed from legal, financial, ethical, and human resources management perspectives. It is a problem for staff providing direct care services to patients with Alzheimer disease. This article suggests strategies and offers a framework for meeting the challenges of managing hidden workplace violence. In addition to the more discrete consequences of violence including physical injury, physical disability, trauma, or even death, the complementary organizational effects call for thoughtful managerial planning and critical thinking. Guidelines for preventing and addressing workplace violence in health care organizations are also published by the Occupational Safety and Health Administration.
    The health care manager 27(4):357-63. DOI:10.1097/HCM.0b013e31818c810b