CHRI-Driven Initiatives

The Impact of Vascular Surgery Procedures on Climate Change

Principal Investigators: Kevin Casey MD, Arianne Johnson PhD, Michelle Wang MD, Fares Al-Khouja MD

Globally, the healthcare sector is a major contributor to greenhouse gases. The operating room contributes up to 70% of hospital waste and up to 30% of a hospital’s CO2 emissions. The goal of this study is to examine the impact of operating room waste in vascular procedures and its contribution to carbon emissions. This includes conducting sub-analyses on types of vascular procedures and type of waste produced (disposable, biohazard, and recycling). Findings can be applied to build awareness in the surgery community in order to create strategies to reduce greenhouse gas emissions and to inform waste reducing education programs for healthcare staff.

Effect of time to administration of anticoagulant reversal in traumatic intracranial head bleeds

Principal Investigators: Rohit Sharma MD, Arianne Johnson PhD, Adrian Moy MD, Aaron Cotton-Betteridge MD

Traumatic brain injury (TBI) is a significant public health concern, contributing to approximately 30% of all injury-related deaths in the United States. Among the various complications associated with TBI, intracranial hemorrhage (ICH) is particularly critical due to its potential to rapidly progress and lead to severe neurological deficits or death. Patients who sustain a TBI while on anticoagulant or antithrombotic therapy are at heightened risk for exacerbated bleeding, which can complicate both the initial presentation and the subsequent clinical course. The approval of specific reversal agents for DOACs, such as Andexanet alfa for Factor Xa inhibitors, has provided clinicians with tools to rapidly counteract the anticoagulant effects in the event of a traumatic ICH. Despite the availability of these agents, there remains a significant gap in the literature regarding the optimal timing of their administration. Early evidence suggests that prompt reversal may be crucial in preventing ICH progression, yet the data is limited and primarily derived from small observational studies or post-hoc analyses of larger trials. The primary aim of this study is to investigate the effect of timing of administering anticoagulant reversal agents to prevent progression of traumatic intracranial hemorrhage.

Geriatric Trauma Care

Principal Investigators: Rohit Sharma MD, Arianne Johnson PhD

Geriatric patients are a common population treated at Santa Barbara Cottage Hospital’s verified Level 1 Trauma Center. Researchers at Cottage Health are investigating management and outcomes of both traumatic brain injury and other injuries after ground-level falls, the most common cause of fatal and nonfatal injury in this age group. Using both national and local hospital data, these studies investigate and improve geriatric trauma care on topics such as traumatic brain injury, end-of-life care, ground-level falls, advanced care directives, and identifying predictors of functional outcomes.

Comparison of door-to-needle time of Tenecteplase & Alteplase in Acute Ischemic Stroke Protocol

Principal Investigators: Loren Pattillo-Lee, PharmD, Fiona Asigbee, PhD, MPH, MEd, and Stacey Campbell, PharmD, MPH, BCPS.

The treatment for acute ischemic stroke (AIS) has long been comprised of a single thrombolytic medication, Alteplase . In 2019, the American Heart and American Stroke Associations updated the AIS guidelines to include a recommendation for the use of Tenecteplase as an alternative to Alteplase.

Figure 1. Treatment for acute ischemic stroke (AIS) focuses on restoration of blood flow and improvement of perfusion to the affected region of the brain. This figure depicts two forms of AIS treatments: (1) Alteplase-a mechanical thrombectomy or IV Thrombolytics treatment, and (2) Tenecteplase – a thrombolytic treatment. This figure depicts the period of time after onset that each form of treatment takes.

There were concerns about delays in therapy with the use of Alteplase due to the lengthy reconstitution process, dosing, and administration of a bolus and continuous infusion. Tenecteplase is administered via an intravenous (IV) push and reconstitution is less labor intensive which may result in more timely administration. In August 2022, Santa Barbara Cottage Hospital (SBCH) transitioned from using Alteplase to Tenecteplase for management of AIS due to comparable efficacy, ease of administration, and similar safety profiles for both medications.

Study Objective: The purpose of this retrospective study was to examine the door-to-needle time for Tenecteplase and Alteplase when used for management of AIS. Methods: Data for this single center, retrospective study were obtained from adults admitted to the SBCH Emergency Department (ED) between November 1, 2021 to August 30, 2023 for management of AIS. Cohort 1 consisted of the protocol pre-implementation group (Alteplase group) from November 1, 2021 to August 30, 2022 and cohort 2 consisted of the post- implementation group (Tenecteplase group) from November 1, 2022 to August 30, 2023. Results: Of the 134 patients that were screened for enrollment, 34 patients were treated with Alteplase and 27 patients were treated with Tenecteplase.

The Alteplase group was 53% male and 74% White with a mean age of 76.1 ± 13.6.The Tenecteplase group was 54% female and 78% White with a mean age of 73.5 ± 15.8. The door to needle time of Tenecteplase was approximately 10 minutes less than the door to needle time of Alteplase.

Figure 2. Depiction of difference in door to needle time of Alteplase and Tenecteplase. The door to needle time for Tenecteplase was approximately 10 minutes less than the door to needle time for Alteplase.

Hospital length of stay was shorter for patients that were administered Tenecteplase compared to Alteplase (5 days vs. 8 days, respectively). There was also a difference in National Institutes of Health Stroke Scale/Score (NIHSS), the primary measure of post stroke neurological function improvement, for the two drugs. Tenecteplase had a mean difference of 5.11 from the first NIHSS score to the last NIHSS score. Alteplase had a mean difference of 4.45 from the first NIHSS score to the last NIHSS score.

Conclusion: The transition from Alteplase to Tenecteplase has proved beneficial at SBCH with a 10-minute decrease in door to needle time. These findings showcase a possible connection between the efficacy of Tenecteplase and the reduction of door-to-needle time, a decrease in length of hospital stay, and comparable improvement in neurological function at discharge in the management of AIS. Future studies should aim for larger sample sizes and have better patient compliance if comparing neurological outcomes.

This study was accepted for an oral presentation at the 2023 Western States Conference in San Diego, California.

Implementation of a Pharmacist-Driven MRSA Nasal Swab Protocol

Principal Investigators: Tiffany Ngo, PharmD, Fiona Asigbee, PhD, MPH, MEd, and Sarah Thompson, PharmD, BCPS

Methicillin-resistant Staphylococcus aureus (MRSA) causes both community and healthcare associated infections, and MRSA-directed empiric therapy is frequently initiated for patients with known or suspected pneumonia and sepsis. Antibiotics such as vancomycin and linezolid are often overused as empiric treatments against MRSA for community-acquired pneumonia. Inappropriate overuse of vancomycin and linezolid increases the risk for bacterial resistance.

Figure 1. Depiction of MRSA polymerase chain reaction (PCR) testing and it’s utility in de-escalation of anti-MRSA antibiotics for several types of infection. The benefits of lowering excessive use of broad-spectrum antibiotics are also depicted.

Studies have shown that early de-escalation of anti-MRSA antibiotics prescribed for pneumonia can be facilitated by MRSA polymerase chain reaction (PCR) testing which decreases days of therapy (DOT), adverse drug reactions, and drug and laboratory costs without differences in clinical outcomes. Lowering excessive use of broad-spectrum antibiotics also contributes to antimicrobial stewardship. Moreover, MRSA nasal PCR reaction testing has approximately a 96 to 97% negative predictive value for pneumonia. The utility of MRSA nasal swab tests has potential to be increased in hospitalized patients.

Study Objective: The purpose of this study was to assess the utility of a pharmacist-driven MRSA nasal swab ordering protocol in assisting in early de-escalation or discontinuation of unnecessary empiric anti-MRSA therapy. Methods: A single-center retrospective pre-post study was conducted at a 519-bed community hospital. Pharmacists ordered MRSA PCR nasal swabs in select patients upon receipt of an admission order for vancomycin or linezolid that was initiated empirically for pneumonia or sepsis secondary to pneumonia. This pharmacist-driven MRSA nasal swab protocol allowed pharmacists to use clinical judgment to determine if de-escalation was appropriate based on test results and make recommendations to ordering providers. Pre protocol implementation and post protocol implementation data were obtained from 151 adult patients with non-intensive care unit admissions who were initiated on anti-MRSA therapy (vancomycin or linezolid) for pneumonia or sepsis secondary to pneumonia in a three-month period. Results: The pre-implementation sample demographics (n=73) included: 59% male, 73% Medicare Insurance, and 75% Not Hispanic with a mean age of 75 ± 13.5. The post-implementation sample demographics (n=78) included: 51% female, 56% Medicare Insurance, and 69% Not Hispanic with a mean age of 70 ± 16.2. When compared to pre-implementation data, mean values for post-implementation anti-MRSA DOT, re-initiation of anti-MRSA therapy, acquired acute kidney injury (AKI), hospital LOS, 30-day readmission rate, and in-hospital mortality decreased indicating a possible link between a pharmacist-driven MRSA nasal swab ordering protocol assisting in early de-escalation or discontinuation of unnecessary empiric anti-MRSA therapy (pre-implementation: 2.98%, 2.74%, 20.60%, 7.59 days, 17.80%, and 4.10%, respectively; post-implementation: 2.56%, 2.56%, 7.69%, 7.24 days, 2.56%, and 2.56%, respectively).

Conclusion: Findings suggest an association between the use of a pharmacist-driven MRSA nasal swab ordering protocol and a decrease in anti-MRSA DOT which may, potentially lower adverse drug reactions, hospital LOS, and hospital readmission rates. Implementing a similar protocol at other institutions may contribute to antimicrobial stewardship and help guide anti-MRSA therapy de-escalation, ultimately reducing unnecessary use of antibiotics and the risk for antibiotic resistance.

A Novel Technique for Commissural Alignment of Balloon-Expandable Transcatheter Aortic Valve Replacement: The SBCA Experience

Principal Investigators: Michael Shenoda, MD, FACC, FSCAI; Bernie Blocker; Colin Shafer; Samantha Yim; Jorgene Gaunia; Joe Tanner; Bryce Jones, MS; Joseph Aragon, MD, FACC, FSCAI

Aortic valve rotation misalignment before and after Commissural Alignment

Click to enlarge image

^{Image Source: Commissural alignment between native and TAVI valve makes for easy... | Download Scientific Diagram . Accessed 16 June 2025.}

Background
Commissural alignment (CA) of balloon-expandable transcatheter aortic valve replacement (BE-TAVR) remains elusive. Despite previous attempts of CA of BE-TAVR, none have been successful at consistently achieving CA. Proposed benefits of CA include simpler coronary re-access, improved hemodynamics, decreased incidence of hypo attenuated leaflet thickening, and decelerated TAVR valve deterioration.

Methods
At Santa Barbara Cottage Hospital, we prospectively evaluated the effects of BE-TAVR crimping orientation based on CT-derived aortic root angulation for 51 patients, utilizing the Shenoda-Blocker Commisural Alignment (SBCA) technique. The rates of successful CA were then retrospectively compared the previous 51 patients who had undergone BE-TAVR using standard crimping and valve implantation techniques.

We used the ALIGN-TAVR Consortium definitions of commissural alignment (CA). However, valve alignment was assessed by real time intraprocedural transesophageal (TEE) during the index TAVR, rather than retrospective CT analysis. Categories included CA (0-15.0°), mild commissural malalignment (CMA) (15.1° - 30.0°), moderate CMA (30.1° - 45.0°), and severe CMA (45.1° - 60.0°).

Results
Patient characteristics for both groups were similar. The rate of CA for BE-TAVR utilizing the SBCA technique was 72.55% as verified by intraprocedural TEE (37/51 patients) compared to 33.33% in the standard crimping and valve implantation technique (17/51 patients) [p<0.01, 95% CI (0.19° -0.59°). The study group of patients that did not achieve commissural alignment using the SBCA technique were either in the mild or moderate CMA categories, none had severe CMA.

Conclusion
The SBCA technique of Sapien 3 THV orientation during valve crimping based on CT-derived aortic root angle and consistent, unmodified delivery catheter orientation resulted in commissural alignment in 72.55% of cases. Outliers were mostly at extremes of aortic root angulation (<35° or >65°) and with significantly tortuous iliofemoral vessels and aortic tortuosity requiring significant catheter manipulation to advance the THV system across the stenotic valve.

This study abstract was submitted to New York Valves: The Structural Heart Summit 2025.

Analysis of Sex Difference in Functional Capacity and Quality of Life in Transcatheter Aortic Valve Replacement – extension of IRB #21-05mx

Principal Investigators: Bryce Jones, MS, Meghali Singhal, MD-R

This study is a retrospective analysis of Transcatheter Aortic Valve Replacement (TAVR) procedures that is overseen by Cardiologist Joseph Aragon, MD, FACC, FSCAI. The purpose of this study was to compare TAVR patients’ pre and post procedural KCCQ scores at the 30 day and one year follow-up between genders. KCCQ (Kansas City Cardiomyopathy Questionnaire) monitors four domains of valvular heart disease: physical limitation, symptom frequency, Quality of Life, and social limitation. Among the 649 patients included in the study, our investigators found that males are older than females when receiving a TAVR. Additionally, we found that male pre and post TAVR KCCQ scores were higher, however females had a higher difference in scores. This indicates that males have a higher baseline KCCQ score than females but not a substantial change.

The study abstract was accepted into the American Heart Association Scientific Sessions 2024.