Effectiveness of an Interdisciplinary, Nurse Driven In-Hospital Code Stroke Protocol on In-Patient Ischemic Stroke Recognition and Management.

BACKGROUND: In-hospital strokes account for up to nearly 1 in 5 strokes. Clinical outcomes, such as length of stay, disability, and mortality are worse for in-hospital strokes than for those that occur in the community. For a variety of reasons, stroke can be more difficult to recognize and treat in hospitalized patients. Earlier recognition of stroke results in better clinical outcomes, presumably due to faster diagnosis and subsequently, prompt treatment. METHODS: This investigation was a retrospective, interrupted time series, observational study of all in-hospital stroke patients between 2008 and 2017. This investigation was a quality improvement project, and a waiver was granted from the institutional review board. We used Lean methodologies to standardize our stroke protocol and optimize skill-task alignment to improve the time from onset of symptoms to brain imaging (primary outcome). RESULTS: Overall, we observed significant improvement in the time from onset of symptoms to brain imaging from a median of 69 minutes to 37 minutes (P = .002). CONCLUSIONS: If successfully implemented, this approach may be useful in other care settings with potential to improve stroke outcomes, and decrease associated complications of stroke.

Use of a real-time, algorithm-driven, publicly displayed, automated signal to improve insulin prescribing practices.

AIM: The clinical andon board (CAB) is a novel electronic surveillance and communication system, which alerts providers to and prompts treatment of dysglycemia. This investigation was designed to determine the CAB's effectiveness in supporting adherence to standardized evidence-based protocols, as well as improving glycemic control. METHODS: This study was a retrospective pre/post analysis of insulin orders and blood glucose values. We used a Student's t-test for continuous variables and Chi2 for all other variables. This study included patients 18 years or older admitted to the hospital medical service as an inpatient with a length of stay greater than 24 h and less than 90 days. We used Pearson's correlation coefficient to evaluate the relationship between CAB and blood glucose. RESULTS: The rate of compliance in prescribing basal insulin for patient with diabetes increased from 56% to 77% (p < 0.001). Similarly, compliance rates for prescribing correctional insulin in patients without diabetes increased from 15% to 37% (p < 0.001). Performance on the CAB was linearly related to blood glucose (p = 0.004), and there was a small statistically (not clinically) significant improvement in mean blood glucose values. CONCLUSION: This approach is effective in alerting and engaging providers to prescribe insulin in a standardized manner with potential to improve glycemic control.

Effectiveness of standardised preoperative assessment and patient instructions on admission blood glucose for patients with diabetes undergoing orthopaedic surgery at a tertiary referral hospital.

Diabetes and hyperglycaemia affect a significant number of people and are associated with a variety of untoward effects, especially under physiological stress such as surgery. Due, in large part to limited evidence, clinical practice in monitoring blood glucose and treating hyperglycaemic conditions in the perioperative period is variable. We used Lean methodologies to implement a standardised approach to preoperative management of patients undergoing elective surgery in an effort to improve glycaemic control. Overall, we saw an appropriate increase in monitoring and a decrease in the rate of hyperglycaemia on presentation to the operating room. This approach may be useful in other care settings or patient populations, potentially contributing to improved glycaemic control and subsequent decrease in associated complications.

The Current State of Advanced Practice Provider Fellowships in Hospital Medicine: A Survey of Program Directors.

BACKGROUND: Postgraduate training for advanced practice providers (APPs) is a growing field in hospital medicine. As hospital programs continue to benefit from highly trained physician assistants (PAs) and nurse practitioners (NPs), fellowship programs have become more prevalent. However, little is known about the number of active programs or how they prepare trainees. OBJECTIVES: To describe the existing APP fellowships in hospital medicine, with a focus on program characteristics, rationale, curricula, and learner assessment. METHODS: An electronic survey was distributed by e-mail to hospital medicine program directors in May 2018. The survey consisted of 25 multiple choice and short answer questions. Descriptive statistics were calculated utilizing Stata 13 for data analysis. RESULTS: Of the 11 fellowships identified, 10 (91%) of directors responded to the survey. Eighty percent of programs accept both NPs and PAs and 80% are between 12 and 13 months long. All programs cite "training and retaining" as the main driver for their creation and 90% were founded in institutions with existing physician residencies. Ninety percent of program curricula are informed by Society of Hospital Medicine resources. Despite these similarities, there was wide variation in both curricular content and APP fellow assessment. CONCLUSION: APP fellowships in hospital medicine are quickly growing as a means to train and retain nonphysician hospitalists. While most programs accept similar types of applicants and share a common rationale for program development, there is little standardization in terms of curriculum or assessment. Further research may be valuable to characterize the best practices to guide the future of these fellowships.

Effectiveness of a multi-component quality improvement intervention on rates of hyperglycaemia.

PURPOSE: To evaluate the effectiveness of a multifaceted, hospital-wide glycaemic control quality improvement programme. METHODS: The quality improvement intervention comprised three components, derived through root cause analysis: standardising and simplifying care (including evidence-based order sets), increasing visibility (through provider access to clinical data and direct feedback) and educational outreach (directed at the entire institution). Effectiveness was determined at a single urban acute care hospital through time-series analysis with statistical process control charts. Primary outcomes included rate of hyperglycaemia and rate of hypoglycaemia. RESULTS: The study included 70 992 hospital admissions for 50 404 patients, with 3 35 645 patient days. The hyperglycaemia ratio decreased 25.2% from 14.1% to 10.5% (95% CI 3.3 to 3.9 percentage points, p<0.001). The ratio of patient days with highly elevated blood glucose (>299 mg/dL) decreased 31.8% from 4.8% to 3.3% (95% CI 1.4 to 1.7 percentage points, p<0.001). Hypoglycaemia ratio decreased from 5.2% to 4.6% (95% CI 0.27 to 0.89 percentage points, p<0.001) in patients with diabetes, but increased in patients without diabetes from 1.2% to 1.7% (95% CI 0.46 to 0.70 percentage points, p<0.001). CONCLUSIONS: We demonstrate improved hospital-wide glycaemic control after a multifaceted quality improvement intervention in the context of strong institutional commitment, national mentorship and Lean management.

Takotsubo cardiomyopathy in two men receiving bevacizumab for metastatic cancer.

Bevacizumab is a monoclonal antibody that inhibits vascular endothelial growth factor (VEGF). It is a novel chemotherapeutic agent currently approved as part of combination chemotherapy for metastatic colorectal cancer, non-small cell lung cancer, and breast cancer (Hurwitz et al 2004; Sandler et al 2006; Traina et al 2007). Arterial thrombosis, including cerebral infarction, transient ischemic attacks, myocardial infarction, and angina are common, occurring in 4.4% of patients whose regimen includes bevacizumab (versus 1.9% on regimen without bevacizumab) (Genetech, Inc. 2008). This series will review two cases of patients exposed to bevacizumab who subsequently developed ST elevations on electrocardiogram (ECG) and elevated cardiac biomarkers. Both patients underwent cardiac catheterization, which demonstrated apical ballooning and akinesis in a distribution discordant with the observed (noncritical) atherosclerotic lesions. Both patients had recovery of left ventricular function within 30 days. The clinical presentation, including ECGs and findings on catheterization as well as the rapid recovery of ventricular function, is consistent with the diagnosis of takotsubo cardiomyopathy. Takotsubo cardiomyopathy was first described in 1991, but the pathophysiology and exact mechanism of injury remain largely unknown. These two cases are notable for their occurrence in men and the association with treatment of metastatic cancer including bevacizumab.