Outcomes of an integrated practice unit for vulnerable emergency department patients.

BACKGROUND: An integrated practice unit (IPU) that provides a multidisciplinary approach to patient care, typically involving a primary care provider, registered nurse, social worker, and pharmacist has been shown to reduce healthcare utilization among high-cost super-utilizer (SU) patients or multi-visit patients (MVP). However, less is known about differences in the impact of these interventions on insured vs. uninsured SU patients and super high frequency SUs ([Formula: see text]8 ED visits per 6 months) vs. high frequency SUs (4-7 ED visits per 6 months). METHODS: We assessed the percent reduction in ED visits, ED cost, hospitalizations, hospital days, and hospitalization costs following implementation of an IPU for SUs located in an academic tertiary care facility. We compared outcomes for publicly insured with uninsured patients, and super high frequency SUs with high frequency SUs 6 months before vs. 6 months after enrollment in the IPU. RESULTS: There was an overall 25% reduction in hospitalizations (p < 0.001), and 23% reduction in hospital days (p = 0.0045), when comparing 6 months before vs. 6 months after enrollment in the program. There was a 26% reduction in average total direct hospitalization costs per patient (p = 0.002). Further analysis revealed a greater reduction in health care utilization for uninsured SU patients compared with publicly insured patients. The program reduced hospitalizations for super high frequency SUs. However, there was no statistically significant impact on overall health care utilization of super high frequency SUs when compared with high frequency SUs. CONCLUSIONS: Our study supports existing evidence that dedicated IPUs for SUs can achieve significant reductions in acute care utilization, particularly for uninsured and high frequency SU patients. TRIAL REGISTRATION: IRB201500212. Retrospectively registered.

A qualitative analysis of clinicians' communication strategies with family members of patients experiencing hospital-acquired delirium.

OBJECTIVE: Identify doctors' and nurses' perceptions of effective communication strategies when talking with family members of patients with hospital-acquired delirium. METHODS: We conducted focus groups and interviews of hospitalists, anesthesiologists, and nurses using a semi-structured approach. We rigorously analyzed transcribed data using a constant comparative method. RESULTS: We conducted six focus groups and 14 interviews. Participants included 20 hospitalists, 9 anesthesiologists, and 21 nurses. Clinicians identified three communication approaches as effective when communicating with family of delirium patients: Provide reassurance, educate families, and engage in family-centered communication. CONCLUSION: In communicating with families of patients with post-operative delirium, clinicians work to reassure and educate families using family-centered communication. Different approaches are used by different types of clinicians to accomplish this goal. Clinicians recognized the importance of involving family members in the patients' recovery. PRACTICE IMPLICATIONS: Though clinically common and familiar to clinicians, delirium may be a new diagnosis for family members and thus compassion and education are vital. Due to the different clinical roles, education may be different for each discipline.

Endogenous Endophthalmitis: yield of the diagnostic evaluation.

BACKGROUND: Endogenous endophthalmitis is an infection of the eye secondary to sepsis, occurring in 0.04-0.5% of bacteremia or fungemia. Risk factors include intravenous drug abuse (IVDA), diabetes, indwelling catheters, and immune suppression. Many patients have known or suspected bacteremia or fungemia; however, culture yield is reported to be low (approximately 50%). The purpose of this study is to elucidate the yield of diagnostic evaluation including microbial cultures over a 6.5 year period at an academic center in the United States. METHODS: Retrospective chart review of patients with endogenous endophthalmitis at the University of Florida from June 2011 to February 2018. RESULTS: Included are 40 eyes of 35 patients. Endophthalmitis was secondary to an endogenous source in 23.5% of all endophthalmitis cases observed. Intraocular culture positivity was 28.6% overall but was 0% after initiation of systemic antibiotics. Most commonly identified organisms from the eye were coagulase-negative Staphylococcus and Candida. Blood culture positivity was 48.6%, most commonly Staphylococcus. IVDA was noted with increasing frequency as a risk factor. Diagnosis of endophthalmitis upon hospital admission was associated with a higher intraocular culture positivity (P = 0.040) and a shorter hospital stay (P = 0.035). Computed tomography (CT) and magnetic resonance imaging (MRI) were the highest yield imaging modalities; X-ray and non-ocular ultrasound were less diagnostically useful. Echocardiogram was positive by transesophageal route (TEE) in 22% and in 9% by transthoracic (TTE) testing. Following discharge from the hospital, 48.4% of patients failed to follow up with outpatient ophthalmology. CONCLUSIONS: Based on the results of this study, the interdisciplinary team should consider directed imaging, eye cultures prior to antimicrobial administration, thorough history for IVDA, and caution with premature discharge from the hospital.

Patient-Centered Anesthesia Triage System Predicts ASA Physical Status.

BACKGROUND: The purpose of this study was to validate a patient-centered anesthesia triage system (PCATS) by examining its association with, and predictive value of, ASA physical status (PS) classification. ASA PS classification is a widely used indicator of health status and the predictor of risk of perioperative complications. Thus, ASA PS is a good triage point such that healthy surgical patients (ASA PS I and II) undergoing low-complexity surgery are assessed by telephone, whereas less-healthy patients (ASA PS III and IV) or those patients undergoing highly complex surgery are seen in person at a presurgical clinic. However, ASA PS is not commonly available in electronic health records or easily determined by nonanesthesiologists. PCATS criteria, including the number of prescription medications used daily, body mass index (BMI), age, and surgical complexity, are readily available in electronic health records. Nonclinical scheduling personnel can use PCATS to make appropriate preassessment appointments for elective surgical patients before surgery. METHODS: After getting approval from the University of Florida IRB for an exempt study, 300 consecutive patients scheduled in the presurgical clinic over a 1-week span were retrospectively enrolled. Each of the records was reviewed and collated for study identification number, number of prescription medications, BMI, and ASA PS classification assigned on the day of surgery. In addition, a surgical complexity score was assigned to each procedure (high, moderate, minimal).The association between PCATS and individual PCATS criteria and ASA PS was assessed by χ test. The utility of PCATS to discriminate between ASA PS classifications was assessed using receiver operating characteristic (ROC) curves as well as other indicators of clinical validity: sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and positive clinical utility index ([CIU+] = sensitivity × PPV) and negative CIU ([CIU-] = specificity × PPV). RESULTS: BMI (P = .002), age (P = .01), surgical complexity (P < .0001), and number of prescriptions (P < .001) were significantly associated with ASA PS. Definitions included as PCATS criteria were BMI > 35, age > 80 years, 5 or more prescriptions, and high surgical complexity. Eighty-seven percent of patients with any PCATS criterion were ASA PS classification III or IV. From ROC curve analysis, PCATS emerged as a significant, and moderately good, predictor of ASA PS class (area under the curve = 0.75, 95% confidence interval [CI], 0.69-0.83). PCATS was highly sensitive (0.88, 95% CI, 0.84-0.92) and specific (0.74; 95% CI, 0.61-0.86), and had excellent utility in confirmation/case finding (CUI+ = 0.83, 95% CI, 0.82-0.84) and moderate utility in screening out cases (CUI- = 0.43, 95% CI, 0.41-0.44). CONCLUSIONS: PCATS serves as a useful, and valid, predictor of ASA PS classification. Thus, it may also serve as a tool to triage patients to an appropriate venue for preoperative assessment that can be utilized by nonclinical schedulers. Using a simple tool such as PCATS may help streamline the presurgical patient experience and improve clinic staff utilization.

Brincidofovir for disease progression due to suspected tecovirimat resistance in association with advanced HIV.

A man with advanced HIV presented with verrucous plaques 2-3 months after initial mpox infection. He received two courses of tecovirimat without resolution of initial mpox lesions and development of new lesions raising concern for resistance. He was treated with two doses of brincidofovir and demonstrated improvement 6 months later.

Abdominal Ecchymosis: Emergency, or Urgen-C?

Scurvy is a multisystem disease caused by vitamin C deficiency, historically associated with lethargy, gingivitis, ecchymosis, edema, and death if left untreated. Contemporary socioeconomic risk factors for scurvy include smoking, alcohol abuse, fad diets, mental health conditions, social isolation, and economic marginalization. Food insecurity is also a risk factor. This report describes a case of a man in his 70s who presented with unexplained dyspnea, abdominal pain, and abdominal ecchymosis. His plasma vitamin C level was undetectable, and he improved with vitamin C supplementation. This case highlights the significance of awareness of these risk factors and emphasizes the need for a comprehensive social and dietary history to enable the timely treatment of this rare but potentially fatal disease.

A Hepatic Manifestation of Anorexia Nervosa.

A 30-year-old woman with a history of anorexia nervosa was admitted with weight loss, hypoglycaemia and electrolyte disturbances. During her admission, transaminases peaked at ALP 457 U/l, AST 817 U/l and ALT 1066 U/l. Imaging and laboratory findings were unrevealing, and she declined liver biopsy. Nutrition was introduced via a nasogastric tube and she demonstrated improvement in her laboratory values over several weeks. Her transaminitis was determined to be secondary to severe malnutrition, which has been previously described, but cases with such profound transaminitis are less common. Studies have demonstrated hepatic autophagocytosis as the likely cause. LEARNING POINTS: Anorexia nervosa can cause severe liver injury as manifested in AST and ALT levels in the thousands.The slow reintroduction of enteral feeding can reverse liver injury.The mechanism is unclear but autophagocytosis of liver cells likely contributes to this phenomenon.

Lessons in clinical reasoning - pitfalls, myths, and pearls: a case of crushing, substernal chest pain.

OBJECTIVES: Diagnostic error is not uncommon and diagnostic accuracy can be improved with the use of problem representation, pre-test probability, and Bayesian analysis for improved clinical reasoning. CASE PRESENTATION: A 48-year-old female presented as a transfer from another Emergency Department (ED) to our ED with crushing, substernal pain associated with dyspnea, diaphoresis, nausea, and a tingling sensation down both arms with radiation to the back and neck. Troponins were elevated along with an abnormal electrocardiogram. A negative myocardial perfusion scan led to the patient's discharge. The patient presented to the ED 10 days later with an anterior ST-elevation myocardial infarction. CONCLUSIONS: An overemphasis on a single testing modality led to diagnostic error and a severe event. The use of pre-test probabilities guided by history-taking can lead to improved interpretation of test results, ultimately improving diagnostic accuracy and preventing serious medical errors.

Chronic ocular small vessel disease: An overview of diabetic retinopathy and its relationship with cardiovascular health.

Diabetic retinopathy (DR) is a potentially blinding disease originating from small vessel damage in the retina in chronic hyperglycemic states. DR has a complex multi-pathway driven pathogenesis resulting in diabetic macular edema and retinal ischemia, the former being the most common cause of vision impairment in DR. Hypoxia induced cytokines stimulate vascular endothelial growth factor (VEGF) production and subsequent angiogenesis with resultant mechanical retinal damage over time. Anti-VEGF therapy is effective for the treatment of center-involving diabetic macular edema. There is evolving evidence showing the effectiveness of anti-VEGF as both adjuvant and monotherapy in the treatment of proliferative DR, however laser photocoagulation continues to remain the standard of care. DR in large cohort studies has been shown to be an independent risk factor for the development of cardiovascular disease and mortality. In addition, changes in retinal vascular caliber ratios may have implications for risk of macrovascular events with a gender discrepancy towards women.

Use of a Data Repository to Identify Delirium as a Presenting Symptom of COVID-19 Infection in Hospitalized Adults: Cross-Sectional Cohort Pilot Study.

BACKGROUND: Delirium, an acute confusional state highlighted by inattention, has been reported to occur in 10% to 50% of patients with COVID-19. People hospitalized with COVID-19 have been noted to present with or develop delirium and neurocognitive disorders. Caring for patients with delirium is associated with more burden for nurses, clinicians, and caregivers. Using information in electronic health record data to recognize delirium and possibly COVID-19 could lead to earlier treatment of the underlying viral infection and improve outcomes in clinical and health care systems cost per patient. Clinical data repositories can further support rapid discovery through cohort identification tools, such as the Informatics for Integrating Biology and the Bedside tool. OBJECTIVE: The specific aim of this research was to investigate delirium in hospitalized older adults as a possible presenting symptom in COVID-19 using a data repository to identify neurocognitive disorders with a novel group of International Classification of Diseases, Tenth Revision (ICD-10) codes. METHODS: We analyzed data from 2 catchment areas with different demographics. The first catchment area (7 counties in the North-Central Florida) is predominantly rural while the second (1 county in North Florida) is predominantly urban. The Integrating Biology and the Bedside data repository was queried for patients with COVID-19 admitted to inpatient units via the emergency department (ED) within the health center from April 1, 2020, and April 1, 2022. Patients with COVID-19 were identified by having a positive COVID-19 laboratory test or a diagnosis code of U07.1. We identified neurocognitive disorders as delirium or encephalopathy, using ICD-10 codes. RESULTS: Less than one-third (1437/4828, 29.8%) of patients with COVID-19 were diagnosed with a co-occurring neurocognitive disorder. A neurocognitive disorder was present on admission for 15.8% (762/4828) of all patients with COVID-19 admitted through the ED. Among patients with both COVID-19 and a neurocognitive disorder, 56.9% (817/1437) were aged ≥65 years, a significantly higher proportion than those with no neurocognitive disorder (P<.001). The proportion of patients aged <65 years was significantly higher among patients diagnosed with encephalopathy only than patients diagnosed with delirium only and both delirium and encephalopathy (P<.001). Most (1272/4828, 26.3%) patients with COVID-19 admitted through the ED during our study period were admitted during the Delta variant peak. CONCLUSIONS: The data collected demonstrated that an increased number of older patients with neurocognitive disorder present on admission were infected with COVID-19. Knowing that delirium increases the staffing, nursing care needs, hospital resources used, and the length of stay as previously noted, identifying delirium early may benefit hospital administration when planning for newly anticipated COVID-19 surges. A robust and accessible data repository, such as the one used in this study, can provide invaluable support to clinicians and clinical administrators in such resource reallocation and clinical decision-making.

Acute limb ischaemia due to vasospasm: a rare presentation.

A 30-year-old woman with active intravenous drug use presented with pain, blue discolouration, paresthesia and lack of grip strength of left hand for 1 week. Physical examination revealed blue discolouration, decreased sensation and cold to touch in the left hand. She had no palpable radial pulse. She admitted Heroin use only but the urine drug screen was also positive for amphetamine. CT angiogram of the left upper extremity was concerning for acute ischaemia due to arterial occlusion. The initial plan was for amputation. However, to salvage the limb with thrombolysis, an interventional radiology angiogram was performed. The angiogram demonstrated diffuse arterial spasm and response to nitroglycerin. She was treated with nitroglycerin drip and transitioned to a calcium channel blocker. She did improve significantly. To ensure no embolic sequelae, the patient was discharged with a month of oral anticoagulation.

Cutaneous Larvae Migrans Treated with a Single Dose of Ivermectin.

Hookworm-related cutaneous larva migrans (HrCLM) is a clinical diagnosis based on a history of exposure to contaminated soil and is associated with a characteristic red serpiginous lesion that migrates within the epidermis. Our patient presented with a red, tortuous migratory rash with localized pruritus on the left plantar foot of 1-month duration. He lacked recent travel history outside the southeastern United States. Upon admission, he presented with peripheral blood eosinophilia, an uncommon feature of HrCLM. A single dose of ivermectin was sufficient for treatment, and symptoms resolved within 3 days. This case highlights the increased incidence of domestically acquired hookworm infections, explores this epidemiological shift, and emphasizes relevant differential diagnoses.

Prospective application of the interdisciplinary bedside rounding checklist 'TEMP' is associated with reduced infections and length of hospital stay.

Protocols that enhance communication between nurses, physicians and patients have had a variable impact on the quality and safety of patient care. We combined standardised nursing and physician interdisciplinary bedside rounds with a mnemonic checklist to assure all key nursing care components were modified daily. The mnemonic TEMP allowed the rapid review of 11 elements. T stands for tubes assuring proper management of intravenous lines and foleys; E stands for eating, exercise, excretion and sleep encouraging a review of orders for diet, exercise, laxatives to assure regular bowel movements, and inquiry about sleep; M stands for monitoring reminding the team to review the need for telemetry and the frequency of vital sign monitoring as well as the need for daily blood tests; and P stands for pain and plans reminding the team to discuss pain medications and to review the management plan for the day with the patient and family. Faithful implementation eliminated central line-associated bloodstream infections and catheter-associated urinary tract infections and resulted in a statistically significant reduction in average hospital length of stay of 13.3 hours, one unit achieving a 23-hour reduction. Trends towards reduced 30-day readmissions (20% down to 10%-11%) were observed. One unit improved the percentage of patients who reported nurses and doctors always worked together as a team from a 56% baseline to 75%. However, the combining of both units failed to demonstrate statistically significant improvement. Psychologists well versed in implementing behavioural change were recruiting to improve adherence to our protocols. Following training physicians and nurses achieved adherence levels of over 70%. A high correlation (r2=0.69) between adherence and reductions in length of stay was observed emphasising the importance of rigorous training and monitoring of performance to bring about meaningful and reliable improvements in the efficiency and quality of patient care.

A rare case of right shoulder pain.

We present a case of a 19-year-old man with right shoulder pain lasting for several months. Abdominal imaging revealed a right adrenal mass directly invading vascular structures into the right atrium. Widespread metastatic adrenocortical carcinoma was confirmed on biopsy. He opted for palliative mitotane treatment with home hospice care. This case emphasises the importance of considering abdominal masses in the differential diagnosis of persistent right shoulder pain after common causes have been ruled out. Early diagnosis could be potentially life-saving.

Increasing adherence to a standardized rounding procedure in two hospital in-patient units.

Standardized bedside rounds can improve communication and the quality of care for patients in hospitals. However, it can be challenging to change previously established provider practices to adhere to new procedures. This study evaluated 2 packaged interventions, derived from a modified Performance Diagnostic Checklist interview, to increase adherence to standardized rounding practices in 2 hospital units. Researchers observed physicians at a university hospital on rounds 2-3 times per week, and 2 phases of intervention were implemented to improve adherence. The interventions included task clarification, feedback, and weekly huddles. Compared to baseline, phases 1 and 2 of the intervention improved clinician adherence to the standardized bedside rounding checklist by 24.94% and 30.94% in unit 1 and 26.76% and 44.06% in unit 2, respectively. The standardized rounds did not require additional time following the intervention. These results indicate that physician adherence can be improved through behavioral interventions.

Improving burnout and well-being among medicine residents: Impact of a grassroots intervention compared to a formal program curriculum.

BACKGROUND: With growing resident burnout, Accreditation Council for Graduate Medical Education issued new requirements for program interventions to optimize resident well-being. Little evidence exists on how to best teach resiliency to residents. This study assesses the impact of both a grassroots intervention and formal resiliency curriculum on resident burnout and well-being. MATERIALS AND METHODS: From November 2016 to August 2017, residents in a large Internal Medicine Residency Program participated in grassroots wellness interventions from the resident-led Gator Council in Gainesville, FL USA. From August 2017 to June 2018, residents participated in a formal program-driven resiliency curriculum. Wellness interventions included monthly morning reports, bimonthly workshops, and biannual noon conferences. Pre- and postintervention Maslach Burnout Inventory (MBI) and Physician Well-Being Index (PWBI) assessed the effect of both interventions on resident burnout and well-being. Statistical analyses used Student's t-test, Fisher's exact tests, and linear regression model. RESULTS: One hundred and twenty-two residents participated in grassroots interventions. One hundred and seventeen (87 residents, 35 students) participated in formal curriculum. Mean MBI scores for all three sections did not differ between pre -and postgrassroots intervention (emotional exhaustion [EE] P = 0.46; depersonalization [DP] P = 0.43; personal accomplishment [PA] P = 0.73]) or between pre- and postcurriculum (EE P = 0.20; DP P = 0.40; PA P = 0.51). Students scored higher burnout levels compared to residents in EE (P = 0.001) and PA (P = 0.02). Pre- versus postcurriculum PWBI scores did not differ among residents (P = 0.20), while PWBI scores improved among students (P = 0.01). CONCLUSIONS: This study found no improvement in resident burnout or well-being from a bottom-up and top-down approach. Our results imply the need for an early wellness curriculum to improve student well-being given their higher level of burnout. System-wide efforts are vital to combat physician burnout.

Implementing Delirium Prevention in the Era of COVID-19.

Patients admitted with COVID-19 can develop delirium due to predisposing factors, isolation, and the illness itself. Standard delirium prevention methods focus on interaction and stimulation. It can be challenging to deliver these methods of care in COVID settings where it is necessary to increase patient isolation. This paper presents a typical clinical vignette of representative patients in a tertiary care hospital and how a medical team modified an evidence-based delirium prevention model to deliver high-quality care to COVID-19 patients. The implemented model focuses on four areas of delirium-prevention: Mobility, Sleep, Cognitive Stimulation, and Nutrition. Future studies will be needed to track quantitative outcome measures.

A Patient-Centered Environmental Scan of Inpatient Visitor Policies During the COVID-19 Pandemic.

Researchers and patients conducted an environmental scan of policy documents and public-facing websites and abstracted data to describe COVID-19 adult inpatient visitor restrictions at 70 academic medical centers. We identified variations in how centers described and operationalized visitor policies. Then, we used the nominal group technique process to identify patient-centered information gaps in visitor policies and provide key recommendations for improvement. Recommendations were categorized into the following domains: 1) provision of comprehensive, consistent, and clear information; 2) accessible information for patients with limited English proficiency and health literacy; 3) COVID-19 related considerations; and 4) care team member methods of communication.

COVID-19-Associated Systemic Thromboembolism: A Case Report and Review of the Literature.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) is a pandemic that has affected >188 countries, involved >24 million people, and caused >840,000 deaths. COVID-19, in its severe form, presents as acute respiratory distress syndrome (ARDS), shock, and multiorgan failure. Thrombotic microangiopathy of the lungs and kidneys has been observed in these patients. Elevated D-dimer levels have been observed in people with serious COVID-19 illness, and this could be helpful in guiding treatment with anticoagulation in these patients. OBJECTIVE: To analyze the role of anticoagulation as a treatment modality for COVID-19. METHODS: We present the unique case of a COVID-19 patient who developed sepsis, ARDS, acute kidney injury, and deep-vein thrombosis (DVT), who was deteriorating clinically. She was treated with anticoagulation. RESULTS: There was rapid recovery after treatment with systemic anticoagulation. CONCLUSIONS: Systemic anticoagulation could prove to be essential in the treatment of CO-VID-19. Further studies are required to assess its role in improving long-term morbidity and mortality in these patients.

Factors Influencing Prescribers' Decision for Extending Venous Thromboembolism Prophylaxis in the Medical Patient Population following Hospitalization.

Introduction Venous thromboembolism (VTE) prophylaxis during hospitalization has clearly defined metrics for risk stratification and practice policy employed to ensure processes of adherence. However, acceptance for practice or even the level and timeline of risk is less clear during the immediate time after hospitalization. With emerging new oral anticoagulant agents, data are available that may influence prescribing in the outpatient setting following hospitalization. A survey was created to determine the level of acceptance or influences for practice surrounding continuation of anticoagulation following hospitalization. Methods This study was designed as a single-center survey of hospitalist and family medicine physician to assess influences to the physician's impression for risk of VTE prophylaxis and knowledge of therapy options. Results Physicians reported depending heavily on medical center protocols for determining anticoagulation at hospital discharge. Prescribing postdischarge anticoagulation was reported to be affected by lack of comfort with prescribing oral medications and concerns with risk of bleeding for all types of anticoagulation outweighing the perceived benefit. Additionally, the decision whether to prescribe these medications at discharge was reported to be related to perceived cost and other patient barriers such as concerns over route of administration. Conclusion Concerns for bleeding were an influence and likely resulted in shorter duration for VTE prophylaxis being prescribed posthospitalization.