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STUDY OBJECTIVE: Our institution experienced a change in SARS-CoV-2 testing policy as well as substantial changes in local COVID-19 prevalence, allowing for a unique examination of the relationship between SARS-CoV-2 testing and emergency department (ED) length of stay. METHODS: This was an observational interrupted time series of all patients admitted to an academic health system between March 15, 2020, and September 30, 2020. Given testing limitations from March 15 to April 24, all patients receiving SARS-CoV-2 tests were symptomatic. On April 24, testing was expanded to all ED admissions. The primary and secondary outcomes were ED length of stay and number needed to test to obtain a positive, respectively. RESULTS: A total of 70,856 patients were cared for in the EDs during the 7-month period. The testing change increased admission length of stay by 1.89 hours (95% confidence interval 1.39 to 2.38). The number needed to test was 2.5 patients and was highest yield on April 1, 2020, when the state positivity rate was 39.7%; however, the number needed to test exceeded 170 patients by Sept 1, 2020, at which point the state positivity rate was 0.5%. CONCLUSION: Although universal SARS-CoV-2 testing of ED admissions may meaningfully support mitigation and containment efforts, the clinical cost of testing all admissions amid low community positivity is notable. In our system, universal ED SARS-CoV-2 testing was associated with a 24% increase in admission length of stay alongside the detection of only 1 positive case every other day. Given the known harms and risks of ED boarding and crowding, solutions must be developed to support regular operational flow while balancing infection prevention needs.
Assuntos
Teste para COVID-19/métodos , COVID-19/diagnóstico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , COVID-19/epidemiologia , Humanos , Pandemias , SARS-CoV-2 , Estados Unidos/epidemiologiaAssuntos
Infecções por Coronavirus/epidemiologia , Parto Obstétrico , Transmissão de Doença Infecciosa do Paciente para o Profissional/prevenção & controle , Pneumonia Viral/epidemiologia , Complicações Infecciosas na Gravidez/epidemiologia , Adulto , Doenças Assintomáticas , Betacoronavirus , COVID-19 , Teste para COVID-19 , Técnicas de Laboratório Clínico , Connecticut/epidemiologia , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/prevenção & controle , Infecções por Coronavirus/transmissão , Feminino , Humanos , Pandemias/prevenção & controle , Parto , Equipamento de Proteção Individual , Pneumonia Viral/prevenção & controle , Pneumonia Viral/transmissão , Gravidez , Prevalência , SARS-CoV-2RESUMO
Concerns persist regarding possible false-negative results that may compromise COVID-19 containment. Although obtaining a true false-negative rate is infeasible, using real-life observations, the data suggest a possible false-negative rate of Ë2.3%. Use of a sensitive, amplified RNA platform should reassure healthcare systems.
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COVID-19 , COVID-19/diagnóstico , Teste para COVID-19 , Técnicas de Laboratório Clínico/métodos , Humanos , Nasofaringe , SARS-CoV-2RESUMO
Mass asymptomatic SARS-CoV-2 nucleic acid amplified testing of healthcare personnel (HCP) was performed at a large tertiary health system. A low period-prevalence of positive HCP was observed. Of those who tested positive, half had mild symptoms in retrospect. HCP with even mild symptoms should be isolated and tested.
Assuntos
Infecções Assintomáticas/epidemiologia , Teste para COVID-19/estatística & dados numéricos , COVID-19/epidemiologia , Pessoal de Saúde/estatística & dados numéricos , COVID-19/diagnóstico , COVID-19/transmissão , Connecticut/epidemiologia , Humanos , SARS-CoV-2/isolamento & purificaçãoRESUMO
BACKGROUND: Waste persists in healthcare and negatively impacts patients. Clinicians have direct control over test ordering and ongoing international efforts to improve test utilisation have identified multifaceted approaches as critical to the success of interventions. Prior to 2015, Yale New Haven Health lacked a coherent strategy for laboratory test utilisation management. METHODS: In 2015, a system-wide laboratory formulary committee was formed at Yale New Haven Health to manage multiple interventions designed to improve test utilisation. We report here on specific interventions conducted between 2015 and 2017 including reduction of (1) obsolete or misused testing, (2) duplicate orders, and (3) daily routine lab testing. These interventions were driven by a combination of modifications to computerised physician order entry, test utilisation dashboards and physician education. Measurements included test order volume, blood savings and cost savings. RESULTS: Testing for a number of obsolete/misused analytes was eliminated or significantly decreased depending on alert rule at order entry. Hard stops significantly decreased duplicate testing and educational sessions significantly decreased daily orders of routine labs and increased blood savings but the impact waned over time for select groups. In total, we realised approximately $100 000 of cost savings during the study period. CONCLUSION: Through a multifaceted approach to utilisation management, we show significant reductions in low-value clinical testing that have led to modest but significant savings in both costs and patients' blood.
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OBJECTIVES: Clinical deterioration detection among adult inpatients is known to be suboptimal, and many electronic health record tools have been developed to help identify these patients. Many of these tools are focused on sepsis spectrum disorders, but the evolution of the definition of sepsis is moving toward increased specificity, which may make automated detection of clinical deterioration from nonsepsis-related conditions less likely. The objectives of this study were to develop and to examine the use of a low-cost, highly sustainable deterioration detection tool based on systemic inflammatory response syndrome (SIRS) criteria. METHODS: Using existing resources, a SIRS-based electronic health record monitoring and intervention tool was developed with a focus on ease of implementation and high sustainability. This tool was used to monitor 15,739 adult inpatients in real time during their admission. RESULTS: The SIRS-based tool, created with focus on ease of implementation and high sustainability, identified patients with higher risk of clinical deterioration. The project was rapidly deployed for a 4-month period at a 900-bed campus of an academic medical center with minimal additional resources required. CONCLUSIONS: Whereas the definition of sepsis moves away from SIRS, SIRS-based criteria may still have clinical benefit as an easy-to-automate detection tool for all-cause clinical deterioration among medical inpatients.
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Registros Eletrônicos de Saúde , Hospitalização , Programas de Rastreamento , Síndrome de Resposta Inflamatória Sistêmica/diagnóstico , Adulto , Automação , Progressão da Doença , Feminino , Humanos , Pacientes Internados , Masculino , Sepse/diagnósticoRESUMO
In-hospital continuous electrocardiographic monitoring, commonly referred to as telemetry, has allowed for rapid recognition of life-threatening conditions, including complex arrhythmias and myocardial ischemia. However, inappropriate use can lead to unnecessary downstream testing from "false alarms," which in turn affects clinician efficiency and increases health care costs without benefiting patients. For these reasons, the Society of Hospital Medicine's Choosing Wisely campaign recommended use of a protocol-driven discontinuation of telemetry. The American Heart Association (AHA) developed a set of Practice Standards for the appropriate use of telemetry monitoring in 2004, which they updated in 2017. Unfortunately, the AHA Practice Standards have not been widely adopted-with as many as 43% of monitored patients lacking a recommended indication for monitoring. Thus, we created an overview discussing the safety and efficacy of incorporating the AHA Practice Standards and a review of studies highlighting their successful incorporation within patient care workflow. We conclude by outlining an "implementation blueprint" for health system professionals and administrators seeking to change their institution's culture of telemetry use. As the health care landscape continues to shift, enacting high-value initiatives that improve patient safety and efficiency of care will be critical.
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Telemetria , Procedimentos Desnecessários , Prática Clínica Baseada em Evidências , Implementação de Plano de Saúde , HumanosAssuntos
COVID-19 , SARS-CoV-2 , COVID-19/diagnóstico , Teste para COVID-19 , Atenção à Saúde , Pessoal de Saúde , HumanosAssuntos
Teste para COVID-19/normas , Programas de Rastreamento/métodos , Métodos , Adulto , Idoso , Anestesia Geral/métodos , Anestesia Geral/estatística & dados numéricos , Doenças Assintomáticas/epidemiologia , Teste para COVID-19/métodos , Teste para COVID-19/estatística & dados numéricos , Sedação Consciente/métodos , Sedação Consciente/estatística & dados numéricos , Feminino , Humanos , Masculino , Programas de Rastreamento/estatística & dados numéricos , Pessoa de Meia-Idade , Melhoria de QualidadeRESUMO
IMPORTANCE: Freedom from symptoms is an important determinant of a good death, but little is known about symptom occurrence during the last year of life. OBJECTIVE: To evaluate the monthly occurrence of physical and psychological symptoms leading to restrictions in daily activities (ie, restricting symptoms) among older persons during the last year of life and to determine the associations of demographic and clinical factors with symptom occurrence. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study. Comprehensive assessments were completed every 18 months, and monthly interviews were conducted to assess the presence of restricting symptoms. Of 1002 nondisabled community-dwelling individuals 70 years or older in greater New Haven, Connecticut, eligible to participate, 754 agreed and were enrolled between 1998 and 1999. MAIN OUTCOMES AND MEASURES: The primary outcome was the monthly occurrence of restricting symptoms as a dichotomous outcome. The monthly mean count of restricting symptoms was a secondary outcome. RESULTS: Among the 491 participants who died after their first interview and before June 30, 2011, mean age at death was 85.8 years, 61.9% were women, and 9.0% were nonwhite. The mean number of comorbid conditions was 2.4, and 73.1% had multimorbidity. The monthly occurrence of restricting symptoms was fairly constant from 12 months before death (20.4%) until 5 months before death (27.4%), when it began to increase rapidly, reaching 57.2% in the month before death. In multivariable analysis, age younger than 85 years (odds ratio [OR], 1.30 [95% CI, 1.07-1.57]), multimorbidity (OR, 1.38 [95% CI, 1.09-1.75]), and proximity to time of death (OR, 1.14 per month [95% CI, 1.11-1.16]) were significantly associated with the monthly occurrence of restricting symptoms. Participants who died of cancer had higher monthly symptom occurrence (OR, 1.80 [95% CI, 1.03-3.14]) than participants who died of sudden death, although this difference was only marginally significant (P = .04). Symptom burden did not otherwise differ substantially according to condition leading to death. CONCLUSIONS AND RELEVANCE: Restricting symptoms are common during the last year of life, increasing substantially approximately 5 months before death. Our results highlight the importance of assessing and managing symptoms in older patients, particularly those with multimorbidity.