"4 E's" Ways That Clinicians Can Reduce Low-Value Care on Medical Wards.

This JAMA Network Insight demonstrates examples of how clinicians can implement stepwise changes to reduce unnecessary patient harms, using the 4 E's.

Effect of Ward-Based High-Flow Nasal Cannula (HFNC) Oxygen Therapy on Critical Care Utilization During the COVID-19 Pandemic: A Retrospective Cohort Analysis.

BACKGROUND: Hospitals expanded critical care capacity during the COVID-19 pandemic by treating COVID-19 patients with high-flow nasal cannula oxygen therapy (HFNC) in non-traditional settings, including general internal medicine (GIM) wards. The impact of this practice on intensive care unit (ICU) capacity is unknown. OBJECTIVE: To describe how our hospital operationalized the use of HFNC on GIM wards, assess its impact on ICU capacity, and examine the characteristics and outcomes of treated patients. DESIGN: Retrospective cohort study of all patients treated with HFNC on GIM wards at a Canadian tertiary care hospital. PARTICIPANTS: All patients admitted with COVID-19 and treated with HFNC on GIM wards from December 28, 2020, to June 13, 2021, were included. MAIN MEASURES: We combined administrative data on critical care occupancy daily with chart-abstracted data for included patients to establish the total number of patients receiving ICU-level care at our hospital per day. We also collected data on demographics, medical comorbidities, illness severity, COVID-19 treatments, HFNC care processes, and patient outcomes. KEY RESULTS: We treated 124 patients with HFNC on the GIM wards (median age 66 years; 48% female). Patients were treated with HFNC for a median of 5 days (IQR 3 to 8); collectively, they received HFNC for a total of 740 hospital days, 71% of which were on GIM wards. At peak ICU capacity strain (144%), delivering HFNC on GIM wards added 20% to overall ICU capacity by managing up to 14 patients per day. Patients required a median maximal fraction of inspired oxygen of 80% (IQR 60 to 95). There were 18 deaths (15%) and 85 patients (69%) required critical care admission; of those, 40 (47%) required mechanical ventilation. CONCLUSIONS: With appropriate training and resources, treatment of COVID-19 patients with HFNC on GIM wards appears to be a feasible strategy to increase critical care capacity.

Don't Interrupt! A Case Report of Continuing Peritoneal Dialysis After Endoscopic Gastric Tumor Resection.

RATIONALE: The evidence supporting the safety of restarting peritoneal dialysis (PD) immediately after abdominal surgery and interventions is scant. In particular, there are no reported cases characterizing periprocedural management of PD for patients undergoing endoscopic submucosal dissection for gastric intramucosal tumor removal. PRESENTING CONCERNS OF THE PATIENT: A 66-year-old female with end-stage kidney disease secondary to diabetic nephropathy, currently on nocturnal automatic PD, presented with new iron-deficiency anemia. Workup revealed an intramucosal gastric lesion proximal to the pylorus, without surrounding lymph node involvement. Endoscopic submucosal dissection was performed with en bloc endoscopic resection of a 5-cm, partially flat, partially sessile mass along the posterior wall and lesser curvature of the gastric antrum. Pathology revealed low-grade dysplasia without features of malignancy. There was no evidence of hemorrhage or leak post-dissection. DIAGNOSES: The clinical presentation was consistent with an uncomplicated endoscopic submucosal dissection. INTERVENTIONS: Peritoneal dialysis was held for 48 hours and restarted thereafter with no complications. The patient did not require bridging with hemodialysis. OUTCOMES: The patient had an uncomplicated post-endoscopic course, with no subsequent episodes of PD-associated peritonitis after at least 6-month follow-up. NOVEL FINDING: This is the first reported case of PD reinitiation after endoscopic submucosal dissection of a gastric tumor.

JUSTIFICATION: Les données probantes soutenant l'innocuité de la reprise de la dialyse péritonéale (DP) immédiatement après une procédure ou une chirurgie abdominale sont rares. Surtout, il n'existe aucun cas signalé caractérisant la prise en charge périprocédurale de la dialyse péritonéale chez les patients subissant une dissection sous-muqueuse endoscopique pour l'ablation d'une tumeur de la muqueuse gastrique. PRÉSENTATION DU CAS: Une patiente de 66 ans atteinte d'insuffisance rénale terminale consécutive à une néphropathie diabétique. La patiente était traitée par dialyse péritonéale nocturne automatique et présentait une anémie ferriprive. Le bilan a révélé une lésion gastrique intramucosale à proximité du pylore, sans atteinte des ganglions lymphatiques environnants. Une dissection sous-muqueuse endoscopique a été pratiquée, avec exérèse endoscopique en monobloc d'une tumeur de 5-cm, partiellement plate et partiellement sessile, le long de la paroi postérieure et de la petite courbure de l'antre pylorique. L'examen pathologique a révélé une dysplasie de bas grade sans caractères de malignité. Aucun signe d'hémorragie ou de fuite n'a été observé après l'intervention. DIAGNOSTIC: Le tableau clinique était typique d'une dissection sous-muqueuse endoscopique sans complication. INTERVENTION: La dialyse péritonéale a été interrompue pour 48 heures, puis redémarrée sans complication. La patiente n'a pas eu besoin d'hémodialyse entre temps. RÉSULTATS: Le parcours post-endoscopique de la patiente s'est avéré simple, aucun épisode subséquent de péritonite associée à la DP n'a été rapporté après au moins six mois de suivi. CONCLUSION: Il s'agit du premier cas rapporté de reprise d'une dialyse péritonéale après la dissection sous-muqueuse endoscopique d'une tumeur gastrique.

Choosing Wisely for Medical Education: Six Things Medical Students and Trainees Should Question.

PROBLEM: Physician behaviors that promote overuse of health care resources develop early in training, and the medical education environment helps foster such behaviors. The authors describe the development of a Choosing Wisely list for medical students aimed at helping to curb overuse. APPROACH: The list was developed in 2015 by Choosing Wisely Canada (CWC) in partnership with the Canadian Federation of Medical Students and the Fédération médicale étudiante du Québec, which together represent all medical students in Canada. CWC convened a student-led taskforce to develop recommendations targeting medical student behaviors with respect to resource stewardship practices. Students at all 17 Canadian medical schools were consulted via an online questionnaire to solicit feedback on a list of 10 candidate recommendations. The taskforce used this student feedback in finalizing the list. OUTCOMES: The final list of "Six Things That Medical Students and Trainees Should Question" highlights both behaviors students should avoid (e.g., "Don't suggest ordering the most invasive test before considering other less invasive options") and behaviors related to aspects of medical training that may promote overuse, such as the hierarchical nature of clinical supervision (e.g., "Don't hesitate to ask for clarification on tests, treatments, or procedures that you believe may be ordered inappropriately"). Based on student requests for illustrative examples, clinical vignettes were developed. NEXT STEPS: This list highlights medical student behaviors and aspects of the academic environment that drive overuse. It is also relevant to faculty, whose behaviors and supervision practices influence trainees.