Medically ready for discharge: A multisite "point-in-time" assessment of hospitalized patients.

BACKGROUND: Time spent awaiting discharge after the acute need for hospitalization has resolved is an important potential contributor to hospital length of stay (LOS). OBJECTIVE: To measure the prevalence, impact, and context of patients who remain hospitalized for prolonged periods after completion of acute care needs. DESIGN, SETTING, AND PARTICIPANTS: We conducted a cross-sectional "point-in-time" survey at each of 15 academic US hospitals using a structured data collection tool with on-service acute care medicine attending physicians in fall 2022. MAIN OUTCOMES AND MEASURES: Primary outcomes were number and percentage of patients considered "medically ready for discharge" with emphasis on those who had experienced a "major barrier to discharge" (medically ready for discharge for ≥1 week). Estimated LOS attributable to major discharge barriers, contributory discharge needs, and associated hospital characteristics were measured. RESULTS: Of 1928 patients sampled, 35.0% (n = 674) were medically ready for discharge including 9.8% (n = 189) with major discharge barriers. Many patients with major discharge barriers (44.4%; 84/189) had spent a month or longer medically ready for discharge and commonly (84.1%; 159/189) required some form of skilled therapy or daily living support services for discharge. Higher proportions of patients experiencing major discharge barriers were found in public versus private, nonprofit hospitals (12.0% vs. 7.2%; p = .001) and county versus noncounty hospitals (14.5% vs. 8.8%; p = .002). CONCLUSIONS: Patients experience major discharge barriers in many US hospitals and spend prolonged time awaiting discharge, often for support needs that may be outside of clinician control.

The Effects of an E-learning Module on Medical Trainees Rotating on a Perioperative Medicine Clinical Service.

Introduction: Dedicated perioperative care can be cost-effective and improve patient outcomes. Training future physicians to practice perioperative medicine is an important responsibility of medical educators. An e-learning module delivered asynchronously during clinical rotations in perioperative medicine may help to better satisfy this responsibility. Method: Articulate software was used to create an interactive, 1-hour e-module based on six educational objectives. The e-module was offered as an elective self-directed learning experience to trainees on perioperative medicine clinical rotations, including third- and fourth-year medical students as well as residents from internal medicine, anesthesiology, neurology, and physical medicine and rehabilitation training programs. We assessed the effectiveness of this learning strategy as a complement to real-time clinical experiences by measuring the knowledge, confidence, and satisfaction of trainees before and after completion of the e-module. Results: Of 113 trainees invited to participate, 75 completed the module and were included in our analysis. Knowledge scores improved for student (p < .001), intern (p < .001), and resident (p < .001) subgroups. Confidence ratings also improved for student (p < .001), intern (p < .001), and resident (p < .001) subgroups. Trainees reported high satisfaction with the e-module, and 60 (87%) reported that it would alter their practice. Discussion: An e-module presenting evidence-based, interactive education to trainees during clinical rotations in perioperative medicine was an effective learning strategy. Sharing e-learning tools across institutions may help to deliver standardized education on core clinical topics, including perioperative medicine.

Long-Term Assessment of the Effects of COVID-19 and Isolation Care on Survivor Disability and Anxiety.

We conducted an assessment of disability, anxiety, and other life impacts of COVID-19 and isolation care in a unique cohort of individuals. These included both community admissions to a university hospital as well as some of the earliest international aeromedical evacuees. Among an initial 16 COVID-19 survivors that were interviewed 6-12 months following their admission into isolation care, perception of their isolation care experience was related to their reporting of long-term consequences. However, anxiety and disability assessed with standard scores had no relationship with each other. Both capture of the isolation care experience and caution relying on single scoring systems for assessing long-term consequences in survivors are important considerations for on-going and future COVID-19 and other pandemic survivor research.

Co-infection of COVID-19 and influenza A in a hemodialysis patient: a case report.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a novel coronavirus that was first discovered in December 2019 in Wuhan, China. With the growing numbers of community spread cases worldwide, the World Health Organization (WHO) declared the COVID-19 outbreak as a pandemic on March 11, 2020. Like influenza viruses, SARS-CoV-2 is thought to be mainly transmitted by droplets and direct contact, and COVID-19 has a similar disease presentation to influenza. Here we present a case of influenza A and COVID-19 co-infection in a 60-year-old man with end-stage renal disease (ESRD) on hemodialysis. CASE PRESENTATION: A 60-year-old man with ESRD on hemodialysis presented for worsening cough, shortness of breath, and diarrhea. The patient first developed a mild fever (37.8 °C) during hemodialysis 3 days prior to presentation and has been experiencing worsening flu-like symptoms, including fever of up to 38.6 °C, non-productive cough, generalized abdominal pain, nausea, vomiting, and liquid green diarrhea. He lives alone at home with no known sick contacts and denies any recent travel or visits to healthcare facilities other than the local dialysis center. Rapid flu test was positive for influenza A. Procalcitonin was elevated at 5.21 ng/mL with a normal white blood cell (WBC) count. Computed tomography (CT) chest demonstrated multifocal areas of consolidation and extensive mediastinal and hilar adenopathy concerning for pneumonia. He was admitted to the biocontainment unit of Nebraska Medicine for concerns of possible COVID-19 and was started on oseltamivir for influenza and vancomycin/cefepime for the probable bacterial cause of his pneumonia and diarrhea. Gastrointestinal (GI) pathogen panel and Clostridioides difficile toxin assay were negative. On the second day of admission, initial nasopharyngeal swab came back positive for SARS-CoV-2 by real-time reverse-transcriptase polymerase chain reaction (RT-PCR). The patient received supportive care and resumed bedside hemodialysis in strict isolation, and eventually fully recovered from COVID-19. CONCLUSIONS: We presented a case of co-infection of influenza and SARS-CoV-2 in a hemodialysis patient. The possibility of SARS-CoV-2 co-infection should not be overlooked even when other viruses including influenza can explain the clinical symptoms, especially in high-risk patients.

Peer Coaching as a Faculty Development Tool: A Mixed Methods Evaluation.

BACKGROUND: In the era of competency-based assessment, medical education faculty are frequently challenged to develop unique teaching approaches. One method to address faculty development needs in a real-time clinical learning environment is peer coaching. OBJECTIVE: We implemented and evaluated a faculty development program involving peer observation and feedback for attending physicians. METHODS: Hospital internal medicine faculty assigned to a teaching service were recruited for the study. Participants voluntarily agreed to observe and be observed by a peer attending physician during a 2-week block of teaching rounds. When serving in the coaching role, faculty were asked to observe 4 separate occasions using an observation tool based on the Stanford Faculty Development Program framework to guide feedback. An outside consultant facilitated a focus group and completed a qualitative content analysis to categorize all participants' experiences during the faculty development activity. RESULTS: Of the 22 eligible faculty, 14 (64%) agreed to participate by committing to 6 to 8 hours observing another faculty member during rounds, 2 feedback sessions, and 90 minutes to provide program feedback during a focus group. The analysis of the focus group revealed favorable reactions to the faculty development program, including (1) observed attending awareness of unrecognized habits; (2) personalized teaching tips for the observed attending to improve teaching quality based on individual style/preferences; and (3) exposure to new teaching techniques. CONCLUSIONS: An inpatient-based peer-coaching faculty development program was acceptable and feasible for a majority of faculty and may improve individual teaching effectiveness among conventionally trained physicians.

Impact of Chronic Kidney Disease in Older Adults Undergoing Hip or Knee Arthroplasty: A Large Database Study.

BACKGROUND: Hip and knee arthroplasties are among the most commonly performed surgical procedures in the elderly. In this age group, uncertainty exists regarding the importance of mild to moderate chronic kidney disease (CKD), which is prevalent but often unrecognized in the perioperative setting. This study evaluates the association between mild to moderate CKD and adverse postoperative outcomes in patients 65 years or older METHODS: This retrospective study selected patients 65 years or older undergoing hip or knee arthroplasty between 2006 and 2016 from the National Surgical Quality Improvement Program database. We created logistic regression models to analyze the relationship between CKD stage and each of our coprimary outcomes. The primary outcomes were major complication and mortality occurring within 30 days of surgery. RESULTS: Of the 193,747 included patients, 68,424 (35.3%) underwent hip and 125,323 (64.7%) knee arthroplasty. Within 30 days of surgery, 12,767 patients (6.6%) experienced a major complication and 352 (0.2%) died. Compared to patients with no kidney disease, patients with CKD stages 3b and 4 were at higher risk for both major complication (adjusted odds ratio [aOR] 1.28 [1.08-1.52], aOR 1.5 [1.13-1.98], respectively) and mortality (aOR 3.17 [1.23-8.14], aOR 3.93 [1.26-12.21], respectively) after hip arthroplasty, and for major complication (aOR 1.42 [1.23-1.63], aOR 1.52 [1.19-1.93], respectively) after knee arthroplasty. CONCLUSION: Among elderly patients, stage 3b and stage 4 CKD were associated with 30-day postoperative major complication after hip or knee arthroplasty, and with 30-day postoperative mortality after hip, but not knee, arthroplasty. Further research will be required to inform perioperative management decisions.

Prospective Randomized Evaluation of Preoperative Angiotensin-Converting Enzyme Inhibition (PREOP-ACEI).

BACKGROUND: Intraoperative hypotension is associated with an increased risk of end organ damage and death. The transient preoperative interruption of angiotensinconverting enzyme inhibitor (ACEI) therapy prior to cardiac and vascular surgeries decreases the occurrence of intraoperative hypotension. OBJECTIVE: We sought to compare the effect of two protocols for preoperative ACEI management on the risk of intraoperative hypotension among patients undergoing noncardiac, nonvascular surgeries. DESIGN: Prospective, randomized study. SETTING: Midwestern urban 489-bed academic medical center. PATIENTS: Patients taking an ACEI for at least six weeks preoperatively were considered for inclusion. INTERVENTIONS: Randomization of the final preoperative ACEI dose to omission (n = 137) or continuation (n = 138). MEASUREMENTS: The primary outcome was intraoperative hypotension, which was defined as any systolic blood pressure (SBP) < 80 mm Hg. Postoperative hypotensive (SBP < 90 mm Hg) and hypertensive (SBP >> 180 mm Hg) episodes were also recorded. Outcomes were compared using Fisher's exact test. RESULTS: Intraoperative hypotension occurred less frequently in the omission group (76 of 137 [55%]) than in the continuation group (95 of 138 [69%]) (RR: 0.81, 95% CI: 0.67 to 0.97, P = .03, NNH 7.5). Postoperative hypotensive events were also less frequent in the ACEI omission group (RR: 0.49, 95% CI: 0.28 to 0.86, P = .02) than in the continuation group. However, postoperative hypertensive events were more frequent in the omission group than in the continuation group (RR: 1.95, 95%: CI: 1.14 to 3.34, P = .01). CONCLUSIONS: The transient preoperative interruption of ACEI therapy is associated with a decreased risk of intraoperative hypotension. REGISTRATION: ClinicalTrials.gov: NCT01669434.

The Relationship Between Age and Chronic Kidney Disease in Patients Undergoing Pancreatic Resection.

BACKGROUND: Severe chronic kidney disease (CKD) predicts adverse outcomes in patients undergoing pancreatectomy, but the impact of milder CKD is unknown. Additionally, some authors have suggested that, due to physiologic changes of aging, CKD is over-diagnosed in patients above age 65. METHODS: Patients undergoing pancreatectomy for malignancy from 2005 to 2014 were identified from the National Surgical Quality Improvement Program. Primary outcomes were all-cause mortality and major complication, defined as myocardial infarction, cardiac arrest, stroke, venous thromboembolism, respiratory failure, deep surgical site infection, pneumonia, acute kidney injury, coma > 24 h, or re-operation occurring within 30 days of surgery. RESULTS: The mean age of 16,173 participants was 66 (range 18-90). Median preoperative creatinine was 0.80 mg/dL (0.10-11.0), and median preoperative eGFR was 86.36 mL/min/1.73m2 (2.98-182.2). Mortality and major complication occurred in 3 and 23% of patients, respectively. In adjusted analyses, CKD stages 2 (adjusted odds ratio (aOR) 1.24, 95% confidence interval (CI) 1.10-1.40), 3a (aOR 1.50, 95% CI 1.24-1.82), 3b (aOR 1.56, 95% CI 1.19-2.06), and 4 (aOR 2.17, 95% CI 1.25-3.76) were associated with increased major complication, and CKD stage 4 was associated with increased mortality (aOR 2.68, 95% CI 1.10-6.56). Age did not influence the relationship between CKD and either outcome. CONCLUSION: CKD of any stage was associated with an increased risk of postoperative major complication, and severe CKD was associated with increased mortality among patients undergoing pancreatectomy for malignancy. These associations were not diminished in elderly patients. Our findings could inform preoperative counseling and decision-making.

Model for prioritization of Graduate Medical Education funding at a university setting - Engagement of GME committee with the Clinical Enterprise.

BACKGROUND: Funding for graduate medical education (GME) is becoming scarce and is likely to worsen. There is a higher degree of accountability and return on investment demanded from public funds dedicated to GME. Academic centers (AC) partnered with clinical enterprises (CE) are finding it increasingly difficult to retain sustainable funding streams for GME activities. METHODS: To develop and implement a novel algorithmic funding model at one AC in symbiotic partnership with the CE for all 50 GME programs with nearly 500 residents. RESULTS: A new GME Finance and Workforce Committee was convened which was tasked with developing the novel algorithmic financial model to prioritize GME funding. Early outcomes measures that were monitored consisted of: satisfaction of all stakeholders and financial savings. CONCLUSIONS: The model was presented to all the stakeholders and was well received and approved. Early signs, demonstrated AC and CE satisfaction with the model, financial savings and increased efficiency. This GME funding model may serve as a template for other academic centers with tailored modifications to suit their local needs, demands and constraints.