The care of pregnant women during the COVID-19 pandemic - response of a large health system in metropolitan New York.

The rapid progression of the coronavirus disease 2019 (COVID-19) outbreak presented extraordinary challenges to the US health care system, particularly straining resources in hard hit areas such as the New York metropolitan region. As a result, major changes in the delivery of obstetrical care were urgently needed, while maintaining patient safety on our maternity units. As the largest health system in the region, with 10 hospitals providing obstetrical services, and delivering over 30,000 babies annually, we needed to respond to this crisis in an organized, deliberate fashion. Our hospital footprint for Obstetrics was dramatically reduced to make room for the rapidly increasing numbers of COVID-19 patients, and established guidelines were quickly modified to reduce potential staff and patient exposures. New communication strategies were developed to facilitate maternity care across our hospitals, with significantly limited resources in personnel, equipment, and space. The lessons learned from these unexpected challenges offered an opportunity to reassess the delivery of obstetrical care without compromising quality and safety. These lessons may well prove valuable after the peak of the crisis has passed.

Risk Management in Obstetrics and Gynecology.

This article will review the basic principles of risk management, the role of the risk manager, and the importance of risk management in the patient safety movement as it pertains to obstetrics and gynecology. Several tools that are used by risk managers including risk assessments and root cause analyses will be used to illustrate positive patient safety measures that can be initiated to decrease adverse outcomes and reduced risk to an organization. The dramatic reduction in adverse outcomes and claims after the introduction of patient safety initiatives in a major obstetrical service will be reviewed.

A call for safety: Anticipating and mitigating risk across an obstetrics and gynecology service line.

Delivery of healthcare is a complex interaction of patients, healthcare providers, nurses, ambulatory practices, and hospitals. As the model of health care transitioned, free standing physician practices and hospitals have coalesced to form networks of ambulatory practices and hospitals. This change in the model of healthcare delivery presented challenges to provide safe, quality, cost-effective care for patients, with potentially increased risk to an organization. The development and imbedding of comprehensive safety strategies are imperative to the foundation of this model. Northwell Health, a large health system in the northeastern United States developed a strategy for their Obstetrics and Gynecology Service Line which includes weekly interaction by departmental leadership from each hospital to discuss operations, share concerns and identify potential opportunities to prevent recurrent suboptimal outcomes and improve patient safety. The weekly Safety Call, described in this article is a component of the safety and quality program that has contributed to a 19% decrease in the Weighted Adverse Outcomes Index for the 10 maternity hospitals delivering over 30,000 babies annually within the system since inception. There was also a significant reduction in insurance premiums based on actuarial projections of risk reduction because of the implementation of an Obstetrical Safety Program.

Predicting outcome after cardiac resynchronisation therapy defibrillator implantation: the cardiac resynchronisation therapy defibrillator Futility score.

BACKGROUND: Risk-benefit for cardiac resynchronisation therapy (CRT) defibrillator (CRT-D) over CRT pacemaker remains a matter of debate. We aimed to identify patients with a poor outcome within 1 year of CRT-D implantation, and to develop a CRT-D Futility score. METHODS: Based on an administrative hospital-discharge database, all consecutive patients treated with prophylactic CRT-D implantation in France (2010-2019) were included. A prediction model was derived and validated for 1-year all-cause death after CRT-D implantation (considered as futility) by using split-sample validation. RESULTS: Among 23 029 patients (mean age 68±10 years; 4873 (21.2%) women), 7016 deaths were recorded (yearly incidence rate 7.2%), of which 1604 (22.8%) occurred within 1 year of CRT-D implantation. In the derivation cohort (n=11 514), the final logistic regression model included-as main predictors of futility-older age, diabetes, mitral regurgitation, aortic stenosis, history of hospitalisation with heart failure, history of pulmonary oedema, atrial fibrillation, renal disease, liver disease, undernutrition and anaemia. Area under the curve for the CRT-D Futility score was 0.716 (95% CI: 0.698 to 0.734) in the derivation cohort and 0.692 (0.673 to 0.710) in the validation cohort. The Hosmer-Lemeshow test had a p-value of 0.57 suggesting accurate calibration. The CRT-D Futility score outperformed the Goldenberg and EAARN scores for identifying futility. Based on the CRT-D Futility score, 15.9% of these patients were categorised at high risk (predicted futility of 16.6%). CONCLUSIONS: The CRT-D Futility score, established from a large nationwide cohort of patients treated with CRT-D, may be a relevant tool for optimising healthcare decision-making.

Atrial Fibrillation Detected by Implantable Monitor in Embolic Stroke of Undetermined Source: A New Clinical Entity.

BACKGROUND: High incidence of covert paroxysmal atrial fibrillation (CPAF) detected by an implantable cardiac monitor (ICM) is expected in embolic stroke of undetermined source (ESUS) patients. This study aimed to determine the CPAF rate in an ESUS cohort using ICMs and compare stroke characteristics of patients with CPAF to those with known or inpatient-diagnosed AF (KIDAF). METHODS: ESUS patients with ICMs were enrolled. ESUS diagnosis was defined as a non-lacunar stroke in the absence of symptomatic atherosclerotic stenosis (≥50%), no major-risk cardioembolic source, and no other specific cause. ESUS characteristics of patients with CPAF were compared to ESUS patients without CPAF and to KIDAF stroke patients. RESULTS: During the median follow-up of 476 (371-615) days, CPAF was newly detected in 38/163 (23.31%) patients within 236 (115.50-510.75) days after the stroke. CPAF was independently associated to older age, coronaropathy, left atrial dilation, and atrial hyperexcitability, but not to stroke severity. Compared to KIDAF strokes, ESUS with CPAF had lower rates of proximal occlusion leading to milder clinical severity (NIHSS: 3.00 (1.00-8.25) vs. 14.50 (6.00-21.00)). CONCLUSIONS: Our study revealed a high proportion of CPAF in ESUS. We highlight that CPAF is a distinct clinical entity compared to KIDAF based on differences in stroke characteristics and AF diagnosis temporality.

Adenosine and Adenosine Receptors: Advances in Atrial Fibrillation.

Atrial fibrillation (AF) is the most common arrhythmia in the world. Because the key to developing innovative therapies that limit the onset and the progression of AF is to fully understand the underlying molecular mechanisms of AF, the aim of the present narrative review is to report the most recent advances in the potential role of the adenosinergic system in the pathophysiology of AF. After a comprehensive approach describing adenosinergic system signaling and the mechanisms of the initiation and maintenance of AF, we address the interactions of the adenosinergic system's signaling with AF. Indeed, adenosine release can activate four G-coupled membrane receptors, named A1, A2A, A2B and A3. Activation of the A2A receptors can promote the occurrence of delayed depolarization, while activation of the A1 receptors can shorten the action potential's duration and induce the resting membrane's potential hyperpolarization, which promote pulmonary vein firing, stabilize the AF rotors and allow for functional reentry. Moreover, the A2B receptors have been associated with atrial fibrosis homeostasis. Finally, the adenosinergic system can modulate the autonomous nervous system and is associated with AF risk factors. A question remains regarding adenosine release and the adenosine receptors' activation and whether this would be a cause or consequence of AF.

Testosterone-Secreting Ovarian Tumor: A Rare Cause of Erythrocytosis and Pulmonary Embolus.

OBJECTIVE: To raise awareness of the clinical presentation of a testosterone-secreting steroid cell tumor, not otherwise specified, causing pulmonary embolus (PE) and erythrocytosis. METHODS: Report of the first known case of ovarian steroid cell tumor not otherwise specified leading to PE. RESULTS: A 67-year-old Caucasian postmenopausal woman was referred for endocrine evaluation of a 1-year history of hirsutism, weight gain, and elevated total testosterone level of 672 ng/dL (normal, <75 ng/dL). She reported increased hair growth on her chin for the past year, unintentional weight gain, and low energy levels. Laboratory data from the initial visit included a total testosterone level of 672 ng/dL (normal, <75 ng/dL), hemoglobin level of 18.0 g/dL (normal, 11.7-15 g/dL), and hematocrit level of 50.4% (normal, 35%-45%). Four months after initial presentation, the patient developed acute-onset chest pain and shortness of breath and was diagnosed with a right PE on computed tomography chest angiogram. Evaluation with imaging for an ovarian mass revealed a negative workup including computed tomography abdomen pelvis, transvaginal ultrasound, and pelvic magnetic resonance imaging. Despite negative findings during imaging, because of the markedly elevated testosterone levels, this presentation was thought to correspond to a testosterone-secreting ovarian tumor. The patient was referred for bilateral oophorectomy. Pathology of the right ovary revealed a 2-cm steroid cell tumor, not otherwise specified. CONCLUSIONS: PE and erythrocytosis can be presentations of a testosterone-secreting ovarian tumor, not otherwise specified. This case is the first known presentation of an ovarian steroid cell tumor, not otherwise specified, leading to PE and erythrocytosis.

Epigenetic Control of the Notch and Eph Signaling Pathways by the Prion Protein: Implications for Prion Diseases.

Among the ever-growing number of self-replicating proteins involved in neurodegenerative diseases, the prion protein PrP remains the most infamous for its central role in transmissible spongiform encephalopathies (TSEs). In these diseases, pathogenic prions propagate through a seeding mechanism, where normal PrPC molecules are converted into abnormally folded scrapie isoforms termed PrPSc. Since its discovery over 30 years ago, much advance has contributed to define the host-encoded cellular prion protein PrPC as a critical relay of prion-induced neuronal cell demise. A current consensual view is that the conversion of PrPC into PrPSc in neuronal cells diverts the former from its normal function with subsequent molecular alterations affecting synaptic plasticity. Here, we report that prion infection is associated with reduced expression of key effectors of the Notch pathway in vitro and in vivo, recapitulating changes fostered by the absence of PrPC. We further show that both prion infection and PrPC depletion promote drastic alterations in the expression of a defined set of Eph receptors and their ephrin ligands, which represent important players in synaptic function. Our data indicate that defects in the Notch and Eph axes can be mitigated in response to histone deacetylase inhibition in PrPC-depleted as well as prion-infected cells. We thus conclude that infectious prions cause a loss-of-function phenotype with respect to Notch and Eph signaling and that these alterations are sustained by epigenetic mechanisms.

A new frontier in healthcare risk management: Working to reduce avoidable patient suffering.

This article presents a new avenue for healthcare risk managers to drive improvement for patients and healthcare organizations alike: working to reduce avoidable patient suffering. It briefly describes the problem of patient suffering, differentiates between avoidable and unavoidable suffering, and suggests that common risk management tools can be used to tackle the problem. It also highlights a success story from one large health system.

Pearls of wisdom: practical application of the Pearls Series.

Scores of ASHRM members have collaborated to produce the Pearls Series, a set of pocket guides on topics of interest for not only risk managers but also administrators, clinicians, and board members. The succinct format facilitates the dissemination of pertinent information to a wide audience. Risk managers should be knowledgeable of the Pearls topics, understand how to develop appropriate metrics, and manage the monitoring and performance improvement aspects that are critical to ensuring successful knowledge transfer.

TeamSTEPPS and patient safety in healthcare.

Communication problems in healthcare are considered to be a leading cause of medical errors and often the root cause of sentinel events. This article will review the implementation of TeamSTEPPS in the two large health systems. The challenges in the implementation process, the successes, failures, and the obstacles will be discussed. Comparisons between the systems as well as lessons learned after implementation will be reviewed to enable hospitals and health systems to implement and sustain a successful TeamSTEPPS program.