Sitting at the Bedside: Patient and Internal Medicine Trainee Perceptions.

BACKGROUND: Sitting at the bedside may strengthen physician-patient communication and improve patient experience. Yet despite the potential benefits of sitting, hospital physicians, including resident physicians, may not regularly sit down while speaking with patients. OBJECTIVE: To examine the frequency of sitting by internal medicine residents (including first post-graduate year [PGY-1] and supervising [PGY-2/3] residents) during inpatient encounters and to assess the association between patient-reported sitting at the bedside and patients' perceptions of other physician communication behaviors. We also assessed residents' attitudes towards sitting. DESIGN: In-person survey of patients and email survey of internal medicine residents between August 2019 and January 2020. PARTICIPANTS: Patients admitted to general medicine teaching services and internal medicine residents at The Johns Hopkins Hospital. MAIN MEASURES: Patient-reported frequency of sitting at the bedside, patients' perceptions of other communication behaviors (e.g., checking for understanding); residents' attitudes regarding sitting. KEY RESULTS: Of 334 eligible patients, 256 (76%) completed a survey. Among these 256 respondents, 198 (77%) and 166 (65%) reported recognizing the PGY-1 and PGY-2/3 on their care team, respectively, for a total of 364 completed surveys. On most surveys (203/364, 56%), patients responded that residents "never" sat. Frequent sitting at the bedside ("every single time" or "most of the time," together 48/364, 13%) was correlated with other positive behaviors, including spending enough time at the bedside, checking for understanding, and not seeming to be in a rush (p < 0.01 for all). Of 151 residents, 77 (51%) completed the resident survey; 28 of the 77 (36%) reported sitting frequently. The most commonly cited barrier to sitting was that chairs were not available (38 respondents, 49%). CONCLUSIONS: Patients perceived that residents sit infrequently. However, sitting was associated with other positive communication behaviors; this is compatible with the hypothesis that promoting sitting could improve overall patient perceptions of provider communication.

Bed downtime: the novel use of a quality metric allows inpatient providers to improve patient flow from the emergency department.

BACKGROUND: Emergency department (ED) boarding time is associated with increased length of stay (LOS) and inpatient mortality. Despite the documented impact of ED boarding on inpatient outcomes, a disparity continues to exist between the attention paid to the issue by inpatient and ED providers. A perceived lack of high yield strategies to address ED boarding from the perspective of the inpatient provider may discourage involvement in improvement initiatives on the subject. As such, further work is needed to identify inpatient metrics and strategies to address patient flow problems, and which may improve ED boarding time. METHODS: After initial system analysis, our multidisciplinary quality improvement (QI) group defined the process time metric 'bed downtime'-the time from which a bed is vacated by a discharged patient to the time an ED patient is assigned to that bed. Using the Lean Sigma QI approach, this metric was targeted for improvement on the internal medicine hospitalist service at a tertiary care academic medical centre. INTERVENTIONS: Interventions included improving inpatient provider awareness of the problem, real-time provider notification of empty beds, a weekly retrospective emailed performance dashboard and the creation of a guideline document for admission procedures. RESULTS: This package of interventions was associated with a 125 min reduction in mean bed downtime for incoming ED patients (254 min to 129 min) admitted to the intervention unit. CONCLUSION: Use of the bed downtime metric as a QI target was associated with marked improvements in process time during our project. The use of this metric may enhance the ability of inpatient providers to participate in QI efforts to improve patient flow from the ED. Further study is needed to determine if use of the metric may be effective at reducing boarding time without requiring alterations to LOS or discharge patterns.

Opioid Prescribing After Implementation of Single Click Access to a State Prescription Drug Monitoring Program Database in a Health System's Electronic Health Record.

OBJECTIVES: To determine the effect of one-click integration of a state's prescription drug monitoring program (PDMP) on the number of PDMP searches and opioid prescriptions, stratified by specialty. METHODS: Our large health system worked with the state department of public health to integrate the PDMP with the electronic health record (EHR), which enabled providers to query the data with a single click inside the EHR environment. We evaluated Schedule II or III opioid prescriptions reported to the Massachusetts PDMP 6 months before (November 15, 2017-May 15, 2018) and 6 months after (May 16, 2018, to November 16, 2018) integration. Search counts, prescriptions, patients, morphine milligram equivalents, as well as prescriber specialty were compared. RESULTS: There were 3,185 unique prescribers with a record of a Schedule II and/or III opioid prescription in both study periods that met inclusion criteria. After integration, the number of PDMP searches increased from 208,684 in the pre-integration phase to 298,478 searches in the post-integration phase (+43.0%). The number of opioid prescriptions dispensed decreased by 4.8%, the number of patients receiving a prescription decreased by 5.1%, and the mean morphine milligram equivalents (MMEs) per prescriber decreased by 5.4%. There were some notable specialty-specific differences in these measures. CONCLUSIONS: Integration of the PDMP into the EHR markedly increased the number of searches but was associated with modest decreases in opioids prescribed and patients receiving a prescription. Single click EHR integration of the PDMP, if implemented broadly, may be a way for states to significantly increase PDMP utilization.

An Elusive Case of Mycosis Fungoides: Case Report and Review of the Literature.

Erythroderma refers to a spectrum of skin diseases resulting in diffuse erythema and scaling encompassing ≥ 90% of the body surface area. The differential diagnosis ranges from primary dermatologic diseases such as atopic dermatitis and psoriasis to potentially deadly causes such as staphylococcal toxic shock syndrome, toxic epidermal necrolysis, and malignancy. Cutaneous T cell lymphoma (CTCL) is an uncommon but highly morbid cause of erythroderma. This non-Hodgkin lymphoma remains a diagnostic challenge due to its variable clinical presentation and varied histologic features. Mycosis fungoides (MF) is the most common form of CTCL. Making a timely diagnosis is challenging as it may mimic inflammatory diseases of the skin including eczema, psoriasis, lichen planus, and cutaneous lupus. We present a case of a 58-year-old man who presented with 5 years of cutaneous symptoms and several months of fevers and night sweats, ultimately diagnosed as MF. Owing to diffuse CD30 positivity, he was a candidate for brentuximab vedotin, an antibody-drug conjugate medication that selectively targets the CD30 antigen. This resulted in an excellent therapeutic response.

Wall-mounted folding chairs to promote resident physician sitting at the hospital bedside.

BACKGROUND: Sitting at the bedside may improve patient-clinician communication; however, many clinicians do not regularly sit during inpatient encounters. OBJECTIVE: To determine the impact of adding wall-mounted folding chairs inside patient rooms, beyond any impact from a resident education campaign, on the patient-reported frequency of sitting at the bedside by internal medicine resident physicians. DESIGN, SETTING, AND PARTICIPANTS: Prospective, controlled pre-post trial between 2019 and 2022 (data collection paused 2020-2021 due to COVID-19) at an academic hospital in Baltimore, Maryland. Folding chairs were installed in two of four internal medicine units and educational activities were delivered equally across all units. MAIN OUTCOME AND MEASURES: Patient-reported frequency of sitting at bedside, assessed as means on Likert-type items with 1 being "never" and 5 being "every single time." We also examined the frequency of other patient-reported communication behaviors. RESULTS: Two hundred fifty six and 206 patients enrolled in the pre and post-intervention periods, respectively. The mean frequency of patient-reported sitting by resident physicians increased from 1.8 (SD 1.2) to 2.3 (1.2) on education-only units (absolute difference 0.48 [95% CI: 0.21-0.75]) and from 2.0 (1.3) to 3.2 (1.4) on units receiving chairs (1.16, [0.87-1.45]). Comparing differences between groups using ordered logistic regression adjusting for clustering within residents, units with added chairs had greater increases in sitting (odds ratio 2.05 [1.10-3.82]), spending enough time at the bedside (2.43 [1.32-4.49]), and checking for understanding (3.04 [1.44-6.39]). Improvements in sitting and other behaviors were sustained on both types of units. CONCLUSIONS: Adding wall-mounted folding chairs may help promote effective patient-clinician communication.

Outcomes of Telestroke Inter-Hospital Transfers Among Intervention and Non-Intervention Patients.

Background: Telestroke is an established telemedicine method of delivering emergency stroke care. However, not all neurological patients utilizing telestroke service require emergency interventions or transfer to a comprehensive stroke center. To develop an understanding of the appropriateness of inter-hospital neurological transfers utilizing the telemedicine, our study aimed to assess the differences in outcomes of inter-hospital transfers utilizing the service in relation to the need for neurological interventions. Methods: The pragmatic, retrospective analysis included 181 consecutive patients, who were emergently transferred from telestroke-affiliated regional medical centers between October 3, 2021, and May 3, 2022. In this exploratory study investigating the outcomes of telestroke-referred patients, patients receiving interventions were compared to those that did not following transfer to our tertiary center. Neurological interventions included mechanical thrombectomy (MT) and/or tissue plasminogen activator (tPA), craniectomy, electroencephalography (EEG), or external ventricular drain (EVD). Transfer mortality rate, discharge functional status defined by modified Rankin scale (mRS), neurological status defined by National Institutes of Health Stroke Scale (NIHSS), 30-day unpreventable readmission rate, 90-day clinical major adverse cardiovascular events (MACE), and 90-day mRS, and NIHSS were studied. We used χ2 or Fisher exact tests to evaluate the association between the intervention and categorical or dichotomous variables. Continuous or ordinal measures were compared using Wilcoxon rank-sum tests. All tests of statistical significance were considered to be significant at P < 0.05. Results: Among the 181 transferred patients, 114 (63%) received neuro-intervention and 67 (37%) did not. The death rate during the index admission was not statistically significant between the intervention and non-intervention groups (P = 0.196). The discharge NIHSS and mRS were worse in the intervention compared to the non-intervention (P < 0.05 each, respectively). The 90-day mortality and cardiovascular event rates were similar between intervention and non-intervention groups (P > 0.05 each, respectively). The 30-day readmission rates were also similar between the two groups (14% intervention vs. 13.4% non-intervention, P = 0.910). The 90-day mRS were not significantly different between intervention and non-intervention groups (median 3 (IQR: 1 - 6) vs. 2 (IQR: 0 - 6), P = 0.109). However, 90-day NIHSS was worse in the intervention compared to non-intervention group (median 2 (IQR: 0 - 11) vs. 0 (IQR: 0 - 3), P = 0.004). Conclusions: Telestroke is a valuable resource that expedites emergent neurological care via referral to a stroke center. However, not all transferred patients benefit from the transfer process. Future multicenter studies are warranted to study the effects or appropriateness of telestroke networks, and to better understand the patient characteristics, resources allocation, and transferring institutions to improve telestroke care.

Stroke nurse navigator utilization reduces unplanned 30-day readmission in stroke patients treated with thrombolysis.

Background: Unplanned 30-day hospital readmissions following a stroke is a serious quality and safety issue in the United States. The transition period between the hospital discharge and ambulatory follow-up is viewed as a vulnerable period in which medication errors and loss of follow-up plans can potentially occur. We sought to determine whether unplanned 30-day readmission in stroke patients treated with thrombolysis can be reduced with the utilization of a stroke nurse navigator team during the transition period. Methods: We included 447 consecutive stroke patients treated with thrombolysis from an institutional stroke registry between January 2018 and December 2021. The control group consisted of 287 patients before the stroke nurse navigator team implementation between January 2018 and August 2020. The intervention group consisted of 160 patients after the implementation between September 2020 and December 2021. The stroke nurse navigator interventions included medication reviews, hospitalization course review, stroke education, and review of outpatient follow-ups within 3 days following the hospital discharge. Results: Overall, baseline patient characteristics (age, gender, index admission NIHSS, and pre-admission mRS), stroke risk factors, medication usage, and length of hospital stay were similar in control vs. intervention groups (P > 0.05). Differences included higher mechanical thrombectomy utilization (35.6 vs. 24.7%, P = 0.016), lower pre-admission oral anticoagulant use (1.3 vs. 5.6%, P = 0.025), and less frequent history of stroke/TIA (14.4 vs. 27.5%, P = 0.001) in the implementation group. Based on an unadjusted Kaplan-Meier analysis, 30-day unplanned readmission rates were lower during the implementation period (log-rank P = 0.029). After adjustment for pertinent confounders including age, gender, pre-admission mRS, oral anticoagulant use, and COVID-19 diagnosis, the nurse navigator implementation remained independently associated with lower hazards of unplanned 30-day readmission (adjusted HR 0.48, 95% CI 0.23-0.99, P = 0.046). Conclusion: The utilization of a stroke nurse navigator team reduced unplanned 30-day readmissions in stroke patients treated with thrombolysis. Further studies are warranted to determine the extent of the results of stroke patients not treated with thrombolysis and to better understand the relationship between resource utilization during the transition period from discharge and quality outcomes in stroke.

Association between the LACE+ index and unplanned 30-day hospital readmissions in hospitalized patients with stroke.

Background: The LACE+ index is used to predict unplanned 30-day hospital readmissions, but its utility to predict 30-day readmission in hospitalized patients with stroke is unknown. Methods: We retrospectively analyzed 1,657 consecutive patients presenting with ischemic or hemorrhagic strokes, included in an institutional stroke registry between January 2018 and August 2020. The primary outcome of interest was unplanned 30-day readmission for any reason after index hospitalization for stroke. The 30-day readmission risk was categorized by LACE+ index to high risk (≥78), medium-to-high risk (59-77), medium risk (29-58), and low risk (≤ 28). Kaplan-Meier analysis, Log rank test, and multivariable Cox regression analysis (with backward elimination) were used to determine whether the LACE+ score was an independent predictor for 30-day unplanned readmission. Results: The overall 30-day unplanned readmission rate was 11.7% (194/1,657). The median LACE+ score was higher in the 30-day readmission group compared to subjects that had no unplanned 30-day readmission [74 (IQR 67-79) vs. 70 (IQR 62-75); p < 0.001]. On Kaplan-Meier analysis, the high-risk group had the shortest 30-day readmission free survival time as compared to medium and medium-to-high risk groups (p < 0.01, each; statistically significant). On fully adjusted multivariable Cox-regression, the highest LACE+ risk category was independently associated with the unplanned 30-day readmission risk (per point: HR 1.67 95%CI 1.23-2.26, p = 0.001). Conclusion: Subjects in the high LACE+ index category had a significantly greater unplanned 30-day readmission risk after stroke as compared to lower LACE+ risk groups. This supports the validity of the LACE+ scoring system for predicting unplanned readmission in subjects with stroke. Future studies are warranted to determine whether LACE+ score-based risk stratification can be used to devise early interventions to mitigate the risk for unplanned readmission.

A Citywide Approach to SARS-CoV2 Testing.

The COVID-19 pandemic caused more than 30 million infections in the United States between March 2020 and April 2021. In response to systemic disparities in SARS-CoV2 testing and COVID-19 infections, health systems, city leaders and community stakeholders in Worcester, Massachusetts created a citywide Equity Task Force with a specific goal of making low-barrier testing available to individuals throughout our community. Within months, the state of Massachusetts announced the Stop the Spread campaign, a state-funded testing venture. With this funding, and through our community-based approach, our team tested more than 48,363 individuals between August 3, 2020 and February 28, 2021. Through multiple PDSA (Plan-Do-Study-Act) cycles, we optimized our process to test close to 300 individuals per hour. Our positivity rate ranged from 1.5% with our initial testing events to a high of 13.4% on January 6, 2021. During the challenges of providing traditional inpatient and ambulatory care during the pandemic, our health system, city leadership, and community advocacy groups united to broaden the scope of care to include widespread, population-based SARS-CoV2 testing. We anticipate that the lessons learned in conducting this testing campaign can be applied to further surges of SARS-CoV2, international environments, and future respiratory disease pandemics.

Addressing decontaminated respirators: Some methods appear to damage mask integrity and protective function.

Decontamination of N95 respirators is being used by clinicians in the face of a global shortage of these devices. Some treatments for decontamination, such as some vaporized hydrogen peroxide methods or ultraviolet methods, had no impact on respiratory performance, while other treatments resulted in substantial damage to masks.

Impact on Length of Stay of a Hospital Medicine Emergency Department Boarder Service.

BACKGROUND: It is not known whether delivering inpatient care earlier to patients boarding in the emergency department (ED) by a hospitalist-led team can decrease length of stay (LOS). OBJECTIVE: To study the association between care provided by a hospital medicine ED Boarder (EDB) service and LOS. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cross-sectional study (July 1, 2016 to June 30, 2018) conducted at a single, large, urban academic medical center. Patients admitted to general medicine services from the ED were included. EDB patients were defined as those waiting for more than two hours for an inpatient bed. Patients were categorized as covered EDB, noncovered EDB, or nonboarder. INTERVENTION: The hospital medicine team provided continuous care to covered EDB patients waiting for an inpatient bed. PRIMARY OUTCOME AND MEASURES: The primary outcome was median hospital LOS defined as the time period from ED arrival to hospital departure. Secondary outcomes included ED LOS and 30-day ED readmission rate. RESULTS: There were 8,776 covered EDB, 5,866 noncovered EDB, and 2,026 nonboarder patients. The EDB service covered 59.9% of eligible patients and 62.9% of total boarding hours. Median hospital LOS was 4.76 (interquartile range [IQR] 2.90-7.22) days for nonboarders, 4.92 (IQR 3.00-8.03) days for covered EDB patients, and 5.11 (IQR 3.16-8.34) days for noncovered EDB (P < .001). Median ED LOS for nonboarders was 5.6 (IQR 4.2-7.5) hours, 20.7 (IQR 15.8-24.9) hours for covered EDB, and 10.1 (IQR 7.9-13.8) hours for noncovered EDB (P < .001). There was no difference in 30-day ED readmission rates. CONCLUSION: Admitted patients who were not boarders had the shortest LOS. Among boarded patients, coverage by a hospital medicine-led EDB service was associated with a reduced hospital LOS.

EuroSCORE predicts short- and mid-term mortality in combined aortic valve replacement and coronary artery bypass patients.

BACKGROUND AND AIM OF THE STUDY: European system for cardiac operative risk evaluation (EuroSCORE) has been studied for its effectiveness in predicting operative mortality, and more recently, long-term mortality in a wide variety of cardiac surgical procedures. Combined coronary artery bypass and aortic valve replacement (AVR-CABG) carries increased perioperative risk, and tends to have higher-risk patients. Performance of the EuroSCORE system in patients undergoing concomitant AVR-CABG has not been well established. Thus, we aimed to analyze the accuracy of both additive and logistic EuroSCOREs in predicting operative and mid-term mortality. METHODS: We retrospectively reviewed and calculated EuroSCOREs for all patients who underwent AVR-CABG between January 2000 and December 2004. Patients who had previous cardiac surgery and those undergoing any concomitant procedures were excluded. Areas under the receiver operator curves (ROC) were determined to assess EuroSCORE's accuracy in predicting operative mortality. Kaplan-Meier analysis and Cox regression were used to determine mid-term survival, freedom from repeat revascularization, and predictors of these outcomes. RESULTS: There were 233 patients who met study criteria. Mean follow-up period was 2.2 +/- 1.7 years with one patient lost to follow-up. Mean additive and logistic EuroSCOREs were 8.77 and 16.1, respectively, with an observed mortality of 9.44%. The area under the ROC curves for additive EuroSCORE was 0.76 and for logistic EuroSCORE was 0.75. Regression analysis revealed additive EuroSCORE, but not logistic EuroSCORE, to be predictive of mid-term mortality. CONCLUSIONS: Both additive and logistic EuroSCOREs were accurate in predicting operative morality. Only additive EuroSCORE was predictive of mid-term mortality in AVR-CABG patients. EuroSCORE remains a good and well-validated risk stratification model applicable to patients who undergo concomitant AVR-CABG.

Aortic valve replacement and concomitant coronary artery bypass: assessing the impact of multiple grafts.

BACKGROUND: The impact of multivessel coronary artery disease and multivessel coronary artery bypass grafting on outcomes after combined aortic valve replacement and coronary artery bypass grafting (AVR-CABG) has not been sufficiently evaluated. METHODS: We retrospectively reviewed all patients who underwent AVR-CABG at our institution between January 2000 and December 2004. Patients with any previous or concomitant procedures were excluded. The Kaplan-Meier method was used to calculate survival and freedom from postoperative repeat revascularization. Predictors of mortality were determined by Cox regression analysis. RESULTS: The study cohort consisted of 233 AVR-CABG patients. Mean follow-up was 2.2 +/- 1.7 years with one patient lost to follow-up. Preoperative clinical characteristics were well-matched between patients who received one (n = 86), two (n = 81), or three or four (n = 66) bypass grafts. Operative mortality was 9.3%, 11.1%, and 7.6%, respectively (p = 0.76). Patients in all groups demonstrated significant improvement in New York Heart Association (NYHA) status (p < 0.01). Freedom from postoperative repeat revascularization for all patients after five years was 96.8% and did not differ among groups (p = 0.93). Five-year survival for each group was 63.6%, 72.4%, and 63.9%, respectively (p = 0.91). Emergent operation, ejection fraction less than 0.30, operative age greater than 65 years, NYHA class III/IV, and chronic obstructive pulmonary disease were significant predictors of mortality. The number of stenosed vessels, the number of bypass grafts, incomplete revascularization, and the presence of aortic stenosis or aortic insufficiency did not predict mortality. CONCLUSIONS: For patients undergoing AVR-CABG, the number of bypass grafts does not adversely affect survival. Rather, a patient's preoperative risk factors are a better predictor of outcome.

Association Between LACE+ Index Risk Category and 90-Day Mortality After Stroke.

Background and Objectives: A higher LACE+ index risk category (defined as LACE+ score ≥78) typically calculated before hospital discharge has been associated with increased risk of unplanned 30-day hospital readmissions and early death after hospital discharge. However, its utility to predict poststroke mortality is unknown. Here, we examined whether the LACE+ index risk category assessed at both discharge (dLACE+) and admission (aLACE+) was associated with 90-day mortality after stroke. Methods: We retrospectively analyzed 2,729 consecutive patients who presented with ischemic or hemorrhagic strokes, included in an institutional stroke registry between January 2018 and December 2021. The primary outcome of interest was 90-day mortality after the index hospitalization. Patients were categorized as high-risk (≥78), medium-to-high-risk (59-77), and low-to-medium-risk (0-58) according to the LACE+ as automatically calculated at admission and discharge. Analyses were performed on the entire cohort, as well as stratified according to acute ischemic stroke and hemorrhagic stroke diagnosis. Results: Among patients who completed 90-day follow-up, the mortality rate was 24.3% (576/2368). In the Kaplan-Meier analysis, the high-risk aLACE+ group had the highest 90-day mortality rate as compared with low-to-medium-risk and medium-to-high-risk groups (p < 0.001). In a fully adjusted multivariable Cox-regression, the 90-day hazards of death were significantly greater among participants in a high-risk aLACE+ (aHR 1.7, 95% CI 1.080-2.742, p = 0.022) and medium-to-high-risk aLACE+ categories (aHR 1.4, 95% CI 1.141-1.778, p = 0.002) as compared with participants in the low-to-medium-risk aLACE+ category. Results were overall similar for dLACE+. Discussion: The LACE+ calculated at both admission and discharge admission identified patients with stroke at increased risk for 90-day mortality. Future studies are warranted to determine whether LACE+ score-based risk stratification can be used to devise early interventions to mitigate the risk for death.