Determining the Incidence of Asymptomatic SARS-CoV-2 Among Early Recipients of COVID-19 Vaccines (DISCOVER-COVID-19): A Prospective Cohort Study of Healthcare Workers Before, During and After Vaccination.

The impact of coronavirus disease 2019 vaccination on viral characteristics of breakthrough infections is unknown. In this prospective cohort study, incidence of severe acute respiratory syndrome coronavirus 2 infection decreased following vaccination. Although asymptomatic positive tests were observed following vaccination, the higher cycle thresholds, repeat negative tests, and inability to culture virus raise questions about their clinical significance.

Tackling inpatient penicillin allergies: Assessing tools for antimicrobial stewardship.

BACKGROUND: Reported penicillin allergy rarely reflects penicillin intolerance. Failure to address inpatient penicillin allergies results in more broad-spectrum antibiotic use, treatment failures, and adverse drug events. OBJECTIVE: We aimed to determine the optimal approach to penicillin allergies among medical inpatients. METHODS: We evaluated internal medicine inpatients reporting penicillin allergy in 3 periods: (1) standard of care (SOC), (2) penicillin skin testing (ST), and (3) computerized guideline application with decision support (APP). The primary outcome was use of a penicillin or cephalosporin, comparing interventions to SOC using multivariable logistic regression. RESULTS: There were 625 patients: SOC, 148; ST, 278; and APP, 199. Of 278 ST patients, 179 (64%) were skin test eligible; 43 (24%) received testing and none were allergic. In the APP period, there were 292 unique Web site views; 112 users (38%) completed clinical decision support. Although ST period patients did not have increased odds of penicillin or cephalosporin use overall (adjusted odds ratio [aOR] 1.3; 95% CI, 0.8-2.0), we observed significant increased odds of penicillin or cephalosporin use overall in the APP period (aOR, 1.8; 95% CI, 1.1-2.9) and in a per-protocol analysis of the skin tested subset (aOR, 5.7; 95% CI, 2.6-12.5). CONCLUSIONS: Both APP and ST-when completed-increased the use of penicillin and cephalosporin antibiotics among inpatients reporting penicillin allergy. While the skin tested subset showed an almost 6-fold impact, the computerized guideline significantly increased penicillin or cephalosporin use overall nearly 2-fold and was readily implemented.

Evaluation of Point-of-Care Decision Support for Adult Acne Treatment by Primary Care Clinicians.

Importance: Acne is a common reason for referral to dermatologists from primary care clinicians. We previously modeled the impact of algorithm-based acne care in reducing dermatology referrals, missed appointments, and treatment delays. Objective: To prospectively evaluate the downstream outcomes following a real-time, algorithm-based electronic decision-support tool on the treatment of patients referred for acne. Design, Setting, and Participants: This prospective cohort study included 260 treatment-naive patients referred to a dermatologist for the chief concern of acne, as well as the referring primary care clinicians, at 33 primary care sites affiliated with Brigham and Women's Hospital from March 2017 to March 2018. Interventions: We developed and implemented a decision-support tool into the electronic medical record system at an academic medical center. The algorithm identified patients referred to a dermatologist who had not previously been treated for acne and offered guideline-based recommendations for treatment via a real-time notification. Main Outcomes and Measures: Treatment modification by referring clinicians. Results: Of 260 patients referred for acne, 209 (80.4%) were women, 146 (56.1%) were non-Hispanic white, and 236 (90.8%) listed English as the preferred language. Patients had a median (quartile 1-quartile 3) age of 28.8 years (24.4-35.1 years) and 185 of 260 had private insurance (71.1%). In total, the algorithm was associated with cancellation of the initial referral in 35 of 260 (13.5%) instances and treatment initiation by the referring clinician in 51 of 260 (19.6%) instances. Conclusions and Relevance: This decision-support algorithm was associated with a modest reduction in rates of acne-related referrals to dermatologists, and an increased likelihood of treatment initiation by the referring clinician.

An Academic Medical Center-Based Incubator to Promote Clinical Innovation and Financial Value.

INTRODUCTION: Within a health care landscape characterized by increasing financial pressures, fluctuating payment models, and an increasing prevalence of clinician burnout, structures to strategically support innovation are imperative to financial and clinical success. METHODS: We developed the Brigham Care Redesign Incubator and Startup Program (BCRISP), a flexible model to test, evaluate, and scale innovative care redesign proposals. We evaluated its impact via analysis of programmatic and financial data, as well as through exploration of individual project outcomes. RESULTS: In 5 years, BCRISP has evaluated 283 innovations, piloted 25 projects, and generated $1.8 million in total medical expense reduction and $7.1 million in increased net revenue for our institution. Initially, it was conceived as a mechanism to engage staff in population health initiatives. As shifts toward risk-based reimbursement have slowed, we have observed a similar transition among proposed and supported innovation in the program. CONCLUSIONS: BCRISP enabled front-line clinical employees to design and pilot solutions to common and important clinical care problems, delivering financial return and improvements in care delivery. The underlying structure has been able to adapt to the changing political and economic climate, demonstrating a flexible and powerful approach to strategic investment that could be applied broadly by many health care provider organizations.

Uncoupling proteins in heart failure.

The development of heart failure is associated with alterations in the expression of a wide variety of structural, signaling, and metabolic proteins. One such effect is the downregulation of uncoupling proteins in the setting of heart failure. This group of proteins regulates the mitochondrial membrane potential and therefore plays a role in mitochondrial energy metabolism as well as reactive oxygen species generation by the mitochondria. This review discusses the role of uncoupling proteins in regulating oxidant stress and implications with respect to the pathogenesis of heart failure and potential treatments.

Outcomes of Early Dermatology Consultation for Inpatients Diagnosed With Cellulitis.

Importance: Many inflammatory skin dermatoses mimic cellulitis (pseudocellulitis) and are treated with antibiotics and/or hospitalization, leading to unnecessary patient morbidity and substantial health care spending. Objective: To evaluate the impact of early dermatology consultation on clinical and economic outcomes associated with misdiagnosed cellulitis. Design, Setting, and Participants: This prospective cohort study enrolled patients with presumed diagnosis of cellulitis in the emergency department, in the emergency department observation unit, or within 24 hours of admission to an inpatient unit of a large urban teaching hospital between February and September 2017. Patients were provided with telephone and clinic follow-up during the 30-day postdischarge period. We screened 165 patients with the primary concern of cellulitis. Of these, we excluded 44 who required antibiotics for cutaneous, soft-tissue, and deeper-tissue and/or bone infections irrespective of cellulitis status, and 5 who were scheduled to be discharged by the emergency department. Interventions: Early dermatology consultation for presumed cellulitis. Main Outcomes and Measures: Primary outcomes were patient disposition and rates of antibiotic use. Results: Of 116 patients (63 [54.3%] women; 91 [78.4%] non-Hispanic white; mean [SD] age, 58.4 [19.1] years), 39 (33.6%) were diagnosed with pseudocellulitis by dermatologists. Of these, 34 (87.2%) had started using antibiotics for presumed cellulitis as prescribed by the primary team at the time of enrollment. The dermatology team recommended antibiotic discontinuation in 28 of 34 patients (82.4%), and antibiotics were stopped in 26 of 28 cases (92.9%). The dermatologists also recommended discharge from planned observation or inpatient admission in 20 of 39 patients with pseudocellulitis (51.3%), and the primary team acted on this recommendation in 17 of 20 cases (85.0%). No patients diagnosed with pseudocellulitis experienced worsening condition after discharge based on phone and clinic follow-up (30 of 39 [76.9%] follow-up rate). Extrapolating the impact of dermatology consultation for presumed cellulitis nationally, we estimate 97 000 to 256 000 avoided hospitalization days, 34 000 to 91 000 patients avoiding unnecessary antibiotic exposure, and $80 million to $210 million in net cost savings annually. Conclusions and Relevance: Early consultation by dermatologists for patients with presumed cellulitis represents a cost-effective intervention to improve health-related outcomes through the reduction of inappropriate antibiotic use and hospitalization.

ED-based care coordination reduces costs for frequent ED users.

OBJECTIVES: We evaluated a pilot quality improvement intervention implemented in an urban academic medical center emergency department (ED) to improve care coordination and reduce ED visits and hospitalizations among frequent ED users. STUDY DESIGN: Randomized controlled trial. METHODS: We identified the most frequent ED users in both the 30 days prior to the intervention and the 12 months prior to the intervention. We randomized the top 72 patients to receive either our pilot intervention or usual care. The intervention consisted of a community health worker who assisted patients with navigating care and identifying unmet social needs and an ED-based clinical team that developed interdisciplinary acute care plans for eligible patients. After 7 months, we analyzed ED visits, hospitalizations, and costs for the intervention and control groups. RESULTS: We randomized 72 patients to the intervention (n = 36) and control (n = 36) groups. Patients randomized to the intervention group had 35% fewer ED visits (P = .10) and 31% fewer admissions from the ED (P = .20) compared with the control group. Average ED direct costs per patient were 15% lower and average inpatient direct costs per patient were 8% lower for intervention patients compared with control patients. CONCLUSIONS: ED-based care coordination is a promising approach to reduce ED use and hospitalizations among frequent ED users. Our program also demonstrated a decrease in costs per patient. Future efforts to promote population health and control costs may benefit from incorporating similar programs into acute care delivery systems.

A Decision-Making Algorithm for Initiation and Discontinuation of RRT in Severe AKI.

BACKGROUND AND OBJECTIVES: AKI is an increasingly common and devastating complication in hospitalized patients. Severe AKI requiring RRT is associated with in-hospital mortality rates exceeding 40%. Clinical decision making related to RRT initiation for patients with AKI in the medical intensive care unit is not standardized. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: We conducted a 13-month (November of 2013 to December of 2014) prospective cohort study in an academic medical intensive care unit involving the implementation of an AKI Standardized Clinical Assessment and Management Plan, a decision-making algorithm to assist front-line clinicians caring for patients with AKI. The Standardized Clinical Assessment and Management Plan algorithms provided recommendations about optimal indications for initiating and discontinuing RRT on the basis of various clinical parameters; 176 patients managed by nine nephrologists were included in the study. We captured reasons for deviation from the recommended algorithm as well as mortality data. RESULTS: Patients whose clinicians adhered to the Standardized Clinical Assessment and Management Plan recommendation to start RRT had lower in-hospital mortality (42% versus 63%; P<0.01) and 60-day mortality (46% and 68%; P<0.01), findings that were confirmed after multivariable adjustment for age, albumin, and disease severity. There was a differential effect of Standardized Clinical Assessment and Management Plan adherence in low (<50% mortality risk) versus high (≥50% mortality risk) disease severity on in-hospital mortality (interaction term P=0.02). In patients with low disease severity, Standardized Clinical Assessment and Management Plan adherence was associated with lower in-hospital mortality (odds ratio, 0.21; 95% confidence interval, 0.08 to 0.54; P=0.001), but no significant association was evident in patients with high disease severity. CONCLUSIONS: Physician adherence to an algorithm providing recommendations on RRT initiation was associated with lower in-hospital mortality.

Development of Standardized Clinical Assessment and Management Plans (SCAMPs) in Plastic and Reconstructive Surgery.

BACKGROUND: With rising cost of healthcare, there is an urgent need for developing effective and economical streamlined care. In clinical situations with limited data or conflicting evidence-based data, there is significant institutional and individual practice variation. Quality improvement with the use of Standardized Clinical Assessment and Management Plans (SCAMPs) might be beneficial in such scenarios. The SCAMPs method has never before been reported to be utilized in plastic surgery. METHODS: The topic of immediate breast reconstruction was identified as a possible SCAMPs project. The initial stages of SCAMPs development, including planning and implementation, were entered. The SCAMP Champion, along with the SCAMPs support team, developed targeted data statements. The SCAMP was then written and a decision-tree algorithm was built. Buy-in was obtained from the Division of Plastic Surgery and a SCAMPs data form was generated to collect data. RESULTS: Decisions pertaining to "immediate implant-based breast reconstruction" were approved as an acceptable topic for SCAMPs development. Nine targeted data statements were made based on the clinical decision points within the SCAMP. The SCAMP algorithm, and the SDF, required multiple revisions. Ultimately, the SCAMP was effectively implemented with multiple iterations in data collection. CONCLUSIONS: Full execution of the SCAMP may allow better-defined selection criteria for this complex patient population. Deviations from the SCAMP may allow for improvement of the SCAMP and facilitate consensus within the Division. Iterative and adaptive quality improvement utilizing SCAMPs creates an opportunity to reduce cost by improving knowledge about best practice.