Should COVID-19 symptoms be used to cohort patients in the emergency department? A retrospective analysis.

OBJECTIVE: To determine how cohorting patients based on presenting complaints affects risk of nosocomial infection in crowded Emergency Departments (EDs) under conditions of high and low prevalence of COVID-19. METHODS: This was a retrospective analysis of presenting complaints and PCR tests collected during the COVID-19 epidemic from 4 EDs from a large hospital system in Bronx County, NY, from May 1, 2020 to April 30, 2021. Sensitivity, specificity, positive and negative predictive value (PPV, NPV) were calculated for a symptom screen based on the CDC list of COVID-19 symptoms: fever/chills, shortness of breath/dyspnea, cough, muscle or body ache, fatigue, headache, loss of taste or smell, sore throat, nasal congestion/runny nose, nausea, vomiting, and diarrhea. PPV was calculated for varying values of prevalence. RESULTS: There were 80,078 visits with PCR tests. The sensitivity of the symptom screen was 64.7% (95% CI: 63.6, 65.8), specificity 65.4% (65.1, 65.8). PPV was 16.8% (16.5, 17.0) and NPV was 94.5% (94.4, 94.7) when the observed prevalence of COVID-19 in the ED over the year was 9.7%. The PPV of fever/chills, cough, body and muscle aches and nasal congestion/runny nose were each approximately 25% across the year, while diarrhea, nausea, vomiting and headache were less predictive, (PPV 4.7%-9.6%) The combinations of fever/chills, cough, muscle/body aches, and shortness of breath had PPVs of 40-50%. The PPV of the screen varied from 3.7% (3.6, 3.8) at 2% prevalence of COVID-19 to 44.3% (44.0, 44.7) at 30% prevalence. CONCLUSION: The proportion of patients with a chief complaint of COVID-19 symptoms and confirmed COVID-19 infection was exceeded by the proportion without actual infection. This was true when prevalence in the ED was as high as 30%. Cohorting of patients based on the CDC's list of COVID-19 symptoms will expose many patients who do not have COVID-19 to risk of nosocomially acquired COVID-19. EDs should not use the CDC list of COVID-19 symptoms as the only strategy to minimize exposure.

SARS-CoV-2 coinfection with additional respiratory virus does not predict severe disease: a retrospective cohort study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) claimed over 4 million lives by July 2021 and continues to pose a serious public health threat. OBJECTIVES: Our retrospective study utilized respiratory pathogen panel (RPP) results in patients with SARS-CoV-2 to determine if coinfection (i.e. SARS-CoV-2 positivity with an additional respiratory virus) was associated with more severe presentation and outcomes. METHODS: All patients with negative influenza/respiratory syncytial virus testing who underwent RPP testing within 7 days of a positive SARS-CoV-2 test at a large, academic medical centre in New York were examined. Patients positive for SARS-CoV-2 with a negative RPP were compared with patients positive for SARS-CoV-2 and positive for a virus by RPP in terms of biomarkers, oxygen requirements and severe COVID-19 outcome, as defined by mechanical ventilation or death within 30 days. RESULTS: Of the 306 SARS-CoV-2-positive patients with RPP testing, 14 (4.6%) were positive for a non-influenza virus (coinfected). Compared with the coinfected group, patients positive for SARS-CoV-2 with a negative RPP had higher inflammatory markers and were significantly more likely to be admitted (P = 0.01). Severe COVID-19 outcome occurred in 111 (36.3%) patients in the SARS-CoV-2-only group and 3 (21.4%) patients in the coinfected group (P = 0.24). CONCLUSIONS: Patients infected with SARS-CoV-2 along with a non-influenza respiratory virus had less severe disease on presentation and were more likely to be admitted-but did not have more severe outcomes-than those infected with SARS-CoV-2 alone.

Improving thiamine prescribing in alcohol use disorder using electronic decision support in a large urban academic medical center: A pre-post intervention study.

INTRODUCTION: Thiamine is the only therapy for prevention and treatment of Wernicke Encephalopathy among patients with Alcohol Use Disorder (AUD). Despite this fact, up to 75 % of inpatients with AUD are not prescribed thiamine during hospitalization. Even fewer patients are prescribed high-dose thiamine which many experts recommend should be standard of care. Previous attempts to improve thiamine prescribing for inpatients have had limited success. METHODS: We conducted an evaluation of thiamine prescribing in the year before and year after an intervention to increase high-dose thiamine prescribing. Pre-post study analysis occurred on two distinct study cohorts: those with alcohol-related diagnoses and those with elevated alcohol levels. The intervention was new electronic health record-based decision support which encouraged high-dose thiamine when any thiamine order was sought. No educational support was provided. The primary outcome was prescription of high-dose thiamine before versus after intervention. Of those with alcohol-related diagnoses, the monthly percentage of thiamine treatment courses including high-dose thiamine were graphed on a control chart. RESULTS: We examined 5307 admissions with alcohol-related diagnoses (2285 pre- and 3022 post-intervention) and 698 admissions with elevated alcohol levels (319 pre- and 379 post-intervention). Among admissions with alcohol-related diagnoses, the intervention was associated with a higher proportion of admissions receiving high-dose thiamine prescriptions in the first 24 h (4.7 % vs. 1.1 %, adjusted odds ratio 4.50, CI 2.93 to 6.89, p < 0.001). A similar difference in high-dose thiamine was seen post-intervention among admissions with elevated alcohol levels (14.3 % vs. 2.5 %, adjusted odds ratio 6.43, CI 3.05 to 13.53, p < 0.001). The control chart among those with an alcohol-related diagnosis demonstrated special cause variation: the median percentage of thiamine treatment courses including high-dose thiamine improved from 8.2 % to 13.0 %. CONCLUSIONS: Electronic decision support without educational interventions increased the use of high-dose thiamine among patients with alcohol-related diagnoses and with elevated alcohol levels during hospitalization. This increase occurred immediately in the month after the intervention and was sustained in the year-long study period after.

Improving Resident Hospital Discharge Communication by Changing Electronic Health Record Templates to Enhance Primary Care Provider Satisfaction.

BACKGROUND AND OBJECTIVES: Despite use of standardized electronic health record templates, the structure of discharge summaries may hinder communication from inpatient settings to primary care providers (PCPs). We developed an enhanced electronic discharge summary template to improve PCP satisfaction with written discharge summaries targeting diagnoses, medication reconciliation, laboratory test results, specialist follow-up, and recommendations. METHODS: Resident template usage was measured using statistical process control charts. PCP reviewers' discharge summary satisfaction was surveyed using 5-point Likert scales analyzed using the Mann-Whitney U test. Residents were surveyed for satisfaction. RESULTS: Resident template usage increased from 61% initially to 72% of discharge summaries at 6 months. The PCP reviewers reported increased satisfaction for summaries using the template compared with those without (4.3 vs 3.9, P = .003). Surveyed residents desired template inclusion in the default electronic discharge summary (93%). CONCLUSIONS: This system-level resident-initiated quality improvement initiative created a novel discharge summary template that achieved widespread usage among residents and significantly increased outpatient PCP satisfaction.

Hospitalist perspective on pandemic related clinical and administrative changes: a cross sectional survey study.

OBJECTIVE: Hospitalists have played a leading role in caring for hospitalized COVID-19 patients. Many clinical and administrative changes occurred in hospitals to meet the varied pandemic needs. We surveyed hospitalists to understand their perspective on pandemic-related changes in technology, models of care, administration and leadership, impact on personal lives, and which of these changes should be continued versus reverting to pre-pandemic practices. METHODS: A 30-question survey was distributed to hospitalists working across the United States between 6 April 2022 to 16 May 2022. Baseline demographics were measured, and post-pandemic perspectives related to changes were analyzed. Perspectives were measured using a 5-point Likert scale and responses were categorized into 'agree' and 'did not agree' for analysis. Variation was assessed using Chi-square or Fisher exact tests. Open-ended questions were reported following qualitative content analysis organized into themes and reported as frequency. RESULTS: 177 respondents (39%) completed the survey. Nearly three-fourths favored hybrid meetings, and two-thirds preferred to continue new models of care. Nearly 90% desired more family and leisure time, continued wellness, and support services, and resumption of social gatherings. No major differences in perspectives were noted between hospitalists at teaching facilities and non-teaching facilities except for resuming protected time for non-clinical activities in those from teaching facilities (83.0% vs 62.5%). Respondents less than age 50 were more likely to prefer virtual meetings (59.0% vs 31.3%). Content analysis of open-ended questions resulted in different themes for each question. Respondents favored more work-life balance and less administrative and logistical work burden. CONCLUSIONS: Hospitalists preferred to continue the use of technology and new models of care even in the post-pandemic period and express a desire for more work-life balance and less administrative and logistical work burden.

Pharmacy-driven performance improvement initiative to increase compliance with intravenous smart pump drug error reduction systems at a large urban academic medical center.

DISCLAIMER: In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE: Smart pump dose error reduction systems (DERS) reduce errors for intravenous (IV) administration medications by warning users of order, calculation, and programming errors. The purpose of this performance improvement initiative was to increase IV smart pump DERS usage from 77% to 95% at a large, urban academic medical center. METHODS: A pharmacy-led team with nurses, physicians, and quality improvement specialists executed interventions from July 2020 through April 2022 to increase DERS compliance. A discovery phase (phase I) was followed by 6 Plan-Do-Study-Act (PDSA) cycles created to address barriers to DERS utilization. Phase I revealed that problems involving the DERS library and bedside nurse training were the major drivers of noncompliance. Phase II consisted of 3 system-level PDSA cycles, and phase III included 3 focused group PDSA cycles. Data were collected monthly from the smart pump reporting software by the informatics pharmacist and analyzed by the team to assess compliance rates in response to the corresponding interventions. RESULTS: The median DERS compliance increased from 77% to 83% over the 2-year period, which correlates with approximately 109,000 additional infusions run on DERS each year within our institution. The implementation of a DERS problem reporting tool accessed through the medication administration record resulted in the most pronounced improvement. CONCLUSION: DERS compliance improved following system-level sustainable interventions, although further PDSA cycles are needed to meet the goal DERS utilization rate of 95%. The results of this study may help other institutions attempting to improve DERS utilization create targeted interventions.

Early treatment with thiamine and mortality among patients with alcohol use disorder who are hospitalized for pneumonia.

BACKGROUND: The paucity of research linking thiamine treatment with improved outcomes may be driving its underutilization among patients at risk for Wernicke encephalopathy. OBJECTIVE: To assess relationships of thiamine usage to outcomes of patients hospitalized with alcohol use disorder and pneumonia. DESIGN, SETTING AND PARTICIPANTS: This is a retrospective cohort study of adult patients hospitalized with pneumonia who also have alcohol use disorder and were treated with benzodiazepines during the initial two hospital days, between 2010 and 2015 at hospitals participating in the Premier Healthcare Database. EXPOSURE: Any thiamine treatment, and, among those treated, high-dose thiamine treatment, during the initial two hospital days. MAIN OUTCOME AND MEASURES: Death on days 3-14 of hospitalization (primary); discharge home; transfer to intensive care unit; length of stay (LOS). We used propensity-weighted models to estimate treatment effects. RESULTS: Among 36,732 patients from 625 hospitals, 26,520 (72.2%) patients received thiamine, with mortality of 6.5% and 8.1% among recipients and nonrecipients, respectively. With propensity score adjustment, thiamine was associated with reduced mortality (odds ratio [OR]: 0.80, 95% confidence interval [CI]: 0.75-0.85) and more frequent discharges to home (OR: 1.10, 95% CI: 1.06-1.14). Other outcomes were similar. Relative to low-dose thiamine, high-dose thiamine was not associated with mortality (adjusted OR: 0.99, 95% CI: 0.89-1.10), but LOS was longer (ratio of means: 1.06, 95% CI: 1.04-1.08), and discharges to home were less frequent (OR: 0.92, 95% CI: 0.87-0.97). CONCLUSION: Thiamine is not reliably given to patients with pneumonia and alcohol use disorder receiving benzodiazepines. Improving thiamine administration may represent an opportunity to save lives in this high-risk group of inpatients.

Creation of a medical ward from non-clinical space amidst the Covid-19 pandemic.

INTRODUCTION: Hospitals were mandated to dramatically increase capacity during the Covid-19 crisis in New York City. Conversion of non-clinical space into medical units designated for Covid-19 patients became necessary to accommodate this mandate. METHODS: Non-clinical space was converted into medical units at multiple campuses of a large academic hospital system over 1 week. The conversion required construction to deliver basic care including oxygen supplementation. Creation of provider workspaces, handwashing areas, and colour-coded infection control zones was prioritized. Selection criteria were created with a workflow to determine appropriate patients for transfer into converted space. Staffing of converted space shifted as hospitalizations surged. RESULTS: The unit was open for 18 days and accommodated 170 unique patients. Five patients (2.9%) required transfer to a higher level of care. There were no respiratory arrests, cardiac arrests, or deaths in the new unit. CONCLUSION: Converting non-clinical space to a medical unit was accomplished quickly with staffing, workflow for appropriate patients, few patients who returned to a higher level of care, and no respiratory or cardiac arrests or deaths on the unit.

Screening of Clostridioides difficile carriers in an urban academic medical center: Understanding implications of disease.

OBJECTIVE: Efforts to reduce Clostridioides difficile infection (CDI) have targeted transmission from patients with symptomatic C. difficile. However, many patients with the C. difficile organism are carriers without symptoms who may serve as reservoirs for spread of infection and may be at risk for progression to symptomatic C. difficile. To estimate the prevalence of C. difficile carriage and determine the risk and speed of progression to symptomatic C. difficile among carriers, we established a pilot screening program in a large urban hospital. DESIGN: Prospective cohort study. SETTING: An 800-bed, tertiary-care, academic medical center in the Bronx, New York. PARTICIPANTS: A sample of admitted adults without diarrhea, with oversampling of nursing facility patients. METHODS: Perirectal swabs were tested by polymerase chain reaction for C. difficile within 24 hours of admission, and patients were followed for progression to symptomatic C. difficile. Development of symptomatic C. difficile was compared among C. difficile carriers and noncarriers using a Cox proportional hazards model. RESULTS: Of the 220 subjects, 21 (9.6%) were C. difficile carriers, including 10.2% of the nursing facility residents and 7.7% of the community residents (P = .60). Among the 21 C. difficile carriers, 8 (38.1%) progressed to symptomatic C. difficile, but only 4 (2.0%) of the 199 noncarriers progressed to symptomatic C. difficile (hazard ratio, 23.9; 95% CI, 7.2-79.6; P < .0001). CONCLUSIONS: Asymptomatic carriage of C. difficile is prevalent among admitted patients and confers a significant risk of progression to symptomatic CDI. Screening for asymptomatic carriers may represent an opportunity to reduce CDI.

Using clinical decision support through the electronic medical record to increase prescribing of high-dose parenteral thiamine in hospitalized patients with alcohol use disorder.

BACKGROUND: Patients with alcohol use disorder (AUD) are at an increased risk of developing Wernicke's encephalopathy (WE), a devastating and difficult diagnosis caused by thiamine deficiency. Even as AUD is present in up to 25% of hospitalized patients on medical floors, appropriate thiamine supplementation in the hospital setting remains inadequate. These patients are particularly susceptible to thiamine deficiency and subsequent WE due to both their alcohol use and active medical illnesses. The electronic medical record (EMR) has become ubiquitous in health care systems and can be used as a tool to improve the care of hospitalized patients. METHODS: As a quality improvement initiative, we implemented a medication order panel in the EMR with autopopulated orders for thiamine dosing to increase the appropriate use of high-dose parenteral thiamine (HPT) for hospitalized patients with AUD. We conducted a retrospective cohort study of all inpatients with AUD who received an Addiction Psychiatry Consult Service consult three months before and after the EMR change. We compared the proportion of patients receiving HPT prior to consultation (primary outcome) and the length of stay (secondary outcome) between the historical control group and the EMR intervention group. RESULTS: Patients in the EMR intervention group were significantly more likely to receive HPT than the historical control group (20.2% vs. 2.7%, p < 0.0001). This difference remained statistically significant when adjusted for potential confounders (OR: 9.89, 95% CI: [2.77, 35.34], p = 0.0004). There was a trend towards statistical significance that the intervention group had a higher likelihood of being prescribed any thiamine (76.6% vs. 64.6%, p = 0.06) and had a shorter length of stay (median (IQR): 3.8 (2.4, 7.0) vs. 4.6 (2.9, 7.8) days, p = 0.06). CONCLUSION: These results indicate that providing autopopulated thiamine order panels for patients with AUD can be an effective method for specialty services to increase appropriate care practices without additional education or training for providers. Further research should consider the clinical outcomes of increasing HPT for patients with AUD.