Use of a Cirrhosis Admission Order Set Improves Adherence to Quality Metrics and May Decrease Hospital Length of Stay.

INTRODUCTION: Quality metrics for inpatient cirrhosis management have been created to improve processes of care. We aimed to improve adherence to quality metrics by creating a novel clinical decision support (CDS) tool in the electronic health record (EHR). METHODS: We developed and piloted an alert system in the EHR that directs providers to a cirrhosis order set for patients who have a known diagnosis of cirrhosis or are likely to have cirrhosis. Adherence to process measures and outcomes when the CDS was used were compared with baseline performance before the implementation of the CDS. RESULTS: The use of the order set resulted in a significant increase in adherence to process measures such as diagnostic paracentesis (29.6%-51.1%), low-sodium diet (34.3%-77.8%), and social work involvement (36.6%-88.9%) ( P < 0.001 for all). There were also significant decreases in both intensive care and hospital lengths of stay ( P < 0.001) as well as in-hospital development of infection ( P = 0.002). There was no difference in hospital readmissions at 30 or 90 days between the groups ( P = 0.897, P = 0.640). DISCUSSION: The use of CDS in EHR-based interventions improves adherence to quality metrics for patients with cirrhosis and could easily be shared by institutions through EHR platforms. Further studies and larger sample sizes are needed to better understand its impact on additional outcome measures.

Supraventricular Tachycardia as the Initial Presentation of New-Onset Lupus: A Case Report.

ABSTRACT: Systemic lupus erythematosus (SLE) is a chronic, autoimmune, multisystem disorder that can sometimes be life-threatening. The presentation varies widely given the wide range of clinical and serological manifestations coupled with the disease's ability to affect any organ. Prognosis depends on the organ systems involved, as well as the severity of the involvement. This case involves a 17-year-old with initial presentation of supraventricular tachycardia subsequently found to have pancreatitis, myocarditis, and nephritis secondary to a new diagnosis of SLE. Systemic lupus erythematosus can involve virtually any organ system, which leads to the variable nature of presentation, as was the case for our patient and his presentation being supraventricular tachycardia from underlying myocarditis secondary to SLE. Lupus myocarditis is rare, but when present often indicates severe systemic illness. The echocardiogram will often show global hypokinesis without evidence of coronary artery disease. This was the case with our patient. His echocardiogram demonstrated new-onset systolic left-sided heart failure due to nonischemic cardiomyopathy with an ejection fraction of 25%. Unfortunately for our patient, he had several poor prognostic factors on his initial presentation prior to any treatment being started, including renal disease, male, age (17 years), low socioeconomic status, African American race, and high disease activity. Systemic lupus erythematosus is the great mimicker and can present in a variety of ways. Given its ability to involve virtually any organ system, it is important to consider it on the differential diagnoses, especially in patients with a strong family history.

Relationship Between Substance Use and the Onset of Spinal Cord Injuries: A Medical Chart Review.

Background: Opioid misuse is a leading health care concern within the United States. In many cases, opioid misuse and opioid use disorder are associated with pain, a secondary health condition affecting individuals with spinal cord injury (SCI). Further, substance use is a known risk factor for SCI, resulting in the potential for a substance-related risk trajectory running from pre- to post-SCI. However, little research has examined substance use prior to SCI since the opioid epidemic began, and so the relative risk of opioids to patients with SCI is unclear. Objective: To determine whether individuals with SCI tested positive for substance use at the time of injury and identify the primary substances used at the time of injury. Methods: This study retrospectively reviewed all medical charts of individuals ages 18 and older who had sustained an SCI during an identified 18-month period and received medical care at a selected level 1 trauma center in the Midwest. Results: Data revealed an 80% combined positive toxicology and/or self-report of substance use immediately prior to the onset of the SCI. Twenty-five percent of males were positive for more than one substance at time of injury. Substances used prior to injury, listed most to least prevalent, were opioids (37.5%), alcohol (25%), marijuana (25%), methamphetamines (12.5%), benzodiazepines (12.5%), followed by cocaine (6.25%) and synthetic cathinone (6.25%). Conclusion: Although opioids were the most common substance used prior to SCI, none of the individuals positive for opioids at the time of injury were identified by the reviewing medical professional as having pain as a secondary health condition either prior to or after injury. However, pain is commonly listed as the primary health concern among individuals living with SCI, and the possibility of opioid use prior to injury likely warrants pain management planning that includes careful pharmacological and nonpharmacological interventions.

An Initial Assessment of the Utility of Validated Alcohol and Drug Screening Tools in Predicting 30-Day Readmission to Adult General Medicine Wards.

Previous studies have identified drug and alcohol use as risk factors for readmission using claims data, but not by using substance use screening scores. This preliminary study tested the hypothesis that prevalence of 30-day readmission would be higher among patients screening positive on the 10-item Alcohol Use Disorders Identification Test (AUDIT-10) or the 10-item Drug Abuse Screening Test (DAST-10) tools at intake than among the general patient population. Social workers screened 4708 adult inpatients using prescreening questions followed by the AUDIT-10 and/or DAST-10. Patients with positive screens were followed for readmissions within 30 days of discharge. A positive screening score on the AUDIT-10 or DAST-10 instrument at intake was associated with higher risk of readmission to the general medicine wards within 30 days; this relationship appears complex and subject to mediation. Post hoc chart review found that the majority of readmissions among patients with positive screens were not immediately attributable to substance use. Further study is needed to verify these preliminary findings.

An Assessment of SBIRT Prescreening and Screening Outcomes by Medical Setting and Administration Methodology.

BACKGROUND: Screening, brief intervention, and referral to treatment (SBIRT) is an efficacious prevention practice. However, little research has assessed differences in prescreening outcomes between inpatient and outpatient primary care or among different prescreening administration methods. This study tested whether administration method (self-administered vs interview) and setting (inpatient versus outpatient) predicted prescreening outcomes in a large sample of primary care patients. Then, among patients who prescreened positive, it tested whether full screening scores differed by administration method and setting. METHODS: Researchers used binomial logistic regression to assess predicted prescreening outcomes and analysis of variance to assess differences in SBIRT screening scores across a total of 14 447 unique patient visits in 10 outpatient sites and 1 centrally located hospital. RESULTS: Controlling for gender, depression, and other substance use, both medical setting and method of prescreening, predicted prescreening results. Among patients who prescreened positive for alcohol, setting also was associated with mean screening scores. However, outcomes were not uniform by substance (eg, alcohol vs other drugs). CONCLUSION: The results support previous studies on this topic that had utilized cross-study comparison or that were not specific to SBIRT prescreening/screening mechanisms. At the same time, nuanced findings were observed that had not previously been reported and suggest the need for further research in this area.