Evaluation of opt-out inpatient HIV screening at an urban teaching hospital.

This study evaluated opt-out inpatient HIV screening delivered by admitting physicians, and compared number of HIV tests and diagnoses to signs and symptoms-directed HIV testing (based on physician orders) in the emergency department (ED). The opt-out inpatient HIV screening program was conducted over a one year period in patients who were admitted to the 386-bed University of California San Diego (UCSD) teaching hospital. Numbers of HIV tests and diagnoses were compared to those observed among ED patients who underwent physician-directed HIV testing during the same time period. Survey data were collected from a convenience sample of patients and providers regarding the opt-out testing program. Among 8488 eligible inpatients, opt-out HIV testing was offered to 3017 (36%) patients, and rapid antibody testing was performed in 1389 (16.4%) inpatients, resulting in 6 (0.4% of all tests) newly identified HIV infections (5/6 were admitted through the ED). Among 27,893 ED patients, rapid antibody testing was performed in 88 (0.3%), with 7 (8.0% of all tests) new HIV infections identified. HIV diagnoses in the ED were more likely to be men who have sex with men (MSM) (p = 0.029) and tended to have AIDS-related opportunistic infections (p = 0.103) when compared to HIV diagnoses among inpatients. While 85% of the 150 physicians who completed the survey were aware of the HIV opt-out screening program, 44% of physicians felt that they did not have adequate time to consent patients for the program, and only 30% agreed that a physician is best-suited to consent patients. In conclusion, the yield of opt-out HIV rapid antibody screening in inpatients was comparable to the national HIV prevalence average. However, uptake of screening was markedly limited in this setting where opt-out screening was delivered by physicians during routine care, with limited time resources being the major barrier.

Multidisciplinary effort to improve the diagnosis of malnutrition in hospitalized patients.

Malnutrition has been increasingly demonstrated to be common and underrecognized in hospitalized patients. Rates have been demonstrated as high as 55%, but the diagnosis of malnutrition has historically been made in only a minority of inpatients. Laboratory studies, including serum prealbumin level, have been shown to have poor predictive value of malnutrition. In 2014, our institution embarked on a system-wide effort to improve diagnosis of malnutrition in hospitalized patients. We adopted the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (AND/ASPEN) Clinical Characteristics and implemented the Nutrition-Focused Physical Exam/Assessment into clinical practice. Dietitians recorded malnutrition diagnoses in a flow sheet in the electronic medical record (EMR) and alerted the primary team when a patient met criteria for malnutrition. An editable link to malnutrition diagnosis was created in the discharge summary templates in the EMR. Over 4 years, these efforts led to an increase in our rate of diagnosis of malnutrition from 6% to 12%, which was sustained over the last 2 years. We also found that the percentage of inpatients having serum prealbumin levels checked decreased from 13% to 8% over the study period. We found that a system-wide, stepwise approach to improving our diagnosis of inpatients with malnutrition was effective and appears sustainable over the period studied. We noted a behavior change for providers in both documenting the condition and decreasing their utilization of laboratory studies as part of their clinical diagnostic workup, thus avoiding unnecessary laboratory draws and leading to potential cost saving.

Evaluation of the Yale New Haven Readmission Risk Score for Pneumonia in a General Hospital Population.

BACKGROUND: The Yale New Haven Readmission Risk Score (YNHRRS) for pneumonia is a clinical prediction tool developed to assess risk for 30-day readmission. This tool was validated in a cohort of Medicare patients; generalizability to a broader patient population has not been evaluated. In addition, it lacks indicators of functional status or social support, which have been shown in other studies to be predictors of readmission. The objective of this study was to evaluate the generalizability of the YNHRRS for pneumonia in a general population of hospitalized patients, and assess the impact of incorporating measures of functional status and social support on its predictive value. METHODS: This retrospective chart review comprised all patients admitted to a 563-bed academic medical center with a primary diagnosis of pneumonia between March 2014 and March 2015. Abstraction of clinical variables allowed calculation of the YNHRRS and additional indicators of functional status and social support. The primary outcome was 30-day readmission rate. We created a logistic regression model to predict readmission using the YNHRRS, functional status, and social support as covariates. RESULTS: Among 270 discharges with pneumonia, the observed readmission rate was 23%. The YNHRRS was a significant predictor of readmission in our multivariate model, with an odds ratio of 2.20 (95% confidence interval, 1.29-3.73) for each 10% increase in calculated risk. Indicators of functional status and social support were not significant predictors of readmission. CONCLUSIONS: The YNHRRS can be applied to an unselected population as a tool to predict patients with pneumonia at risk for readmission.

Reporting of estimated glomerular filtration rate: effect on physician recognition of chronic kidney disease and prescribing practices for elderly hospitalized patients.

BACKGROUND: Physician recognition of chronic kidney disease (CKD) in elderly patients has been noted to be poor. These patients are at increased risk of medication dosing errors and acute renal failure. OBJECTIVE: To investigate the effect of reporting estimated glomerular filtration rate (GFR) of elderly hospitalized patients on physician recognition of CKD and physician prescribing behaviors. DESIGN: A retrospective combined with a prospective medical record review project. SETTING: A large academic medical center. PATIENTS: Patients included were 65 years of age or older and had creatinine values within the normal laboratory range (< 1.6 mg/dL). INTERVENTION: Reporting a calculated estimate of GFR to physicians. MEASUREMENTS: Rates of recognition of CKD were examined before and after the intervention. The effects of the intervention on prescription of renal-dosed antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDS) and cyclooxygenase- 2 inhibitors (COX-2) at hospital discharge were assessed. RESULTS: A total of 260 and 198 patients were included before and after the intervention, respectively. Recognition of chronic kidney disease was low in both groups but demonstrated a significant increase following reporting of estimated GFR (3.9% to 12.6%, P < .001). Reporting of GFR was not associated with a significant decrease in prescription of NSAID/COX-2 medications or increased rates of correct dosing of antibiotics (P = .10 and P = .81, respectively). CONCLUSIONS: Although reporting of estimated GFR was associated with improved physician recognition of CKD in elderly hospitalized patients, it did not lead to a change in physician prescribing. More extensive interventions are necessary to increase recognition and decrease medication dosing errors.