Differences in international medical graduates' letters of recommendation by gender in pulmonary and critical care medicine: a cohort analysis.

BACKGROUND: International Medical Graduates (IMGs) encounter barriers as they seek to match into fellowship programs in the United States (US). This study's objective is to determine if there are differences in letters of recommendation written for IMGs compared to U.S. Medical Graduates (USMGs) applying to pulmonary and critical care medicine (PCCM) fellowship programs. METHODS: All applications submitted to a PCCM fellowship program in 2021 were included in this study. The applicant demographics and accomplishments were mined from applications. The gender of letter writers was identified by the author's pronouns on professional websites. Word count and language differences in the letters were analyzed for each applicant using the Linguistic Inquiry and Word Count (LWIC2015) program. Multivariable linear regressions were performed controlling for applicant characteristics to identify if IMG status was associated with total word count and degree of support, measured by a composite outcome encompassing several categories of adjectives, compared to USMG status. RESULTS: Of the 573 applications, most of the applicants were USMGs (72%, N = 334/573). When adjusting for applicant characteristics, IMG applicants had shorter letters of recommendation (87.81 total words shorter 95% CI: - 118.61, - 57.00, p-value < 0.01) and less supportive letters (4.79 composite words shorter 95% CI: - 6.61, - 2.97, p-value < 0.01), as compared to USMG applicants. Notably, female IMG applicants had the biggest difference in their word counts compared to USMG applicants when the letter writer was a man. CONCLUSIONS: IMG applicants to a PCCM fellowship received shorter and less supportive letters of recommendation compared to USMG applicants.

Team dynamics in a COVID-19 intensive care unit: A qualitative study.

BACKGROUND: During the COVID-19 pandemic, new intensive care units (ICUs) were created and clinicians were assigned or volunteered to work in these ICUs. These new ICU teams were newly formed and may have had varying practice styles which could affect team dynamics. The purpose of our qualitative descriptive study was to explore clinician perceptions of team dynamics in this newly formed ICU and specifically understand the challenges and potential improvements in this environment to guide future planning and preparedness in ICUs. METHODS: We conducted 14 semistructured one-on-one interviews with six nurses and eight physicians from a newly formed 36- to 50-bed medical ICU designed for COVID-19 patients in a teaching hospital. We purposively sampled and recruited ICU nurses, medical/surgical nurses, fellows, and attending physicians (with pulmonary/critical care and anaesthesia training) to participate. Participants were asked about team dynamics in the ICU, its challenges, and potential solutions. We then used a rapid analytic approach by first deductively categorising interview data into themes, based on our interview guide, to create a unique data summary for each interview. Then, these data were transferred to a matrix to compare data across all interviews and inductively analysed these data to provide deeper insights into team dynamics in ICUs. RESULTS: We identified two themes that impacted team dynamics positively (facilitator) and negatively (barrier): interpersonal factors (individual character traits and interactions among clinicians) and structural factors (unit-level factors affecting workflow, organisation, and administration). Clinicians had several suggestions to improve team dynamics (e.g., scheduling to ensure clinicians familiar with one another worked together, standardisation of care processes across teams, and disciplines). CONCLUSIONS: In a newly formed COVID ICU, interpersonal factors and structural factors impacted the team's ability to work together. Considering team dynamics during ICU reorganisation is crucial and requires thoughtful attention to interpersonal and structural factors.

The Harvard Medical School Pathways curriculum: A comprehensive curricular evaluation.

PURPOSE: The Harvard Medical School Pathways curriculum represents a major reform effort. Our goals were to enhance reasoning and clinical skills and improve the learning environment and students' approach to learning via use of collaborative, case-based pedagogy; early clinical exposure; and enhanced approaches to teaching and evaluating clinical skills. We evaluated the impact of Pathways on key outcomes related to these goals. MATERIALS AND METHODS: In this prospective, mixed-methods study, we compared the last prior-curriculum cohort (2014 matriculation, n = 135) and first new-curriculum cohort (2015 matriculation, n = 135). Measures included Likert-type surveys, focus groups, and test scores to assess outcomes. RESULTS: Compared with prior-curriculum students, new-curriculum students reported higher mean preclerkship learning environment ratings (Educational Climate Inventory, 62.4 versus 51.9, p < 0.0001) and greater satisfaction with the quality of their preclerkship education (88% versus 73%, p = 0.0007). Mean USMLE Step-1 and Step-2 scores did not differ between groups. At graduation, new-curriculum students rated their medical school experience higher in 6 of 7 domains, including 'fostering a culture of curiosity and inquiry' (4.3 versus 3.9, p = 0.006) and focus on 'student-centered learning' (3.9 versus 3.4, p = 0.002). CONCLUSIONS: The new curriculum outperformed or was equal to the prior one on most measures of learning environment and perceived quality of education, without a decline in medical knowledge or clinical skills. Robust longitudinal evaluation provided important feedback for ongoing curriculum improvement.

Causes and characteristics of death in patients with acute hypoxemic respiratory failure and acute respiratory distress syndrome: a retrospective cohort study.

BACKGROUND: Acute hypoxemic respiratory failure (AHRF) and acute respiratory distress syndrome (ARDS) are associated with high in-hospital mortality. However, in cohorts of ARDS patients from the 1990s, patients more commonly died from sepsis or multi-organ failure rather than refractory hypoxemia. Given increased attention to lung-protective ventilation and sepsis treatment in the past 25 years, we hypothesized that causes of death may be different among contemporary cohorts. These differences may provide clinicians with insight into targets for future therapeutic interventions. METHODS: We identified adult patients hospitalized at a single tertiary care center (2016-2017) with AHRF, defined as PaO2/FiO2 ≤ 300 while receiving invasive mechanical ventilation for > 12 h, who died during hospitalization. ARDS was adjudicated by multiple physicians using the Berlin definition. Separate abstractors blinded to ARDS status collected data on organ dysfunction and withdrawal of life support using a standardized tool. The primary cause of death was defined as the organ system that most directly contributed to death or withdrawal of life support. RESULTS: We identified 385 decedents with AHRF, of whom 127 (33%) had ARDS. The most common primary causes of death were sepsis (26%), pulmonary dysfunction (22%), and neurologic dysfunction (19%). Multi-organ failure was present in 70% at time of death, most commonly due to sepsis (50% of all patients), and 70% were on significant respiratory support at the time of death. Only 2% of patients had insupportable oxygenation or ventilation. Eighty-five percent died following withdrawal of life support. Patients with ARDS more often had pulmonary dysfunction as the primary cause of death (28% vs 19%; p = 0.04) and were also more likely to die while requiring significant respiratory support (82% vs 64%; p <  0.01). CONCLUSIONS: In this contemporary cohort of patients with AHRF, the most common primary causes of death were sepsis and pulmonary dysfunction, but few patients had insupportable oxygenation or ventilation. The vast majority of deaths occurred after withdrawal of life support. ARDS patients were more likely to have pulmonary dysfunction as the primary cause of death and die while requiring significant respiratory support compared to patients without ARDS.

Developing internal medicine subspecialty fellows' teaching skills: a needs assessment.

BACKGROUND: For academic physicians, teaching represents an essential skill. The proliferation of educator training programs aimed at residents and medical students signals the increasing commitment of training programs to develop teaching skills in their trainees as early as possible. However, clinical fellowships represent an important opportunity to advance training as educators. In addition to enriching the pipeline of future teachers, developing fellows as teachers augments the training experience for more junior trainees and may impact patient care. Fellows' needs for programs to improve teaching skills have been largely unexplored. METHODS: We conducted a multi-institutional needs assessment of internal medicine (IM) subspecialty fellows to gauge interest in teaching and improvement of teaching skills. We surveyed IM subspecialty fellows at three academic medical centers about their access to fellow-as-teacher programs and other mechanisms to improve their teaching skills during fellowship. We also elicited their attitudes towards teaching and interest in training related to teaching skills. RESULTS: One hundred eighty-three fellows representing 20 programs and nine different subspecialties responded to the survey (48% response rate). The majority of participants (67%) reported having no specific training focused on teaching skills and only 12% reported receiving regular feedback about their teaching during their fellowship. Seventy-nine percent of fellows anticipated teaching to be part of their careers, and 22% planned to participate in medical education scholarship. Fellows reported a strong interest in teaching and programs aimed at improving their teaching skills. CONCLUSIONS: The majority of fellows reported a lack of mechanisms to advance their teaching skills as fellows, despite anticipating teaching to be an important aspect of their future careers and having strong interest in such programs. Our findings at three academic medical centers confirm a lost opportunity among subspecialty fellowships to accelerate teaching skills development for future educators.

Teaching during consultation: factors affecting the resident-fellow teaching interaction.

OBJECTIVES: The subspecialty consultation represents a potentially powerful opportunity for resident learning, but barriers may limit the educational exchanges between fellows (subspecialty registrars) and residents (house officers). We conducted a focus group study of internal medicine (IM) residents and subspecialty fellows to determine barriers against and factors facilitating resident-fellow teaching interactions on the wards, and to identify opportunities for maximising teaching and learning. METHODS: We conducted four focus groups of IM residents (n = 18) and IM subspecialty fellows (n = 16) at two academic medical centres in the USA during February and March 2013. Participants represented trainees in all 3 years of residency training and seven IM subspecialties. Four investigators analysed the transcripts using a structured qualitative framework approach, which was informed by literature on consultation and the theoretical framework of activity theory. RESULTS: We identified two domains of barriers and facilitating factors: personal and systems-based. Sub-themes in the personal domain included fellows' perceived resistance to consultations, residents' willingness to engage in teaching interactions, and perceptions and expectations. Sub-themes in the systems-based domain included the process of requesting the consult, the quality of the consult request, primary team structure, familiarity between residents and fellows, workload, work experience, culture of subspecialty divisions, and fellows' teaching skills. These barriers differentially affected the two stages of the consult identified in the focus groups (initial interaction and follow-up interaction). CONCLUSIONS: Residents and fellows want to engage in positive teaching interactions in the context of the clinical consult; however, multiple barriers influence both parties in the hospital environment. Many of these barriers are amenable to change. Interventions aimed at reducing barriers to teaching in the setting of consultation hold promise for improving teaching and learning on the wards.

Outcomes and Management After COVID-19 Critical Illness.

TOPIC IMPORTANCE: COVID-19 has caused > 7 million deaths worldwide since its onset in 2019. Although the severity of illness has varied throughout the pandemic, critical illness related to COVID-19 persists. Survivors of COVID-19 critical illness can be left with sequelae of both the SARS-CoV-2 virus and long-term effects of critical illness included within post-intensive care syndrome. Given the complexity and heterogeneity of COVID-19 critical illness, the biopsychosocial-ecological model can aid in evaluation and treatment of survivors, integrating interactions among physical, cognitive, and psychological domains, as well as social systems and environments. REVIEW FINDINGS: Prolonged illness after COVID-19 critical illness generally can be classified into effects on physical, cognitive, and psychosocial function, with much interaction among the various effects, and includes a wide range of symptoms such as ICU-acquired weakness, prolonged respiratory symptoms, cognitive changes, post-traumatic stress disorder post-traumatic stress disorder, anxiety, and depression. Risk factors for COVID-19 critical illness developing are complex and include preexisting factors, disease course, and specifics of hospitalization in addition to psychological comorbidities and socioenvironmental factors. Recovery trajectories are not well defined, and management requires a comprehensive, interdisciplinary, and individualized approach to care. SUMMARY: The onset of vaccinations, new therapeutics, and new strains of SARS-CoV-2 virus have decreased COVID-19 mortality; however, the number of survivors of COVID-19 critical illness remains high. A biopsychosocial-ecological approach is recommended to guide care of COVID-19 critical illness survivors.

Post-intensive cardiac care outpatient long-term outreach clinic (PICCOLO clinic): Defining health care needs and outcomes among coronary care unit survivors.

Objective: Patients who survive critical illness endure complex physical and mental health conditions, referred to as post-intensive care syndrome (PICS). The University of Michigan's post-intensive cardiac care outpatient long-term outreach (PICCOLO) clinic is designed for patients recently admitted to the coronary care unit (CCU). The long-term goal of this clinic is to understand post-CCU patients' needs and design targeted interventions to reduce their morbidity and mortality post-discharge. As a first step toward this goal, we aimed to define the post-discharge needs of CCU survivors. Design setting particpants: We retrospectively reviewed case-mix data (including rates of depression, PTSD, disability, and cognitive abnormalities) and health outcomes for patients referred to the PICCOLO clinic from July 1, 2018, through June 30, 2021 at Michigan Medicine. Results: Of the 134 referred patients meeting inclusion criteria, 74 (55 %) patients were seen in the PICCOLO clinic within 30 days of discharge. Patients seen in the clinic frequently screened positive for depression (PHQ-2 score ≥3, 21.4 %) and cognitive impairment (MOCA <26, 38.8 %). Further, patients also reported high rates of physical difficulty (mean WHODAS 2.0 score 28.4 %, consistent with moderate physical difficulty). Consistent with medical intensive care unit (ICU) patients, CCU survivors experience PICS. Conclusion: This work highlights the feasibility of an outpatient care model and the need to leverage information gathered from this care model to develop treatment strategies and pathways to address symptoms of PICS in CCU survivors, including depression, cognitive impairment, and physical disability.

Identification of Patient Safety Threats in a Post-Intensive Care Clinic.

The extent to which postintensive care unit (ICU) clinics may improve patient safety for those discharged after receiving intensive care remains unclear. This observational cohort study conducted at an academic, tertiary care medical center used qualitative survey data analyzed via conventional content analysis to describe patient safety threats encountered in the post-ICU clinic. For 83 included patients, safety threats were identified for 60 patients resulting in 96 separate safety threats. These were categorized into 7 themes: medication errors (27%); inadequate medical follow-up (25%); inadequate patient support (16%); high-risk behaviors (5%); medical complications (5%); equipment/supplies failures (4%); and other (18%). Of the 96 safety threats, 41% were preventable, 27% ameliorable, and 32% were neither preventable nor ameliorable. Nearly 3 out of 4 patients within a post-ICU clinic had an identifiable safety threat. Medication errors and delayed medical follow-up were the most common safety threats identified; most were either preventable or ameliorable.

Postoperative venous thromboembolism predicts survival in cancer patients.

OBJECTIVES: To determine whether a postoperative venous thromboembolism (VTE) is associated with a worse prognosis and/or a more advanced cancer stage and to evaluate the association between a postoperative VTE and cancer-specific survival when known prognostic factors, such as age, stage, cancer type, and type of surgery, are controlled. CONTEXT: It is unknown whether oncology patients who develop a venous thromboembolism after a complete curative resection are at the same survival disadvantage as oncology patients with a spontaneous VTE. METHODS: A retrospective case control study was conducted at Memorial Sloan-Kettering Cancer Center. Years of study: January 1, 2000, to December 31, 2005. Median follow-up: 24.9 months (Interquartile range 13.0, 43.0). All cancer patients who underwent abdominal, pelvic, thoracic, or soft tissue procedures and those who developed a VTE within 30 days of the procedure were identified from a prospective morbidity and mortality database. Overall survival (OS) was calculated for the entire cohort. In the matched cohort, OS and disease-specific survival (DSS) were calculated for stages 0 to 3 and stages 0 to 2. RESULTS: A total of 23,541 cancer patients underwent an invasive procedure and 474 (2%) had a postoperative VTE. VTE patients had a significantly worse 5-year OS compared to no-VTE patients (43.8% vs 61.2%; P < 0.0001); 205 VTE patients (stages 0-3) were matched to 2050 controls by age, sex, cancer type, stage, and surgical procedure. In this matched analysis, VTE patients continued to demonstrate a significantly worse prognosis with an inferior 5-year OS (54.7% vs 66.3%; P < 0.0001) and DSS (67.8% vs 79.5%; P = 0.0007) as compared to controls. The survival difference persisted in early stage disease (stage 0-2), with 5-year DSS of 82.9% versus 87.3% (P = 0.01). CONCLUSIONS: Postoperative VTE in oncology patients with limited disease and a complete surgical resection is associated with an inferior cancer survival. A postoperative VTE remains a poor prognostic factor, even when controlling for age, stage, cancer type, and surgical procedure further supporting an independent link between hypercoagulability and cancer survival.

Survivorship After Critical Illness and Post-Intensive Care Syndrome.

Improvements in critical care medicine have led to a marked increase in survivors of the intensive care unit (ICU). These survivors encounter many difficulties following ICU discharge. The term post -intensive care syndrome (PICS) provides a framework for identifying the most common symptoms which fall into three domains: cognitive, physical, and mental health. There are numerous risk factors for the development of PICS including premorbid conditions and specific elements of ICU hospitalizations. Management is complex and should take an individualized approach with interdisciplinary care. Future research should focus on prevention, identification, and treatment of this unique population.

Characteristics of Post-ICU and Post-COVID Recovery Clinics in 29 U.S. Health Systems.

The multifaceted long-term impairments resulting from critical illness and COVID-19 require interdisciplinary management approaches in the recovery phase of illness. Operational insights into the structure and process of recovery clinics (RCs) from heterogeneous health systems are needed. This study describes the structure and process characteristics of existing and newly implemented ICU-RCs and COVID-RCs in a subset of large health systems in the United States. DESIGN: Cross-sectional survey. SETTING: Thirty-nine RCs, representing a combined 156 hospitals within 29 health systems participated. PATIENTS: None. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: RC demographics, referral criteria, and operating characteristics were collected, including measures used to assess physical, psychologic, and cognitive recoveries. Thirty-nine RC surveys were completed (94% response rate). ICU-RC teams included physicians, pharmacists, social workers, physical therapists, and advanced practice providers. Funding sources for ICU-RCs included clinical billing (n = 20, 77%), volunteer staff support (n = 15, 58%), institutional staff/space support (n = 13, 46%), and grant or foundation funding (n = 3, 12%). Forty-six percent of RCs report patient visit durations of 1 hour or longer. ICU-RC teams reported use of validated scales to assess psychologic recovery (93%), physical recovery (89%), and cognitive recovery (86%) more often in standard visits compared with COVID-RC teams (psychologic, 54%; physical, 69%; and cognitive, 46%). CONCLUSIONS: Operating structures of RCs vary, though almost all describe modest capacity and reliance on volunteerism and discretionary institutional support. ICU- and COVID-RCs in the United States employ varied funding sources and endorse different assessment measures during visits to guide care coordination. Common features include integration of ICU clinicians, interdisciplinary approach, and focus on severe critical illness. The heterogeneity in RC structures and processes contributes to future research on the optimal structure and process to achieve the best postintensive care syndrome and postacute sequelae of COVID outcomes.

Cohort study of hospitalists' procedural skills: baseline competence and durability after simulation-based training.

OBJECTIVES: Hospitalists are expected to be competent in performing bedside procedures, which are associated with significant morbidity and mortality. A national decline in procedures performed by hospitalists has prompted questions about their procedural competency. Additionally, though simulation-based mastery learning (SBML) has been shown to be effective among trainees whether this approach has enduring benefits for independent practitioners who already have experience is unknown. We aimed to assess the baseline procedural skill of hospitalists already credentialed to perform procedures. We hypothesised that simulation-based training of hospitalists would result in durable skill gains after several months. DESIGN: Prospective cohort study with pretraining and post-training measurements. SETTING: Single, large, urban academic medical centre in the USA. PARTICIPANTS: Twenty-two out of 38 eligible participants defined as hospitalists working on teaching services where they would supervise trainees performing procedures. INTERVENTIONS: One-on-one, 60 min SBML of lumbar puncture (LP) and abdominal paracentesis (AP). PRIMARY AND SECONDARY OUTCOME MEASURES: Our primary outcome was the percentage of hospitalists obtaining minimum passing scores (MPS) on LP and AP checklists; our secondary outcomes were average checklist scores and self-reported confidence. RESULTS: At baseline, only 16% hospitalists met or exceeded the MPS for LP and 32% for AP. Immediately after SBML, 100% of hospitalists reached this threshold. Reassessment an average of 7 months later revealed that only 40% of hospitalists achieved the MPS. Confidence increased initially after training but declined over time. CONCLUSIONS: Hospitalists may be performing invasive bedside procedures without demonstration of adequate skill. A single evidence-based training intervention was insufficient to sustain skills for the majority of hospitalists over a short period of time. More stringent practices for certifying hospitalists who perform risky procedures are warranted, as well as mechanisms to support skill maintenance, such as periodic simulation-based training and assessment.

Validating Measures of Disease Severity in Acute Respiratory Distress Syndrome.

Rationale: Quantifying acute respiratory disease syndrome (ARDS) severity is essential for prognostic enrichment to stratify patients for invasive or higher-risk treatments; however, the comparative performance of many ARDS severity measures is unknown.Objectives: To validate ARDS severity measures for their ability to predict hospital mortality and an ARDS-specific outcome (defined as death from pulmonary dysfunction or the need for extracorporeal membrane oxygenation [ECMO] therapy).Methods: We compared five individual ARDS severity measures including the ratio of arterial oxygen tension/pressure to fraction of inspired oxygen (PaO2/FiO2 ratio), oxygenation index, ventilatory ratio, lung compliance, and radiologic assessment of lung edema (RALE); two ARDS composite severity scores including the Murray Lung Injury Score, and a novel score combining RALE, PaO2/FiO2 ratio, and ventilatory ratio; and the Acute Physiology and Chronic Health Evaluation IV score, using data collected at ARDS onset in patients hospitalized at a single center in 2016 and 2017. Discrimination of hospital mortality and the ARDS-specific outcome was evaluated using the area under the receiver operator characteristic curve (AUROC). Measure calibration was also evaluated.Results: Among 340 patients with ARDS, 125 (37%) died during hospitalization and 36 (10.6%) had the ARDS-specific outcome, including one who received ECMO. Among the five individual ARDS severity measures, the RALE score had the highest discrimination of the ARDS-specific outcome (AUROC = 0.67; 95% confidence interval [CI], 0.58-0.77), although other ARDS severity measures had similar performance. However, their ability to discriminate overall mortality was low. In contrast, the Acute Physiology and Chronic Health Evaluation IV score best discriminated overall mortality (AUROC = 0.73; 95% CI, 0.67-0.79) but was unable to discriminate the ARDS-specific outcome (AUROC = 0.54; 95% CI, 0.44-0.65). Among ARDS composite severity scores, the lung injury score had an AUROC = 0.67 (95% CI, 0.58-0.75) for the ARDS-specific outcome whereas the novel score had an AUROC = 0.70 (95% CI, 0.61-0.79). Patients grouped by quartile of the novel score had a 6%, 2%, 10%, and 24% rate of the ARDS-specific outcome.Conclusions: Although most ARDS severity measures had poor discrimination of hospital mortality, they performed better at predicting death from severe pulmonary dysfunction or ECMO needs. A novel composite score had the highest discrimination of this outcome.

Impact of Risk and Volume on Procedural Traning of Pulmonary and Critical Care Fellows.

Background: Invasive procedures are a core aspect of pulmonary and critical care practice. Procedures performed in the intensive care unit can be divided into high-risk, low-volume (HRLV) procedures and low-risk, high-volume (LRHV) procedures. HRLV procedures include cricothyroidotomy, pericardiocentesis, Blakemore tube placement, and bronchial blocker placement. LRHV procedures include arterial line placement, central venous catheter placement, thoracentesis, and flexible bronchoscopy. Despite the frequency and importance of procedures in critical care medicine, little is known about the similarities and differences in procedural training between different Pulmonary and Critical Care Medicine (PCCM) and Critical Care Medicine (CCM) training programs. Furthermore, differences in procedural training practices for HRLV and LRHV procedures have not previously been described.Objective: To assess procedural training practices in PCCM and CCM fellowship programs in the United States, and compare differences in training between HRLV and LRHV procedures.Methods: A novel survey instrument was developed and disseminated to PCCM and CCM program directors and associate program directors at PCCM and CCM fellowship programs in the United States to assess procedural teaching practices for HRLV and LRHV procedures.Results: The survey was sent to 221 fellowship programs, 168 PCCM and 34 CCM, with 70 unique respondents (31.7% response rate). Of the procedural educational strategies assessed, each strategy was used significantly more frequently for LRHV versus HRLV procedures. The majority of respondents (51.1%) report having no dedicated training for HRLV procedures versus 6.9% reporting no dedicated training for any LRHV procedure (P < 0.001). For HRLV procedures, 76.9% of respondents indicated that there was no set number of procedures required to determine competency, versus 25.3% for LRHV procedures (P < 0.001). For LRHV procedures, fellows were allowed to perform procedures independently without supervision 21.7% of the time versus 3.9% for HRLV procedures (P = 0.004). Program directors' confidence in their ability to determine fellows' competence in performing procedures was significantly lower for HRLV versus LRHV versus HRLV procedures (P < 0.001).Conclusion: Significant differences exist in procedural training education for PCCM and CCM fellows for LRHV versus HRLV procedures, and awareness of this discrepancy presents an opportunity to address this educational gap in PCCM and CCM fellowship training.

Variation in COVID-19 disease severity at hospital admission over time and across hospitals: A multi-institution cohort of Michigan hospitals.

ABSTRACT: During the spring 2020 COVID-19 surge, hospitals in Southeast Michigan were overwhelmed, and hospital beds were limited. However, it is unknown whether threshold for hospital admission varied across hospitals or over time.Using a statewide registry, we performed a retrospective cohort study. We identified adult patients hospitalized with COVID-19 in Southeast Michigan (3/1/2020-6/1/2020). We classified disease severity on admission using the World Health Organization (WHO) ordinal scale. Our primary measure of interest was the proportion of patients admitted on room air. We also determined the proportion without acute organ dysfunction on admission or any point during hospitalization. We quantified variation across hospitals and over time by half-month epochs.Among 1315 hospitalizations across 22 hospitals, 57.3% (754/1,315) were admitted on room air, and 26.1% (343/1,315) remained on room air for the duration of hospitalization. Across hospitals, the proportion of COVID-19 hospitalizations admitted on room air varied from 32.3% to 80.0%. Across half-month epochs, the proportion ranged from 49.4% to 69.4% and nadired in early April 2020. Among patients admitted on room air, 75.1% (566/754) had no acute organ dysfunction on admission, and 35.3% (266/754) never developed acute organ dysfunction at any point during hospitalization; there was marked variation in both proportions across hospitals. In-hospital mortality was 13.7% for patients admitted on room air vs 26.3% for patients requiring nasal cannula oxygen.Among patients hospitalized with COVID-19 during the spring 2020 surge in Southeast Michigan, more than half were on room air and a third had no acute organ dysfunction upon admission, but experienced high rates of disease progression and in-hospital mortality.