Patient Trajectories Among Persons Hospitalized for COVID-19 : A Cohort Study.

BACKGROUND: Risk factors for progression of coronavirus disease 2019 (COVID-19) to severe disease or death are underexplored in U.S. cohorts. OBJECTIVE: To determine the factors on hospital admission that are predictive of severe disease or death from COVID-19. DESIGN: Retrospective cohort analysis. SETTING: Five hospitals in the Maryland and Washington, DC, area. PATIENTS: 832 consecutive COVID-19 admissions from 4 March to 24 April 2020, with follow-up through 27 June 2020. MEASUREMENTS: Patient trajectories and outcomes, categorized by using the World Health Organization COVID-19 disease severity scale. Primary outcomes were death and a composite of severe disease or death. RESULTS: Median patient age was 64 years (range, 1 to 108 years); 47% were women, 40% were Black, 16% were Latinx, and 21% were nursing home residents. Among all patients, 131 (16%) died and 694 (83%) were discharged (523 [63%] had mild to moderate disease and 171 [20%] had severe disease). Of deaths, 66 (50%) were nursing home residents. Of 787 patients admitted with mild to moderate disease, 302 (38%) progressed to severe disease or death: 181 (60%) by day 2 and 238 (79%) by day 4. Patients had markedly different probabilities of disease progression on the basis of age, nursing home residence, comorbid conditions, obesity, respiratory symptoms, respiratory rate, fever, absolute lymphocyte count, hypoalbuminemia, troponin level, and C-reactive protein level and the interactions among these factors. Using only factors present on admission, a model to predict in-hospital disease progression had an area under the curve of 0.85, 0.79, and 0.79 at days 2, 4, and 7, respectively. LIMITATION: The study was done in a single health care system. CONCLUSION: A combination of demographic and clinical variables is strongly associated with severe COVID-19 disease or death and their early onset. The COVID-19 Inpatient Risk Calculator (CIRC), using factors present on admission, can inform clinical and resource allocation decisions. PRIMARY FUNDING SOURCE: Hopkins inHealth and COVID-19 Administrative Supplement for the HHS Region 3 Treatment Center from the Office of the Assistant Secretary for Preparedness and Response.

Development and implementation of an alcohol withdrawal protocol using a 5-item scale, the Brief Alcohol Withdrawal Scale (BAWS).

BACKGROUND: The standard of care for management of alcohol withdrawal is symptom-triggered treatment using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar). Many items of this 10-question scale rely on subjective assessments of withdrawal symptoms, making it time-consuming and cumbersome to use. Therefore, there is interest in shorter and more objective methods to assess alcohol withdrawal symptoms. METHODS: A 6-item withdrawal scale developed at another institution was piloted. Based on comparison with the CIWA-Ar, this was adapted into a 5-item scale named the Brief Alcohol Withdrawal Scale (BAWS). The BAWS was compared with the CIWA-Ar and a withdrawal protocol utilizing the BAWS was developed. The new protocol was implemented on an inpatient unit dedicated to treating substance withdrawal. Data was collected on the first 3 months of implementation and compared with the 3 months prior to that. RESULTS: A BAWS score of 3 or more predicted CIWA-Ar score ≥8 with a sensitivity of 85.3% and specificity of 65.8%. The demographics of the patients in the 2 time periods were similar: the mean age was 45.9; 70.6% were male; 30.9% received concurrent treatment for opioid withdrawal; and 14.2% were receiving methadone maintenance. During the BAWS phase, patients received significantly less diazepam (mean dose 81.4 vs. 60.3 mg, P < .001). There was no significant difference in length of stay. No patients experienced a seizure, delirium, or required transfer to a higher level of care during any of the 664 admissions in either phase. CONCLUSIONS: This simple protocol utilizing a 5-item withdrawal scale performed well in this setting. Its use in other settings, particularly with patients with concurrent medical illnesses or more severe withdrawal, needs to be explored further.

A novel bedside cardiopulmonary physical diagnosis curriculum for internal medicine postgraduate training.

BACKGROUND: Physicians spend less time at the bedside in the modern hospital setting which has contributed to a decline in physical diagnosis, and in particular, cardiopulmonary examination skills. This trend may be a source of diagnostic error and threatens to erode the patient-physician relationship. We created a new bedside cardiopulmonary physical diagnosis curriculum and assessed its effects on post-graduate year-1 (PGY-1; interns) attitudes, confidence and skill. METHODS: One hundred five internal medicine interns in a large U.S. internal medicine residency program participated in the Advancing Bedside Cardiopulmonary Examination Skills (ACE) curriculum while rotating on a general medicine inpatient service between 2015 and 2017. Teaching sessions included exam demonstrations using healthy volunteers and real patients, imaging didactics, computer learning/high-fidelity simulation, and bedside teaching with experienced clinicians. Primary outcomes were attitudes, confidence and skill in the cardiopulmonary physical exam as determined by a self-assessment survey, and a validated online cardiovascular examination (CE). RESULTS: Interns who participated in ACE (ACE interns) by mid-year more strongly agreed they had received adequate training in the cardiopulmonary exam compared with non-ACE interns. ACE interns were more confident than non-ACE interns in performing a cardiac exam, assessing the jugular venous pressure, distinguishing 'a' from 'v' waves, and classifying systolic murmurs as crescendo-decrescendo or holosystolic. Only ACE interns had a significant improvement in score on the mid-year CE. CONCLUSIONS: A comprehensive bedside cardiopulmonary physical diagnosis curriculum improved trainee attitudes, confidence and skill in the cardiopulmonary examination. These results provide an opportunity to re-examine the way physical examination is taught and assessed in residency training programs.

The association of sleep quality, delirium, and sedation status with daily participation in physical therapy in the ICU.

BACKGROUND: Poor sleep is common in the ICU setting and may represent a modifiable risk factor for patient participation in ICU-based physical therapy (PT) interventions. This study evaluates the association of perceived sleep quality, delirium, sedation, and other clinically important patient and ICU factors with participation in physical therapy (PT) interventions. METHOD: This was a secondary analysis of a prospective observational study of sleep in a single academic medical ICU (MICU). Perceived sleep quality was assessed using the Richards-Campbell Sleep Questionnaire (RCSQ) and delirium was assessed using the Confusion Assessment Method for the ICU (CAM-ICU). Other covariates included demographics, pre-hospitalization ambulation status, ICU admission diagnosis, daily mechanical ventilation status, and daily administration of benzodiazepines and opioids via bolus and continuous infusion. Associations with participation in PT interventions were assessed among patients eligible for PT using a multinomial Markov model with robust variance estimates. RESULTS: Overall, 327 consecutive MICU patients completed ≥1 assessment of perceived sleep quality. After adjusting for all covariates, daily assessment of perceived sleep quality was not associated with transitioning to participate in PT the following day (relative risk ratio [RRR] 1.02, 95 % CI 0.96-1.07, p = 0.55). However, the following factors had significant negative associations with participating in subsequent PT interventions: delirium (RRR 0.58, 95 % CI 0.41-0.76, p <0.001), opioid boluses (RRR 0.68, 95 % CI 0.47-0.99, p = 0.04), and continuous sedation infusions (RRR 0.58, 95 % CI 0.40-0.85, p = 0.01). Additionally, in patients with delirium, benzodiazepine boluses further reduced participation in subsequent PT interventions (RRR 0.25, 95 % CI 0.13-0.50, p <0.001). CONCLUSIONS: Perceived sleep quality was not associated with participation in PT interventions the following day. However, continuous sedation infusions, opioid boluses, and delirium, particularly when occurring with administration of benzodiazepine boluses, were negatively associated with subsequent PT interventions and represent important modifiable factors for increasing participation in ICU-based PT interventions.

Delirium transitions in the medical ICU: exploring the role of sleep quality and other factors.

OBJECTIVES: Disrupted sleep is a common and potentially modifiable risk factor for delirium in the ICU. As part of a quality improvement project to promote sleep in the ICU, we examined the association of perceived sleep quality ratings and other patient and ICU risk factors with daily transition to delirium. DESIGN: Secondary analysis of prospective observational study. SETTING: Medical ICU over a 201-day period. PATIENTS: Two hundred twenty-three patients with greater than or equal to one night in the medical ICU in between two consecutive days of delirium assessment. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Daily perceived sleep quality ratings were measured using the Richards-Campbell Sleep Questionnaire. Delirium was measured twice daily using the Confusion Assessment Method for the ICU. Other covariates evaluated included age, sex, race, ICU admission diagnosis, nighttime mechanical ventilation status, prior day's delirium status, and daily sedation using benzodiazepines and opioids, via both bolus and continuous infusion. Perceived sleep quality was similar in patients who were ever versus never delirious in the ICU (median [interquartile range] ratings, 58 [35-76] vs 57 [33-78], respectively; p = 0.71), and perceived sleep quality was unrelated to delirium transition (adjusted odds ratio, 1.00; 95% CI, 0.99-1.00). In mechanically ventilated patients, receipt of a continuous benzodiazepine and/or opioid infusion was associated with delirium transition (adjusted odds ratio, 4.02; 95% CI, 2.19-7.38; p < 0.001), and patients reporting use of pharmacological sleep aids at home were less likely to transition to delirium (adjusted odds ratio, 0.40; 95% CI, 0.20-0.80; p = 0.01). CONCLUSIONS: We found no association between daily perceived sleep quality ratings and transition to delirium. Infusion of benzodiazepine and/or opioid medications was strongly associated with transition to delirium in the ICU in mechanically ventilated patients and is an important, modifiable risk factor for delirium in critically ill patients.

Transforming the transfer process: A quality improvement project to assess and improve transfer notes.

Transfer notes (TNs) standardize handoffs from one inpatient unit to another to optimize patient safety. They are especially important when patients are downgraded from high acuity settings such as intensive care units (ICU). Despite this, there is a paucity of evidence around safe transfers. The study objective was to assess the impact of a quality improvement initiative on the completion rate and quality of TNs. A retrospective chart review of TNs was conducted at a single academic center in Baltimore, MD. We analyzed 76 MICU to floor transfers pre-intervention and 73 transfers during the intervention period. Note quality was determined using a novel TN assessment tool; validity evidence was established. Chi-square analysis was used to compare the presence and quality of TNs. There was a statistically significant increase in note completion rate from 19.7% to 42.5 % during the study (p < 0.003). There was a statistically significant increase in mean quality of completed TNs (10.3 pre-intervention vs. 12.3 intervention period: maximum score 15, p = 0.005). This QI intervention appears to have translated into more consistent and higher quality TNs. These improvements should facilitate better and safer care of patients moving from MICU to medical floors.

Performance of Cardiovascular Physical Exam Skills by Internal Medicine Residents.

BACKGROUND: Few studies have assessed the ability of internal medicine residents to perform a cardiovascular physical examination using real patients. METHODS: First year internal medicine interns from 2 large academic medical centers in Maryland examined the same patient with aortic insufficiency as part of the Assessment of Physical Examination and Communication Skills (APECS). Interns were assessed on 5 clinical domains: physical exam technique, identifying physical signs, generating a differential diagnosis, clinical judgment, and maintaining patient welfare. Spearman's correlation test was used to describe associations between clinical domains. Preceptor comments were examined to identify common errors in physical exam technique and identifying physical signs. RESULTS: One hundred nine interns examined the same patient with aortic insufficiency across 14 APECS sessions. Only 58 interns (53.2%) correctly identified the presence of a diastolic murmur, and only 52 interns (47.7%) included aortic insufficiency on their differential diagnosis. There was a significant and positive correlation between physical exam technique and identification of the correct physical findings (r = 0.42, P < .001). Both technique (r = 0.34, P = .003) and identifying findings (r = 0.42, P < .001) were significantly associated with generating an appropriate differential diagnosis. Common errors in technique included auscultating over the gown, timing the cardiac cycle with the radial pulse, and failing to palpate for the apical impulse. CONCLUSIONS: Internal medicine interns had variable skills in performing and interpreting the cardiovascular physical exam. Improving cardiovascular exam skills would likely lead to increased identification of relevant cardiovascular findings, inform clinical decision making and improve overall patient care.

Development of a novel rapid response event review process for quality improvement.

INTRODUCTION: Rapid response team (RRT) and code activation events occur relatively commonly in inpatient settings. RRT systems have been the subject of a significant amount of analysis, although this has been largely focused on the impact of RRT system implementation and RRT events on patient outcomes. There is reason to believe that the structured assessment of RRT and code events may be an effective way to identify opportunities for system improvement, although no standardised approach to event analysis is widely accepted. We developed and refined a protocolised system of RRT and code event review, focused on sustainable, timely and high value event analysis meant to inform ongoing improvement activities. METHODS: A group of clinicians with expertise in process and quality improvement created a protocolised analytic plan for rapid response event review, piloted and then iteratively optimised a systematic process which was applied to all subsequent cases to be reviewed. RESULTS: Hospitalist reviewers were recruited and trained in a methodical approach. Each reviewer performed a chart review to summarise RRT events, and collect specific variables for each case (coding). Coding was then reviewed for concordance, at monthly interdisciplinary group meetings and 'Action Items' were identified and considered for implementation. In any 12-month period starting in 2021, approximately 12-15 distinct cases per month were reviewed and coded, offering ample opportunities to identify trends and patterns. CONCLUSION: We have developed an innovative process for ongoing review of RRT-Code events. The review process is easy to implement and has allowed for the timely identification of high value improvement opportunities.

In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time?

BACKGROUND: The 2003 and 2011 Accreditation Council for Graduate Medical Education (ACGME) common program requirements compress busy inpatient schedules and increase intern supervision. At the same time, interns wrestle with the effects of electronic medical record systems, including documentation needs and availability of an ever-increasing amount of stored patient data. OBJECTIVE: In light of these changes, we conducted a time motion study to determine how internal medicine interns spend their time in the hospital. DESIGN: Descriptive, observational study on inpatient ward rotations at two internal medicine residency programs at large academic medical centers in Baltimore, MD during January, 2012. PARTICIPANTS: Twenty-nine interns at the two residency programs. MAIN MEASURES: The primary outcome was percent of time spent in direct patient care (talking with and examining patients). Secondary outcomes included percent of time spent in indirect patient care, education, and miscellaneous activities (eating, sleeping, and walking). Results were analyzed using multilevel regression analysis adjusted for clustering at the observer and intern levels. KEY RESULTS: Interns were observed for a total of 873 hours. Interns spent 12 % of their time in direct patient care, 64 % in indirect patient care, 15 % in educational activities, and 9 % in miscellaneous activities. Computer use occupied 40 % of interns' time. There was no significant difference in time spent in these activities between the two sites. CONCLUSIONS: Interns today spend a minority of their time directly caring for patients. Compared with interns in time motion studies prior to 2003, interns in our study spent less time in direct patient care and sleeping, and more time talking with other providers and documenting. Reduced work hours in the setting of increasing complexity of medical inpatients, growing volume of patient data, and increased supervision may limit the amount of time interns spend with patients.

Relationship of Physical Examination Technique to Associated Clinical Skills: Results from a Direct Observation Assessment.

BACKGROUND: The purpose of this research was to use direct observation of the physical examination to elucidate the role physical examination technique plays in diagnostic accuracy. Physical examination is important for quality clinical care and requires multiple interrelated skills. The relationship of physical examination technique to related skills is poorly understood. Current methods of teaching and assessing physical examination skills provide few opportunities to evaluate physical examination technique and accuracy. METHODS: The authors developed a clinical examination assessment using volunteer patients and direct observation. Trained faculty preceptors rated resident performance in 7 domains: 1) physical examination technique, 2) identification of physical signs, 3) clinical communication, 4) differential diagnosis, 5) clinical judgment, 6) managing patient concerns, and 7) maintaining patient welfare. The Pearson correlation coefficient was used to determine relationships between performance in each of these domains. Data on residents' self-assessed competency in the physical examination and perceptions of feedback received during the assessment were collected. RESULTS: From December 2018 to February 2020, 113 interns from 2 internal medicine residency programs participated in the assessment. Physical examination technique was significantly correlated with accurate identification of physical signs, differential diagnosis and clinical judgment. Time spent in graduate medical education was negatively correlated with performance. Interns more highly rated the feedback received from this assessment than traditional clinical skills feedback. CONCLUSIONS: Our findings emphasize the necessity of multi-dimensional physical examination assessment. Observed deterioration of physical examination skill during internship may reflect contemporary practice patterns, which deprioritize the physical examination. Future research on physical examination education should focus on the interface between physical examination technique and related clinical skills.