Development of a Complex Care Transition Team to Improve the Transition of Patients With Complex Care Needs to the Community.

PURPOSE: Health care systems have historically struggled to provide adequate care for patients with complex care needs that often result in overuse of hospital and emergency department resources. Patients with complex care needs generally have increased expenses, longer length of hospital stays, an increased need for care management resources during hospitalization, and high readmission rates. Mayo Clinic in Arizona aimed to ensure successful transitions for hospitalized patients with complex care needs to the community by developing a complex care transition team (CCTT) program. With typical care management models, patients are assigned to registered nurse case managers and social workers according to the inpatient nursing unit rather than patient care complexity. Patients with complex care needs may not receive the amount of time needed to ensure an efficient and effective transition to the community setting. Furthermore, after transitioning to the community, patients with complex care needs often do not have access to care management resources if further care coordination needs arise. PRIMARY PRACTICE SETTING: Acute care hospital in the US Southwest. METHODOLOGY AND SAMPLE: The CCTT was composed of a registered nurse case manager, social worker, and care management assistant, with physician advisor support. The CCTT followed patients with complex care needs during their hospitalization and transition to the community for 90 days after discharge. The number of inpatient admissions and hospital readmission rates were compared between 6 months before and after enrollment in the CCTT program. Cost savings for decreased hospital length of stay, emergency department visits, and hospital readmissions were also determined. RESULTS: The CCTT selected patients according to a complex care algorithm, which identified patients who required high use of the health care system. The CCTT then followed this cohort of patients for an average of 90 days after discharge. A total of 123 patients were enrolled in the CCTT program from July 1, 2019, to April 30, 2021, and 80 patients successfully graduated from the program. Readmission rates decreased from 51.2% at 6 months before the intervention to 22.0% at 6 months after the intervention. This reduced readmission rate resulted in a cost savings of more than $1 million. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The outcomes resulting from implementation of the multidisciplinary CCTT highlight the need for a patient-specific approach to transitioning care to the outpatient setting. The patient social determinants of health that often contributed to overuse of health care resources included poor access to outpatient specialists, difficulty navigating the health care system due to illness or poor health literacy, and limited social support. The success of the CCTT program prompted the implementation of other specialty-specific pilot programs at Mayo Clinic in Arizona. The investment of time and resources, including dedicated personnel to follow patients with high hospital service usage, allows health care systems to reduce emergency department visits and hospital admissions and to provide patients with the best opportunity for success as they transition from the inpatient to outpatient setting.

Esophageal Actinomycosis Presenting as an Obstructive Esophageal Mass.

Esophageal actinomycosis is a rare type of esophageal infection, with only approximately 24 cases previously reported in the United States. Most of these cases were described as erosions or ulcers when examined endoscopically. We present a 47-year-old woman who presented with dysphagia. Endoscopy showed a lower esophageal fungating mass, mimicking a malignant mass. Although there was a high suspicion of esophageal carcinoma, biopsy results showed esophageal actinomyces infection.

Predictive value of methicillin-resistant Staphylococcus aureus (MRSA) nasal swab PCR assay for MRSA pneumonia.

Pneumonia due to methicillin-resistant Staphylococcus aureus (MRSA) is associated with poor outcomes and frequently merits empirical antibiotic consideration despite its relatively low incidence. Nasal colonization with MRSA is associated with clinical MRSA infection and can be reliably detected using the nasal swab PCR assay. In this study, we evaluated the performance of the nasal swab MRSA PCR in predicting MRSA pneumonia. A retrospective cohort study was performed in a tertiary care center from January 2009 to July 2011. All patients with confirmed pneumonia who had both a nasal swab MRSA PCR test and a bacterial culture within predefined time intervals were included in the study. These data were used to calculate sensitivity, specificity, positive predictive value, and negative predictive value for clinically confirmed MRSA pneumonia. Four hundred thirty-five patients met inclusion criteria. The majority of cases were classified as either health care-associated (HCAP) (54.7%) or community-acquired (CAP) (34%) pneumonia. MRSA nasal PCR was positive in 62 (14.3%) cases. MRSA pneumonia was confirmed by culture in 25 (5.7%) cases. The MRSA PCR assay demonstrated 88.0% sensitivity and 90.1% specificity, with a positive predictive value of 35.4% and a negative predictive value of 99.2%. In patients with pneumonia, the MRSA PCR nasal swab has a poor positive predictive value but an excellent negative predictive value for MRSA pneumonia in populations with low MRSA pneumonia incidence. In cases of culture-negative pneumonia where initial empirical antibiotics include an MRSA-active agent, a negative MRSA PCR swab can be reasonably used to guide antibiotic de-escalation.

Guideline-concordant antibiotic therapy and clinical outcomes in healthcare-associated pneumonia.

BACKGROUND: The 2005 ATS/IDSA guidelines defined healthcare-associated pneumonia (HCAP) as a novel category of pneumonia in patients with significant healthcare exposure in whom the risk of drug resistant bacteria may be higher. In this study, we compare clinical outcomes in patients with HCAP who were treated with guideline-concordant antibiotic regimens with those who were not. METHODS: Medical records of 100 patients meeting HCAP criteria admitted to an academic tertiary care hospital between January 2009 and January 2011 were retrospectively reviewed. Cases were divided into guideline-concordant and guideline-discordant groups based on antibiotic therapy. Demographic, microbiological and clinical outcome data were compared for both groups. RESULTS: Patients in this cohort had multiple co-morbidities, severe pneumonia (mean PSI score 124.1), and significant mortality (22%). 21 of the 100 cases (21.0%) were culture positive, of which 11 (53.8%) represented drug-resistant pathogens. No statistically significant differences for any of the four clinical outcome measures were detected between the guideline-concordant therapy group and guideline-discordant group. In multivariate regression analysis controlling for possible confounders, similar results were observed, with the exception that length of stay was significantly longer (3.99 days, p < 0.001) in the discordant group. Three or more HCAP criteria (OR 10.89) and wound care (OR 6.32) were characteristics found to be associated with increased risk for drug-resistant pathogens. CONCLUSION: In our cohort, the HCAP model identified a population with significant co-morbidities and increased risk for drug-resistant pathogens, severe pneumonia, and increased mortality. However, clinical outcomes were not significantly improved with guideline-concordant antibiotic therapy.

Asymmetric synthesis of beta-hydroxy amino acids via aldol reactions catalyzed by chiral ammonium salts.

The Cinchona alkaloid derived chiral ammonium salt developed by Park and Jew functions as an effective catalyst for the synthesis of beta-hydroxy alpha-amino acids via asymmetric aldol reactions under homogeneous conditions. The syn diastereomers are obtained in good ee, and aryl-substituted aliphatic aldehydes are the best substrates for the reaction. These results represent the highest ee's obtained to date in direct aldol reactions of glycine equivalents catalyzed by inexpensive, readily prepared chiral ammonium salts.