Discharge in the a.m.: A randomized controlled trial of physician rounding styles to improve hospital throughput and length of stay.

BACKGROUND: To relieve hospital capacity strain, hospitals often encourage clinicians to prioritize early morning discharges which may have unintended consequences. OBJECTIVE: We aimed to test the effects of hospitalist physicians prioritizing discharging patients first compared to usual rounding style. DESIGN, SETTING AND PARTICIPANTS: Prospective, multi-center randomized controlled trial. Three large academic hospitals. Participants were Hospital Medicine attending-level physicians and patients the physicians cared for during the study who were at least 18 years of age, admitted to a Medicine service, and assigned by standard practice to a hospitalist team. INTERVENTION: Physicians were randomized to: (1) prioritizing discharging patients first as care allowed or (2) usual practice. MAIN OUTCOME AND MEASURES: Main outcome measure was discharge order time. Secondary outcomes were actual discharge time, length of stay (LOS), and order times for procedures, consults, and imaging. RESULTS: From February 9, 2021, to July 31, 2021, 4437 patients were discharged by 59 physicians randomized to prioritize discharging patients first or round per usual practice. In primary adjusted analyses (intention-to-treat), findings showed no significant difference for discharge order time (13:03 ± 2 h:31 min vs. 13:11 ± 2 h:33 min, p = .11) or discharge time (15:22 ± 2 h:50 min vs. 15:21 ± 2 h:50 min, p = .45), for physicians randomized to prioritize discharging patients first compared to physicians using usual rounding style, respectively, and there was no significant change in LOS or on order times of other physician orders. CONCLUSIONS: Prioritizing discharging patients first did not result in significantly earlier discharges or reduced LOS.

Predictors for Surgical Referral in Patients With Pancreatic Cystic Lesions Undergoing Endoscopic Ultrasound: Results From a Large Multicenter Cohort Study.

OBJECTIVE: Endoscopic ultrasound (EUS) plays an integral role in the evaluation of pancreatic cysts lesions (PCLs). The aim of the study was to determine predictors of surgical referral in patients with PCLs undergoing EUS. METHODS: We performed a multicenter retrospective study of patients undergoing EUS for evaluation of PCLs. Demographics, EUS characteristics, and fine-needle aspiration results were recorded. Patients were categorized into surgery or surveillance groups on the basis of post-EUS recommendations. Univariate and multivariate analyses were performed to identify predictors of surgical referral. RESULTS: 1804 patients were included. 1301 patients were recommended to undergo surveillance and 503 patients were referred for surgical evaluation, of which 360 patients underwent surgery. Multivariate analysis revealed the following 5 independent predictors of surgical referral: symptoms of weight loss on presentation (odds ratio [OR], 2.69; 95% confidence interval [CI], 1.44-5.03), EUS findings of associated solid mass (OR, 7.34; 95% CI, 3.81-14.16), main duct communication (OR, 4.13; 95% CI, 1.71-9.98), multilocular macrocystic morphology (OR, 2.79; 95% CI, 1.78-4.38), and fine-needle aspiration findings of mucin on cytology (OR, 3.06; 95% CI, 1.94-4.82). CONCLUSIONS: This study identifies factors associated with surgical referral in patients with PCLs undergoing EUS. Future studies should focus on creation of risk stratification models to determine the need for surgery or enrollment in surveillance programs.

Suboptimal accuracy of carcinoembryonic antigen in differentiation of mucinous and nonmucinous pancreatic cysts: results of a large multicenter study.

BACKGROUND AND AIMS: The exact cutoff value at which pancreatic cyst fluid carcinoembryonic antigen (CEA) level distinguishes pancreatic mucinous cystic neoplasms (MCNs) from pancreatic nonmucinous cystic neoplasms (NMCNs) is unclear. The aim of this multicenter retrospective study was to evaluate the diagnostic accuracy of cyst fluid CEA levels in differentiating between MCNs and NMCNs. METHODS: Consecutive patients who underwent EUS with FNA at 3 tertiary care centers were identified. Patients with histologic confirmation of cyst type based on surgical specimens served as the criterion standard for this analysis. Demographic characteristics, EUS morphology, FNA fluid, and cytology results were recorded. Multivariate logistic regression analysis to identify predictors of MCNs was performed. Receiver-operating characteristic (ROC) curves were generated for CEA levels. RESULTS: A total of 226 patients underwent surgery (mean age, 61 years, 96% white patients, 39% female patients) of whom 88% underwent Whipple's procedure or distal pancreatectomy. Based on surgical histopathology, there were 150 MCNs and 76 NMCNs cases. The median CEA level was 165 ng/mL. The area under the ROC curve for CEA levels in differentiating between MCNs and NMCNs was 0.77 (95% confidence interval, 0.71-0.84, P < .01) with a cutoff of 105 ng/mL, demonstrating a sensitivity and specificity of 70% and 63%, respectively. The cutoff value of 192 ng/mL yielded a sensitivity of 61% and a specificity of 77% and would misdiagnose 39% of MCN cases. CONCLUSIONS: Cyst fluid CEA levels have a clinically suboptimal accuracy level in differentiating MCNs from NMCNs. Future studies should focus on novel cyst fluid markers to improve risk stratification of pancreatic cystic neoplasms.