Tell-a provider about tele: Reducing overuse of telemetry across 10 hospitals in a safety net system.

BACKGROUND: Telemetry is often a scarce resource at hospitals and is important for arrhythmia and myocardial ischemia detection. Overuse of telemetry monitoring leads to alarm fatigue resulting in failure to respond to arrhythmias, patient harm, and possible unnecessary testing. METHODS: This quality improvement initiative was implemented across NYC Health and Hospitals, an 11-hospital urban safety net system. The electronic health record intervention involved the addition of a mandatory indication in the telemetry order and a best practice advisory (BPA) that would fire after the recommended time period for reassessment had passed. RESULTS: The average telemetry hours per patient encounter went from 60.1 preintervention to 48.4 postintervention, a 19.5% reduction (p < .001). When stratified by the 11 hospitals, decreases ranged from 9% to 30%. The BPA had a 53% accept rate and fired 52,682 times, with 27,938 "discontinue telemetry" orders placed. The true accept rate was 50.4%, as there was a 2.6% 24-h reorder rate. There was variation based on clinician specialty and clinician type (attending, fellow, resident, physician associate, nurse practitioner). CONCLUSION: We successfully reduced telemetry monitoring across a multisite safety net system using solely an electronic health record (EHR) intervention. This expands on previous telemetry monitoring reduction initiatives using EHR interventions at single academic sites. Further study is needed to investigate variation across clinician type, specialty, and post-acute sites.

National Outreach of Telepalliative Medicine Volunteers for a New York City Safety Net System COVID-19 Pandemic Response.

The coronavirus disease 2019 surge in New York City created an increased demand for palliative care (PC) services. In staff-limited settings such as safety net systems, and amid growing reports of health care worker illness, leveraging help from less-affected areas around the country may provide an untapped source of support. A national social media outreach effort recruited 413 telepalliative medicine volunteers (TPMVs). After expedited credentialing and onboarding of 67 TPMVs, a two-week pilot was initiated in partnership with five public health hospitals without any previous existing telehealth structure. The volunteers completed 109 PC consults in the pilot period. Survey feedback from TPMVs and on-site PC providers was largely positive, with areas of improvement identified around electronic health record navigation and continuity of care. This was a successful, proof of concept, and quality improvement initiative leveraging TPMVs from across the nation for a PC pandemic response in a safety net system.

Gastrointestinal Manifestations of Systemic Sclerosis.

Systemic sclerosis (SSc) is a rare autoimmune disease characterized by fibroproliferative alterations of the microvasculature leading to fibrosis and loss of function of the skin and internal organs. Gastrointestinal manifestations of SSc are the most commonly encountered complications of the disease affecting nearly 90% of the SSc population. Among these complications, the esophagus and the anorectum are the most commonly affected. However, this devastating disorder does not spare any part of the gastrointestinal tract (GIT), and includes the oral cavity, esophagus, stomach, small and large bowels as well as the liver and pancreas. In this review, we present the current understanding of the pathophysiologic mechanisms of SSc including vasculopathy, endothelial to mesenchymal transformation as well as the autoimmune pathogenetic pathways. We also discuss the clinical presentation and diagnosis of each part of the GIT affected by SSc. Finally, we highlight the latest developments in the management of this disease, addressing the severe malnutrition that affects this vulnerable patient population and ways to assess and improve the nutritional status of the patients.

Prevalence and Clinical Characteristics of Rheumatoid Arthritis in an Inner City Population with Sickle Cell Disease.

OBJECTIVES: Rheumatoid arthritis (RA) has been rarely reported in association with sickle cell disease (SCD). Our study aimed to estimate the prevalence of RA in SCD population and to describe the clinical characteristics of RA associated with SCD. METHODS: Retrospective chart review of SCD and RA patients followed at 2 large urban hospitals. Seven RA/SCD patients were identified and compared to age and sex matched cohort of SCD only and of RA only group. All patients were Black. RESULTS: There were 739 SCD cases, seven (0.94%) met ACR criteria for RA (SCD-RA), 411 cases were RA only group. Mean age was significantly higher in SCD-RA compared to the entire population of SCD and RA (41.7 ± 3.9 (± SEM) vs. 33.26 ± 0.47, vs. 61.39 ± 0.79, p<0.01). SCD-RA patients had lower hemoglobin (g/dl) when compared to the age and sex matched SCD or RA only patients (7.4 ± 0.49 vs. 8.3 ± 0.60 vs. 11 ± 0.59, p <0.01) respectively. There were no significant differences in laboratory and treatment approach between SCD-RA and RA only groups, except for the radiographic evidence of periarticular osteopenia and greater difficulty in the activities of daily living (ADL) among SCD-RA cohort, compared to the age and sex matched RA cohort (p=0.01). CONCLUSION: In contrast to older reports, the prevalence of RA among SCD patients in our study (0.94%) was similar to that reported in the general population (0.5-1%) and was to be associated with difficulty in ADL and periarticular osteopenia. Since RA manifests at an older age, our reported prevalence is likely explainable by improved survival of SCD patients due to enhanced medical care and the advent of hydroxyurea as a major therapeutic breakthrough for SCD.

Age-dependent mycorrhizal specificity in an invasive orchid, Oeceoclades maculata.

PREMISE OF THE STUDY: Oeceoclades maculata is a naturalized, invasive, terrestrial orchid in Puerto Rico and elsewhere in the neotropics. We asked whether its success might be partly explained by its mycorrhizal associations, hypothesizing a relationship with many fungal partners or with one widely distributed partner. METHODS: Oeceoclades maculata roots were collected throughout Puerto Rico, and the degree of mycorrhizal colonization was measured. For identification of fungi, the ITS region was sequenced from pure cultures and directly from roots. Representative fungi were used for symbiotic seed germination experiments. KEY RESULTS: Colonization of O. maculata roots was very variable. The most common fungus identified by BLAST searches was Psathyrella cf. candolleana, but typical orchid mycorrhizal fungi (Ceratobasidium and Tulasnella) were also found, as were a range of saprotrophs. Seeds germinated in vitro only in the presence of Psathyrella. CONCLUSIONS: These results are surprising in two respects. First, O. maculata appears to be highly specific for fungi during seed germination, but unusually promiscuous as adult plants. Second, mycorrhizal associations with Psathyrella and with other saprotrophic fungi have been previously reported, but only from mycoheterotrophic (i.e., nonphotosynthetic) orchids, not from green orchids like Oeceoclades. This combination may partly explain the success of Oeceoclades.