Association of a Novel Protocol for Rapid Exclusion of Myocardial Infarction With Resource Use in a US Safety Net Hospital.

Importance: High-sensitivity cardiac troponin T (hs-cTnT) protocols for the evaluation of chest pain in the emergency department (ED) may reduce unnecessary resource use and overcrowding. Objective: To determine whether the implementation of a novel hs-cTnT protocol, which incorporated troponin values drawn at 0, 1, and 3 hours after ED presentation and the modified HEART score (history, electrocardiogram, age, risk factors), was associated with improvements in resource use while maintaining safety. Design, Setting, and Participants: This retrospective cohort study from Parkland Health and Hospital System, a large safety net hospital in Dallas, Texas, included data on 31 543 unique ED encounters in which patients underwent electrocardiographic and troponin testing from January 1, 2017, to October 16, 2018. The hs-cTnT protocol was implemented in December 2017. Main Outcomes and Measures: Resource use outcomes included trends in ED dwell time, troponin to disposition decision time (the difference between the first troponin draw time and the time an order was placed for inpatient admission, admission to observation, or discharge), and final patient disposition. Safety outcomes included readmission for myocardial infarction and death. Results: In 31 543 encounters, mean (SD) patient age was 54 (14.4) years and 14 675 patients (48%) were female. Department dwell time decreased by a mean of -1.09 (95% CI, -2.81 to 0.64) minutes per month in the preintervention period. The decline was steeper after the intervention (-4.69 [95% CI, -9.05 to -0.33] minutes per month) (P for interaction = .007). The troponin to disposition time was increasing in the preintervention period by 1.72 (95% CI, 1.08 to 2.36) minutes per month; postintervention, the mean difference increased more slowly (0.37 [95% CI, -1.25 to 1.99 minutes per month; P value for interaction = .007]). The proportion of patients discharged from the ED increased after the intervention (48% vs 54%, P < .001). Thirty-day major adverse cardiac event rates were low and did not differ before and after the intervention. Conclusions and Relevance: Implementation of a novel protocol incorporating serial hs-cTnT measurements over 3 hours with the Modified HEART Score was associated with reduction in ED dwell times and attenuation of temporal increases in time from troponin measurement to disposition. This or similar protocols to rule out myocardial infarction have the potential to reduce ED overcrowding and improve health care quality while maintaining safety.

Validation and implementation of the fifth-generation high sensitivity Troponin T (hs-TnT) assay at a large teaching county hospital. A laboratory-driven multi-speciality effort.

We describe the validation and implementation of the new 5th generation high sensitivity Troponin T assay (Roche Diagnostics®). In addition to the assay improved sensitivity, the numerical values, reporting units, reference intervals, and critical limits are markedly different. We describe the use of clinical correlation as the basis for implementation and validation of the fifth-generation hs-TnT assay at a large teaching county hospital.

Postdischarge Correlates of Health Literacy Among Medicaid Inpatients.

Health literacy may represent a target for intervention to improve hospital transitions. This study analyzed the association of health literacy with postdischarge utilization among Medicaid patients treated in an integrated health care system. Discharged inpatients covered by Medicaid (N = 112) participated in this observational study set in a single 600-bed hospital in a private, nonprofit, integrated health care system in the southwestern United States. Participants completed surveys within 15 days of discharge, self-reporting demographics, self-care behaviors, and 2 measures of health literacy (REALM-SF [Short Form of the Rapid Estimate of Adult Literacy in Medicine] and Chew [health literacy screen from Chew et al]). Electronic medical records data were incorporated to determine occurrence of 30-day/90-day postdischarge emergency visits and readmission. Half the respondents (54%) scored at the high-school grade equivalent on REALM-SF, while 46% scored adequate health literacy on the Chew. Forty percent (40%) experienced either emergency care or readmission within 90 days post discharge. Patients who were younger, female, or living with children had relatively better health literacy. Health literacy itself was not associated with readmission or postdischarge emergency care, although African American race was. Although Medicaid patients varied considerably on health literacy, this factor was not associated with adverse health care outcomes. Future work should better identify individuals requiring supportive transition services to reduce problems following hospital discharge.

Fit & strong! Promotes physical activity and well-being in older cancer survivors.

INTRODUCTION: Physical activity reduces fatigue and depression while improving quality of life in cancer survivors. Exercise is generally considered safe and is recommended to survivors of all ages. Despite the high prevalence of cancer in the elderly, few studies address physical activity interventions targeting this older population. Fit & Strong! is an evidence-based physical activity program shown to improve level of physical activity, exercise-self-efficacy, and mood in older adults with osteoarthritis. This study tests the feasibility and short-term impact of the Fit & Strong! exercise program adapted for older cancer survivors. METHODS: Participants were cancer survivors at least 50 years of age who were not on active treatment with intravenous chemotherapy or radiation. They participated in the 8-week Fit & Strong! program, which included three 90-min sessions per week; 60 min of group physical activity and 30 min of education. Education on osteoarthritis was removed from the Fit & Strong! program and replaced with relevant topics on cancer survivorship issues. Feasibility was measured by the ability to recruit and retain older cancer survivors. Pre and post-intervention surveys evaluated the effect of the intervention on physical activity and quality of life. RESULTS: The study enrolled 72 cancer survivors to participate in an 8-week exercise program. The mean age of participants was 70. Over two-thirds (68%) of participants completed the program and with a mean attendance rate of 75% (18 of 24 sessions). No safety issues occurred. Improvements from baseline to post-intervention were observed for self-reported minutes of physical activity per week, self-efficacy for aerobic exercise, and symptoms related to depression and anxiety. CONCLUSION: This study was successful in recruiting and retaining a population of older cancer survivors to participate in a group exercise program. Significant improvement in level of physical activity and mood suggests this evidence-based physical activity intervention can be adapted to promote health benefits in cancer survivors. Additional studies are necessary to confirm efficacy and assess long-term benefits.