National Early Warning Score Deployment in a Veterans Affairs Facility: A Quality Improvement Initiative and Analysis.

Early warning scores are algorithms designed to identify clinical deterioration. Current literature is predominantly in non-Veteran populations. Studies in Veterans are lacking. This study was a prospective quality improvement project deploying and assessing the National Early Warning Score (NEWS) at Kansas City VA Medical Center. Performance of NEWS was assessed as follows: discrimination for predicting a composite outcome of intensive care unit transfer or mortality within 24 hours via area under the receiver operating curve. A total of 4781 Veterans with 142 375 NEWS values were included. The NEWS area under the receiver operating curve for the composite outcome was 0.72 (95% CI, 0.71-0.74), indicating acceptable predictive accuracy. A NEWS of ≥7 was more likely associated with the composite outcome versus <7 (13.6% vs 0.8%; P < 0.001). This is one of the first studies to demonstrate successful deployment of NEWS in a Veteran population, with resultant important implications across the Veterans Health Administration.

Multicenter assessment of the outcomes of subcutaneous ICD implantation in patients with prior or future sternotomy.

BACKGROUND: The subcutaneous ICD (S-ICD) is a viable alternative to transvenous ICD and avoids intravascular complications in patients without a pacing indication. The outcomes of S-ICD implantation are uncertain in patients with prior sternotomy. OBJECTIVE: We aim to compare the implant techniques and outcomes with S-ICD implantation in patients with and without prior sternotomy. METHODS: Multicenter retrospective cohort study including adult patients with an S-ICD implanted between January 2014 and June 2020. Outcomes were compared between patients with and without prior sternotomy. RESULTS: Among the 212 patients (49 ± 15 years old, 43% women, BMI 30 ± 8 kg/m2 , 68% primary prevention, 30% ischemic cardiomyopathy, LVEF median 30% IQR 25%-45%) who underwent S-ICD implantation, 47 (22%) had a prior sternotomy. There was no difference in the sensing vector (57% vs. 53% primary, p = 0.55), laterality of the S-ICD lead to the sternum (94% vs. 96% leftward, p = 0.54), or the defibrillation threshold (65 ± 1.4 J vs. 65 ± 0.8 J, p = 0.76) with versus without prior sternotomy. The frequency of 30-day complications was similar with and without prior sternotomy (n = 3/47 vs. n = 15/165, 6% vs. 9%, p = 0.56). Over a median follow-up of 28 months (IQR 10-49 months), the frequency of inappropriate shocks was similar between those with and without prior sternotomy (n = 3/47 and n = 16/165, 6% vs. 10%, p = 0.58). CONCLUSION: Implantation of an S-ICD in patients with prior sternotomy is safe with a similar risk of 30-day complications and inappropriate ICD shocks as patients without prior sternotomy.

Reducing Resident Physician Workload to Improve Well Being.

Introduction Resident physician's well-being has been postulated to worsen with longer shifts. At our institution, the admitting physician evening shift (known as short call) had been associated with higher levels of stress and reduced well-being among residents due to longer work hours and an excessive number of admissions. We introduced an intermediate swing shift to help mitigate those effects. This study sought to assess the outcomes of introducing the swing shift on the timeliness of leaving the hospital for the short call physician, and the median number of admissions done by the short call, swing shift, and night shift resident physicians. Method  The swing shift was designed to cover admitting duties from 4:00 to 11:00 pm on weekdays, with support from both the short call and night shift resident physicians. Internal Medicine residents in their second or third year of training and combined Medicine/Psychiatry residents in their third, fourth or fifth year of training, were surveyed prior to the implementation of the swing shift and four-months post-implementation. Time of leaving the hospital and number of admissions before and after the introduction of the swing shift were compared. Data were recorded as frequencies and presented as medians. Results There were 27 surveys completed prior to swing shift implementation and 43 surveys completed post-implementation with a response rate of 52% and 83%, respectively. Surveys post-implementation were divided into 29 for the short call shift survey, six for the swing shift survey, and eight for the night shift survey. Residents who did not perform the short call physician duties were excluded, limiting the prior to implementation surveys from 27 to 25 and the post-implementation short call surveys from 29 to 19. Prior to swing shift implementation, the median time of leaving for the short call physician was 8:30 to 9:00 pm; the median number of admissions were four and eight, done by short call physician and night shift physician, respectively. Whereas post-swing shift implementation, the median time of leaving for short call physician was 7:00 to 7:30 pm, and for swing shift physician was 11:30 pm to midnight. The median number of admissions were two, five, and five done by the short call, swing shift, and night shift physicians, respectively. All residents reported the swing shift allowed them to take better care of patients and follow up on their tasks. Discussion and conclusion Delayed resident physicians departure at the end of their respective shift was associated with extended shifts. It is thought to be caused by an increased number of admissions, late shift admissions, and time of day shift with 4:00 to 9:00 pm being the busiest. The addition of the swing shift increased the ability of the short call resident physician to leave the hospital at the end of their shift and reduced the median number of admissions done by the short call and night shift resident physicians, hence likely improving resident's well-being while preserving the total number of admissions.

The Full Spectrum of Infective Endocarditis: Case Report and Review.

Over the past five decades, the incidence of intravenous drug use- (IVDU-) associated infective endocarditis (IE) has been on the rise in North America. Classically, IVDU has been thought to affect right-sided valves. However, in recent times a more variable presentation of IVDU-associated IE has been reported. Here, we report a case of a patient with a known history of IVDU who presented with clinical symptoms concerning for right- as well as left-sided endocarditis. In addition, we also discuss what should be considered adequate evaluation for patients with suspected endocarditis, and more specifically, what should be the role of transesophageal echocardiography in patients with IE noted on transthoracic echocardiography.