Improving Patient Outcomes Using Measures to Increase Discharge Rates to Home.

Background Post-acute care (PAC) centers are facilities used for recuperation, rehabilitation, and symptom management in an effort to improve the long-term outcomes of patients. PAC centers include skilled nursing facilities, inpatient rehabilitation facilities, and long-term care hospitals. In the 1990s, Medicare payment reforms significantly increased the discharge rates to PAC centers and subsequently increased the length of stay (LOS) among these patient populations. Over the last several years, there have been national initiatives and multidisciplinary approaches to improve safe discharge rates to home. Multiple studies have shown that patients who are discharged to home have decreased rates of 30-day readmissions, reduced short-term mortality, and an improvement in their activities of daily living.  Objectives This study aimed to investigate how multidisciplinary approaches could improve a single institution's discharge rates to home. In doing so, we aim to lower hospital readmission rates, hospital length of stay, morbidity and mortality rates, and healthcare-associated costs. Methods A retrospective single-institution cohort study was implemented at Jersey Shore University Medical Center (JSUMC). Data from January 2015 to December 2019 served as the control period, compared to the intervention period from January 2020 to January 2024. Patients were either admitted to JSUMC teaching faculty, hospitalists, or "others," which is composed of various medical and surgical subspecialists. Interventions performed to improve home discharge rates can be categorized into the following: physician education, patient education, electronic medical record (EMR) initiatives, accountability, and daily mobility initiatives. All interventions were performed equally across the three patient populations. The primary endpoint was the proportion of patients discharged to home. Results There were 190,699 patients, divided into a pre-intervention group comprising 98,885 individuals and a post-intervention group comprising 91,814 patients. Within the pre-intervention group, the faculty attended to 8,495 patients, hospitalists cared for 39,145 patients, and others managed 51,245 patients. In the post-intervention period, the faculty oversaw 8,014 patients, hospitalists attended to 35,094 patients, and others were responsible for 48,706 patients. After implementing a series of multidisciplinary interventions, there was a significant increase in the proportion of patients discharged home, rising from 74.9% to 80.2% across the entire patient population. Specifically, patients under the care of the faculty experienced a more substantial improvement, with a discharge rate increasing from 73.6% to 84.4%. Similarly, the hospitalists exhibited a rise from 69.4% to 74.3%, and the others demonstrated an increase from 79.3% to 83.7%. All observed changes yielded a p-value < 0.001. Conclusions By deploying a multifaceted strategy that emphasized physician education, patient education, EMR initiatives, accountability measures, and daily mobility, there was a statistically significant increase in the rate of patient discharges to home. These initiatives proved to be cost-effective and led to a tangible reduction in healthcare-associated costs and patient length of stay. Further studies are required to look into the effect on hospital readmission rates and morbidity and mortality rates. The comprehensive approach showcased its potential to optimize patient outcomes.

Improving Discharge Rates to Home With the Help of Mobility Technicians: A Step in the Right Direction.

Background Early ambulation during acute hospitalization has been associated with improved clinical outcomes for patients. Despite the benefits of mobility in the hospital setting, physical therapists and nursing staff are often constrained by time. Mobility technicians (MTs) are individuals with specialized training who have emerged as a potential solution by providing safe ambulation for patients during their hospital stay. Objectives The purpose of this quality improvement project was to investigate the impact of MTs on clinical and financial outcomes for admitted patients at a high-volume tertiary institution. Methods A quality improvement project was implemented at Jersey Shore University Medical Center, Neptune City, from October 2022 to March 2023. The study was a prospective, single-institution cohort study and included patients admitted to two medical floors. Patients were divided into an experimental group that received services from MTs and a control group that did not receive this service but was eligible based on clinical status. The primary endpoint was the proportion of patients discharged to home. Secondary outcomes included the length of stay and financial impact. Results A total of 396 admitted patients were included, with 222 patients in the MT group and 174 in the non-MT group. Patients in the MT group were discharged home more frequently, at a rate of 79.7% compared to 66.1% for patients in the non-MT group (p = 0.002). MTs contributed to an average 2.4-day reduction in the length of hospital stay (7.8 days vs. 10.2 days, p = 0.007). The MT intervention led to an estimated net savings of $148,500 during the six-month study period. Additionally, 2.9 daily hospital beds were created. Conclusion Implementing an MT program significantly increased the discharge-to-home rates and decreased hospital length of stay. Preliminary analysis suggests that this intervention is cost-effective and can assist institutions in managing increased hospital capacity strain through the creation of additional hospital beds.

The Utilization of 15-Minute Multidisciplinary Rounds to Reduce Length of Stay in Patients under Observation Status.

With the recent change to value-based care, institutions have struggled with the appropriate management of patients under observation. Observation status can have a huge impact on hospital and patient expenses. Institutions have implemented specialized observation units to provide better care for these patients. Starting in January 2020, coinciding with the initiation of daily multidisciplinary rounds, our study focused on patients aged 18 and older admitted to our hospital under observation status. Efforts were built upon prior initiatives at Jersey Shore University Medical Center (JSUMC) to optimize patient care and length of stay (LOS) reduction. The central intervention revolved around the establishment of daily "Observation Huddles"-succinct rounds led by hospital leaders to harmonize care for patients under observation. The primary aim was to assess the impact of daily multidisciplinary rounds (MDR) on LOS, while our secondary aim involved identifying specific barriers and interventions that contributed to the observed reduction. Our study revealed a 9-h reduction in observation time, resulting in approximately USD 187.50 saved per patient. When accounting for the period spanning 2020 to 2022, potential savings totaled USD 828,187.50 in 2020, USD 1,046,062.50 in 2021, and USD 1,243,562.50 in 2022. MDR for observation patients led to a reduction in LOS from 29 h to 20 h (p < 0.001).

Rare Presentation of Stercoral Ulcer Spontaneous Perforation Without Preceding Radiographic Evidence of Colonic Inflammation and Fecal Impaction.

Stercoral ulcers are caused by persistent fecal impaction. A life-threatening consequence of stercoral ulcers is colonic perforation, which is rare. A high index of clinical suspicion should be held for patients with stercoral ulcer, as colonic perforation is a medical emergency, requiring immediate surgical intervention. Here, we report a case of a 45-year-old female admitted with sepsis of unknown picture and subsequently developed stercoral ulcer perforation (SUP), diagnosed intraoperatively, without prior radiographic evidence of colonic inflammation. She was successfully managed with emergency laparotomy and left colectomy with sigmoid colectomy.

COVID-19 Infection Presenting With Severe Hydrocephalus and Acute Stroke: A Case Report.

Hydrocephalus is the accumulation of cerebrospinal fluid (CSF) in the cerebral ventricles and is considered an emergency in acute presentation. Hydrocephalus typically presents with symptoms of headache, nausea, vomiting, lethargy, vision changes and seizure; furthermore, narrowing down the underlying etiology of hydrocephalus can aid in treatment and management options. We present a rare case of a patient that presented with a recent diagnosis of COVID-19 and was found to have acute hydrocephalus and stroke. The aim of this case report is to explore the link between COVID-19 and the development of hydrocephalus and stroke by delineating the underlying pathophysiology of COVID-19 as well as the etiologies of hydrocephalus and possible management strategies. We hope to highlight the importance of keeping an open differential for presentations of headaches and also emphasize the potential complications of COVID-19 infection to help better patient outcomes.

Atypical Stress Cardiomyopathy: A Case Report.

Stress cardiomyopathy is a reversible cause of cardiomyopathy characterized by a transient dysfunction in left ventricular systolic function. It is most common in postmenopausal women and usually occurs following an emotional and/or physical stressor. The classical imaging finding is described as left ventricular apical ballooning. However, several rare variants have been reported with a strikingly different regional distribution of wall motion abnormalities. We describe a case of a 65-year-old female who was found to have stress cardiomyopathy with variant wall motion abnormality on the left ventriculogram without a preceding stressor event. We postulate that there may be a link between stress-induced cardiomyopathy without a preceding stressor event and variant wall motion abnormality patterns.

Methotrexate Failure in the Treatment of Adult-Onset Still's Disease: A Case Report.

Adult-onset Still's disease (AOSD) is a rheumatological condition associated with significant morbidity and mortality. Typically a diagnosis of exclusion, the therapeutic management has relied mainly on symptom control and immune suppression. Methotrexate (MTX), a disease-modifying anti-rheumatoid drug (DMARDs), has become a drug of choice in treating several autoimmune conditions, including AOSD. Unfortunately, despite being largely effective, this medication can result in treatment failure, exacerbation, and a flare of symptoms. We present the case of a 31-year-old male who presented to us with weakness and palpitations, who was ultimately found to have a flare of his Still's disease, despite being on MTX therapy. Our hope is to encourage a suspicion for treatment failure in patients with similar symptoms, in order to encourage a faster initiation of alternative therapies to alleviate their discomfort.

A Rare Case of Superior Vena Cava Syndrome in a Patient With Rheumatoid Arthritis and IgA Nephropathy.

Superior vena cava syndrome (SVCS) is a vascular condition resulting from an impaired venous return to the right atrium. The majority of SVCS cases are caused by mass effect in which extrinsic compression of the vessel leads to obstruction of blood flow. In less common cases of SVCS, thrombus formation and luminal narrowing can result in poor return through the SVC. Inflammatory causes of SVCS are even rarer and poorly documented. IgA nephropathy and rheumatoid arthritis (RA) are two autoimmune diseases with the potential to cause vasculitis, thus increasing the likelihood of intraluminal vessel occlusion. We report a rare case of SVCS in a 65-year-old female with a past medical history significant for atrial fibrillation, IgA nephropathy, chronic kidney disease stage IIIA, and RA who presented with headache, dizziness, and neck pain and swelling extending down the left upper extremity for three days. Inflammatory SVCS is uncommon and cases of SVCS secondary to RA and IgA nephropathy are underreported in the literature thus far. Our hope in presenting this case is to encourage a greater degree of suspicion for vascular complications, such as SVCS, in patients with autoimmune and inflammatory conditions.

Supraventricular Tachycardia: An Atypical Presentation of Thyroid Storm.

Thyroid storm (or thyrotoxic crisis) is commonly defined as a life-threatening condition caused by the exaggeration of the clinical manifestations of thyrotoxicosis. Supraventricular tachycardia (SVT) is an atypical precipitating symptom of thyrotoxicosis that clinicians should be aware of. An empirically derived scoring system known as the Burch-Wartofsky Point Scale (BWPS) has been used by clinicians since the early 1990s. The BWPS considers an array of precipitating factors and the severity of symptoms of multiple organ decompensation. In recent years, there has been an increasing correlation between SARS-CoV-2 and thyroid pathologies. We present a case of an unresponsive elderly male with a recent coronavirus disease 2019 (COVID-19) infection presenting with SVT and a BWPS score of 45, highly indicative of a thyroid storm.

Multiple Primary Malignancies With Hypercalcemia Presentation: A Case Report.

Multiple primary malignancies (MPMs) are defined as having more than one primary malignancy and when each tumor is histologically distinct and unrelated to the others. Multiple risk factors have been found to be associated with MPMs. These include familial syndromes, sequela from treatments of previous malignancies, and environmental factors such as smoking, alcohol consumption, obesity, and male sex. Hypercalcemia has a well-known association with malignancy and is often the first abnormality that leads to further testing. Lung cancer followed by colorectal cancer has the highest mortality of all cancers in the USA, with adenocarcinoma being the most prevalent histological subtype. Further, estimates show that those with one malignancy have a 1.29 times higher risk of developing another malignancy. Hereby, we present a case of a patient with squamous cell carcinoma of the lung who presented with hypercalcemia and incidentally was found to have another primary adenocarcinoma of the colon.

COVID-19-Induced Cavitary Lesion: A Rare Presentation.

The coronavirus disease 2019 (COVID-19) pandemic has resulted in widespread infection with significant morbidity and mortality. Primarily involving the respiratory system, COVID-19 has also been known to cause systemic findings. Cavitary lesions in the setting of COVID-19 have been rarely reported in literature and the treatment and management of these lesions are poorly understood and defined. We present a case of a patient with a history of COVID-19 infection found to have cavitary lesions, eventually improving with supportive care. While our patient showed marked improvement with observation, more extensive studies and patient populations are needed to guide clinicians and cavitary lesion management in the setting of COVID-19.

Eculizumab as a Treatment for Hyper-Haemolytic and Aplastic Crisis in Sickle Cell Disease.

BACKGROUND: Patients with sickle cell disease can experience various crises including sequestration crisis, haemolytic crisis and aplastic crisis. Due to alloantibody formation, transfusion alloantibodies can cause a haemolytic crisis. Treatment involves avoiding packed red blood cell transfusions, as well as intravenous immunoglobulin, steroids and eculizumab to decrease the chances of haemolysis. CASE DESCRIPTION: We report the case of a 42-year-old man who was found to have worsening anaemia after packed red blood cell transfusion with evidence suggestive of haemolytic crisis. Due to reticulocytopenia, aplastic crisis was also suspected and later confirmed via parvovirus IgG and IgM titres. The patient did not improve with steroid and intravenous immunoglobulin therapy and was treated with eculizumab as a salvage therapy. CONCLUSION: Concurrent hyper-haemolytic crisis and aplastic crisis should be suspected in patients with features of haemolysis and reticulocytopenia. Prompt recognition and treatment with eculizumab are paramount in those who fail steroid and intravenous immunoglobulin treatment. LEARNING POINTS: Treatment of hyper-haemolytic and aplastic crisis in sickle cell disease with eculizumab offers therapeutic benefit.A high index of suspicion for hyper-haemolytic crisis and aplastic crisis should be maintained in those with haemolytic features as well as reticulocytopenia in the setting of sickle cell disease.

A Cerebrovascular Accident Presenting With Bilateral Vocal Cord Paresis.

Diagnosing a stroke requires careful attention to clinical indicators on physical exam, especially the more subtle manifestations of cerebellar lesions. An 85-year-old male with vascular risk factors and new-onset atrial fibrillation was admitted for left upper extremity weakness, headaches, and tremors. The patient developed stridor during hospitalization and was found to have a new cerebellar infarct with hemorrhagic transformation on computed tomography (CT) of the head, with laryngoscopy showing bilateral vocal cord paresis. While strokes outside of the cerebellum are a known cause of unilateral vocal cord paresis, cerebellar strokes are a rare culprit and rarely cause bilateral cord paresis. Consideration beyond the more common pulmonary and iatrogenic causes of vocal cord paresis should be considered, with particular attention to stroke.

Rare Case of Small Bowel Obstruction Secondary to Cryptosporidium in a Young Patient With Uncontrolled AIDS.

Small bowel obstruction is a common cause of abdominal pain and accounts for approximately 20% of surgical admissions related to abdominal pain. In the United States alone, there are over 300,000 admissions annually for small bowel obstruction and account for every 15 out of 100 admissions for abdominal pain. If treated appropriately with medical management, over 80% of cases resolve without life-threatening, long-term complications or the need for surgical intervention. The three most common causes including adhesions, tumors, and hernias account for the majority of cases. Less frequently reported causes include infections. We present the case of a 26-year-old male with a history of AIDS who was found to have a small bowel obstruction in the setting of active Cryptosporidium infection. Cryptosporidium is an opportunistic infection that more commonly affects immunocompromised hosts, especially those noncompliant with antiretroviral therapy. Our patient had an uncomplicated hospital course and made a full recovery due to early diagnosis and immediate intervention. We hope to make the medical community more aware of this rare and potentially life-threatening association given the rarity of such a presentation. Early diagnosis and intervention are critical to preventing morbidity and mortality.

Atypical Presentation of Plasma Cell Neoplasm of the Sternum.

Multiple myeloma (MM) is a rare plasma cell neoplasm characterized by monoclonal cell infiltration in the bone marrow, which can cause anemia, bone pain, and recurrent infections. Extramedullary myeloma (EM) is a rare clinical presentation with a poor prognosis. It involves the accumulation of clonal plasma cells in soft tissues with a tumor-like appearance, either presenting as a primary (initial) or secondary (relapse) malignancy. We present a case of a 65-year-old male who experienced an abrupt onset of chest pain associated with a localized sternal mass while exercising the day prior to arrival. Chest computed tomography (CT) scan with contrast revealed an expansile lytic lesion around the sternal area. Due to high suspicion for malignancy, a CT-guided core needle biopsy was done, which showed plasma cells with rare Dutcher bodies consistent with MM. Bone marrow smear showed the presence of 70% plasma cells confirming a diagnosis of MM. Early detection of this devastating disease may help improve survival. Therefore, physicians should have a high index of suspicion for MM in older patients with similar clinical presentations.

Anticoagulants Used in Cardiac Catheterization of Patients With Chronic Lymphocytic Leukemia: A Case Report and Overview.

Percutaneous coronary intervention (PCI) is one of the most frequently performed invasive therapeutic procedures and plays a key role in the long-term survival of patients with ischemic heart disease. Over 965,000 angioplasties are performed annually in the United States alone. While the technique and equipment have undergone significant revisions and improvement, the medical community will still benefit from more data and guidance on the optimal selection of mandatory peri-operation anticoagulation in specific, high-risk populations. Many of these procedures are performed on high-risk individuals who have an inherently higher risk of hemorrhage or thrombosis. Unfractionated heparin is the most popular choice in the general population, however, its use carries certain limitations. Here we will describe the use of an uncommonly used anticoagulant in a patient being actively treated for leukemia. We will also discuss the unique properties and benefits of the four most frequently used anticoagulants during a cardiac angioplasty. Our team describes the successful use of bivalirudin during an urgent PCI in a 71-year-old female with eight previous stents that was followed by an uncomplicated recovery period. Our experience contributes to a small, but growing, body of evidence that bivalirudin may be a safe choice to use in lieu of unfractionated heparin in patients with underlying oncological disease. Our patient had several comorbidities that significantly increased their risk of bleeding. We will also review the clinical trials that compared the four most commonly used anticoagulants during cardiac catheterization.

Septic Arthritis Caused by Perirectal Abscess.

Septic arthritis is a debilitating, inflammatory condition of joints that can cause patients to experience significant pain and discomfort. An estimated 0.006% of people annually develop the condition; the absence of prompt diagnosis and treatment can lead to long-term joint dysfunction. Septic arthritis is usually caused by hematologic seeding of the joint space by bacteria, however, those who receive intra-joint injections and IV access are also at high risk for developing the condition. In this article, we present the case of a 58-year-old male with no immediately identifiable risk factors for septic arthritis, who was found to have a septic joint as a result of an invading perirectal abscess that was discovered in an imaging study.

Disseminated Pulmonary with Isolated Muscular Mucormycosis in an Acute Myeloid Leukemia Patient: A Case Report and Literature Review.

BACKGROUND Mucormycosis is a serious, potentially fatal fungal infection caused by species in the Mucorales order. Together with candidiasis and aspergillosis, it is one of the most significant fungal infection that carries a high rate of mortality. Early detection and initiation of antifungal therapy with adequate surgical debridement improves the clinical outcome. CASE REPORT We describe a case of mucormycosis in a patient with acute myeloid leukemia who developed disseminated lung disease with muscular involvement without any cutaneous manifestation. Successful treatment was achieved with surgical debridement, amphotericin B lipid-complex and posaconazole step-down therapy. CONCLUSIONS Mucormycosis can present in various clinical scenarios. Key to diagnosis depends on tissues diagnosis from the affected system, as was done with lung and muscle biopsy in our patient. Clinicians should maintain high suspicion for early diagnosis and prompt treatment.