Development of a novel rapid response event review process for quality improvement.

INTRODUCTION: Rapid response team (RRT) and code activation events occur relatively commonly in inpatient settings. RRT systems have been the subject of a significant amount of analysis, although this has been largely focused on the impact of RRT system implementation and RRT events on patient outcomes. There is reason to believe that the structured assessment of RRT and code events may be an effective way to identify opportunities for system improvement, although no standardised approach to event analysis is widely accepted. We developed and refined a protocolised system of RRT and code event review, focused on sustainable, timely and high value event analysis meant to inform ongoing improvement activities. METHODS: A group of clinicians with expertise in process and quality improvement created a protocolised analytic plan for rapid response event review, piloted and then iteratively optimised a systematic process which was applied to all subsequent cases to be reviewed. RESULTS: Hospitalist reviewers were recruited and trained in a methodical approach. Each reviewer performed a chart review to summarise RRT events, and collect specific variables for each case (coding). Coding was then reviewed for concordance, at monthly interdisciplinary group meetings and 'Action Items' were identified and considered for implementation. In any 12-month period starting in 2021, approximately 12-15 distinct cases per month were reviewed and coded, offering ample opportunities to identify trends and patterns. CONCLUSION: We have developed an innovative process for ongoing review of RRT-Code events. The review process is easy to implement and has allowed for the timely identification of high value improvement opportunities.

NCCP-ICS joint consensus-based clinical practice guidelines on medical thoracoscopy.

ABSTRACT: Medical Thoracoscopy (MT) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. The aim of the study was to provide evidence-based information regarding all aspects of MT, both as a diagnostic tool and therapeutic aid for pulmonologists across India. The consensus-based guidelines were formulated based on a multistep process using a set of 31 questions. A systematic search of published randomized controlled clinical trials, open labelled studies, case reports and guidelines from electronic databases, like PubMed, EmBase and Cochrane, was performed. The modified grade system was used (1, 2, 3 or usual practice point) to classify the quality of available evidence. Then, a multitude of factors were taken into account, such as volume of evidence, applicability and practicality for implementation to the target population and then strength of recommendation was finalized. MT helps to improve diagnosis and patient management, with reduced risk of post procedure complications. Trainees should perform at least 20 medical thoracoscopy procedures. The diagnostic yield of both rigid and semirigid techniques is comparable. Sterile-graded talc is the ideal agent for chemical pleurodesis. The consensus statement will help pulmonologists to adopt best evidence-based practices during MT for diagnostic and therapeutic purposes.

Hospitalists Improving Transitions of Care Through Virtual Collaborative Rounding with Skilled Nursing Facilities-the HiToC SNF Study.

BACKGROUND: Over one in five Medicare patients discharged to skilled nursing facilities (SNFs) are re-hospitalized within 30 days of discharge. Poor communication between the hospital and SNF upon hospital discharge is frequently cited as the most common cause of readmission. AIM: The goal of this program was to assess the ability of a weekly post-discharge hospitalist led virtual rounding program to augment the written discharge summary sent to SNFs. SETTING: Two academic hospitals and six SNFs in Baltimore, MD. PARTICIPANTS: Hospitalists and medical directors or directors of nursing from the partner SNF. PROGRAM DESCRIPTION: During weekly encounters, the hospitalist and SNF providers discussed the clinical status, discharge medications, treatment plan, and follow-up care of all discharged patients. The intervention took place from July 2021 to December 2021. PROGRAM EVALUATION: During the study, 544 patients were discussed in a post-discharge virtual encounter. After the discussions, hospitalists identified clinically significant errors in 124 discharge summaries. A survey of participating hospitalists and SNF medical and nursing leadership indicated the intervention was thought to improve care transitions. DISCUSSION: Our innovation was successful in identifying errors in discharge summaries and was thought to improve the transition of care by participating SNF and hospitalist providers.

Doxycycline for the prevention of progression of COVID-19 to severe disease requiring intensive care unit (ICU) admission: A randomized, controlled, open-label, parallel group trial (DOXPREVENT.ICU).

BACKGROUND: After admission to hospital, COVID-19 progresses in a substantial proportion of patients to critical disease that requires intensive care unit (ICU) admission. METHODS: In a pragmatic, non-blinded trial, 387 patients aged 40-90 years were randomised to receive treatment with SoC plus doxycycline (n = 192) or SoC only (n = 195). The primary outcome was the need for ICU admission as judged by the attending physicians. Three types of analyses were carried out for the primary outcome: "Intention to treat" (ITT) based on randomisation; "Per protocol" (PP), excluding patients not treated according to randomisation; and "As treated" (AT), based on actual treatment received. The trial was undertaken in six hospitals in India with high-quality ICU facilities. An online application serving as the electronic case report form was developed to enable screening, randomisation and collection of outcomes data. RESULTS: Adherence to treatment per protocol was 95.1%. Among all 387 participants, 77 (19.9%) developed critical disease needing ICU admission. In all three primary outcome analyses, doxycycline was associated with a relative risk reduction (RRR) and absolute risk reduction (ARR): ITT 31.6% RRR, 7.4% ARR (P = 0.063); PP 40.7% RRR, 9.6% ARR (P = 0.017); AT 43.2% RRR, 10.8% ARR (P = 0.007), with numbers needed to treat (NTT) of 13.4 (ITT), 10.4 (PP), and 9.3 (AT), respectively. Doxycycline was well tolerated with not a single patient stopping treatment due to adverse events. CONCLUSIONS: In hospitalized COVID-19 patients, doxycycline, a safe, inexpensive, and widely available antibiotic with anti-inflammatory properties, reduces the need for ICU admission when added to SoC.

Delayed cardiomyopathy and cardiogenic shock due to intravenous methamphetamine use requiring hemodynamic support with veno-arterial extracorporeal membrane oxygenation.

Cardiovascular disease is the leading cause of mortality in chronic methamphetamine users. We present the case of a 29-year-old man, a prior heroin user, who presented following first-time use of intravenous methamphetamine, with delayed development of cardiomyopathy and severe cardiogenic shock, treated with veno-arterial extracorporeal membrane oxygenation (VA ECMO), and subsequent recovery. His initial chief complaint was shortness of breath, a common presentation to the emergency department. However, this case presentation is unique in three aspects: (1) a delayed presentation, (2) methamphetamine was administered intravenously as opposed to the common methods of being snorted or smoked, (3) and the effects were seen after first-time usage as compared to in a chronic user. This unique presentation can bring awareness to an uncommon etiology of shortness of breath due to intravenous methamphetamine usage.

Comparison of fluticasone/formoterol with budesonide/formoterol pMDI in adults with moderate to severe persistent asthma: Results from a 12-week randomized controlled trial.

BACKGROUND: Combination therapy of inhaled corticosteroid/long acting ß2-agonist (ICS/LABA) is the cornerstone of managing asthmatics who are uncontrolled with low-medium dose of ICS. The novel ICS/LABA combination of fluticasone propionate and formoterol (flu/form) provides potent anti-inflammatory and rapid bronchodilatory effect. This randomized, multi-centre, double-blind study compared the efficacy and safety of flu/form (125/6 mcg BD; Maxiflo®) with the well-established budesonide/formoterol combination (bud/form 200/6 mcg BD), both delivered through a pressurized metered dose inhaler (pMDI) in patients with moderate to severe persistent asthma over 12 weeks. METHODS: This study enrolled patients between 18 and 65 years. The primary end-point was to demonstrate non-inferiority for the mean change in the pre-dose morning peak expiratory flow values (PEF). The secondary end-points included lung function assessments, number of symptom-free days and nights, rescue medication use, day-and night-time symptom scores and safety evaluation. RESULTS: Two hundred and thirty-two patients were randomized to either flu/form (n = 117) or bud/form (n = 115). At the end of 12 weeks, flu/form was non-inferior to bud/form with regards to the primary end-point of morning PEF (48.07 L/min vs. 49.03 L/min, p > 0.05). These improvements were statistically significant (p < 0.0001) vs baseline. Similar improvements were observed between the two groups for secondary efficacy end-points including FEV1, symptom-free nights, rescue medication use, day-and night-time symptom scores (p > 0.05). Flu/form exhibited a safety profile comparable to that of bud/form. CONCLUSION: Fluticasone/formoterol combination administered through a pMDI is as efficacious and well-tolerated as budesonide/formoterol and offers a new therapeutic option for patients with moderate to severe persistent asthma.

Use of Electronic Clinical Decision Support and Hard Stops to Decrease Unnecessary Thyroid Function Testing.

NewYork-Presbyterian Brooklyn Methodist Hospital embarked on a Zero Unnecessary Study (ZEUS) initiative, whereby all aspects of clinical care were evaluated and strategies were implemented to mitigate waste. An opportunity was found in regards to thyroid function testing. It has been shown that certain TFTs are ordered far more often than clinically indicated. Free T3 (fT3) and Free T4 (fT4) are only indicated when the TSH is abnormal in the inpatient setting, with rare exceptions. Thus, a clinical algorithm for Clinical Decision Support (CDS) and Hard Stops (HS) were incorporated into the Electronic Medical Record (EMR) to prevent fT3 or fT4 to be ordered without an abnormal TSH, with certain predefined exceptions. In addition, a reflex rule was built which automatically orders (reflex) fT3 and fT4 if the TSH is abnormal. The pre and post-intervention ratios of fT3 and fT4 orders per total TSH orders were analyzed. Pre-intervention data revealed that fT4 was the most frequently ordered TFT laboratory test on admission, after TSH. Post-Intervention, there was a decrease in the ratio of fT4 to TSH orders (fT4/TSH) of 35.2%, from 44.6% to 28.9%. The percentage of fT4 ordered due to abnormal TSH increased by 126.1%, from 36.8% to 83.2%. The fT3 to TSH ordering ratio similarly decreased by 55.2%, from 6.2% to 2.9%. The decreases in both fT3/TSH and fT4/TSH ratios were statistically significant. Any unnecessary orders are a burden on healthcare. It is now possible to achieve goals that were not previously thought to be possible because of advancement in medicine and technology. By making small changes and saving costs, we can target our energy and resources toward effectively treating patients.

Salmeterol/fluticasone through breath-actuated inhaler versus pMDI: a randomized, double-blind, 12 weeks study.

OBJECTIVE: Salmeterol/fluticasone combination (SFC) formulated in a breath-actuated inhaler (BAI) overcomes the co-ordination problem associated with the pressurized-metered dose inhaler (pMDIs). Our aim was to compare the efficacy and the safety of SFC given through the BAI versus the conventional pMDI in moderate-to-severe asthmatics. METHODS: In this randomized, double-blind, double-dummy, prospective, active-controlled, parallel group, multicenter, 12 weeks study, 150 asthmatics were randomized to receive SFC (25/125 mcg) through either BAI or pMDI. The primary efficacy endpoint was mean change in pre-dose morning PEFR value at 12 weeks and the secondary efficacy endpoints included, mean change in FEV(1), pre-bronchodilator FVC, pre-dose morning and evening PEFR, symptom scores at 2, 4, 8, and 12 weeks. Patient preferences for device and safety were also assessed. RESULTS: At 12 weeks, the mean change in pre-dose morning PEFR in BAI and pMDI groups was 50.72 L/min and 48.82 L/min, respectively (p < 0.0001; both groups) and the difference between the two groups was not significant. Both the treatment groups showed a statistically significant improvement in secondary endpoints at all-time points compared with baseline. The usability questionnaire assessment results showed that the BAI device was preferred by 75% of patients as compared with 25% preferring pMDI. SFC in both BAI and pMDI devices was found to be safe and well tolerated. CONCLUSION: This is the first study to demonstrate that SFC given through the BAI produces comparable efficacy and safety endpoints as pMDI. Additionally, BAI was the preferred inhaler by patients compared to conventional pMDI.

Soluble CD80 restores T cell activation and overcomes tumor cell programmed death ligand 1-mediated immune suppression.

Many tumor cells escape anti-tumor immunity through their expression of programmed death ligand-1 (PDL1 or B7-H1), which interacts with T cell-expressed PD1 and results in T cell apoptosis. We previously reported that transfection of human tumor cells with a membrane-bound form of the human costimulatory molecule CD80 prevented PD1 binding and restored T cell activation. We now report that a membrane-bound form of murine CD80 similarly reduces PDL1-PD1-mediated suppression by mouse tumor cells and that a soluble protein consisting of the extracellular domains of human or mouse CD80 fused to the Fc domain of IgG1 (CD80-Fc) overcomes PDL1-mediated suppression by human and mouse tumor cells, respectively. T cell activation experiments with human and mouse tumor cells indicate that CD80-Fc facilitates T cell activation by binding to PDL1 to inhibit PDL1-PD1 interactions and by costimulating through CD28. CD80-Fc is more effective in preventing PD1-PDL1-mediated suppression and restoring T cell activation compared with treatment with mAb to either PD1 or PDL1. These studies identify CD80-Fc as an alternative and potentially more efficacious therapeutic agent for overcoming PDL1-induced immune suppression and facilitating tumor-specific immunity.