Closing the Gap in Direct Admissions: A Quality Improvement Project.

BACKGROUND AND OBJECTIVES: Direct admissions (DAs) are nonemergent admissions to the inpatient unit that bypass the emergency department. Our institution lacked a standardized DA process, which resulted in postponement of prompt patient care. The purpose of the present study was to review and modify the existing DA process and to decrease the time between patient arrival for DA and placement of initial clinician orders. METHODS: A team was assembled and tasked with using quality improvement tools (eg, Define-Measure-Analyze-Improve-Control, fishbone diagrams, process mapping) to streamline the DA process to decrease average time between patient arrival for DA and initial clinician orders, from 84.4 minutes in July 2018 to 60 minutes or less by June 2019, without negatively affecting patient admission loyalty questionnaire scores. RESULTS: In a standardized and streamlined DA process, average time between patient arrival and provider order placement decreased to less than 60 minutes. This reduction was achieved without substantially affecting patient loyalty questionnaire scores. CONCLUSION: By using a quality improvement methodology, we developed a standardized DA process that resulted in prompt care for patients without decreasing admission loyalty scores.

Hiatal Hernia Associated with Higher Odds of Dysplasia in Patients with Barrett's Esophagus.

BACKGROUND: Patients with Barrett's esophagus (BE) are more likely to have associated hiatal hernia (HH) compared to the general population. Studies show that HH are typically longer and wider in patients with BE. AIMS: To determine whether patients with HH have associated increased odds of coexistence of BE by examining inpatient prevalence, as well as determining other inpatient outcomes. METHODS: This was a case-control study using the NIS 2016, the largest public inpatient database in the USA. All patients with ICD10CM codes for BE were included. None were excluded. The primary outcome was determining the association between BE and HH in hospitalized patients, stratified by grade of dysplasia. Secondary outcomes included measuring use of endoscopic ablation in patients with BE and HH compared to patients with BE and no HH, determining the degree of association between HH and esophagitis in patients with or without BE, as well as the association between esophagitis and dysplasia in patients with BE and HH. RESULTS: A total of 118,750 patients with BE were identified, of which 24,030 had associated HH. Adjusted odds of having associated BE in patients with HH was 10.9 (p < 0.01) compared to patients without HH. Patients with HH also displayed significantly higher odds of both low-grade dysplasia (aOR 34.5, p < 0.01) and high-grade dysplasia (aOR 14.7, p < 0.01). For secondary outcomes, the odds of undergoing ablation for BE was higher 4.77 (p < 0.01) in patients with HH. CONCLUSIONS: Patients with HH have significantly higher odds of having associated BE, regardless of the level of dysplasia. Furthermore, the odds of undergoing ablation are much higher, likely reflecting higher odds of dysplasia. This highlights the importance of BE in patients with HH, and potentially consider these patients as higher risk.

Increased rates of spinal fusion surgery in patients with hereditary hemochromatosis: a five-year propensity matched cohort analysis.

OBJECT: Spinal arthropathy is associated with hereditary hemochromatosis and has been linked to calcium pyrophosphate dehydrate crystal deposition (CPPD) which resembles ankylosing spondylitis on radiograph, yet lacks clinical findings of inflammatory spinal arthritis. The aim of our study was to assess the use of spinal surgery and its outcomes in the US inpatient population with hereditary hemochromatosis from 2012 to 2016 by using the US Nationwide Inpatient Sample (NIS) database. METHODS: The observational retrospective cohort study uses the NIS 2012 to 2016. All patients with hereditary hemochromatosis were included using International Classification of Diseases 9th and 10th revisions, Clinical Modification codes. The cohort was stratified according to having undergone spinal surgery and substratified by the type of surgery. The primary outcome was determining the use of spinal surgery in patients with hereditary hemochromatosis. Secondary outcomes were determining length of hospital stay and total hospital charges and costs. RESULTS: A total of 39 780 patients with hereditary hemochromatosis were identified and propensity matched to nonhereditary hemochromatosis controls. The mean patient age was 61 years, and 65% were females. For the primary outcome patients with hereditary hemochromatosis underwent significantly more spinal fusion surgery compared to patients without hereditary hemochromatosis odds of 2.13 (P = 0.05). While there was no difference in mean LOS, or costs, patients with hereditary hemochromatosis had higher hospital charges. CONCLUSION: Hereditary hemochromatosis is associated with higher odds of spinal fusion. It is a major complication not improved by phlebotomy, and there are currently no therapies to prevent this joint disease.

Acute Pancreatitis in Patients with a History of Bariatric Surgery: Is It Less Severe?

INTRODUCTION: Bariatric surgery (BSx) leads to weight loss and causes alterations in gastrointestinal and pancreatic peptides. This raises questions on acute pancreatitis (AP) occurrence and outcomes in this cohort of patients. We aim to assess mortality, morbidity, and resource utilization of AP in patients with BSx. METHODS: Observational retrospective cohort study (2012-2016) with propensity score match. Patients with a principal diagnostic ICD9-10CM code for AP were included. Stratification for the coexistence of history of BSx was performed. The primary outcome was mortality. Secondary outcomes were morbidity, resource utilization, length of hospital stay (LOS), total hospital charges, and costs. RESULTS: Out of 920,615 AP patients, 15,345 had undergone BSx. After propensity matching, 8220 patients with BSx had AP. The mortality for AP was 0.42 (p < 0.01) and for biliary AP 0.29 (< 0.04) in the history of BSx group compared to patients without BSx history. Acute kidney insufficiency (AKI), shock, ICU, multiorgan failure, ERCP, costs, charges, and LOS were all lower for patients with AP who had history of BSx. Patients with biliary AP showed even lower odds of AKI, ICU, multiorgan failure, costs, charges, and LOS, but higher odds of cholecystectomy. CONCLUSION: Patients with AP with history of BSx have lower mortality, morbidity, and resource utilization. This may be due to post-surgical alterations in pancreatic and gastrointestinal functions including hormonal and anatomical changes. Interestingly, patients with biliary AP and BSx had even lower odds of mortality and morbidity than patients with non-biliary AP, suggesting an added benefit with milder disease course.

Hypokalemic periodic paralysis - the importance of patient education.

Hypokalemic periodic paralysis (HOKPP) is a rare neuromuscular disorder caused by altered transport of cellular potassium that leads to significant muscle weakness of the extremities. Paralytic attacks are induced by a drop in the serum potassium level and they have been associated with specific triggers. This case describes a 21-year-old male who has had recurrent presentations of acute paralytic attacks following vigorous physical activity. At presentation, this patient exhibited flaccid paralysis of all skeletal muscles below the neck, but was alert and oriented with stable vital signs. The patient was found to have a potassium level of 2.1 mmol/L and an EKG demonstrating U waves (characteristic of hypokalemia). The patient was treated with potassium supplementation with resolution of symptoms. The mainstay of prevention of long term permanent muscle weakness is avoidance of triggers that can lead to hypokalemia. Through education on disease process and lifestyle modifications, we were able to end the cycle of recurrent hospital readmissions and the subsequent financial burden this generated for the patient and his family.