Expansion of telehealth in primary care during the COVID-19 pandemic: benefits and barriers.

ABSTRACT: The novel coronavirus disease 2019 (COVID-19) pandemic remarkably accelerated the adoption of telemedicine in outpatient settings. Out of necessity, virtual care became a preferred and default modality of extending primary care services to health care consumers. Although telemedicine is not a new concept and had been used in many organizations and health systems, the COVID-19 pandemic scaled up its use in a variety of health care settings. Telehealth's use in primary care was particularly important because of the need to maintain continuity of care for successful coordination of chronic disease management. This article examines the benefits of telehealth, including continuity of care, convenience of access to care, screening and triaging, and social distancing and disease prevention. The utilization of telehealth and financial implications are discussed, including reimbursement and cost-effectiveness. Barriers and challenges are addressed, including methods for successful implementation of nurse practitioner (NP) in primary care practices as a response to the COVID-19 pandemic. The leadership role of the NP in telehealth is discussed and implementation guidance is provided.

Dinitrophenol (DNP) Fatality Associated with a Falsely Elevated Salicylate Level: a Case Report with Verification of Laboratory Cross Reactivity.

INTRODUCTION: 2,4-Dinitrophenol (DNP) is a known uncoupler of oxidative phosphorylation that clinically leads to hyperthermia, tachycardia, tachypnea, and metabolic acidosis. Intentional overdoses of DNP are often fatal. We present an analytically confirmed fatal case of DNP overdose with a falsely positive elevated salicylate concentration. We further explored this cross reactivity of DNP with two salicylate assays. METHODS: Clinically relevant serial dilutions of DNP were prepared in drug-free serum and analyzed using two different colorimetric NADH/NAD-based analytical methodologies. RESULTS: The enzymatic salicylate assay demonstrated a reproducible false elevation of salicylate starting at a DNP level of 100 mg/L while the EMIT-based methodology was without any such interference at the maximum concentration tested (150 mg/L). CONCLUSIONS: DNP cross reacts with some salicylate assays. This knowledge is important for providers, as there are significant variations in the management of DNP versus salicylate toxicity.

Detection of ingested nitromethane and reliable creatinine assessment using multiple common analytical methods.

AIM: Nitromethane, found in fuels used for short distance racing, model cars, and model airplanes, produces a falsely elevated serum creatinine with standard creatinine analysis via the Jaffé method. Erroneous creatinine elevation often triggers extensive testing, leads to inaccurate diagnoses, and delayed or inappropriate medical interventions. Multiple reports in the literature identify "enzymatic assays" as an alternative method to detect the true value of creatinine, but this ambiguity does not help providers translate what type of enzymatic assay testing can be done in real time to determine if there is indeed false elevation. METHODS: We report seven cases of ingested nitromethane where creatinine was determined via Beckman Coulter® analyser using the Jaffé method, Vitros® analyser, or i-Stat® point-of-care testing. Nitromethane was detected and semi-quantified using a common clinical toxic alcohol analysis method, and quantified by headspace-gas chromatography-mass spectrometry. RESULTS: When creatinine was determined using i-Stat® point-of-care testing or a Vitros® analyser, levels were within the normal range. Comparatively, all initial creatinine levels obtained via the Jaffé method were elevated. Nitromethane concentrations ranged from 42 to 310 µg/mL. CONCLUSIONS: These cases demonstrate reliable assessment of creatinine through other enzymatic methods using a Vitros® analyser or i-STAT®. Additionally, nitromethane is detectable and quantifiable using routine alcohols gas chromatography analysis and by headspace-gas chromatography-mass spectrometry.

Implementing clinical practice guidelines for screening and detection of delirium in a 21-hospital system in northern California: real challenges in performance improvement.

PURPOSE: The purpose of this article was to describe a quality improvement process on a diverse adult intensive care unit (ICU) population for a large healthcare organization for early detection of delirium. BACKGROUND: Delirium is often considered a common unpreventable problem in the ICU. A process for early detection of delirium allows the critical care team to evaluate the patient and intervene to improve or reverse the delirium. DESCRIPTION: A business case was first developed, and then using performance improvement methodology combined with quality improvement methods and oversight from a Delirium/Sedation Workgroup, an implementation plan was developed. Intensive care clinical nurse specialists were educated; patients in the ICU were screened for delirium twice daily by bedside nurses using the Confusion Assessment Method. The clinical nurse specialist in each ICU was instrumental for driving the process of change and supporting the bedside nurse and physicians to discuss preventing, screening, and treating delirium. OUTCOME: System-wide process implementation was completed in 1 year, 2011. In 2012, all medical centers had a program in place to decrease the use of benzodiazepines and improve communication in the multidisciplinary teams during daily rounds about the treatment and prevention of delirium. The process of performance improvement is ongoing with continual reassessment and feedback required to ensure sustainability. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: Performance improvement involving 21 medical centers is a large-scale undertaking by an organization. It requires a systematic approach with key stakeholders and advanced practice nurses as subject matter experts involved throughout all phases of the implementation. Bedside clinicians assessing the patient must feel supported and valued members of the process. Challenges of all care providers need to be acknowledged and addressed.

Impact of increased body mass index on accuracy of B-type natriuretic peptide (BNP) and N-terminal proBNP for diagnosis of decompensated heart failure and prediction of all-cause mortality.

BACKGROUND: BNP and N-terminal proBNP (NT-proBNP) concentrations may be depressed in patients with increased body mass index (BMI). Whether increased BMI affects accuracy of these biomarkers for diagnosing decompensated heart failure (HF) and predicting outcomes is unknown. METHODS: We measured BNP and NT-proBNP in 685 patients with possible decompensated HF in a free-living community population subdivided by BMI as obese, overweight, and normal weight. HF diagnosis was adjudicated by a cardiologist blinded to BNP and NT-proBNP results. We tabulated all-cause mortality over a median follow-up of 401 days and assessed marker accuracy for HF diagnosis and mortality by ROC analysis. RESULTS: Of the 685 patients, 40.9% were obese (n = 280), 28.2% were overweight (n = 193), and 30.9% had normal BMI (n = 212). Obese patients had lower BNP and NT-proBNP compared with overweight or normal-weight individuals (P < 0.001) and decreased mortality compared with normal-weight individuals (P < 0.001). Both biomarkers added significantly to a multivariate logistic regression model for diagnosis of decompensated HF across BMI categories. NT-proBNP outperformed BNP for predicting all-cause mortality in normal-weight individuals (chi(2) for BNP = 6.4, P = 0.09; chi(2) for NT-proBNP = 16.5, P < 0.001). Multivariate regression showed that both biomarkers remained significant predictors of decompensated HF diagnosis in each BMI subgroup. CONCLUSIONS: In this study population, obese patients had significantly lower BNP and NT-proBNP that reflected lower mortality. BNP and NT-proBNP can be used in all BMI groups for decompensated HF diagnosis, although BMI-specific cutpoints may be necessary to optimize sensitivity.

Impact of renal disease on natriuretic peptide testing for diagnosing decompensated heart failure and predicting mortality.

BACKGROUND: Concomitant occurrence of kidney disease (KD) and heart failure (HF) is common and associated with poor outcomes. Natriuretic peptide studies have typically excluded many individuals with KD. We compared the accuracy of B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP) for diagnosing decompensated HF and predicting mortality across the spectrum of renal function. METHODS: BNP and NT-proBNP were prospectively measured in a cohort of 831 dyspnea patients. KD was defined as an estimated glomerular filtration rate <60 mL . min(-1) . (1.73 m(2))(-1). The accuracy and predictive value of each test for diagnosing decompensated HF and predicting all-cause 1-year mortality were assessed by ROC area under the curve (AUC) and multivariate regression analysis. RESULTS: Among the 831 dyspnea patients, 393 (47%) had KD. The diagnostic accuracies of BNP and NT-proBNP in detecting decompensated HF were similar to each other in patients without KD (AUC 0.75 vs 0.74, respectively; P = 0.60) and in patients with KD (AUC 0.68 vs 0.66; P = 0.10). One-year mortality rates were 36.3% and 19.0% in those with and without KD, respectively (P <0.001). Progressively higher BNP and NT-proBNP concentrations remained predictive of increased mortality in KD patients. Compared with the lowest quartile, quartile 4 of BNP had an adjusted hazards ratio (HR) of 2.6 (95% CI 1.4-4.8; P = 0.004 for trend) and NT-proBNP quartile 4 had an HR of 4.5 (95% CI 2.0-10.2; P <0.001 for trend). Only NT-proBNP remained a predictor of death after adjustment for clinical confounders and the other natriuretic peptide marker. CONCLUSIONS: NT-proBNP and BNP are equivalent predictors of decompensated HF across a spectrum of renal function, but NT-proBNP is a superior predictor of mortality.