Improving the utilization of admission order sets in a computerized physician order entry system by integrating modular disease specific order subsets into a general medicine admission order set.

CASE DESCRIPTION: We evaluated the effects of integrating order subsets for the most common medical diagnoses into a general medical admission order set of our electronic medical records (EMR) in order to improve order set integration by clinicians. METHODS OF IMPLEMENTATION: We identified the most common primary and secondary diagnoses for patients admitted to our medical service and developed order subsets comprising only of the orders necessary for the management of these individual diagnoses. Using the capabilities of our computerized physician order entry (CPOE), we nested these order subsets into the general order set and evaluated the resulting change in order set utilization by our clinicians. EXAMPLE AND OBSERVATIONS: The total number of order sets used by clinicians in all departments increased fivefold during the 16-month period following the implementation of the integrated order sets in July 2008. A before and after time series was used to analyze the trend in increased order set usage and showed an effect of the intervention (p=0.023). DISCUSSION: Integration of disease specific order subsets into a single general admission order set significantly improved the overall adoption of order sets by clinicians. This provides health care systems with the opportunity to improve patient safety and implement evidence based care in clinical practice.

Eustachian valve endocarditis: a rare complication of automatic implantable cardioverter defibrillator placement.

Eustachian valve (EV) endocarditis is extremely rare and often difficult to diagnose. An extensive review of the English literature has shown no report of EV endocarditis as a complication of the automatic implantable cardioverter defibrillator (AICD). A rare case is reported following AICD placement that was diagnosed by clinical findings of sepsis and positive blood cultures, and supported (using transesophageal echocardiography) by the presence of vegetations attached to the EV. Previously reported cases of EV endocarditis are reviewed, and its significance discussed in the setting of an increased use of AICD.

Hyperparathyroidism, hypercalcemia, and calcified brain metastatic lesions in a patient with small cell carcinoma demonstrating positive immunostain for parathyroid hormone.

OBJECTIVE: To describe a patient with metastatic small cell lung carcinoma, who presented with hypercalcemia, a high level of intact parathyroid hormone (iPTH), and multiple calcified metastatic lesions in the brain. METHODS: We review the clinical findings, laboratory data, and results of imaging studies in our patient. In addition, we summarize the previously reported cases of ectopic iPTH-producing tumors. RESULTS: A previously healthy 50-year-old man had a 2-month history of back pain, hip pain, and weight loss. Physical examination revealed a confused patient with dehydration, cachexia, and tenderness of the neck and both hips. His serum calcium concentration was 19.1 mg/dL, and the serum iPTH level was 107 pg/mL (normal range, 10 to 65). Imaging studies revealed multiple bilateral calcified metastatic lesions in the brain, a cavitary mass in the right lung, and osteolytic lesions in the left femur, pelvis, and spine. Biopsy of the femoral lesion yielded histologic findings consistent with small cell carcinoma. An immunohistochemistry stain was strongly positive for iPTH in the biopsy tissue. CONCLUSION: Previously, only seven cases of true ectopic production of iPTH from nonparathyroid malignant lesions had been reported, of which only two were in patients with small cell carcinoma. We report the eighth such case and describe an association between hypercalcemia and calcified metastatic lesions, which has not been previously reported.