Secondary review reduced inpatient MRI orders and avoidable hospital days.

INTRODUCTION: Medical centers have dramatically increased the use of magnetic resonance imaging (MRI). At 2 large academic tertiary care centers in New York City, nearly half of inpatient MRI orders took more than 12 h to complete, delaying patient discharge and increasing avoidable hospital days. We posited that transitioning inpatient MRIs to outpatient facilities, when safe and appropriate, could reduce inpatient MRI orders and avoidable hospital days. METHODS: We manually reviewed 59 inpatient MRI orders delayed on the estimated date of discharge (EDD). These orders were often delayed due to no standard process to escalate orders for medical reasons or no system to coordinate outpatient orders. We developed a revised workflow involving an automation platform that flagged inpatient MRI orders requested within 24 h of the EDD and emailed the care team to request a second review of the order. The care team reconsidered whether the order was (1) required for discharge, (2) non-urgent and could be converted to an outpatient order, or (3) unnecessary and could be canceled. RESULTS: Over 9 months, the automation platform flagged 618 inpatient MRI orders, of which 53.9% (333/618) were reviewed by the care team. Among the orders, 24.0% (80/333) of reviewed orders and 12.9% (80/618) of all orders were transitioned to either outpatient or canceled orders. These transitioned orders were associated with 267 fewer avoidable hospital days and a cost savings of $199,194. CONCLUSION: A standardized process and second review of inpatient MRI orders on the EDD can reduce inappropriate orders and more effectively use inpatient imaging resources. PRECIS: A standardized workflow and automation platform encouraged a second review of inpatient MRI orders to reduce inappropriate orders, avoidable hospital days, and hospital costs.

From Hospital to Home: A Resident-Driven Quality Improvement Project to Overcome Discharge Prescription Barriers.

BACKGROUND AND OBJECTIVES: Inability to obtain timely medications is a patient safety concern that can lead to delayed or incomplete treatment of illness. While there are many patient and system factors contributing to postdischarge medication nonadherence, availability and insurance-related barriers are preventable. PURPOSE: To implement a systematic process ensuring review of discharge prescriptions to ensure availability and resolve insurance barriers before patient discharge. METHODS: A prospective single-arm quality improvement intervention study to identify and address insurance-related prescription barriers using nonclinical staff. Intervention was pilot tested with sequential spread across general medicine resident teams. The primary outcome was successful obtainment of postdischarge prescriptions confirmed by phone calls to patients or their pharmacies. RESULTS: From April to August 2015, 59 of 161 patients included in the improvement process (36.6%) had one or more insurance or availability-related barriers with their prescriptions, totaling 89 issues. Forty-three of the 59 patients (72.9%) responded to postdischarge phone calls, 39 of whom (39/43, 90.7%) successfully filled their prescriptions on the first pharmacy visit. CONCLUSIONS: In our study, we preemptively identified that over a third of patients discharged would have encountered barriers filling their prescriptions. This interdisciplinary quality improvement project using nonclinical team members removed barriers for over 90% of our patients to ensure continuation of medical therapy without disruption and a safer postdischarge plan.

Cutaneous and mucocutaneous leishmaniasis: Clinical perspectives.

Leishmaniasis is endemic in 98 countries and territories, with 1.2 million new cases per year, making it a worldwide concern. The deadly visceral form is a leading cause of death from tropical parasitic infections, second only to malaria. Leishmaniasis appears to be increasing in many countries because of extended urbanization. The disease reservoir includes small mammals; parasite transmission occurs via bite of the female phlebotomine sandfly. Disease manifestations vary and largely depend upon the Leishmania species acquired. It may be first evident with a range of findings-from a localized cutaneous ulcer to diffuse painless dermal nodules-or, in the mucocutaneous form, ulceration of the oropharynx. In the potentially deadly visceral form, the internal organs and bone marrow are affected.

Cutaneous and mucocutaneous leishmaniasis: Differential diagnosis, diagnosis, histopathology, and management.

The diagnosis of leishmaniasis can be challenging because it mimics both infectious and malignant conditions. A misdiagnosis may lead to an unfavorable outcome. Using culture, histologic, and/or polymerase chain reaction study results, a diagnosis of leishmaniasis can be established and treatment initiated. Appropriate management requires an accurate diagnosis, which often includes identification of the specific etiologic species. Different endemic areas have varying sensitivities to the same medication, even within individual species. Species identification may be of practical value, because infections with select species have a substantial risk of visceral involvement. In addition, HIV and otherwise immunocompromised patients with leishmaniasis have a propensity for diffuse cutaneous leishmaniasis. For most New World Leishmania species, parenteral antimonial drugs remain the first line of therapy, while Old World species are easily treated with physical modalities. Historically, live organism vaccination has been used and is effective in preventing leishmaniasis, but results in an inoculation scar and an incubation period that may last for years. A more effective method of vaccination would be welcome.