Reining in Unnecessary Admission EKGs: A Successful Interdepartmental High-Value Care Initiative.

Introduction Unnecessary "admission electrocardiograms (EKGs)" on admitted patients waiting ("boarding") in the emergency department (ED) are often ordered. We introduced evidence-based EKG ordering guidelines and determined changes in the percent of patients with "preadmission" and "admission" EKGs ordered before vs. after guideline introduction and which patient characteristics predicted EKG ordering. Methods In 2016, our ED, cardiology, and hospitalist services implemented EKG ordering guidelines to reduce unnecessary ED EKGs ordered after disposition. We compared pre- vs. post-guideline EKG ordering to determine whether guidelines were associated with changes in "preadmission" or "admission EKG" ordering. Patients with an admission diagnosis unrelated to cardiac or pulmonary systems were included. An EKG was "admission" if the order time was after disposition time. The numerator was the number of "admission EKGs" ordered; the denominator was the total number of such admissions; those with "preadmission EKGs" were excluded from this analysis. Variables that might influence EKG ordering were explored. The chi-square test with Bonferroni adjustment was used to compare 2015 vs. 2016 percentages of patients with an "admission EKG." Results There was a decrease in unwarranted "admission EKGs" among ED boarding patients (44.1% pre-implementation to 27.5% by two years post-implementation) and an increase in unwarranted "preadmission EKGs" (66.1% pre-implementation to 72.8% post-implementation). Age ≥40 and past medical history independently predicted EKG ordering. Discussion The decrease in the ordering of "admission EKGs" but "preadmission EKGs" suggests the decline reflects a true change in ordering and not a general environmental/ecologic decline in ordering. This highlights the importance of careful guideline development and implementation.

Selfing is the safest sex for Caenorhabditis tropicalis.

Mating systems have profound effects on genetic diversity and compatibility. The convergent evolution of self-fertilization in three Caenorhabditis species provides a powerful lens to examine causes and consequences of mating system transitions. Among the selfers, Caenorhabditis tropicalis is the least genetically diverse and most afflicted by outbreeding depression. We generated a chromosomal-scale genome for C. tropicalis and surveyed global diversity. Population structure is very strong, and islands of extreme divergence punctuate a genomic background that is highly homogeneous around the globe. Outbreeding depression in the laboratory is caused largely by multiple Medea-like elements, genetically consistent with maternal toxin/zygotic antidote systems. Loci with Medea activity harbor novel and duplicated genes, and their activity is modified by mito-nuclear background. Segregating Medea elements dramatically reduce fitness, and simulations show that selfing limits their spread. Frequent selfing in C. tropicalis may therefore be a strategy to avoid Medea-mediated outbreeding depression.