Outcomes of an integrated practice unit for vulnerable emergency department patients.

BACKGROUND: An integrated practice unit (IPU) that provides a multidisciplinary approach to patient care, typically involving a primary care provider, registered nurse, social worker, and pharmacist has been shown to reduce healthcare utilization among high-cost super-utilizer (SU) patients or multi-visit patients (MVP). However, less is known about differences in the impact of these interventions on insured vs. uninsured SU patients and super high frequency SUs ([Formula: see text]8 ED visits per 6 months) vs. high frequency SUs (4-7 ED visits per 6 months). METHODS: We assessed the percent reduction in ED visits, ED cost, hospitalizations, hospital days, and hospitalization costs following implementation of an IPU for SUs located in an academic tertiary care facility. We compared outcomes for publicly insured with uninsured patients, and super high frequency SUs with high frequency SUs 6 months before vs. 6 months after enrollment in the IPU. RESULTS: There was an overall 25% reduction in hospitalizations (p < 0.001), and 23% reduction in hospital days (p = 0.0045), when comparing 6 months before vs. 6 months after enrollment in the program. There was a 26% reduction in average total direct hospitalization costs per patient (p = 0.002). Further analysis revealed a greater reduction in health care utilization for uninsured SU patients compared with publicly insured patients. The program reduced hospitalizations for super high frequency SUs. However, there was no statistically significant impact on overall health care utilization of super high frequency SUs when compared with high frequency SUs. CONCLUSIONS: Our study supports existing evidence that dedicated IPUs for SUs can achieve significant reductions in acute care utilization, particularly for uninsured and high frequency SU patients. TRIAL REGISTRATION: IRB201500212. Retrospectively registered.

Lessons in clinical reasoning - pitfalls, myths, and pearls: a case of crushing, substernal chest pain.

OBJECTIVES: Diagnostic error is not uncommon and diagnostic accuracy can be improved with the use of problem representation, pre-test probability, and Bayesian analysis for improved clinical reasoning. CASE PRESENTATION: A 48-year-old female presented as a transfer from another Emergency Department (ED) to our ED with crushing, substernal pain associated with dyspnea, diaphoresis, nausea, and a tingling sensation down both arms with radiation to the back and neck. Troponins were elevated along with an abnormal electrocardiogram. A negative myocardial perfusion scan led to the patient's discharge. The patient presented to the ED 10 days later with an anterior ST-elevation myocardial infarction. CONCLUSIONS: An overemphasis on a single testing modality led to diagnostic error and a severe event. The use of pre-test probabilities guided by history-taking can lead to improved interpretation of test results, ultimately improving diagnostic accuracy and preventing serious medical errors.

A Hepatic Manifestation of Anorexia Nervosa.

A 30-year-old woman with a history of anorexia nervosa was admitted with weight loss, hypoglycaemia and electrolyte disturbances. During her admission, transaminases peaked at ALP 457 U/l, AST 817 U/l and ALT 1066 U/l. Imaging and laboratory findings were unrevealing, and she declined liver biopsy. Nutrition was introduced via a nasogastric tube and she demonstrated improvement in her laboratory values over several weeks. Her transaminitis was determined to be secondary to severe malnutrition, which has been previously described, but cases with such profound transaminitis are less common. Studies have demonstrated hepatic autophagocytosis as the likely cause. LEARNING POINTS: Anorexia nervosa can cause severe liver injury as manifested in AST and ALT levels in the thousands.The slow reintroduction of enteral feeding can reverse liver injury.The mechanism is unclear but autophagocytosis of liver cells likely contributes to this phenomenon.

Abdominal Ecchymosis: Emergency, or Urgen-C?

Scurvy is a multisystem disease caused by vitamin C deficiency, historically associated with lethargy, gingivitis, ecchymosis, edema, and death if left untreated. Contemporary socioeconomic risk factors for scurvy include smoking, alcohol abuse, fad diets, mental health conditions, social isolation, and economic marginalization. Food insecurity is also a risk factor. This report describes a case of a man in his 70s who presented with unexplained dyspnea, abdominal pain, and abdominal ecchymosis. His plasma vitamin C level was undetectable, and he improved with vitamin C supplementation. This case highlights the significance of awareness of these risk factors and emphasizes the need for a comprehensive social and dietary history to enable the timely treatment of this rare but potentially fatal disease.

Chronic ocular small vessel disease: An overview of diabetic retinopathy and its relationship with cardiovascular health.

Diabetic retinopathy (DR) is a potentially blinding disease originating from small vessel damage in the retina in chronic hyperglycemic states. DR has a complex multi-pathway driven pathogenesis resulting in diabetic macular edema and retinal ischemia, the former being the most common cause of vision impairment in DR. Hypoxia induced cytokines stimulate vascular endothelial growth factor (VEGF) production and subsequent angiogenesis with resultant mechanical retinal damage over time. Anti-VEGF therapy is effective for the treatment of center-involving diabetic macular edema. There is evolving evidence showing the effectiveness of anti-VEGF as both adjuvant and monotherapy in the treatment of proliferative DR, however laser photocoagulation continues to remain the standard of care. DR in large cohort studies has been shown to be an independent risk factor for the development of cardiovascular disease and mortality. In addition, changes in retinal vascular caliber ratios may have implications for risk of macrovascular events with a gender discrepancy towards women.

Cutaneous Larvae Migrans Treated with a Single Dose of Ivermectin.

Hookworm-related cutaneous larva migrans (HrCLM) is a clinical diagnosis based on a history of exposure to contaminated soil and is associated with a characteristic red serpiginous lesion that migrates within the epidermis. Our patient presented with a red, tortuous migratory rash with localized pruritus on the left plantar foot of 1-month duration. He lacked recent travel history outside the southeastern United States. Upon admission, he presented with peripheral blood eosinophilia, an uncommon feature of HrCLM. A single dose of ivermectin was sufficient for treatment, and symptoms resolved within 3 days. This case highlights the increased incidence of domestically acquired hookworm infections, explores this epidemiological shift, and emphasizes relevant differential diagnoses.

Acute limb ischaemia due to vasospasm: a rare presentation.

A 30-year-old woman with active intravenous drug use presented with pain, blue discolouration, paresthesia and lack of grip strength of left hand for 1 week. Physical examination revealed blue discolouration, decreased sensation and cold to touch in the left hand. She had no palpable radial pulse. She admitted Heroin use only but the urine drug screen was also positive for amphetamine. CT angiogram of the left upper extremity was concerning for acute ischaemia due to arterial occlusion. The initial plan was for amputation. However, to salvage the limb with thrombolysis, an interventional radiology angiogram was performed. The angiogram demonstrated diffuse arterial spasm and response to nitroglycerin. She was treated with nitroglycerin drip and transitioned to a calcium channel blocker. She did improve significantly. To ensure no embolic sequelae, the patient was discharged with a month of oral anticoagulation.

Prospective application of the interdisciplinary bedside rounding checklist 'TEMP' is associated with reduced infections and length of hospital stay.

Protocols that enhance communication between nurses, physicians and patients have had a variable impact on the quality and safety of patient care. We combined standardised nursing and physician interdisciplinary bedside rounds with a mnemonic checklist to assure all key nursing care components were modified daily. The mnemonic TEMP allowed the rapid review of 11 elements. T stands for tubes assuring proper management of intravenous lines and foleys; E stands for eating, exercise, excretion and sleep encouraging a review of orders for diet, exercise, laxatives to assure regular bowel movements, and inquiry about sleep; M stands for monitoring reminding the team to review the need for telemetry and the frequency of vital sign monitoring as well as the need for daily blood tests; and P stands for pain and plans reminding the team to discuss pain medications and to review the management plan for the day with the patient and family. Faithful implementation eliminated central line-associated bloodstream infections and catheter-associated urinary tract infections and resulted in a statistically significant reduction in average hospital length of stay of 13.3 hours, one unit achieving a 23-hour reduction. Trends towards reduced 30-day readmissions (20% down to 10%-11%) were observed. One unit improved the percentage of patients who reported nurses and doctors always worked together as a team from a 56% baseline to 75%. However, the combining of both units failed to demonstrate statistically significant improvement. Psychologists well versed in implementing behavioural change were recruiting to improve adherence to our protocols. Following training physicians and nurses achieved adherence levels of over 70%. A high correlation (r2=0.69) between adherence and reductions in length of stay was observed emphasising the importance of rigorous training and monitoring of performance to bring about meaningful and reliable improvements in the efficiency and quality of patient care.

A Patient-Centered Environmental Scan of Inpatient Visitor Policies During the COVID-19 Pandemic.

Researchers and patients conducted an environmental scan of policy documents and public-facing websites and abstracted data to describe COVID-19 adult inpatient visitor restrictions at 70 academic medical centers. We identified variations in how centers described and operationalized visitor policies. Then, we used the nominal group technique process to identify patient-centered information gaps in visitor policies and provide key recommendations for improvement. Recommendations were categorized into the following domains: 1) provision of comprehensive, consistent, and clear information; 2) accessible information for patients with limited English proficiency and health literacy; 3) COVID-19 related considerations; and 4) care team member methods of communication.

Increasing adherence to a standardized rounding procedure in two hospital in-patient units.

Standardized bedside rounds can improve communication and the quality of care for patients in hospitals. However, it can be challenging to change previously established provider practices to adhere to new procedures. This study evaluated 2 packaged interventions, derived from a modified Performance Diagnostic Checklist interview, to increase adherence to standardized rounding practices in 2 hospital units. Researchers observed physicians at a university hospital on rounds 2-3 times per week, and 2 phases of intervention were implemented to improve adherence. The interventions included task clarification, feedback, and weekly huddles. Compared to baseline, phases 1 and 2 of the intervention improved clinician adherence to the standardized bedside rounding checklist by 24.94% and 30.94% in unit 1 and 26.76% and 44.06% in unit 2, respectively. The standardized rounds did not require additional time following the intervention. These results indicate that physician adherence can be improved through behavioral interventions.

A rare case of right shoulder pain.

We present a case of a 19-year-old man with right shoulder pain lasting for several months. Abdominal imaging revealed a right adrenal mass directly invading vascular structures into the right atrium. Widespread metastatic adrenocortical carcinoma was confirmed on biopsy. He opted for palliative mitotane treatment with home hospice care. This case emphasises the importance of considering abdominal masses in the differential diagnosis of persistent right shoulder pain after common causes have been ruled out. Early diagnosis could be potentially life-saving.

Implementing Delirium Prevention in the Era of COVID-19.

Patients admitted with COVID-19 can develop delirium due to predisposing factors, isolation, and the illness itself. Standard delirium prevention methods focus on interaction and stimulation. It can be challenging to deliver these methods of care in COVID settings where it is necessary to increase patient isolation. This paper presents a typical clinical vignette of representative patients in a tertiary care hospital and how a medical team modified an evidence-based delirium prevention model to deliver high-quality care to COVID-19 patients. The implemented model focuses on four areas of delirium-prevention: Mobility, Sleep, Cognitive Stimulation, and Nutrition. Future studies will be needed to track quantitative outcome measures.

Acute right ventricular failure: a novel presentation of methadone-induced cardiotoxicity.

As methadone use increases, the potential for methadone-induced cardiotoxicity (MIC) may rise. We describe a case of acute right ventricular (RV) failure leading to cardiogenic shock after methadone overdose. This presentation was followed by full RV recovery. This previously undescribed presentation highlights the challenges involved with MIC, its diagnosis and its management.

Endogenous Endophthalmitis: yield of the diagnostic evaluation.

BACKGROUND: Endogenous endophthalmitis is an infection of the eye secondary to sepsis, occurring in 0.04-0.5% of bacteremia or fungemia. Risk factors include intravenous drug abuse (IVDA), diabetes, indwelling catheters, and immune suppression. Many patients have known or suspected bacteremia or fungemia; however, culture yield is reported to be low (approximately 50%). The purpose of this study is to elucidate the yield of diagnostic evaluation including microbial cultures over a 6.5 year period at an academic center in the United States. METHODS: Retrospective chart review of patients with endogenous endophthalmitis at the University of Florida from June 2011 to February 2018. RESULTS: Included are 40 eyes of 35 patients. Endophthalmitis was secondary to an endogenous source in 23.5% of all endophthalmitis cases observed. Intraocular culture positivity was 28.6% overall but was 0% after initiation of systemic antibiotics. Most commonly identified organisms from the eye were coagulase-negative Staphylococcus and Candida. Blood culture positivity was 48.6%, most commonly Staphylococcus. IVDA was noted with increasing frequency as a risk factor. Diagnosis of endophthalmitis upon hospital admission was associated with a higher intraocular culture positivity (P = 0.040) and a shorter hospital stay (P = 0.035). Computed tomography (CT) and magnetic resonance imaging (MRI) were the highest yield imaging modalities; X-ray and non-ocular ultrasound were less diagnostically useful. Echocardiogram was positive by transesophageal route (TEE) in 22% and in 9% by transthoracic (TTE) testing. Following discharge from the hospital, 48.4% of patients failed to follow up with outpatient ophthalmology. CONCLUSIONS: Based on the results of this study, the interdisciplinary team should consider directed imaging, eye cultures prior to antimicrobial administration, thorough history for IVDA, and caution with premature discharge from the hospital.

Bilateral lower extremity ulcerations, less is more.

The differential diagnosis of lower extremity ulcers must be broad since debridement can be harmful in certain conditions such as pyoderma gangrenosum. Biologic agents may be helpful in the treatment of pyoderma gangrenosum.

Teaching novice clinicians how to reduce diagnostic waste and errors by applying the Toyota Production System.

Background Diagnostic waste, defined as the ordering of low value tests, increases cost, causes delays, increases complexity, and reduces reliability. The Toyota Production System (TPS) is a powerful approach for process improvement that has not been applied to the diagnostic process. We describe a curriculum based on tools and principles of TPS that provides medical students with an approach for reducing diagnostic waste and improving patient management. Methods A 2-day elective course "Fixing Healthcare Delivery" was offered to medical students at the University of Florida, Gainesville. A section within the course had three learning objectives related to TPS: (1) define value in health care; (2) describe how diagnostic waste leads to time delays and diagnostic errors; and (3) apply sequential and iterative value streams for patient management. Instruction methods included videos, readings, and online quizzes followed by a 2-h seminar with facilitated discussion and active problem solving. Results During the 3 years the course was offered students (n = 25) achieved average scores of 95% on a pre-seminar test of manufacturing principles applied to the diagnostic and management process. Course evaluations averaged 4.94 out of 5 (n = 31). Conclusions Students appreciated the application of the TPS principles to the diagnostic process and expressed the desire to apply these manufacturing principles in their future diagnostic and management decision-making.

A resident-driven mortality case review innovation to teach and drive system-based practice improvements in the United States.

PURPOSE: Traditionally, Morbidity and Mortality Conference (M&MC) are forums where medical errors are discussed. Though M&MC can lead to identification of opportunities for system wide improvements, there is little in the literature to describe the use for this purpose, particularly in residency training programs. This paper describes the use of M&MC case review as a quality improvement activity that teaches systems-based practice and can engage residents in improving systems of care. METHODS: Internal medicine residents at a tertiary care academic medical center reviewed 347 consecutive mortalities from March 2104 to September 2017. Residents used case review worksheets to categorize and track causes of mortality. The residents then debriefed with a faculty member. Selected cases were then presented at a larger interdepartmental meeting and action items were implemented. Descriptive statistics and thematic analysis were used to analyze the results. RESULTS: The residents identified a diagnosis mismatch from admission to death in 54.5 % (n=189) of cases and possible need for improvement in management in 48.0% cases. Three 'management failure' themes were identified including failures to plan, failure to communicate and failure to rescue, consisting of 21.9%, 10.7 %, and 10.1% of cases respectively. Following the reviews, quality improvement initiatives proposed by residents lead to system-based changes. CONCLUSION: A resident-driven mortality review curriculum can lead to improvement in systems of care. This type of novel curriculum can teach systems-based practice. The recruitment of teaching faculty with expertise in quality improvement and mortality case analyses is essential for such a project.

Implementation of a Routine Health Literacy Assessment at an Academic Medical Center.

Limited health literacy is a common but often unrecognized problem associated with poor health outcomes. Well-validated screening tools are available to identify and provide the opportunity to intervene for at-risk patients in a resource-efficient manner. This is a multimethod study describing the implementation of a hospital-wide routine health literacy assessment at an academic medical center initiated by nurses in April 2014 and applied to all adult inpatients. Results were documented in the electronic health record, which then generated care plans and alerts for patients who screened positive. A nursing survey showed good ease of use and adequate patient acceptance of the screening process. Six months after hospital-wide implementation, retrospective chart abstraction of 1,455 patients showed that 84% were screened. We conclude that a routine health literacy assessment can be feasibly and successfully implemented into the nursing workflow and electronic health record of a major academic medical center.