What's the CATCH? A Participatory Learning Model for Case Review Rounds to Support a Culture of Safety and Quality Improvement in Pediatric Hospital Medicine.

OBJECTIVE: To evaluate the effectiveness of a new model, Case Analysis and Translation to Care in Hospital (CATCH), for the review of pediatric inpatient cases when an adverse event or "close call" had occurred. STUDY DESIGN: The curricular intervention consisted of an introductory podcast/workshop, mentorship of presenters, and monthly CATCH rounds over 16 months. The study was conducted with 22 pediatricians at a single tertiary care center. Intervention assessment occurred using participant surveys at multiple intervals: pre/post the intervention, presenter experience (post), physicians involved and mentors experience (post), and after each CATCH session. Paired t-tests and thematic analysis were used to analyze data. Time required to support the CATCH process was used to assess feasibility. RESULTS: Our overall experience and data revealed a strong preference for the CATCH model, high levels of engagement and satisfaction with CATCH sessions, and positive presenter as well as physicians-involved and mentor experiences. Participants reported that the CATCH model is feasible, engages physicians, promotes a safe learning environment, facilitates awareness of tools for case analysis, and provides opportunities to create "CATCH of the Day" recommendations to support translation of learning to clinical practice. CONCLUSIONS: The CATCH model has significant potential to strengthen clinical case rounds in pediatric hospital medicine. Future research is needed to assess the effectiveness of the model at additional sites and across medical specialities.

The Impact of Undernutrition Risk on Rehabilitation Outcomes in Ischemic Stroke Survivors: A Hospital-Based Study.

Patients experiencing a cerebrovascular event are vulnerable to declining nutritional status, hindering rehabilitation. This study aims to analyze the association between malnutrition risk and hospital rehabilitation indicators in ischemic stroke survivors (ISS). This analytical study examined medical records of 160 adult patients (69.3 ± 13 years). Undernutrition risk (UR; independent variable) and rehabilitation indicators (dependent variables) like hospital stay, clinical outcome, functionality, stroke severity, food intake, mobility (bedridden), mechanical ventilation, and enteral nutrition were assessed. Data were dichotomized, and the chi-square test identified associations (p ≤ 0.05), followed by Poisson regression for prevalence ratios. Patients at UR had 2-fold higher risk of death (95% confidence interval [CI], 0.99-4.79), 1.8-fold higher risk of high stroke severity (95% CI, 1.06-3.11), 76% higher chance of being bedridden (95% CI, 1.28-2.44), and 3-fold higher risk of mechanical ventilation (95% CI, 1.20-9.52). UR in hospitalized ISS is associated with deteriorating rehabilitation indicators, including mobility, decreased food intake, mechanical ventilation use, and neurological deficit, indicating an increased mortality risk post-stroke.

Reduction of hospital length of stay through the implementation of SAFER patient flow bundle and Red2Green days tool: a pre-post study.

BACKGROUND: In 2018, the National Health System released the 'Guide to reducing long hospital stays' to stimulate improvement and decrease length of stay (LOS) in England hospitals. The SAFER patient flow bundle and Red2Green tool were described as strategies to be implemented in inpatient wards to reduce discharge delays. OBJECTIVE: To verify if implementing the SAFER patient flow bundle and Red2Green days tool is associated with LOS reduction in the internal medicine unit (IMU) wards of a university hospital in Brazil. METHODS: In this pre post study, we compared the LOS of patients discharged from the IMU wards in 2019, during the implementation of the SAFER bundle and Red2Green tool, to the LOS of patients discharged in the same period in 2018. The Diagnosis-Related Group Brazil algorithm compared groups according to complexity and resource requirements. In-hospital mortality, readmission rates, the number of hospital acquired conditions and the number and causes of inappropriate hospital days were also evaluated. RESULTS: Two hundred and eight internal medicine patients were discharged in 2018, and 252 were discharged in 2019. The median hospital LOS was significantly lower during the intervention period (14.2 days (IQR, 8-23) vs 19 days (IQR, 12-32); p<0.001). In-hospital mortality, 30-day mortality, readmission in 30 days and the number of hospital acquired conditions were the same between groups. Of the 3350 patient days analysed, 1482 (44.2%) were classified as green and 1868 (55.8%) as red. The lack of senior review was the most frequent cause of a red day (42.4%). CONCLUSION: The SAFER patient flow bundle and Red2Green days tool implementation were associated with a significant decrease in hospital LOS in a university hospital IMU ward. There is a considerable improvement opportunity for hospital LOS reduction by changing the multidisciplinary team's attitude during patient hospitalisation using these strategies.

Undernutrition risk is independently associated with worsened indicators of hospital rehabilitation in COVID-19 patients.

OBJECTIVE: This study was designed to analyze the association between the risk of undernutrition and indicators of hospital rehabilitation in patients with COVID-19 while controlling for confounding variables. METHODS: This was an analytical study conducted by analyzing the medical records of patients with COVID-19. A total of 562 adult patients were eligible for the study. In addition to the risk of undernutrition (independent variable), indicators of hospital rehabilitation (dependent variables) were evaluated. These indicators included the length of hospital stay, clinical outcome (discharge or death), food intake, mobility (bedridden status), the use of mechanical ventilation, and the need for enteral nutrition. Pre-existing comorbidities (confounding/control variables) were grouped into cardiovascular, metabolic/endocrine, neurological, chronic obstructive pulmonary disease, and other categories (neoplasms, multiple sclerosis, and kidney disease). A dichotomization model was applied for data analysis. The Chi-Square test was used to verify the association between the risk of undernutrition and the dependent variables. Associations with a significance level of P < 0.05 were subjected to Poisson regression to identify the prevalence ratio. RESULTS: Patients at risk of undernutrition had a 90% higher chance of being bedridden and were 35 times more likely to experience a decrease in food intake. They also had an 89% higher chance of using invasive mechanical ventilation and a 91% higher chance of requiring enteral nutrition. Additionally, individuals at risk of undernutrition had a 73% higher chance of death. Adjustment for comorbidities did not alter these associations, demonstrating that the risk of undernutrition is independently associated with indicators of hospital rehabilitation. CONCLUSION: The risk of undernutrition is independently associated with worsened indicators of hospital rehabilitation in patients with COVID-19, including higher prevalence of mortality.

Evaluation of factors predicting the benefit from systemic oncological treatment for severely ill hospitalized patients: a retrospective study.

BACKGROUND: Patients with cancer in the disease's end-stage with poor performance represent a challenging clinical scenario, as they have high chance of a fatal outcome due to clinical conditions, oncological emergencies, and/or metastatic disease. This study examines the factors predicting the potential benefit of "urgent" chemotherapy during hospitalization in this setting, thus addressing a research gap. METHODS: This retrospective observational study was conducted in the largest cancer center in the outskirts of São Paulo. It identified factors predicting the benefit from antineoplastic treatment in severe in-hospital patients admitted during 2019-2020, considering post-chemotherapy survival time as the main dependent variable. Data were retrieved from medical records. All patients aged ≥ 18 years, with an ECOG-PS score ≥ 2, and undergoing non-elective systemic cancer treatment were included. RESULTS: This study evaluated 204 records, of which 89 were included in the final analysis. A statistically significant association with the worse outcome (death within 30 days of chemotherapy) was found with higher ECOG performance status; chemotherapy dose reduction; lower values of serum albumin, hemoglobin, and creatinine clearance; and higher values of leukocytes, neutrophils, direct bilirubin, urea, and C-reactive protein. In the multivariate analysis, only albumin remained statistically associated with the outcome (hazard ratio = 0.35; confidence interval: 0.14, 0.90; p = 0.034). CONCLUSIONS: Serum albumin and other clinical and laboratory variables might be associated with early post-treatment deaths in patients with cancer. The study data might help guide the decision to administer systemic treatment in this scenario and manage critically ill patients. This study adds to our knowledge of the factors predicting the objective benefits from "heroic" or "urgent" chemotherapy for hospitalized and severely ill patients with cancer.

Experiencia de la pandemia por SARS-CoV-2 en un centro hospitalario de alta complejidad en Chile / Epidemiological profile of patients with COVID-19 admitted to a tertiary care public hospital

BACKGROUND The knowledge about the epidemiological profile of patients admitted to the hospital for severe COVID infection, allows an adequate health care planning and resource allocation. AIM: To describe the epidemiology of patients with COVID-19 admitted to a public hospital between March 2020 and July 2021. Material and Methods: Demographic variables, comorbidities, ventilatory support requirements, and hospital resources were recorded from clinical records and hospital databases of diagnosis related groups. The primary outcomes were overall mortality and need of ventilatory support. RESULTS: In the study period, 4,474 patients (56% males) were hospitalized with a diagnosis of COVID-19. Overall mortality was 25.8% and in-hospital mortality was 18%. Invasive and non-invasive ventilatory support was required in 1349 (30.2%) and 2060 (46%) patients, respectively. The most common comorbidities in admitted patients were diabetes mellitus (29.2%), chronic kidney disease (11.1%), and chronic liver disease (10.4%). The readmission rate was 3.2%. CONCLUSIONS: Mortality associated with COVID-19 in this hospital was similar to the rates reported abroad. Local risk predictors for this infection should be identified.

Telehealth Coverage for a Pediatric Gastroenterology Consult Service at a Regional Hospital: An Accepted, Useful, and Sustainable Model of Care.

OBJECTIVE: To evaluate a novel telehealth inpatient pediatric gastroenterology (GI) consult service at a regional children's hospital in regard to acceptance, utility, quality, sustainability, and provider resiliency. STUDY DESIGN: Patients requiring GI care at a regional children's hospital between July 2020 and June 2021 were treated by an in-person or telehealth physician with physician assistant support, randomly assigned based on a weekly preset staffing schedule. A retrospective, multidomain program evaluation was performed based on the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) and STEM (SPROUT Telehealth Evaluation and Management) frameworks, using statistical analysis to compare the patient cohorts and anonymous surveys to assess provider perceptions. RESULTS: In total, 1051 patient-days of GI care were provided for 348 patients, 17% by telehealth and 83% in-person. There were no significant differences in diagnosis, transfer, or readmission rates between the cohorts. No transfers occurred for reasons other than need to access specialized services not available at the regional hospital. Daily consult workload was slightly greater for telehealth physicians. Primary and consult team providers accepted the practice. The model continued beyond the first year. In total, 75% of local GI physicians reported greater Brief Resilience Scores in the context of shifting 20% of their inpatient call weeks to another campus's physicians. CONCLUSION: Episodic pediatric GI consult service coverage via telehealth at a regional hospital was well accepted, useful, and sustainable, with improved physician resilience and no adverse outcomes seen. Telehealth holds promise for leveraging pediatric subspecialty physicians across hospitals, allowing complex patients to be admitted closer to home while reducing inpatient coverage requirements for smaller physician groups.

Behavioural intention of hand hygiene compliance in an average Ecuadorian hospital

SUMMARY OBJECTIVE: This study aimed to characterize hand hygiene behavioural intention by hospital services clusters in a medium-sized hospital in an Ecuadorian city. METHODS: This is a cross-sectional study based on the World Health Organization Hand Hygiene Knowledge Questionnaire for Health-Care Workers. The responses on hand hygiene behavioural intention for the Five Moments for hand hygiene according to the World Health Organization were recorded in three categories: before patient contact, before and after sterile technique and management of body fluids, and after contact with the environment of the patient. The variables were the knowledge regarding the source of germs causing nosocomial infections, the optimal time to achieve disinfection with alcohol, hospital services clusters (clinical medicine, surgery, and therapeutic services), and history of previous formal hand hygiene training. The variables in each moment were analysed using a saturated log-linear model. RESULTS: The average age of participants was 34 years (Q1 32.1-Q3 36.4). Of them, 62% belonged to the clinic cluster and 87.6% had previous formal hand hygiene training. The incorrect response rates for before and after sterile technique and management of body fluids, before patient contact, and after contact with the environment of the patient were 30.2, 88.4, and 99.2%, respectively. In before patient contact, the incorrect responses for optimal time depended on the department (worse surgery cluster situation), and in before and after sterile technique and management of body fluids and after contact with the environment of the patient, the incorrect responses for source of germs depended on the previous formal hand hygiene training and the department (worse surgery and clinic clusters). CONCLUSION: The incorrect answer related to hand hygiene behavioural intention was high compared to other reports, and the worse situation was found in after contact with the environment of the patient and before patient contact. These data suggest the need of strengthening permanently the hand hygiene programme.

Poor oral health status and adverse COVID-19 outcomes: A preliminary study in hospitalized patients.

BACKGROUND: Most of the common risk factors for severe outcomes of coronavirus disease 2019 (COVID-19) are correlated with poor oral health, tooth loss, and periodontitis. This has pointed to a possible relationship between oral and systemic health in COVID-19 patients. Hence, this study aimed to assess the dental and periodontal status of hospitalized COVID-19 patients and their associations with the incidence of adverse COVID-19 outcomes. METHODS: We included 128 hospital patients aged between 20 and 97 years and with diagnoses of COVID-19 in this prospective observational study. Dental and periodontal status was assessed using in-hospital clinical examinations, including the Decayed, Missing, and Filled Teeth index, periodontal status, and tooth loss patterns (Eichner index). Associations between oral health measures, the severity of COVID-19 symptoms, and hospitalization endpoints were tested using chi-square test and incidence rate ratio (IRR) estimation using a generalized linear model with log-Poisson regression. The regression models used a block-wise selection of predictors for oral health-related variables, comorbidities, and patients' ages. RESULTS: Overall, poor oral health conditions were highly prevalent and associated with critical COVID-19 symptoms, higher risk for admission in the intensive care unit (ICU), and death. Periodontitis was significantly associated with ICU admission (IRR = 1.44; 95% confidence interval [95%CI] = 1.07-1.95; P = 0.017), critical symptoms (IRR = 2.56; 95%CI = 1.44-4.55; P = 0.001), and risk of death (IRR = 2.05; 95%CI = 1.12-3.76; P = 0.020) when adjusted for age and comorbidities. The Eichner index (classes B and C) was associated with ICU admission. CONCLUSION: There was a positive association between deleterious oral health-related conditions, especially periodontitis, and severe COVID-19 outcomes in hospitalized COVID-19 patients.

A Rare Case of Typhoid Fever in the United States Associated With Travel to Mexico.

Typhoid fever is an infectious febrile illness caused by Salmonella typhi that is rare in the United States but is endemic in regions of South Asia and Africa. Typhoid fever initially presents with nonspecific symptoms such as fever, malaise, and abdominal pain. We describe a case of typhoid fever in an adult in the United States with recent travel to Mexico. After a nonspecific presentation, the patient developed Faget sign and computed tomography (CT) of the abdomen revealed mesenteric adenitis, which prompted additional workup. Diagnosis of typhoid fever was established by blood culture and the patient was treated with ciprofloxacin.

Patterns, appropriateness and outcomes of peripherally inserted central catheter use in Brazil: a multicentre study of 12 725 catheters.

BACKGROUND: Little is known about peripherally inserted central catheter (PICC) use, appropriateness and device outcomes in Brazil. METHODS: We conducted an observational, prospective, cohort study spanning 16 Brazilian hospitals from October 2018 to August 2020. Patients ≥18 years receiving a PICC were included. PICC placement variables were abstracted from medical records. PICC-related major (deep vein thrombosis (DVT), central line-associated bloodstream infection (CLABSI) and catheter occlusion) and minor complications were collected. Appropriateness was evaluated using the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC). Devices were considered inappropriate if they were in place for <5 days, were multi-lumen, and/or were placed in patients with a creatinine >2.0 mg/dL. PICCs considered appropriate met none of these criteria. Mixed-effects logistic regression models adjusting for patient-level and hospital-level characteristics assessed the association between appropriateness and major complications. RESULTS: Data from 12 725 PICCs were included. Mean patient age was 66.4±19 years and 51.0% were female. The most common indications for PICCs were intravenous antibiotics (81.1%) and difficult access (62.7%). Most PICCs (72.2%) were placed under ultrasound guidance. The prevalence of complications was low: CLABSI (0.9%); catheter-related DVT (1.0%) and reversible occlusion (2.5%). Of the 12 725 devices included, a total of 7935 (62.3%) PICCs were inappropriate according to MAGIC. With respect to individual metrics for appropriateness, 17.0% were placed for <5 days, 60.8% were multi-lumen and 11.3% were in patients with creatinine >2.0 mg/dL. After adjusting for patient and hospital-level characteristics, multi-lumen PICCs considered inappropriate were associated with greater odds of major complications (OR 2.54, 95% CI 1.61 to 4.02). CONCLUSIONS: Use of PICCs in Brazilian hospitals appears to be safe and comparable with North America. However, opportunities to improve appropriateness remain. Future studies examining barriers and facilitators to improving device use in Brazil would be welcomed.

[COVID-19 pneumonia. Experience of a public hospital in Argentina]. / Neumonía por COVID-19. Experiencia de un hospital público de Argentina.

COVID-19 pneumonia represents a challenge for health systems. The objective of this study is to describe the clinical presentation and evolution of hospitalized patients with COVID-19 pneumonia. This is a prospective and descriptive study. Patients older than 16 years with a PCR confirmed diagnosis of COVID-19 were included in 94.0% (n = 395) of the cases. Biochemical and imaging determinations were made. 421 patients were included, 57.0% male (n = 240), with a mean age of 56.1 ± 15.1 years. 41.0% (n = 172) were older than 60 years. 79.7% (n = 333) had comorbidities. They had seven days 7 days (IQR 5) from symptom onset to hospitalization. The most frequent symptoms were: dyspnea (78.1%, n = 307), cough (76.5%, n = 297) and fever (73.6%, n = 289). 50.2% (n = 204) presented respiratory failure upon admission. 63.4% (n = 173) presented pathological infiltrates on radiography and 96.0% (n = 312) on chest tomography. The 4C score was 8 (IQR 6). 31.6% (n = 133) had a poor clinical evolution. In-hospital mortality was 18.9% (n = 80) and 23.7% (n = 100) received mechanical ventilation. 21.9% (n = 92) presented in-hospital complications. 39.6% (n = 67) of those over 60 years of age were admitted to the Intensive Care Unit and 31.4% (n = 54) died. 76.9% (n = 319) of the patients received corticosteroids, 69.3% (n = 289) antibiotics, and convalescent plasma 10.5% (n = 43). This series stands out for the high rate of comorbidities and the severity of the patients included. Mortality was similar to other international series.

El objetivo del presente estudio fue describir la presentación clínica y la evolución de los pacientes hospitalizados con neumonía por COVID-19. Se trata de un estudio descriptivo prospectivo. Se incluyeron individuos mayores de 16 años con diagnóstico de COVID-19 confirmado por reacción en cadena de la polimerasa en el 94.0% (n = 395) de los casos. Se realizaron determinaciones bioquímicas e imagenológicas. Se incluyeron 421 sujetos, 57.0% (n = 240) de sexo masculino, con una edad media de 56.1 ± 15.1 años. El 41.0% (n = 172) comprendió a mayores de 60 años. El 79.7% (n = 333) tenía comorbilidades. Llevaban 7 días (IQR 5) de sintomatología al ingreso hospitalario. Los síntomas más frecuentes fueron: disnea (78.1%, n = 307), tos (76.5%, n = 297) y fiebre (73.6%, n = 289). El 50.2% (n = 204) tenía insuficiencia respiratoria al ingreso. En el 63.4% (n = 173) se observaron infiltrados patológicos en la radiografía y en el 96.0% (n = 312) en las tomografías de tórax. El score 4C fue de 8 (IQR 6). El 31.6% (n = 133) tuvo mala evolución clínica. La mortalidad intrahospitalaria fue del 18.9% (n = 80) y el 23.7% (n = 99) recibió asistencia respiratoria mecánica. El 21.9% (n = 92) presentó complicaciones intrahospitalarias. El 39.6% (n = 67) de los mayores de 60 años fue admitido a la Unidad de Cuidados Intensivos y el 31.4% (n = 54) falleció. Recibieron corticoides el 76.9% (n = 319) de los pacientes, antibióticos el 69.3% (n = 289) y plasma de convaleciente el 10.5% (n = 43). Esta serie se destaca por la alta tasa de comorbilidades y la gravedad de los pacientes incluidos. La mortalidad fue similar a otras series internacionales.

Neumonía por COVID-19. Experiencia de un hospital público de Argentina / COVID-19 pneumonia. Experience of a public hospital in Argentina

Resumen El objetivo del presente estudio fue describir la presentación clínica y la evolución de los pacientes hospitalizados con neumonía por COVID-19. Se trata de un estudio descriptivo prospectivo. Se incluyeron individuos mayores de 16 años con diagnóstico de COVID-19 confirmado por reacción en cadena de la polimerasa en el 94.0% (n = 395) de los casos. Se realizaron determinaciones bioquímicas e imagenológicas. Se incluyeron 421 sujetos, 57.0% (n = 240) de sexo masculino, con una edad media de 56.1 ±15.1 años. El 41.0% (n = 172) comprendió a mayores de 60 años. El 79.7% (n = 333) tenía comorbilidades. Llevaban 7 días (IQR 5) de sintomatología al ingreso hospitalario. Los síntomas más frecuentes fueron: disnea (78.1%, n = 307), tos (76.5%, n = 297) y fiebre (73.6%, n = 289). El 50.2% (n = 204) tenía insuficiencia respiratoria al ingreso. En el 63.4% (n = 173) se observaron infiltrados patológicos en la radiografía y en el 96.0% (n = 312) en las tomo grafías de tórax. El score 4C fue de 8 (IQR 6). El 31.6% (n = 133) tuvo mala evolución clínica. La mortalidad intrahospitalaria fue del 18.9% (n = 80) y el 23.7% (n = 99) recibió asistencia respiratoria mecánica. El 21.9% (n = 92) presentó complicaciones intrahospitalarias. El 39.6% (n = 67) de los mayores de 60 años fue admitido a la Unidad de Cuidados Intensivos y el 31.4% (n = 54) falleció. Recibieron corticoides el 76.9% (n = 319) de los pacientes, antibióticos el 69.3% (n = 289) y plasma de convaleciente el 10.5% (n = 43). Esta serie se destaca por la alta tasa de comorbilidades y la gravedad de los pacientes incluidos. La mortalidad fue similar a otras series internacionales.

Abstract COVID-19 pneumonia represents a challenge for health systems. The objective of this study is to describe the clinical presentation and evolution of hospitalized patients with COVID-19 pneumonia. This is a prospective and descrip tive study. Patients older than 16 years with a PCR confirmed diagnosis of COVID-19 were included in 94.0% (n = 395) of the cases. Biochemical and imaging determinations were made. 421 patients were included, 57.0% male (n = 240), with a mean age of 56.1 ± 15.1 years. 41.0% (n = 172) were older than 60 years. 79.7% (n = 333) had comorbidities. They had seven days 7 days (IQR 5) from symptom onset to hospitalization. The most frequent symptoms were: dyspnea (78.1%, n = 307), cough (76.5%, n = 297) and fever (73.6%, n = 289). 50.2% (n = 204) presented respiratory failure upon admission. 63.4% (n = 173) presented pathological infiltrates on radiography and 96.0% (n = 312) on chest tomography. The 4C score was 8 (IQR 6). 31.6% (n = 133) had a poor clinical evolution. In-hospital mortality was 18.9% (n = 80) and 23.7% (n = 100) received mechanical ventilation. 21.9% (n = 92) presented in-hospital complications. 39.6% (n = 67) of those over 60 years of age were admitted to the Intensive Care Unit and 31.4% (n = 54) died. 76.9% (n = 319) of the patients received corticosteroids, 69.3% (n = 289) antibiotics, and convalescent plasma 10.5% (n = 43). This series stands out for the high rate of co morbidities and the severity of the patients included. Mortality was similar to other international series.

Diagnostic discrepancies between emergency department admissions and hospital discharges among older adults: secondary analysis on a population-based survey

BACKGROUND: Older adults frequently experience nonspecific clinical features. However, there is limited evidence on how often admission diagnoses for hospitalized older patients are incorrect, potentially leading to treatment delays. OBJECTIVES: To determine the consistency between hospital admission and discharge diagnoses, and identify factors associated with diagnostic discrepancies in older adults. DESIGN AND SETTING: Population-based cohort study in the United States. We included adults aged ≥ 18 years who were admitted from emergency departments (EDs) to hospitals, identified using the 2005-2010 National Hospital Ambulatory Medical Survey, a nationally representative survey. METHODS: Three admission diagnoses and the principal discharge diagnosis were captured and classified as discrepant if they involved considerably different conditions within the same organ system, or different organ systems altogether. RESULTS: Each year, 12 million adults were hospitalized following ED visits in the United States; 45% were aged ≥ 65 years. These patients' mean age was 79 years and 58% were women. Diagnostic discrepancies between admission and discharge were more common among adults ≥ 65 years (12.5 versus 8.3%; P < 0.001). Certain admission diagnoses had particularly high rates of diagnostic discrepancies: 26-27% of patients presenting with mental disorders or with endocrine and metabolic diseases had substantial diagnostic discrepancies between admission and discharge. Substantial diagnostic discrepancy was independently associated with longer hospitalization and higher in-hospital mortality. CONCLUSION: One out of eight older adults hospitalized from EDs was discharged with a principal diagnosis differing considerably from the admission diagnosis. Given that missed or delayed diagnoses are a critical safety problem, clinicians should be vigilant and frequently cogitate alternative diagnostic possibilities

Asociación entre niveles de vitamina B-12 y mortalidad en pacientes hospitalizados adultos mayores / Association between high vitamin B12 levels and one year mortality in older people admitted to the hospital

Background: Supplementation of vitamin B12 in older adults is a common practice to avoid vitamin B12 insufficiency. However, there is a paucity of information about the effects of cobalamin excess. Aim: To asses any potential effects of high levels vitamin B12 on mortality on adults aged ≥ 65 years admitted to an internal medicine service. Material and Methods: We Prospectively studied patients admitted to an internal medicine service of an academic hospital from September 2017 to September 2018, who were able to give their consent and answer questionnaires. We tabulated age, gender, medical history, comorbidity index (Charlson), frailty score (Fried scale), admission diagnosis and blood tests performed within 48 hours of admission. The primary outcome was death by any cause in less of 30 days or after one of year follow up, determined according to death certificates. Results: We included 93 patients aged 65 to 94 years (53% males). Fifteen patients died during the year of follow up (five within 30 days of admission). Those who died had higher cobalamin levels than survivors (1080.07 ± 788.09 and 656.68 ± 497.33 pg/mL respectively, p = 0.02). Patients who died had also a significantly lower corrected serum calcium, sodium (p = 0.04) and a medical history of chronic liver disease (p = 0.03). In the multivariable analysis, only vitamin B12 preserved the association with mortality (p = 0.009). Conclusions: There was a significant association between high levels of cobalamin and all-cause mortality in this group of patients aged ≥ 65 years-old.

Discharge Instruction Comprehension and Adherence Errors: Interrelationship Between Plan Complexity and Parent Health Literacy.

OBJECTIVE: To examine associations between parent health literacy, discharge plan complexity, and parent comprehension of and adherence to inpatient discharge instructions. STUDY DESIGN: This was a prospective cohort study of English/Spanish-speaking parents (n = 165) of children ≤12 years discharged on ≥1 daily medication from an urban, public hospital. Outcome variables were parent comprehension (survey) of and adherence (survey, in-person dosing assessment, chart review) to discharge instructions. Predictor variables included low parent health literacy (Newest Vital Sign score 0-3) and plan complexity. Generalized estimating equations were used to account for the assessment of multiple types of comprehension and adherence errors for each subject, adjusting for ethnicity, language, child age, length of stay, and chronic disease status. Similar analyses were performed to assess for mediation and moderation. RESULTS: Error rates were highest for comprehension of medication side effects (50%), adherence to medication dose (34%), and return precaution (78%) instructions. Comprehension errors were associated with adherence errors (aOR, 8.7; 95% CI, 5.9-12.9). Discharge plan complexity was associated with comprehension (aOR, 7.0; 95% CI, 5.4-9.1) and adherence (aOR, 5.5; 95% CI, 4.0-7.6) errors. Low health literacy was indirectly associated with adherence errors through comprehension errors. The association between plan complexity and comprehension errors was greater in parents with low (aOR, 8.3; 95% CI, 6.2-11.2) compared with adequate (aOR, 3.8; 95% CI, 2.2-6.5) health literacy (interaction term P = .004). CONCLUSIONS: Parent health literacy and discharge plan complexity play key roles in comprehension and adherence errors. Future work will focus on the development of health literacy-informed interventions to promote discharge plan comprehension.

Metabolic alkalosis is related to delayed response to treatment of hypokalemia in non-surgical critically ill patients.

Background: Potassium (K+) homeostasis is closely related to acid - base disorders. The aim of this study is to analyze the possible causes of hypokalemia non-surgical critically ill patients including acid - base disorders and its relationship with response to K+ supplementation. Methods: We performed a retrospective cohort study of 122 consecutive non-surgical patients admitted to the Intensive Care Unit during July 2016 Patients were classified according to the presence of hypokalemia or not. Demographic data, morbidities associated with hypokalemia, with emphasis in acid-base disorders and response to treatment were described and analyzed. Results: Hypokalemia was observed in 32,7% (n = 40) of the patients included. Hypokalemic group had a higher value of base excess (median of -0.65 [IQR -3.3-5.2] Vs -3.2 [IQR -5.1--1.4]; p < 0.001). The patients with hypokalemia that achieved normal serum K+ in more than 25 h had a higher value of excess base than those who did so in less than 24 h (median of 4.3 [IQR -2.1-5.5] vs -1.9 [IQR -4.8-3]; p < 0.05). Neither the degree of hypokalemia, the time to development, route of administration or solution concentration, speed of infusion, the amount of K+ administered per day per kg of weight were related with the response of treatment. Conclusions: Hypokalemia is a common disorder in non-surgical critically ill patients. Hypokalemic patients had a higher incidence of metabolic alkalosis. Patients with hypokalemia and metabolic alkalosis needed a higher amount of potassium administration and higher time to achieve correction.