Academic Medical Center Hospital Research Articles

Music in Care (MIC) by Nurses: Initial Validation of a Questionnaire to Characterize Nurses' Attitudes and Feasibility of Implementation on the Use of Music in Patient Care.

Purpose: The purpose of this study was to characterize nurses' attitudes toward music and implementation of music into patient care and to characterize barriers and facilitators toward the implementation of music into patient care. Design: A cross-sectional, quantitative, web-based questionnaire with minor qualitative elements. Methods: The questionnaire contained both open- and closed-ended questions. It was developed in Qualtrics and sent via email to nurses working on inpatient units at an academic medical center hospital in the southeastern United States. Findings: A total of 348 nurses responded to the questionnaire. Eighty-nine percent of nurses reported having used music in their care. The methods of implementation most employed by nurses were streaming (90%) or encouraging a patient to play music on the patient's personal device (76.8%). Eighty-eight percent of nurses reported that access to music streaming services (e.g., Spotify) would be very helpful or extremely helpful. In response to the open-ended questions, nurses indicated a lack of equipment as the primary barrier to implementing music in care. Conclusion: Nurses reported having a positive attitude toward the use of music, strongly endorsing its utility in patient care. Although most nurses reported implementing music, many nurses reported barriers and facilitators to the implementation of music in patient care.

Nudging Towards Sleep-Friendly Hospitalizations: A Multifaceted Approach on Reducing Unnecessary Overnight Interventions.

Choice architecture refers to the design of decision environments, which can influence healthcare decision-making. Nudges are subtle adjustments in these environments that guide decisions toward desired outcomes. For example, Computerized Provider Order Entry (CPOE) within Electronic Health Records (EHR) recommends frequencies for interventions such as nursing assessments and medication administrations, but these can link to around-the-clock schedules without clinical necessity. This study aimed to evaluate an intervention to promote sleep-friendly practices by optimizing choice architecture and employing targeted nudges on inpatient order frequencies. We employed a quasi-experimental interrupted time series analysis of a multifaceted, multiphase intervention to reduce overnight interventions in a hospital system. Our intervention featured EHR modifications to optimize the scheduling of vital sign checks, neurological checks, and medication administrations. Additionally, we used targeted secure messaging reminders and education on an inpatient neurology unit (INU) to supplement the initiative. Significant increases in sleep-friendly medication orders were observed at the academic medical center (AMC) and community hospital affiliate (CHA), particularly for acetaminophen and heparin at the AMC. This led to a reduction in overnight medication administrations, with the most substantial decrease observed with heparin at all locations (CHA: 18%, AMC: 10%, INU: 10%, p<0.05). Sleep-friendly vital sign orders increased significantly at all sites (AMC: 6.7%, CHA 4.3%, INU: 14%, p<0.05), and sleep-friendly neuro check orders increased significantly at the AMC (8.1%, p<0.05). There was also a significant reduction in overnight neurological checks at the AMC. Tailoring EHR modifications and employing multifaceted nudging strategies emerged as promising approaches for reducing unnecessary overnight interventions. The observed shifts in sleep-friendly ordering translated into decreases in overnight interventions. Multifaceted nudges can effectively influence clinician decision-making and patient care. The varied impacts across nudge types and settings emphasize the importance of thoughtful nudge design and understanding local workflows.

Assessing Patient Readiness for Hospital Discharge, Discharge Communication, and Transitional Care Management.

Discharge communication between hospitalists and primary care clinicians is essential to improve care coordination, minimize adverse events, and decrease unplanned health services use. Health-related social needs are key drivers of health, and hospitalists and primary care clinicians value communicating social needs at discharge. To 1) characterize the current state of discharge communications between an academic medical center hospital and primary care clinicians at associated clinics; 2) seek feedback about the potential usefulness of discharge readiness information to primary care clinicians. Exploratory, convergent mixed methods. Primary care clinicians from Family Medicine and General Internal Medicine of an academic medical center in the US Intermountain West. Literature-informed REDCap survey. Semistructured interview guide developed with key informants, grounded in current literature. Survey data were descriptively summarized; interview data were deductively and inductively coded, organized by topics. Two key topics emerged: 1) discharge communication, with interrelated topics of transitional care management and follow-up appointment challenges, and recommendations for improving discharge communication; and 2) usefulness of the discharge readiness information, included interrelated topics related to lack of shared understanding about roles and responsibilities across settings and ethical concerns related to identifying problems that may not have solutions. While reiterating perennial discharge communication and transitional care management challenges, this study reveals new evidence about how these issues are interrelated with assessing and responding to patients' lack of readiness for discharge and unmet social needs during care transitions. Primary care clinicians had mixed views on the usefulness of discharge readiness information. We offer recommendations for improving discharge communication and transitional care management (TCM) processes, which may be applicable in other care settings.

High Reliability in a Safety Net Hospital Leading to Operational Excellence.

The objective of this work was to establish sustainable systems for quality improvement in an Academic Medical Center and Safety Net Hospital. High reliability principles of leadership engagement, a culture of safety, and sustainable performance improvement were used. Target areas for improvement were clinical outcomes for patients, public reputation scores, and lower cost of care. The system was based on annual focused goals with specific targets, improvement teams, transparent scorecards, and data driven work. Program visibility was championed by leaders. Consistent education on quality, safety, efficiency, and effectiveness for all employees created buy-in. Data review and accountability tracked progress, helped resource allocation, and defined next steps. In the first 5 years, all patient quality and safety metrics improved between 10% and 60%. This improvement resulted in higher CMS Star Ranking and Leapfrog patient safety grade. The next phase included maximizing value by expanding into hospital operations and finance with a focus on improved clinical documentation and reduced length of stay and cost of care. Clinical documentation improvement led to a 15% increase in comorbidity capture. This positively impacted reported outcomes and hospital payment by appropriate risk adjustment. Length of stay was addressed with a new care coordination program and physician-driven utilization review. High reliability principles are applicable in a resource limited healthcare system. Improved clinical and operational results were achieved through goal setting, improvement teams, and data driven projects leading to creation of an office of operational excellence.

Clinical decision support tools useful for identifying sepsis risk.

Evaluate the effectiveness of the clinical decision support tools (CDSTs), POC Advisor (POCA), and Modified Early Warning System (MEWS) in identifying sepsis risk and influencing time to treatment for inpatients, comparing their respective alert mechanisms. This study was conducted at two academic university medical center hospitals. Data from adult inpatients in medical-surgical and telemetry units were analyzed from January 1, 2020, to December 31, 2020. Criteria included sepsis-related ICD-10 codes, antibiotic administration, and ordered sepsis labs. Subsequent statistical analyses utilized Fisher's exact test and Wilcoxon Rank Sum test, focusing on mortality differences by age, sex, and race/ethnicity. Among 744 patients, 143 sepsis events were identified, with 83% already receiving treatment upon CDST alert. Group 1 (POCA alert) showed reduced response time compared with MEWS, while Group 3 (MEWS) experienced longer time to treatment. Group 4 included sepsis events missed by both systems. Mortality differences were not significant among the groups. While CDSTs play a role, nursing assessment and clinical judgment are crucial. This study recognized the potential for alarm fatigue due to a high number of CDST-driven alerts, while emphasizing the importance of a collaborative approach for prompt sepsis treatment and potential reduction in sepsis-related mortality.

Exploring the Roles of Nurses in Medication Reconciliation for Older Adults at Hospital Discharge: A Narrative Approach.

Medication reconciliation (MR) is the process of comparing a patient's medication orders to all of the medications that the patient has been taking in order to identify and resolve medication discrepancies. It is an effective means of risk management to avoid medication errors (eg, omissions, duplication, dosage errors, or drug interactions). Some guidelines explicitly state that MR is a pharmacist-led transition of care; however, there is a shortage of qualified pharmacists to meet the increasing clinical needs, and clinical nurses' roles have not been clearly described. This paper aimed to enable nurses to gain confidence in contributing to MR at discharge and to make the industry aware of the potential risks if nurses do not actively intervene in this area. A narrative approach was used to introduce experiences in identifying discrepancies and medication errors through MR at discharge in a geriatric ward of an academic medical center hospital in China. The nurses' main roles in MR involve chasing, checking, and education. Clinical nurses, an untapped hospital resource, can actively engage in MR at discharge if they receive effective training and motivation. Multidisciplinary collaboration at discharge allowed many discrepancies to be reconciled before harming older patients. It is worth conducting further research in MR when discharging older adults, such as the cost-effectiveness of nurses' efforts, the value of electronic tools and the impact of MR-targeted education and training for nursing students and nursing staff.

Clinical and molecular determinants of bleeding-related adverse outcomes in high-grade glioma.

Cancer is an independent risk factor for the development of venous thromboembolism (VTE). However, patients with high-grade glioma (HGG) including glioblastoma (GBM) are at a particularly high risk of VTE with an incidence up to 20-30% per year. Patients are often placed on anticoagulation if they are found to have VTE. However, patients with primary brain tumors such as HGG are at increased risk for intracerebral hemorrhage (ICH) even without the administration of anticoagulation. The combination of risk factors for ICH with anticoagulation and HGG complicates decision-making. Currently it is not known which of the direct oral anticoagulants (DOACs) are safest for patients with HGG in terms of adverse bleeding-related outcomes such as ICH. Furthermore, a deeper understanding of the clinical and molecular determinants of bleeding-related adverse outcomes in HGG is not fully characterized. In this retrospective study, we identified and gathered data on 75 consecutive patients with pathology-confirmed HGG with hospital encounters at two academic medical center hospitals in Austin between July 1, 2017 and June 30, 2022. We compared clinical and treatment-related factors among cohorts who had received various forms of anticoagulation or no anticoagulation. Patients who were on rivaroxaban (3/7 (43%)) had a statistically significant association with more bleeding-related adverse events compared to those on apixaban (0/12 (0%)) or enoxaparin (0/5 (0%), p = 0.022) even though the groups were similar in characteristics including total time on the respective anticoagulation. Patients on anticoagulation vs those never on anticoagulation did not differ in terms of their studied demographic and clinical characteristics. Intriguingly, logistic regression analysis revealed that patients Astrocytoma, isocitrate dehydrogenase (IDH) mutant, grade 4 had a significant association with more adverse bleeding-related events even when controlling for other relevant factors (Odds Ratio compared to reference GBM: 49.4, 95% CI: 2.8, 2084.7; p = 0.013). In this study we found that the use of rivaroxaban was associated with more bleeding-related events compared to apixaban and enoxaparin in patients with high-grade glioma. In this study we also found that the diagnosis of astrocytoma, IDH mutant, grade 4 was associated with more bleeding events. However, this is based on a small study and there is a need for larger studies to further evaluate these results.

Length of Stay Index – A Retrospective Chart Review on In-patient Dermatology Consults

Background and Objective: In monitoring inpatient care quality and efficiency, one metric of interest is Length of Stay (LOS) by diagnosis-related group (DRG) system and how this compares to peer institutions. Vizient Inc. provides a source of such benchmarking - collecting and analyzing individual case-level data from community and academic medical center hospitals nationwide. Using this data, Vizient calculates an expected LOS by DRGs and adjusts for severity of illness and other factors for inter-hospital comparison. Because LOS reduction is an important mechanism for improving outcomes and efficiency of care, The Department of Dermatology would like to understand which dermatologic consults are exceeding the Vizient expected LOS (LOS index &gt; 1). &#x0D; Project Methods: Consecutive charts of 663 patients with dermatology-related diagnoses in the inpatient setting at IU University and Methodist Hospitals between January 2021 and January 2023 were reviewed. Parameters identified included: category of dermatologic disorder, LOS index, time to consult, and quarter of encounter. Data was organized and analyzed using paired t-tests, linear regression, and descriptive statistics in JMP software. &#x0D; Results: The mean LOS index for Dermatology inpatient consults was 1.89 (n=469). Patients whose dermatologic diagnosis fell under chronic wound, mechanical, infectious, drug adverse event, autoimmune, neoplasm, inflammatory, vascular, and blistering had a significant increase in observed length of stay compared to expected length of stay (p &lt; 0.05). Time to dermatology consult was not found to correlate to shortening or prolonging LOS index. &#x0D; Potential Impact: The data from this review will help direct the Department of Dermatology to the dermatologic consults with the highest need for potential interventions.

1275. Impact of a bundled antimicrobial stewardship intervention leveraging frontline pharmacist response to rapid blood culture diagnostics at an academic medical center and community hospital

Abstract Background Rapid Blood Culture Identification (BCID) panels have been shown to improve patient outcomes, including mortality and length of stay, when paired with antimicrobial stewardship (ASP) intervention. We report the results of a quality improvement initiative to expand to 24/7 pharmacist response to BCID results in a large academic medical center and a community hospital within the same health system. Methods A pre/post review was performed following a bundled stewardship intervention. Prior to the intervention, BCID results were addressed by the antimicrobial stewardship team Monday through Friday between 8am and 4pm. The bundled ASP intervention consisted of standardized treatment guidance, clinical education on result interpretation, frontline pharmacist evaluation of BCID results during off-peak hours to provide 24/7 response, and electronic health record documentation at each site. Clinical and microbiological data were collected for all patients. The primary outcome was time to optimal therapy (TTOT) for patients with a positive BCID within the first 72 hours of hospital admission. The secondary outcome assessed observed to expected length of stay (O/E LOS) ratios based on Vizient® Clinical Database estimates. The pre-intervention period included patients with a positive BCID between 1/1/2021 and 10/14/2022. The post-intervention period included patients with a positive BCID between 1/3/2023 and 3/31/2023. Results Clinical data and outcomes are reported in Table 1. During the first three months following ASP intervention, TTOT decreased at the academic medical center (15.0 to 6.4 hours) but did not change at the community hospital (25.9 to 25.1 hours). The O/E LOS ratio decreased for the academic medical center from 0.92 to 0.78 while the O/E LOS remained similar (0.85 to 0.83) for the community hospital. Conclusion A bundled ASP intervention utilizing frontline, non-ASP pharmacist review and prescriber outreach of BCID results quickly adopted. The intervention demonstrated benefit in the academic medical center, including quicker time to appropriate therapy and reduced length of hospitalization. Additional interventions may be needed for community sites depending on existing resources, staffing models and pharmacist/physician experience. Disclosures Nathaniel J. Rhodes, PharmD MS, Third Pole Therapeutics: Advisor/Consultant

213. Do Patients with Candidemia Need an Ophthalmology Exam?

Abstract Background Candidemia can lead to hematogenous seeding of the eye resulting in chorioretinitis or endophthalmitis. IDSA recommends a screening dilated retinal examination for patients with candidemia, whilst American Academy of Ophthalmology (AAO) recently declared this a low value practice. Using an inter-disciplinary team, we evaluated ophthalmology examination for patients with candidemia. Methods We performed a retrospective study of patients with candidemia at an academic medical center and affiliated hospitals between January 2011 – June 2022. Electronic medical records were reviewed for demographics and baseline characteristics. The primary outcome was chorioretinitis and/or endophthalmitis. The study was adjudicated by independent review from infectious disease and ophthalmology providers. Results We included 308 patients with a blood culture positive for candida species. 149 patients (48%) received an ophthalmologic exam, of which 55% (82) were asymptomatic. Abnormal ocular findings concerning for presumed ocular candida complications were found in 12 patients (8%, 12/149), of which 4 had alternative diagnoses to candida choriorentinits or endophthalmitis. All of the remaining 8 patients (5%, 8/149) had presumed candida chorioretinitis with no cases of candida endophthalmitis and this led to a change in management in 88% (7/8) of patients (Table 1). Of the 8 patients, 3 patients were asymptomatic, making the number needed to screen 28 to detect presumed candida chorioretinitis amongst asymptomatic patients. We did not identify statistically significant risk factors for development of abnormal ocular findings (Table 2). Table 1 Clinical diagnosis and management of patients with candida chorioretinitis and/or endophthalmitis Table 2 Clinical features of patients with and without ocular candidiasis Conclusion IDSA and AAO recommend ophthalmologic examination in symptomatic and intubated patients with candidemia. We found a 5% incidence of presumed ocular candidiasis in patients with candidemia. Given the limitations of our study, we could not conclude for or against screening in asymptomatic patients as this did not lead to a significant change in patient outcomes. Inter-disciplinary decisions involving ophthalmology and infectious diseases can help inform best practices for screening in asymptomatic patients. Future studies should evaluate ocular photography and teleophthalmology as screening strategies. Disclosures All Authors: No reported disclosures

Laboratory-Developed Tests Account for a Small Minority of Tests Ordered in an Academic Hospital System.

To determine the frequency of use of laboratory-developed tests (LDTs) in an academic medical center system. Retrospective analysis of 2021 test order data from an academic medical center (hospital, outpatient clinics, and cancer center) was done. Measures included assay type, assay methodology, regulatory status, test order volume, inpatient vs outpatient setting, and provider medical specialty. Of the 3,016,928 tests ordered in 2021, 2,831,489 (93.9%) were tests cleared, approved, and/or authorized by the US Food and Drug Administration (FDA); 116,583 (3.9%) were LDTs; and 68,856 (2.3%) were standard methods. These test orders were performed using a total of 1,954 distinct assays. Of these, 983 (50.3%) were FDA assays, 880 (45.0%) were LDTs, and 91 (4.7%) were standard methods. Laboratory-developed tests were more commonly ordered in the outpatient vs inpatient setting and represented a higher proportion of the test volume at the cancer center compared with the university hospital (5.6% vs 3.6%, respectively). The top 167 LDT assays accounted for 90% of the LDT volume (104,996 orders). Among the 20 most frequently ordered LDTs were mass spectrometry assays and tests used in the care of immunocompromised patients. Internal/family medicine placed the greatest number of orders (1,044,642) and ordered one of the lowest proportions of LDTs (3.2%). Laboratory-developed tests made up a small percentage of the total laboratory tests ordered within the academic health system studied.

Implementation of an HIV RNA Qualitative PCR Assay in an HIV Diagnostic Algorithm: A Single-Institution Experience.

Boston Medical Center (BMC) is a private, not-for-profit 514-bed academic medical center and legacy safety net hospital serving a diverse global patient population. BMC recently implemented a new HIV-1/HIV-2 Qualitative RNA PCR (HIV RNA QUAL) cleared by the US Food and Drug Administration to (1) replace antibody discrimination follow-up testing after a reactive fourth-generation (4G) serology screen and (2) use as a stand-alone diagnostic for suspected seronegative acute HIV infection. This report summarizes the results of a production monitor for the first 3 months postimplementation. The monitor characterized test utilization, diagnostic turnaround time, impact on send-out testing, results reflexed to HIV RNA discrimination follow-up, and discrepancies between screening and HIV RNA results that necessitated additional investigation. Another element was the novelty of using HIV RNA QUAL while awaiting the existing Centers for Disease Control and Prevention HIV testing algorithm update. The 4G screening components and the HIV RNA QUAL were also used to create an algorithm specific to and compliant with current guidelines for screening patients on HIV preexposure prophylaxis. Based on our findings, this new test algorithm may be reproducible and instructive at other institutions.

SAFETY AND EFFICACY OF MYCOPHENOLATE MOFETIL TREATMENT FOR REFRACTORY CROHN'S DISEASE

Abstract BACKGROUND Medically refractory Crohn’s disease is a significant challenge with poor remission rates and limited medication options. Mycophenolate mofetil (MMF), a small molecule immune suppressant, has mixed data to support its use in Crohn’s disease and has not been studied in refractory disease or biologic experienced patients. AIMS We aimed to evaluate the safety and efficacy of off-label clinical MMF treatment for refractory Crohn’s disease as monotherapy or in combination with a biologic. METHODS We retrospectively assessed adverse events (AEs), clinical response (Harvey-Bradshaw Index, HBI), endoscopic response (Simple Endoscopic Score in Crohn’s Disease, SES-CD), and physician’s subjective assessment (scale of 0-3) over 52 weeks at a single medical system including an academic medical center and county hospital. RESULTS 61 patients received MMF as monotherapy (n=41) or in combination with a biologic (n=20) between 2008 and 2021 at a dose ranging from 500 – 2000 mg BID. Median age was 39 years (range 19-69) and median disease duration was 11 years (range 2-54). All patients had failed one or more TNF-alpha antagonist; the median number of failed biologics was 4. Median duration of therapy was 27 weeks. Of patients with requisite data, 14/27 (52%) achieved clinical response (HBI decreased by ≥3) after mean 24.2 weeks (SD 20.4). 6/27 (22%) achieved clinical remission (HBI ≤4). Endoscopic response (SES-CD reduction ≥50%) occurred in 7/26 patients (27%) after mean 43.5 weeks (SD 29.5). Endoscopic remission (SES-CD ≤3) occurred in 4/26 patients (15%) and endoscopic healing (SES-CD =0) in 2/26 patients (8%). Per physician’s subjective assessment, 17/51 patients (33%) achieved clinical response (score improved by ≥1), 16/51 (31%) achieved clinical remission (score of 0 or 1), 10/34 patients (29%) achieved endoscopic response and 9/34 patients (26%) achieved endoscopic remission. Table 1 shows clinical and endoscopic response separated by monotherapy or in combination with a biologic. AEs were reported in 27/61 patients (44%); 16 on monotherapy and 11 on combination. Most common AEs were mild infection, nausea/vomiting, abdominal pain, and diarrhea. Nausea/vomiting and diarrhea led to early discontinuation for several patients. Serious adverse events occurred in 2/61 patients (pneumonia requiring hospitalization and SVT) both on monotherapy. CONCLUSIONS MMF appears well-tolerated and results in clinical and endoscopic benefit for some patients with refractory Crohn’s disease. This study is limited by uncontrolled, retrospective design and small numbers that were eligible for analysis. The results support additional prospective testing of MMF either as monotherapy or in combination with a biologic for patients with refractory Crohn’s disease.

Frontline Nurses' clinical judgment in recognizing, understanding, and responding to patient deterioration: A qualitative study

BackgroundEarly warning systems and rapid response teams have been widely implemented in hospitals worldwide to facilitate early recognition and response to patient deterioration. Unfortunately, evidence suggests that these interventions have made little impact on unexpected cardiac or respiratory arrest, hospital mortality, unplanned admission to intensive care units, or hospital length of stay. These programs depend on nurses recognizing at risk patients and initiating a timely response. Although physiologic abnormalities commonly precede serious adverse events, nurses often fail to recognize or respond effectively. Clinical judgment is a critical component in the effective response to deterioration, yet little is known about factors that influence nurses' clinical judgment in these situations. Noticing, interpreting, and responding are aspects of clinical judgment and are essential to preventing further patient deterioration and serious adverse events. ObjectiveTo describe medical-surgical nurses' perceptions of factors that influenced their clinical judgment in situations of patient deterioration. DesignA qualitative descriptive design using individual, semi-structured interviews. Tanner's Clinical Judgment Model served as the framework for interview questions and data analysis. ParticipantsA purposive sample of 20 medical-surgical registered nurses were recruited from 10 adult medical-surgical units at an academic medical center hospital in the United States. MethodsTelephone interviews occurred between March and July 2018. A directed approach to content analysis was used to code the transcribed data and identify themes. ResultsEight themes related to each aspect of clinical judgment emerged from the analysis: Knowing the patient, Experience matters, Lots of small points where the system can fail, Making sense of the data, Something doesn't go together, Caught in the middle, Culture of teamwork, and Increased nursing workload. An overarching theme was Nurses' keen sense of responsibility. Findings revealed that factors within the nurse, the patient, and the work environment influence each component of noticing, interpreting, and initiating an effective response to deteriorating patients. ConclusionsFindings have implications for health care systems regarding interventions to support timely recognition and response to deterioration. Nurses' clinical judgment and factors that influence each aspect (noticing, interpreting, and responding) should be a key consideration in organizational efforts to improve the overall response to patient deterioration. Research is needed to enhance understanding of the contextual factors that impact nurses' clinical judgment to inform interventions to support timely recognition and response.

Introduction to Section IV: Academic Medical Center Hospital Standards

Introduction to Section IV: Academic Medical Center Hospital Standards

Abstract 14227: Development of a Tool To Improve Risk Stratification of Patients With Atrial Fibrillation in the Emergency Department

Introduction: Currently, no tool exists to help emergency department (ED) physicians determine which patients with atrial fibrillation (AF) may be low risk for adverse outcomes and potential candidates for expedited discharge. Hypothesis: A simple decision aid can assess 90-day risk for a combined outcome of mortality, stroke, or re-presentation to the ED in AF patients. Methods: Through multi-disciplinary meetings, clinically relevant and easily attainable factors were selected to risk stratify AF patients in the ED, including: primary ED diagnosis (AF or other), age, AF symptom severity (Canadian Cardiovascular Society - Symptom of AF [CCS-SAF]), heart rate, blood pressure, and laboratory assessment. Logistic regression analyses were used to develop a scoring tool. Results: Over 15 months (Jan 2015 - Mar 2016), 935 consecutive patients presenting to the ED of an academic medical center hospital (University of North Carolina) with AF were included in the cohort. Ninety days from presentation, there were 275 (29.4%) adverse events. In multivariable analyses, 4 factors were identified which independently associated events among all patients with AF: non-AF primary ED diagnosis, age, heart rate, and severe AF symptoms (CCS-SAF 4). Using a scoring tool with these 4 factors (range 0-18), a score ≥ 14 predicted events with 72% accuracy. Including only the 223 patients with a primary diagnosis of AF, using a scoring tool with 3 factors (age ≥ 70, heart rate ≥ 105, severe AF symptoms) a score ≥ 10 (range 0-13) predicted events with 78% accuracy (25% sensitivity, 95% specificity). Conclusions: A simple risk stratification scoring tool may be useful to determine patient disposition for AF patients in the ED. In patients with a primary diagnosis of AF, the scoring tool was particularly useful (95% specific) in identifying patients unlikely to have an event. Further analyses of larger data sets are required for validation.

Institutional Trends in Hysterectomy Volume and Route of Surgery

<h3>Study Objective</h3> To report the trends in hysterectomy volume and route of surgery at a single tertiary-care institution as the overall surgical landscape has shifted towards minimally invasive surgery. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Large academic medical center and affiliated community hospital. <h3>Patients or Participants</h3> All patients who underwent hysterectomy for benign and malignant indications between January 2010 and August 2021. <h3>Interventions</h3> N/A. <h3>Measurements and Main Results</h3> During the study period, there were 4722 hysterectomies performed at our institution: 4059 total (86%) and 663 supracervical (14%). Hysterectomy volume rose steadily from 2010 (306 annual cases), peaked in 2016 (483 annual cases), and remained relatively stable through 2021. The laparoscopic approach (conventional laparoscopic, robotic, and laparoscopic-assisted vaginal hysterectomy) was the most common route of hysterectomy overall (59.3%, n=2799), followed by abdominal (30.2%, n=1425) and vaginal (10.5%, n=498) (P < .0001). Among the laparoscopic hysterectomies, there were 1546 robot-assisted laparoscopic hysterectomies (32.7%), 1097 conventional laparoscopic hysterectomies (23.2%), and 156 laparoscopic-assisted vaginal hysterectomies (3.3%). The distribution of route of hysterectomy changed from 2010 (44.8% abdominal, 41.2% laparoscopic, 14.1% vaginal) to 2021 (22.6% abdominal, 66.1% laparoscopic, 11.3% vaginal) (P < .0001). While abdominal hysterectomies constituted the largest proportion of cases in the beginning of our study period, the proportion dropped substantially by the end. Most notably, robot-assisted hysterectomies had the greatest increase from 6.2% of cases in 2010 to 41.1% of cases in 2021, while conventional laparoscopic hysterectomies slightly increased from 21.6% of cases to 24.3%, and vaginal hysterectomies slightly decreased from 14.1% to 11.3%. <h3>Conclusion</h3> There has been a large shift towards laparoscopic hysterectomies in the last 10 years, with the most substantial increase in robot-assisted laparoscopy. This trend reflects the increasing popularity of minimally invasive surgery in the gynecology field as a whole.

Vaginal Cuff Dehiscence Rates by Mode of Hysterectomy: An Update

<h3>Study Objective</h3> To report vaginal cuff dehiscence rates by mode of hysterectomy as the surgical landscape has shifted towards minimally invasive approaches. <h3>Design</h3> Retrospective cohort study. <h3>Setting</h3> Large academic medical center and affiliated community hospital. <h3>Patients or Participants</h3> 4722 patients who underwent hysterectomy for benign and malignant indications between January 2010 and August 2021. <h3>Interventions</h3> Hysterectomy patients and vaginal cuff dehiscences were identified by ICD and CPT codes. <h3>Measurements and Main Results</h3> There were 663 supracervical hysterectomies and 4059 total hysterectomies identified (1360 robot-assisted total laparoscopic hysterectomies [RA-TLH, 28.8%], 1107 total abdominal hysterectomies [TAH, 23.4%], 938 total laparoscopic hysterectomies [TLH, 19.9%], 498 total vaginal hysterectomies [TVH, 10.5%], and 156 laparoscopic-assisted vaginal hysterectomies [LAVH, 3.3%]). Supracervical hysterectomies were excluded from analysis. Among 4059 total hysterectomies, there were 15 vaginal dehiscences (0.37%). The dehiscence rate was highest after RA-TLH at 0.66% (n=9), followed by TLH at 0.32% (n=3), and TAH at 0.27% (n=3), with no dehiscences after TVH or LAVH; these differences were not statistically significant (<i>p</i>=0.31). Compared to TAH, the relative risk for dehiscence after RA-TLH was 2.44 (95% CI 0.66 – 9.00), and after TLH was 1.18 (95% CI 0.24 – 5.83), which were also not statistically significant. Patient characteristics were reviewed including age, hysterectomy indication, colpotomy type, suture type, medical comorbidities, and presentation. The mean time to dehiscence was 39 days (range 8 – 145). The most common trigger event was coitus (41%). Most dehiscences followed benign hysterectomies (88%). <h3>Conclusion</h3> Our study offers the largest representation of robotic hysterectomies to date. Although dehiscence rates were higher after laparoscopic hysterectomy (RA-TLH 0.66%, TLH 0.32%) compared to abdominal hysterectomy (TAH 0.27%), the differences were not significant. Our 0.66% RA-TLH dehiscence rate is much lower than previously reported in large studies (1.6 – 4.1%). While broad conclusions are limited, dehiscences are overall rare (0.37%). More research is needed to evaluate factors responsible for increased risk.

Pediatric Residency Training amid the COVID-19 Pandemic: Exploring the Impact of Supervision and Clinical Practice Guidelines on Clinical and Financial Outcomes.

Objective This study is aimed at calculating the magnitude of the effect of clinical practice guidelines (CPG) and supervision in inhibiting the negative impact of the COVID-19 pandemic on clinical and financial outcomes of non-COVID-19 inpatient care by pediatric residents in academic medical center (AMC) hospitals during the COVID-19 pandemic. Methods The cohort retrospective study was conducted. This study collected patient data from pediatric residency programs. A research cohort consisted of non-COVID-19 pediatric patients at Dr. Soetomo General Academic Hospital. This study compared the subgroup of patients treated during the pandemic with those treated before the pandemic. The results were analyzed using SPSS 26.0 and Smart-PLS. Results There was a 41.4% decrease in pediatric inpatients during the pandemic with an increased severity level and complexity level, a reduction of 7.46% availability of supervisors, an increase of 0.4% in readmission < 30 days, an increase of 0.31% in-hospital mortality, an increase the total costs of care, and a decrease of insurance claim profit. CPG did not moderate the effect of the COVID-19 pandemic on the clinical outcomes (β = −0.006, P = 0.083) but moderated the financial outcomes (β = −0.022, P = 0.000), by reducing the total cost of care and increasing insurance claim profit. Supervision moderated the effect of the COVID-19 pandemic on the clinical outcomes (β = 0.040, P = 0.000) by increasing aLOS and on the financial outcomes (β = −0.031, P = 0.000) by reducing the total cost of care and increasing insurance claim profit. This study model had a 24.0% variance of explanatory power for clinical outcomes and 49.0% for financial outcomes. This study's structural model effectively predicted clinical outcomes (Q2 = 0.238) and financial outcomes (Q2 = 0.413). Conclusion Direct supervision inhibited the negative impact of the COVID-19 pandemic on both clinical and financial outcomes of non-COVID-19 inpatient care by pediatric residents, while CPG only inhibited the negative impact on financial outcomes. Implication of This Study. In a disaster, the availability of CPG and direct supervision makes AMC hospitals able to inhibit the negative impact of disasters on clinical and financial outcomes.

Remote vs In-home Physician Visits for Hospital-Level Care at Home

Home hospital care is the substitutive provision of home-based acute care services usually associated with a traditional inpatient hospital. Many home hospital models require a physician to see patients at home daily, which may hinder scalability. Whether remote physician visits can safely substitute for most in-home visits is unknown. To compare remote and in-home physician care. This randomized clinical trial assessed 172 adult patients at an academic medical center and community hospital who required hospital-level care for select acute conditions, including infection, heart failure, chronic obstructive pulmonary disease, and asthma, between August 3, 2019, and March 26, 2020; follow-up ended April 26, 2020. All patients received acute care at home, including in-home nurse or paramedic visits, intravenous medications, remote monitoring, and point-of-care testing. Patients were randomized to receive physician care remotely (initial in-home visit followed by daily video visit facilitated by the home hospital nurse) vs in-home care (daily in-home physician visit). In the remote care group, the physician could choose to see the patient at home beyond the first visit if it was felt to be medically necessary. The primary outcome was the number of adverse events, compared using multivariable Poisson regression at a noninferiority threshold of 10 events per 100 patients. Adverse events included a fall, pressure injury, and delirium. Secondary outcomes included the Picker Patient Experience Questionnaire 15 score (scale of 0-15, with 0 indicating worst patient experience and 15 indicating best patient experience) and 30-day readmission rates. A total of 172 patients (84 receiving remote care and 88 receiving in-home physician care [control group]) were randomized; enrollment was terminated early because of COVID-19. The mean (SD) age was 69.3 (18.0) years, 97 patients (56.4%) were female, 77 (45.0%) were White, and 42 (24.4%) lived alone. Mean adjusted adverse event count was 6.8 per 100 patients for remote care patients vs 3.9 per 100 patients for control patients, for a difference of 2.8 (95% CI, -3.3 to 8.9), supporting noninferiority. For remote care vs control patients, the mean adjusted Picker Patient Experience Questionnaire 15 score difference was -0.22 (95% CI, -1.00 to 0.56), supporting noninferiority. The mean adjusted 30-day readmission absolute rate difference was 2.28% (95% CI, -3.23% to 7.79%), which was inconclusive. Of patients in the remote group, 16 (19.0%) required in-home visits beyond the first visit. In this study, remote physician visits were noninferior to in-home physician visits during home hospital care for adverse events and patient experience, although in-home physician care was necessary to support many patients receiving remote care. Our findings may allow for a more efficient, scalable home hospital approach but require further research. ClinicalTrials.gov Identifier: NCT04080570.