Affairs Hospital Research Articles

Abstract 4129440: Ventricular Stunning Following Direct Current Cardioversion: A Case Report

Background: Ventricular stunning refers to a transient mechanical dysfunction of the myocardium, typically manifesting in response to ischemic insults, reperfusion injury, inflammatory states, or neurohormonal overload. Here, we present an unusual case of ventricular stunning precipitated by direct current electrical cardioversion (DEC). Case Report: A 73-year-old man with a history of heart failure with reduced ejection fraction, paroxysmal atrial fibrillation (AF), coronary artery disease, and chronic kidney disease was admitted to a Veterans Affairs hospital for heart failure exacerbation. His hospitalization was complicated by recurrent episodes of symptomatic AF with ventricular rates in the 120-150’s. This was initially managed with intravenous amiodarone and eventually DEC. He continued to experience symptomatic episodes of AF. Later in the hospitalization a repeat DEC with a single 200 joule shock was performed with restoration of sinus rhythm. Several hours afterwards he was found to be unresponsive and hypotensive. Cool extremities and rising serum lactate raised suspicion for cardiogenic shock resulting in transfer to the intensive care unit where vasopressor and inotropic support were initiated. Echocardiogram revealed a precipitous decrease in left ventricular ejection fraction from 25% to 5%. Serum troponin concentrations were unchanged from prior and ECGs demonstrated rate-controlled AF. Clinical Decision Making: This case highlights an episode of unexpected decrease in cardiac output following an otherwise routine repeat DEC for recurrent AF requiring escalation to mechanical circulatory support. His decompensation worsened, necessitating transfer to the local university center for placement of catheter-based miniaturized ventricular assist device (Impella 5’5). Over the subsequent days, with supportive care, his left ventricular ejection fraction recovered to baseline, and mechanical and inotropic support were withdrawn. Conclusion: Ventricular stunning, leading to cardiogenic shock, is a rare and incompletely understood complication of DEC. It warrants consideration when monitoring patients after cardioversion. Implementing vigilant observation protocols post-DEC to detect ventricular stunning and predisposing risk factors could significantly enhance clinical management strategies.

Predictive Factors in Asymptomatic Bacteriuria Treatment

Background Asymptomatic bacteriuria (ASB) can often be inappropriately treated with antibiotics. The primary objective was to identify factors associated with antibiotic treatment of ASB. The secondary objective was to identify the prevalence of ASB treatment at our institution before and after Infectious Diseases Society of America (IDSA) updated Clinical Practice Guidelines for the Management of Asymptomatic Bacteriuria in 2019. 1 Methods This is a retrospective chart review of adults admitted to a rural Veterans Affairs Hospital in White River Junction, Vermont, with culture confirmed bacteriuria. Those who did not meet National Healthcare Safety Network criteria for diagnosis of urinary tract infection were classified as having ASB. Results The prevalence of ASB treatment was 58% (n = 61/106). Patients older than 80 years had 3.73 increased odds of receiving antibiotics for ASB (adjusted odds ratio 3.73, 95% confidence interval 1.43–9.71 P < 0.01). Leukocytes >5/hpf on urinalysis (adjusted odds ratio 4.45, confidence interval 1.19–16.57, P = 0.03) was significantly associated with antibiotic treatment in ASB. There was no significant difference between ASB treatment before 2019 versus after 2019. Conclusions Predictors of clinicians treating ASB with antibiotics were most significant in patients older than 80 years and those with leukocytes >5/hpf on urinalysis. The 2019 IDSA guidance on avoiding antibiotic treatment for ASB was not well adopted to clinical practice for hospitalized patients at our institution.

Clinical features of suspected and unsuspected fatal pulmonary emboli in hospitalized patients.

Pulmonary embolism (PE) is often unsuspected by treating clinicians. Since the adoption of clinical prediction scores for PE and the widespread availability of computed tomography (CT)-pulmonary angiogram, there are few reports of clinical presentations of hospitalized patients who died of PE. To compare the clinical signs, symptoms, and comorbidities of hospitalized patients who died of PE for whom PE was suspected versus not suspected antemortem. Case-control study from January 1999 to December 2018 in one Veterans Affairs (VA) hospital. We compared groups to examine differences in clinical presentations of fatal PE over the two decades. Among 1345 autopsies performed during the study period, 52 patients (4%) with fatal PE were included in the final analyses. PE was unsuspected before death in 29/52 patients (56%). Comparing groups, there were significant differences for: dyspnea (suspected 91%; unsuspected: 59%, p = 0.01); active malignancy (suspected 74%; unsuspected: 28%, p = 0.002); and atrioventricular (AV) nodal blocking treatment (suspected: 62%; unsuspected 30%,p= 0.03). A greater proportion of patients with unsuspected PE lacked symptoms of PE (suspected 0%; unsuspected: 31%, p = 0.003). Fatal PE remains a common, unsuspected cause of inpatient death in the modern era. Symptoms of PE, active malignancy, and potentially confounding AV nodal blocking treatment were less frequent in patients with unsuspected PE. These data highlight the variation in presentation and the challenge of making the diagnosis in many hospitalized patients, particularly those without typical symptoms.

8125 Long-term Effects of Gender Affirming Hormone Therapy (GAHT) on Lipid Profile

Abstract Disclosure: G. Le: None. S. Pinkson: None. J. Trejo: None. D. Tripathy: None. Long-term Effects of Gender Affirming Hormone Therapy (GAHT) on Lipid Profile There is differential effect of long-term Estrogen and Testosterone therapy on lipid profile. While oral estradiol therapy in post-menopausal women has been associated with increased serum triglyceride and HDL, testosterone therapy in hypogonadal men decreases total cholesterol, LDL and HDL cholesterol. However, the long-term effects of Estrogen and Testosterone on lipid profile in transgender patients are not clear. We conducted a retrospective study to analyze the long-term effects of GAHT in transgender men and women followed in Endocrinology Clinic at Veterans Affairs Hospital. 36 transgender men (age 38 ± 2 years, on IM Testosterone cypionate) and 54 transgender women (age 46 ± 2 years, 36 on E2 tablet, 12 on patch, 6 on IM) were followed for 46 ± 5 months and 61 ± 5 months, respectively. Total cholesterol, triglyceride, HDL, LDL cholesterol, systolic and diastolic blood pressures, and BMI were compared before and after initiation of therapy. As expected, following GAHT, total testosterone was higher (546 ± 48 vs. 35 ± 9 ng/dL, P<0.001) in transgender men; in transgender women, serum E2 was higher (110 ± 9 vs. 26 ± 2 pg/dL, P<0.001) and total testosterone was suppressed (444 ± 29 ng/dL vs. 66 ± 13 ng/dL). In transgender men, after a follow-up period of approximately 4 years, there were no significant changes in lipid profile (total cholesterol 178 ± 8 vs. 175 ± 8 mg/dL, triglyceride 121 ± 4 vs 134 ± 12 mg/dL, HDL 47 ± 2 vs. 44 ± 2 mg/dL, LDL 107 ± 7 vs. 106 ± 8 mg/dL, all p=NS). Similarly in transgender women, no difference in lipid profile (total cholesterol 170 ± 5 vs. 175 ± 4 mg/dL, triglyceride 118 ± 7 vs 140 ± 9 mg/dL, HDL 49 ± 2 vs. 53 ± 3 mg/dL, LDL 99 ± 4 vs. 97 ± 4 mg/dL, all p=NS) was observed after 5 years of GAHT. There were no differences in lipid profile regardless of E2 tablet, patch or IM therapy. In transgender men, there was an increase in diastolic blood pressure (72 ± 3 vs. 76 ± 2 mmHg, P<0.05) while in transgender women there was decrease in systolic blood pressure (124 ± 2 vs. 118 ± 2 mmHg, p<0.005), and slight increase in BMI (28 ± 0.9 vs. 30 ± 1 kg.m2, P<0.005). In conclusion, long-term testosterone therapy in transgender men and estrogen therapy in transgender women was not associated with worsening lipid profile. Estrogen therapy was associated with lower BP in transgender women and testosterone therapy led to higher BP in transgender men. Presentation: 6/2/2024

8125 Long-term Effects of Gender Affirming Hormone Therapy (GAHT) on Lipid Profile

Abstract Disclosure: G. Le: None. S. Pinkson: None. J. Trejo: None. D. Tripathy: None. There is differential effect of long-term Estrogen and Testosterone therapy on lipid profile. While oral estradiol therapy in post-menopausal women has been associated with increased serum triglyceride and HDL, testosterone therapy in hypogonadal men decreases total cholesterol, LDL and HDL cholesterol. However, the long-term effects of Estrogen and Testosterone on lipid profile in transgender patients are not clear. We conducted a retrospective study to analyze the long-term effects of GAHT in transgender men and women followed in Endocrinology Clinic at Veterans Affairs Hospital. 36 transgender men (age 38 ± 2 years, on IM Testosterone cypionate) and 54 transgender women (age 46 ± 2 years, 36 on E2 tablet, 12 on patch, 6 on IM) were followed for 46 ± 5 months and 61 ± 5 months, respectively. Total cholesterol, triglyceride, HDL, LDL cholesterol, systolic and diastolic blood pressures, and BMI were compared before and after initiation of therapy. As expected, following GAHT, total testosterone was higher (546 ± 48 vs. 35 ± 9 ng/dL, P<0.001) in transgender men; in transgender women, serum E2 was higher (110 ± 9 vs. 26 ± 2 pg/dL, P<0.001) and total testosterone was suppressed (444 ± 29 ng/dL vs. 66 ± 13 ng/dL). In transgender men, after a follow-up period of approximately 4 years, there were no significant changes in lipid profile (total cholesterol 178 ± 8 vs. 175 ± 8 mg/dL, triglyceride 121 ± 4 vs 134 ± 12 mg/dL, HDL 47 ± 2 vs. 44 ± 2 mg/dL, LDL 107 ± 7 vs. 106 ± 8 mg/dL, all p=NS). Similarly in transgender women, no difference in lipid profile (total cholesterol 170 ± 5 vs. 175 ± 4 mg/dL, triglyceride 118 ± 7 vs 140 ± 9 mg/dL, HDL 49 ± 2 vs. 53 ± 3 mg/dL, LDL 99 ± 4 vs. 97 ± 4 mg/dL, all p=NS) was observed after 5 years of GAHT. There were no differences in lipid profile regardless of E2 tablet, patch or IM therapy. In transgender men, there was an increase in diastolic blood pressure (72 ± 3 vs. 76 ± 2 mmHg, P<0.05) while in transgender women there was decrease in systolic blood pressure (124 ± 2 vs. 118 ± 2 mmHg, p<0.005), and slight increase in BMI (28 ± 0.9 vs. 30 ± 1 kg.m2, P<0.005). In conclusion, long-term testosterone therapy in transgender men and estrogen therapy in transgender women was not associated with worsening lipid profile. Estrogen therapy was associated with lower BP in transgender women and testosterone therapy led to higher BP in transgender men. Presentation: 6/2/2024

Longitudinal Assessment of Ocular Biomarkers in Individuals With Gulf War Illness Symptoms.

Gulf War illness (GWI) is characterized by a constellation of symptoms, including, but not limited to, diarrhea, fatigue, and memory problems that affect Gulf War veterans. Currently, there are no objective biomarkers for GWI. Previous studies have identified differences in optical coherence tomography (OCT) metrics between individuals with GWI symptoms and those without. However, there are limited data on how these metrics change over time. Therefore, in this current study, we conducted a prospective case-control investigation to determine if OCT metrics show longitudinal changes in those affected by GWI. We conducted a prospective study with 100 Gulf War-era veterans at the Miami Veterans Affairs Hospital from November 2018 to February 2022. Inclusion criteria required service during 1990-1991, with both deployed and nondeployed veterans included. Exclusions were based on factors like active infection, unmanaged psychotic disorders, significant head injuries, severe neurological disorders, and eye pathologies affecting OCT imaging. All participants provided informed consent, and the study was institutional review board-approved and conducted per the Declaration of Helsinki and Health Insurance Portability and Accountability Act guidelines. GWI symptoms were assessed using the modified Kansas questionnaire, categorizing veterans into groups based on GWI symptoms presence and deployment status. Data on demographics, comorbidities, medications, and medical and ocular diagnoses were collected. Participants underwent OCT imaging at 2 time points, 1 year apart, with macular, retinal nerve fiber layer, and ganglion cell layer-inner plexiform layer (GCL-IPL) thicknesses measured. Additionally, blood samples were collected and cytokine levels measured at baseline. Data analysis involved descriptive statistics, t-tests, and multivariable regression models. Statistical analyses were performed using SPSS 28.0. Logistic regression demonstrated that post-traumatic stress disorder (odds ratio [OR]: 8.18, 95% confidence interval [CI]: 2.327-28.851, P = .001) and a lower baseline macular thickness in the outer nasal segment (OR: 0.959, 95% CI: 0.924-0.994, P = .023) remained significantly associated with GWI symptoms. The model also found that individuals with GWI symptoms were more likely to have an increase in inner temporal GCL-IPL layer thickness over a 1-year period (OR: 1.187, 95% CI: 0.974-1.447, P = .089). When analysis was conducted only among those deployed, only baseline interleukin (IL) 1a (OR = 1.24, CI = 1.019-1.52, P = .03) and interleukin-10 (OR = 0.95, CI = 0.91-0.99, P = .02) levels remained significantly associated with GWI symptoms. Baseline OCT measures, especially a thinner outer nasal macula, were associated with GWI symptoms. Longitudinally, individuals with GWI symptoms had greater thickening of their inferotemporal GCL compared to those without symptoms. When the model was re-examined in deployed veterans, OCT measures (at baseline and longitudinally) no longer remained significantly related with GWI symptoms and instead baseline levels of plasma inflammatory cytokine markers, IL1a and IL10, were most closely related to symptoms. Our longitudinal study builds on our previous retrospective and cross-sectional work on identifying ocular biomarkers in GWI. Across the studies, macular thinning at baseline and inferotemporal GCL-IPL thickening have been noted between cases and controls. Some of these findings share correlates with OCT biomarkers identified in conditions such as Alzheimer's, Parkinson's and Multiple Sclerosis. This is significant as it may help contextualize future research and help us develop better models of GWI.

S527 Colonoscopy Quality Metrics at a Community Veterans Affairs Hospital: A Snapshot From July 2023 to March 2024 at the Robert J. Dole VA Medical Center

S527 Colonoscopy Quality Metrics at a Community Veterans Affairs Hospital: A Snapshot From July 2023 to March 2024 at the Robert J. Dole VA Medical Center

Nurse-Supported Self-Directed Cognitive Behavioral Therapy for Insomnia

Cognitive behavioral therapy for insomnia (CBTi) is the standard of care for treating insomnia disorder, but access is limited. Alternative approaches are needed to expand access to the standard of care. To examine the effectiveness of a nurse-supported, self-directed behavioral insomnia intervention for decreasing insomnia severity and improving sleep outcomes among veterans, a population with considerable mental health comorbidity. This randomized clinical trial included 178 patients with insomnia disorder who were recruited from a Veterans Affairs hospital (Durham VA Healthcare System) from September 2019 to April 2022 and randomized following baseline assessment; follow-ups were conducted at 8 weeks (primary end point) and 6 months. Data analysis was primarily conducted during the summer of 2023 and concluded in May 2024. Six weekly phone calls from a nurse interventionist plus assigned treatment manual readings covering CBTi treatment components. The health education manual focused on health topics but not sleep. The primary outcome was the Insomnia Severity Index (score range, 0-28; remission <8; differential improvement of 3 points targeted) score assessed at 8 weeks postrandomization. Secondary outcomes were sleep outcomes, depression, fatigue, treatment response, and remission. Of 178 study participants, the mean (SD) age was 55.1 (13.2) years, and 128 (71.9%) identified as men. At 8 weeks, Insomnia Severity Index scores decreased by an estimated mean (SE) of 5.7 (0.51) points in the intervention group and 2.0 (0.47) points in the control group, a differential mean improvement of 3.7 points (95% CI, -5.0 to -2.4; P < .001). Differences were sustained at 6 months (mean, -2.8; 95% CI, -4.4 to -1.3; P < .001). The intervention also resulted in greater improvements at 8 weeks postrandomization in diary sleep onset latency, wake after sleep onset, and sleep efficiency and actigraphy sleep efficiency; these differences were sustained at 6 months. At 8 weeks, depression and fatigue were significantly reduced, and the odds of treatment response and remission were greater in the intervention group compared with controls. This randomized clinical trial found that despite greater prevalence of mental health conditions and sleep difficulties among veterans, a nurse-supported self-directed CBTi was more effective than health education control for reducing insomnia severity and improving sleep outcomes. Although less effective than therapist-delivered CBTi, findings were comparable with other trials using modified CBTi protocols. ClinicalTrials.gov Identifier: NCT03727438.

Reducing 30-Day Readmissions in Patients With Alcohol Use Disorder

The 30-day hospital readmission rate for alcohol use disorder (AUD) at a Veteran’s Affairs hospital is 2% higher than the national benchmark. This quality improvement project aimed to implement a holistic approach to care of veterans with AUD through optimization of the Clinical Institute Withdrawal Assessment for Alcohol Scale-Revised protocol and development of a revised and evidence-based alcohol withdrawal syndrome order set. After implementation, there was a statistically significant decrease in 30-day readmissions and an increase in prescription of adjuvant therapies such as gabapentin and hydroxyzine. This quality improvement project improved the processes of care related to treatment of veterans with AUD admitted with alcohol withdrawal syndrome.

Needs of family caregivers of hospitalised adults with dementia during care transitions: a qualitative study in a US Department of Veterans Affairs Hospital

ObjectiveTo identify the needs of caregivers of hospitalised adults with dementia in the hospital and during care transitions.DesignPragmatic qualitative inquiry with semi-structured interviews.SettingMichael E. DeBakey Veterans Affairs Medical Center in...

Salivary CD44 and Total Protein Levels to Detect Risk for Oral and Oropharyngeal Cancer Recurrence

Oral and oropharyngeal cancer have low survival rates, and incidence continues to increase. To determine whether soluble CD44 and total protein (TP) are useful for monitoring head and neck cancer recurrence, either used in a point-of-care (POC) test or as individual laboratory-based biomarkers. This multi-institutional nonrandomized clinical trial testing a novel diagnostic/screening assay took place across the University of California, San Diego; Johns Hopkins University; the Greater Baltimore Medical Center; New York University; and the San Diego Veterans Affairs Hospital. Patients with newly biopsy-proven, untreated oral cavity and oropharyngeal cancer were enrolled. Patients were enrolled April 2017 to April 2019, and data were analyzed December 2022 to June 2023. POC salivary oral rinse test. Oral rinses were collected at pretreatment baseline and 3, 6, 12, and 18 months after completion of therapy; participants were then followed up for 3 years to define disease status. Associations of baseline characteristics with a positive test were evaluated by Fisher exact test. The association of a positive value on the CD44 or TP test with progression-free survival was evaluated in an adjusted multivariable proportional hazards model. Of 172 patients enrolled, the mean (SD) age was 62.5 (10.2) years, and 122 (70.9%) identified as male. Additionally, 92 patients (53.3%) had never smoked, 99 (57.6%) formerly or currently drank alcohol, and 113 (65.7%) presented with oropharyngeal cancers, which were positive for human papillomavirus in 95 (84.1%). Tumor site was associated with test results at baseline; patients with oral cavity cancer had a higher baseline positive POC test rate (47 of 51 [92.2%]) compared to patients with oropharyngeal cancer (85 of 110 [77.3%]). Using Cox regression models with CD44 or TP level as a time-varying covariate, a higher CD44 level showed a statistically significant association with a higher hazard of recurrence (hazard ratio, 1.06; 95% CI, 1.00-1.12), though the TP level was not statistically significant. In multivariate adjusted analysis, higher CD44 and TP levels were associated with increased hazard ratios of recurrence of 1.13 (95% CI, 1.04-1.22) and 3.51 (95% CI, 1.24-9.98), respectively. In this multi-institutional nonrandomized clinical trial of an assay, posttreatment longitudinal monitoring for elevated salivary CD44 and TP levels using an enzyme-linked immunosorbent assay-based laboratory test identified patients at increased risk of future cancer recurrence. The CD44 and TP rapid POC test holds some promise, but further development is needed for this indication. ClinicalTrials.gov Identifier: NCT03148665.

Perceptions of organizational culture among mental health providers at a Veterans Affairs hospital.

A mixed method approach was utilized to assess the organizational culture of the mental health service line at a large Veterans Affairs (VA) hospital. The goals of the study were to assess the organizational culture, identify how employees differ in perceptions of organizational culture, and identify areas of strength and challenges. Two hundred thirteen participants returned a questionnaire assessing perceptions of organizational culture using the Organizational Culture Assessment Questionnaire (Sashkin & Rosenbach, 2013). Additionally, 22 employees and seven service line leaders participated in five focus groups that assessed for perceptions of culture. Quantitative results suggest that employees had a generally average to high average opinion of the organizational culture of the mental health service line within their VA hospital. Subscale scores suggested that customer orientation was a particular strength of the organization. Relative areas of weakness were that staff felt many decisions were imposed from outside the service line and that hard-working clinical staff were not always sufficiently recognized or rewarded for their actions. In general, demographic variables were not significantly related toward respondent opinion of the organizational culture. Substantial overlap existed between the qualitative and quantitative results. This study suggests that, at this VA's mental health service line, customer service was a strength. However, increased recognition of employees and externally imposed decision-making needed improvement. Although interventions have been implemented in these areas, it would be useful to repeat aspects of this study over time and across different institutions. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Neuraxial Analgesia for Scoliosis Correction: A Case Series in a Specialised Children's Centre.

Surgical correction of spinal deformities in children presents a challenge to the anaesthetist due to the extensive nature of the surgery, the co-morbidities of the patients and the constraints on aesthetic techniques of intraoperative neurophysiological monitoring of the spinal cord. Patients undergoing scoliosis surgery are considered to suffer severe pain, which may lead to a negative impact on patient psychology and physical well-being. By using effective postoperative pain regimens to enhance recovery after surgery, pain can be significantly reduced, leading to patient satisfaction, facilitating early mobilisation, promoting oral intake, lowering postoperative pain and shortening the length of hospital stay. Thus, the primary objectives of this study were to assess the postoperative pain management andfirst rescue analgesic medications, by using preservative-free morphine 50 mcg/kg and dexmedetomidine 4 mcg along with normal saline 0.5 ml kg caudally, as well as to look for thesecondary objectivesside effects, including respiratory depression, nausea, vomiting and pruritis, timing of postoperative ambulation and length of hospital stay. Methods: In this study, we retrospectively included children under 14 years of age and above three years who underwent scoliosis surgery under a caudal epidural-general anaesthesia using caudal morphine and the dexmedetomidine technique in the period from January to May 2023 at the National Guard Health Affairs Hospital (NGHA), Riyadh. We collected the data of seven cases using the electronic chart system of the Best Care database to extract the specific cases that meet the inclusion criteria for the study, which are idiopathic scoliosis patients, aged 3-14 years, and primary correction procedures. Results: The pain-free duration was between seven hours and 48 hours (about two days). There were four female cases (57.14%), and three cases were male (42.85%). The patients' American Society of Anesthesiologists (ASA) status were II to III. In all the cases, there was no documentation of any episodes of postoperative nausea and vomiting (PONV), respiratory distress or pruritus, except for one case where the patient had an episode of PONV. Conclusion: In this study, our aim was to present our experience with dexmedetomidine as an efficient medication when coadministered with morphine to be used in the operating room. We found a high level of reliability in prolonging analgesia time and delaying the usage of rescue medication. We encourage more studies on caudal dexmedetomidine for patients undergoing scoliosis surgery.

Diagnostic Discordance, Uncertainty, and Treatment Ambiguity in Community-Acquired Pneumonia : A National Cohort Study of 115 U.S. Veterans Affairs Hospitals.

Evidence-based practice in community-acquired pneumonia often assumes an accurate initial diagnosis. To examine the evolution of pneumonia diagnoses among patients hospitalized from the emergency department (ED). Retrospective nationwide cohort. 118 U.S. Veterans Affairs medical centers. Aged 18 years or older and hospitalized from the ED between 1 January 2015 and 31 January 2022. Discordances between initial pneumonia diagnosis, discharge diagnosis, and radiographic diagnosis identified by natural language processing of clinician text, diagnostic coding, and antimicrobial treatment. Expressions of uncertainty in clinical notes, patient illness severity, treatments, and outcomes were compared. Among 2 383 899 hospitalizations, 13.3% received an initial or discharge diagnosis and treatment of pneumonia: 9.1% received an initial diagnosis and 10.0% received a discharge diagnosis. Discordances between initial and discharge occurred in 57%. Among patients discharged with a pneumonia diagnosis and positive initial chest image, 33% lacked an initial diagnosis. Among patients diagnosed initially, 36% lacked a discharge diagnosis and 21% lacked positive initial chest imaging. Uncertainty was frequently expressed in clinical notes (58% in ED; 48% at discharge); 27% received diuretics, 36% received corticosteroids, and 10% received antibiotics, corticosteroids, and diuretics within 24 hours. Patients with discordant diagnoses had greater uncertainty and received more additional treatments, but only patients lacking an initial pneumonia diagnosis had higher 30-day mortality than concordant patients (14.4% [95% CI, 14.1% to 14.7%] vs. 10.6% [CI, 10.4% to 10.7%]). Patients with diagnostic discordance were more likely to present to high-complexity facilities with high ED patient load and inpatient census. Retrospective analysis; did not examine causal relationships. More than half of all patients hospitalized and treated for pneumonia had discordant diagnoses from initial presentation to discharge. Treatments for other diagnoses and expressions of uncertainty were common. These findings highlight the need to recognize diagnostic uncertainty and treatment ambiguity in research and practice of pneumonia-related care. The Gordon and Betty Moore Foundation.

A qualitative exploration of barriers, facilitators and best practices for implementing environmental sustainability standards and reducing food waste in veterans affairs hospitals.

To improve the healthfulness of foods offered while accelerating the use of environmental sustainability practices, it is important to engage hospital food service operators in the adoption of such practices. The purpose of this study was to explore barriers, facilitators and best practices for implementing environmental sustainability standards in food service among veterans affairs (VA) hospitals in the United States. We conducted an online survey with 14 VA hospital food service directors and then 11 qualitative interviews. The survey assessed motivations for initiating sustainability standards and included a self-rating of implementation for each of five standards: increasing plant-forward dishes, procuring and serving sustainable foods that meet organic/fair trade and other certifications, procuring and serving locally produced foods, reducing food waste and reducing energy consumption. Interviews were transcribed verbatim. Qualitative analysis, including coding of themes and subthemes, was conducted by two coders to determine barriers, facilitators and best practices for each of these five standards. Quantitative methods (counts and frequencies) were used to analyse the survey data. Participants had an average of 5 years of experience implementing sustainability standards. The top three motivators cited were reducing food waste, serving healthier foods and increasing efficiency or cost savings. Barriers revolved around patient preferences, contractual difficulties and costs related to reducing waste. Facilitators included taste testing new recipes that include more sustainable food options and easy access to sustainable products from the prime vendor. Best practices included making familiar dishes plant-forward and plate waste studies to prevent overproduction. Although there were many barriers to implementation, food service directors had solutions for overcoming challenges and implementing food service sustainability standards, which can be tested in future sustainability initiatives.

Streamlining Communication: "Resident Huddle" on General Medicine Wards at a Veterans Affairs Hospital.

Background Orienting medical trainees to new practice environments is essential. Huddles have been shown to improve communication and safety outcomes. However, their use in orienting trainees to systems processes and changes on inpatient general medicine (GM) wards remains unexplored. Objective Implement a weekly inpatient huddle between residents and hospital leaders to improve dissemination of information around health system operations. Methods In 2019, we established "Resident Huddle," a weekly 20-minute huddle for senior internal medicine residents rotating on GM wards at a US Department of Veterans Affairs Hospital led by the site leads. Resident Huddle content included system updates, rotation updates, process reminders, performance feedback, and systems and patient safety concerns raised by trainees. Reactions to the huddle were assessed via survey. Behavioral change was assessed by rates of complete trainee admission medication reconciliation documentation before and after huddle implementation. Results Resident Huddle started in October 2019 and continues to this day. Between October 2019 and June 2022, 136 of 205 participants completed surveys (66% response rate). Respondents agreed or strongly agreed that the huddle provided useful information for care delivery (94%, 128 of 136), improved work engagement (73%, 99 of 136), provided feedback on practice patterns (90%, 121 of 135), and that issues they experienced were acknowledged and acted upon (86%, 114 of 133). Retrospective medical record analysis demonstrated improvement in admission medication reconciliation completion rate by trainees from pre-intervention (32%, 19 of 60) to post-intervention (73%, 44 of 60). Conclusions A weekly huddle between hospital leaders and residents strengthened communication and equipped trainees with operational health systems knowledge to enhance patient care outcomes while fostering a greater sense of engagement with their work environment.

Automated Versus Semi-Automated Lab Value Extraction for the VA Cardiac Surgical Quality Improvement Program

IntroductionThe Veterans Affairs Surgical Quality Improvement Program (VASQIP) trains surgical quality nurses (SQNs) at each Veterans Affairs (VA) hospital to extract or verify 187 variables from the medical record for all cardiac surgical cases. For ten preoperative laboratory values, VASQIP has a semiautomated (SA) system in which local lab values are automatically extracted, verified by SQNs, and lab values recorded at other VA facilities are manually extracted. The objective of this study was to develop and validate a method to automate the extraction of these ten preoperative laboratory values and compare results with the current SA method. Materials and methodsWe developed methods to extract ten preoperative laboratory values and measurement dates from the VA Corporate Data Warehouse using Logical Observation Identifiers Names and Codes. Automated (A) versus SA information extraction was compared in terms of agreement, conformance to data definitions, proximity to surgery, and missingness. ResultsFor surgeries with both A and SA lab values, the intraclass correlation coefficients for the ten variables ranged from 0.90 to 0.98. For several variables, the A method resulted in much lower rates of missing data (e.g., 2.4% versus 22.5% missing data for high-density lipoprotein) and eliminated out-of-date-range entries. ConclusionsAlthough SQN-extracted data are widely considered the gold standard within National Surgical Quality Improvement Programs, there may be advantages to fully automating extraction of lab values, including high congruence with SA SQN-extracted or verified values and lower rates of missingness and out-of-date-range data.

Acute hospitalizations and outcomes in Veterans Affairs Hospitals 2011 to 2017.

Hospitals within the Veterans Affairs (VA) health care system exhibited growing use of observation care. It is unknown how this affected VA hospital performance since observation care is not included in acute inpatient measures. To examine changes in VA hospitalization outcomes and whether it was affected by shifting acute inpatient care to observation care. Longitudinal analysis of 986,355 acute hospitalizations and observation stays in 11 states 2011 to 2017. We estimated temporal changes in 30-day mortality, 30-day readmissions, costs, and length of stay (LOS) for all hospitalizations and 6 conditions in adjusted models. Changes in mortality and readmissions were compared including and excluding observation care. A 9% drop in acute hospitalizations was offset by a 157% increase in observation stays 2011 to 2017. A 30-day mortality decreased but readmissions did not when observation stays were included (all P < .05). Mean costs increased modestly; mean LOS was unchanged. There were differences by condition. VA hospital mortality decreased; there was no change in readmissions.

Incidence and Risk Factors of Developing Post-operative Delirium Among Elderly Patients in a Tertiary Care Hospital: A Retrospective Chart Review.

Introduction Delirium is an acute and fluctuating decline in attention and cognition caused by reversible neural disruption. Post-operative delirium (POD) may happen 10 minutes after anesthesia administration up to discharge. POD has been associated with increased days of mechanical ventilation, increased patients' functional decline, prolonged intensive care unit(ICU) stay, and prolonged hospital length of stay, which can lead to nosocomial complications, further investigations, and increased treatment costs. In this study, we aim to determine the prevalence of POD and identify demographic or surgical variables associated with POD. Materials and methods This retrospective cross-sectional study was conducted at the National Guard Health Affairs Hospital (NGHA), a teaching tertiary care center in Riyadh, Kingdom of Saudi Arabia. The study included all patients older than 65 who developed POD from January 2017 to January 2023 and a control group of the same time window. The data were analyzed using custom Python code. Results The study included 108 patients, 72 of whom were male patients. General anesthesia was most used compared to other anesthesia techniques (79.630%). Patients with hypertension (HTN) and diabetes mellitus (DM) each account for 75 cases. Elective surgeries account for 86.111% of cases. Our analysis showed a significant association between POD and advanced age, male gender, DM, HTN, congestive heart failure (CHF), and chronic kidney disease (CKD). Conclusion With our study, we hope to aid the process of better understanding POD to help healthcare providers identify high-risk patients, implement preventative measures, and enhance patient safety and satisfaction.

Evaluating the Prognostic Accuracy of AMPREDICT in Predicting 1-Year Mortality Following Major Lower Limb Amputation

Accurately predicting postoperative outcomes is fundamental to informed clinical decision making, and alignment of patient, and family expectations. The AMPREDICT Decision Support Tool is a predictive tool designed to assess the probability of mortality one year after major and minor amputations. We aimed to evaluate the prognostic accuracy of AMPREDICT in our Veteran patient population. Retrospective review of lower extremity amputations completed at the West Los Angeles Veterans Affairs hospital from 2000 to 2020. Staged open amputations, and previous minor amputations were excluded. Using the AMPREDICT tool, the probability of mortality one-year post-surgery for single stage transfemoral and transtibial amputations was calculated, then compared with observed patient outcomes. Observed to predicted mortality was compared through boxplots, at one year after surgery, confidence intervals were calculated, and group means were compared using Students T-test. Receiver operator curves were constructed to assess discriminatory capacity of the tool. Significance was set at p < 0.05. 423 patients underwent 650 lower extremity amputations during our study period. 267 patients underwent single stage transfemoral or transtibial amputations comprising our study cohort. The average age at amputation was 66 years with an average age of death at 71 years. AMPREDICT tool's prognostic capability varied across the two amputations studied. For single staged transfemoral amputations, prediction aligned closely with observed outcomes, as indicated by a significant p-value of 0.0002 (C.I. 12.73 - 36.37). For single stage transtibial amputations, the predictions were also significant, p-value 0.0017 (C.I. 5.25 - 21.20), though had a wider prediction range. Our study confirms the reliability of the AMPREDICT tool in predicting one-year mortality for patients undergoing major lower limb amputations. The predictive accuracy was found to be statistically significant for both single staged transfemoral and transtibial amputations. These findings suggest that AMPREDICT may be a valuable tool in the clinical setting for patients undergoing major lower limb amputation.