New York Hospital Research Articles

Comparison of Disaster Preparedness Between Urban and Rural Community Hospitals in New York State.

The intent of this study was to determine whether there are differences in disaster preparedness between urban and rural community hospitals across New York State. Descriptive and analytical cross-sectional survey study of 207 community hospitals; thirty-five questions evaluated 6 disaster preparedness elements: disaster plan development, on-site surge capacity, available materials and resources, disaster education and training, disaster preparedness funding levels, and perception of disaster preparedness. Completed surveys were received from 48 urban hospitals and 32 rural hospitals.There were differences in disaster preparedness between urban and rural hospitals with respect to disaster plan development, on-site surge capacity, available materials and resources, disaster education and training, and perception of disaster preparedness. No difference was identified between these hospitals with respect to disaster preparedness funding levels. The results of this study provide an assessment of the current state of disaster preparedness in urban and rural community hospitals in New York. Differences in preparedness between the two settings may reflect differing priorities with respect to perceived threats, as well as opportunities for improvement that may require additional advocacy and legislation. (Disaster Med Public Health Preparedness. 2019;13:424-428).

Immediate Complications of Elective Newborn Circumcision.

To determine the incidence of immediate complications of elective newborn circumcision in 2 community teaching hospitals. We performed a retrospective chart review of all term neonates who had circumcision performed between August 2011 and December 2014 at 2 community hospitals in New York. Neonatal hospital records and subsequent inpatient and outpatient records were reviewed. We classified complications as minor, intermediate, and major. Out of a total of 1115 circumcisions, 1064 met inclusion criteria. There were 41 complications (3.9%), all involving hemorrhage. Sutures were used to control hemorrhage in 3 patients (0.3%). Local pressure or application of hemostatic chemical agents controlled bleeding in the remainder of patients. Bleeding was more common with the use of the Gomco clamp than with the Mogen clamp. Circumcisions performed with Gomco clamp represented 73.2% of the total complications compared with 26.8% with the Mogen clamp. There were no injuries to structures outside the prepuce or problems requiring medical treatment after discharge from the neonatal hospitalization. The most common immediate complication encountered during an elective neonatal circumcision was bleeding that required only pressure or topical thrombin to achieve hemostasis. Bleeding was more common with the use of the Gomco versus the Mogen clamp. To conclude, our data support the theory that elective infant circumcision can be performed safely in a hospital setting.

RAPID RESPONSE TEAMS (RRTS) IN FIVE US STATES

SESSION TITLE: Education, Research, and Quality Improvement 2 SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/10/2018 01:00 pm - 02:00 pm PURPOSE: RRTs are units of skilled healthcare providers that respond to inpatient calls of clinical concern to assess, triage, and intervene on deteriorating patients. RRTs have become ubiquitous throughout the United States (US), despite equivocal data on outcomes and a lack of standardization. While most studies on RRTs investigate outcomes, no studies in the US have explored the structure or procedure of RRTs. We sought to describe the composition, leadership, and activation criteria of RRTs with hopes of shedding light on the status quo and possible areas for improvement. METHODS: The study was approved by the New York University School of Medicine’s Institutional Review Board. Acute care hospitals in New York, Pennsylvania, New Jersey, Rhode Island, and Vermont were contacted by study team members and asked to complete an online survey. RESULTS: Out of 378 hospitals, contacts were identified for 303, and 101 surveys were completed. All 101 hospitals had a RRT, 100 of which were available 24 hours a day and 73% of which changed members daily. Reason for activation and team composition varied widely. The most common reasons for RRT activation were clinical concern (96%) and a single vital sign abnormality (74%). Only 57% of RRTs used a scale such as an Early Warning Score to raise critical concern and call the RRT. The most common specialties present at RRTs were respiratory therapy (88%), critical care nursing (75%), and nurse managers (49%). Only 64% of RRTs always had a physician present, 40% always had an attending physician present, and attending physicians were never part of 9% of the teams. Critical care physicians were always present at 20% of RRTs and a physician likely to have advanced airway skills (critical care or anesthesia) was always present in only 30%. In 51% of the 63 hospitals with an internal medicine residency, residents led the RRTs and were routinely supervised by an internal medicine attending only 19% of the time. CONCLUSIONS: Understanding RRT composition and activation criteria is crucial to improving performance. The best outcomes will occur when RRTs are called efficiently, led by experienced clinicians, and comprised of skilled team players. It is likely factors such as these, and not solely the presence of the RRT, that determines success and patient outcomes. As the largest study to date on RRTs in the US, we have demonstrated wide variability in practice and a concerning lack of attending supervision and advanced airway skills in critical situations. CLINICAL IMPLICATIONS: The heterogeneity among RRTs likely contributes to the mixed outcomes noted in studies. Understanding the details of delivering ICU level care to the bedside is the first step to identifying space for improvement and warrants further investigation. DISCLOSURES: No relevant relationships by Laura Evans, source=Web Response Speaker/Speaker's Bureau relationship with Zoll Please note: $1001 - $5000 Added 03/02/2018 by james horowitz, source=Web Response, value=Honoraria No relevant relationships by Oscar Mitchell, source=Web Response No relevant relationships by Caroline Motschwiller, source=Web Response No relevant relationships by Vikramjit Mukherjee, source=Web Response

379 Sepsis Presenting in Emergency Department Versus Inpatient Settings: Divergences in Prevalence, Patient Characteristics, Initial Resuscitation, Outcomes, and Costs

Comparisons of community versus hospital presenting sepsis are surprisingly lacking. 1) Characterize baseline differences in emergency department (ED) versus inpatient (IP) presenting sepsis patients; 2) Compare ED versus IP presenting sepsis in 2 outcome domains: process outcomes and patient centered outcomes. 3) Estimate risk-differences for patient centered outcomes attributable to disparities in initial resuscitation. Design: Retrospective consecutive sample cohort. Setting: 9 Tertiary and Community Hospitals in New York over 1.5 years. Patients: All hospitalized patients with sepsis or septic shock, defined simultaneous 1) Infection AND 2) ≥2 SIRS criteria AND 3) ≥1 acute organ dysfunction criterion; with post-hoc confirmation. Exposure: ED versus IP presenting sepsis. ED sepsis defined as meeting all objective sepsis inclusion criteria while physically in the emergency department. IP sepsis defined as admitted patients meeting criteria after physically leaving the ED. Outcomes & Analysis: We assessed differences in baseline characteristics for IP versus ED sepsis with a generalized linear model using random effects to account for inter-hospital variability. We then generated a propensity-score for patient “location” when they presented with sepsis, and created a matched (PSM) cohort. We used doubly robust estimation in the PSM cohort to compare outcomes controlling for baseline differences. Process outcomes included 3h-bundle compliance and time to antibiotics. The primary patient outcome was hospital mortality. We calculated attributable risk to determine the proportion of patient outcome differences that were explained by resuscitation differences in groups. Of 11,182 sepsis hospitalizations, we classified 2,509 (22.4%) as IP and 8,673 (77.6%) as ED. Compared to ED sepsis, IP sepsis patients more often had heart failure (OR: 1.31, 95% CI: 1.18-1.47), renal failure (OR: 1.62, 1.38-1.91), or gastrointestinal infection (OR: 1.84, 1.48-2.29); more often presented with hypotension (OR: 1.85, 1.65-2.08), or impaired gas exchange (OR: 2.46, 1.43-4.24). IP sepsis less often were admitted from skilled nursing centers (OR: 0.44, 0.32-0.60), had COPD (OR: 0.53, 0.36-0.78), were febrile (OR: 0.64, 0.52-0.78) or tachypneic (OR: 0.76, 0.58-0.98), and presented with acute kidney injury (OR: 0.82, 0.68-0.97). In a cohort of 1,922 propensity matched pairs (n=3,844), IP sepsis patients had less than half the odds of receiving 3h-bundle compliant care (17.0% versus 30.3%, OR: 0.47, 0.40-0.57) or receiving antibiotics within 3-hrs (66.2% versus 83.8%, OR: 0.38, CI:0.32-0.44) versus. ED sepsis. IP sepsis was associated with higher mortality (31.2% versus 19.3%, OR:1.90, CI:1.64-2.20), but only 23.3% of this association was attributable to initial resuscitation differences (resuscitation adjusted OR:1.69, 1.43-2.00). Sepsis patients in the ED differed dramatically from IP sepsis by demographics, infection source, chronic and acute illness at presentation, and presenting signs. ED patients receive markedly more timely initial resuscitation, and have substantially better outcomes, but this disparity explains only a modest proportion of mortality differences. If and how these 2 populations should be conflated by treatment recommendations is unclear.

Preoperative QTc Interval is Not Associated With Intraoperative Cardiac Events or Mortality in Liver Transplantation Patients

The primary objective of this study was to determine whether liver transplantation recipients with preoperative prolonged corrected (QTc) intervals have a higher incidence of intraoperative cardiac events and/or postoperative mortality compared with their peers with normal QTc intervals. This was a retrospective cohort study. Single academic hospital in New York, NY. Patients undergoing liver transplantation between 2007 and 2016. None. Data relating to all liver transplantation recipients with preoperative electrocardiograms were queried from an institutional anesthesia data warehouse and electronic medical records. Primary outcomes were a composite outcome of intraoperative cardiac events and postoperative mortality. Patients with a prolonged QTc interval (>450 ms for men, >470 ms for women) did not demonstrate an association with intraoperative cardiac events, 30- or 90-day mortality, in-hospital mortality, or overall mortality compared with recipients in the normal QTc interval group. A prolonged QTc was found to be associated with increased anesthesia time, surgical time, length of hospital stay, and incidence of fresh frozen plasma and platelets transfusion. Prolonged QTc interval is not associated with an increased incidence of intraoperative cardiac events or mortality in liver transplantation recipients. The demonstrated correlation among QTc length and Model for End-stage Liver Disease score, blood component requirements, surgical and anesthetic times, and hospital length of stay likely represents the association between QTc length and severity of liver disease.

Greater Proptosis Is Not Associated With Improved Compressive Optic Neuropathy in Thyroid Eye Disease.

Despite the paucity of supporting data, it has generally been held that proptosis in thyroid eye disease (TED) may provide relative protection from compressive optic neuropathy (CON) by producing spontaneous decompression. The objective of this study was to investigate this phenomenon in patients with bilateral TED-CON. We retrospectively reviewed the charts of 67 patients (134 orbits) with bilateral TED-CON at Columbia-Presbyterian Medical Center. Significant asymmetric proptosis (Hertel) was defined as ≥ 2 mm. Significant asymmetric CON was defined first, as the presence of an relative afferent pupillary defect. Those without an relative afferent pupillary defect were evaluated according to the TED-CON formula y = -0.69 - 0.31 × (motility) - 0.2 × (mean deviation) - 0.02 × (color vision) as previously established for the diagnosis of TED-CON. A difference in the formula result ≥ 1.0 between eyes was considered significant. Patients were then divided into 4 groups. Forty-one of 67 patients demonstrated asymmetric CON (29 by relative afferent pupillary defect, 12 by formula). Twenty-one of 67 patients demonstrated asymmetric proptosis. Only 5 of 12 (41.6%) of the patients who had both asymmetric proptosis and asymmetric CON (group 1) showed greater proptosis in the eye with less CON. Twenty-nine patients (group 2) showed that asymmetric CON occurred despite symmetrical proptosis. Seventeen patients (group 3), showed the inverse, that asymmetric differences in proptosis occurred with symmetrical CON. Despite commonly held assumptions, our results suggest that greater proptosis is not associated with improved TED-CON. Combining groups 1 to 3-all of which demonstrated asymmetry of either proptosis, CON, or both-91.4% of patients did not show a relationship between greater proptosis and improved CON.

Assessing the effectiveness of New York’s 911 Good Samaritan Law—Evidence from a natural experiment

BackgroundDrug overdose is the leading cause of accidental death in the United States. Nationally, opioids are the primary drugs associated with accidental overdoses. In response to increasing overdose deaths, 40 states and the District of Columbia have enacted Good Samaritan Laws (GSLs). Generally, these policies attempt to encourage witnesses or those experiencing an overdose to call 911 by providing limited immunity from arrest, charge and/or prosecution of possession of narcotics. The aim of the current study is to evaluate the effectiveness of New York State’s 911 GSL. MethodsWe exploit a difference in state law between New York State, where the policy was adopted in 2011, and New Jersey, where the policy was not adopted until 2013, to provide a reasonable comparison condition. We examine variation in accidental opioid overdose emergency department visits and inpatient admissions from 2010 to 2012 across 270 hospitals in New York and New Jersey at the quarterly level controlling for hospital fixed effects and time trends using State Emergency Department Databases (SEDD) and State Inpatient Databases (SID). ResultsAccidental opioid overdose emergency department visits and inpatient hospital admissions were increasing in both New York and New Jersey. After the enactment of New York’s 911 GSL, emergency department visits and inpatient hospital admissions for accidental heroin overdoses increased differently in New York and New Jersey, with an incident rate ratio (IRR) of 1.34 (95% CI = 1.00, 1.86). The results were inconclusive for accidental non-heroin opioid overdoses (IRR = 0.98, 95% CI = 0.86, 1.13). ConclusionsAccidental heroin overdose emergency department visits and inpatient hospital admissions increased in New York State after the enactment of the 911 GSL, consistent with the intended effect of the GSL. Preliminary evidence suggests that either persons who use heroin and/or those around them were impacted by the policy change.

Major Barbara Stimson: A Historical Perspective on the American Board of Surgery Through the Accomplishments of the First Woman to Achieve Board Certification.

: Dr. Barbara Bartlett Stimson, AB, MD, MedScD, FACS (1898-1986) was a pioneering orthopedic surgeon from a prominent American family who, in 1940, became the first woman certified by the American Board of Surgery (ABS, certificate number 860). It would be another 7 years and approximately 2500 candidates before the next female surgeon would be certified. A member of the third class to admit women to Columbia Medical School and the second female surgical resident to complete training at Columbia-Presbyterian Medical Center, Dr. Stimson was a confident and exceptionally accomplished trailblazer for women in surgery. In this biographical sketch based upon documents from the ABS, and the archives of Vassar College and the College of Physicians and Surgeons at Columbia-Presbyterian Medical Center, Dr. Stimson's motivations, attitudes, and unique accomplishments emerge as testimony to the exceptional career of this driven, self-possessed woman. Stimson was undaunted by the sex-based conventions of her time, and achieved a notable career as a surgeon in the profession she loved; first honing her skills at a busy urban fracture service in New York, then serving with distinction in the Royal Army Medical Corps during World War II, and finally returning to the states to become a respected leader in her field. Her life story and unprecedented ABS certification affirm her conviction that proven skill and ability can be used as a means of overcoming unfounded biases, and helped pave the way for future generations of board certified female surgeons in the United States.

Endoscopic endonasal resection of epidermoid cysts involving the ventral cranial base.

Epidermoid cysts (ECs) commonly extend to involve the ventral cisterns of the cranial base. When present, symptoms arise due to progressive mass effect on the brainstem and adjacent cranial nerves. Historically, a variety of open microsurgical approaches have been used for resection of ECs in this intricate region. In recent years, the endoscopic endonasal approach (EEA) has been proposed as an alternative corridor that avoids crossing the plane of the cranial nerves. To date, there is a paucity of data in the literature regarding the safety and efficacy of the EEA in the treatment of ECs of the ventral cranial base. The authors reviewed a prospectively acquired database of EEAs for resection of ECs over 8 years at Weill Cornell, NewYork-Presbyterian Hospital. All procedures were performed by the senior authors. Standardized clinical and radiological parameters were assessed before and after surgery. Statistical tests were used to determine the impact of previous surgery and tumor volume on extent of resection and recurrence as well as the method of closure on rate of CSF leak. Between January 2009 and February 2017, 7 patients (4 males and 3 females; age range 16-70 years) underwent a total of 8 surgeries for EC resection utilizing the EEA. Transplanum and transclival extensions were performed in 3 and 5 patients, respectively. Methods of closure incorporated a gasket seal in 6 of 8 procedures and a nasoseptal flap in 7 of 8 procedures. Gross-total resection (GTR) was achieved in 43% of patients, and near-total resection (> 95%) was obtained in another 43%. Complications included diabetes insipidus (n = 2), postoperative CSF leak (n = 2), transient third cranial nerve palsy (n = 1), and epistaxis (n = 1). With a mean follow-up of 43.5 months, recurrence has been observed in 2 of 7 patients. In 1 case, reoperation for recurrence was required 71 months following the initial surgery. Use of the gasket-seal technique with nasoseptal flap coverage significantly correlated with the absence of postoperative CSF leakage (p = 0.018). GTR was achieved in 25% of the patients who had prior surgeries and in 50% of patients without previous resections. The mean volume of cysts in which GTR was achieved (4.3 ± 1.8 cm3) was smaller than that in which subtotal or near-total resection was achieved (12.2 ± 11 cm3, p = 0.134). The EEA for resection of ECs of the ventral cranial base is a safe and effective operative strategy that avoids crossing the plane of the cranial nerves. In the authors' experience, gasket-seal closure with nasoseptal flap coverage has been associated with a decreased risk of postoperative CSF leakage.

Radiation therapy rather than prior surgery reduces extent of resection during endonasal endoscopic reoperation for craniopharyngioma.

Radiation therapy is often advocated for residual or recurrent craniopharyngioma following surgical resection to prevent local recurrence. However, radiation therapy is not always effective and may render tumors more difficult to remove. If this is the case, patients may benefit more from reoperation if gross total resection can be achieved. Nevertheless, there is little data on the impact of radiation on reoperations for craniopharyngioma. In this study, we sought to analyze whether a history of previous radiation therapy (RT) affected extent of resection in patients with recurrent craniopharyngiomas subsequently treated with reoperation via endoscopic endonasal approach (EEA). The authors reviewed a prospectively acquired database of EEA reoperations of craniopharyngiomas over 13years at Weill Cornell, NewYork-Presbyterian Hospital. All procedures were performed by the senior author. The operations were separated into two groups based on whether the patient had surgery alone (group A) or surgery and RT (group B) prior to recurrence. A total of 24 patients (16 male, 8 female) who underwent surgery for recurrent craniopharyngioma were identified. The average time to recurrence was 7.64 ± 4.34months (range 3-16months) for group A and 16.62 ± 12.1months (range 6-45months) for group B (p < 0.05). The average tumor size at recurrence was smaller in group A (1.85 ± 0.72cm; range 0.5-3.2) than group B (2.59 ± 0.91cm; range 1.5-4.6; p = 0.00017). Gross total resection (GTR) was achieved in 91% (10/11) of patients in group A and 54% (7/13) of patients in group B (p = 0.047). There was a near significant trend for higher average Karnofsky performance status (KPS) score at last follow-up for group A (83 ± 10.6) compared with group B (70 ± 16.3, p = 0.056). While RT for residual or recurrent craniopharyngioma may delay time to recurrence, ability to achieve GTR with additional surgery is reduced. In the case of recurrent craniopharyngioma, if GTR can be achieved, consideration should be given to endonasal reoperation prior to the decision to irradiate residual or recurrent tumor.

Facilitators and Barriers to Oncologists' Conduct of Goals of Care Conversations.

Goals of care (GoC) conversations optimally begin early in the course of cancer care, yet most happen near the end of life. We sought to describe oncologist-reported facilitators of and barriers to GoC conversations with patients who have advanced cancer. We conducted individual, semistructured qualitative interviews with oncologists from 4 academic, community, municipal, and rural hospitals in New York and Connecticut. Interview topics included approach to GoC conversations, facilitators, barriers, and organizational influences. We analyzed data using interpretive description. We collected demographic and practice information and surveyed oncologists on their communication skills training. We calculated descriptive statistics for quantitative data. Oncologists (n = 21) had a mean age of 46 years (range: 34-68), 67% were male, 71% were White, 24% were Asian, 10% were Hispanic, and 5% were Black. They reported an average of 20 years in practice (range: 8-42), and 62% had received training on having GoC conversations. Facilitators included patient's poor functional status, patient's high health literacy, family understanding and acceptance, oncologist's practice experience, and a supportive practice environment. Barriers included certain patient demographic and clinical characteristics, patient religion and culture, patient's denial, and lack of time. GoC conversations may be facilitated by enabling oncologists to conduct these conversations despite difficult circumstances and emotional reactions by activating patients and family via increased health literacy and by advancing palliative-informed practice environments.

Measuring Functional Status in Hospitalized Older Adults Through Electronic Health Record Documentation

Hospitalization-associated disability affects up to 60% of older adults; however, standardized measures of function are not routinely used and documented. We sought to determine whether nursing documentation in electronic medical records can be used to determine mobility status and associated clinical outcomes. A retrospective study of 2383 medical patients aged 75 years and older was conducted at a large academic tertiary hospital in New York. Mobility (low, intermediate, and high) was the primary variable of interest. Short-term clinical outcomes, including length of stay (LOS), discharge disposition, and readmissions, were the primary outcome variables. Average age and Charlson Comorbidity Index were 84.7 (range 74-107) and 6.46, respectively; 84.5% of patients were documented to have been ambulatory before admission. More than half (52.8%) of the subjects with in-hospital mortality were in the low mobility group (27.2 vs 0.27 vs 0, P < 0.0001). Low mobility was associated with increased LOS (7.42 vs 5.69 vs 4.14, P < 0.0001), discharge to a skilled nursing facility (39.36 vs 14.67 vs 1.91, P < 0.0001), and 30-day readmission (24.40 vs 16.67 vs 10.93, P < 0.0001). After controlling for demographics, ambulatory status before admission, and Charlson Comorbidity Index, low mobility was statistically significantly associated with increased LOS, discharge to a skilled nursing facility, and 30-day readmissions. The use of documented nursing observation may provide a practical way to systematically identify patients at risk for poor outcomes associated with low mobility to ultimately improve outcomes of hospitalized older adults.

Valentín Fuster: From Platelets to Preschoolers, Always With Scientific Rigor.

Why did Sesame Street’s Cookie Monster cut his consumption of the sweet treat from daily to once a week? The credit (or blame, depending on your perspective) goes to Valentin Fuster, who was asked to consult on the Spanish version of the show and eventually became Dr Ruster, a muppet sharing health advice with its young and avid audience. “Our behavior as adults depends greatly on the environment we are in between ages 3 and 6, and Sesame Street wasn’t taking advantage of this to focus on prevention and heart health,” says Fuster. Fuster, a renowned physician scientist with a daunting schedule and a decades-long record of bench and translational science and clinical trials, sees no discontinuity between the work that made him famous and his recent focus on preschoolers. “I became convinced that the same scientific tools I used to understand disease could be used to understand and promote health and prevent disease,” Fuster says. Fuster received his undergraduate and medical degrees in his hometown, Barcelona, and did clinical training and completed his doctorate in pathology at the University of Edinburgh. While at the Mayo Clinic between 1971 and 1982, starting as a medical resident and ending as professor of medicine and cardiovascular diseases, he showed in a dog model that platelets were important in the occlusion of bypass grafts and that aspirin could prevent it. Then, in the first clinical trial of aspirin in cardiac disease,1 the team demonstrated that aspirin prevented the occlusion of bypass grafts, leading to clinical guidelines calling for its use. In 1982, Fuster was recruited to become head of cardiology at Mt. Sinai Hospital in New York. After 10 years there, he spent 3 years in Boston at Harvard Medical School and Massachusetts General Hospital, where he began work on using magnetic …

What Makes a Good Endoscopic Teacher: A Qualitative Analysis

Teaching learners to perform endoscopic procedures is challenging, yet effective endoscopy teaching practices are not well-described in the literature, and prior studies have focused on perspectives of supervising physicians rather than learners. We sought to characterize, from the perspective of endoscopy learners, endoscopic teaching behaviors perceived as beneficial and detrimental to learning using qualitative methods. This is a prospective qualitative content analysis. Gastroenterology fellows from 2 tertiary care centers anonymously provided feedback regarding supervising physicians' teaching behaviors during endoscopic training between March 2016 and December 2016. Preprinted cards were completed at the conclusion of procedures to document behaviors that fellows perceived as enhancing or hampering their learning. Two investigators performed content analysis of written comments; each identified behavior was assigned positive or negative valence. Mount Sinai Hospital in New York, New York and University of California San Francisco in San Francisco, California. Both institutions are academic tertiary care centers. A total of 19 gastroenterology fellows at 2 training institutions participated. A total of 239 teaching behaviors were identified by 19 fellows who worked with 31 supervising physicians; 29 unique behaviors were identified and organized into 7 themes: teaching, learning environment, autonomy, communication, coaching, feedback, and professionalism. Of all, 185 (77.4%) behaviors were reported as beneficial, and 54 (22.6%) as detrimental to the learning experience. Behaviors related to teaching were most often perceived as beneficial, while behaviors related to professionalism and communication were most often perceived as detrimental to learning. Specific teaching behaviors may help or hinder learning of endoscopic skills. These behaviors may be useful for efforts related to teaching evaluation, faculty development, and direct teaching.

Carrying Forward a Legacy: A Tribute to Jerold F. Lucey, MD, Pediatrics Editor-in-Chief (1974-2008).

Creating a legacy is something few can accomplish. Former Editor-in-Chief of Pediatrics Dr Jerold F. (Jerry) Lucey, MD, FAAP, did so most admirably. Sadly, on December 10, 2017, Jerry Lucey died in Sarasota, Florida. With his passing, we lost a champion who led our journal for three-and-a-half decades. Jerry’s influence on all of us fortunate to know him and work with him is apparent in every issue we publish. Jerry Lucey grew up in Holyoke, Massachusetts, graduated from Dartmouth College in 1948, and received his doctor of medicine degree at New York University College of Medicine in 1952. He did his internship at Bellevue Hospital and residency at Columbia-Presbyterian Medical Center, and conducted research in newborn jaundice there and then at Harvard Medical School, triggering the start of his career as a neonatologist before formal fellowships existed in the field. Jerry joined the faculty of the University of Vermont College of Medicine (now the University of Vermont Robert Larner, MD, College of Medicine) in 1956, rose to the rank of professor in 1967, and was named the Harry Wallace Professor of Neonatology in 1995. He was an active member of the department until his retirement in 2009, when he was named professor emeritus. His contributions … Address correspondence to Lewis R. First, MD, MS, University of Vermont Robert Larner, MD College of Medicine, 89 Beaumont Ave, Given Courtyard S250, Burlington, VT 05405-0068. E-mail: lewis.first{at}med.uvm.edu

André Cournand, Bellevue's Cardiopulmonary Laboratory, and Research on Heart Failure.

In 1954-1955, the author served as a research fellow in the cardiopulmonary laboratory led by André Cournand at Bellevue Hospital in New York. Cournand was a pulmonary physiologist and a professor of medicine at Columbia University. In his quest to obtain mixed venous blood to calculate pulmonary blood flow, he catheterized the right atrium, right ventricle, and pulmonary artery in patients and also measured the pressures in these chambers. Cournand and his collaborators soon appreciated the enormous potential of cardiac catheterization in deepening the understanding of cardiovascular pathophysiology. After a series of groundbreaking studies, Cournand and his coworker Dickinson Richards, as well as German physician Werner Forssmann, were awarded a Nobel Prize in 1956. Cournand's laboratory, his work habits, and his rigorous approach to science are described, as well as the stimulation the author received during the author's fellowship. As a result, the author went on to extend to the left side of the heart the observations that the Cournand group had conducted in the right heart. Also, the author continued Cournand's work on heart failure by developing techniques to measure ventricular function in patients and to describe the neurohumoral changes that occur in human heart failure.

Clinical Information Systems Integration in New York City's First Mobile Stroke Unit.

Mobile stroke units (MSUs) reduce time to thrombolytic therapy in acute ischemic stroke. These units are widely used, but the clinical information systems underlying MSU operations are understudied. The first MSU on the East Coast of the United States was established at New York Presbyterian Hospital (NYP) in October 2016. We describe our program's 7-month pilot, focusing on the integration of our hospital's clinical information systems into our MSU to support patient care and research efforts. NYP's MSU was staffed by two paramedics, one radiology technologist, and a vascular neurologist. The unit was equipped with four laptop computers and networking infrastructure enabling all staff to access the hospital intranet and clinical applications during operating hours. A telephone-based registration procedure registered patients from the field into our admit/discharge/transfer system, which interfaced with the institutional electronic health record (EHR). We developed and implemented a computerized physician order entry set in our EHR with prefilled values to permit quick ordering of medications, imaging, and laboratory testing. We also developed and implemented a structured clinician note to facilitate care documentation and clinical data extraction. Our MSU began operating on October 3, 2016. As of April 27, 2017, the MSU transported 49 patients, of whom 16 received tissue plasminogen activator (t-PA). Zero technical problems impacting patient care were reported around registration, order entry, or intranet access. Two onboard network failures occurred, resulting in computed tomography scanner malfunctions, although no patients became ineligible for time-sensitive treatment as a result. Thirteen (26.5%) clinical notes contained at least one incomplete time field. The main technical challenges encountered during the integration of our hospital's clinical information systems into our MSU were onboard network failures and incomplete clinical documentation. Future studies are necessary to determine whether such integrative efforts improve MSU care quality, and which enhancements to information systems will optimize clinical care and research efforts.

Discussions in Cardiothoracic Treatment and Care: Mechanical Circulatory Support Left Ventricular Assist Device Therapy for Patients With Advanced Heart Failure

Discussions in Cardiothoracic Treatment and Care: Mechanical Circulatory Support Left Ventricular Assist Device Therapy for Patients With Advanced Heart Failure

When religion opens the door: Despite the challenges, partnerships with religious and spiritual communities can address medical disparities and improve patients' wellbeing.

When religion opens the door: Despite the challenges, partnerships with religious and spiritual communities can address medical disparities and improve patients' wellbeing.

Impact of Public Reporting of 30-day Mortality on Timing of Death after Coronary Artery Bypass Graft Surgery.

Recent reports have raised concerns that public reporting of 30-day mortality after cardiac surgery may delay decisions to withdraw life-sustaining therapies for some patients. The authors sought to examine whether timing of mortality after coronary artery bypass graft surgery significantly increases after day 30 in Massachusetts, a state that reports 30-day mortality. The authors used New York as a comparator state, which reports combined 30-day and all in-hospital mortality, irrespective of time since surgery. The authors conducted a retrospective cohort study of patients who underwent coronary artery bypass graft surgery in hospitals in Massachusetts and New York between 2008 and 2013. The authors calculated the empiric daily hazard of in-hospital death without censoring on hospital discharge, and they used joinpoint regression to identify significant changes in the daily hazard over time. In Massachusetts and New York, 24,864 and 63,323 patients underwent coronary artery bypass graft surgery, respectively. In-hospital mortality was low, with 524 deaths (2.1%) in Massachusetts and 1,398 (2.2%) in New York. Joinpoint regression did not identify a change in the daily hazard of in-hospital death at day 30 or 31 in either state; significant joinpoints were identified on day 10 (95% CI, 7 to 15) for Massachusetts and days 2 (95% CI, 2 to 3) and 12 (95% CI, 8 to 15) for New York. In Massachusetts, a state with a long history of publicly reporting cardiac surgery outcomes at day 30, the authors found no evidence of increased mortality occurring immediately after day 30 for patients who underwent coronary artery bypass graft surgery. These findings suggest that delays in withdrawal of life-sustaining therapy do not routinely occur as an unintended consequence of this type of public reporting.