Major Academic Medical Center Research Articles

Ethics Consultations at a Major Academic Medical Center: A Retrospective, Longitudinal Analysis

Background Evidence suggests that healthcare professionals feel inadequately equipped to manage ethical issues that arise, resulting in ethics-related stress. Clinical ethics consultation, and preventive ethics strategies, have been described as ways to decrease ethics-related stress, however information is limited regarding specific sources of ethical concern. Methods The purpose of this study was to conduct a retrospective, longitudinal analysis of a comprehensive database of ethics consultations, at a major academic medical center in the Northeast United States in order to: (1) Discern major sources of ethical concern, (2) Evaluate how these have changed over time in their content and frequency, (2a) Evaluate trends in nurse versus physician-initiated requests. Results Six major reasons for requesting an ethics consult were identified: Conflict Over Goals of Care, Decisional Capacity, Withholding/Withdrawing Treatment, Proxy Decision Making, Communication, and Behavior. Themes were operationally defined by the study team. An increase in requests related to Conflict Over Goals of Care (β = 0.7, 95% CI = 0.2–1.2, p = 0.008) and Discharge Planning (β = 2.2, 95% CI = 1.4–3.1, p < 0.001), and a trend toward increased number of consults for behavior-related consults from nurses (median 6.5% versus 2.3%, p = 0.07) were noted. Nurses were significantly more likely than physicians to request ethics consultation for Communication (yearly median 10.4% of cases vs 1.3% of cases, p = 0.01), whereas, physicians were significantly more likely to request ethics consultation for Proxy Decision-Making than nurses (yearly median 26.0% of cases vs 13.0%, p = 0.005) and for Decision-Making Capacity (yearly median 7.5% of cases vs 4.0%, p = 0.04). Conclusions This study revealed several noteworthy and previously unidentified trends in consultation requests, and several important distinctions between the sources of ethical concern nurses identify versus those physicians identify. These findings can be used to develop future preventive-ethics frameworks.

Patients’ reasons for missing scheduled clinic appointments and their solutions at a major urban-based academic medical center

ABSTRACT Objective Patients that do not show up for scheduled clinic appointments affect the quality of healthcare provided. This study aimed to recognize the reasons behind missing scheduled appointments and understand possible solutions from the patient’s perspective. Method We included 100 patients that attended the outpatient Medicine clinic in January 2020. Selection criteria were based on missing one or more of the scheduled clinic appointments in the last year. The participants answered a questionnaire to clarify the reasons for missing a scheduled clinic appointment and offer suggestions for a solution. The recruiter, in turn, answered several demographical questions Results The study showed a statistically significant difference between the no-show rate in females at 60% compared to males at 40% (P = 0.0023). The no show rate was not significantly affected by the day of the week, time of appointment, or the weather. Forgetting about the appointment was the most common cause (36 subjects). Work-related issues were reported in 17 participants, making it the 2nd most common cause. Not notified about the appointment, Lack of transportation, childcare-related issues, along with other reasons, were less likely reported (Table 2). 11 out of 36 (30%) subjects suggested a reminder text message in their preferred language; meanwhile, 4 others suggested a weekend clinic. Conclusion The patients should be aware of different appointment reminders options and have the freedom to choose a suitable reminder. Patients should be educated about the importance of calling to cancel the appointment since some of the reasons for no show are unpreventable.

110. IMPROVING E-CIGARETTE AND VAPING USE SCREENING AMONG ADOLESCENTS

Background Recent data suggests that 27.5% of high school students reported using electronic cigarettes (e-cigarettes) in the past 30 days, a rise from 1.5% in 2011. Only 37% of adolescents recognized nicotine presence in these products. Screening, educating and providing cessation counseling for adolescents using e-cigarettes is fundamental. It has been documented that physicians infrequently screen or counsel their adolescent patients about e-cigarette use. According to a recent study, physicians using advanced electronic medical record (EMR) systems were more likely to record smoking status, and counsel patients on smoking cessation than those using less sophisticated technology, hence the idea to encourage the use of the e-cigarette/vaping screening tab in the EMR during adolescent visits. Aim Statement To improve e-cigarette/vaping use screening among adolescents attending school-based clinics to a minimum of 80% in six months by encouraging the use of a specific tab embedded in the EMR. Interventions This quality improvement project included a baseline retrospective chart review of 100 health maintenance and sports physical visits in four school-based clinics associated to a major Academic Medical Center in Miami, Florida. The first Plan-Do-Study-Act (PDSA) cycle consisted of an email sent to health care providers encouraging them to utilize the e-cigarette tab in the EMR. Measures 100 charts were reviewed one month after the intervention to assess whether e-cigarette use or vaping was assessed at health maintenance and sports physical visits in the same four school-based clinics. Results At baseline (September-October 2019) 23% of adolescent patients were screened for e-cigarette/vaping use. This varied by school location, ranging from 12-36%. In the first PDSA cycle (November-December 2019) 55% of adolescents were screened. This varied by school location, ranging from 16-88%. Conclusions and Next Steps Encouraging health care providers to use a designated e-cigarette screening tab embedded in the EMR through an email alert increased the number of patients screened during their health maintenance or sports physical visit. One of the four school-based clinics exceeded the goal of screening at least 80% of adolescents. Because locating the e-cigarette tab was identified as a barrier by some health care providers, a second intervention that included step-by-step information about where to access the tab was implemented. Results for the second PDSA cycle will be available February 2020.

Cardiac electrophysiology consultative experience at the epicenter of the COVID-19 pandemic in the United States

BackgroundThe COVID-19 pandemic has greatly altered the practice of cardiac electrophysiology around the world for the foreseeable future. Professional organizations have provided guidance for practitioners, but real-world examples of the consults and responsibilities cardiac electrophysiologists face during a surge of COVID-19 patients is lacking. MethodsIn this observational case series we report on 29 consecutive inpatient electrophysiology consultations at a major academic medical center in New York City, the epicenter of the pandemic in the United States, during a 2 week period from March 30-April 12, 2020, when 80% of hospital beds were occupied by COVID-19 patients, and the New York City metropolitan area accounted for 10% of COVID-19 cases worldwide. ResultsReasons for consultation included: Atrial tachyarrhythmia (31%), cardiac implantable electronic device management (28%), bradycardia (14%), QTc prolongation (10%), ventricular arrhythmia (7%), post-transcatheter aortic valve replacement conduction abnormality (3.5%), ventricular pre-excitation (3.5%), and paroxysmal supraventricular tachycardia (3.5%). Twenty-four patients (86%) were positive for COVID-19 by nasopharyngeal swab. All elective procedures were canceled, and only one urgent device implantation was performed. Thirteen patients (45%) required in-person evaluation and the remainder were managed remotely. ConclusionOur experience shows that the application of a massive alteration in workflow and personnel forced by the pandemic allowed our team to efficiently address the intersection of COVID-19 with a range of electrophysiology issues. This experience will prove useful as guidance for emerging hot spots or areas affected by future waves of the pandemic.

Disparities in Care: The Role of Race on the Utilization of Physical Restraints in the Emergency Setting.

Race-based bias in health care occurs at organizational, structural, and clinical levels and impacts emergency medical care. Limited literature exists on the role of race on patient restraint in the emergency setting. This study sought to examine the role of race in physical restraint in an emergency department (ED) at a major academic medical center. Retrospective chart analysis was performed, querying all adult ED visits over a 2-year period (2016-2018) at Massachusetts General Hospital. The associations between race and restraint and selected covariates (sex, insurance, age, diagnosis, homelessness, violence) were analyzed. Of the 195,092 unique ED visits by 120,469 individuals over the selected period, 2,658 (1.4%) involved application of a physical restraint by health care providers. There was a significant effect of race on restraint (p<0.0001). The risk ratio (RR) for Asian patients compared to white patients was 0.71 (95% confidence interval [CI]=0.55 to 0.92, p=0.009). The RR for Black patients compared to white patients was 1.22 (95% CI=1.05 to 1.40, p=0.007). Visits with patients having characteristics of male sex, public or no insurance, younger age, diagnoses pertaining to substance use, diagnoses pertaining to psychotic or bipolar disorders, current homelessness, and a history of violence were more likely to result in physical restraint. There was a significant effect of race on restraint that remained when controlling for sex, insurance, age, diagnosis, homelessness, and history of violence, all of which additionally conferred independent effects on risk. These results warrant a careful examination of current practices and potential biases in utilization of restraint in emergency settings.

On-Call Examinations for Acute Onset of Flashes, Floaters, or Curtain by Junior Ophthalmology Residents: Outcomes, Safety, and Resource Use

To determine whether an on-call system serviced by junior residents can safely triage patients with symptoms concerning for posterior vitreous detachment, retinal tear, and retinal detachment. Quality improvement study structured as a prospective cohort study. All symptomatic patients seen in 2017 by an on-call junior resident were followed up (257 patients). Those with follow-up within 6 months of initial presentation (228 patients, 246 unique encounters) were included. We prospectively tracked all symptomatic patients seen on-call by a junior resident in 2017 at a major academic medical center. Incidence and predictors of true retinal tears or detachments, false-positive tears or detachments, false-negative tears or detachments, and resource use. Of 246 symptomatic encounters, 83 (33.7%) had a perceived retinal tear or detachment. Residents used B-scan ultrasonography in a high number of encounters (41.0%). Ten (4.1%) false-positive tears or detachments were identified, with the presence of intraretinal hemmorhage predicting a false-positive examination (adjusted odds ratio, 3.86; 95% confidence interval, 1.1-13.5). Thirteen (5.3%) false-negative tears and no false-negative detachments were identified. Eleven (84.6%) false-negative tears underwent follow-up within days based on high-risk characteristics, and no false-negative tears progressed to detachment at follow-up. Measures of resource use included an in-person confirmation of examination findings by the senior resident or fellow in 59 encounters (24.0%) and shorter follow-up times to a retina rather than a nonretina clinic for 52 of 151 patients who showed no pathologic features on initial examination. Junior residents can safely provide on-call triage of patients with symptoms concerning for a posterior vitreous detachment, retinal tear, or retinal detachment. The system requires moderate resource use, including occasional confirmatory examinations by a second physician and shorter follow-up times to retina clinic for high-risk patients.

Postoperative Nausea and Vomiting and Pain After Robotic-Assisted Mitral Valve Repair

To determine the rate and clinical factors associated with postoperative nausea and vomiting (PONV) and severe pain after robotic-assisted mitral valve repair. Retrospective chart review. Major quaternary academic medical center. Adult patients undergoing robotic-assisted mitral valve repair from May 5, 2018 through September 13, 2019. Participant electronic medical records were abstracted for clinical characteristics, PONV within the first 72 postoperative hours, episodes of severe pain (defined as pain score ≥7 using an 11-point numerical pain rating scale), and opioid use within the first 24 postoperative hours. Multivariate analyses were performed. Of 124 participants, PONV was noted in 83 (67%; 95% confidence interval [CI] 58%-75%) patients and severe pain in 96 (77%, 95% CI 69%-84%) patients. The median (interquartile range) time to PONV was 6.1 (3.7-14.7) hours. After adjusting for age, sex, and duration of surgery, pre-incisional use of methadone was associated with reduced risk for severe pain (odds ratio 0.40 [95% CI 0.16-0.99]; p = 0.048) and a lower 24-postoperative hour opioid requirement (estimate -29.0 mg intravenous morphine equivalents [95% CI -46.7 to -11.3]; p = 0.006). However, methadone was not associated with a reduction of the cumulative opioid dose (intraoperative and 24-hour postoperative opioid dose; p = 0.248). Both severe pain and PONV were associated with longer hospital stay. PONV and severe pain are common after robotic-assisted mitral valve repair. Peri-incisional methadone is associated with a modest decrease in the severe pain rate but without a reduction in opioid dose or hospital stay.

Outpatient Cardiac Palliative Care Reduces Healthcare Utilization (RP524)

•Outline hospitalization and healthcare utilization savings from an outpatient palliative care clinic.•Analyze the impact of a high value cardiac palliative care clinic from for a healthcare institution. The American Heart Association and American Stroke Association have put forth policy statements recommending early and continuous access to palliative care for patients with advanced heart disease. Early integration of palliative care has been proven to improve the quality of life of patients with advanced heart failure. Other studies have suggested that palliative care in general has cost savings to hospital systems. Determine if outpatient cardiac palliative care impacts hospitalization rates and cost of care in a quaternary care center. A cardiac specific outpatient palliative care clinic was opened at a major academic medical center in the United States. In the first 6 months (N=104) patients were referred to the clinic for goals of care and symptom management. Patients were tracked 90 days prior to their initial outpatient palliative care clinic visit and 90 days post visit to assess hospital utilization and total cost of care in the university hospital system. Total hospitalizations reduced 30% (91 prior to palliative care compared to 64 post). 30-day readmission dropped by 11%. 36% (N=33) of pre-intervention hospitalizations were 30-day readmissions compared to 25% (N=16) in the post intervention time period. Total per-patient hospital system health expenditures were $121,549 pre-palliative intervention and reduced to $60,857 post-palliative intervention. This represents a total reduction in health spending of $5,886,599.51 in the post palliative care time period. Average per hospital stay cost dropped by 27% from $133,571 to $97,943. A paired T-test shows this is a statistically significant reduction in per hospital stay charges (p=0.03). Outpatient palliative care is known to improve quality of life in patients with advanced heart disease. Integration of outpatient cardiac palliative care reduces hospitalizations, 30-day readmission, total healthcare expenditures, and reduces cost of hospitalizations.

Regulatory and Safety Considerations in Deploying a Locally Fabricated, Reusable Face Shield in a Hospital Responding to the COVID-19 Pandemic

BackgroundDue to supply chain disruption, the COVID-19 pandemic has caused severe shortages in personal protective equipment for health care professionals. Local fabrication based on 3D printing is one way to address this challenge, particularly in the case of products such as protective face shields. No clear path exists, however, for introducing a locally fabricated product into a clinical setting.MethodsWe describe a research protocol under Institutional Review Board supervision that allowed clinicians to participate in an iterative design process followed by real-world testing in an emergency department. All designs, materials used, testing protocols, and survey results are reported in full to facilitate similar efforts in other clinical settings.FindingsClinical testing allowed the incident command team at a major academic medical center to introduce the locally fabricated face shield into general use in a rapid but well-controlled manner. Unlike standard hospital face shields, the locally fabricated design was intended to be reusable. We discuss the design and testing process and provide an overview of regulatory considerations associated with fabrication and testing of personal protective equipment, such as face shields.ConclusionsOur work serves as a case study for robust, local responses to pandemic-related disruption of medical supply chains with implications for health care professionals, hospital administrators, regulatory agencies, and concerned citizens in the COVID-19 and future health care emergencies.Funding: This work was supported by the Harvard MIT Center for Regulatory Sciences, NIH/NCI grants U54-CA225088 and T32-GM007753, and the Harvard Ludwig Center. M.-J.A. is a Friends of McGovern Graduate Fellow.

Creating and Implementing a Nurse Mentoring Program

This article describes a team approach to developing an evidence-based mentoring program for nurses at a major academic medical center. The center's nursing leadership empowered nurses to design and implement a program that supports staff engagement and professional development. This structured, collaborative process resulted in an innovative mentoring program that is aligned with the organizational culture and practices.

Major Radiologic and Clinical Outcomes of Total Spine MRI Performed in the Emergency Department at a Major Academic Medical Center.

Total spine MRIs are requested by the emergency department when focused imaging can not be ordered on the basis of history or clinical findings. However, their efficacy is not known. We assessed the following: 1) major radiologic and clinical outcomes of total spine MR imaging performed by the emergency department, and 2) whether the presence of a high-risk clinical profile and/or neurologic findings impacts the clinical outcomes. Total spine MRIs requested by the emergency department during a 28-month period were evaluated for major radiologic (cord compression, cauda equina compression, and other significant findings) and major clinical outcomes (hospital admission during the visit followed by an operation, radiation therapy, or intravenous antibiotics or steroids). Associations between a high-risk clinical profile (cancer, infection, coagulopathy) and/or the presence of neurologic findings and outcomes were assessed. After we excluded trauma or nondiagnostic studies, 321/2047 (15.7%) MRIs ordered during study period were total spine MR imaging; 117/321 (36.4%) had major radiologic and 60/321 (18.6%) had major clinical outcomes (34/60 in <24 hours); and 58/117(49.6%) with major radiologic outcome were treated compared with 2/205 (1.0%) without (OR = 99, P < .001). The presence of both a high-risk clinical profile and neurologic findings concurrently in a patient (142/321) increased the likelihood of major clinical outcomes during the same visit (OR = 3.1, P < .001) and in <24-hours (OR = 2.6, P = .01) compared with those with either a high-risk clinical profile or neurologic findings alone (179/321). Total spine MR imaging ordered by our emergency department has a high radiologic and significant clinical yield. When a high-risk clinical profile and neurologic findings are both present in a patient, they should be prioritized for emergent total spine MR imaging, given the increased likelihood of clinical impact.

Coronavirus Disease 2019 (COVID-19) Clinical Trial Oversight at a Major Academic Medical Center: Approach of Michigan Medicine.

Clinicians – eager to offer the best care in the absence of guiding data – have provided patients with COVID-19 diverse clinical interventions. This usage has led to perceptions of efficacy of some interventions that, while receiving media coverage, lack robust evidence. Moving forward, randomized controlled clinical trials (RCTs) are necessary to ensure that clinicians can treat patients effectively during this outbreak and the next. To do so, academic medical centers must address two key research issues: (1) how to effectively and efficiently determine which trials have the best chance of benefiting current and future patients, and (2) how to establish a transparent and ethical process for subject recruitment while maintaining research integrity and without overburdening patients or staff. We share here the current methods used by the University of Michigan to address these issues.

The Response of an Orthopedic Department and Specialty Hospital at the Epicenter of a Pandemic: The NYU Langone Health Experience

As the world grapples with the COVID-19 pandemic, we as health care professionals thrive to continue to help our patients, and as orthopedic surgeons, this goal is ever more challenging. As part of a major academic tertiary medical center in New York City, the orthopedic department at New York University (NYU) Langone Health has evolved and adapted to meet the challenges of the COVID pandemic. In our report, we will detail the different aspects and actions taken by NYU Langone Health as well as NYU Langone Orthopedic Hospital and the orthopedic department in particular. Among the steps taken, the department has reconfigured its staff’s assignments to help both with the institution’s efforts and our patients’ needs from reassigning operating room nurses to medical COVID floors to having attending surgeons cover urgent care locations. We have reorganized our residency and fellowship rotations and assignments as well as adapting our educational programs to online learning. While constantly evolving to meet the institution’s and our patient demands, our leadership starts planning for the return to a new “normal”.

Introducing New Technologies in a Training Program: Lessons from Implementing a Stat Electroencephalography Program at a Major Academic Medical Center (2479)

Introducing New Technologies in a Training Program: Lessons from Implementing a Stat Electroencephalography Program at a Major Academic Medical Center (2479)

Outpatient Cardiac Palliative Care Reduces Healthcare Utilization

The American Heart Association and American Stroke Association have put forth statement recommending early and continuous access to palliative care for patients with heart disease. There is a national shortage of palliative care providers, and often outpatient palliative care clinics are not profitable to institutions with billing alone. However, early integration of palliative care has been proven to improve the quality of life of patients with advanced heart failure. Other studies have suggested that general palliative care has cost savings to hospital systems. A cardiac specific outpatient palliative care clinic was opened at a major academic medical center in the United States. In the first 6 months (N=104) patients were referred to the clinic for goals of care and symptom management. Patients were seen by a palliative care physician and registered nurse and screened for quality of life with the FACIT-Pal, HADS anxiety and depression screening, and Fried Frailty Assessment to guide clinical interventions. Patients were tracked 90 days prior to their initial outpatient palliative care clinic visit and 90 days post visit to assess hospital utilization and total cost of care in the university hospital system. Total hospitalizations reduced 30% (91 prior to palliative care compared to 64 post). 30-day readmission dropped by 11%. 36% (N=33) of pre-intervention hospitalizations were 30-day readmissions compared to 25% (N=16) in the post intervention time period. Total per-patient hospital system health expenditures were $121,549 pre-palliative intervention and reduced to $60,857 post-palliative intervention. This represents a total reduction in health spending of $5,886,599.51 in the post palliative care time period. Average per hospital stay cost dropped by 27% from $133,571 to $97,943. A paired T-test shows this is a statistically significant reduction in per hospital stay charges (p=0.03). Outpatient palliative care is known to improve quality of life in patients with advanced heart disease. Integration of outpatient cardiac palliative care reduces hospitalizations, 30-day readmission, total healthcare expenditures, and reduces cost of hospitalizations. Therefore, cardiac palliative care clinics are high value entities for patients and healthcare systems and teams should consider subsidizing the cost of palliative care clinic development.

“I Wish They Had Asked”: a Qualitative Study of Emotional Distress and Peer Support During Internship

Interns are vulnerable to emotional distress and burnout. Little is known about the extent to which interns' well-being can be influenced by peer support provided by their senior residents. To elucidate contributors to interns' emotional distress and ways that peer support from senior residents may impact intern well-being. Qualitative study using semi-structured interviews conducted December 2017-March 2018. Second year residents (n = 11) in internal medicine at a major academic medical center during the data collection period. Constructivist grounded theory approach in which transcripts were analyzed in an iterative fashion using constant comparison to identify themes and to create a conceptual model. The investigators identified three themes around emotional distress and two themes around resident peer support. Distress was a pervasive experience among participants, caused by a combination of contextual factors that decreased emotional resilience (e.g., sleep deprivation) and acute triggers (e.g., patient death) that led to an abrupt increase in distress. Participants grappled with identity reconciliation throughout internship. Reaching clinical competency reinforced self-efficacy for participants. With regard to peer support, participants recalled that resident support was ad hoc, primarily involving task support and debriefing traumatic events. Participants reflected that their intern experiences shaped their supervisory support style once they became senior residents; they did not perceive any formalized, systematic approach to supporting interns. We propose a model illustrating key points at which near-peers can make an impact in reducing interns' distress and suggest strategies they can use. Given the substantial role peer learning plays in intern development, senior residents can impact their interns by normalizing emotions, allowing vulnerability, and highlighting the importance of self-care. A formalized peer support skill-building curriculum for senior residents may empower them to provide more effective support as part of their supervisory efforts.

The Effect of Improving Basic Preventive Measures in the Perioperative Arena on Staphylococcus aureus Transmission and Surgical Site Infections

Surgical site infections increase patient morbidity and health care costs. The Centers for Disease Control and Prevention emphasize improved basic preventive measures to reduce bacterial transmission and infections among patients undergoing surgery. To assess whether improved basic preventive measures can reduce perioperative Staphylococcus aureus transmission and surgical site infections. This randomized clinical trial was conducted from September 20, 2018, to September 20, 2019, among 19 surgeons and their 236 associated patients at a major academic medical center with a 60-day follow-up period. Participants were a random sample of adult patients undergoing orthopedic total joint, orthopedic spine, oncologic gynecological, thoracic, general, colorectal, open vascular, plastic, or open urological surgery requiring general or regional anesthesia. Surgeons and their associated patients were randomized 1:1 via a random number generator to treatment group or to usual care. Observers were masked to patient groupings during assessment of outcome measures. Sustained improvements in perioperative hand hygiene, vascular care, environmental cleaning, and patient decolonization efforts. Perioperative S aureus transmission assessed by the number of isolates transmitted and the incidence of transmission among patient care units (primary) and the incidence of surgical site infections (secondary). Of 236 patients (156 [66.1%] women; mean [SD] age, 57 [15] years), 106 (44.9%) and 130 (55.1%) were allocated to the treatment and control groups, respectively, received the intended treatment, and were analyzed for the primary outcome. Compared with the control group, the treatment group had a reduced mean (SD) number of transmitted perioperative S aureus isolates (1.25 [2.11] vs 0.47 [1.13]; P = .002). Treatment reduced the incidence of S aureus transmission (incidence risk ratio; 0.56; 95% CI, 0.37-0.86; P = .008; with robust variance clustering by surgeon: 95% CI, 0.42-0.76; P < .001). Overall, 11 patients (4.7%) experienced surgical site infections, 10 (7.7%) in the control group and 1 (0.9%) in the treatment group. Transmission was associated with an increased risk of surgical site infection (8 of 73 patients [11.0%] with transmission vs 3 of 163 [1.8%] without; risk ratio, 5.95; 95% CI, 1.62-21.86; P = .007). Treatment reduced the risk of surgical site infection (hazard ratio, 0.12; 95% CI, 0.02-0.92; P = .04; with clustering by surgeon: 95% CI, 0.03-0.51; P = .004). Improved basic preventive measures in the perioperative arena can reduce S aureus transmission and surgical site infections. ClinicalTrials.gov Identifier: NCT03638947.

What is the frequency of pressure injury in vascular patients undergoing major amputations?

Individuals with peripheral arterial disease who have undergone below or above knee amputations have limited mobility and may sit for long periods of time in a wheelchair, increasing their risk for pressure injury. The aim of this descriptive cross-sectional research study was to retrospectively review the charts of those patients with peripheral arterial disease undergoing lower limb amputations from 2016 to 2017 at a major academic medical center to determine the frequency of pressure injury. Hospital data were used to identify patients discharged from 2016 to 2017 with primary International Classification of Diseases (10th Revision) codes for below knee amputations/above knee amputations and pressure injury (ulcer). From 2016 to 2017, 46 patients were admitted to the inpatient vascular surgery service for a below or above knee amputation. Seventeen of those patients had documented pressure injuries at hospital discharge for a frequency of 37%. There were 11 males and 6 females with age range of 44 to 82 years with a mean age of 66 years. There was a total of 19 pressure injuries (2 patients had 2 pressure injuries). Ten of those 19 pressure injuries were present on admission to the hospital and 9 pressure injuries were hospital-acquired pressure injuries. Thirteen of the 19 pressure injuries (68%) were on the sacrum. Three of the pressure injuries (16%) were on the heel. Two (11%) were ischial pressure injuries with one knee (5%) pressure injury. Risk assessment is an essential part of vascular nursing practice that aims to identify individuals at risk for pressure injury with appropriate interventions to prevent their occurrence. Vascular nurses should be encouraged to educate patients/family members on the increased risk of pressure injuries in those undergoing amputation during hospitalization and after discharge to prevent them from occurring.

Evaluation of Radiology Reports by the Emergency Department Clinical Providers: A Message to Radiologists [Formula: see text

This study is an evaluation of the emergency department (ED) satisfaction with the current radiologic reporting system used at a major Northeastern academic medical center. The radiology reports are the main form of communication and usually the final product of any radiological investigation delivered to clinicians. The aim of this study was to improve current radiology reporting practices and to better tailor reports to match the needs and expectations of ED clinicians. A 9-question online survey was sent to ED residents, fellows, faculty, and nurse practitioners/advanced practice providers at a major Northeastern academic medical center in the United States. For the open-ended section, coding and emergent theme categorization was conducted for quantification of responses. The survey was designed to evaluate the attitudes toward the structure, style, form, and wording used in reports. The response rate was 48.6% (68/140). The ED respondents were generally satisfied with radiology reports, their language, vocabulary, and clarity. They preferred the impression section to be before the findings in simple examinations and to stratify the reports according to emergency status for complex examinations. They did not like extended differential, hedge terms, and delayed reporting. Additionally, ED respondents recommended focused, fast reporting with considerable changes toward a more standardized report. This evaluation delivered a list of actionable recommendations. The top recommendation is to standardize reporting structure, style, and lexicon, in addition to being focused, timely, and brief.

Abstract NS5: Use of a Multidisciplinary Approach to Successfully Improve Inpatient Diabetes Self-Management Education and Diabetes Medication Reconciliation at Discharge for Persons With Diabetes and Stroke at a Major Academic Medical Center

Background: Persons with diabetes are 1.5 times more likely to have a stroke. Research shows that there is a correlation between increasing diabetes and stroke. Education for stroke patients, however, continues to focus on medication management and blood pressure reduction. American Diabetes Association indicates, “There should be a structured discharge plan tailored to the individual patient with diabetes.” Transitioning from the acute care is risky for diabetics, recommendations now include individualized education for diabetics with stroke. 40% of the stroke population at our institution showed risk factors for diabetes, yet 11% received diabetes education, and only 59% had diabetes medication pre-prescribed at discharge. The stroke team initiated an inpatient diabetes education to increase patient awareness and medication adherence. Purpose: The purpose of this project was to identify and address barriers related to the provision of individualized inpatient diabetes education and outpatient diabetes medication reconciliation for persons with diabetes and stroke. Method: The Endocrinology team was consulted for patients with diabetes and stroke with an A1c level of 7%. These team worked collaboratively to establish a consult process. Endocrinology APPs provided diabetic education and advised the Neurology team on the appropriate discharge medication regimen and follow-up. The stroke coordinator provided reminders during rounds to assure that consults were ordered for patients with diabetes having A1c 7% or greater. Results: Inpatient diabetes education improved from 11% in 2017 to 96% in 2019. Diabetes medication reconciliation, with listing of diabetes medications on the after visit summary at discharge increased from 59% in 2017 to 93% in 2019. Conclusions: Both metrics reflect improvement over a 2-year period, showing that collaboration between the Endocrinology and Neurology teams is key to effective discharge planning, diabetes medication reconciliation and outpatient follow-up.