Multihospital System Research Articles

Incidence of Venous Thromboembolism and Mortality in Patients with Initial Presentation of COVID-19.

Venous thromboembolism (VTE) has emerged as an important issue in patients with COVID-19. The purpose of this study is to identify the incidence of VTE and mortality in COVID-19 patients initially presenting to a large health system. Our retrospective study included adult patients (excluding patients presenting with obstetric/gynecologic conditions) across a multihospital health system in the New York Metropolitan Region from March 1-April 27, 2020. VTE and mortality rates within 8 h of assessment were described. In 10,871 adults with COVID-19, 118 patients (1.09%) were diagnosed with symptomatic VTE (101 pulmonary embolism, 17 deep vein thrombosis events) and 28 patients (0.26%) died during initial assessment. Among these 146 patients, 64.4% were males, 56.8% were 60 years or older, 15.1% had a BMI > 35, and 11.6% were admitted to the intensive care unit. Comorbidities included hypertension (46.6%), diabetes (24.7%), hyperlipidemia (14.4%), chronic lung disease (12.3%), coronary artery disease (11.0%), and prior VTE (7.5%). Key medications included corticosteroids (22.6%), statins (21.2%), antiplatelets (20.6%), and anticoagulants (20.6%). Highest D-Dimer was greater than six times the upper limit of normal in 51.4%. Statin and antiplatelet use were associated with decreased VTE or mortality (each p < 0.01). In COVID-19 patients who initially presented to a large multihospital health system, the overall symptomatic VTE and mortality rate was over 1.0%. Statin and antiplatelet use were associated with decreased VTE or mortality. The potential benefits of antithrombotics in high risk COVID-19 patients during the pre-hospitalization period deserves study.

Comparison of Aspirin Monotherapy versus Dual Antiplatelet Therapy Following Coronary Artery Bypass Grafting

Aspirin remains the gold standard antiplatelet regimen following coronary artery bypass grafting (CABG), however, there is growing support for dual antiplatelet therapy (DAPT). This study compares outcomes of aspirin monotherapy versus DAPT following CABG. This was a propensity-matched retrospective study from a large, multi-hospital healthcare system. It included patients who received either aspirin monotherapy or DAPT following isolated CABG between 2011 and 2018. Patients prescribed aspirin monotherapy were started on 81 mg aspirin daily, and patients on DAPT were prescribed 81 mg aspirin daily and 75 mg clopidogrel daily. Patients received alternative drug dosing or antiplatelet agents other than clopidogrel only if this was prescribed for another diagnosis or they had a preexisting contraindication. Primary outcomes included overall survival and major adverse cardiac and cerebrovascular events (MACCE), defined as a composite of death, myocardial infarction, stroke, or repeat revascularization. Kaplan-Meier analysis and the log-rank test were used to compare survival and cumulative incidence curves and Gray's test were used to compare MACCE. A total of 3,562 propensity-matched patients were included, 1,242 (34.9%) receiving aspirin monotherapy and 2,320 (65.1%) receiving DAPT. Groups were well-matched with respect to age, baseline comorbidity, indication for CABG, and completeness of revascularization. Median follow-up was 4.90 years (IQR 3.30 to 6.90 years). DAPT was associated with higher rate of postoperative transfusion (30.7% vs 25.4%, p = 0.001). Overall survival was comparable between groups (1-year aspirin 95.9% versus DAPT 97.2% and 5-years aspirin 86.3% versus DAPT 87.8%; log-rank p = 0.194). Rates of MACCE were also similar (1-year aspirin 9.4% versus DAPT 8.7% and 5-years aspirin 26.7% versus DAPT 24.7%; p = 0.798). In this propensity-matched analysis, DAPT did not confer any advantage in terms of improved survival or freedom from MACCE compared to aspirin monotherapy following isolated CABG, and was associated with a higher postoperative transfusion rate.

Patients undergoing overlapping posterior single-level lumbar fusion are not at greater risk for adverse 90-day outcomes

ObjectiveThis study evaluated overlapping surgery on long-term outcomes following elective, single-level lumbar fusion on exact matched patients undergoing surgery with or without overlap. Patients and Methods3799 consecutive adult patients undergoing single-level, posterior-only lumbar fusion over a six-year period at a multi-hospital university health system were retrospectively followed. Reported outcomes included reoperation, emergency department (ED) visit, readmission, overall morbidity and mortality in the 90 days following surgery. Coarsened Exact Matching was used to match patients with and without overlap on key demographic factors. Patients were subsequently matched by both demographic data and by the attending surgeon performing the operation. Univariate analysis was carried out on the whole population, the demographic matched cohort, and demographic and surgeon matched cohort, with significance set at a p-value < 0.05. ResultsPatients with overlap had a longer duration of surgery and were less likely to have an ED visit within 90 days of surgery (p < 0.03) but had no other significant differences. Within the demographic matched cohort and demographic/surgeon matched cohort, there was no significant difference in age, gender, history of prior surgery, ASA score, or CCI score, but patients with overlap had a longer duration of surgery (p < 0.01). Patients did not have significant differences with respect to any morbidity or mortality outcome in either the demographic or surgeon matched cohort. ConclusionsPatients undergoing overlapping, single-level lumbar fusion were not at greater risk of long-term morbidity or mortality, despite having a significantly longer duration of surgery.

Abstract P122: The Impact of Center Certification Status on Acute Stroke Care Within a Multi-Hospital System in Western United States

Introduction: We aimed to investigate the impact of certification status on process of care metrics and clinical outcome in a large multi-center hospital system. Methods: We analyzed data obtained from the Providence Stroke Registry between January 2016 and December 2019. Key process of care metrics and clinical outcome were compared among patients with a discharge diagnosis of stroke and stratified based on site certification: comprehensive stroke center (CSC), thrombectomy-capable stroke center (TSC), primary stroke center (PSC) and no certification (NC). Donner’s adjusted chi-square tests were used to compare proportions for each metric grouped by certification. Generalized linear mixed effects logistic regression models were used to adjust for mode of patient arrival, age, sex, admit NIHSS, and medical history. Results: Data included 45,278 patients. Results from the analyses are summarized in the table. Donner’s adjusted chi-square analyses showed significant differences for metrics across certification groups. Results from the logistic regression models indicated significant differences in IV TPA and EVT treatment, as well as IV TPA treatment times across certification groups. There were no significant differences between TSC and CSC. Conclusions: Patients presenting with acute ischemic stroke at NC and PSC were significantly less likely to receive IV TPA or EVT with significantly less efficient IV tPA treatment times as compared to CSC. However, CSC and TSC sites performed similarly.

Abstract P77: Acute Stroke Trends and Outcomes During the COVID-19 Pandemic in a Multi-System Hospital System in the Western US

Introduction: We aimed to evaluate the impact of Covid-19 pandemic on stroke systems of care and outcomes within a large multi-hospital system in the Western US. Methods: Retrospective data from 37 hospitals within a large multi-hospital stroke registry was analyzed. All patients with a confirmed discharge diagnosis of stroke or TIA during the pandemic (March and April 2020) were compared to cohorts during the same periods in 2018 and 2019. Analyzed factors included demographics, stroke mechanism, admission NIHSS, reperfusion therapy rates (IV TPA and EVT), reperfusion performance metrics (door-to-CT, door-to-needle, door-to-puncture, door-to-first pass), TICI score, discharge and 90-day mRS, discharge disposition, and length of stay. Analyses were conducted using ANOVA, Kruskal-Wallis, or Person’s Chi-square test, as appropriate, adjusting for multiple comparisons. Results: Among the 7,201 analyzed patients, 2,378 (33.0%) were admitted in 2018, 2,613 (36.3%) in 2019 and 2,210 (30.7%) in 2020. Fewer patients were hospitalized with TIA during the pandemic compared to 2018 and 2019 (23.6% vs 36.8% vs 39.6%, p&lt;.001). More patients arrived via EMS (52.2% vs 45.7% vs 45.4 %) and fewer via private car (29.8% vs 37.8% vs 38.7%) (p&lt;.001) during the pandemic. Median door-to-CT (in minutes) (26 vs 35 vs 33, p&lt;.001) time was significantly shorter during the pandemic. Additionally, a greater percentage of patients were treated with EVT during the pandemic (7.5 vs 5.7 vs 5.4, p=.005). Shorter arrival-to-first pass times (in minutes) occurred in 2020 compared to previous years (103 vs 119 vs 115, p=0.091) but this difference did not reach statistical significance. Fewer patients were discharged to a skilled nursing facility during the pandemic (12.7%) compared to 2018 and 2019 (15.1% and 15.2%, p=.012). There were no other significant differences in stroke admission volumes, treatment trends, or outcomes between the pandemic and pre-pandemic periods. Conclusion: Fewer walk-in strokes and TIAs were hospitalized during the pandemic while an increased rate of thrombectomy procedures occurred compared to the pre-pandemic era. Despite anticipated delays in acute stroke care, our study demonstrates improvement in key triage and treatment times and similar outcomes.

Abstract 26: Treatment Choice and Discharge Outcomes in Patients Presenting With Large Vessel Occlusion and Low National Institutes of Health Stroke Scale

Introduction: Since 2015, endovascular thrombectomy (EVT) has been widely accepted as the standard of care for patients presenting proximal anterior circulation large vessel occlusion (LVO). However, patient selection for EVT remains uncertain in patients presenting with LVO and low NIHSS. Methods: Retrospective data from 37 hospitals within a large multi-hospital system stroke registry were analyzed and included patients age 18 or over, discharged between January 2016 and May 2020, with an admission NIHSS &lt; 6, and who had a LVO visualized in the internal carotid artery or middle cerebral artery. Patients treated with EVT (with or without IV alteplase), IV alteplase alone, or best medical management (BMM) without IV alteplase or EVT were compared with regard to modified Rankin scale (mRS) at hospital discharge and hospital length of stay (LOS). Pearson’s chi-square square test and Mann-Whitney U test were conducted. Results: Discharge mRS analysis included 742 patients, 211 (28.4%) treated with EVT (with or without IV alteplase), 107 (14.4%) treated with IV alteplase alone, and 424 (57.2%) treated with BMM. A greater proportion of patients treated with IV alteplase alone (71.0%) had no or slight disability (mRS 0-2) compared to EVT (with or without IV alteplase) (51.7%), or BMM (52.6%) (p=.001). Analyses of LOS included 1,037 patients, 298 (28.7%) treated with EVT (with or without IV alteplase), 157 (15.1%) treated with IV alteplase alone, and 582 (56.1%) treated with BMM. Patients treated with IV alteplase alone had significantly shorter LOS (2.0 days, [Interquartile Range:3.0]) compared to EVT (with or without IV alteplase) (3.0 days [4.0]), or BMM (3.0 days [4.0]) (p&lt;.001). Conclusion: Amongst this cohort of patients presenting with anterior circulation LVO and low NIHSS, better discharge outcomes were seen in patients treated with IV alteplase alone, compared to EVT (with or without IV alteplase) or BMM. The best treatment for this patient population remains unclear, and further research is needed.

ASHP Pharmacy Executive Leadership Alliance kicks off with discussion with AHA CEO Richard Pollack.

ASHP’s Pharmacy Executive Leadership Alliance (PELA™) held its inaugural event virtually Oct. 29 to celebrate the creation of the new ASHP member engagement opportunity, share experiences, and brainstorm about innovations that will drive financial and organizational recovery from the effects of the COVID-19 pandemic. PELA™ was created by ASHP for chief pharmacy officers and multihospital system pharmacy executive leaders who face distinct challenges working within highly complex vertically and horizontally integrated networks and multihospital health systems. The inaugural session of what is just the start of a series of events included more than 160 pharmacy executives representing chief pharmacy officers and directors of pharmacy from more than 100 multihospital health systems and 80 major hospitals and academic medical centers. “The idea for PELA™ has been at the forefront of ASHP leadership discussions for some time,” said ASHP Chief Executive Officer (CEO) Paul W. Abramowitz. “We understand that there is a...

Impact of Initial eGlycemic Management System Dosing Strategy on Time to Target Blood Glucose Range.

Glucommander™ (GM), an electronic glycemic management system, was implemented across a multi-hospital health system as the standard of care for glycemic control. GM provides insulin dosing recommendations based on patient-specific blood glucose (BG) trends after providers select either a custom dose or weight-based multiplier as the initial dosing strategy for the first 24 hours. This study evaluated the impact of initial subcutaneous (SC) GM insulin dosing strategies on glycemic management. Non-intensive care unit patients treated with SC GM using either initial custom (based on provider discretion) or weight-based multiplier settings (0.3, 0.5, or 0.7 units/kg/day) were evaluated in this retrospective chart review. The primary endpoint was time to target BG range defined as time to first two consecutive in range point of care BG. Secondary endpoints included percentage of BG values in target range, percentage of orders following institutional recommendations, length of stay (LOS), average BG, and incidence of hypoglycemia and hyperglycemia. A review of 348 patients showed time to target BG was not significantly different between custom and multiplier groups (55 vs 64 hours, P = .07). Target BG was achieved in less than half of patients in both groups (47% vs 44%, respectively). There were no differences in hospital LOS, proportion of BG in target range, rates of hypo/hyperglycemia, and average BG. Custom initial SC GM insulin dosing settings showed a nonsignificant decrease in time to target BG range compared to pre-defined multiplier settings. Future studies evaluating the impact of compliance with institutional recommendations on BG control are warranted.

Validation of the IMPROVE‐DD risk assessment model for venous thromboembolism among hospitalized patients with COVID‐19

BackgroundAntithrombotic guidance statements for hospitalized patients with coronavirus disease 2019 (COVID‐19) suggest a universal thromboprophylactic strategy with potential to escalate doses in high‐risk patients. To date, no clear approach exists to discriminate patients at high risk for venous thromboembolism (VTE). ObjectivesThe objective of this study is to externally validate the IMPROVE‐DD risk assessment model (RAM) for VTE in a large cohort of hospitalized patients with COVID‐19 within a multihospital health system. MethodsThis retrospective cohort study evaluated the IMPROVE‐DD RAM on adult inpatients with COVID‐19 hospitalized between March 1, 2020, and April 27, 2020. Diagnosis of VTE was defined by new acute deep venous thrombosis or pulmonary embolism by Radiology Department imaging or point‐of‐care ultrasound. The receiver operating characteristic (ROC) curve was plotted and area under the curve (AUC) calculated. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated using standard methods. ResultsA total of 9407 patients were included, with a VTE prevalence of 2.9%. The VTE rate was 0.4% for IMPROVE‐DD score 0‐1 (low risk), 1.3% for score 2‐3 (moderate risk), and 5.3% for score ≥ 4 (high risk). Approximately 45% of the total population scored high VTE risk, while 21% scored low VTE risk. IMPROVE‐DD discrimination of low versus medium/high risk showed sensitivity of 0.971, specificity of 0.218, PPV of 0.036, and NPV of 0.996. ROC AUC was 0.702. ConclusionsThe IMPROVE‐DD VTE RAM demonstrated very good discrimination to identify hospitalized patients with COVID‐19 as low, moderate, and high VTE risk in this large external validation study with potential to individualize thromboprophylactic strategies.

An early experience on the effect of solid organ transplant status on hospitalized COVID-19 patients.

We compared the outcome of COVID-19 in immunosuppressed solid organ transplant (SOT) patients to a transplant naïve population. In total, 10356 adult hospital admissions for COVID-19 from March 1, 2020 to April 27, 2020 were analyzed. Data were collected on demographics, baseline clinical conditions, medications, immunosuppression, and COVID-19 course. Primary outcome was combined death or mechanical ventilation. We assessed the association between primary outcome and prognostic variables using bivariate and multivariate regression models. We also compared the primary endpoint in SOT patients to an age, gender, and comorbidity-matched control group. Bivariate analysis found transplant status, age, gender, race/ethnicity, body mass index, diabetes, hypertension, cardiovascular disease, COPD, and GFR <60mL/min/1.73m2 to be significant predictors of combined death or mechanical ventilation. After multivariate logistic regression analysis, SOT status had a trend toward significance (odds ratio [OR] 1.29; 95% CI 0.99-1.69, p=.06). Compared to an age, gender, and comorbidity-matched control group, SOT patients had a higher combined risk of death or mechanical ventilation (OR 1.34; 95% CI 1.03-1.74, p=.027).

The Evolving Structure of Multi-Hospital Systems in the US: Focus on California

Objectives: Hospital consolidation and the growth of multi-hospital systems are generating media headlines in the US. While there is a growing literature on the role of multi-hospital systems in the US health care system, it is still quite limited. This study helps fill the gap by documenting and describing the structure and evolution of multi-hospital systems in California over a recent 18-year period. Methods: Descriptive analysis of a hospital level longitudinal database covering the period 2002-2019 in California. Results: The total number of hospitals declined by 40 hospitals, from 445 to 405, over the study period and the total number of multi-hospital systems increased substantially from 14 systems in 2002 to 30 systems in 2019. As a result, the number and proportion of all California hospitals that were part of a multi-hospital system grew—from 177 in 2002 to 238 in 2019. By 2019, 59% of all hospitals were part of systems (compared to 40% in 2002). The size distribution of multi-hospital systems in California changed substantially over time. In the early period, larger systems dominated the system landscape. Now, half of all systems have 5 or fewer hospitals compared to 29% in 2002, while the percentage of systems with 25 or more members has declined from 25% to just 7%. Interestingly, the clinical service mix of hospital systems has changed substantially. In 2002, all 14 systems were largely acute care focused. By 2019, less than half of systems had acute care as their only and primary focus. Conclusions: Combined, these findings provide insight into the development, evolution and growing role of hospitals systems in our health care system and identify new areas for further research.

A multifaceted study of hospital variables and interventions to improve inpatient satisfaction in a multi-hospital system.

Knowing the areas of service, actions, and parameters that can influence patient perception about a service provided can help hospital executives and healthcare workers to devise improvement plans, leading to higher patient satisfaction.To identify inpatient satisfaction determinants, assess their relationships with hospital variables, and improve patient satisfaction through interventions.We studied the inpatient population of an eight-hospital tertiary medical center in 2015. The satisfaction determinants were based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey answers and included clinical and organizational variables.Interventions began at the end of 2016 included bedside care coordination rounds (BCCR), medications best practices alert (BPA), connect transitions post-discharge calls (CONNECT Transitions) and a framework for provider-patient interactions called AIDET (Acknowledge, Introduce, Duration, Explain, and Thank). Substantial impact upon patient satisfaction was observed after the introduction of these interventions.Three groups were identified: 1.high satisfaction, which correlated with race, surgery, and cancer care;2.low satisfaction, correlated with elderly, emergency room, intensive care unit, chronic obstructive pulmonary disease, and vascular diseases; and3.neutral, correlated with hospital-acquired complications, several diagnostic procedures, and medical care delay.Significant improvements in the 3 groups were achieved with interventions that optimize care provider interactions with patients and their families.Based on the HCAHPS-based analysis, we implemented new measures and programs for addressing coordination of care, improving patient safety, reducing the length of stay, and ultimately improving patient satisfaction.

Readmission and Death After Initial Hospital Discharge Among Patients With COVID-19 in a Large Multihospital System

This study describes reasons for readmission, use of ICU interventions during readmission, and proportions of death after initial hospital discharge of COVID-19 patients from US Veterans Affairs (VA) hospitals in March-June 2020.

Relationship between predicting bleeding complication in patients undergoing stent implantation and subsequent dual antiplatelet therapy (PRECISE‐DAPT) score and mortality among patients with atrial fibrillation undergoing percutaneous coronary intervention

The predicting bleeding complication in patients undergoing stent implantation and subsequent dual antiplatelet therapy, PRECISE-DAPT (P-DAPT) score has been validated in large cohorts as an effective tool in predicting bleeding complication after dual antiplatelet therapy (DAPT) as well as in predicting in-hospital mortality. The implication of using this score to predict outcomes, including mortality in patients with atrial fibrillation (AF) undergoing PCI is unknown. Role of P-DAPT score to study clinical outcomes, including mortality, hospitalization, and major bleeding, particularly among patients with AF. This is a retrospective observational study of 18,850 consecutive patients who underwent percutaneous coronary intervention (PCI) across a large multihospital healthcare system from 2010 to 2019. Patients were stratified into four groups depending on the presence or absence of AF and P-DAPT score, with score ≥ 25 defined as high risk. The primary outcome was all-cause mortality. The secondary outcomes evaluated were hospitalization and major bleeding. In the unadjusted analyses, a P-DAPT score ≥ 25, in both AF and non-AF population, was associated with increased mortality, hospitalization, and bleeding. After adjusting for baseline covariates, no significant differences in major bleeding risk were found across the four groups. However, a P-DAPT score of ≥25 in AF patients was associated with a higher risk for hospitalizations related to cardiovascular causes (HR: 2.15 95% CI 2.00-2.3, p < .0001). Among AF patients, P-DAPT score ≥ 25 was found to be strongly associated with mortality (HR 3.5; 95% CI 2.95-4.25, p < .0001) as compared with AF patients with score < 25 (HR 1.18, 95% CI 0.88-1.54, p=.26). In this large cohort of patients undergoing PCI, the P-DAPT score can help to identify patients at high risk for long-term mortality, particularly among those with atrial fibrillation.

Hemodynamic Response to Vasopressin Dosage of 0.03 Units/Min vs. 0.04 Units/Min in Patients With Septic Shock.

Arginine vasopressin (AVP) is suggested as an adjunct to norepinephrine in patients with septic shock. Guidelines recommend an AVP dosage up to 0.03 units/min, but 0.04 units/min is commonly used in practice based on initial studies. This study was designed to compare the incidence of hemodynamic response between initial fixed-dosage AVP 0.03 units/min and AVP 0.04 units/min. This retrospective, multi-hospital health system, cohort study included adult patients with septic shock receiving AVP as an adjunct to catecholamine vasopressors. Patients were excluded if they received an initial dosage other than 0.03 units/min or 0.04 units/min, or AVP was titrated within the first 6 hours of therapy. The primary outcome was hemodynamic response, defined as a mean arterial pressure ≥65 mm Hg and a decrease in catecholamine dosage at 6 hours after AVP initiation. Inverse probability of treatment weighting (IPTW) based on the propensity score for initial AVP dosage receipt was utilized to estimate adjusted exposure effects. Of the 1536 patients included in the observed data, there was a nearly even split between initial AVP dosage of 0.03 units/min (n = 842 [54.8%]) and 0.04 units/min (n = 694 [45.2%]). Observed patients receiving AVP 0.03 units/min were more frequently treated at the main campus academic medical center (96.3% vs. 52.2%, p < 0.01) and in a medical intensive care unit (87.4% vs. 39.8%, p < 0.01). The IPTW analysis included 1379 patients with achievement of baseline covariate balance. There was no evidence for a difference between groups in the incidence of hemodynamic response (0.03 units/min 50.0% vs. 0.04 units/min 53.1%, adjusted relative risk 1.06 [95% CI 0.94, 1.20]). Initial AVP dosing varied by hospital and unit type. Although commonly used, an initial AVP dosage of 0.04 units/min was not associated with a higher incidence of early hemodynamic response to AVP in patients with septic shock.

Peripheral arterial occlusion due to COVID-19: CT angiography findings of nine patients

BackgroundReports have indicated an association of large vessel peripheral arterial occlusion in the setting of Coronavirus Disease 2019 (COVID-19). While prior investigations have mostly focused on venous or cerebral arterial occlusions, we examined patients presenting exclusively with peripheral arterial extremity occlusions to investigate for any predisposing factors in this subset of COVID-19 patients. Materials and methodsThis is a retrospective study of COVID-19 patients with peripheral arterial occlusions presenting to a multi-hospital health care system in New York City between February 1st, 2020 and April 30th, 2020. Patient data and computed tomography angiography (CTA) exams in this subset were then collected and analyzed. ResultsFor the months of February, March, and April 2020, we identified 9 patients (ages 37–93 yrs) at our health care system who underwent extremity CTA for large vessel upper or lower extremity arterial occlusion and were diagnosed with COVID-19. Patient medical histories and clinical parameters were evaluated to identify common risk factors including obesity, hypertension, hyperlipidemia, and diabetes. Patients presented with increased inflammatory markers including ferritin, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) as well as increased D-dimer. ConclusionOur findings suggest patients with COVID-19 and comorbidities presenting with elevated inflammatory markers and D-dimer may be at increased risk of large vessel peripheral arterial occlusion.

Let Sleeping Patients Lie, avoiding unnecessary overnight vitals monitoring using a clinically based deep-learning model

Impaired sleep for hospital patients is an all too common reality. Sleep disruptions due to unnecessary overnight vital sign monitoring are associated with delirium, cognitive impairment, weakened immunity, hypertension, increased stress, and mortality. It is also one of the most common complaints of hospital patients while imposing additional burdens on healthcare providers. Previous efforts to forgo overnight vital sign measurements and improve patient sleep used providers’ subjective stability assessment or utilized an expanded, thus harder to retrieve, set of vitals and laboratory results to predict overnight clinical risk. Here, we present a model that incorporates past values of a small set of vital signs and predicts overnight stability for any given patient-night. Using data obtained from a multi-hospital health system between 2012 and 2019, a recurrent deep neural network was trained and evaluated using ~2.3 million admissions and 26 million vital sign assessments. The algorithm is agnostic to patient location, condition, and demographics, and relies only on sequences of five vital sign measurements, a calculated Modified Early Warning Score, and patient age. We achieved an area under the receiver operating characteristic curve of 0.966 (95% confidence interval [CI] 0.956–0.967) on the retrospective testing set, and 0.971 (95% CI 0.965–0.974) on the prospective set to predict overnight patient stability. The model enables safe avoidance of overnight monitoring for ~50% of patient-nights, while only misclassifying 2 out of 10,000 patient-nights as stable. Our approach is straightforward to deploy, only requires regularly obtained vital signs, and delivers easily actionable clinical predictions for a peaceful sleep in hospitals.

Type of Intensive Care Unit Matters: Variations in Palliative Care for Critically Ill Patients with Chronic, Life-Limiting Illness.

Background: It is not clear whether use of specialty palliative care consults and "comfort measures only" (CMO) order sets differ by type of intensive care unit (ICU). A better understanding of palliative care provided to these patients may help address heterogeneity of care across ICU types. Objectives: Examine utilization of specialty palliative care consultation and CMO order sets across several different ICU types in a multihospital academic health care system. Design: Retrospective cohort study using Washington State death certificates and data from the electronic health record. Setting/Subjects: Adults with a chronic medical illness who died in an ICU at one of two hospitals from July 2013 through December 2018. Five ICU types were identified by patient population and attending physician specialty. Measurements: Documentation of a specialty palliative care consult during a patient's terminal ICU stay and a CMO order set at time of death. Results: For 2706 eligible decedents, ICU type was significantly associated with odds of palliative care consultation (p < 0.001) as well as presence of CMO order set at time of death (p < 0.001). Compared with medical ICUs, odds of palliative care consultation were highest in the cardiothoracic ICU and trauma ICU. Odds of CMO order set in place at time of death were highest in the neurology/neurosurgical ICU. Conclusion: Utilization of specialty palliative care consultations and CMO order sets varies across types of ICUs. Examining this variability within institutions may provide an opportunity to improve end-of-life care for patients with chronic, life-limiting illnesses who die in the ICU.

Integration and Standardization of Clinical Nurse Specialists in a Multihospital System: Exemplars in Practice.

In 2013, our multihospital system began the process to integrate and standardize clinical nurse specialist (CNS) practice. The goal was to standardize work and to increase collaboration as part of one system. An overall job description was established to provide a framework inclusive of the broad areas of practice. Clinical nurse specialists were positioned to support medical-surgical, critical care, or women and children's services offered at community-based hospitals. Main campus and community-based CNSs led significant system integration efforts such as the standardization of nursing policies and procedures across the health system. System CNSs were created to address the needs of specialties common to all hospitals. As an example, a system CNS collaborated with the main campus and community-based CNSs to improve the delirium screening process. Clinical nurse specialists across the system have been integrated into a single team and report to 1 central director. Efforts to leverage expertise included the creation of a CNS-led practice council, increased communication via regular departmental meetings, and the sharing of resources using electronic platforms. There is now a CNS at hospitals that previously did not have one. The group values the structure and opportunities it provides as evidenced by favorable engagement surveys. Our integration efforts improved collaboration and could be modified to benefit other care settings.

Reflections on a Health System's Telemedicine Marathon.

The coronavirus disease 2019 (COVID-19) public health emergency necessitated changes in health care delivery that will have lasting implications. The University of Pennsylvania Health System is a large multihospital system with an academic medical center at its core. To continue to care for patients with and without COVID-19, the system had to rapidly deploy telemedicine. We describe the challenges faced with the existing telemedicine infrastructures, the central mechanisms created to facilitate the necessary conversions, and the workflow changes instituted to support both inpatient and outpatient activities for thousands of providers, many of whom had little or no experience with telemedicine. We also discuss innovations that occurred as a result of this transition and the future of telemedicine at our institution.