Multisite Hospital Research Articles

Outcomes of patients with cancer cared for in a multisite home hospital program.

394 Background: Home hospital provides hospital-level care for acutely ill patients in their homes as a substitute for care in brick-and-mortar hospitals. Since the Centers for Medicare and Medicaid Services’ acute hospital care at home waiver in November 2020, 330 hospitals have received approval to launch home hospital programs. Prior research has shown that patients cared for in home hospital have improved physical activity, and lower mortality and readmission rates. However, many of these programs exclude patients with cancer, and data describing outcomes of patients with cancer cared for in home hospital programs are limited. Methods: We identified patients admitted to a multisite home hospital program affiliated with an urban health system between February 1, 2020 and May 1, 2024 who had a diagnosis of cancer (ICD-10: C00-C96) or myelodysplastic syndrome (ICD-10: D46) managed by an oncologist within the health system. For each admission we conducted chart reviews to determine whether the malignancy was active at the time of admission, defined by ongoing antineoplastic treatment or an admission directly related to the malignancy. We also captured the patient’s cancer diagnosis, the admission diagnosis, total length of stay, and length of time in home hospital. We identified readmissions within 30 days of discharge and escalations of care, defined as a return to a brick-and-mortar hospital for additional care spanning at least one midnight, and calculated rates of these outcomes. Results: There were 141 home hospital admissions among 128 patients with cancer diagnoses (mean age: 77, 36% female). The most common oncologic diagnoses were lymphoma (16%, N = 22), chronic leukemias and MDS (14%, N = 20), and lung cancer (13%, N = 18). Seventy-one patients (50%) had active cancer at the time of admission. The leading admission diagnoses were pneumonia (N = 28, 16%), heart failure exacerbations (N = 19, 13%), complicated urinary tract infections (N = 12, 9%) and soft tissue infections (N = 10, 7%). The mean total length of stay was 7.9 days (SD 5.6) and patients were admitted to home hospital for a mean of 4.9 days (SD: 3.5). Escalation rates and 30-day readmission rates were 7% (N = 10) and 13% (N = 19), respectively, among all patients, and 5% (N = 4) and 14% (N = 10) among patients with active malignancies. Conclusions: These data describe a cohort of patients with cancer cared for in a multisite home hospital program. They show low rates of transfer back to brick-and-mortar hospitals and low 30-day readmission rates, and they demonstrate that patients with cancer can be safely cared for in a home hospital. As home hospital programs build new capabilities, a larger proportion of oncology patients will be eligible for home hospital. More work is needed to estimate risk-adjusted outcomes among these populations and to understand the patient and caregiver experience with oncology home hospital.

Missed Follow-up is associated with worse survival in stage I lung cancer: results from a large multi-site academic hospital system

The purpose of this study is to examine the effect of early incomplete follow-up on overall survival among stage I lung cancer patients. Patients with clinical stage I lung cancer at our institution between 2007 and 2016 were identified (N = 1111). Exclusions included < 18 years of age (N = 2), missing stage or demographics (N = 56), incomplete appointment data or had only one scheduled appointment (N = 351), or did not survive for at least 1 year after diagnosis (N = 120). Missed appointments were defined as unattended follow-up appointments within the first year of diagnosis without an attended appointment in the subsequent 60 days. The primary outcome was the hazard ratio (HR) for death associated per 10% increase in missed oncology follow-up appointments. Univariable and descriptive statistics were performed, and a multivariable landmark Cox regression model was created to examine the effect of missed oncology follow-up on survival. A total of 582 patients were analyzed with median follow-up of 3.2 years and median age of 69 years. On multivariable analysis controlling for age, sex, race, insurance status, and definitive treatment type the HR for death was 1.44 (95% CI 1.05–1.97) for every 10% increase in missed appointments. Incomplete oncologic follow-up may negatively impact overall survival among survivors of early-stage lung cancer.

Understanding patient and family experiences of critical care in Bangladesh and India: What are the priority actions to promote person-centred care?

Patients' experiences in the intensive care unit (ICU) can enhance or impair their subsequent recovery. Improving patient and family experiences on the ICU is an important part of providing high quality care. There is little evidence to guide how to do this in a South Asian critical care context. This study addresses this gap by exploring the experiences of critically ill patients and their families in ICUs in Bangladesh and India. We elicit suggestions for improvements from patients, families and staff and highlight examples of practices that support person-centred care. This multi-site hospital ethnography was carried out in five ICUs in government hospitals in Bangladesh and India, selected using purposive sampling. Qualitative data were collected using non-participant observation and semi-structured interviews and analysed using reflexive thematic analysis. A total of 108 interviews were conducted with patients, families, and ICU staff. Over 1000 hours of observation were carried out across the five study sites. We identified important mediators of patient and family experience that span many different aspects of care. Factors that promote person-centred care include access to ICU for families, support for family involvement in care delivery, clear communication with patients and families, good symptom management for patients, support for rehabilitation, and measures to address the physical, environmental and financial needs of the family. This study has generated a list of recommendations that can be used by policy makers and practitioners who wish to implement person-centred principles in the ICU.

Risk Controls Identified in Action Plans Following Serious Incident Investigations in Secondary Care: A Qualitative Study.

The impact of incident investigations in improving patient safety may be linked to the quality of risk controls recommended in investigation reports. We aimed to identify the range and apparent strength of risk controls generated from investigations into serious incidents, map them against contributory factors identified in investigation reports, and characterize the nature of the risk controls proposed. We undertook a content analysis of 126 action plans of serious incident investigation reports from a multisite and multispeciality UK hospital over a 3-year period to identify the risk controls proposed. We coded each risk control against the contributory factor it aimed to address. Using a hierarchy of risk controls model, we assessed the strength of proposed risk controls. We used thematic analysis to characterize the nature of proposed risk controls. A substantial proportion (15%) of factors identified in investigation reports as contributing to serious incidents were not addressed by identifiable risk controls. Of the 822 proposed risk controls in action plans, most (74%) were assessed as weak, typically focusing on individualized interventions-even when the problems were organizational or systemic in character. The following 6 broad approaches to risk controls could be identified: improving individual or team performance; defining, standardizing, or reinforcing expected practice; improving the working environment; improving communication; process improvements; and disciplinary actions. The identified shortfalls in the quality of risk controls following serious incident investigations-including a 15% mismatch between contributory factors and aligned risk controls and 74% of proposed risk controls centering on weaker interventions-represent significant gaps in translating incident investigations into meaningful systemic improvements. Advancing the quality of risk controls after serious incident investigations will require involvement of human factors specialists in their design, a theory-of-change approach, evaluation, and curation and sharing of learning, all supported by a common framework.

Implementation of Agile in healthcare: methodology for a multisite home hospital accelerator

BackgroundThe diffusion of innovation in healthcare is sluggish. Evidence-based care models and interventions take years to reach patients. We believe the healthcare community could deliver innovation to the bedside faster...

Building large-scale registries from unstructured clinical notes using a low-resource natural language processing pipeline

Building clinical registries is an important step in clinical research and improvement of patient care quality. Natural Language Processing (NLP) methods have shown promising results in extracting valuable information from unstructured clinical notes. However, the structure and nature of clinical notes are very different from regular text that state-of-the-art NLP models are trained and tested on, and they have their own set of challenges. In this study, we propose Sentence Extractor with Keywords (SE-K), an efficient and interpretable classification approach for extracting information from clinical notes and show that it outperforms more computationally expensive methods in text classification. Following the Institutional Review Board (IRB) approval, we used SE-K and two embedding based NLP approaches (Sentence Extractor with Embeddings (SE-E) and Bidirectional Encoder Representations from Transformers (BERT)) to develop comprehensive registry of anterior cruciate ligament surgeries from 20 years of unstructured clinical data at a multi-site tertiary-care regional children's hospital. The low-resource approach (SE-K) had better performance (average AUROC of 0.94 ± 0.04) than the embedding-based approaches (SE-E: 0.93 ± 0.04 and BERT: 0.87 ± 0.09) for out of sample validation, in addition to minimum performance drop between test and out-of-sample validation. Moreover, the SE-K approach was at least six times faster (on CPU) than SE-E (on CPU) and BERT (on GPU) and provides interpretability. Our proposed approach, SE-K, can be effectively used to extract relevant variables from clinic notes to build large-scale registries, with consistently better performance compared to the more resource-intensive approaches (e.g., BERT). Such approaches can facilitate information extraction from unstructured notes for registry building, quality improvement and adverse event monitoring.

Implementation of large, multi-site hospital interventions: a realist evaluation of strategies for developing capability

BackgroundThis study presents guidelines for implementation distilled from the findings of a realist evaluation. The setting was local health districts in New South Wales, Australia that implemented three clinical improvement initiatives as part of a state-wide program. We focussed on implementation strategies designed to develop health professionals’ capability to deliver value-based care initiatives for multisite programs. Capability, which increases implementers’ ability to cope with unexpected scenarios is key to managing change.MethodsWe used a mixed methods realist evaluation which tested and refined program theories elucidating the complex dynamic between context (C), mechanism (M) and outcome (O) to determine what works, for whom, under what circumstances. Data was drawn from program documents, a realist synthesis, informal discussions with implementation designers, and interviews with 10 key informants (out of 37 identified) from seven sites. Data analysis employed a retroductive approach to interrogate the causal factors identified as contributors to outcomes.ResultsCMO statements were refined for four initial program theories: Making it Relevant– where participation in activities was increased when targeted to the needs of the staff; Investment in Quality Improvement– where engagement in capability development was enhanced when it was valued by all levels of the organisation; Turnover and Capability Loss– where the effects of staff turnover were mitigated; and Community-Wide Priority– where there was a strategy of spanning sites. From these data five guiding principles for implementers were distilled: (1) Involve all levels of the health system to effectively implement large-scale capability development, (2) Design capability development activities in a way that supports a learning culture, (3) Plan capability development activities with staff turnover in mind, (4) Increased capability should be distributed across teams to avoid bottlenecks in workflows and the risk of losing key staff, (5) Foster cross-site collaboration to focus effort, reduce variation in practice and promote greater cohesion in patient care.ConclusionsA key implementation strategy for interventions to standardise high quality practice is development of clinical capability. We illustrate how leadership support, attention to staff turnover patterns, and making activities relevant to current issues, can lead to an emergent learning culture.

Managing the COVID-19 Pandemic: Experience of Managers in Healthcare: A Narrative Inquiry.

The pandemic represented a challenge for hospital managers at different levels, required to reorganise services without compromising care. This study aimed to analyse the experiences of hospital managers during the COVID-19 pandemic. A narrative inquiry was conducted in a multisite acute hospital. Data were collected through narratives and open-ended questions. Direct and non-direct-care managers were invited to participate. Data were analyzed considering Clandinin & Connelly's (2000) framework and Braun & Clarke, (2006). Thirty-six narratives and open-ended question responses were analysed. Participants were nurses (n = 20), doctors, technicians, administrative and hospitality service managers. Themes were grouped into three narrative dimensions: (1) personal-"the emergency engulfed us", (2) practical/professional-"managing the pandemic", (3) social-"the strength of the team and people". Different narrative threads were identified between direct-care and non direct-care managers. Problems faced, factors helpful for management and suggestions for improvement were also reported. The pandemic had an important impact on managers and their roles, in terms of the need for clear concise information, staff support, and adequate professional and technical resources. A sense of unity and belonging facilitated management.

Exploring resilience among hospital workers: a Bayesian approach.

Healthcare professionals face significant workloads, as their roles are among the most demanding and stressful. Resilience serves as a crucial factor in helping them cope with the challenges encountered in their work environment and effectively manage stress. Assessing the level of resilience among healthcare workers and identifying potential variations across different groups is essential for effective public health management, preventing burnout, and ultimately enhancing patient care. To assess the resilience of various categories of workers operating within a tertiary care multisite hospital and understanding if there are any differences in resilience, based on their characteristics, the type of department they work in, and personality traits. This was a cross-sectional study conducted in January 2024 at EOC, a multi-site tertiary care hospital located in Southern Switzerland. 1,197 hospital workers answered an online survey which included: (1) an ad hoc questionnaire on personal and job characteristics, well-being-related activities, satisfaction level regarding communication, collaboration, support, and training opportunities in the workplace, (2) the Connor-Davidson Resilience Scale 10-Item on resilience, and (3) the Big Five Personality Inventory 10-item on personality traits. Proportion of resilient and highly resilient individuals within the various categories of workers were analyzed with Bayesian approach and Bayesian robust regression. Being part of the hospitality staff, working as a doctor, and having a male sex were associated to the highest scores of resilience. Surgery and emergency departments had the highest proportion of highly resilient individuals. Male sex, older age, seniority, higher hierarchical rank, engagement in physical activities, relaxation or mindfulness practices, religiosity, perception of good collaboration, communication, support, and physical activity correlated with higher resilience skills. This cross-sectional study found that physicians and hospitality staff within our multi-site Swiss hospital are more resilient compared to other categories of hospital workers, and among departments, those working in surgery and Emergency Medicine. Enhancing our comprehension of resilience is crucial for more precise management of healthcare systems and the development of employment policies aimed at sustaining the capacity of healthcare systems to serve patients effectively, while also mitigating shortages of healthcare professionals.

Patients with Sickle Cell Disease Can Demonstrate a Constellation of Symptoms Associated with Hyper-Hemolysis without Recent Transfusion

Background A hallmark characteristic in patients with Sickle Cell Disease (SCD) is chronic hemolysis, the severe exacerbation of which has been linked to RBC transfusion in some cases. This hyper-hemolysis (HH) is defined as a rapid decline of hemoglobin (Hb) and HbA% below pre-transfusion values. HH has been considered a severe form of antibody negative DHTR (Ab (-) DHTR) in patients with SCD and defined by the American Society of Hematology as hemolysis within 21 days of transfusion, negative DAT and absence of new alloantibody. Herein, we present a case series of 5 SCD patients with transfusion &amp;gt; 21 days from presentation demonstrating symptoms and lab findings consistent with HH. The purpose of this study is to characterize patients with SCD diagnosed with HH as a working diagnosis without temporal relation to transfusion. To our knowledge, this is the first and largest case series of its kind. Methods An IRB approved retrospective EMR review collected demographic and clinical data for patients with SCD admitted for concern for HH or DHTR to a large multi-site Pediatric Hospital in the Southeastern USA (2020-2023). All patients in this study were identified from Transfusion Medicine consults to investigate DHTR. Patient admission diagnosis was obtained from EMR review. Findings Cohort patients were 15-19 years with HbSS or HbS-beta thalassemia zero. All patients had transfusion &amp;gt;21 days from presentation. Of note, patient #5 received a transfusion during their first admission and was readmitted for signs and symptoms of HH/Ab (-) DHTR within 24hrs of discharge. All patients admitted for &amp;gt;1 day demonstrated an average 47% fall in hemoglobin (range: 24-69%), negative antibody screen/DAT, reticulocytopenia and mild to moderate thrombocytopenia. Four patients demonstrated elevated LDH. One patient died prior to discharge. Day of stay (DOS) of labs is in brackets []. Refer to table 1 for detailed patient data. Conclusion This case series demonstrates that patients with SCD can experience a constellation of symptoms identified in patients with HH without temporal relation to transfusion. These include hemolysis, reticulocytopenia, and thrombocytopenia as well as elevation of complement proteins. Given the overlap in presentation, HH in patients with SCD should be considered independently of proximity to transfusion for prompt diagnosis. Further study should include a retrospective review for further characterization. In addition, given the finding of elevations in C5a, further study into complement as a mechanism and target of therapy would be valuable.

Medical Specialty Interest Survey (MSIS): understanding career interest and specialty training in commencing Australian medical interns

AimTo assess specialisation interests in commencing interns and create a standardised survey to aid medical schools, supervisors and health services in quantifying, understanding and supporting medical career development to improve...

Real-world experience of an in-house dihydropyrimidine dehydrogenase (DPYD) genotype test to guide fluoropyrimidine (FP) dosing at a multisite cancer hospital.

1534 Background: FPs, including 5-fluorouracil and capecitabine, are widely used to treat solid tumor malignancies like gastrointestinal (GI) cancers. One-third of patients (pts) develop severe toxicities which may lead to treatment delays or hospitalization. Toxicities can be partly due to genetic variations in DPYD. Herein, we describe the implementation of an in-house DPYD test and its impact on FP dosing at a multisite cancer hospital. Methods: This is an observational study of pts starting or continuing FP-based chemotherapy who received DPYD testing as part of routine care. Buccal swabs were collected in clinic and sent to an in-house lab for genotyping using a polymerase chain reaction-based Drug Metabolizing Enzyme assay that interrogates all 5 variants with moderate-to-strong evidence according to the Clinical Pharmacogenetics Implementation Consortium (CPIC) (c.1905+1G&gt;A, c.2846A&gt;T, c.1679T&gt;G, c.1236G&gt;A and c.557A&gt;G). Phenotype translations and dosing were based on CPIC guidelines. Test results and dose recommendations were uploaded to the electronic medical record (EMR) and emailed to the care team. In April 2022, pre- and post-test EMR alerts were built to prompt test ordering and dose modifications. The primary objective was to evaluate the proportion of DPYD variant carriers in tested pts receiving FP. Secondarily, we evaluated turnaround time and impact on FP dosing. Results: From March 2020-December 2022, 491 pts across 14 clinics received DPYD genotyping (54% male, 74% White, 20% Black, median age 53 years). GI cancers (~50% colorectal) represented 90% of the diagnoses. The median lab turnaround time was 3 (IQR 2-6) days. Pretreatment testing was ordered in 389 (79%) pts, of which 360 (93%) had results before cycle 1. Overall, 30 pts (6.1%) were heterozygous carriers (4.9% in pretreatment and 10.8% in reactive testing groups). Variants observed were c.1236G&gt;A (n=13), c.2846A&gt;T (n=8), c.1905+1G&gt;A (*2A) (n=4), c.557A&gt;G (n=4), and c.1679T&gt;G (*13) (n=1). FP dose was modified in 27 (90%) pts (reduced in 25, avoided in 1, discontinued in 1). Of 19 carriers with pretreatment testing, 17 (90%) received an upfront dose reduction (mean reduction 42%; 3 had subsequent dose escalations); 1 avoided FP and 1 declined chemotherapy. Of 11 carriers with reactive testing, 9 had dose reductions (mean reduction 39%) and 2 discontinued FP due to toxicity. The mean FP dose intensity at cycle 1 was 56% in pretreatment carriers, 97% in reactive carriers, and 94% in wild type pts. Conclusions: DPYD genotype-guided FP dosing is feasible at a multisite cancer hospital. In-house rapid turnaround DPYD testing identified variant carriers and resulted in treatment/dose modifications for most carriers, potentially avoiding or mitigating severe toxicities and/or hospitalization, particularly with pretreatment testing. Toxicity evaluation is ongoing.

Guiding principles for effective collaborative implementation strategies for multisite hospital improvement initiatives: a mixed-method realist evaluation of collaborative strategies used in four multisite initiatives at public hospitals in New South Wales, Australia

ObjectiveLarge-scale, multisite hospital improvement initiatives can advance high-quality care for patients. Implementation support is key to adoption of change in this context. Strategies that foster collaboration within local teams, across...

Time savings from integrating discrete, genomic data into the electronic health record using the Epic Aura Network.

e13568 Background: The capability to deliver, order, and receive discrete genomics data from external pathology laboratories into the electronic health record (EHR) has improved dramatically. As opposed to unstructured PDF integrations, discrete genomic results allow physicians real-time receipt of results which may trigger rapid clinical actions and expedite patient care. However, these genomic integrations, traditionally point-to-point (P2P), can be time consuming. On the other hand, Epic’s order and results network (Aura) connects pathology labs directly to Epic, which has pre-existing connections to Epic EHR sites. This eliminates the need to create a new connection, and is designed to provide a faster and simpler approach. Tempus was the first vendor to use the Epic genomics module for delivery of discrete, somatic mutational data and now is also the first company to leverage Aura for this purpose. Here, we report on our early Aura integration experiences. Methods: Using the Tempus Database, we retrospectively analyzed medical systems that were all Epic customers and determined their EHR genomic integration time using Aura. Integration time was defined as the time between initial start date of creating “orderables” to time of site testing. The number of EHR medical center analysts was also quantified. We used our prior P2P EHR deployments as a historical control. Results: Six bidirectional Tempus genomic integrations using Aura were performed from July 2022 to December 2022. All medical centers were expansive, multisite hospital systems. Mean number of integrated departments per hospital was 249 (range: 19-699). In 17 P2P integrations prior to Aura, mean integration time was 6.7m (range: 4m-18m). In contrast, mean integration time using Aura over the 6 sites was 1.5m (range: 0.75m-2m), which is a 78% improvement. No correlation was noted between the integration time and number of EHR analysts staffed or departments integrated. The two slowest integration sites (2m and 2.5m) had competing EHR deployment priorities. Conclusions: Using Aura, the speed of Tempus EHR integration was improved by 78% for bidirectional, discrete genomic data. Dedicated EHR integration resourcing reduced deployment times to as low as 3 weeks. This reduction in integration time may further the adoption of genomic EHR integrations and improve patient care by expediting time to appropriate, targeted treatments.

"The Person Gets Lost in the Whole Process": Access to Physical Healthcare for Patients Hospitalized in a Psychiatric Hospital.

Background and Purpose: Persons living with mental illnesses have unmet physical healthcare needs, leading to premature death. When they attempt to access physical health services, they are faced with numerous barriers that lead to delays in care. Although mental health nurses are identified as being essential actors in helping persons with mental illnesses navigate the complexities of the healthcare system, they also engage in conduct that further stigmatizes them. To complicate matters more, mental health nurses themselves face stigmatization when they help their patients living with mental illnesses access physical healthcare services. The aim of the study was to explore mental health nurses' experiences of associative stigma when accessing physical health services for their patients. Methods: To achieve this aim, we used an interpretive phenomenology methodology and a theoretical framework rooted in Erving Goffman's notion of associative stigma. Specifically, we conducted six interviews with mental health nurses working at an urban multisite psychiatric hospital to elicit accounts of their experiences of associative stigma when seeking physical healthcare for their patients and the meanings they make of these. Results: The results presented in this article illustrate some of the mechanisms by which stigmatization toward persons living with mental illnesses and mental health nurses cause delays in physical healthcare accessibility. Implications for Practice: In our discussion, we highlight the implications of these results for the practice of nurses and propose two structural solutions to improve access to physical healthcare and reduce stigmatizing experiences.

Predictors of Patient-Related Cancellations and No-Shows for Pediatric Orthopaedics and Sports Medicine Appointments Are Condition Specific

Background: Visit cancellations have detrimental effects on patient health and reduce clinic productivity. We sought to understand the factors that influence cancellation rates across the major subspecialties in pediatric orthopaedics and sports medicine (OSM).Methods: In-person OSM visits from a high-volume multi-site academic pediatric hospital (01/01/2019-02/28/2020) were used to study the effect of patient demographics, distance to clinic, insurance type, visit type (new vs. follow-up) on visit cancellation (canceled by patient and no-shows). When available, chief complaint was used to categorize visits into major subspecialties: cerebral palsy, foot and ankle, hip, knee, other lower extremity, spine, and upper extremity. Logistic regression was used to identify contributors to the visit cancellations in a multivariate model.Results: 424,397 visits (15.9% canceled) were included in the analysis. Based on the multivariate analysis, being non-white (OR=1.139), Hispanic (OR=1.133), older age (OR=1.007), female (OR=1.046), living farther from clinic (OR=1.002), and having public insurance (OR=1.163) were associated with higher cancellations, whereas median household income (OR=0.994, per $10,000) and new visit (OR=0.969) were associated with lower cancellations (P<0.04). 241,305 visits were categorized into subspecialties. The effects of studied patient-related factors and visit types on cancellations were highly variable across subspecialties. When significant, having public insurance and living farther from the clinic were consistently associated with higher rates of cancellations, while being a non-English speaker and having a new visit were associated with lower rates of cancellation. The remaining factors showed variable effects.Conclusion: Disparities exist in patient-related visit cancellations in pediatric and young-adult OSM with different patterns across major OSM subspecialties. These findings highlight the importance of looking at these specific orthopedic conditions separately to develop more effective strategies to improve patient compliance and efficiently utilize healthcare resources.Level of Evidence: Level IIIKey Concepts•Across all pediatric and young-adult OSM visits, being non-white, Hispanic, female, living farther from clinic, and having public insurance were associated with higher odds of cancellation.•While disparities exist in patient-related visit OSM care, the factors that influence cancellation in specific subspecialties are varied and complex.•Further research that looks at specific orthopedic conditions separately will improve efficiency and effectiveness of care and increasing patient compliance.

Impacts of a dispersed unit structure on allied health professionals' experiences in an Australian public hospital setting.

The limited published evidence relating to the experiences and outcomes of a unit dispersement model is generally more negative than positive from an allied health perspective. The perceptions of allied health managers and leaders after the transition to a unit dispersement structure were explored in this study. The objectives were to review the impacts of this type of structure and the factors for health care organizations to consider before incorporating allied health professions into a clinical matrix structure. A qualitative study was conducted in a large regional multisite public hospital and health service located in Australia. Semistructured interviews and focus groups were conducted with 30 allied health frontline managers and leaders. Four negative impacts on the work experience of allied health professionals in a dispersement structure were identified through data analysis as: a negative impact on service delivery to patients, a detrimental effect on professional identity, reduced ability of allied health managers and leaders to do their role effectively, and a negative impact on morale, culture, and emotional well-being. Several key factors for public hospitals to consider before embarking on an organizational structure that includes allied health professionals were identified. The impacts of the unit dispersement structure on allied health professionals working within the organization under study were generally negative and did not deliver on the desired objectives. The findings reinforce the unique requirements pertaining to allied health professionals for optimal functioning. The learnings have implications for administrators in health care organizations embarking on organizational change that incorporates allied health professions in certain settings. The findings recommend that health care organizations consider several important factors before they introduce any structural change that would affect the delivery of allied health services.

The impact of COVID-19 vaccinations on stillbirth rates among pregnant women in the Metro-Detroit area

Infection by COVID-19 increases maternal morbidity and mortality prompting both the American College of Obstetrics and Gynecology and the Society of Maternal Fetal Medicine to strongly recommend vaccination during pregnancy. Limited data exist assessing the risk of intrauterine fetal death (IUFD) associated with COVID vaccination during pregnancy.This was a retrospective chart review at a large multisite hospital system in Metro Detroit which reviewed data from 13,368 pregnancies. We compared IUFD rates between vaccinated and unvaccinated patients. The rate of stillbirths among unvaccinated women (0.75%) was not statistically different from those who were vaccinated (0.60%). Individuals with government insurance were less likely to be vaccinated and more likely to have IUFD in comparison to patients with private insurance. The rate of stillbirths among Black women was significantly higher than among White women at a rate of 1.1% compared to 0.53% (p=0.008) with no difference in stillbirth rates among vaccinated vs unvaccinated racial distribution. Lastly, it is worth noting that the overall vaccination rate at our healthcare system in pregnancy was very poor (0.26%).In conclusion, this is a large population of highly diverse patients which indicates that COVID-19 vaccination does not lead to IUFD. We plan to use this data to help drive an educational vaccination campaign to try to increase our COVID-19 vaccination rate in our pregnant patients. Systemic racism and social determinants of health have played a large factor in COVID-19 outcomes, and our data highlights that this is the case for IUFD in Black women. Improvements must be made to identify barriers for these women to allow for better pregnancy outcomes. We acknowledge that individuals with government insurance may also have other barriers to healthcare or face healthcare inequity which leaves room for improvement on getting these individuals vaccinated and getting the resources they need to have better pregnancy outcomes.

Post–Acute Coronary Syndrome Disparities in Guideline-Directed Lipid Therapy and Insufficient Achievement of Optimal Low-Density Lipoprotein

Lipid-lowering therapies are an established cornerstone of secondary prevention. For patients with clinical atherosclerotic cardiovascular disease, guidelines provide a class I recommendation for high-intensity statins. Furthermore, patients with low-density lipoprotein cholesterol (LDL-c) levels >70mg/100ml are considered at a higher risk for recurrent cardiovascular events. Previous trends in guideline-directed lipid therapy (GDLT) for secondary prevention have noted insufficiencies. In this study, we aimed to explore GDLT-prescribing patterns and assess subsequent effects on outcomes through LDL-c reduction. We used a cross-sectional study across a large, multisite university hospital system. Electronic medical records were queried for all admitted patients diagnosed with acute coronary syndrome. Data were collected for age, gender, race, and prescribed lipid medication at discharge and 1 year after discharge. Chi-square analysis was performed to assess the statistical differences in prescription rates and achieved optimal LDL-c levels. A total of 3,386 patients were studied with 2/3 of the population identified as non-Hispanic White men. Men were prescribed GDLT at a statistically significant higher rate than women, and subsequently, men were found to achieve optimal LDL-c at a statistically significant higher rate. Interestingly, Black and Hispanic patients were prescribed GDLT at the highest rates; however, these patients achieved optimal LDL-c levels at the lowest rates (significance only met for Black patients). East Indian patients achieved optimal LDL-c levels at the lowest rate among all racial groups, despite having average GDLT prescription rates. White and Asian groups achieved optimal LDL-c levels at the highest rates, with average GDLT prescription rates. Among all patients, those who achieved LDL-c levels <70mg/100ml were prescribed GDLT at a statistically higher rate than those who did not achieve LDL- c levels <70mg/100ml. We found distinct disparities in both GDLT-prescribing rates and achievement of optimal LDL-c levels for patients presenting with clinical atherosclerotic cardiovascular disease. Our findings may help delineate patients who should be considered at a higher risk for recurrent major adverse cardiovascular events. We also found an interesting paradox between GDLT-prescribing patterns and achievement of optimal LDL-c levels among certain racial groups. However, among all patients who achieved LDL-c levels <70mg/100ml, the majority were prescribed GDLT, supporting the efficacy of statins. Prescribing GDLT does not reliably achieve optimal LDL-c levels across genders and racial groups for unclear reasons. Our study adds to the growing body of knowledge assessing the complexity in secondary cardiovascular prevention.

Low Molecular Weight Heparin Anti-Factor Xa Level Monitoring in a Healthcare System

Purpose: Low molecular weight heparin (LMWH) is widely used for the prevention and treatment of deep vein thrombosis and pulmonary embolism. Routine monitoring of therapeutic effects through anti-Xa levels is not recommended but may be beneficial in patients with altered pharmacokinetics including pregnancy, weight extremes, or renal impairment. Levels should be drawn approximately four hours after the third dose to measure peak anti-Xa activity after achieving steady state. Untimely monitoring results in excessive testing, increased laboratory costs, and unwarranted dose adjustments compromising patient safety and efficacy. The purpose of this performance improvement project was to evaluate the appropriateness of monitoring LMWH anti-Xa levels and identify opportunities to optimize ordering within a healthcare system. Methods: A random sample, retrospective chart review of patients at a multi-site hospital system over a 3 year period was conducted. Inclusion criteria were adult inpatients with at least one anti-Xa level ordered. Data collection included the anticoagulant agent, dose, indication, and administration time; indication for anti-Xa level monitoring, and anti-Xa sample collection time relative to the dose of the anticoagulant administered. Data was collected to assess if the dose was appropriately adjusted in patients who received an anticoagulant dose adjustment following anti-Xa level monitoring. Baseline characteristics collected included patient's creatinine clearance (CrCl), weight, and COVID-19 status. Primary outcomes of this study consisted of ordering trends for anti-Xa levels including indication and corresponding dose adjustments. Secondary outcomes included anti-Xa levels ordered at the appropriate time window and incidence of bleeding or thrombosis following inappropriate dose adjustments. Results: A total of 220 patients with anti-Xa level monitoring were reviewed. An appropriate indication for anti-Xa level monitoring was identified in 28% of patients. Of the 49 patients that warranted anticoagulant dose adjustments following anti-Xa levels, 45 patients (92%) received appropriate dose adjustments. Anti-Xa levels were drawn after the third therapeutic dose of LMWH in 146 patients and 84 of these patients had levels drawn 3-5 hours post-dose. Therefore, 54% of levels drawn were within the appropriate time frame. A total of 4 patients had documentation of bleeding and 1 patient had thrombosis following an inappropriate dose adjustment of LMWH. Conclusion: Appropriate anti-Xa level monitoring in patients with altered pharmacokinetics resulted in justified LMWH dose adjustments and ensured therapeutic concentrations were attained. In patients who received appropriate monitoring and subsequent dose adjustments, there were no adverse events noted. The results of this performance improvement project will be reviewed with pertinent stakeholders and a multi-disciplinary approach will be utilized to develop a protocol for LMWH anti-Xa level monitoring.