Tertiary Academic Medical Center Research Articles

Exploring lymphocyte subsets in COVID-19 patients: insights from a tertiary academic medical center with a high proportion of patients on immunosuppression

IntroductionSevere COVID-19 is associated with reduced absolute lymphocyte counts, suggesting that lymphocyte subsets may serve as predictors of clinical outcomes in affected patients. Early identification of patients at risk for severe disease is crucial for optimizing care, accurately informing patients and their families, guiding therapeutic interventions, and improving patient flow in the ED. Given that immunosuppressive drugs significantly impact lymphocyte profiles, we aimed to determine the association between prior use of immunosuppressive drugs, lymphocyte subsets, and COVID-19 severity in our population with a high prevalence of immunosuppression.MethodsIn 2021, suspected COVID-19 patients were included in the ED. Lymphocyte subsets were determined in peripheral blood within 24 hours after presentation and comparative analyses was performed between SARS-CoV-2 negative and positive patients, mild versus severe disease and patients with and without prior immunosuppressive drug use. Mild cases were patients discharged home or admitted to a general ward, severe cases were patients with COVID-19-related mortality or necessitating ICU admission. Logistic regression analysis was performed to assess the association between lymphocyte subsets and COVID-19 severity, and between prior immunosuppressive drug use and COVID-19 severity.ResultsTwenty-five SARS-CoV-2 negative and 77 SARS-CoV-2 positive patients were included, whereof 57 (74%) had mild and 20 (26%) severe COVID-19. No significant differences were observed in the absolute counts of CD3+, CD4+, and CD8+ T-lymphocytes, B-lymphocytes, and NK-cells between SARS-CoV-2 negative and positive patients or between mild and severe cases. The 36 patients with prior use of immunosuppressive drugs had significantly lower CD4+ T-lymphocytes (p<0.01). Prior use of immunosuppressive drugs was not associated with COVID-19 severity (adjusted OR 1.074, 0.355-3.194).ConclusionLymphocyte subsets were not significantly different between SARS-CoV-2 negative and positive patients and between mild versus severe cases. Neither lymphocyte subsets nor prior immunosuppressive drug use were associated with COVID-19 severity.

Sensitivity and Costs of Intraoperative Trans-Impedance Matrix Recordings, Spread of Excitation Functions, and X-ray Imaging in Detecting Cochlear Implant Tip Foldovers.

Evaluate the sensitivity and financial costs of Trans-Impedance Matrix recordings, Spread of Excitation functions, and x-rays in detecting cochlear implant tip foldovers. Tertiary academic medical center. 113 ears of 108 patients. Following cochlear implantation and before concluding surgery, intraoperative Trans-Impedance Matrix recordings, Spread of Excitation functions, and x-rays were conducted to evaluate presence of tip foldover. Presence of tip foldover; recording time necessary for and costs of Trans-Impedance Matrix, spread of excitation, and x-rays. There were six tip foldovers. Trans-Impedance Matrix showed 100% sensitivity, 100% specificity, 100% positive predictive value, and 100% negative predicative value in detecting tip foldovers. Spread of excitation showed 29% sensitivity, 99% specificity, 67% positive predictive value, and 95% negative predicative value. Trans-Impedance Matrix recordings were completed significantly faster than spread of excitation and x-rays. Elimination of x-rays from our intraoperative workflow results in a twofold cost reduction. Trans-Impedance Matrix recordings have potential great clinical utility in evaluating proper CI placement intraoperatively and reducing costs of surgery while not compromising patient care. Given the low tip foldover rate, a multicenter study is in progress to evaluate the sensitivity, specificity, positive predictive value, and negative predicative value of Trans-Impedance Matrix in a larger dataset. This can provide better guidance to cochlear implant clinics interested in evaluating the impact of using Trans-Impedance Matrix on patient care as well as the economics of reducing use of intraoperative imaging.

Early Hearing Outcomes and Audiological Experiences With a Novel Fully Implanted Cochlear Implant.

To review audiological experiences and early hearing outcomes from the early feasibility study of a fully implanted cochlear implant. Prospective cohort. Tertiary academic medical center. Three adults (two-male, one female) with bilateral sensorineural hearing loss. Implantation with a fully implanted cochlear implant as part of an early feasibility study. Postoperative unaided and aided pure-tone audiometry, tympanometry, mapping parameters, speech perception, battery life, and quality-of-life assessment. All patients in the early feasibility study of this fully implanted cochlear implant now use their devices regularly. Preoperative and postoperative audiometric measurements showed that their residual hearing in the implanted ear decreased slightly after surgery but was preserved. All patients had type A tympanograms after their transient middle ear effusion resolved. Electrical stimulation levels were comparable to those routinely used in traditional cochlear implants. Two of the three patients use a hearing aid in the implanted ear for additional gain and show significant improvement in speech perception since implantation. Average battery life before recharging is 4 days. All patients are regular users with two showing improvement in quality-of-life metrics after receiving the fully implanted cochlear implant. The patient experience and hearing outcomes from the early feasibility study of a novel fully implanted cochlear implant are detailed in this study and demonstrate ease of operation and daily use by all participants. All patients obtained hearing, but two of three use a hearing aid with their device to overcome unanticipated implant circuitry noise and achieve improved speech perception scores. Current work is focused on reducing this system noise to allow for the device to be used as intended, without a hearing aid.

Examining the impact of Anticholinergic Burden on Hospitalized Older People Receiving Concomitant Cholinesterase inhibitors.

Background: Cholinesterase (ChE) inhibitors enhance central cholinergic function and are considered as standard treatments to ameliorate symptoms relating to Alzheimer's disease. Though anticholinergic medications directly antagonize the effects of ChE inhibitors, they are commonly prescribed among hospitalized adults. Objective: To determine the impact of high anticholinergic burden (ACB) on length of stay (LOS) and 30-day readmission rates among hospitalized patients receiving concomitant ChE inhibitors. Methods: This was a retrospective cohort study conducted at a tertiary care academic medical center involving hospitalized patients on medical floors who received any Food and Drug Administration-approved ChE inhibitors during their hospital stay from October 1, 2022, to September 30, 2023. The primary outcome of the study was to compare hospital LOS among patients with high (ACB ≥ 3) versus low (ACB < 3) ACB. The secondary outcome was to assess the impact of ACB burden on 30-day readmission rates. Results: Among hospitalized adults, patients with high ACB exposure had a significantly longer hospital LOS (median: 5.50 vs 4.25 days; P < 0.001) than patients with low ACB exposure, after adjusting for covariates. Analysis of secondary outcome revealed that though the high ACB group had a higher 30-day readmission rate compared with the lower ACB group (6.8% vs. 2.2%), the difference was not statistically significant (OR = 3.46, 95% CI 0.85-14.08; P = 0.083). Conclusion: A high ACB exposure among older individuals taking concurrent ChE inhibitors is associated with a longer hospital stay.

Comparing Cochlear Implant Outcomes in 100 Patients With Sporadic Vestibular Schwannoma Managed With Observation, Radiosurgery, or Microsurgery: A Multi-Institutional Review.

To compare cochlear implant (CI) speech perception outcomes in patients with sporadic vestibular schwannoma (VS) managed with observation, radiosurgery, or microsurgery. Retrospective review. Eleven tertiary academic medical centers. One hundred patients with sporadic VS who received an ipsilateral CI. Ipsilateral cochlear implantation. Pure-tone thresholds, monosyllabic speech perception testing scores, and rates of open-set speech acquisition. Of the 100 patients studied, 54 underwent microsurgery, 26 underwent radiosurgery, 19 continued observation, and 1 underwent multimodal therapy. Among all patients, the median post-implantation pure-tone average was 31 dB (interquartile range [IQR] 25-39 dB) and the median monosyllabic speech perception score was 30% (IQR 0-60%) at a median of 12 months (IQR 5-25 months) post-implantation. Patients who were managed with microsurgery (median speech perception score 11%, IQR 0-52%) exhibited poorer implant outcomes overall compared with those managed with observation (median speech perception score 52%, IQR 40-72%) or radiosurgery (median speech perception score 30%, IQR 16-60%). Open-set speech perception was achieved in 61% of patients managed with microsurgery, 100% with observation, and 80% with radiosurgery. In a multivariable setting, those managed with observation (p = 0.02) or who underwent radiosurgery (p = 0.04) were significantly more likely to achieve open-set speech perception compared with patients who underwent microsurgery. Cochlear implants offer benefit in selected patients with sporadic VS. Although achieved in over half of people after microsurgery, open-set speech perception is more reliably attained in patients who are treated with observation or radiosurgery compared with microsurgical resection. These data may inform patient counseling and VS tumor management in people who may benefit from implantation.

Performance of Abbreviated Breast MRI in High-Risk Patients in a Tertiary Care Academic Medical Center.

The development of abbreviated breast MRI (AB-MRI) protocols reduce scan times. This paper reports the performance of AB-MRI at a tertiary care public academic medical center in comparison with established literature. This HIPAA-compliant IRB-approved retrospective study reviewed 413 AB-MRI screenings in high-risk patients from June 2020 to March 2023. Data were collected from 3 databases (MagView, Cerner PowerChart, and Prism Primordial). Demographics and overall BI-RADS assessment were recorded. For all positive (BI-RADS 0, 3, 4, 5) examinations, manual review of each case was performed. Performance metrics (sensitivity, specificity, cancer detection rate [CDR], recall rate, positive predictive value [PPV] 3 and negative predictive value [NPV]) were calculated. PubMed and Google Scholar were used to review similar AB-MRI studies to compare performance metrics. There were 413 AB-MRI examinations from 413 unique patients. The majority of cases were audit-negative BI-RADS 1 or 2 (83.8%, 346/413). There were 67 (16.2%, 67/413) audit-positive cases with 3.6% (15/413) BI-RADS 3, 10.9% (45/413) BI-RADS 4, 0.7% (3/413) BI-RADS 5, and 1.0% (4/413) BI-RADS 0. Performance metrics showed a sensitivity of 100.0% (95% CI, 63.1%-100.0%) and a specificity of 85.7% (95% CI, 81.9%-88.9%). The PPV3 was 14.3% (95% CI, 5.1%-23.5%), and the NPV was 100.0% (95% CI, 99.0%-100.0%). The CDR was 19.4 per 1000 screenings. The results are comparable to prior literature and benchmark data. This study demonstrates high sensitivity (100.0%) and NPV (100.0%) of AB-MRI with comparable specificity (85.7%) and CDR (19.4/1000) to the literature, adding support to the use of AB-MRI. Further research is needed to optimize AB-MRI protocols.

Abstract 4121624: Ambulatory Inotropic Support in Patients with Stage D Heart Failure Does Not Increase ICD Therapies

Background: Ambulatory inotropic infusions can be used as a palliative therapy (PT) or bridge to advanced therapies in end-stage heart failure (ESHF) patients, many of whom have implantable cardioverter defibrillators (ICDs). Research Questions: How often do patients receive ICD therapies after initiation of outpatient inotropic support and how often is defibrillation inactivated? Methods: We conducted a retrospective review of all patients discharged from an academic tertiary medical center with a new prescription for inotropic therapy between November 2017 and March 2023. Clinical data, Palliative Care consultation, and ICD interrogations before and after inotrope initiation were extracted from the electronic health record. Results: The cohort comprised 45 patients discharged on new inotropic support, including 22 (49%) with intent of PT and 23 (51%) as a bridge to advanced therapies (Figure). Among PT patients, 15 (68%) had an ICD in place with only 4 having ICD therapies deactivated at discharge. Only 2 additional PT patients had a documented discussion regarding ongoing ICD therapies. By 1 year, 4 (18%) PT patients were transitioned to hospice and 13 (59%) had died, with only 1 additional patient having ICD deactivation. Of 28 patients discharged on inotropic infusions with ICD therapies on (both PT and bridge patients), only 4 patients had ICD therapies turned off later and no ICD shocks were reported for the year following initiation of inotropic support. Conclusion: In a series of 45 patients initiated on inotropic support for PT or bridge to advanced therapies, the majority (77%) had an active ICD, but therapies were rarely delivered. Notably, there were very few documented discussions regarding ICD therapies in PT patients even with specialty Palliative Care consultation. In patients with ESHF initiated on inotropic support as PT, most patients chose to leave ICD therapies in place. For those patients, there was a low rate of ICD therapies delivered.

Abstract Su901: Association of Hemoglobin and Partial Pressure of Oxygen in Arterial Blood on Survival and Neurologic Outcomes in In-Hospital Cardiac Arrest Patients

Background: Lower hemoglobin levels have been associated with poor outcomes in patients with out-of-hospital cardiac arrests. Pre-arrest hemoglobin (within 24 hours) and its association with outcomes and PaO2 in in-hospital cardiac arrest (IHCA) remains unknown. We aimed to evaluate the association of pre-arrest hemoglobin levels with survival and neurologic outcomes, and intra-arrest PaO2 levels in adults with IHCA. Methods: The study population included adults with IHCA undergoing resuscitation at an academic tertiary medical center from 2011-2019. Hemoglobin levels were obtained within 24 hours prior to arrest, and PaO2 levels were obtained intra-arrest via arterial blood gas samples. Patients were classified based upon three pre-arrest hemoglobin (Hgb) levels: Hgb &lt; 8.5, Hgb 8.5-10.5, Hgb &gt; 10.5. Return of spontaneous circulation (ROSC), survival to discharge, favorable neurological outcome (defined as a Glasgow Outcome Score of 4-5), and association with PaO2 served as outcomes of interest. Results: Of the 799 patients studied, 493 patients had pre-arrest hemoglobin data and 164 had intra-arrest PaO2 data. Of those patients that had pre-arrest hemoglobin data, 145 (29.4%) had Hgb &lt; 8.5, 178 (36.1%) had Hgb 8.5-10.5, 170 (34.5%) had Hgb &gt;10.5. Charlson Comorbidity Score was similar across each hemoglobin group. Most patients had PEA/Asystole as the initial rhythm at onset of cardiac arrest, and the number was similar across each hemoglobin group. Mean intra-arrest PaO2 was higher in the Hgb &lt; 8.5 group. Compared to Hgb &lt; 8.5, higher hemoglobin levels were associated with higher rates of ROSC in both univariate (Hgb &lt; 8.5: 46.9% vs. Hgb 8.5-10.5: 59.6% vs. Hgb &gt; 10.5: 62.9%, p = 0.012) and multivariate (Hgb 8.5-10.5: OR 1.51, 95% CI 0.96-2.39; Hgb &gt; 10.5: OR 1.75, 95% CI 1.10-2.79) analyses. Higher hemoglobin levels were associated with higher rates of favorable neurologic outcome in the univariate analysis only (Hgb &lt; 8.5: 10.5% vs. Hgb 8.5-10.5: 11.8% vs. Hgb &gt; 10.5: 19.4%, p = 0.043). There was no significant correlation between pre-arrest hemoglobin and intra-arrest PaO2. Conclusions: In this contemporary registry of adults with IHCA, higher hemoglobin values were associated with higher rates of ROSC. There may be an association between higher hemoglobin levels and favorable neurologic outcome. There was no association between pre-arrest hemoglobin and intra-arrest PaO2.

Abstract 4127071: Pulmonary Artery Catheter Utilization in Cardiogenic Shock: Clinical Characteristics and Outcomes

Background: The pulmonary artery catheter (PAC) is used for hemodynamic monitoring, but its impact on patient outcomes, especially in cardiogenic shock (CS), is controversial. Several studies have shown no significant benefits and noted complications, leading to a decline in PAC use. However, PAC use appears to have increased recently in guiding management decisions in CS. Our study aims to assess the clinical characteristics and outcomes of CS patients receiving PACs versus not. Methods: We included patients with CS admitted to a tertiary academic medical center between May 2015 and December 2023. Variables were compared using Kruskal-Wallis, chi-squared, and Fisher's exact tests. Hemodynamic parameters were collected from either right heart catheterization or from a PAC. Endpoints included native heart survival to discharge, durable left ventricular assist device (LVAD) implantation, heart transplant (HTx), and 30-day and 1-year survival from discharge. Results: The study group consisted of 742 patients with CS. Of these, 385 (52%) received a PAC and 357 (48%) did not. The baseline characteristics of the two groups are shown in Table 1A . PAC patients had more severe shock, worse hemodynamics, and higher rates of temporary mechanical circulatory support (MCS) use. Hemodynamic measurements at shock onset differed, with PAC patients having higher right atrial pressures and lower cardiac index by Fick. Clinical outcomes and MCS related complications are shown in Table 1B. There was no significant difference in native heart survival at discharge, but HTx and durable LVAD implantation was higher in the PAC group. PAC placement was associated with longer hospital stays and more MCS related complications, including bleeding and hemolysis. The 30-day survival rate was similar between groups, and 1-year survival was marginally higher in the PAC group. Conclusion: PAC patients exhibited more severe clinical characteristics, longer hospital stays, higher rates of temporary MCS use and complications, durable LVAD implantation, and HTx. Short-term survival rates were similar, but 1-year survival was slightly better for PAC patients. Further studies are needed to provide clearer insights into PAC use in CS.

Intraoperative Acoustic Monitoring Using Threshold and Suprathreshold Pure Tone Audiometry during Cochlear Implantation Under Local Anesthesia: A Simple and Novel Method to Potentially Enhance Hearing Preservation Cochlear Implant Surgery.

To report the feasibility and potential utility of monitoring acoustic hearing on awake patients using intraoperative behavioral responses to threshold and suprathreshold stimuli while undergoing cochlear implantation (CI) under local anesthesia, without any form of sedation. Retrospective review of the first five cases performed by one surgeon. Tertiary care academic medical center. Adult patients with residual acoustic hearing undergoing CI. CI under local anesthesia, without any form of sedation. Procedural tolerance, reliability of intraoperative pure tone threshold and suprathreshold audiometry, and correlation of intraoperative findings with early postoperative residual hearing. Five ears in four patients underwent CI, including three males and one female, with a median age of 61 years. Intraoperatively, patients reported reliable behavioral responses to pure tone threshold and suprathreshold stimuli and provided real-time feedback on perceived stimulus change to the surgeon just prior to, during, and immediately following electrode insertion. All patients were able to complete the operation under local anesthesia. During electrode insertion, three cases reported no change and two cases reported diminished stimulus perception that reversed with limited electrode pull back near terminal insertion. Immediate postoperative audiograms demonstrated preservation of bone conduction thresholds within 10 dB of their preoperative baseline for all cases, suggesting hearing preservation. Three-month postoperative AzBio in quiet scores were available for two patients, measuring 45% and 94%, respectively. This report describes the feasibility of intraoperative behavioral audiometry during CI under local anesthesia, using patient feedback during electrode insertion to optimize hearing preservation surgery. Akin to other surgical subspecialties that use real-time patient feedback where objective intraoperative measures of neurofunction are imperfect, we demonstrate feasibility and potential utility of live acoustic monitoring during CI.

Prophylactic Swallowing Exercises in Patients with Laryngeal Cancer Who Underwent Total Laryngectomy-A Randomized Trial.

This study aims to determine the efficacy of prophylactic swallowing exercises on swallowing function in patients undergoing total laryngectomy for laryngeal cancer. The design was a randomized controlled trial set in one tertiary care academic medical center. A total of 92 patients undergoing total laryngectomy for stages III and IV laryngeal cancer performed five targeted swallowing exercises for a period of three months after their surgery, starting two weeks after the surgery. Weekly swallowing therapy sessions were held with the patients in order to encourage adherence and proper technique. The controls received no preventive exercise and were referred for swallowing treatment following the surgery, as well as radiation therapy if necessary. The Functional Oral Intake Scale (FOIS) and the Performance Status Scale for Head and Neck Cancer Patients (PSS-H&N) were used to measure swallowing function at the baseline, one week following the surgery, and three, six, nine, and twelve months following the surgery. Right after the surgery, there were no statistically significant variations between the intervention and control groups in the FOIS scores (p value = 0.64), the Eating in Public subscale scores (p value = 1) and Normalcy of Diet subscale scores (p = 0.33) of the PSS-H&N. The scores were significantly better among the intervention patients at months 3, 6, 9, and 12 for all the scores, with p values smaller than 0.000. Although not immediately following the surgery, the patients who engaged in prophylactic swallowing exercises showed improvements in their ability to swallow at 3, 6, 9, and 12 months following their procedure.

Identification of Risk Factors Associated with Early Discontinuation of Physical Therapy Following Shoulder Surgery.

Postoperative physical therapy (POPT) is a critical aspect of patient recovery following orthopedic shoulder surgery. Despite the importance of POPT, some patients do not complete their course of physical therapy, which can affect postoperative recovery and outcomes. This study aimed to identify risk factors that influence patient adherence and attendance of POPT. Patients >90 days postop from elective shoulder surgery were retrospectively recruited for this study from an urban, academic tertiary medical center. Patient charts were reviewed for demographic factors with eligible patients being contacted via telephone call to answer a questionnaire concerning their use of POPT. Inadequate levels of POPT were defined as stopping formal physical therapy earlier than the physical therapist recommended. Final analysis cohorts were compared using Fisher's Exact Test and Wilcoxon Rank Sum Test. A total of 104 patients were included in the final analysis with 84 completing POPT and 20 reporting having stopped therapy early. Patient medical history including elevated BMI (mean significance difference 3.8, [0.018 to 7.6 95% CI]) p=0.026)), being a smoker (p=0.027), having diabetes (p<0.001), and having Medicaid as their primary insurance (p=0.008) were significantly associated with stopping physical therapy earlier than recommended by the physical therapist (Table I). Demographic factors such as requiring additional assistance to get to medical appointments (p=0.012) and living farther away from a physical therapy center (p=0.007) were also substantially associated with a greater risk of stopping physical therapy earlier than recommended by the physical therapist (Table II). Elevated BMI, tobacco use, diabetes, Medicaid enrollment status, requiring additional assistance to get to PT appointments, and living farther away from their physical therapy center are risk factors associated with patients stopping PT after elective shoulder surgery earlier than recommended by a physical therapist. Knowledge of these patient-specific risk factors should be considered by orthopedic surgeons and physical therapists when tailoring a POPT protocol.

A Readmission Risk Assessment Tool Is Not Predictive of 90-Day Readmission After Total Joint Arthroplasty at an Urban Tertiary Referral Hospital.

Readmission within 90 days of total joint arthroplasty (TJA) via an emergency department (ED) encounter represents a significant economic burden to the healthcare system. We aimed to determine the utility of a previously described readmission risk assessment tool (RRAT) in predicting readmission after presentation to the ED within 90 days of primary TJA. At a single academic tertiary referral medical center, a retrospective chart review was used to collect demographic data, surgery type, medical history, reason for presentation in the ED, and ED disposition for the 1,576 patients who underwent TJA between April 1, 2016, and December 31, 2018. The RRAT score of patients was calculated and compared between patients who were discharged home versus readmitted to inpatient care. We identified 244 patients (328 encounters) who presented to the ED within 90 days of primary TJA, resulting in a 3.1% readmission rate. No statistical difference was found between the RRAT scores of readmitted and discharged patients (p=0.24). The most common reason for presentation to the ED for discharged patients was surgical site pain compared to medical concerns (cardiac, hematological, and renal concerns) in the readmitted group. Although the RRAT score alone is not predictive of readmission within 90 days of TJA, the reason for presentation to the ED between discharged and readmitted patients does differ. These results present an opportunity for orthopedic surgery providers to discuss with other providers ways to optimize postoperative pain management and decrease readmissions. This study underscores the need for improved postoperative pain and chronic condition management to reduce ED visits and readmissions and highlights the necessity for larger, multi-center studies to better assess the RRAT score's predictive value.

Effect of Dexmedetomidine on Rescue Analgesic Needs in Non-intubated Intensive Care Patients.

Dexmedetomidine is a centrally acting alpha-2-adrenoceptor agonist that is usually used in the intensive care unit (ICU) for its sedative, analgesic, and anxiolytic properties. Studies have shown that dexmedetomidine can be an effective adjunct analgesic, but they are limited and usually use a population of intubated patients. To better evaluate the role of dexmedetomidine use in the adult ICU, more information needs to be gathered on its analgesic effect and its utility in non-intubated patients. This study was a retrospective cohort analysis between adult non-intubated ICU patients on dexmedetomidine and non-intubated ICU patients not on dexmedetomidine who were admitted to a 302-bed tertiary academic medical center between October 1, 2022, and August 31, 2023. Inclusion criteria necessitated an as-needed opioid order with a corresponding pain score and at least 1 other pain assessment and no history of symptomatic bradycardia, nor could it be present on admission. The primary study objective was to assess the amount of morphine milligram equivalents (MMEs) received during ICU admission with concomitant dexmedetomidine infusion. Secondary outcomes included the time to first dose of rescue opioid analgesia and ICU length of stay. A total of 38 patients were included. Baseline demographics did not differ significantly between groups. There was a significant statistical difference in the total amount of MMEs received, with the dexmedetomidine group having significantly less than the control group (P < 0.001). The dexmedetomidine group also had a significantly longer time to first rescue analgesia dose (P = 0.025) and a significantly increased incidence of delirium (P < 0.001). There was no difference in other adverse events between groups. Dexmedetomidine significantly decreased MME requirements and increased time to first rescue analgesia dose in non-intubated ICU patients without increasing adverse effects but was associated with an increased incidence of delirium.

Validating a Pneumatic Tube System for Blood Product Delivery

Abstract Introduction/Objective Timely delivery of blood products can be of utmost importance to providing quality care. We aimed to validate the use of a high-speed pneumatic tube system (PTS) that was already installed at our hospital. By reducing delivery times, patient resuscitation and survivability can be increased. Methods/Case Report We followed the Association for the Advancement of Blood &amp; Biotherapies (AABB) guidelines to validate a PTS in a large tertiary academic medical center. The requirements include: verifying product suitability, ensuring product integrity, temperature monitoring, transportation time measurements, and proper packaging and tracking of product receipt. We validated the transfer of packed red blood cells (PRBC), plasma, platelets, and cryoprecipitate from the central blood transfusion services lab (BTS) to nursing stations in a separate building up to 1500 feet (&amp;gt;1/4 mile) away using a Swisslog Translogic® PTS Inclusion with foam inside the PTS carriers helped reduce bumps during transit and insulated products from heat. Results (if a Case Study enter NA) The mean temperature of the PRBC was 6.6 degrees Celsius and none exceeded the AABB maximum of 10 degrees Celsius. The mean time for blood products transit to the nursing stations was 3 minutes (m) and 33 seconds (s). The median time was 3m 31s, and it ranged from 2m 18s to 5m 38s. The PTS reduced delivery times of blood products by up to 10-12 minutes compared to manual porters. Conclusion Transporting blood products via PTS is an efficient method that reduces the required manpower and leads to better utilization of resources. However, it is essential to validate the PTS system before implementing it operationally.

Valves for the Voiceless: Time to Speaking Valve Use in Posttracheostomy Patients After Multidisciplinary Initiative.

To review speaking valve (SV) use at a tertiary academic medical center and determine whether a multidisciplinary team implementation of SV protocols increased SV use and decreased time to SV trials. Retrospective case series of patients who underwent a tracheostomy between 2017 and 2023 before and after the dissemination of new protocols from a new multidisciplinary tracheostomy care initiative in 2019. The calendar days between meeting SV eligibility criteria and initial trial of SV were compared. Eligibility criteria for SV was defined as any patient ≥48 hours posttracheotomy who can breathe unassisted, off mechanical ventilation, tolerate a deflated cuff, and participate in an evaluation. Interrupted time series analysis using segmented negative binomial regression assessed the change in time to SV placement before and after protocol implementation. A total of 421 patients were identified. After new protocols were disseminated, eligible patients with a SV trial increased from 75% to 95% with an increase in percentage of patients who tolerated the SV on their first attempt from 60% to 75%. Interrupted time series analysis demonstrated protocol implementation was associated with an overall 80% decrease in time to SV placement. Continued barriers to SV implementation such as elevated tracheal pressures due to large tracheostomy sizes, or inappropriately early consultations with patients unable to participate in SV exam, may be amenable to further institution-level quality improvement initiatives. A multidisciplinary initiative's dissemination of protocols with algorithms for SLP consultation and SV use can help standardize post-operative tracheostomy care.

Sex Differences in Obstructive Patterns on Drug-Induced Sleep Endoscopy.

To identify and characterize sex differences in collapse patterns on drug-induced sleep endoscopy (DISE) in patients with obstructive sleep apnea (OSA). Retrospective cohort analysis. An outpatient tertiary care academic medical center. A retrospective cohort study at a single tertiary care institution was performed from 2020 to 2023. All adult patients who underwent a DISE were included in this study. Univariate and multivariate analyses were used to compare differences between males and females on DISE. 117 patients who underwent DISE were included in this study, including 30% females (n = 35). The average age was 54.7 years (SD 15.2), mean BMI was 28.6 kg/m2 (SD 4.1), and mean apnea-hypopnea index (AHI) was 32.3 events per hour (SD 21.3). Most patients had severe OSA (48.7%). There was no difference in palatine or lingual tonsil size between sexes. On DISE, a significantly lower proportion of females demonstrated complete oropharyngeal lateral wall collapse (25.7% females vs 51.2% males, P = .008). Multivariate analysis revealed that male sex was independently associated with the presence of complete collapse at the oropharynx (odds ratio [OR] 2.55, 95% confidence interval [CI] [0.005-1.868], P = .048) but not at other levels. Additionally, higher BMI was associated with any collapse (partial or complete) at the oropharynx (OR 1.30, 95% CI [0.131-0.392], P < .001). This study demonstrates that a lower proportion of females have complete oropharyngeal lateral wall collapse even when controlling for BMI and AHI. Additional studies are needed to better understand the differences in OSA physiology between the sexes.

Implementing a letter template to expedite specialty medication appeal letter submission

BackgroundPrior authorizations (PAs) for biologic medications, used to treat inflammatory bowel disease (IBD), are often denied by pharmacy benefits managers and can require a complex appeal process for patients to gain access to medication. ObjectiveThis quality improvement project evaluated the impact of implementing a standardized appeal letter template and customizable clinical rationale letter content on specialty pharmacist workflow and workload in an integrated hospital health system specialty pharmacy (HSSP) IBD clinic. Practice descriptionThis initiative was conducted in an IBD outpatient clinic at a tertiary academic medical center with an integrated HSSP whose specialty pharmacists work collaboratively with providers to manage specialty medications. Practice innovationA letter template was created in the electronic health record (EHR) for pharmacists to use when submitting appeal letters. The template automatically populates patient results from recent labs, imaging, and clinic visit notes as part of the appeal documentation. Clinical rationale letter content was developed for the most common appeal reasons using EHR functionality that allows the creation of standardized notes that can be shared among team members and customized at time of use. Evaluation methodAn analysis of 2 months of data preimplementation/postimplementation was conducted using descriptive statistics to report the number of appeals submitted, time from PA denial to appeal submission, and appeal approval rate. A pharmacist postimplementation satisfaction score was also collected. ResultsThe number of appeals submitted preimplementation (n = 73) and postimplementation (n = 73) was the same. Postimplementation, 89% of appeals were submitted within 3 days of PA denial compared to 29% preimplementation. PA approval rate was high (93%) preimplementation and postimplementation. Overall pharmacist satisfaction was 9.7 out of 10. ConclusionImplementation of an appeal letter template and standardized clinical rationale letter content in the EHR led to decreased time to appeal submission and high specialty pharmacist satisfaction.

Rethinking Surgical Safety: Investigating the Impact of Gamified Training on Severe Flow Disruptions in Surgery.

There is a need for effective and engaging training methods to enhance technical and nontechnical skills in robotic-assisted surgery (RAS), where deficiencies can compromise safety and efficiency. This study aims to evaluate the impact of a gamified team training intervention, the "RAS Olympics," on the safety and efficiency of RAS procedures. The study was conducted at a 958-bed tertiary care academic medical center in with a robust robotic surgery program. A total of 56 RAS procedures (general, urology, and gynecology) were included in the analysis, with a mix of procedure types representative of the surgical caseload at the medical center. A pretest posttest experimental design was employed, comparing the frequency and severity of flow disruptions (FD) between preintervention, postintervention without "RAS Olympics" participants, and postintervention with "RAS Olympics" participants. The "RAS Olympics" involved safety hazard identification, troubleshooting, workspace navigation, instrument retrieval, and turnover optimization. Postintervention cases with "RAS Olympics" participants exhibited significantly lower overall FDs compared to the postintervention control group. The reduction was particularly notable during phase 3 (surgeon on console) and in cases involving more severe FDs. Gamified team training interventions may improve the safety and efficiency of RAS procedures. The positive outcomes underscore the potential of innovative and engaging training methods to address the evolving challenges in surgical practice, emphasizing the relevance of gamification in healthcare education. As the healthcare landscape continues to advance, incorporating such interventions may be crucial in ensuring the adaptability and competence of surgical teams.

Special Issue on Informatics Education A Longitudinal Graduate Medical Education Curriculum in Clinical Informatics: Function, Structure, and Evaluation.

There is a need to integrate informatics education into medical training programs given the rise in demand for health informaticians and the call on the Accreditation Council for Graduate Medical Education (ACGME) and the body of undergraduate medical education (UGME) for implementation of informatics curricula. This report outlines a 2-year longitudinal informatics curriculum now currently in its seventh year of implementation. This report is intended to inform United States (US) Graduate Medical Education (GME) program leaders of the necessary requirements for implementation of a similar program at their institution. The curriculum aligns with the core content for the subspecialty of clinical informatics (CI) and is led by a multidisciplinary team with both informatics and clinical expertise. This educational pathway has a low direct cost and is a practical example of the academic learning health system (aLHS) in action. The pathway is housed within an internal medicine department at a large tertiary academic medical center. The curriculum has yielded 13 graduates from both internal medicine (11, 85%) and pediatrics (2, 15%) whose projects have spanned acute and ambulatory care and multiple specialties. Projects have included Clinical Decision Support (CDS) tools, of which some will be leveraged as substrate in applications seeking extramural funding. Graduates have gone on to CI board certification and fellowship, as well as several other specialties, creating a distributed network of clinicians with specialized experience in applied CI. An informatics curriculum at the GME level may increase matriculation to CI fellowship and more broadly increase development of the CI workforce through building a cadre of physicians with HIT expertise across specialties without formal CI board certification. We offer an example of a longitudinal pathway which is rooted in aLHS principles. The pathway requires a dedicated multidisciplinary team and departmental and IT leadership support.