York Hospital Research Articles

Application of Community Detection Methods to Identify Emergency General Surgery–Specific Regional Networks

There is growing interest in developing coordinated regional systems for nontraumatic surgical emergencies; however, our understanding of existing emergency general surgery (EGS) care communities is limited. To apply network analysis methods to delineate EGS care regions and compare the performance of this method with the Dartmouth Health Referral Regions (HRRs). This cross-sectional study was conducted using the 2019 California and New York state emergency department and inpatient databases. Eligible participants included all adult patients with a nonelective admission for common EGS conditions. Interhospital transfers (IHTs) were identified by transfer indicators or temporally adjacent hospitalizations at 2 different facilities. Data analysis was conducted from January to May 2024. Admission for primary EGS diagnosis. Regional EGS networks (RENs) were delineated by modularity optimization (MO), a community detection method, and compared with the plurality-based Dartmouth HRRs. Geographic boundaries were compared through visualization of patient flows and associated health care regions. Spatial accuracy of the 2 methods was compared using 6 common network analysis measures: localization index (LI), market share index (MSI), net patient flow, connectivity, compactness, and modularity. A total of 1 244 868 participants (median [IQR] age, 55 [37-70 years]; 776 725 male [62.40%]) were admitted with a primary EGS diagnosis. In New York, there were 405 493 EGS encounters with 3212 IHTs (0.79%), and 9 RENs were detected using MO compared with 10 Dartmouth HRRs. In California, there were 839 375 encounters with 10 037 IHTs (1.20%), and 14 RENs were detected compared with 24 HRRs. The greatest discrepancy between REN and HRR boundaries was in rural regions where one REN often encompassed multiple HRRs. The MO method was significantly better than HRRs in identifying care networks that accurately captured patients living within the geographic region as indicated by the LI and MSI for New York (mean [SD] LI, 0.86 [1.00] for REN vs 0.74 [1.00] for HRR; mean [SD] MSI, 0.16 [0.13] for REN vs 0.32 [0.21] for HRR) and California (mean [SD] LI, 0.83 [1.00] for REN vs 0.74 [1.00] for HRR; mean [SD] MSI, 0.19 [0.14] for REN vs 0.39 [0.43] for HRR). Nearly 27% of New York hospitals (37 of 139 hospitals [26.62%]) and 15% of California hospitals (48 of 336 hospitals [14.29%]) were reclassified into a different community with the MO method. Development of optimal health delivery systems for EGS patients will require knowledge of care patterns specific to this population. The findings of this cross-sectional study suggest that network science methods, such as MO, offer opportunities to identify empirical EGS care regions that outperform HRRs and can be applied in the development of coordinated regional systems of care.

Evaluation of the Implementation of Low-Low Hospital Beds With Respect to Fall Frequency and Patient Harms: ARetrospective Analysis.

To identify whether the introduction of low-low hospital beds resulted in changes in the incidence, associated patient harms and event characteristics of bed-related falls where implemented. This retrospective quality improvement study covered 36 months: 18 months pre-intervention and 18 months post-intervention. Our analysis incorporated patient fall data from a hospital in upstate New York. Pre-/post-intervention data covered 18 months on either side of introduction at the units of implementation. Data were sourced from contemporaneously recorded incident reports and the organisation's business intelligence records. Analysis addressed the incidence rate, frequency, patient harm classification and recurrence of bed-related falls, as well as Morse Fall Scale risk classification, patient age, gender and other individualised risk factors. Lastly, we reviewed the presence of individualised interventions, staff assistance during the event, patient census and staffing ratios. Chi-square goodness of fit tests were employed to compare the distribution, and Brunner-Munzel tests the stochastic equality, of the pre- and post-implementation categorical and continuous data. There were no significant differences in the incidence rate of bed-related falls, patient harms or in the need for medical intervention following implementation of the low-low hospital beds. Neither were there any significant differences in the proportion of events resulting in detectable harm or the need for medical intervention post-implementation. The total number of bed-involved falls substantively increased following implementation of the low-low beds, as did the number of events resulting in detectable harms and medical intervention. Among these, substantive increases were noted among events resulting in minor temporary harm and patients referred for diagnostic imaging. The number of events involved patients experiencing recurrent falls of any kind increased significantly post-implementation. We found that the introduction of low-low hospital beds preceded no change in the incidence of bed-related falls, associated patient harms or the need for post-event medical intervention where implemented. While data limitations precluded definitive determination with respect to certain event characteristics, several post-implementation changes, including substantive increases in the number of falls occurring during ingress and egress, may suggest a potential for relationship worthy of future study. Low-low hospital beds are purported to help reduce the occurrence and severity of bed-related falls, both serious problems in inpatient settings. This study describes null outcomes following an implementation of such beds, with implications for adoption in similar settings. We adhered to the relevant Enhancing the Quality and Transparency of Health Research guidelines, specifically following the Standards for Quality Improvement Reporting Excellence standards. No patient or public involvement in the design or conduct of the study. Nurses and medical staff were involved in intervention implementation, data collection and the conception, design and conduct of the study.

Premorbid Incidence of Mental Health and Substance Abuse Disorders in Facial Trauma Patients

Study Design A retrospective study. Objective Facial trauma is a prevalent cause of morbidity and mortality with increasing incidence over recent decades. Few studies have examined the prevalence of mental health and substance abuse disorders at the time of diagnosis. Herein we investigate the psychosocial demographics associated with facial trauma. Methods The 2016 State Inpatient Database (SID) was used to identify patients with facial trauma from all hospitals in New York, Florida, and Maryland. A non-trauma control group undergoing elective same-day surgeries at ambulatory surgical centers in Florida, Kentucky, Nevada, North Carolina, New York, and Maryland was identified using the State Ambulatory Surgery and Services Database (SASD) from the Healthcare Cost and Utilization Project (HCUP). 777 patients were identified with facial trauma and compared to 500 patients without facial fractures. Results Patients with facial fractures were statistically significantly more likely to have a substance abuse disorder (OR 34.78, P < .001) or mental health disorder (OR 2.75, P < .001) compared to controls. Patients with facial fractures were significantly more likely to be black than white (OR 4.80, P < .001). Patients with facial fractures were significantly more likely to have Medicaid compared to Medicare (OR 2.12, P = .005). Conclusions Patients with facial fractures are more likely to have premorbid substance abuse and mental health disorders as compared to controls.

Assessing the Role of Flexible Sigmoidoscopy for Patients With Positive Fecal Immunochemical Test (FIT) and Rectal Bleeding as a Sole Symptom Within the Fast-Track Pathway.

Background Rectal bleeding is a frequent symptom, with causes ranging from benign conditions to serious diseases like colorectal cancer (CRC) and inflammatory bowel disease (IBD). In the UK, the two-week wait (2WW) referral pathway, which includes the fecal immunochemical test (FIT), plays a key role in triaging suspected CRC cases. This study evaluates the effectiveness of flexible sigmoidoscopy (FS) in detecting significant bowel pathologies (SBPs) in FIT-positive patients with isolated rectal bleeding. Methods We reviewed records of 344 patients with isolated rectal bleeding and a positive FIT result, referred to the 2WW pathway at York and Scarborough Teaching Hospitals NHS Foundation Trust from February to December 2023. All patients underwent colonoscopy. Findings from colonoscopy were used as a standard to compare with the expected reach of FS. Pathologies were categorized into SBPs (cancer, IBD, polyps ≥10 mm) and non-SBPs, and the location of SBPs in relation to the splenic flexure was also assessed. Results The average age of patients was 61.58 years. Significant bowel pathology (SBP) was identified in 89 of 344 (25.9%) patients, including 16 (18%) patients with cancer, 21 (23.6%) patients with IBD, and 52 (58.4%) patients with large polyps. All cases of cancer and IBD were found distal to the splenic flexure, while 21.1% (11/89) of large polyps were proximal. Higher FIT values (>100 µg Hb/g feces) and older age were significantly associated with SBPs. However, age and higher FIT values did not predict whether SBPs were proximal or distal. Conclusion For FIT-positive patients with isolated rectal bleeding, FS can serve as an effective initial diagnostic tool. Patients without detected cancer can be downgraded from the fast-track pathway to routine colonoscopy follow-up to avoid missing proximal premalignant lesions. This approach enhances resource utilization while ensuring comprehensive patient care. Further studies are needed to improve triage criteria and diagnostic accuracy within the 2WW pathway.

Application of sensory and motor training in AIDET communication mode in patients after knee arthroplasty.

Patients with knee arthroplasty often have problems such as slow recovery of knee function, which may cause negative emotions and affect their postoperative rehabilitation. The application of sensory and motor training in the Acknowledge, Introduce, Duration, Evaluation, Thank You (AIDET) communication mode in patients after knee arthroplasty can provide reference for the selection of postoperative rehabilitation training measures. To explore the sensory and motor training effects in AIDET communication mode on knee function recovery and resilience of patients after knee arthroplasty. One hundred patients who underwent knee arthroplasty at our hospital between January 2022 and January 2024 were randomly divided into two groups. The control group (n = 50) received routine rehabilitation training. In the observation group (n = 50), the AIDET communication mode was used to perform sensory and motor training, in addition to routine rehabilitation training. The rehabilitation training was administered for 8 weeks. After surgery, knee function, balance ability, walking ability, proprioception, and resilience were compared between the two groups. The New York Hospital for Special Surgery knee scores of the observation group at the time of discharge and 8 weeks after intervention were (65.23 ± 6.84, 84.53 ± 5.27), which was higher than those of the control group (61.03 ± 7.15, 74.92 ± 6.52) (P < 0.05). The balance ability of the observation group at the time of discharge and 8 weeks after the intervention was higher than that of the control group, the time of time up to go test was shorter than that of the control group, and proprioceptive function was higher than that of the control group (P < 0.05). The resilience level in the observation group after the intervention was higher than that in the control group (P < 0.05). Sensory and motor training in AIDET communication mode promotes knee function recovery of patients after knee arthroplasty, improves their limb walking ability and balance function, and increases their resilience level.

Improving Time to Antibiotics in Patients with Long Bone Open Fractures Presenting to the Pediatric Emergency Department.

To evaluate a new triage workflow aimed at improving time to intravenous antibiotics in open fractures to under 60 minutes of arrival to the Pediatric Emergency Department. Design: A prospective, multi-disciplinary, quality improvement project. A tertiary care, Level 1 Pediatric Trauma hospital in New York. Patients aged 17 and under with long bone open fractures between June 1, 2020 and May 31, 2021, excluding those transferred from an outside hospital, with non-long bone fractures and non-fractured, injured extremities.Outcome Measures and Comparisons: The new workflow involved splint removal and skin assessment during triage to identify open fractures. Serial Plan-Do-Study-Act (PDSA) cycles aimed to refine this workflow and reduce antibiotic administration time. Primary outcome: Percentage of open fracture patients receiving intravenous (IV) antibiotics within 60 minutes. Secondary outcome: Assessment of triage documentation regarding splint presence and removal. An exact Wilcoxon two-sample test compared time from patient arrival (quick-registration) to antibiotic administration before, during and after workflow implementation on 6/1/2020. A total of 51 patients (33 male) aged 17 and under, with open fractures were reviewed: 25 during the pre-intervention phase 1/1/18-5/31/20, 14 during the intervention phase 6/1/20-5/31/21, and 12 during the post-intervention phase 6/1/21-11/30/21. Continuous improvement efforts via PDSA cycles focusing on education, reinforcement, recognition, and barrier identification increased the percentage of patients receiving antibiotics within 60 minutes from 36% to 87.5%. Median time and Interquartile range (IQR: 25th percentile-75th percentile) from quick-registration to administration was 86 minutes (IQR: 51-147) before 6/1/2020, and 34 minutes (IQR: 16- 42) thereafter. The implemented triage workflow led to improved time to antibiotics to within 60 minutes for patients with long bone open fractures in the Pediatric Emergency Department. Level III. See Instructions for Authors for a complete description of levels of evidence.

Dr Catherine Chisholm, 'children's physician': Her work for child welfare and feminist networking in Manchester.

Catherine Chisholm BA MB ChB MD FRCP CBE (1879-1952) is celebrated as the first woman to qualify in medicine from Manchester University in 1904 and is remembered for founding the Manchester Babies Hospital in 1914 (later renamed in 1935 as the Duchess of York Hospital for Babies). She was indefatigable in her pursuit to improve the education and status of women doctors; the first woman member and president of the British Paediatric Society; first woman president of the Manchester Medical Society and was mainly responsible for establishing the Medical Women's Federation in 1917. Her career was a complex mixture of medical and social networks that linked her work as a children's physician to the Manchester Public Health Committee, Liberal politics and feminist groups. These networks played an important role in Dr Chisholm's successful career and are at the centre of this paper.

Universal clinical decision support tool for thromboprophylaxis in hospitalized COVID-19 patients: post hoc analysis of the IMPROVE-DD cluster randomized trial

BackgroundInpatient and extended postdischarge thromboprophylaxis of COVID-19 patients remains suboptimal despite antithrombotic guidelines. ObjectivesTo determine whether a novel electronic health record–agnostic clinical decision support (CDS) tool incorporating the International Medical Prevention Registry on Venous Thromboembolism plus D-dimer (IMPROVE-DD) venous thromboembolism (VTE) scores increases appropriate inpatient and extended postdischarge thromboprophylaxis and improves outcomes in COVID-19 inpatients. MethodsThis post hoc analysis of the IMPROVE-DD cluster randomized trial evaluated thromboprophylaxis CDS among COVID-19 inpatients at 4 New York hospitals between December 21, 2020, and January 21, 2022. Hospitals were randomized 1:1 to CDS (intervention, n = 2) vs no CDS (usual care, n = 2). The primary outcome was rate of appropriate thromboprophylaxis. Secondary outcomes included rates of major thromboembolism, all-cause and VTE-related readmissions and death, major bleeding (MB), and all-cause mortality 30 days after discharge. ResultsTwo thousand four hundred fifty-two COVID-19 inpatients were analyzed (CDS, 1355; no CDS, 1097). Mean age was 73.7 ± 9.37 years; 50.1% of participants were male. CDS adoption was 96.8% (intervention group). CDS was associated with increased appropriate at-discharge extended thromboprophylaxis (42.6% vs 28.8%; odds ratio [OR], 1.83; 95% CI, 1.39-2.41; P < .001). CDS was associated with reduced VTE (OR, 0.54; 95% CI, 0.39-0.75; P < .001), arterial thromboembolism (OR, 0.10; 95% CI, 0.01-0.81; P = .01), total thromboembolism (OR, 0.50; 95% CI, 0.36-0.69; P < .001), and 30-day all-cause readmission/death (OR, 0.78; 95% CI, 0.62-0.99; P = .04). There were no differences in MB, VTE-related readmissions/death, or all-cause mortality. ConclusionElectronic health record–agnostic CDS incorporating IMPROVE-DD VTE scores had high adoption, was associated with increased appropriate at-discharge extended thromboprophylaxis, and reduced thromboembolism and all-cause readmission/death without increasing MB in COVID-19 inpatients.

Addiction Consultation Services for Opioid Use Disorder Treatment Initiation and Engagement

Medications for opioid use disorder (MOUD) are highly effective, but only 22% of individuals in the US with opioid use disorder receive them. Hospitalization potentially provides an opportunity to initiate MOUD and link patients to ongoing treatment. To study the effectiveness of interprofessional hospital addiction consultation services in increasing MOUD treatment initiation and engagement. This pragmatic stepped-wedge cluster randomized implementation and effectiveness (hybrid type 1) trial was conducted in 6 public hospitals in New York, New York, and included 2315 adults with hospitalizations identified in Medicaid claims data between October 2017 and January 2021. Data analysis was conducted in December 2023. Hospitals were randomized to an intervention start date, and outcomes were compared during treatment as usual (TAU) and intervention conditions. Bayesian analysis accounted for the clustering of patients within hospitals and open cohort nature of the study. The addiction consultation service intervention was compared with TAU using posterior probabilities of model parameters from hierarchical logistic regression models that were adjusted for age, sex, and study period. Eligible participants had an admission or discharge diagnosis of opioid use disorder or opioid poisoning/adverse effects, were hospitalized at least 1 night in a medical/surgical inpatient unit, and were not receiving MOUD before hospitalization. Hospitals implemented an addiction consultation service that provided inpatient specialty care for substance use disorders. Consultation teams comprised a medical clinician, social worker or addiction counselor, and peer counselor. The dual primary outcomes were (1) MOUD treatment initiation during the first 14 days after hospital discharge and (2) MOUD engagement for the 30 days following initiation. Of 2315 adults, 628 (27.1%) were female, and the mean (SD) age was 47.0 (12.4) years. Initiation of MOUD was 11.0% in the Consult for Addiction Treatment and Care in Hospitals (CATCH) program vs 6.7% in TAU, engagement was 7.4% vs 5.3%, respectively, and continuation for 6 months was 3.2% vs 2.4%. Patients hospitalized during CATCH had 7.96 times higher odds of initiating MOUD (log-odds ratio, 2.07; 95% credible interval, 0.51-4.00) and 6.90 times higher odds of MOUD engagement (log-odds ratio, 1.93; 95% credible interval, 0.09-4.18). This randomized clinical trial found that interprofessional addiction consultation services significantly increased postdischarge MOUD initiation and engagement among patients with opioid use disorder. However, the observed rates of MOUD initiation and engagement were still low; further efforts are still needed to improve hospital-based and community-based services for MOUD treatment. ClinicalTrials.gov Identifier: NCT03611335.

Patient-Centered Outcomes of a Lymphedema Pump in Patients with Symptomatic Lower Extremity Edema

Phlebolymphedema is a challenging condition to manage, with limited options for effective treatment. For patients, this may be debilitating and lead to infection, loss of independence and affect quality of life. This study aims to evaluate patient-reported outcomes of an advanced pneumatic compression device (APCD) in the treatment of lower extremity phlebolymphedema. Patients with diagnosis of lower extremity phlebolymphedema at an acute care facility within the New York City Health and Hospitals Cooperation treated with the Flexitouch (FLX) (Tactile Systems Technology, Inc, Minneapolis, Minnesota) APCD from December 2021 to March 2023 were evaluated. Patient-perceived subjective outcomes were assessed via a short questionnaire, with subsequent analysis using chi-squared test. Primary end points were subjective improvements in 1) swelling, 2) pain, and 3) ease of use of device as surrogates for patient satisfaction. Secondary end point was subjective patient-reported compliance, obtained by investigating 1) if patients were trained to use device, and 2) if patients were using the device. A total of 52 participants were included in this study, consisting of 30.8% male and 69.2% female patients with a mean age of 71.7years. While selection criteria did not exclude unilateral disease or alternative etiologies, we note that the entire study population had been diagnosed with bilateral lower extremity lymphedema in the setting of chronic venous insufficiency. Other patient characteristics including race, comorbidities and smoking status were documented in Table1. Table2 demonstrates the results of chi-squared analysis. This study noted significant patient-perceived improvement in swelling and pain (91.4% with P<0.00001; 85.7% with P=0.00002 respectively) and patient-reported ease of use of the FLX device (85.7% with P=0.00002). Additional secondary findings included a majority of patients reporting being trained on how to use FLX and also maintaining compliance with the device (69.2% with P=0.005; 67.3% with P=0.012 respectively). FLX APCD use has been found to demonstrate desirable patient-reported outcomes as a general trend. The participants in this study noted statistically significant subjective improvement in swelling and pain, ease of use of device and adherence to training and compliance with device. FLX appears to be positively received by patients, and the authors recommend its consideration for management of bilateral lower extremity phlebolymphedema.

Burnout and psychological distress among Hispanic nurses across Illinois and New York hospitals: Implications for structural and person-centered solutions

BackgroundDespite high levels of burnout and psychological distress among nurses, few studies have evaluated these outcomes among Hispanic nurses. PurposeTo evaluate the differences in job-related and psychological well-being outcomes for Hispanic and non-Hispanic White nurses and the association of nurse work environments. MethodsCross-sectional analysis of the 2021 RN4CAST-New York-Illinois nurse survey. Multilevel logistic regression models examined the association between nurse ethnicity and job-related outcomes and psychological well-being. DiscussionOur sample included 798 (10.7%) Hispanic and 6,642 (89.3%) non-Hispanic White nurses in 249 hospitals. In unadjusted models, Hispanic ethnicity was associated with higher odds of burnout (odds ratio (OR) 1.21, 95% confidence interval (CI): 1.03–1.42), which diminished when considering the work environment (OR 1.16, 95% CI: 1.01–1.35) and nurse characteristics (i.e., age) (OR 1.01, 95% CI: 0.83–1.21). ConclusionEquity-driven solutions to support the well-being of Hispanic nurses should consider a focus on the needs of young Hispanic nurses and include increased support in work environments.

Hospital nurse staffing variation and Covid-19 deaths: A cross-sectional study

BackgroundDuring the Covid-19 pandemic, Covid-19 mortality varied depending on the hospital where patients were admitted, but it is unknown what aspects of hospitals were important for mitigating preventable deaths. ObjectiveTo determine whether hospital differences in pre-pandemic and during pandemic nursing resources—average patient-to-registered nurse (RN) staffing ratios, proportion of bachelor-qualified RNs, nurse work environments, Magnet recognition—explain differences in risk-adjusted Covid-19 mortality; and to estimate how many deaths may have been prevented if nurses were better resourced prior to and during the pandemic. MethodsThis is a cross-sectional study of 87,936 Medicare beneficiaries (65–99 years old) hospitalized with Covid-19 and discharged (or died) between April 1 and December 31, 2020, in 237 general acute care hospitals in New York and Illinois. Measures of hospital nursing resources (i.e. patient-to-RN staffing ratios, proportion of bachelor-qualified RNs, nurse work environments, Magnet recognition) in the pre-pandemic period (December 2019 to February 2020) and during (April to June 2021) were used to predict in-hospital and 30-day mortality using adjusted logistic regression models. ResultsThe mean age of patients was 78 years (8.6 SD); 51 % were male (n = 44,998). 23 % of patients admitted to the hospital with Covid-19 died during the hospitalization (n = 20,243); 31.5 % died within 30-days of admission (n = 27,719). Patients admitted with Covid-19 to hospitals with better nursing resources pre-pandemic and during the pandemic were statistically significantly less likely to die. For example, each additional patient in the average nurses' workload pre-pandemic was associated with 20 % higher odds of in-hospital mortality (OR 1.20, 95 % CI [1.12–1.28], p < 0.001) and 15 % higher odds of 30-day mortality (OR 1.15, 95 % CI [1.09–1.21], p < 0.001). Hospitals with greater proportions of BSN-qualified RNs, better quality nurse work environments, and Magnet recognition offered similar protective benefits to patients during the pandemic. If all hospitals in the study had superior nursing resources prior to or during the pandemic, models estimate many thousands of deaths among patients hospitalized with Covid-19 could have been avoided. ConclusionsPatients with Covid-19 admitted to hospitals with adequate numbers of RNs caring for patients, a workforce rich in BSN-qualified RNs, and high-quality nurse work environments (both prior to and during the Covid-19 pandemic) were more likely to survive the hospitalization. Bolstering these hospital nursing resources during ordinary times is necessary to ensure better patient outcomes and emergency-preparedness of hospitals for future public health emergencies.

Maternal Characteristics and Rates of Unexpected Complications in Term Newborns by Hospital

The Joint Commission Unexpected Complications in Term Newborns measure characterizes newborn morbidity potentially associated with quality of labor and delivery care. Infant exclusions isolate relatively low-risk births, but unexpected newborn complications (UNCs) are not adjusted for maternal factors that may be associated with outcomes independently of hospital quality. To investigate the association between maternal characteristics and hospital UNC rates. This cohort study was conducted using linked 2016 to 2018 New York City birth and hospital discharge datasets among 254 259 neonates at low risk (singleton, ≥37 weeks, birthweight ≥2500 g, and without preexisting fetal conditions) at 39 hospitals. Logistic regression was used to calculate unadjusted hospital-specific UNC rates and replicated analyses adjusting for maternal covariates. Hospitals were categorized into UNC quintiles; changes in quintile ranking with maternal adjustment were examined. Data analyses were performed from December 2022 to July 2023. UNCs were classified according to Joint Commission International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) criteria. Maternal preadmission comorbidities, obstetric factors, social characteristics, and hospital characteristics were ascertained. Among 254 259 singleton births at 37 weeks or later who were at low risk (125 245 female [49.3%] and 129 014 male [50.7%]; 71 768 births [28.2%] to Hispanic, 47 226 births [18.7%] to non-Hispanic Asian, 42 682 births [16.8%] to non-Hispanic Black, and 89 845 births [35.3%] to non-Hispanic White mothers and 2738 births [1.0%] to mothers with another race or ethnicity), 148 393 births (58.4%) were covered by Medicaid and 101 633 births (40.0%) were covered by commercial insurance. The 2016 to 2018 cumulative UNC incidence in New York City hospitals was 37.1 UNCs per 1000 births. Infants of mothers with preadmission risk factors had increased UNC risk; for example, among mothers with vs without preeclampsia, there were 104.4 and 35.8 UNCs per 1000 births, respectively. Among hospitals, unadjusted UNC rates ranged from 15.6 to 215.5 UNCs per 1000 births and adjusted UNC rates ranged from 15.6 to 194.0 UNCs per 1000 births (median [IQR] change from adjustment, 1.4 [-4.7 to 1.0] UNCs/1000 births). The median (IQR) change per 1000 births for adjusted vs unadjusted rates showed that hospitals with low (<601 deliveries/year; -2.8 [-7.0 to -1.6] UNCs) to medium (601 to <954 deliveries/year; -3.9 [-7.1 to -1.9] UNCs) delivery volume, public ownership (-3.6 [-6.2 to -2.3] UNCs), or high proportions of Medicaid-insured (eg, ≥90.72%; -3.7 [-5.3 to -1.9] UNCs), Black (eg, ≥32.83%; -5.3 [-9.1 to -2.2] UNCs), or Hispanic (eg, ≥6.25%; -3.7 [-5.3 to -1.9] UNCs) patients had significantly decreased UNC rates after adjustment, while rates increased or did not change in hospitals with the highest delivery volume, private ownership, or births to predominantly White or privately insured individuals. Among all 39 hospitals, 7 hospitals (17.9%) shifted 1 quintile comparing risk-adjusted with unadjusted quintile rankings. In this study, adjustment for maternal case mix was associated with small overall changes in hospital UNC rates. These changes were associated with performance assessment for some hospitals, and these results suggest that profiling on this measure should consider the implications of small changes in rates for hospitals with higher-risk obstetric populations.

Dr. Newton Shaffer (1846-1928): Renowned Orthopedic Surgeon and Founder of the American Orthopaedic Association.

An unsung hero of American orthopedic surgery is the largely forgotten Dr. Newton Melman Shaffer (1846-1928). Upon graduating from medical school at New York University, Shaffer began his career training at the Hospital for the Ruptured and Crippled in 1867. Shaffer then went on to practice at St. Luke's Hospital and New York Orthopaedic Dispensary and Hospital where he became chief. Here, Shaffer made major contributions to the field in treating clubfoot and tuberculosis. He then declared orthopedics as a separate entity from general surgery at the 10th International Medical Congress. He helped start the American Orthopaedic Association to push for the recognition of American orthopedics to the international community. In 1900, Shaffer opened the first state-run hospital for underprivileged children requiring rehabilitation. During his career, Shaffer advocated for conservative orthopedic treatments, aided in the invention of medical devices, contributed largely to academic orthopedics, and successfully advocated for the inception of the field of orthopedic surgery.

Telemedicine critical care availability and outcomes among mechanically ventilated patients

PurposeTelemedicine Critical Care (TCC) improves adherence to evidence based protocols associated with improved mortality among patients receiving invasive mechanical ventilation (IMV). We sought to evaluate the relationship between hospital availability of TCC and outcomes among patients receiving IMV. Materials and methodsWe performed a cross-sectional study of 66,522 adults who received IMV for non-postoperative acute respiratory failure at 318 non-federal hospitals in New York, Massachusetts, Maryland, and Florida in 2018. Hospital-level TCC availability was ascertained from the 2018 American Hospital Association Annual Survey. The primary outcome was in-hospital mortality. Secondary outcomes included the composite of tracheostomy or reintubation and duration of IMV. We used two-level hierarchical multivariable regression models to investigate the association between TCC availability and outcomes. Results20,270 (30.5%) patients were admitted into 89 TCC-available hospitals. There was no difference between TCC and non-TCC-available hospitals in mortality (odds ratio [OR] 0.94, 99% confidence interval [CI] 0.84–1.05), composite of tracheostomy or reintubation (OR 0.95 [0.82–1.11], or duration of IMV (OR 0.95 [0.83–1.09]). There was no difference in outcomes among the subgroup of patients with acute respiratory distress syndrome. ConclusionsHospital TCC availability was not associated with improved outcomes among patients receiving IMV.

Socioeconomic factors influence surgical wait times for non-emergent gynecologic surgical procedures: a retrospective analysis

BackgroundIn various disciplines, an association between surgical wait times and patient outcomes has been identified. This study is among the first to investigate whether practice setting influences wait times for elective surgeries in benign gynecology.MethodsThis retrospective study of patients at three New York hospitals from 10/2019–2/2020 compared surgical wait times among patients seen in federally-qualified health centers (FQHC’s) and private practice settings. Emergent surgeries, oncology cases, abortions, urogynecology procedures, and cases concurrently booked with another specialty were excluded. Surgical wait time was defined as the time (days) from the decision to operate to the day of the procedure. A multivariable mixed model was used to model surgical wait time by setting of care, adjusting for age, BMI, race, ethnicity, insurance, need for medical clearance, and scheduled block time. A univariable analysis was then utilized to assess surgical wait times by clinical setting for each insurance type.ResultsFive hundred forty patients were identified with a median age of 45.6 years (range 16–87). Average surgical wait time was 27 days (range 1–288 days). In multivariable analysis, longer surgical wait times were associated with being seen preoperatively in a FQHC compared to the private practice setting (102% longer, 59.5 days vs. 22 days, p < 0.0001), and with needing medical clearance (56.4% longer, 45 days vs. 22 days. p = 0.0001).ConclusionsThese results suggest that in benign gynecology, surgical wait times are significantly influenced by the practice setting in which a patient gets care, with notable delays in care among patients who are seen in a federally qualified health center preoperatively.

The Impact of Glycemic Control on Sodium-Glucose Co-Transporter 2 Inhibitor-Associated Genitourinary Infections.

Patients with type 2 diabetes (T2D) are at an increased risk of genital urinary (GU) infections, with the risk increasing with higher A1Cs. Given the broad adoption of sodium-glucose co-transporter 2 inhibitors (SGLT2is) in patients with T2D, both providers and patients need to be aware of common adverse effects associated with these medications, specifically GU infections. However trials involving SGLT2is looked at patients with an average A1C of less than 9%, and thus, the incidence of GU infections may not truly reflect the general diabetic population. The purpose of this study is to assess the association between GU infections in patients started on SGLT2is and A1C levels. A retrospective study was conducted on patients seen in an adult, primary care clinic, at New York City Health and Hospitals, South Brooklyn Health. Men and nonpregnant, nonlactating women >18 years old with a diagnosis of T2D who were initiated on an SGLT2i between January 2018 and January 2023 were included in the analysis. The primary endpoint is to compare the risk of GU infections in patients with T2D who were started on SGLT2is, regardless of dose, with hemoglobin A1C of >9% to those with hemoglobin A1C <9% at baseline. Three hundred and twenty-eight patients were eligible based on specified inclusion and exclusion criteria. Overall, there was a statistically significant difference in the number of GU infections that occurred in patients with a baseline A1C >9% compared with those with an A1C <9% (95% confidence interval [CI] = 1.05-2.88; P = 0.041). Type 2 diabetes patients initiated on SGLT2is may experience an increased risk of GU infection, especially in those patients with an A1C of 9% or greater. Further research is necessary to validate and expand upon these findings.

Differential Mortality Among Heart Failure Patients Across Different COVID-19 Surges in New York City.

Learning from the healthcare system's response to the COVID-19 pandemic is essential to better prepare for potential future crises. We sought to assess mortality rates for patients admitted for acute decompensated heart failure (HF) and to analyze which factors demonstrated a statistically significant correlation with this primary endpoint. We performed a retrospective analysis of patients hospitalized with a primary diagnosis of acute decompensated HF within the New York City Health and Hospitals 11-hospital system across the different COVID surge periods. Mortality information was collected in 4,405 participants (mean [SD] age 70.54 [14.44] years, 1885 [42.87%] female).The highest mortality existed in the first surge (9.02%), then improved to near prepandemic levels (3.65%) in the second (3.91%) and third surges (5.94%, p < 0.0001). In-hospital mortality inversely correlated with receipt of a COVID-19 vaccination, but had no correlation with left ventricular ejection fraction or the number of vaccination doses. Mortality for acute decompensated HF patients improved after the first surge, suggesting that hospitals adequately adapted to provide quality care. As future infectious outbreaks may occur, emergency preparedness must ensure that adequate focus and resources remain for other clinical entities, such as HF, to ensure optimal care is delivered across all areas of illness.

Investigating ethical tradeoffs in crisis standards of care through simulation of ventilator allocation protocols.

Arguments over the appropriate Crisis Standards of Care (CSC) for public health emergencies often assume that there is a tradeoff between saving the most lives, saving the most life-years, and preventing racial disparities. However, these assumptions have rarely been explored empirically. To quantitatively characterize possible ethical tradeoffs, we aimed to simulate the implementation of five proposed CSC protocols for rationing ventilators in the context of the COVID-19 pandemic. A Monte Carlo simulation was used to estimate the number of lives saved and life-years saved by implementing clinical acuity-, comorbidity- and age-based CSC protocols under different shortage conditions. This model was populated with patient data from 3707 adult admissions requiring ventilator support in a New York hospital system between April 2020 and May 2021. To estimate lives and life-years saved by each protocol, we determined survival to discharge and estimated remaining life expectancy for each admission. The simulation demonstrated stronger performance for age-sensitive protocols. For a capacity of 1 bed per 2 patients, ranking by age bands saves approximately 29 lives and 3400 life-years per thousand patients. Proposed protocols from New York and Maryland which allocated without considering age saved the fewest lives (~13.2 and 8.5 lives) and life-years (~416 and 420 years). Unlike other protocols, the New York and Maryland algorithms did not generate significant disparities in lives saved and life-years saved between White non-Hispanic, Black non-Hispanic, and Hispanic sub-populations. For all protocols, we observed a positive correlation between lives saved and life-years saved, but also between lives saved overall and inequality in the number of lives saved in different race and ethnicity sub-populations. While there is significant variance in the number of lives saved and life-years saved, we did not find a tradeoff between saving the most lives and saving the most life-years. Moreover, concerns about racial discrimination in triage protocols require thinking carefully about the tradeoff between enforcing equality of survival rates and maximizing the lives saved in each sub-population.

Longitudinal dynamic clinical phenotypes of in-hospital COVID-19 patients across three dominant virus variants in New York

BackgroundCOVID-19 is a challenging disease to characterize given its wide-ranging heterogeneous symptomatology. Several studies have attempted to extract clinical phenotypes but often relied on data from small patient cohorts, usually limited to only one viral variant and utilizing a static snapshot of patient data. ObjectiveThis study aimed to identify clinical phenotypes of hospitalized COVID-19 patients and investigate their longitudinal dynamics throughout the pandemic, with the goal to relate these phenotypes to clinical outcomes and treatment strategies. MethodsWe utilized routinely collected demographic and clinical data throughout the hospitalization of 38,077 patients admitted between 3/2020 to 5/2022, in 12 New York hospitals. Uniform Manifold Approximation and Projection and agglomerative hierarchical clustering were used to derive the clusters, followed by exploratory data analysis to compare the prevalence of comorbidities and treatments per cluster. Results4 distinct clinical phenotypes remained robust in multi-site validation and were associated with different mortality rates. The temporal progression of these phenotypes throughout the COVID-19 pandemic demonstrated increased variability across the waves of the three dominant viral variants (alpha, delta, omicron). Longitudinal analysis evaluating changes in clinical phenotypes of each patient throughout the course of a 4-week hospital stay exemplified the dynamic nature of the disease progression. Factors such as sex, race/ethnicity and specific treatment modalities revealed significant and clinically relevant differences between the observed phenotypes. ConclusionsOur proposed methodology has the potential of enabling clinicians and policy makers to draw evidence-based conclusions for guiding treatment modalities in a dynamic fashion.