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The role of early Do Not Resuscitate (DNR) in hospitalized older adults (OAs) with SARS-CoV-2 infection is unknown. The objective of the study was to identify characteristics and outcomes associated with early DNR in hospitalized OAs with SARS-CoV-2. We conducted a retrospective chart review of older adults (65+) hospitalized with COVID-19 in New York, USA, between March 1, 2020, and April 20, 2020. Patient characteristics and hospital outcomes were collected. Early DNR (within 24 hours of admission) was compared to non-early DNR (late DNR, after 24 hours of admission, or no DNR). Outcomes included hospital morbidity and mortality. Of 4961 patients, early DNR prevalence was 5.7% (n = 283). Compared to non-early DNR, the early DNR group was older (85.0 vs 76.8, P < .001), women (51.2% vs 43.6%, P = .012), with higher comorbidity index (3.88 vs 3.36, P < .001), facility-based (49.1% vs 19.1%, P < .001), with dementia (13.3% vs 4.6%, P < .001), and severely ill on presentation (57.9% vs 32.3%, P < .001). In multivariable analyses, the early DNR group had higher mortality risk (OR: 2.94, 95% CI: 2.10–4.11), less hospital delirium (OR: 0.55, 95% CI: 0.40–.77), lower use of invasive mechanical ventilation (IMV, OR: 0.37, 95% CI: .21–.67), and shorter length of stay (LOS, 4.8 vs 10.3 days, P < .001), compared to non-early DNR. Regarding early vs late DNR, while there was no difference in mortality (OR: 1.12, 95% CI: 0.85–1.62), the early DNR group experienced less delirium (OR: 0.55, 95% CI: .40–.75), IMV (OR: 0.53, 95% CI: 0.29–.96), and shorter LOS (4.82 vs 10.63 days, OR: 0.35, 95% CI: 0.30–.41). In conclusion, early DNR prevalence in hospitalized OAs with COVID-19 was low, and compared to non-early DNR is associated with higher mortality but lower morbidity.

Purpose: Oropharyngeal dysphagia (OD) affects nearly 90% of hospitalized persons with dementia. Yet, little is known about the care partner experience. The purpose of our study was to describe the experience of care partners related to OD management in patients with dementia as they transition from the hospital to the community setting. Method: Using a mixed-methods approach, we conducted telephone interviews with care partners of recently hospitalized older adults with dementia and OD. Interviews consisted of quantitative/qualitative assessments: communication with health care team, perception about risks/benefits of dysphagia diet, and informational needs. Descriptive statistics were used for quantitative data. For the qualitative data, transcripts were independently coded by research team and categorized into themes. Results: Of the care partners interviewed ( N = 24), mean age was 63.5 ( SD = 14.9), 62.5% were female, and 66.7% were White. Nearly 60% of patients had severe dementia, and 66.7% required feeding assistance. Care partners ( n = 18) reported moderate burden of 14.11 ( SD = 10.03). Most care partners (83.3%) first learned about OD during hospitalization. Only 29.2% of care partners reported that they discussed OD with a physician. Care partner perception of dysphagia diet risks/benefits ranged widely: 33.3% thought dysphagia diets would promote a more enjoyable existence. Over half (54.2%) of care partners indicated no choice regarding dysphagia diets was presented to them. Two thirds ( n = 16) of care partners were nonadherent to diet recommendations; the top reason ( n = 13%) was diet refusal by patients. Although 83.3% of care partners wanted additional information regarding dysphagia management, only 20.8% sought any. Conclusions: Our findings highlight that care partners of persons with dementia face significant OD-related communication and informational gaps, which may lead to elevated burden. Future studies are needed to address unmet OD-related care partner needs.

Chest radiographs (CXRs) are the most widely available radiographic imaging modality used to detect respiratory diseases that result in lung opacities. CXR reports often use non-standardized language that result in subjective, qualitative, and non-reproducible opacity estimates. Our goal was to develop a robust deep transfer learning framework and adapt it to estimate the degree of lung opacity from CXRs. Following CXR data selection based on exclusion criteria, segmentation schemes were used for ROI (Region Of Interest) extraction, and all combinations of segmentation, data balancing, and classification methods were tested to pick the top performing models. Multifold cross validation was used to determine the best model from the initial selected top models, based on appropriate performance metrics, as well as a novel Macro-Averaged Heatmap Concordance Score (MA HCS). Performance of the best model is compared against that of expert physician annotators, and heatmaps were produced. Finally, model performance sensitivity analysis across patient populations of interest was performed. The proposed framework was adapted to the specific use case of estimation of degree of CXR lung opacity using ordinal multiclass classification. Acquired between March 24, 2020, and May 22, 2020, 38,365 prospectively annotated CXRs from 17,418 patients were used. We tested three neural network architectures (ResNet-50, VGG-16, and ChexNet), three segmentation schemes (no segmentation, lung segmentation, and lateral segmentation based on spine detection), and three data balancing strategies (undersampling, double-stage sampling, and synthetic minority oversampling) using 38,079 CXR images for training, and validation with 286 images as the out-of-the-box dataset that underwent expert radiologist adjudication. Based on the results of these experiments, the ResNet-50 model with undersampling and no ROI segmentation is recommended for lung opacity classification, based on optimal values for the MAE metric and HCS (Heatmap Concordance Score). The degree of agreement between the opacity scores predicted by this model with respect to the two sets of radiologist scores (OR or Original Reader and OOBTR or Out Of Box Reader) in terms of performance metrics is superior to the inter-radiologist opacity score agreement.

The epidemiology of Behavioral and Psychological Symptoms of Dementia (BPSD) in hospitalized older adults with Alzheimer’s Disease (AD) and AD-related dementias (ADRD) has not been well-characterized. The purpose of this abstract is to examine the prevalence, patient-level factors and hospital outcomes associated with BPSD in hospitalized older adults with AD/ADRD. Data was extracted from the electronic health record (EHR) of older adults (aged 65+ years) with AD/ADRD, admitted to one of 7 hospitals in the greater New York metropolitan area during 2019. Three independent coders reviewed the EHR and recorded the presence or absence of the 11 domains of the Neuropsychiatric Inventory (NPI), a validated measure of BPSD. Of N = 1,865 hospitalized older adults with AD/ADRD, 1,564 had BPSD (prevalence = 83.9%). The most commonly reported BPSD were agitation (72.3%) and anxiety (17.7%). Older age (M = 84.6, SD = 7.6 versus M = 82.4, SD = 7.8, p = .000) and antipsychotic medication use prior to hospital admission (91% of the older adults who used home antipsychotics had BPSD, p = 000) was associated with BPSD. With regard to hospital outcomes, BPSD was associated with: increased mortality (of those who died, 90.6% had BPSD, p = .006), and increased likelihood of readmission to the hospital within 30 days of discharge (of those readmitted, 89.3% had BPSD, p = .007). Given its high prevalence and associated poor outcomes, recognizing and managing BPSD in hospitalized patients with AD/ADRD is critical to improving quality of care for this vulnerable population.

OBJECTIVE. Currently, chest radiography is the first-line imaging test for identifying pneumonia; chest CT is considered the reference standard. The purpose of this study was to calculate the statistical measures of performance of chest radiography for identifying pneumonia when taking into account uncertain results of both chest radiography and CT examinations. MATERIALS AND METHODS. Statistical measures of performance of chest radiography, using CT as the reference standard, were calculated with 95% CIs by varying uncertain radiology report impressions of both chest radiography and CT to all negative or all positive. The resulting scenarios were as follows: scenario 1, uncertain chest radiography and CT impressions are considered positive for pneumonia; scenario 2, uncertain chest radiography impressions are positive but uncertain CT impressions are negative; scenario 3, uncertain chest radiography impressions are negative and uncertain CT impressions are positive; scenario 4, uncertain chest radiography and CT impressions are negative; and scenario 5, uncertain chest radiography and CT impressions are excluded. RESULTS. A retrospective analysis of 2411 patient visits revealed the prevalence of uncertain radiology report impressions to be 31.8% for chest radiography and 21.7% for CT. Scenario 1 yielded the following performance values: sensitivity, 51.9%; specificity, 71.3%; PPV, 59.4%; and NPV, 64.5%. Scenario 2 produced the following performance values: sensitivity, 59.6%; specificity, 67.1%; PPV, 59.6%; and NPV, 67.1%. Scenario 3 showed the following performance values: sensitivity, 13.4%; specificity, 97.7%; PPV, 82.6%; and NPV, 58.1%. Scenario 4 yielded the following performance values: sensitivity, 19.6%; specificity, 96.4%; PPV, 81.6%; and NPV, 59.5%. Scenario 5 produced the following performance values: sensitivity, 32.7%; specificity, 96.8%; PPV, 89.2%; and NPV, 63.8%. CONCLUSION. Uncertain chest radiography results for the evaluation of pneumonia are prevalent. A chest radiography impression using the strongest language in support of a pneumonia diagnosis is useful to rule in pneumonia radiographically, but a negative result performs poorly at ruling out disease.

Background Age has been implicated as the main risk factor for COVID-19-related mortality. Our objective was to utilize administrative data to build an explanatory model accounting for geriatrics-focused indicators to predict mortality in hospitalized older adults with COVID-19. Methods Retrospective cohort study of adults age 65 and older (N = 4783) hospitalized with COVID-19 in the greater New York metropolitan area between 3/1/20-4/20/20. Data included patient demographics and clinical presentation. Stepwise logistic regression with Akaike Information Criterion minimization was used. Results The average age was 77.4 (SD = 8.4), 55.9% were male, 20.3% were African American, and 15.0% were Hispanic. In multivariable analysis, male sex (adjusted odds ration (adjOR) = 1.06, 95% CI:1.03-1.09); Asian race (adjOR = 1.08, CI:1.03-1.13); history of chronic kidney disease (adjOR = 1.05, CI:1.01-1.09) and interstitial lung disease (adjOR = 1.35, CI:1.28-1.42); low or normal body mass index (adjOR:1.03, CI:1.00-1.07); higher comorbidity index (adjOR = 1.01, CI:1.01-1.02); admission from a facility (adjOR = 1.14, CI:1.09-1.20); and mechanical ventilation (adjOR = 1.52, CI:1.43-1.62) were associated with mortality. While age was not an independent predictor of mortality, increasing age (centered at 65) interacted with hypertension (adjOR = 1.02, CI:0.98-1.07, reducing by a factor of 0.96 every 10 years); early Do-Not-Resuscitate (DNR, life-sustaining treatment preferences) (adjOR = 1.38, CI:1.22-1.57, reducing by a factor of 0.92 every 10 years); and severe illness on admission (at 65, adjOR = 1.47, CI:1.40-1.54, reducing by a factor of 0.96 every 10 years). Conclusion Our findings highlight that residence prior to admission, early DNR, and acute illness severity are important predictors of mortality in hospitalized older adults with COVID-19. Readily available administrative geriatrics-focused indicators that go beyond age can be utilized when considering prognosis.

Background: Understanding heterogeneity seen in patients with COVIDARDS and comparing to non-COVIDARDS may inform tailored treatments. Methods: A multidisciplinary team of frontline clinicians and data scientists worked to create the Northwell COVIDARDS dataset (NorthCARDS) leveraging over 11,542 COVID-19 hospital admissions. The data was then summarized to examine descriptive differences based on clinically meaningful categories of lung compliance, and to examine trends in oxygenation. Findings: Of the 1595 COVIDARDS patients in the NorthCARDS dataset, there were 538 (34·6%) who had very low lung compliance (2O), 982 (63·2%) with low-normal compliance (20-50ml/cmH2O), and 34 (2·2%) with high lung compliance (>50ml/cmH2O). The very low compliance group had double the median time to intubation compared to the low-normal group (107 hours (IQR 26·3, 238·3) vs. 37·9 hours (IQR 4·8, 90·7)). Overall, 67·5% (n=1049) of the patients died during the hospitalization. In comparison to non-COVIDARDS reports, there were less patients in the high compliance category (2.2%vs.12%, compliance ≥50mL/cmH20), and more patients with P/F ≤ 150 (57·8% vs. 45.6%). No correlation was apparent between lung compliance and P/F ratio. The Oxygenation Index was similar, (11·12(SD 5·67) vs.12·8(SD 10·8)).1

Dysphagia is prevalent in older adults with dementia, particularly in the acute care setting. The objective of this study was to use an innovative approach to extract a more representative sample of patients with dysphagia from the electronic health record (EHR) to determine patient characteristics, hospital practices, and outcomes associated with dysphagia in hospitalized persons with dementia.A retrospective study of hospitalized adults (aged ≥65 years) with dementia was conducted in 7 hospitals across the greater New York metropolitan area.Data were obtained from the inpatient EHR with the following inclusion criteria: age ≥65 years; admitted to one of 7 health system hospitals between January 1, 2019, and December 31, 2019; and documented past medical diagnosis of dementia (based on International Classification of Diseases, Ninth Revision).A diagnosis of dysphagia was defined as nurse documentation of a positive bedside swallow screening, nurse documentation of "difficulty swallowing" as reason for not performing bedside swallow screening, and physician documentation of a dysphagia diagnosis.Of adults with dementia (N = 8637), the average age was 84.5 years, 61.6% were female, and 18.1% were Black and 9.3% Hispanic. Dysphagia was identified in 41.8% (n = 3610). In multivariable models, dysphagia was associated with invasive mechanical ventilation [odds ratio (OR) 4.53, 95% CI 3.55-5.78], delirium (OR 1.53, 95% CI 1.40-1.68), increased length of stay (B = 3.29, 95% CI 2.98-3.60), and mortality (OR 4.44, 95% CI 3.54-5.55).Given its high prevalence, underrecognition, and associated poor outcomes, improving large-scale dysphagia identification can impact clinical care and advance research in hospitalized persons with dementia.

Background Literature indicates an atypical presentation of COVID-19 among older adults (OAs). Our purpose is to identify the frequency of atypical presentation and compare demographic and clinical factors, and short-term outcomes, between typical versus atypical presentations in OAs hospitalized with COVID-19 during the first surge of the pandemic. Methods Data from the inpatient electronic health record were extracted for patients aged 65 and older, admitted to our health systems’ hospitals with COVID-19 between March 1 and April 20, 2020. Presentation as reported by the OA or his/her representative is documented by the admitting professional and includes both symptoms and signs. Natural language processing was used to code the presence/absence of each symptom or sign. Typical presentation was defined as words indicating fever, cough, or shortness of breath; atypical presentation was defined as words indicating functional decline or altered mental status. Results Of 4 961 unique OAs, atypical presentation characterized by functional decline or altered mental status was present in 24.9% and 11.3%, respectively. Atypical presentation was associated with older age, female gender, Black race, non-Hispanic ethnicity, higher comorbidity index, and the presence of dementia and diabetes mellitus. Those who presented typically were 1.39 times more likely than those who presented atypically to receive intensive care unit–level care. Hospital outcomes of mortality, length of stay, and 30-day readmission were similar between OAs with typical versus atypical presentations. Conclusion Although atypical presentation in OAs is not associated with the same need for acute intervention as respiratory distress, it must not be dismissed.

Background: Age has been implicated as the main risk factor for COVID-19-related mortality. Our objective was to determine patient factors associated with mortality in hospitalized older adults with COVID-19. Methods: Retrospective cohort study of adults age 65+ (N=4,949) hospitalized with COVID-19 in the greater New York metropolitan area between 3/1/20-4/20/20. Data included patient demographics and clinical presentation. Multivariate logistic regression was used to evaluate associations. Results: Average age 77.3 (SD=8.4), 56.0% male, 20.8% African American, 15.1% Hispanic. In a multivariate analysis, male gender (OR=1.47), higher comorbidity index (OR=1.10), admission from a facility (lower baseline function; OR=1.71), early DNR (declining life-sustaining treatments, OR=2.45), and higher illness severity (higher MEWS, OR=6.26, and higher oxygen requirements, OR=15.00) were associated with mortality, while age was not (p = 0.22). Conclusion: Our findings highlight the need to look beyond age in hospitalized older adults with COVID-19 when considering prognosis and treatment decisions.

RationaleThe preliminary reports of COVID Acute Respiratory Distress Syndrome (COVIDARDS) suggest the existence of a subset of patients with higher lung compliance despite profound hypoxemia. Understanding heterogeneity seen in patients with COVIDARDS and comparing to non-COVIDARDS may inform tailored treatments.ObjectivesTo describe the trajectories of hypoxemia and respiratory compliance in COVIDARDS and associations with outcomes.MethodsA multidisciplinary team of frontline clinicians and data scientists created the Northwell COVIDARDS dataset (NorthCARDS) leveraging over 11,542 COVID-19 hospital admissions. Data was summarized to describe differences based on clinically meaningful categories of lung compliance, and compared to non-COVIDARDS reports. A sophisticated method of extrapolating PaO2 from SpO2, as well estimating FiO2 from non invasive oxygen delivery devices were utilized to create meaningful trends of derived PaO2 to FiO2 (P/F).Measurements and Main ResultsOf the 1595 COVIDARDS patients in the NorthCARDS dataset, there were 538 (34·6%) who had very low lung compliance (50ml/cmH2O). The very low compliance group had double the median time to intubation compared to the low-normal group (107 hours(IQR 26·3, 238·3) vs. 37·9 hours(IQR 4·8, 90·7)). Oxygenation trends have improved in all groups after a nadir immediately post intubation. The P/F ratio improved from a mean of 109 to 155, with the very low compliance group showing a smaller improvement compared to low compliance group. The derived P/F trends closely correlated with blood gas analysis driven P/F trends, except immediately post intubation were the trends diverge as illustrated in the image. Overall, 67·5% (n=1049) of the patients died during the hospitalization. In comparison to non-COVIDARDS reports, there were less patients in the high compliance category (2.2%vs.12%, compliance ≥50mL/cmH20), and more patients with P/F ≤ 150 (57·8% vs. 45.6%). No correlation was apparent between lung compliance and P/F ratio. The Oxygenation Index was similar, (11·12(SD 5·67)vs.12·8(SD 10·8)).ConclusionsHeterogeneity in lung compliance is seen in COVIDARDS, without apparent correlation to degree of hypoxemia. Notably, time to intubation was greater in the very low lung compliance category. Understanding ARDS patient heterogeneity must include consideration of treatment patterns in addition to trajectories of change in patient-level data and demographics.

Background The number of cases from the coronavirus disease 2019 (COVID-19) global pandemic has overwhelmed existing medical facilities and forced clinicians, patients, and families to make pivotal decisions with limited time and information. Main body While machine learning (ML) methods have been previously used to augment clinical decisions, there is now a demand for “Emergency ML.” Throughout the patient care pathway, there are opportunities for ML-supported decisions based on collected vitals, laboratory results, medication orders, and comorbidities. With rapidly growing datasets, there also remain important considerations when developing and validating ML models. Conclusion This perspective highlights the utility of evidence-based prediction tools in a number of clinical settings, and how similar models can be deployed during the COVID-19 pandemic to guide hospital frontlines and healthcare administrators to make informed decisions about patient care and managing hospital volume.

This study examined the prognostic value of the Charlson Comorbidity Index (CCI) in predicting short-term clinical outcomes in hospitalized older adults. We conducted a retrospective cohort study of patients, older than 75 years, admitted to the medicine service at a large tertiary hospital (New York). We used the Enhanced International Classification of Disease, 9th Revision, Clinical Modification adaptation to abstract the CCI from electronic medical records. The CCI scores were compared, using the standard Deyo version and the Schneeweiss version. Outcome measures included in-hospital mortality, length of stay (LOS), and 30-day readmissions. When comparing Charlson/Deyo and Charlson/Deyo/Schneeweiss with and without age, we found similar significant association with regard to in-hospital mortality, with a moderate predictive ability (area under the curve [AUC]: 0.5906-0.6433). However, for 30-day readmissions and LOS, the predictive ability was poor (AUC: 0.5598-0.6106 and ρ: 0.11-0.12, respectively). The CCI is, at most, a moderate predictor of in-hospital mortality and a poor predictor of other important healthcare outcomes relevant to administrative healthcare practices.

ObjectiveTo describe the pattern of hydroxychloroquine use and examine the association between hydroxychloroquine use and clinical outcomes arising from changes in the US Food and Drug Administration (FDA)’s recommendation during the coronavirus disease 2019 (COVID-19) pandemic.DesignA retrospective cross-sectional analysis.Setting and participantsWe included hospitalised adult patients at Northwell Health hospitals with confirmed COVID-19 infections between 1 March 2020 and 11 May 2020. We categorised changes in the FDA’s recommendation as pre-FDA approval (1 March 2020–27 March 2020), FDA approval (28 March 2020–23 April 2020), and FDA warning (24 April 2020–11 May 2020). The hydroxychloroquine-treated group received at least one dose within 48 hours of hospital admission.Primary outcomeA composite of intubation and inpatient death.ResultsThe percentages of patients who were treated with hydroxychloroquine were 192/2202 (8.7%) pre-FDA approval, 2902/6741 (43.0%) FDA approval, and 176/1066 (16.5%) FDA warning period (pConclusionsHydroxychloroquine use was associated with adverse clinical outcomes only during the pre-FDA approval period but not during the FDA approval and warning periods, even after adjusting for concurrent changes in the percentage of patients with COVID-19 treated with hydroxychloroquine and the number (and disease severity) of hospitalised patients with COVID-19 infections.

Older adults are disproportionately affected by the coronavirus (COVID-19) pandemic. While age has been used to guide resource allocation based on studies implicating age as the main risk factor for COVID-19-related mortality, most did not account for critical factors such as baseline functional and cognitive status, or life-sustaining treatment preferences. The objective of this study was to determine whether age is independently associated with mortality in older adults hospitalized with COVID-19. We conducted a retrospective cohort study of adults age 65+ with confirmed COVID-19 hospitalized in the greater NY metropolitan area between 3/1/20-4/20/20. Primary outcome was in-hospital mortality, with age as the primary predictor. Multivariate logistic regression was used to evaluate association between age and in-hospital mortality after controlling for demographics, severity of acute illness, comorbidities, and baseline function, cognition, and life-sustaining treatment preferences. 4,969 patients were included, average age 77.3, 56.0% male, 46.8% White, 20.8% African American, 15.1% Hispanic. Common comorbidities included hypertension (61.1%), and diabetes (36.8%); average number of comorbidities was 3.4 (SD 2.8) and 13.0% had dementia. 20.8% arrived from a facility and 5.7% had early do-not-resuscitate orders. On arrival, the Modified Early Warning System score was 4.2 (SD 1.7) and 79.6% required oxygen therapy. 35.3% of patients expired. In multivariate analysis, age was not independently associated with mortality (p = .173). Functional status, multi-morbidity, life-sustaining treatment preferences, and illness severity, not age, were associated with mortality among older adults hospitalized with COVID-19, suggesting age should not be used as the main indicator to guide resource allocation.

BACKGROUND Use of computed tomography pulmonary angiography (CTPA) in the assessment of pulmonary embolism (PE) has markedly increased over the past two decades. While this technology has improved the accuracy of radiological testing for PE, CTPA also carries the risk of substantial iatrogenic harm. Each CTPA carries a 14% risk of contrast-induced nephropathy and a lifetime malignancy risk that can be as high as 2.76%. The appropriate use of CTPA can be estimated by monitoring the CTPA yield, the percentage of tests positive for PE. This is the first study to propose and validate a computerized method for measuring the CTPA yield in the emergency department (ED). OBJECTIVE The objective of our study was to assess the validity of a novel computerized method of calculating the CTPA yield in the ED. METHODS The electronic health record databases at two tertiary care academic hospitals were queried for CTPA orders completed in the ED over 1-month periods. These visits were linked with an inpatient admission with a discharge diagnosis of PE based on the International Classification of Diseases codes. The computerized the CTPA yield was calculated as the number of CTPA orders with an associated inpatient discharge diagnosis of PE divided by the total number of orders for completed CTPA. This computerized method was then validated by 2 independent reviewers performing a manual chart review, which included reading the free-text radiology reports for each CTPA. RESULTS A total of 349 CTPA orders were completed during the 1-month periods at the two institutions. Of them, acute PE was diagnosed on CTPA in 28 studies, with a CTPA yield of 7.7%. The computerized method correctly identified 27 of 28 scans positive for PE. The one discordant scan was tied to a patient who was discharged directly from the ED and, as a result, never received an inpatient discharge diagnosis. CONCLUSIONS This is the first successful validation study of a computerized method for calculating the CTPA yield in the ED. This method for data extraction allows for an accurate determination of the CTPA yield and is more efficient than manual chart review. With this ability, health care systems can monitor the appropriate use of CTPA and the effect of interventions to reduce overuse and decrease preventable iatrogenic harm.

Venous thromboembolism (VTE) is a major cause of morbidity and mortality in the United States. Hospitalized, medically ill older adults have increased risk; despite guidelines, data suggest suboptimal pharmacologic prophylaxis rates. Factors influencing provider prescribing non-compliance are unclear. We aimed to describe VTE prophylaxis practices and identify risk factors for, and outcomes of, prescribing non-compliance. A retrospective study was conducted of hospitalized adults aged ≥ 75 years, admitted to the medicine service of a large academic tertiary center from May 1, 2014 to June 30, 2015. The primary outcome was non-compliance, defined as the absence of an order for VTE prophylaxis for the duration of hospitalization or an interruption of prophylaxis exceeding 24 h. Secondary measures included in-hospital mortality, length of stay (LOS), and 30-day readmissions. Of 3751 patients (mean age 84.7 years), 97.6% of charts had prophylaxis orders; 11.0% showed non-compliance. Pharmacologic prophylaxis was prescribed in 83.3% of patients and mechanical prophylaxis alone in 14.3%. Factors associated with non-compliance included: higher body mass index (BMI) (p = 0.04), myocardial infarction (p = 0.01), congestive heart failure (p = 0.001), metastatic tumor (p = 0.01). Low mobility was not significantly associated with compliance. Subcutaneous unfractionated heparin was associated with compliance (p

Aspiration pneumonia refers to an infection of the lung parenchyma in an individual that has inhaled a bolus of endogenous flora that overwhelms the natural defenses of the respiratory system. While there are not universally agreed upon criteria, the diagnosis can be made in patients with the appropriate risk factors and clinical scenario, in addition to a radiographic or an ultrasonographic image of pneumonia in the typical dependent lung segment. Treatment options for aspiration pneumonia vary based on the site of acquisition (community-acquired aspiration pneumonia [CAAP] versus healthcare-associated aspiration pneumonia [HCAAP]), the risk for multidrug-resistant (MDR) organisms, and severity of illness. Hospitalized CAAP patients without severe illness and with no risk for MDR organisms or Pseudomonas aeruginosa (PA) can be treated with standard inpatient community-acquired pneumonia therapy covering anaerobes. Patients with CAAP and either of the following-risk factors for MDR pathogens, septic shock, need for an intensive care unit (ICU) admission, or mechanical ventilation-can be considered for broader coverage against anaerobes, methicillin-resistant Staphylococcus aureus (MRSA), and PA. Severe aspiration pneumonia that originates in a long-term care facility or HCAAP with one or more risk factors for MDR organisms should be considered for similar treatment. HCAAP with one or more risk factors for MDR organisms or PA, plus septic shock, need for ICU admission or mechanical ventilation should receive double coverage for PA in addition to coverage for MRSA and anaerobes. Multiple gaps in current understanding and management of aspiration pneumonia require future research, with a particular focus on antibiotic stewardship.

Background: Use of computed tomography pulmonary angiography (CTPA) in the assessment of pulmonary embolism (PE) has markedly increased over the past two decades. While this technology has improved the accuracy of radiological testing for PE, CTPA also carries the risk of substantial iatrogenic harm. Each CTPA carries a 14% risk of contrast-induced nephropathy and a lifetime malignancy risk that can be as high as 2.76%. The appropriate use of CTPA can be estimated by monitoring the CTPA yield, the percentage of tests positive for PE. This is the first study to propose and validate a computerized method for measuring the CTPA yield in the emergency department (ED). Objective: The objective of our study was to assess the validity of a novel computerized method of calculating the CTPA yield in the ED. Methods: The electronic health record databases at two tertiary care academic hospitals were queried for CTPA orders completed in the ED over 1-month periods. These visits were linked with an inpatient admission with a discharge diagnosis of PE based on the International Classification of Diseases codes. The computerized the CTPA yield was calculated as the number of CTPA orders with an associated inpatient discharge diagnosis of PE divided by the total number of orders for completed CTPA. This computerized method was then validated by 2 independent reviewers performing a manual chart review, which included reading the free-text radiology reports for each CTPA. Results: A total of 349 CTPA orders were completed during the 1-month periods at the two institutions. Of them, acute PE was diagnosed on CTPA in 28 studies, with a CTPA yield of 7.7%. The computerized method correctly identified 27 of 28 scans positive for PE. The one discordant scan was tied to a patient who was discharged directly from the ED and, as a result, never received an inpatient discharge diagnosis. Conclusions: This is the first successful validation study of a computerized method for calculating the CTPA yield in the ED. This method for data extraction allows for an accurate determination of the CTPA yield and is more efficient than manual chart review. With this ability, health care systems can monitor the appropriate use of CTPA and the effect of interventions to reduce overuse and decrease preventable iatrogenic harm.