Search

It is unknown how hospital- and systems-level factors have impacted patient safety in the intensive care unit (ICU) during the COVID-19 pandemic. We sought to understand how the pandemic has exacerbated preexisting patient safety issues and created novel patient safety challenges in ICUs in the United States.We performed a national, multi-institutional, mixed-methods survey of critical care clinicians to elicit experiences related to patient safety during the pandemic. The survey was disseminated via email through the Society of Critical Care Medicine listserv. Data were reported as valid percentages, compared by COVID caseload and peak of the pandemic; free-text responses were analyzed and coded for themes.We received 335 survey responses. On general patient safety, 61% felt that conditions were more hazardous when compared with the prepandemic period. Those who took care of mostly COVID-19 patients were more likely to perceive that care was more hazardous (odds ratio, 4.89; 95% CI, 2.49-9.59) compared with those who took care of mostly non-COVID-19 or no COVID-19 patients. In free-text responses, providers identified patient safety risks related to pandemic adaptations, such as ventilator-related lung injury, medication and diagnostic errors, oversedation, oxygen device removal, and falls.Increased COVID-19 case burden was significantly associated with perceptions of a less safe patient care environment by frontline ICU clinicians. Results of the qualitative analysis identified specific patient safety hazards in ICUs across the United States as downstream consequences of hospital and provider strain during periods of the COVID-19 pandemic.

The paucity of research linking thiamine treatment with improved outcomes may be driving its underutilization among patients at risk for Wernicke encephalopathy.To assess relationships of thiamine usage to outcomes of patients hospitalized with alcohol use disorder and pneumonia. DESIGN, SETTING AND PARTICIPANTS: This is a retrospective cohort study of adult patients hospitalized with pneumonia who also have alcohol use disorder and were treated with benzodiazepines during the initial two hospital days, between 2010 and 2015 at hospitals participating in the Premier Healthcare Database.Any thiamine treatment, and, among those treated, high-dose thiamine treatment, during the initial two hospital days.Death on days 3-14 of hospitalization (primary); discharge home; transfer to intensive care unit; length of stay (LOS). We used propensity-weighted models to estimate treatment effects.Among 36,732 patients from 625 hospitals, 26,520 (72.2%) patients received thiamine, with mortality of 6.5% and 8.1% among recipients and nonrecipients, respectively. With propensity score adjustment, thiamine was associated with reduced mortality (odds ratio [OR]: 0.80, 95% confidence interval [CI]: 0.75-0.85) and more frequent discharges to home (OR: 1.10, 95% CI: 1.06-1.14). Other outcomes were similar. Relative to low-dose thiamine, high-dose thiamine was not associated with mortality (adjusted OR: 0.99, 95% CI: 0.89-1.10), but LOS was longer (ratio of means: 1.06, 95% CI: 1.04-1.08), and discharges to home were less frequent (OR: 0.92, 95% CI: 0.87-0.97).Thiamine is not reliably given to patients with pneumonia and alcohol use disorder receiving benzodiazepines. Improving thiamine administration may represent an opportunity to save lives in this high-risk group of inpatients.

BACKGROUND Pediatric patients from families with limited English proficiency (LEP) are at risk for health care disparities. We examined timeliness of analgesic administration in pediatric postoperative patients with a limb fracture from LEP versus non-LEP families. METHODS This was a retrospective cohort study of children aged 1 year to RESULTS We examined 306 patients, of whom 59 (19%) were from LEP families. Children in LEP families were significantly less likely to receive any analgesia (86.4% vs 96.8%, P ≤ .01) and experienced longer time to first analgesia in unadjusted (hazard ratio = 0.68, 95% confidence interval: 0.50–0.92) and adjusted analyses (hazard ratio = 0.68, 95% confidence interval: 0.50–0.94). There was no significant association between LEP and time to first opioid, proportion given opioid analgesia, or number of pain assessments. CONCLUSION Hospitalized children from LEP families experience a longer time to analgesia administration after surgery. The mechanisms that lead to these differences in care must be identified so that interventions can be designed to address them.

BackgroundThe coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) claimed over 4 million lives by July 2021 and continues to pose a serious public health threat.ObjectivesOur retrospective study utilized respiratory pathogen panel (RPP) results in patients with SARS-CoV-2 to determine if coinfection (i.e. SARS-CoV-2 positivity with an additional respiratory virus) was associated with more severe presentation and outcomes.MethodsAll patients with negative influenza/respiratory syncytial virus testing who underwent RPP testing within 7 days of a positive SARS-CoV-2 test at a large, academic medical centre in New York were examined. Patients positive for SARS-CoV-2 with a negative RPP were compared with patients positive for SARS-CoV-2 and positive for a virus by RPP in terms of biomarkers, oxygen requirements and severe COVID-19 outcome, as defined by mechanical ventilation or death within 30 days.ResultsOf the 306 SARS-CoV-2-positive patients with RPP testing, 14 (4.6%) were positive for a non-influenza virus (coinfected). Compared with the coinfected group, patients positive for SARS-CoV-2 with a negative RPP had higher inflammatory markers and were significantly more likely to be admitted (P = 0.01). Severe COVID-19 outcome occurred in 111 (36.3%) patients in the SARS-CoV-2-only group and 3 (21.4%) patients in the coinfected group (P = 0.24).ConclusionsPatients infected with SARS-CoV-2 along with a non-influenza respiratory virus had less severe disease on presentation and were more likely to be admitted—but did not have more severe outcomes—than those infected with SARS-CoV-2 alone.

Objective To determine the effect of a uniform, reduced, default dispense quantity for new opioid analgesic prescriptions on the quantity of opioids prescribed in dentistry practices. Methods We conducted a cluster-randomized controlled trial within a health system in the Bronx, NY, USA. We randomly assigned three dentistry sites to a 10-tablet default, a 5-tablet default, or no change (control). The primary outcome was the quantity of opioid analgesics prescribed in the new prescription. Secondary outcomes were opioid analgesic reorders and health service utilization within 30 days after the new prescription. We analyzed outcomes from 6 months before implementation through 18 months after implementation. Results Overall, 6,309 patients received a new prescription. Compared with the control site, patients at the 10-tablet-default site had a significantly larger change in prescriptions for 10 tablets or fewer (38.7 percentage points; confidence interval [CI]: 11.5 to 66.0), lower number of tablets prescribed (–3.3 tablets; CI: –5.9 to –0.7), and lower morphine milligram equivalents (MME) prescribed (–14.1 MME; CI: –27.8 to –0.4), which persisted in the 30 days after the new prescription despite a higher percentage of reorders (3.3 percentage points; CI: 0.2 to 6.4). Compared with the control site, patients at the 5-tablet-default site did not have a significant difference in any outcomes except for a significantly higher percentage of reorders (2.6 percentage points; CI: 0.2 to 4.9). Conclusions Our findings further support the efficacy of strategies that lower default dispense quantities, although they indicate that caution is warranted in the selection of the default. Trial registration ClinicalTrials.org ID: NCT03030469.

BACKGROUND: Third year clerkship grades include subjective evaluations. The purpose of this study is to identify if personality traits and self-esteem predispose students to better clerkship performance. METHODS: Third-year medical students completed the OCEAN Five Factor Model Personality Test and Rosenberg Self-Esteem Scale. Clerkship grades were matched to survey results. Chi-squared and linear regression analyses assessed the correlation between students’ clerkship grades, personality traits, and self-esteem. RESULTS: There was no association between OCEAN personality domains and any component of clerkship grade. In secondary post hoc analysis, students who are “deep thinking” (OR 2.97, 95% CI 1.26–7.01, p = 0.01), “sophisticated” (OR 2.70, 95% CI 1.12–6.50, p = 0.03), and “outgoing” (OR 2.45, 95% CI 1.02–5.89, p = 0.04) were significantly more likely to get an overall clerkship grade of Honors. "Deep thinking" (OR 3.44, 95% CI 1.47-8.04, p = 0.004) and “efficient” (OR 2.87, 95% CI 1.12–7.36, p = 0.03) students scored better on shelf exams, while “shy” students scored worse (OR 0.30, 95% CI 0.13–0.69, p = 0.004); “aloof” students received worse clinical scores (OR 0.57, 95% CI 0.37–0.89, p = 0.03), and "rude" (OR 5.08, 95% CI 1.03–24.94, p = 0.03) and "sophisticated" (OR 2.47, 95% CI 1.02–6.00, p = 0.04) students received higher preceptor scores. There was no correlation between self-esteem and clerkship grades. CONCLUSION: Students with certain personality traits may be predisposed to success during clerkships. Medical educators should be cognizant of biases favoring certain personalities and help students maximize success by recognizing their strengths and identifying gaps.

BACKGROUND: Corticosteroids may be beneficial in a subset of patients with coronavirus disease 2019 (COVID-19), but predictors of therapeutic response remain unknown. C-reactive protein (CRP) is a routinely measured biomarker, and reduction in its levels after initiation of therapy may predict inpatient mortality. METHODS: In this retrospective cohort study, the charts of patients who were admitted to Montefiore Medical Center between March 10, 2020, and May 2, 2020 for the management of COVID-19 were examined. Of all patients who met inclusion criteria, patients who received corticosteroid treatment were categorized as CRP responders (≥50% CRP level reduction) and CRP nonresponders (

The efficacy of glucocorticoids in COVID-19 is unclear. This study was designed to determine whether systemic glucocorticoid treatment in COVID-19 patients is associated with reduced mortality or mechanical ventilation. This observational study included 1,806 hospitalized COVID-19 patients; 140 were treated with glucocorticoids within 48 hours of admission. Early use of glucocorticoids was not associated with mortality or mechanical ventilation. However, glucocorticoid treatment of patients with initial C-reactive protein (CRP) ≥20 mg/dL was associated with significantly reduced risk of mortality or mechanical ventilation (odds ratio, 0.23; 95% CI, 0.08- 0.70), while glucocorticoid treatment of patients with CRP

Objective:Efforts to reduceClostridioides difficileinfection (CDI) have targeted transmission from patients with symptomaticC. difficile. However, many patients with theC. difficileorganism are carriers without symptoms who may serve as reservoirs for spread of infection and may be at risk for progression to symptomaticC. difficile. To estimate the prevalence ofC. difficilecarriage and determine the risk and speed of progression to symptomaticC. difficileamong carriers, we established a pilot screening program in a large urban hospital.Design:Prospective cohort study.Setting:An 800-bed, tertiary-care, academic medical center in the Bronx, New York.Participants:A sample of admitted adults without diarrhea, with oversampling of nursing facility patients.Methods:Perirectal swabs were tested by polymerase chain reaction forC. difficilewithin 24 hours of admission, and patients were followed for progression to symptomaticC. difficile. Development of symptomaticC. difficilewas compared amongC. difficilecarriers and noncarriers using a Cox proportional hazards model.Results:Of the 220 subjects, 21 (9.6%) wereC. difficilecarriers, including 10.2% of the nursing facility residents and 7.7% of the community residents (P= .60). Among the 21C. difficilecarriers, 8 (38.1%) progressed to symptomaticC. difficile, but only 4 (2.0%) of the 199 noncarriers progressed to symptomaticC. difficile(hazard ratio, 23.9; 95% CI, 7.2–79.6;P< .0001).Conclusions:Asymptomatic carriage ofC. difficileis prevalent among admitted patients and confers a significant risk of progression to symptomatic CDI. Screening for asymptomatic carriers may represent an opportunity to reduce CDI.

BackgroundTraining nurses in ultrasound-guided peripheral intravenous catheter placement might reduce the use of more invasive venous access devices (peripherally inserted central catheters (PICC) and midline catheters).MethodsWe implemented an abbreviated training in ultrasound-guided peripheral intravenous catheter placement for nurses on an inpatient medical unit and provided a portable ultrasound device for 10 months.ResultsNurses on this unit placed 99 ultrasound-guided peripheral intravenous catheters with a high level of success. During the implementation period, PICC and midline catheter placement decreased from a mean 4.8 to 2.5 per month, meeting criteria for special cause variation. In the postimplementation period, the average catheter use reverted to 4.3 per month on the intervention unit. A comparison inpatient medical unit without training or access to a portable ultrasound device experienced no significant change in PICC and midline catheter use throughout the study period (mean of 6.0 per month).ConclusionsThese results suggest that an abbreviated training in ultrasound-guided peripheral intravenous catheter placement for nurses on an inpatient medical unit is sufficient to reduce PICC and midline catheters.

BACKGROUND: High-flow nasal cannula (HFNC), a form of noninvasive respiratory support, is effective for the treatment of respiratory distress in ICUs. Although HFNC has been used outside of the ICU, there is little research that examines its safety in this less-monitored setting. METHODS: Children ≤ 24 months old admitted with bronchiolitis to a pediatric floor at a tertiary care center from April 1 2013, to March 31 2015, were identified by using standard diagnostic codes. Exclusion criteria were concomitant pneumonia or complex comorbidities. Demographic and clinical characteristics were abstracted. Outcomes included transfer to the ICU, higher levels of respiratory support, intubation, pneumothorax, or aspiration events. RESULTS: Eighty children admitted with bronchiolitis who were treated with HFNC while on the pediatric floor were examined. The median age was 4.6 months, 45% were girls, and the majority were either Hispanic (41%) or black (36%). Flow ranged from 3 to 10 L/min. Thirty-three subjects (41% of the sample) required subsequent transfer to the ICU. No children were intubated or developed a pneumothorax. Eighty-three percent were fed while on HFNC. No children had an aspiration event. CONCLUSIONS: HFNC may be a safe modality of respiratory support outside of the ICU for children ages ≤ 24 months with bronchiolitis and without comorbidities up to a maximum flow of 10 L/min. There were no adverse events among the subjects who were fed while on HFNC.

Background: Larger studies are needed to evaluate whether COVID-19 increases the risk of DKA presentation. Methods: We examined individual and joint associations of COVID-19 and preexisting diabetes (DM) with DKA presentation in a retrospective cohort of patients who presented to Montefiore Medical Center in the Bronx, NY from March to June 2020. We defined DKA as acidosis (pH 250 mg/dl. We defined COVID-19 status by PCR test result and preexisting DM by HbA1c ≥6.5%, ICD-10 code, or outpatient DM medications. Given likely bias in hospital presentation during the pandemic, a historical control from March to June 2019 was included in the COVID negative group. Data were analyzed using multivariate regression. Results: We included 46,479 patients: mean age 43 yrs, 56% male, 57% with DM of which 94% type 2 DM. COVID-19 alone was not associated with higher odds of DKA presentation, though as expected preexisting DM was. Adjusted regression analyses for interaction showed 64% higher odds of DKA for patients with both COVID-19 and preexisting DM than the additive effect of each condition alone (Table 1). Conclusions: COVID-19 has a multiplicative effect on the risk of hospital presentation of DKA in people with preexisting DM. Mechanistic studies examining DKA in COVID-19 in people with preexisting DM may help identify preventive targets. Disclosure J. Mathew: None. C. Schechter: None. W. Southern: None. J. P. Crandall: None. Y. Tomer: None. S. Agarwal: None.

Auto-reactivity in COVID-19 is increasingly being recognized and may identify a group of patients with inflammation severe enough to result in loss of self-tolerance. Corticosteroids are potent anti-inflammatory agents and now the standard of care for patients with severe Covid-19 requiring oxygen support/mechanical ventilation. We studied the outcomes of COVID-19 patients who demonstrated clinically identifiable auto-reactivity and received corticosteroid treatment.In this retrospective cohort study, we included 51 COVID-19 patients admitted between March 10, 2020 and May 2, 2020 who received corticosteroid treatment and also had serum sample in our institution bio-bank available for ANA and RF ELISA. Twelve patients (23.5%) had positive ANA or RF. Mortality rate among patients with positive autoantibodies was significantly higher than those without (9/12 or 75% versus 13/39 or 33.3%, p= 0.02). The high mortality rate in patients with auto-reactivity warrants further investigation and may be the subgroup where additional immunomodulation is effective.

The first Covid-19 patient was admitted to Montefiore Medical Center (MMC) on March 10, 2020. Soon thereafter there was a rapid and exponential surge of Covid-19 admissions to MMC that could have resulted in catastrophic consequences if MMC had been overwhelmed, as happened in Europe. To adjust to this crisis our institution, under the inspiring leadership of Dr. Philip Ozuah, President and CEO of Montefiore Medicine, adopted an “all hands on deck” approach, mobilizing our entire workforce to expand our units to accommodate the growing number of patients being admitted. Given that the internal medicine (IM) and ICU units are part of the department of medicine (DOM), the DOM was at the center of this mobilization. The DOM is the largest department at MMC and mobilizing it required careful planning, seamless teamwork, and strong leadership. To achieve that goal, we applied a framework that we designate the “3C framework,” denoting Coordination, Communication, and Collaboration. In this report we describe the many initiatives the Montefiore Einstein DOM implemented during the Covid-19 pandemic using the 3C framework. These included establishing the Medicine Covid-19 Taskforce to lead our efforts, starting a daily newsletter for up-to-date communications, rapidly expanding the ICU and IM units, converting most specialty inpatient consults to eConsults, coordinating research studies, and more. The goal of this report is to serve as a guide on how the 3C framework helped us organize, mobilize, and energize the department of medicine effectively and efficiently during this unprecedented crisis.

SESSION TITLE: Pulmonary Vascular Disease Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Novel coronavirus disease 2019 (COVID-19) is associated with significant morbidity and high mortality, however, 70-81% of all cases are classified as non-severe COVID-19 disease is being increasingly recognized as a prothrombotic state with a high incidence of coagulopathy Up to 30% of intensive care unit patients with COVID-19 develop a venous thromboembolism (VTE) Limited studies of non-ICU and non-mechanically ventilated patients have suggested a 5 to 10% risk of VTE However, these studies have been limited in scope and may not be generalizable to patients seen in the United States The goal of this study is to further characterize non-critically ill COVID-19 patients at our institution who develop VTEs METHODS: This is a retrospective cohort study using data from the electronic medical record It examined all adult inpatients diagnosed with COVID-19 based on a positive nasopharyngeal/oropharyngeal swab who were not mechanically ventilated during hospitalization and who were discharged alive from three hospitals comprising an integrated health system in Bronx, NY between March 11, 2020 and May 2, 2020 Patients were eligible for study inclusion if an upper or lower extremity duplex or Computerized Tomography (CT) imaging with contrast to rule out PE was performed during admission or within 14 days of discharge Summary statistics were used to characterize patients with and without VTE based on imaging findings Unpaired two-tailed t-test, Wilcoxon rank sum test or test of proportion were used to compare the groups RESULTS: Of the 2671 adult inpatients with COVID-19 who were not mechanically ventilated and survived to discharge, 313 (11 7%) completed CT or duplex imaging to identify VTE, and 72 patients (72/2671, 2 7%) were found to have a confirmed VTE Out of the 72 VTE identified, 31 were located in peripheral veins, 38 were in pulmonary veins, and 3 were in both peripheral and pulmonary veins Compared to patients without VTE on imaging, patients with VTE were of similar age (60 3 vs 61 5 years, p=0 55) and body mass index (30 8 vs 30 2, p=0 56) Patients who developed a VTE had a longer length of stay (10 vs 8 days, p=0 02) and a more elevated admission white blood cell count (10 3 vs 8 4 k/uL, p=0 002), d-dimer (4 37 vs 1 67 ug/mL, p

Objective To evaluate obesity counseling competence among residents in a primary care training program Methods We delivered a 3 h obesity curriculum to 28 Primary Care residents and administered a pre-curriculum and post curriculum survey looking specifically at self-assessed obesity counseling competence. Results Nineteen residents completed both the pre curriculum survey and the post curriculum survey. The curriculum had a positive impact on residents’ ability to ascertain patient’s stage of change, use different methods to obtain diet history (including 24 h recall, food record or food frequency questionnaire), respond to patient’s questions regarding treatment options, assist patients in setting realistic goals for weight loss based on making permanent lifestyle changes, and use of motivational interviewing to change behavior. When looking at the 5As domains, there was a significant improvement in the domains of Assess, Advise, and Assist. The proportion of residents with a lower level of self-assessed obesity counseling competence reduced from 75% before the curriculum to 37.5% (p = 0.04) after the curriculum. Conclusion Our curriculum addressing weight loss counseling using the 5As model increased obesity counseling competence among residents in a primary care internal medicine residency program.

BACKGROUND: Although most children with bronchiolitis only require supportive care, some decompensate and require ventilatory support. We examined predictors of respiratory decompensation among hospitalized children to identify which patients may benefit from expectant monitoring. METHODS: We examined children ≤24 months old with bronchiolitis admitted to the general infant and toddler floor. Children with pneumonia or comorbidities were excluded. Demographic and clinical characteristics were abstracted from a clinical database and medical records. Respiratory decompensation was defined as the need for initiating high-flow nasal cannula oxygen, continuous positive airway pressure, nasal intermittent mandatory ventilation, bilevel positive airway pressure, or intubation. A multivariable logistic regression model was constructed to identify independent predictors of respiratory decompensation. RESULTS: A total of 1217 children were included. The median age was 6.9 months, 41% were girls, 49% were Hispanic, 21% were black, and 18% were premature. Significant independent predictors of respiratory decompensation were age ≤3 months (odds ratio [OR]: 3.25; 95% confidence interval [CI]: 2.09–5.07), age 3 to 6 months (OR: 1.76; 95% CI: 1.04–3.0), black race (OR: 1.94; 95% CI: 1.27–2.95), emergency department hypoxemia (OR: 2.34; 95% CI: 1.30–4.21), and retractions or accessory muscle use (OR: 2.26; 95% CI: 1.48–3.46). Children with 0 of 4 predictors were found to have a low risk of decompensation (3%). CONCLUSIONS: Young age, black race, emergency department hypoxemia, and retractions or accessory muscle use were associated with respiratory decompensation in children with bronchiolitis. These factors should be considered at presentation, as they identify children who require a higher level of respiratory monitoring and support and others who may not benefit.

OBJECTIVE: Efforts to reduce C. difficile infections have targeted transmission from patients with symptomatic C. difficile. However, many patients with the C. difficile organism are carriers without symptoms who may serve as reservoirs for spread of infection and may be at risk for progression to symptomatic C. difficile. To estimate the prevalence of C. difficile carriage and determine the risk and speed of progression to symptomatic C. difficile among carriers, we established a pilot screening program in a large urban hospital. DESIGN: Prospective cohort study SETTING: An 800-bed, tertiary-care, academic medical center in the Bronx, NY PARTICIPANTS: A sample of admitted adults without diarrhea, with oversampling of nursing facility patients METHODS: Perirectal swabs were tested by Polymerase Chain Reaction for C. difficile within 24 hours of admission, and patients were followed for progression to symptomatic C. difficile. Development of symptomatic C. difficile was compared among C. difficile carriers and non-carriers using a Cox proportional hazards model. RESULTS: Of the 220 subjects, 21 (9.6%) were C. difficile carriers, including 10.2% of the nursing facility residents and 7.7% of the community residents (p=0.60). Among the 21 C. difficile carriers, 8 (38.1%) progressed to symptomatic C. difficile while only 4 (2.0%) of the 199 non-carriers progressed to symptomatic C. difficile (p

This survey study of more than 1200 clinicians from several large urban medical centers highlights clinicians’ experiences with restrictions on the number of electronic health records that can be opened and displayed concurrently.

IMPORTANCE: Multiple-birth infants in neonatal intensive care units (NICUs) have nearly identical patient identifiers and may be at greater risk of wrong-patient order errors compared with singleton-birth infants. OBJECTIVES: To assess the risk of wrong-patient orders among multiple-birth infants and singletons receiving care in the NICU and to examine the proportion of wrong-patient orders between multiple-birth infants and siblings (intrafamilial errors) and between multiple-birth infants and nonsiblings (extrafamilial errors). DESIGN, SETTING, AND PARTICIPANTS: A retrospective cohort study was conducted in 6 NICUs of 2 large, integrated health care systems in New York City that used distinct temporary names for newborns per the requirements of The Joint Commission. Data were collected from 4 NICUs at New York–Presbyterian Hospital from January 1, 2012, to December 31, 2015, and 2 NICUs at Montefiore Health System from July 1, 2013, to June 30, 2015. Data were analyzed from May 1, 2017, to December 31, 2017. All infants in the 6 NICUs for whom electronic orders were placed during the study periods were included. MAIN OUTCOMES AND MEASURES: Wrong-patient electronic orders were identified using the Wrong-Patient Retract-and-Reorder (RAR) Measure. This measure was used to detect RAR events, which are defined as 1 or more orders placed for a patient that are retracted (ie, canceled) by the same clinician within 10 minutes, then reordered by the same clinician for a different patient within the next 10 minutes. RESULTS: A total of 10 819 infants were included: 85.5% were singleton-birth infants and 14.5% were multiple-birth infants (male, 55.8%; female, 44.2%). The overall wrong-patient order rate was significantly higher among multiple-birth infants than among singleton-birth infants (66.0 vs 41.7 RAR events per 100 000 orders, respectively; adjusted odds ratio, 1.75; 95% CI, 1.39-2.20; P

Importance Interventions to improve judicious prescribing of opioid analgesics for acute pain are needed owing to the risks of diversion, misuse, and overdose. Objective To assess the effect of modifying opioid analgesic prescribing defaults in the electronic health record (EHR) on prescribing and health service use. Design, setting, and participants A cluster randomized clinical trial with 2 parallel arms was conducted between June 13, 2016, and June 13, 2018, in a large urban health care system comprising 32 primary care and 4 emergency department (ED) sites in the Bronx, New York. Data were analyzed using a difference-in-differences method from 6 months before implementation through 18 months after implementation. Data were analyzed from January 2019 to February 2020. Interventions A default dispense quantity for new opioid analgesic prescriptions of 10 tablets (intervention) vs no change (control) in the EHR. Main outcomes and measures The primary outcome was the quantity of opioid analgesics prescribed with the new default prescription. Secondary outcomes were opioid analgesic reorders and health service use within 30 days after the new prescription. Intention-to-treat analysis was conducted. Results Overall, 21 331 patients received a new opioid analgesic prescription from 490 prescribers. Comparing the intervention and control arms, site, prescriber, and patient characteristics were similar. For the new prescription, compared with the control arm, patients in the intervention arm had significantly more prescriptions for 10 tablets or fewer (7.6 percentage points; 95% CI, 6.1-9.2 percentage points), a lower number of tablets prescribed (-2.1 tablets; 95% CI, -3.3 to -0.9 tablets), and lower morphine milligram equivalents (MME) prescribed (-14.6 MME; 95% CI, -22.6 to -6.6 MME). Within 30 days after the new prescription, significant differences remained in the number of tablets prescribed (-2.7 tablets; 95% CI, -4.8 to -0.6 tablets), but not MME (-15.8 MME; 95% CI, -33.8 to 2.2 MME). Within this 30-day period, there were no significant differences between the arms in health service use. Conclusions and relevance In this study, implementation of a uniform reduced default dispense quantity of 10 tablets for opioid analgesic prescriptions led to a modest reduction in the quantity prescribed initially, without significantly increasing health service use. However, during 30 days after implementation, the influence on prescribing was mixed. Reducing EHR default dispense quantities for opioid analgesics is a feasible strategy that can be widely disseminated and may modestly reduce prescribing. Trial registration ClinicalTrials.gov Identifier: NCT03003832.

Hyponatremia is a common electrolyte disorder and is associated with mortality. We examined the frequency of appropriate testing in response to an episode of inpatient hyponatremia in a large urban hospital to better inform our educational intervention. We then evaluated the impact of a live CME activity with a focus on CKD- and ESRD-associated hyponatremia physiology, on diagnostic practices of audience hospitalist attendings. We performed a retrospective database analysis of all patients admitted to Montefiore Medical Center in 2014 to examine the performance of hospital staff in response to hyponatremia across all CKD stages. We then did a comparative analysis of diagnostic workup orders for hyponatremic patients admitted to audience members of a live CME activity in the 4 months prior as compared to the 4 months after the activity. The prevalence of hyponatremia was 27% in a cohort of hospitalized patients: 41% of these hyponatremia inpatients had CKD, and 11.4% had ESRD. Overall less than 10% of patients had orders written for serum and urine osmolality without a differential pattern based on CKD or ESRD diagnosis. Among the patients admitted to the CME audience hospitalists, urine/serum osmolality and urine sodium orders occurred infrequently overall and did not differ after vs. before the lecture. The frequency of appropriate diagnostic orders written in response to an episode of hyponatremia was very low and did not vary based on degree of CKD. A CME activity with an emphasis on the role of CKD/ESRD in diagnostic accuracy did not improve the order quality in a group of audience hospitalists. Efforts to improve the diagnostic workup of hyponatremia with concomitant kidney disease are crucial to proper management of these patients.

BACKGROUND Risk adjustment for mortality is increasingly important in an era when hospitals and health care systems are being compared with respect to health outcomes and quality. A powerful predictive model has been developed to risk-adjust for 30-day mortality among inpatients, but it is complex and not widely used. OBJECTIVE To develop and validate a simpler model, with predictive power similar to more complex models. RESEARCH DESIGN This was a retrospective split-validation study. In a derivation cohort, a predictive model for 30-day mortality was developed using logistic regression with the Charlson comorbidity score, Laboratory-Based Acute Physiology Score, and age as the predictor variables. In the validation cohort, the performance and calibration of the model to predict 30-day mortality was examined. SUBJECTS All admissions to the medical service of 2 urban university-based teaching hospitals located in Bronx, New York, between July 1, 2002, and April 30, 2008. MEASURES All-cause mortality was taken from the social security death registry. Predictor variables were constructed from demographic characteristics, laboratory and billing data extracted from a clinical data repository. RESULTS The study sample included 147 991 admissions and overall 30-day mortality was 5.4%. The model had excellent discrimination, with a c-statistics of 0.8585 in the derivation cohort and 0.8484 in the validation cohort. The model accurately predicts 30-day mortality in all risk deciles. CONCLUSIONS This simple and powerful predictive model can be used by hospitals and health care systems as a risk-adjustment tool for quality and research purposes.

Although cocaine is a well-recognized risk factor for coronary disease, detailed information is lacking regarding related behavioral and clinical features of cocaine-associated ST-segment elevation myocardial infarction (STEMI), particularly in socioeconomically disadvantaged urban settings. Nor are systematic or extended follow-up data available on outcomes for cocaine-associated STEMI in the contemporary era of percutaneous coronary intervention. We leveraged a prospective STEMI registry from a large health system serving an inner-city community to characterize the clinical features, acute management, and middle-term outcomes of cocaine-related versus cocaine-unrelated STEMI. Of the 1,003 patients included, 60% were black or Hispanic. Compared with cocaine-unrelated STEMI, cocaine-related STEMI (n = 58) was associated with younger age, male gender, lower socioeconomic score, current smoking, high alcohol consumption, and human immunodeficiency virus seropositivity but less commonly with diabetes or hypertension. Cocaine users less often received drug-eluting stents or β blockers at discharge. During median follow-up of 2.7 years, rates of death, death or any rehospitalization, and death or cardiovascular rehospitalization did not differ significantly between cocaine users and nonusers but were especially high for death or any hospitalization in the 2 groups (31.4 vs 32.4 per 100 person-years, p = 0.887). Adjusted hazard ratios for outcomes were likewise not significantly different. In conclusion, in this low-income community, cocaine use occurred in a substantial fraction of STEMI cases, who were younger than their nonuser counterparts but had more prevalent high-risk habits and exhibited similarly high rates of adverse outcomes. These data suggest that programs targeting cocaine abuse and related behaviors could contribute importantly to disease prevention in disadvantaged communities.

Purpose The traditional technique of placing a peripheral intravenous (IV) catheter is successful in most cases on inpatient wards. However, when the traditional method fails, a central venous catheter may be placed to maintain IV access. These catheters are associated with risks including central line-associated bloodstream infection. Methods We evaluated the effectiveness and acceptability of an ultrasound-guided peripheral IV service to reduce the number of newly placed central venous catheters on an inpatient ward. Central venous catheters were counted daily on intervention and control wards using a standard protocol, and rates of newly placed catheters were compared using a Poisson regression model. Nurses were surveyed to assess acceptability and perceived benefit. Results We found a reduction in the rate of newly placed central venous catheters on the intervention unit compared with the control unit at 90 days: mean 0.47 versus 0.67 newly placed central venous catheters/day, but the difference was not significant (P = .08). Nurses were in favor of the ultrasound-guided IV service, with perceived benefit to their patients. Conclusion Ultrasound-guided peripheral IV might reduce unnecessary central venous catheters on general inpatient wards. A portable ultrasound used for this purpose was found to be acceptable by nursing staff.

Patient experience is a critical measure for ambulatory primary care, although it is unclear how to best improve patient experience scores. This study aimed to determine whether use of a real-time feedback (RTF) device improved patient experience scores in a cluster-randomized trial. The primary outcomes were change from baseline in 9 Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) question and domain scores most closely related to the RTF questions asked in a linear mixed effects model. There were no observed statistically significant intervention-related differences in CG-CAHPS scores in any of the 9 CG-CAHPS questions or domains ( P = .12-.99). In intervention clinics, there were no statistically significant correlation between CG-CAHPS top box scores and RTF device scores ( P = .23-.98). Clinics in an urban primary care network randomized to receive RTF devices did not significantly improve related CG-CAHPS question or domain scores nor were those scores correlated with RTF device scores. More research is needed to identify effective interventions to improve ambulatory primary care patient experience.

Using serial measurements of brain natriuretic peptide (BNP) has been proposed as a method to guide therapy for patients treated for acute decompensated heart failure. However, 20-47% of patients do not achieve the target BNP thresholds despite treatment. We hypothesised that "BNP unresponsive" patients represent a distinct group at high risk for poor outcomes and sought to examine the characteristics and outcomes of this group.In a retrospective study using electronic health record (EHR) data, we examined the outcomes of patients admitted with acute decompensated heart failure. Patients were divided into two groups based on their pro-BNP response to treatment: (1) pro-BNP responsive to treatment (decrease by at least 30%) and (2) pro-BNP unresponsive to treatment (decrease by less than 30%). The primary outcomes of interest were 180-day mortality and 180-day readmission. Univariate and multivariate Cox proportional hazard models were used to assess the independent association between pro-BNP response to treatment and 180-day mortality and readmission. Adjustment variables included age, gender, Charlson co-morbidity score, admission creatinine, admission haematocrit, ejection fraction, preserved ejection fraction, and LV end-diastolic dimension.The total study population included 819 patients with 455 (55.6%) in the pro-BNP responsive group and 364 (44.4%) in the pro-BNP unresponsive group. Admissions whose BNP was unresponsive to treatment had significantly increased risk for 180-day mortality, compared with BNP-responsive admissions (26.4% vs. 13.2%, p 0.001). Brain natriuretic peptide unresponsiveness remained significantly associated with increased 180-day mortality after adjustment for demographic and clinical characteristics (HRPatients whose pro-BNP did not improve by30% were at increased risk for 180-day mortality, but not 180-day readmission. Thus, BNP-unresponsiveness provides meaningful prognostic information, and it may define a patient population that would benefit from specific therapies to reduce the risk.

BACKGROUND: Because there can be no delay in providing identification wristbands to newborns, some hospitals assign newborns temporary first names such as Babyboy or Babygirl. These nondistinct naming conventions result in a large number of patients with similar identifiers in NICUs. To determine the level of risk associated with nondistinct naming conventions, we performed an intervention study to evaluate if assigning distinct first names at birth would result in a reduction in wrong-patient errors. METHODS: We conducted a 2-year before/after implementation study to examine the effect of a distinct naming convention that incorporates the mother’s first name into the newborn’s first name (eg, Wendysgirl) on the incidence of wrong-patient errors. We used the Retract-and-Reorder (RAR) tool, an established, automated tool for detecting the outcome of wrong-patient electronic orders. The RAR tool identifies orders placed on a patient that are retracted within 10 minutes and then placed by the same clinician on a different patient within the next 10 minutes. RESULTS: The reduction in RAR events post- versus preintervention was 36.3%. After accounting for clusters of orders within order sessions, the odds ratio of an RAR event post- versus preintervention was 0.64 (95% confidence interval: 0.42–0.97). CONCLUSIONS: The study results suggest that nondistinct naming conventions are associated with an increased risk of wrong-patient errors and that this risk can be mitigated by changing to a more distinct naming convention.

Low molecular weight heparins (LMWHs) have been cautiously used in patients with chronic kidney disease (CKD) due to fear of accumulation. Dalteparin, however, has shown minimal tendency to accumulate in patients with CKD and may be safe to use in this patient population.We compared the incidence of clinically significant bleeding in patients with CKD receiving therapeutic doses of dalteparin to that of patients with CKD receiving therapeutic doses of UFH.This was a retrospective cohort study.Inpatients with CKD (GFR 60 ml/min) who were treated with therapeutic dalteparin or UFH were included in the studyPrimary outcome was major bleeding within 10 days of anticoagulation, identified by ICD-9 code and confirmed by chart review. Demographic characteristics, laboratory values, comorbidities, prior bleeding history and inpatient medications were extracted for each admission from the electronic medical record. Logistic regression models were created to examine the association between choice of anticoagulant and bleeding rates, after adjustment for demographic and clinical characteristics.Dalteparin-treated patients were significantly less likely to experience a major bleed than patients treated with UFH (1.14 % vs. 3.49 %, p 0.001). The reduced likelihood of bleeding associated with dalteparin treatment remained significant after adjustment for patient characteristics (HR 0.39, 95 % CI: 0.21-0.70, p 0.0001). A stratified analysis for subgroups with GFR30 mL/min and with GFR between 30 and 60 mL/min showed that dalteparin was still associated with lower odds of bleeding compared to treatment with unfractionated heparin, but the difference was nonsignificant for GFR30 (HR 0.35, 95 % CI: 0.11-1.15), even after adjustment (OR 0.37, 95 % CI: 0.11-1.22).In patients with CKD, treatment with therapeutic dose dalteparin was associated with lower rates of bleeding than treatment with unfractionated heparin. For patients with severe CKD (GFR30), dalteparin was shown to be at least as safe as unfractionated heparin.

Background End stage renal disease (ESRD) patients on maintenance hemodialysis, are high utilizers of inpatient services. Because of data showing improved outcomes in medical patients admitted to hospitalist-run, non-teaching services, we hypothesized that discharge from a hospitalist-run, non-teaching service is associated with lower risk of 30-day re-hospitalization in a cohort of patients on hemodialysis. Methods One thousand and 84 consecutive patients with ESRD on maintenance hemodialysis who were admitted to Montefiore, a tertiary care center, in 2014 were analyzed using the electronic medical records. We evaluated factors associated with 30-day readmission in multivariable regression models. We then tested the association of care by a hospitalist-run, non-teaching service with 30-day readmission in a propensity score matched analysis. Results Patients cared for on the hospitalist-run, non-teaching service had lower socio-economic scores (SES) and had longer lengths of stay (LOS), as compared to a standard teaching service, but otherwise the populations were similar. In multivariable testing, severity of illness, (OR 2.40, (95%CI: 1.43–4.03) for highest quartile) number of previous hospitalizations (OR 1.22 (95%CI:1.16–1.28) for each admission), and discharge to a skilled nursing facility (SNF)(OR 1.56 (95%CI:1.01–2.43) were significantly associated with 30-day re-admissions. Care by the non-teaching service was associated with a lower risk of 30-day readmission, even after adjusting for clinical factors and matching based on propensity score (OR 0.65(95%CI:0.46–0.91) and 0.71(95%CI:0.66–0.77) respectively). Conclusions Patients with ESRD on hemodialysis discharged from a hospitalist-run, non-teaching medicine service had lower odds of readmission as compared to those patients discharged from a standard teaching service.

BACKGROUND: NICU patients have characteristics believed to increase their risk for wrong-patient errors; however, little is known about the frequency of wrong-patient errors in the NICU or about effective interventions for preventing these errors. We conducted a quality improvement study to evaluate the frequency of wrong-patient orders in the NICU and to assess the effectiveness of an ID reentry intervention and a distinct naming convention (eg, “Wendysgirl”) for reducing these errors, using non-NICU pediatric units as a comparator. METHODS: Using a validated measure, we examined the rate of wrong-patient orders in NICU and non-NICU pediatric units during 3 periods: baseline (before implementing interventions), ID reentry intervention (reentry of patient identifiers before placing orders), and combined intervention (addition of a distinct naming convention for newborns). RESULTS: We reviewed >850 000 NICU orders and >3.5 million non-NICU pediatric orders during the 7-year study period. At baseline, wrong-patient orders were more frequent in NICU than in non-NICU pediatric units (117.2 vs 74.9 per 100 000 orders, respectively; odds ratio 1.56; 95% confidence interval, 1.34–1.82). The ID reentry intervention reduced the frequency of errors in the NICU to 60.2 per 100 000 (48.7% reduction; P < .001). The combined ID reentry and distinct naming interventions yielded an additional decrease to 45.6 per 100 000 (61.1% reduction from baseline; P < .001). CONCLUSIONS: The risk of wrong-patient orders in the NICU was significantly higher than in non-NICU pediatric units. Implementation of a combined ID reentry intervention and distinct naming convention greatly reduced this risk.

Importance Recommendations in the United States suggest limiting the number of patient records displayed in an electronic health record (EHR) to 1 at a time, although little evidence supports this recommendation. Objective To assess the risk of wrong-patient orders in an EHR configuration limiting clinicians to 1 record vs allowing up to 4 records opened concurrently. Design, Setting, and Participants This randomized clinical trial included 3356 clinicians at a large health system in New York and was conducted from October 2015 to April 2017 in emergency department, inpatient, and outpatient settings. Interventions Clinicians were randomly assigned in a 1:1 ratio to an EHR configuration limiting to 1 patient record open at a time (restricted; n = 1669) or allowing up to 4 records open concurrently (unrestricted; n = 1687). Main Outcomes and Measures The unit of analysis was the order session, a series of orders placed by a clinician for a single patient. The primary outcome was order sessions that included 1 or more wrong-patient orders identified by the Wrong-Patient Retract-and-Reorder measure (an electronic query that identifies orders placed for a patient, retracted, and then reordered shortly thereafter by the same clinician for a different patient). Results Among the 3356 clinicians who were randomized (mean [SD] age, 43.1 [12.5] years; mean [SD] experience at study site, 6.5 [6.0] years; 1894 females [56.4%]), all provided order data and were included in the analysis. The study included 12 140 298 orders, in 4 486 631 order sessions, placed for 543 490 patients. There was no significant difference in wrong-patient order sessions per 100 000 in the restricted vs unrestricted group, respectively, overall (90.7 vs 88.0; odds ratio [OR], 1.03 [95% CI, 0.90-1.20]; P = .60) or in any setting (ED: 157.8 vs 161.3, OR, 1.00 [95% CI, 0.83-1.20], P = .96; inpatient: 185.6 vs 185.1, OR, 0.99 [95% CI, 0.89-1.11]; P = .86; or outpatient: 7.9 vs 8.2, OR, 0.94 [95% CI, 0.70-1.28], P = .71). The effect did not differ among settings ( P for interaction = .99). In the unrestricted group overall, 66.2% of the order sessions were completed with 1 record open, including 34.5% of ED, 53.7% of inpatient, and 83.4% of outpatient order sessions. Conclusions and Relevance A strategy that limited clinicians to 1 EHR patient record open compared with a strategy that allowed up to 4 records open concurrently did not reduce the proportion of wrong-patient order errors. However, clinicians in the unrestricted group placed most orders with a single record open, limiting the power of the study to determine whether reducing the number of records open when placing orders reduces the risk of wrong-patient order errors. Trial Registration clinicaltrials.gov Identifier:NCT02876588

Background Testing for patients at risk for hepatitis C virus (HCV) infection is recommended, but it is unclear whether providers adhere to testing guidelines. We aimed to measure adherence to an HCV screening protocol during a multifaceted continuous intervention. Subjects and methods Prospective cohort design to examine the associations between patient-level, physician-level, and visit-level characteristics and adherence to an HCV screening protocol. Study participants included all patients with a visit to 1 of the 3 study clinics and the physicians who cared for them. Adherence to the HCV screening protocol and patient-level, physician-level, and visit-level predictors of adherence were measured. Results A total of 8981 patients and 154 physicians were examined. Overall protocol adherence rate was 36.1%. In multivariate analysis, patient male sex (odds ratio [OR] = 1.18), new patient (OR = 1.23), morning visit (OR = 1.32), and patients' preferred language being non-English (OR = 0.87) were significantly associated with screening adherence. There was a wide variation in overall adherence among physicians (range, 0%-92.4%). Screening adherence continuously declined from 59.1% in week 1 of the study to 13.7% in week 15 (final week). When implementing complex clinical practice guidelines, planners should address physician attitudinal barriers as well as gaps in knowledge to maximize adherence.

Little research has been performed on the impact of race/ethnicity and obesity on the course of diverticulitis.To determine whether patients of different racial/ethnic backgrounds and patients who are obese have disparate courses of disease with regard to complications, recurrence rates, and need for surgery.We conducted a retrospective review of the charts of 347 patients with confirmed diverticulitis in 2 university teaching hospitals at Bronx, NY.African Americans were more likely [odds ratio (OR), 2.28, 95% confidence interval (CI), 1.04-5.00, P = 0.04] and Hispanics were less likely than other racial/ethnic groups (OR, 0.47; 95% CI, 0.22-0.97; P = 0.04) to require surgery for recurrent diverticulitis after at least 1 medically managed hospital admission for diverticulitis. Caucasians were less likely than other racial/ethnic groups to suffer a recurrence of diverticulitis (OR, 0.48; 95% CI, 0.27-0.86; P = 0.01). Obese patients [ body mass index (BMI)30] were more likely than nonobese patients to experience a recurrent episode of diverticulitis (OR, 1.69; 95% CI, 1.08-2.64; P = 0.02). The odds of requiring surgery on the initial presentation of diverticulitis were not significantly different among the various races/ethnicities nor was the likelihood of surgery influenced by BMI. Complication rates did not differ significantly when patients were stratified by age, sex, race, BMI, or number of prior episodes of diverticulitis.Surgery for diverticulitis after at least 1 medically managed hospital admission for diverticulitis is more frequently needed in African Americans and less frequently needed in Hispanics. Caucasians are less likely than other races/ethnicities to suffer a recurrence of diverticulitis. Finally, obesity is a risk factor for recurrent diverticulitis, but not for surgical therapy of diverticulitis.

To reduce the risk of wrong-patient errors, safety experts recommend limiting the number of patient records providers can open at once in electronic health records (EHRs). However, it is unknown whether health care organizations follow this recommendation or what rationales drive their decisions. To address this gap, we conducted an electronic survey via 2 national listservs. Among 167 inpatient and outpatient study facilities using EHR systems designed to open multiple records at once, 44.3% were configured to allow ≥3 records open at once (unrestricted), 38.3% allowed only 1 record open (restricted), and 17.4% allowed 2 records open (hedged). Decision-making centered on efforts to balance safety and efficiency, but there was disagreement among organizations about how to achieve that balance. Results demonstrate no consensus on the number of records to be allowed open at once in EHRs. Rigorous studies are needed to determine the optimal number of records that balances safety and efficiency.

Objectives. We evaluated an intervention designed to identify patients at risk for hepatitis C virus (HCV) through a risk screener used by primary care providers. Methods. A clinical reminder sticker prompted physicians at 3 urban clinics to screen patients for 12 risk factors and order HCV testing if any risks were present. Risk factor data were collected from the sticker; demographic and testing data were extracted from electronic medical records. We used the t test, χ2 test, and rank-sum test to compare patients who had and had not been screened and developed an analytic model to identify the incremental value of each element of the screener. Results. Among screened patients, 27.8% (n = 902) were identified as having at least 1 risk factor. Of screened patients with risk factors, 55.4% (n = 500) were tested for HCV. Our analysis showed that 7 elements (injection drug use, intranasal drug use, elevated alanine aminotransferase, transfusions before 1992, ≥ 20 lifetime sex partners, maternal HCV, existing liver disease) accounted for all HCV infections identified. Conclusions. A brief risk screener with a paper-based clinical reminder was effective in increasing HCV testing in a primary care setting.

Introduction The clinical work in academic internal medicine inpatient units is done by teaching teams. To date, few studies have investigated how team workload affects patient safety outcomes. Objective We examined the association between the number of patients seen by a teaching team, 30-day readmission, and 60-day mortality. Methods In this retrospective observational study we defined each team as “less busy” (total monthly admissions ≤49, the median for all teams) or “more busy” (total monthly admissions >49). We compared patients in both groups' demographic characteristics, comorbidities (Charlson score), severity of illness (the Laboratory-based Acute Physiology Score [LAPS]), and length of stay using t tests, χ2 tests, and rank sum tests, as appropriate. Logistic regression models were constructed to determine whether there was an association between assignment to a busy team and readmission and mortality. Results Of 12 119 admissions examined, 6398 (52.8%) were assigned to the less busy teams and 5721 (47.2%) were assigned to busy teams. Mean length of stay was not statistically different between the groups (5.2 vs 5.3 days; P = .08). After adjustment for demographic and clinical characteristics (LAPS and Charlson score), care by a busy team was associated with greater 30-day readmission rate (odds ratio, 1.21; 95% confidence interval [CI], 1.10–1.34) but not with increased risk of mortality (odds ratio, 1.05; 95% CI, 0.88–1.27). There was a significant linear association between the number of monthly admissions to teams and the readmission rate. Conclusions Admission to a busier teaching team is associated with a 21% increase in the odds of 30-day readmission. Sixty-day mortality was not affected by the number of monthly admissions to the teaching team.

Background Approximately 500,000 patients are discharged from US hospitals against medical advice annually, but the associated risks are unknown. Methods We examined 148,810 discharges from an urban, academic health system between July 1, 2002 and June 30, 2008. Of these, 3544 (2.4%) were discharged against medical advice, and 80,536 (54.1%) were discharged home. We excluded inpatient deaths, transfers to other hospitals or nursing facilities or discharges with home care. Using adjusted and propensity score-matched analyses, we compared 30-day mortality, 30-day readmission, and length of stay between discharges against medical advice and planned discharges. Results Discharge against medical advice was associated with higher mortality than planned discharge, after adjustment (odds ratio [OR] adj 2.05; 95% confidence interval [CI], 1.48-2.86), and in propensity-matched analysis (OR matched 2.46; 95% CI, 1.29-4.68). Discharge against medical advice also was associated with higher 30-day readmission after adjustment (OR adj 1.84; 95% CI, 1.69-2.01), and in propensity-matched analysis (OR matched 1.65; 95% CI, 1.46-1.87). Finally, discharges against medical advice had shorter lengths of stay than matched planned discharges (3.37 vs 4.16 days, P Conclusions Discharge against medical advice is associated with increased risk for mortality and readmission. In addition, discharges against medical advice have shorter lengths of stay than matched planned discharges, suggesting that the increased risks associated with discharge against medical advice are attributable to premature discharge.

Elevated alkaline phosphatase (AlkPhos) and phosphate levels are associated with cardiovascular morbidity and mortality in patients receiving dialysis. A retrospective cohort study was conducted to test these associations in outpatients with an estimated GFRor =60 ml/min/1.73 m(2).Patients with serum AlkPhos and phosphate levels measured between 2000 and 2002 (n = 10,743) at Montefiore Medical Center (MMC) clinics were followed through September 11, 2008 (median 6.8 years). Mortality data were obtained via Social Security Administration records (n = 949 deaths). Hospitalization data were obtained from MMC records.The mean age was 51 years, 64% were women, 22% were white, 26% were non-Hispanic black, 16% were Hispanic, 13% had a diagnosis of hypertension, 9% had diabetes mellitus, and 8% had cardiovascular disease at baseline. AlkPhos and phosphate were independently associated with mortality and cardiovascular-related hospitalization after multivariable adjustment. Comparing patients in the highest (or =104 U/L) versus lowest quartile of AlkPhos (or =66 U/L), the adjusted hazard ratio (HR) for mortality was 1.65 (P trend across quartiles0.001). For the highest compared with the lowest quartile of serum phosphate (or =3.8 mg/dl versusor =3.0 mg/dl), the adjusted HR for mortality was 1.29 (P trend across quartiles = 0.008). High AlkPhos but not phosphate levels were also associated with all-cause, infection-related, and fracture-related hospitalization.Higher levels of serum AlkPhos and phosphate were associated with increased mortality and cardiovascular-related hospitalization in an inner-city clinic population. Further studies are needed to elucidate mechanisms underlying these associations.

Introduction As opioid analgesic consumption has grown, so have opioid use disorder and opioid-related overdoses. Reducing the quantity of opioid analgesics prescribed for acute non-cancer pain can potentially reduce risks to the individual receiving the prescription and to others who might unintentionally or intentionally consume any leftover tablets. Reducing the default dispense quantity for new opioid analgesic prescriptions in the electronic health record (EHR) is a promising intervention to reduce prescribing. Methods and analysis This study is a prospective cluster randomised controlled trial with two parallel arms. Primary care sites (n=32) and emergency departments (n=4) will be randomised in matched pairs to either a modification of the EHR so that new opioid analgesic prescriptions default to a dispense quantity of 10 tablets (intervention) or to no EHR change (control). The dispense quantity will remain fully modifiable by providers in both arms. From 6 months preintervention to 18 months postintervention, patient-level data will be analysed (ie, the patient is the unit of inference). Patient eligibility criteria are: (A) received a new opioid analgesic prescription, defined as no other opioid analgesic prescription in the prior 6 months; (B) age ≥18 years; and (C) no cancer diagnosis within 1 year prior to the new opioid analgesic prescription. The primary outcome will be the quantity of opioid analgesics prescribed in the initial prescription. Secondary outcomes will include opioid analgesic reorders and health service utilisation within 30 days after the initial prescription. Outcomes will be compared between study arms using a difference-in-differences analysis. Ethics and dissemination This study has been approved by the Montefiore Medical Center/Albert Einstein College of Medicine Institutional Review Board with a waiver of informed consent (2016-6036) and is registered on ClinicalTrials.gov (NCT03003832, 6 December 2016). Findings will be disseminated through publication, conferences and meetings with health system leaders. Trial registration number NCT03003832; Pre-results.