Small Bowel Obstruction Conservatively Managed in Hospital-At-Home

In 2020, Mayo Clinic established an Advanced Care at Home (ACH) program. ACH is a virtual hybrid hospital-at-home (HaH) program that combines telemedicine with in-home care services by utilizing a state that is software-driven, vendor-mediate medical supply chain. The program initially focused on acute medical diagnosis but has expanded to oversee surgical and postsurgical patients with continued inpatient needs. Here, we report the first case of a small bowel obstruction (SBO) managed under a HaH program. A 52-year-old lady presented to the emergency department with symptoms suggestive of mechanical SBO. The diagnosis was confirmed with an abdominopelvic computed tomography (CT) scan, and the patient was admitted to the hospital. Based on the patient's presentation and laboratory results, the care team proceeded with conservative treatment including nasogastric tube (NG) placement and suctioning, intravenous (IV) fluid replacement, and daily laboratory studies. She spent the first hospital day in the physical hospital ward so that the surgical team could ensure stability clinically and no urgent need for surgical intervention. On hospital day two, she was transferred home with ACH where the NG suctioning and IV replacement therapy could continue, while the medical team conducted daily virtual visits to ensure continued improvement. Additionally, a paramedic and a nurse performed an in-person, head-to-toe assessment and administered medications to the patient twice daily. She spent 5 days in ACH getting acute care and then was discharged into a postacute phase equivalent to outpatient monitoring called the restorative phase. She was monitored remotely for the duration of the restorative phase for 10 more days, and then she recovered fully. This case highlights that high-acuity patients with SBO can receive invasive treatments like NG tube suction as well as be appropriately monitored for clinical decompensation by a virtual hybrid home hospital program which combines virtual care providers with an in-home vendor-mediated supply chain.

Telemedicine allows for effective communication between a medically complex cancer patient and his virtual hospital medical team

Good physician-patient communication is key for effective hospital care. We describe a patient diagnosed with an acute pulmonary embolism and bacteremia who was treated in a virtual hybrid hospital-at-home program. Constant communication with the virtual and in-home healthcare teams enabled a unified knowledge of the patient's wishes.

Effect of hospital-at-home vs. traditional brick-and-mortar hospital care in acutely ill adults: study protocol for a pragmatic randomized controlled trial

BACKGROUND

Delivering acute hospital care to patients at home might reduce costs and improve patient experience. Mayo Clinic's Advanced Care at Home (ACH) program is a novel virtual hybrid model of "Hospital at Home." This pragmatic randomized controlled non-inferiority trial aims to compare two acute care delivery models: ACH vs. traditional brick-and-mortar hospital care in acutely ill patients.

METHODS

We aim to enroll 360 acutely ill adult patients (≥18 years) who are admitted to three hospitals in Arizona, Florida, and Wisconsin, two of which are academic medical centers and one is a community-based practice. The eligibility criteria will follow what is used in routine practice determined by local clinical teams, including clinical stability, social stability, health insurance plans, and zip codes. Patients will be randomized 1:1 to ACH or traditional inpatient care, stratified by site. The primary outcome is a composite outcome of all-cause mortality and 30-day readmission. Secondary outcomes include individual outcomes in the composite endpoint, fall with injury, medication errors, emergency room visit, transfer to intensive care unit (ICU), cost, the number of days alive out of hospital, and patient-reported quality of life. A mixed-methods study will be conducted with patients, clinicians, and other staff to investigate their experience.

DISCUSSION

The pragmatic trial will examine a novel virtual hybrid model for delivering high-acuity medical care at home. The findings will inform patient selection and future large-scale implementation.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05212077. Registered on 27 January 2022.

Psychologic wellness of PA, NP, and physician hospitalists during the COVID-19 pandemic

OBJECTIVES

Hospitalists, comprising PAs, NPs, and physicians, manage patients hospitalized with COVID-19. To guide the development of support programs, this study compared the psychologic wellness of hospitalist PAs, NPs, and physicians during the COVID-19 pandemic.

METHODS

We surveyed hospitalists in 16 hospitals at Mayo Clinic, from May 4 to 25, 2020. We used PROMIS surveys for self-reported global well-being (two single-item measures), anxiety, social isolation, and emotional support, before and during the pandemic. Linear and logistic regression models were adjusted for personal and professional factors.

RESULTS

The response rate was 52.2% (N = 154/295). In adjusted linear regression models, the change in scores (before minus during pandemic) for anxiety, social isolation, and emotional support was similar for PAs and NPs compared with physicians. In adjusted logistic regression models, physicians, compared with PAs and NPs, had a higher odds of top global well-being for mental health (adjusted odds ratio [95% confidence interval]: 2.82 [1.12, 7.13]; P = .03) and top global well-being for social activities and relationships (adjusted odds ratio 4.08 [1.38, 12.08]; P = .01).

CONCLUSIONS

During the COVID-19 pandemic, global well-being was lower for PAs and NPs compared with physician hospitalists. These results can guide support programs for hospitalists.

Overall patient experience with a virtual hybrid hospital at home program

Objectives:

Traditional hospital at home models often have high patient experience scores. The purpose of this study is to look at the patient experience of a new virtual hybrid model of hospital at home called Advanced Care at Home.

Methods:

Patients in Mayo Clinic’s Advanced Care at Home program received a survey via email from 1 January–31 May 2021. Each survey consisted of 20 questions divided into 18 multiple-choice and two open-ended questions.

Results:

Ninety-nine surveys were sent and 41 partially or completely finished surveys were returned for a response rate of 41.4%. Patients responded positively, denoted by answering “strongly agree or somewhat agree,” with regard to the ability to reach the team right away 100% of the time, being kept informed 92% of the time, the command center responding promptly to their needs 95% of the time, the team providing comfort and support 98% of the time, feeling comfortable with interacting with their provider by phone or tablet 95% of the time, the ease of use from the equipment 97% of the time, the virtual and in-person staff working well together 98% of the time, the staff treating patients with courtesy and respect 100% of the time, and the ease of understanding the discharge process and feeling ready to leave the program 100% of the time. All providers received positive responses on listening ⩾88% of the time. Patients gave a top rating in likelihood to recommend the program 100% of the time.

Conclusion:

Overall, the Advanced Care at Home model of hospital at home was highly recommended by patients. Patients scored the program high on responsiveness, staff engagement and communication, ease of equipment use, and readiness for discharge, strengthening the overall confidence in this novel program.

A Virtual Hybrid Care Hotel Model Supports the Recovery of Post-procedural Patients with Mild to Severe Systemic Diseases

BACKGROUND

Patients with mild to severe chronic systemic disease undergoing low-risk procedures are often hospitalized for observation. The Care Hotel is a novel virtual medicine hybrid model of care that offers patients a comfortable, out of hospital environment where they can receive both in-person and virtual care after a surgery or procedure. This study aimed to analyze if virtual hybrid post-procedure care in a hotel could be both conducted on and accepted by patients, even those with moderate to severe chronic diseases.

METHODS

This retrospective cohort study was conducted between July 23, 2020 and June 4, 2021 at Mayo Clinic in Florida, a 306-bed community academic hospital. We collected the sex, age, race, ethnicity, acceptance rate, ASA score, and primary procedure of patients using the Care Hotel.

RESULTS

Out of 392 patients, 272 (69.4%) opted for care in the program. Median patient age was 61.5 years, 59.56% were males, and 86.40% were white. We found that 50.37% had an ASA score of 2 and 43.4% had an ASA score of 3. Ten different surgical specialties were able to utilize the Care Hotel for care in 47 different procedure types. Urology had the most patients (n=70, 25.7%). Post-electrophysiologic procedures were the most common procedures (n=39, 14.3%).

CONCLUSION

Our virtual hybrid Care Hotel program was widely accepted by patients and could care for a multitude of post-operative procedures. Additionally, this novel program can care for patients with both mild and severe systemic diseases.

Wellness of hospitalists and hospital medicine advanced practice providers during the COVID-19 pandemic, 2020-2021

BACKGROUND

The early phase of the coronavirus disease 2019 (COVID-19) pandemic had a negative impact on the wellness of hospitalists and hospital medicine advanced practice providers (APPs). However, the burden of the pandemic has evolved and the change in hospitalist and hospital medicine APP wellness is unknown.

OBJECTIVE

To evaluate the longitudinal trend in wellness of hospitalists and hospital medicine APPs during the COVID-19 pandemic and guide wellness interventions.

DESIGN, SETTING AND PARTICIPANTS

Between May 4, 2020, and June 6, 2021, we administered three surveys to Internal Medicine hospitalists (physicians) and hospital medicine APPs (nurse practitioners and physician assistants) at 16 Mayo Clinic hospitals in four U.S. states.

MEASUREMENTS

We evaluated the association of hospitalist and hospital medicine APP characteristics with PROMIS® measures of global wellbeing-mental health, global wellbeing-social activities and relationships, anxiety, social isolation, and emotional support, using logistic and linear regression models.

RESULTS

The response rates were 52.2% (n=154/295; May 2020), 37.1% (n=111/299; October 2020) and 35.5% (n=114/321; May 2021). In mixed models that included hospitalist and hospital medicine APP characteristics and survey period, APPs, compared with physicians, had lower odds of top global wellbeing-social activities and relationships (adjusted odds ratio 0.42 [0.22-0.82]; p = .01), whereas survey period showed no association. The survey period showed an independent association with higher anxiety (May 2020 vs. others) and higher social isolation (October 2020 vs. others), whereas profession showed no association. Concern about contracting COVID-19 at work was significantly associated with lower odds of top global wellbeing-mental health and global wellbeing-social activities and relationships, and with higher anxiety and social isolation. Hospitalist and hospital medicine APP characteristics showed no association with levels of emotional support.

CONCLUSIONS

In this longitudinal assessment of hospitalists and hospital medicine APPs, concern about contracting COVID-19 at work remained a determinant of wellness. The trend for global wellbeing, anxiety, and social isolation may guide wellness interventions.

Provider Evaluation of a Novel Virtual Hybrid Hospital at Home Model

Background

Healthcare provider’s experience with new models of care is crucial for long-term success. In July 2020, Mayo Clinic implemented a novel virtual hybrid hospital at home program called Advanced Care at Home (ACH). This model allows virtual providers in a command center to care for high-acuity patients in the home setting through collaboration with a vendor-mediated supply chain. This study aims to describe the outcomes obtained from a survey applied to the ACH providers to determine their acceptance of the quality and safety of the virtual hybrid care model, their perception towards the decision-making and teamwork between the command center and supplier network, and determine if the overall experience with ACH was rewarding.

Methods

A 15-question anonymous survey was distributed via email quarterly to all the physicians and nurse practitioners registered in ACH program at Mayo Clinic. The survey encompassed questions related to the overall experience in ACH concerning work environment, quality of care, service reliability, teamwork, decision-making, and satisfaction. All the questions were Likert-like scale choice, and a descriptive analysis using frequency distribution and percentages of the data was performed.

Results

Between September 1, 2020 and April 30, 2021, three quarterly surveys were sent to a total of 21 physicians and nurse practitioners caring for patients virtually in ACH. The response rate reported was 72%, 33%, and 66%, respectively, at the first, second, and third quarters. Eighty percent or more of providers consistently gave positive scores to all three areas analyzed throughout the 8-month study.

Conclusion

Providers found the ACH virtual hybrid model of home hospital care very rewarding. They were able to deliver high-quality and safe care to their patients through positive teamwork with a vendor-mediated supply chain. This novel model of hospital at home has the potential to be a great provider satisfier moving forward.

Medication non-adherence as a cause of apixaban failure in venous thromboembolism: The importance of pharmacist medication reconciliation

Venous thromboembolism is often treated with direct oral anticoagulants. In order for direct oral anticoagulants to be effective, patients must adhere to a specific dosing strategy. We report a case of apixaban failure, the clinical workup that ensued, and the eventual discovery of unsuccessful medication adherence as the cause.

Improving Patient Selection and Prioritization for Hospital at Home Through Predictive Modeling

Hospital at home is designed to offer patients hospital level care in the comfort of their own home. The process by which clinicians select eligible patients that are clinically and socially appropriate for this model of care requires labor-intensive manual chart reviews. We addressed this problem by providing a predictive model, web application, and data pipeline that produces an eligibility score based on a set of clinical and social factors that influence patients' success in the program. Providers used this predictive model to prioritize the order in which they perform chart reviews and patient screenings. Training performance area under the curve (AUC) was 0.77. Testing 'in production' had an AUC of 0.75. Admission criteria in training rapidly changed over the course of the study due to the novelty of the clinical model. The current algorithm successfully identified many inconsistencies in enrollment and has streamlined the process of patient identification.

Home Telemonitoring to Reduce Readmission of High-Risk Patients: a Modified Intention-to-Treat Randomized Clinical Trial

BACKGROUND

Home telemonitoring has been used with discharged patients in an attempt to reduce 30-day readmissions with mixed results.

OBJECTIVE

To assess whether home 30-day telemonitoring after discharge for patients at high risk of readmission would reduce readmissions or mortality.

DESIGN

Prospective, randomized controlled trial.

PATIENTS

We compared 30-day readmission rates and mortality for patients at high risk for readmission who received home telemonitoring versus standard care between November 1, 2014, and November 30, 2018, in 2 tertiary care hospitals.

INTERVENTIONS

The intervention group received home-installed equipment to measure blood pressure, heart rate, pulse oximetry, weight if heart failure was present, and glucose if diabetes was present. Results were transmitted daily and reviewed by a nurse. Both groups received standard care.

MAIN MEASURES

The primary outcome was a composite end point of hospital readmission or death within 30 days after discharge. The secondary outcome was an emergency department visit within 30 days after discharge.

KEY RESULTS

A total of 1380 participants (mean [SD] age, 66 [14] years; 722 [52.3%] men and 658 [47.7%] women) participated in this study. Using a modified intention-to-treat analysis, the risk of readmission or death within 30 days among patients at high readmission risk was 23.7% (137/578) in the control group and 18.2% (87/477) in the telemonitoring group (absolute risk difference, - 5.5% [95% CI, - 10.4 to - 0.6%]; relative risk, 0.77 [95% CI, 0.61 to 0.98]; P = .03). Emergency department visits occurred within 30 days after discharge in 14.2% (81/570) of patients in the control group and 8.6% (40/464) of patients in the telemonitoring group (absolute risk difference, - 5.6% [95% CI, - 9.4 to - 1.8%]; relative risk, 0.61 [95% CI, 0.42 to 0.87]; P = .005).

CONCLUSIONS

Thirty days of postdischarge telemonitoring may reduce readmissions of high-risk patients.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02136186.

Hospitalist perspectives on barriers to recommend and potential benefit of the COVID-19 vaccine

Background: Hospitalists, comprised of nurse practitioners and physician assistants (collectively, advanced practice providers [APPs]) and physicians, have opportunities to counsel patients and reduce SARS-CoV-2 related coronavirus disease 2019 (COVID-19) vaccine hesitancy. However, hospitalist perspectives on the COVID-19 vaccine and potential differences between APPs and physicians are unknown. Understanding hospitalist perspectives could help to address vaccine hesitancy among patients.Methods: We conducted an online survey of hospitalists at Mayo Clinic sites in Arizona, Florida, Minnesota, and Wisconsin from 14 December 2020 through 4 January 2021. We collected demographic information and assessed perspectives on the COVID-19 vaccine and, for comparison, on the influenza vaccine. Descriptive statistics were used to compare responses between APPs and physicians.Results: The overall response rate was 42.7% (n = 128/300) and comprised of 53.9% women (n = 69/128) and 41.4% APPs (n = 53/128). Most hospitalists reported receiving or planning to receive vaccination against COVID-19 (93.7%; n = 119/128) and influenza (97.7%; n = 125/128). Most hospitalists reported they would advise 100% of patients to receive the COVID-19 vaccine (66% for APPs; 74.7% for physicians) and influenza vaccine (83% for APPs; 80% for physicians). Barriers to recommending the COVID-19 vaccine included patient health status and vaccine safety profile. Hospitalists reported that patients and coworkers receiving the COVID-19 vaccine would reduce their anxiety (~80% of hospitalists), social isolation (~64% of hospitalists), and improve their emotional support (~40% of hospitalists). APP and physician responses were similar. The possible reduction in social isolation was associated with higher odds of hospitalists advising all patients to receive the COVID-19 vaccine (adjusted odds ratio 2.95 [95% confidence interval, 1.32-6.59]; P< .008), whereas hospitalist age, gender, and profession showed no association.Conclusion: Most hospitalists would reportedly advise patients to receive the COVID-19 vaccine. Barriers to this recommendation included patient health status and vaccine safety. Hospitalists are an important resource to provide patient education and reduce COVID-19 vaccine hesitancy.

Psychological wellness of internal medicine hospitalists during the COVID-19 pandemic

BACKGROUND

Patients with COVID-19 infection requiring in-hospital care are frequently managed by Internal Medicine hospitalists, comprised of physicians, nurse practitioners and physician assistants. There is sparse information on the psychological impact of the COVID-19 pandemic on Internal Medicine hospitalists.

METHODS

We surveyed Internal Medicine hospitalists at Mayo Clinic sites in four states (Arizona, Florida, Minnesota, and Wisconsin). We collected demographic information, and used Patient-Reported Outcomes Measurement Information System (PROMIS®) measures to assess global well-being, anxiety, social isolation, and emotional support. Descriptive statistics were used to compare responses between two periods: prior to the pandemic (before March 15^th, 2020), and during the pandemic (March 15 through 30 April 2020). The survey was conducted from May 4-25, 2020.

RESULTS

Of 295 Internal Medicine hospitalists, 154 (52%) responded. Fifty-six percent were women (n = 85/154) and 54% were physicians (n = 84/154). Most hospitalists (75%; n = 115/154) reported concerns about contracting COVID-19 infection at work, and 5% (n = 8/154) reported changing where they lived during the pandemic. Most hospitalists (73%; n = 112/154) reported relying primarily on institutional resources for COVID-19 information. During the pandemic, the percentage of participants with excellent or very good global well-being decreased (90% prior to pandemic vs. 53% during pandemic), with increases in mean anxiety (-4.88 [95% confidence interval, - 5.61 to - 4.16]; P<.001) and social isolation (-3.91[95% confidence interval, - 4.68 to - 3.13]; P<.001). During the same period, there was a small decrease in mean emotional support (1.46 [95% confidence interval, 0.83 to 2.09]; P<.001).

CONCLUSION

During the COVID-19 pandemic, Internal Medicine hospitalists reported lower global well-being, higher anxiety and social isolation, and a small decrease in emotional support. These results provide a framework to develop programs to support hospitalists and potentially mitigate long-term psychological sequelae including burnout.

Are pre-existing psychiatric disorders the only reason for involuntary holds in the emergency department?

Objectives

To determine the role of previous psychiatric disorders including substance use disorders on emergency department (ED) patients on involuntary holds and compare presentations, treatment, and outcomes based on cause.

Methods

We conducted a retrospective study of patients ≥ 18 years old on involuntary holds in the ED of a tertiary care center from January 1, 2013, to November 30, 2015. Demographic and clinical information were collected. Those with and without prior psychiatric disorder including substance use disorder were compared.

Results

We identified 251 patients of which 129 (51.4%) had a psychiatric disorder, 23 (9.2%) had a substance use disorder, and 86 (34.3%) had both. Thirteen patients (5.2%) had no psychiatric disorder or substance use disorder and the majority 10 (76.9%) were on involuntary holds due to suicidal threats related to pain or another medical problem. Patients without a psychiatric or substance use disorder were older (55 years [17.8] vs 42 [19]; P = 0.01), more likely to be married (10 [76.9%] vs 64 [26.9%]; P < 0.001), and had more medical comorbidities (10 [76.9%] vs 114 [47.9%]; P = 0.049) compared with those without a psychiatric or substance use disorder.

Conclusion

Patients on involuntary holds most commonly have pre-existing psychiatric disorder including substance use disorder. Patients on involuntary holds without history of psychiatric disorder often have severe pain or other active medical conditions which may contribute to suicidal thoughts. Addressing these underlying medical issues may be crucial in preventing further psychiatric decompensation.

Perspectives on and barriers to research among advanced practice provider and physician hospitalists

Advanced practice providers and physicians at an academic healthcare system comprising more than 15 hospitals across four US states were surveyed to identify barriers to participation in research. Overall, barriers reported by advanced practice providers and physicians were more similar than different, highlighting system-level opportunities to build research skills and accelerate academic productivity.

Perception of barriers to research among internal medicine physician hospitalists by career stage

BACKGROUND

Physician hospitalists may participate in research and generate knowledge for evidence-based hospital practice. Despite this, physician hospitalists are primarily involved in patient care, and there is sparse information on barriers for their participation in research and if these barriers differ by career stage.

METHODS

We conducted a survey of physician hospitalists at Mayo Clinic sites based in four states (Arizona, Florida, Minnesota, and Wisconsin). We surveyed physician hospitalists on demographics, academic rank, current research skills, barriers for participation in research, and research skills they aspire to acquire. Responses were summarized using descriptive statistics and categorized by early-career (<10 years), mid-career (10-20 years), and later-career (≥20 years) stages at Mayo Clinic. The survey was conducted from March to April 2019.

RESULTS

Of 188 physician hospitalists, there was a 52% response rate with 71% in early career, 21% mid-career, and 7% late career, with 39% female. Physician hospitalists at early-career (90%), mid-career (76%), and later-career (71%) stages were interested in participating in research. Among physician hospitalists with ≤3 peer-reviewed publications, barriers for participation in research included lack of mentorship, time, research skills, and funding. Among physician hospitalists with ≥4 peer-reviewed publications, factors for research success included mentorship (89% early-career, 38% mid-career, 75% later-career; p = 0.002) and membership in a research team. Compared to mid- and later-career physician hospitalists, a higher proportion of early-career hospitalists was interested in acquiring skills to both critically review the literature (70% early-career, 43% mid-career, 0% later-career; p = 0.006) and write manuscripts (86% early-career, 57% mid-career, 50% later-career; p = 0.02); there was generally similar interest across career stages to acquire skills to conduct literature searches and write grants.

CONCLUSION

The generally similar responses from physician hospitalists across career stages highlight system-level opportunities to increase research mentorship, promote the acquisition of research skills, and reduce barriers for participation in research.

A Longitudinal Curriculum In Point-Of-Care Ultrasonography Improves Medical Knowledge And Psychomotor Skills Among Internal Medicine Residents

PURPOSE

Despite its growing popularity and clinical utility among hospital-based physicians, there are no formal competency requirements nor training standards for United States based Internal Medicine Residencies for learning point-of-care ultrasonography (POCUS). The purpose of this investigation was to study the impact and effectiveness of a novel POCUS curriculum for an Internal Medicine (IM) residency program.

PATIENTS AND METHODS

This was a Single-Group Educational Quasi-Experiment involving Categorical and Preliminary Internal Medicine Residents in Post-Graduate Years 1 through 3 at a single United States academic tertiary center. The study period was from January 1, 2017, through June 30, 2017, during which time the residents participated in monthly modules including didactics and hands-on ultrasound scanning skills with live models. Participants completed a comprehensive knowledge examination at the beginning and end of the six-month period. Participants were also tested regarding hands-on image acquisition and interpretation immediately before and after the hands-on skills labs. The primary outcome measure was performance improvement in a comprehensive medical knowledge assessment.

RESULTS

In total, 42 residents consented for participation. The residents' monthly rotations were adjusted in order to accommodate the new educational process. Among 29 participants with complete data sets for analysis, the mean (SD) comprehensive knowledge examination score improved from 60.9% before curriculum to 70.2% after curriculum completion (P<0.001). Subgroup analysis determined that improvement in medical knowledge required attending at least 2 out of the 6 (33%) educational sessions. Attendance at hands-on skills labs correlated significantly with improvement; didactics alone did not.

CONCLUSION

A longitudinal POCUS curriculum consisting of both didactic sessions and hands-on skills labs improves knowledge, image acquisition, and interpretation skills of residents. Having this curriculum span at least 6 months provides learners the opportunity to attend multiple classes which strengthens learning through repetition while also providing learners flexibility in schedule.

Goal-Directed Achievement Through Geographic Location (GAGL) Reduces Patient Length of Stay and Adverse Events

This prospective cohort study aimed to improve hospital outcomes through geographic location of hospitalist patients and conducting daily multidisciplinary team rounds-Goal-directed Achievements through Geographic Location (GAGL). Patients were admitted to a geographic (GAGL) study unit where daily multidisciplinary rounds took place among nursing, case management, a hospitalist, pharmacy, physical and occupational therapy, respiratory therapy, and nutrition services. A total of 985 (56.4%) patients were admitted to the GAGL study unit and 760 patients (43.6%) were admitted to non-GAGL units. Patients admitted to the GAGL study unit had a shorter average length of stay (3.64 days vs 4.35 days, P = .0001) and a lower number of risk events (91 [9.2%] vs 93 [12.2%], P = .038). There was no significant difference in 30-day readmissions, avoidable day events, or code blue team activations. GAGL provides a framework for hospital organizations to improve provider communication, hospital efficiency, and patient safety.

Patients Threatening Harm to Others Evaluated in the Emergency Department under the Florida Involuntary Hold Act (Baker Act)

OBJECTIVES

This study describes the specific threats of harm to others that led to the use of the Baker Act, the Florida involuntary hold act for emergency department (ED) evaluations. The study also summarizes patient demographics, concomitant psychiatric diagnoses, and emergent medical problems.

METHODS

This is a retrospective review of 251 patients evaluated while on involuntary hold from January 1, 2014 through November 30, 2015 at a suburban acute care hospital ED. The data that were collected included demographic information, length of stay, reason for the involuntary hold, psychiatric disorder, substance use, medical illness, and violence in the ED. The context of the homicidal threat also was collected.

RESULTS

We found that 13 patients (5.2%) were homicidal. Three patients had homicidal ideations alone, whereas 10 made homicidal threats toward others. Of the 10 making homicidal threats, 7 named a specific person to harm. Ten of the 13 homicidal patients (76.9%) also were suicidal. Eleven patients (84.6%) had a psychiatric disorder: 9 patients (69.2%) had a depressive disorder and 8 patients (61.5%) had a substance use disorder. Eight patients had active medical problems that required intervention in the ED.

CONCLUSIONS

We found that three-fourths of patients expressing homicidal threats also were suicidal. The majority of patients making threats of harm had a specific plan of action to carry out the threat. It is important to screen any patient making homicidal threats for suicidal ideation. If present, there is a need to implement immediate management appropriate to the level of the suicidal threat, for the safety of the patient. Eighty-five percent of patients making a homicidal threat had a previously documented psychiatric disorder, the most common being a depressive disorder. This finding differs from previous studies in which psychosis predominated. More than 60% of homicidal patients had an unrelated medical disorder requiring intervention. It is important not to overlook these medical disorders while focusing on the psychiatric needs of the patient; most of our homicidal patients proved to be cooperative in the ED setting.

Intracranial Hemorrhage following Lumbar Puncture in a Patient on Apixaban

Currently, clinical practice recommendations regarding patients in need of emergent lumbar puncture who are taking direct oral anticoagulants (DOACs) are based upon expert opinion, as evidence-based guidelines are unavailable. We present the case of an 80-year-old Caucasian lady who underwent diagnostic lumbar puncture for presumed meningitis while on therapeutic apixaban for nonvalvular atrial fibrillation. She was subsequently found to have bilateral subdural hematomas. This case report reviews both the current criteria for computerized tomography brain imaging prior to lumbar puncture as well as the bleeding risks of lumbar puncture while on a DOAC.

Pregnancy and Parenting During Cardiology Fellowship

Background

An increasing number of residents and fellows have children during training. However, little is known about the specific experience of cardiology fellows who become parents during training.

Methods and Results

A 66‐question Internet‐based survey about experiences of pregnancy during graduate medical training was administered between May 1 and July 15, 2013, to all trainees (N=1516) in the Mayo School of Graduate Medical Education across 3 academic sites. Questions explored the experiences of new mothers, fathers, and their fellow trainees. There were 644 survey respondents overall (response rate, 42%), and of 73 cardiovascular trainees, 29 (10 women [35%]) completed the survey. Of those surveyed, 59% reported having children. All trainee mothers reported making alterations to their training schedule due to pregnancy and maternity leave. Twenty percent of trainee fathers also reported changing their training because of their partner's pregnancy. Of trainees with children, 41% reported difficulty completing research because of pregnancy and childcare obligations. Nontrainee mothers were significantly more likely to breastfeed beyond 6 months compared with trainee mothers (P=0.018). A perceived stigma attached to pregnancy was reported by 62% of trainees. Both male and female trainees felt that their programs did not promote pregnancy‐related schedule flexibility.

Conclusions

Our study shows that both men and women entering parenthood during cardiology training often have to change their schedule, research, and career path. Cardiology training programs should focus on curriculum design and supportive parenthood policies to both avoid negative stigma and optimize fellowship training during this time period.

See Editorial Jarvie and Levy

Use of a simulation-based advanced resuscitation training curriculum: Impact on cardiopulmonary resuscitation quality and patient outcomes

Background

Despite a continued focus on improved cardiopulmonary resuscitation quality, survival remains low from in-hospital cardiac arrest. Advanced Resuscitation Training has been shown to improve survival to hospital discharge and survival with good neurological outcome following in-hospital cardiac arrest at its home institution. We sought to determine if Advanced Resuscitation Training implementation would improve patient outcomes and cardiopulmonary resuscitation quality at our institution.

Methods

This was a prospective, before-after study of adult in-hospital cardiac arrest victims who had cardiopulmonary resuscitation performed. During phase 1, standard institution cardiopulmonary resuscitation training was provided. During phase 2, providers received the same quantity of training, but with emphasis on Advanced Resuscitation Training principles. Primary outcomes were return of spontaneous circulation, survival to hospital discharge, and neurologically favorable survival. Secondary outcomes were cardiopulmonary resuscitation quality parameters.

Results

A total of 156 adult in-hospital cardiac arrests occurred during the study period. Rates of return of spontaneous circulation improved from 58.1 to 86.3% with an adjusted odds ratios of 5.31 (95% CI: 2.23-14.35, P < 0.001). Survival to discharge increased from 26.7 to 41.2%, adjusted odds ratios 2.17 (95% CI: 1.02-4.67, P < 0.05). Survival with a good neurological outcome increased from 24.8 to 35.3%, but was not statistically significant. Target chest compression rate increased from 30.4% of patients in P1 to 65.6% in P2, adjusted odds ratios 4.27 (95% CI: 1.72-11.12, P = 0.002), and target depth increased from 23.2% in P1 to 46.9% in P2, adjusted odds ratios 2.92 (95% CI: 1.16-7.54, P = 0.024).

Conclusions

After Advanced Resuscitation Training implementation, there were significant improvements in cardiopulmonary resuscitation quality and rates of return of spontaneous circulation and survival to discharge.

Acute Unilateral Vision Loss Due to Optic Neuropathy in a Patient with Systemic Lupus Erythematosus

Patient: Female, 44

Final Diagnosis: Optic neuritis

Symptoms: Unilateral vision loss

Medication: —

Clinical Procedure: Fundoscopic examination

Specialty: Ophthalmology