Tell-a provider about tele: Reducing overuse of telemetry across 10 hospitals in a safety net system

BACKGROUND

Telemetry is often a scarce resource at hospitals and is important for arrhythmia and myocardial ischemia detection. Overuse of telemetry monitoring leads to alarm fatigue resulting in failure to respond to arrhythmias, patient harm, and possible unnecessary testing.

METHODS

This quality improvement initiative was implemented across NYC Health and Hospitals, an 11-hospital urban safety net system. The electronic health record intervention involved the addition of a mandatory indication in the telemetry order and a best practice advisory (BPA) that would fire after the recommended time period for reassessment had passed.

RESULTS

The average telemetry hours per patient encounter went from 60.1 preintervention to 48.4 postintervention, a 19.5% reduction (p < .001). When stratified by the 11 hospitals, decreases ranged from 9% to 30%. The BPA had a 53% accept rate and fired 52,682 times, with 27,938 "discontinue telemetry" orders placed. The true accept rate was 50.4%, as there was a 2.6% 24-h reorder rate. There was variation based on clinician specialty and clinician type (attending, fellow, resident, physician associate, nurse practitioner).

CONCLUSION

We successfully reduced telemetry monitoring across a multisite safety net system using solely an electronic health record (EHR) intervention. This expands on previous telemetry monitoring reduction initiatives using EHR interventions at single academic sites. Further study is needed to investigate variation across clinician type, specialty, and post-acute sites.

Pilot study of autologous fecal microbiota transplants in nursing home residents: Feasibility and safety

Introduction

Antibiotic resistant bacterial infections (ARBIs) are extremely common in nursing home residents. These infections typically occur after a course of antibiotics, which eradicate both pathological and beneficial organisms. The eradication of beneficial organisms likely facilitates subsequent ARBIs. Autologous fecal microbiota transplant (aFMT) has been proposed as a potential treatment to reduce ARBIs in nursing home residents. Our objective was to determine the feasibility and safety of aFMT in a nursing home population.

Methods

Pilot clinical trial. We evaluated feasibility as total number of stool samples collected for aFMT production and safety as the number and relatedness of serious (SAE) and non-serious adverse events (AE).

Results

We screened 468 nursing home residents aged ≥18 years for eligibility; 67 enrolled, distributed among three nursing homes. Participants were 62.7% female and 35.8% Black. Mean age was 82.2 ± 8.5 years. Thirty-three participants underwent successful stool collection. Seven participants received antibiotics; four participants underwent aFMT. There were 40 SAEs (17 deaths) and 11 AEs. In the aFMT group, there were 3 SAEs (2 deaths) and 10 AEs. All SAEs and AEs were judged unrelated to the study intervention.

Conclusions

In this pilot study of aFMT in nursing home residents, less than half were able to provide adequate stool samples for aFMT. There were no related SAEs or AEs during the study. In sum, we conclude aFMT has limited feasibility in a nursing home population due to logistic and technical challenges but is likely safe.

Trial registration

ClinicalTrials.gov Identifier: NCT03061097.

Effect of parenteral nutrition in oxygen escalation/de-escalation in SARS-CoV-2 infected patients who are pre-intubation: A multicenter, observational study

Background & aims

SARS-CoV-2 infection includes a variety of gastrointestinal manifestations along with the usual viral symptoms of malaise and myalgias. The objective of this study was to determine if intravenous parenteral nutrition (PN) affected the risk of intubation in SARS-CoV-2 patients who were dependent on non-invasive ventilation.

Methods

Retrospective, multicenter case-control study which analyzed oxygen requirements for 1974 adults with SARS-CoV-2, who were admitted to the local public hospital system between March 1 and May 17, 2020. Relevant baseline biomarkers were studied over 5 days. The main outcome was an escalation or de-escalation of oxygen requirements relative to the exposure of PN.

Results

111 patients received PN while on non-invasive ventilation. Patients who received PN had a significantly lower odds (p < 0.001) of oxygen escalation in comparison to their control group counterparts (OR = 0.804, 95% CI 0.720, 0.899) when matched for age, body mass index, Charlson comorbidity index, and gender.

Conclusion

Initiating PN in the setting of non-invasive ventilation of SARS-CoV-2 infected patients was significantly associated with a lower odds of oxygen escalation. PN does not independently exacerbate oxygen requirements in SARS-CoV-2 infected pre-intubated patients.

Albumin as a Prognostic Indicator in Pre-Intubated Patients With SARS-CoV-2: A Retrospective, Multi-Institutional Study

Background

Much effort has been placed on evaluating serological tests that can predict worsening prognosis in severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Endotracheal intubation in SARS-CoV-2 is associated with a higher risk of mortality. While studies have evaluated serological markers that can predict worsening prognosis, the likelihood of intubation in these patients has not been evaluated. The objective of this study was to determine if any serum marker corresponded to oxygen escalation or de-escalation in SARS-CoV-2-infected pre-intubated patients.

Methodology

This retrospective study reviewed 1,754 SARS-CoV-2 patients in the New York City Health and Hospitals Corporation (NYCHHC) system who required non-invasive positive pressure ventilation (NIPPV) such as continuous positive airway pressure or bilevel positive airway pressure. All patients were above the age of 18, were not terminally ill and requiring hospice care, and were admitted to the NYCHHC system between March 1, 2020 and May 17, 2020. SARS-CoV-2 serological labs were collected for five days for patients initiated on NIPPV, such that day one was 24 hours after NIPPV initiation.

Results

Multivariate and univariate linear regression modeling on this population cohort was remarkable for a significant association between serum albumin levels and oxygen escalation or de-escalation from NIPPV.

Conclusions

We conclude that serum albumin level may have further utility in predicting oxygen escalation in pre-intubated patients with SARS-CoV-2, especially in a low-resource and high-demand setting.

Wound Care Consultation in Postacute/Long-term Care: Characteristics and Practice Implications

OBJECTIVE

To study the characteristics of residents in postacute (PA)/long-term care (LTC) facilities with wounds and prevalence of wound types other than pressure injuries (PIs).

METHODS

The authors conducted a retrospective review of all wound care consultations over 1 year at The New Jewish Home, a 514-bed academically affiliated facility in an urban setting. Investigators analyzed residents by age, sex, type of wound, presence of infection, and whether the resident was PA or LTC. Authors designated PIs as facility acquired or present on admission.

RESULTS

During the study period, 190 wound care consultations were requested; 74.7% of consults were for those in PA care. The average patient age was 76.3 years, and there were 1.7 wounds per resident receiving consultation. Of studied wounds, 53.2% were PIs, 15.8% surgical, 6.8% arterial, 6.3% soft tissue injury, 5.8% venous, 2.6% malignant wounds, and 2.1% diabetic ulcers; however, 11.6% of residents receiving consults had more than one wound type. In this sample, 13.2% of residents had infected wounds, and 76.2% of PIs were present on admission.

CONCLUSIONS

The wide variety of wounds in this sample reflects the medical complexity of this population. The transformation of LTC into a PA environment has altered the epidemiology of chronic wounds and increased demand for wound care expertise. These results challenge traditional perceptions of wound care centered on PIs. Given its importance, a wound care skill set should be required of all PA/LTC providers.

Effect of zinc supplementation on serum zinc concentration and T cell proliferation in nursing home elderly: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Zinc is essential for the regulation of immune response. T cell function declines with age. Zinc supplementation has the potential to improve the serum zinc concentrations and immunity of nursing home elderly with a low serum zinc concentration.

OBJECTIVE

We aimed to determine the effect of supplementation with 30 mg Zn/d for 3 mo on serum zinc concentrations of zinc-deficient nursing home elderly.

DESIGN

This was a randomized, double-blind, placebo-controlled study. Of 53 nursing home elderly (aged ≥65 y) who met eligibility criteria, 58% had a low serum zinc concentration (serum zinc <70 μg/dL); these 31 were randomly assigned to zinc (30 mg Zn/d) (n = 16) or placebo (5 mg Zn/d) (n = 15) groups. The primary outcome measure was change in serum zinc concentrations between baseline and month 3. We also explored the effects of supplementation on immune response.

RESULTS

Baseline characteristics were similar in the 2 groups. The difference in the mean change in serum zinc was significantly higher, by 16%, in the zinc group than in the placebo group (P = 0.007) when baseline zinc concentrations were controlled for. In addition, controlling for baseline C-reactive protein, copper, or albumin did not change the results. However, supplementation of participants with ≤60 μg serum Zn/dL failed to increase their serum zinc to ≥70 μg/dL. Zinc supplementation also significantly increased anti-CD3/CD28 and phytohemagglutinin-stimulated T cell proliferation, and the number of peripheral T cells (P < 0.05). When proliferation was expressed per number of T cells, the significant differences between groups were lost, suggesting that the zinc-induced enhancement of T cell proliferation was mainly due to an increase in the number of T cells.

CONCLUSIONS

Zinc supplementation at 30 mg/d for 3 mo is effective in increasing serum zinc concentrations in nursing home elderly; however, not all zinc-deficient elderly reached adequate concentrations. The increase in serum zinc concentration was associated with the enhancement of T cell function mainly because of an increase in the number of T cells.

Polyarthritis as the initial symptom of secondary syphilis: case report and review

The differential diagnosis of the patient with acute polyarthritis is lengthy. We present the case of a young man with acute inflammation of the knees and ankles in whom a diagnosis of acute rheumatic fever was initially considered. The clinical course and laboratory findings suggested that secondary syphilis was also a likely etiology of his problem. We believe that in some patients with acute polyarthritis, secondary syphilis must be seriously considered as part of the differential diagnosis.

Distribution of phosphatidylethanolamine arachidonic acid in platelet membranes

Arachidonic acid (20 : 4) and other fatty acids and aldehydes in phosphatidylethanolamine (PE) present on the platelet surface was determined. Surface-exposed PE was isolated by using 2,4,6-trinitrobenzenesulfonate, a non-penetrating probe (Schick, P.K., Kurica, K.B. and Chacko, G.K. (1976) J. Clin. Invest. 57, 1221--1226). PE contains 50% total platelet arachidonic acid. Approx. 16% platelet PE is present on the platelet surface. The study showed that the fatty acid and aldehyde composition of PE on the platelet surface is virtually identical to that in PE present inside the platelet. Therefore, 8 nmol arachidonic acid are present in PE in the outer layer of the plasma membrane in 10(9) platelets.