Got Diabetes? With Us, You\u27ll Have Complete Diabetic Care

AIM: By April 2016, we aim to improve Complete Diabetic Care of Thursday JHAP Clinic\u27s patients with diabetes by 50%. * These authors contributed equallyhttps://jdc.jefferson.edu/patientsafetyposters/1007/thumbnail.jp

Utilization of a multimodal preoperative pain regimen prior to gynecologic oncology exploratory laparotomies

Objective: The aim of this study was to evaluate the use of a combination of non-opioid preoperative pain medications including Tylenol, Lyrica, and Celecoxib (TLC) in patients undergoing gynecologic oncologic exploratory laparotomies. We evaluated postoperative narcotic use in morphine equvalents (ME) as well as pain scores, anti-emetic use, and length of stay.https://jdc.jefferson.edu/patientsafetyposters/1055/thumbnail.jp

Improving Productivity Through Scheduling at the WMed Family Medicine Residency Clinic

INTRODUCTION: The Accreditation Council for Graduate Medical Education (ACGME) requires every family medicine residency program to have a practice site that supports, “continuous, comprehensive, convenient, accessible, and coordinated patient care”. The WMed Family Medicine Resident Clinic (Team Oakland), located within the Family Health Center (FHC) – Paterson location, has long been plagued by scheduling difficulties, as evidenced by high no-show rates, empty appointment slots, and frequent cancellations threatening the ability of our residents to achieve the required number of outpatient visits mandated by the Family Medicine Residency Review Committee (RRC) and the requirement for continuity from the ACGME. We believe many of these issues arise from the FHC’s open-access scheduling template, which heavily favors same day and walk in visits. PURPOSE: This quality improvement project aims to assess the productivity of the Western Michigan Family Medicine Clinic through a scheduling analysis to determine how we can better meet the needs of our patients while also meeting the visit numbers required of the RRC for our residents. STUDY DESIGN: This study is a retrospective scheduling analysis in which our no show rate and unfilled appointments will be considered. Scheduling data for Team Oakland was collected from December 1st, 2016 to January 31st, 2017 through customizable EPIC reports. RESULTS: Data shown below exhibits the total number of appointment slots for Team Oakland broken down by the number of appoints filled, unfilled appointment slots and no show appointments. Data was subsequently broken down by day of the week and hour of the day. The fill rate for the 8:00 hour is 51% compared to 80-90% for most other hours. Image Table 1. Scheduling data for Team Oakland December 2016 through January 2017 DISCUSSION: Literature review revealed conflicting evidence in support of open-access scheduling. We found limited alternative scheduling approaches and limited data specific to residency clinic productivity. Data analysis confirmed that we have a high proportion of appointments that go unfilled as well as a significant no-show rate. Proposed changes to the scheduling template include increasing the number of advanced scheduled appointments-particularly during early morning hours, obtaining an independent scheduler for the resident clinic, and a novel scheduling model targeted at filling no-show appointments with walk-in patients. CONCLUSION: The current scheduling model used at the FHC does not adequately meet the needs of the Family Medicine Residency clinic and data-driven alternative scheduling models should be explored

Dextromethorphan-quinidine is helpful for pseudobulbar affect disorder in stroke patients

An informed consent article using Hammond FM, Alexander DN, Cutler AJ, et al. PRISM II: an open-label study to assess effectiveness of dextromethorphan/quinidine for pseudobulbar affect in patients with dementia, stroke or traumatic brain injury. BMC Neurology. 2016;16:89. https://doi.org/10.1186/s12883-016-0609-0 for a patient with pseudobulbar affect following strok

Clitic Left Dislocation in Absence of Clitics: a Study in Trilingual Acquisition

This paper discusses an unusual structure in the English of a trilingual child acquiring English, Italian and Scottish Gaelic. The child uses a structure where it appears that an object DP is “dou-bled” by a pronoun for an extended period of time (10 months): (1) He don\u27t like it dinosaur (2) He forget it the teddy In Italian, sentences that contain old information take two possible structures: they might contain a left dislocated topic resumed by a clitic: (3) Il libro, l\u27ho letto the book it-have.1SG read \u27The book, I have read it\u27 These are called Clitic Left Dislocation (CLLD) structures in the literature. Alternatively, the topic (the given information) can be introduced as a right dislocated element, again linked to a clitic: (4) L\u27ho letto, il libro It-have.1SG read the book ‘I have read it, the book’ These are called clitic right dislocation (CLRD) structures. The structures produced in English by the subject of this study seem to be similar in some fundamental ways to this second kind of topi-calisation strategy. We suggest that this reflects a deep: transfer of CLRD structures from Italian, even though at the stage when the doubling structures occur, there is no evidence of overt clitics in the child’s Italian. Our paper contributes to the debate in the literature concerning the existence or not of some form of transfer in multilingual acquisitio

Outcomes of a Modification of the Brain Injury Guidelines (BIG) on Resource Utilization and its Impact on Outcomes

Background: Brain injury guidelines (BIG) were developed to classify traumatic brain injury (TBI) patients and identify those that did not require ICU admission. Our aim was to implement our modified BIG (mBIG) in hopes of decreasing use of ICU beds for small TBI hemorrhages without compromising outcomes. Methods: Our mBIG protocol was implemented in January 2021 at Detroit Receiving Hospital with patients classified per the Table. Concurrent and retrospective data collected included demographics, ICU admission, outcomes, head CT scans and need for neurosurgical intervention. One-way ANOVA and chi-squared analysis were used with a p-value of ≤0.05 being significant. Results: 125 patients met inclusion criteria including 16 mBIG1, 18 mBIG2, and 91 mBIG3. mBIG3 category had lower GCS (11.0±4.5; p\u3c0.001), higher ISS (19.4±9.2; p\u3c0.001), longer ICU LOS (7.7±13.5 days; p=0.011) and more head CT scans(3.4±1.9; p=0.004). Overall, 67% were admitted to ICU, 7.2% to stepdown, and 25.6% to the acute care floor. Adherence to the guidelines for ICU admission was 71% with 15 mBIG1 and mBIG2 patients inappropriately admitted to the ICU and 14 mBIG3 patients admitted to acute care. Adverse outcomes were only in mBIG3 group admitted to the ICU (19 patients with neurological changes, 6 patients underwent operative intervention based on a second CT scan and 12 patients died). Conclusions: Our mBIG criteria accurately identified patients WITHOUT severe TBI as well as those at high risk for progression requiring neurosurgical intervention. Adherence to guidelines will decrease resource utilization without causing harm

The effect of rapid response teams on end-of-life care: A retrospective chart review

R apid response teams (RRTs) were designed to assess and treat deteriorating ward patients. The aim of RRTs is to decrease the number of cardiac arrests, intensive care unit (ICU) transfers and inhospital mortality. These goals have been met with variable success in the literature, with some prospective cohort studies reporting reductions in cardiac arrests (1-4). However, these results were not replicated in the large, multicentre, cluster randomized controlled Medical Early Response Intervention and Therapy (MERIT) trial (5). The MERIT trial suggested that there was an association with RRTs and an increase in do-not-resuscitate orders (6,7). Further studies have also documented RRT involvement in end-of-life (EOL) care (8-10). To support EOL care, our institution implemented a hospital-wide policy and associated preprinted order set known as the PhysicianOrdered Spectrum of Treatment (POST) form. The POST form acted as an extension of a 'do not resuscitate' status. The form engaged health care providers in conversations with patients and families regarding life-sustaining interventions such as cardiopulmonary resuscitation, intubation, defibrillation, ICU transfer, antibiotics, blood products or intravenous lines The premise of our study was that hospitalized patients are in fragile condition and, although restorative therapies are often the goal, there are patients who do not want or who would not benefit from aggressive resuscitative measures. As 'first responders' for critically ill ward patients, RRTs have the opportunity to recognize and treat patients who would benefit from EOL care. We sought to characterize the effect of RRT EOL discussions on EOL care. We also characterized the proportion of patients seen by RRTs with EOL care issues. Finally, we examined how the introduction of a hospital-wide EOL preprinted order set influenced EOL discussions and EOL care. Methods The present study was a single-centre, retrospective chart review conducted at the Hamilton Health Sciences Hamilton General Hospital BACkgRound: A subset of critically ill patients have end-of-life (EOL) goals that are unclear. Rapid response teams (RRTs) may aid in the identification of these patients and the delivery of their EOL care. oBJeCtives: To characterize the impact of RRT discussion on EOL care, and to examine how a preprinted order (PPO) set for EOL care influenced EOL discussions and outcomes. Methods: A single-centre retrospective chart review of all RRT calls (January 2009 to December 2010) was performed. The effect of RRT EOL discussions and the effect of a hospital-wide PPO set on EOL care was examined. Charts were from the Ontario Ministry of Health and LongTerm Care Critical Care Information Systemic database, and were interrogated by two reviewers. Results: In patients whose EOL status changed following RRT EOL discussion, there were fewer intensive care unit (ICU) transfers (8.4% versus 17%; P<0.001), decreased ICU length of stay (5.8 days versus 20 days; P=0.08), increased palliative care consultations (34% versus 5.3%; P<0.001) and an increased proportion who died within 24 h of consultation (25% versus 8.3%; P<0.001). More patients experienced a change in EOL status following the introduction of an EOL PPO, from 20% (before) to 31% (after) (P<0.05). ConClusions: A change in EOL status following RRT-led EOL discussion was associated with reduced ICU transfers and enhanced access to palliative care services. Further study is required to identify and deconstruct barriers impairing timely and appropriate EOL discussions. Effect of RRTs on EOL care Can Respir J Vol 21 No 5 September/October 2014 303 (Hamilton, Ontario), a 458-bed tertiary care centre and regional centre of excellence specializing in cardiac and vascular care, neuroscience, trauma and burn treatment, stroke and rehabilitation. The RRT at the authors' site has been a Ministry of Health and Long-Term Care of Ontario-funded team since 2006 and includes an ICU physician, critical care nurses and registered respiratory therapists. Critical care residents or fellows may support the team on some occasions. Any health care provider with concerns regarding patients' airway, breathing or circulation can activate the team. The nurses and respiratory therapists on the RRT also have several medical directives that allows them to initiate resuscitative therapy before a licensed physician arrives at the bedside. They have also received additional training in EOL discussions. The POST was implemented in January 2010 as a hospital-wide policy to improve EOL care. Institutional policy dictated that the POST form was to be completed for all hospitalized patients with a predicted life expectancy <1 year. Before its implementation, there was a one-month period of distributed education on using the POST form. The POST form was examined because it coincided with the study period and was a confounder that may have effected RRT EOL discussions. ethics The present study was approved by Hamilton Health Sciences Research Ethics Board (approval number was 11-463-C). The need for informed consent was waived. data collection The chart review was composed of all patients seen by the RRT team between January 1, 2009 and December 31, 2010. RRT-based EOL discussions were tracked. Data were gathered from the Ontario Ministry of Health and Long-Term Care Critical Care Information Systemic database. Charts were divided into code status discussion initiated, code status discussion revisited, code status previously established and code status discussion not appropriate at the time or for this patient. These distinctions were determined by the RRT's registered nurse or respiratory therapist, who completed the team call record at the time of RRT consultation. Charts coded as 'discussion initiated' and 'discussion revisited' were considered to be positive for EOL discussion. Two reviewers reviewed the charts independently. If the RRT had an EOL discussion, the patient's medical record was reviewed for patient demographics, admitting service, code status at time of consultation, completion of POST form, a change in EOL status following consultation, ICU transfer following consultation, total ICU length of stay (LOS) following transfer, if death occurred within 24 h following consultation and whether palliative care was involved in EOL care. data analysis The analysis focused on RRT EOL discussion with critically ill ward patients. To determine the effect of the RRT on EOL care, patients with and without a change in EOL status following RRT EOL discussion were compared. To determine the effect of the POST form on RRT EOL discussions, the outcomes before the introduction of the POST (January 1, 2009 to December 31 2009) and following the introduction of the POST (January 1, 2010 to Decemebr 31, 2010) were compared. Discrete variables were described as proportions and compared using χ 2 tests. Continuous variables were reported as mean ± SD and compared using unpaired t tests; P<0.05 was considered to be statistically significant. Results Patient population Between January 1, 2009 and December 31, 2010, the RRT saw 5320 patients. Of 5320 patients, 1254 (24%) were seen as a new RRT consultation while 3155 (59%) were seen in ICU discharge follow-up. The method in which RRT was involved was not documented for 911 patients (17%). Three hundred nineteen patients (6%) had their code status discussion initiated or revisited by the RRT; 3081 (58%) had a previously established code status. A code status discussion was deemed not appropriate for 1920 patients (36%) effect of RRt eol discussion on eol care Of the patients who RRT initiated or revisited code status, 276 (89%) were for full resuscitation at the time of consultation. The EOL status was changed in 83 (27%) patients, all of whom were for full resuscitation at the time of consultation. In patients with a change in EOL status, there were fewer ICU transfers (8% versus 16%; P<0.01), more palliative services arranged (34% versus 5%; P<0.01) and more patients who passed away within 24 h of RRT consultation (25% versus 8%; P<0.01). There was a trend toward decreased ICU LOS (six days versus 20 days; P=0.08) ( effect of Post form on eol care There were minimal differences when comparing outcomes before and following POST implementation. There were similar proportions of patients who were for full resuscitation at time of consultation (89% before versus 85% after; P=0.72). There was a significant increase in the proportion of patients who had a change in code status following implementation of the POST form (20% before versus 31% after; P<0.05). However, there was no difference in proportion transferred to the ICU (13% before versus 15% after; P=0.55), average ICU LOS (12 days before versus 14 days after; P=0.38), nor was there a difference in proportion with palliative care involved (14% before versus 12% after; P=0.55). There was a trend toward increased proportion of patients who died within 24 h of RRT consultation (8.6% before versus 16% after; P=0.08) ( disCussion We found that RRTs influenced EOL care through EOL discussions. In patients who experienced a change in EOL status following RRT EOL discussion, there were fewer ICU transfers, increased palliative services and more patients who died within 24 h. Furthermore, the POST form may be a tool that is associated with more EOL discussions, although it did not impact other EOL outcomes in our critical care setting. RRT involvement in EOL care is an evolving concept. Vasquez et al The extent of RRT involvement in EOL care is not yet clear. Downar et al (9,10) found that RRT involvement was not associated with improved access to palliative services, spiritual care and comfort medications. This outcome may be attributed to the study population. Downar et al (10) compared EOL care for patients who had died with versus without RRT consult. Patients referred to the RRT may have had a reversible condition amenable to restorative therapy as opposed to palliation. Conversely, patients who were not referred may have had irreversible conditions more suited to palliative care. This was suggested by the significantly increased proportion of patients with irreversible poor prognostic factors, palliative care consultations and shorter time to withdrawal of life support (10). In contrast, we studied patients who the RRT selected for an EOL discussion at the time of RRT consultation. As such, our study suggests that the RRT was able to identify and treat patients who would benefit from palliative care in the critical care setting. Although our study showed that RRTs could successfully initiate EOL care in critical care scenarios, this may not by the optimal time to discuss goals of care and resuscitation status. RRT involvement in EOL care suggests that there was room to enhance predeterioration EOL care. Previous studies have shown that clinical deterioration is not a sudden process and that the majority of cases present with antecedent clues such as hypotension or hypoxia (19). Responding to these clinical perturbations is only part of the care process. These fluctuations in clinical status should act as stop points for all health care providers to reassess the goals of care and resuscitation status with the patients and families. However, EOL care is not well addressed in hospital. Heyland (20) found that 76% of elderly patients have considered EOL care and only 12% preferred life-prolonging care. However, only 30% of medical documentation accurately reflected the patients' wishes. Reasons for not documenting an EOL status could be influenced by the patient and family, the clinician or the institution. Family/patient factors included unrealistic patients and families, inability of patients to participate in discussions and lack of advance directives (21,22). Clinician factors included insufficient training, competing time demands and insufficient remuneration (21-24). Institutional factors included suboptimal space for family meetings and lack of palliative care services Enhancing EOL quality will require multitiered interventions enacted through institutions, clinicians and patient/families. One intervention our institute implemented to support EOL discussions is the POST form. Previous literature suggested that similar forms may be used in a hospice or long-term care setting to effectively ensure adherence to patient wishes in an EOL setting (11-13). However, benefit of the POST form requires further study in critical care settings (15). Curtis et al Enhanced in-hospital EOL care is unlikely to arise from policy changes alone. There is room to improve clinician involvement in EOL care. O'Mahony et al (26) reported successful integration of a palliative care team into an ICU. They found that there was increased opioid use, formalized advanced directives and utilization of hospices, in addition to decreased investigations and nonbeneficial life-prolonging therapies. Furthermore, it is important to consider patient and family factors in a comprehensive plan for improving in-hospital EOL care. Heyland One systematic difference that may have influenced the results of our study was patient illness severity. The change in EOL status following RRT involvement may have been driven by illness severity as opposed to RRT EOL discussions. Due to data limitations, we were unable to determine whether there were any systematic differences in illness severity between patients who had a change in EOL status and those who did not. Even if this was the case, increased illness severity in patients with high unlikelihood of benefiting from resuscitative measures should drive EOL discussions and subsequent EOL care. The present study would then suggest that RRTs had the ability to identify deteriorating patients who benefited from palliation rather than resuscitation. More work is required to determine how accurately RRTs prognosticate patients. Furthermore, although we selected quantifiable and patientimportant outcomes to review, the scope of our analysis was limited by data restrictions inherent in a retrospective study. We found that 26% of patients who had an EOL discussion with the RRT had a subsequent change in EOL status; we do not know whether this number was appropriate. Seventy-four percent of patients who the RRT believed warranted an EOL discussion did not have a subsequent change in EOL status. EOL discussions could have resulted in more than a change in EOL status. Other outcomes that may have been affected include dyspnea management, avoiding unnecessary and invasive therapies, treatment of pain, ascertaining patient and family values, and providing support suMMARy We found that a change in EOL status following RRT-led EOL discussions was associated with reduced ICU transfers and enhanced access to palliative services. Our study suggested that there is a need to enhance predeterioration EOL planning. Moreover, there is a need to develop institutional support for EOL care, clinician training on EOL care and enhanced access to palliative care services. Future areas of study are to identify patients who will benefit from EOL discussion and to identify the barriers to engaging these patients in EOL discussion. ACknoWledgeMents: BT contributed to research design, dat