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Evaluating Whether an Inpatient Initiative to Time Lab Draws in the Evening Reduces Anemia

Zaretsky, Jonah; Eaton, Kevin P; Sonne, Christopher; Zhao, Yunan; Jones, Simon; Hochman, Katherine; Blecker, Saul
BACKGROUND:Hospital acquired anemia is common during admission and can result in increased transfusion and length of stay. Recumbent posture is known to lead to lower hemoglobin measurements. We tested to see if an initiative promoting evening lab draws would lead to higher hemoglobin measurements due to more time in upright posture during the day and evening. METHODS:We included patients hospitalized on 2 medical units, beginning March 26, 2020 and discharged prior to January 25, 2021. On one of the units, we implemented an initiative to have routine laboratory draws in the evening rather than the morning starting on August 26, 2020. There were 1217 patients on the control unit and 1265 on the intervention unit during the entire study period. First we used a linear mixed-effects model to see if timing of blood draw was associated with hemoglobin level in the pre-intervention period. We then compared levels of hemoglobin before and after the intervention using a difference-in-difference analysis. RESULTS:In the pre-intervention period, evening blood draws were associated with higher hemoglobin compared to morning (0.28; 95% CI, 0.22-0.35). Evening blood draws increased with the intervention (10.3% vs 47.9%, P > 0.001). However, the intervention floor was not associated with hemoglobin levels in difference-in-difference analysis (coefficient of -0.15; 95% CI, -0.51-0.21). CONCLUSIONS:While evening blood draws were associated with higher hemoglobin levels, an intervention that successfully changed timing of routine labs to the evening did not lead to an increase in hemoglobin levels.
PMID: 37478815
ISSN: 2576-9456
CID: 5536212

Novel Note Templates to Enhance Signal and Reduce Noise in Medical Documentation: Prospective Improvement Study

Feldman, Jonah; Goodman, Adam; Hochman, Katherine; Chakravartty, Eesha; Austrian, Jonathan; Iturrate, Eduardo; Bosworth, Brian; Saxena, Archana; Moussa, Marwa; Chenouda, Dina; Volpicelli, Frank; Adler, Nicole; Weisstuch, Joseph; Testa, Paul
Background: The introduction of electronic workflows has allowed for the flow of raw uncontextualized clinical data into medical documentation. As a result, many electronic notes have become replete of "noise" and deplete clinically significant "signals." There is an urgent need to develop and implement innovative approaches in electronic clinical documentation that improve note quality and reduce unnecessary bloating. Objective: This study aims to describe the development and impact of a novel set of templates designed to change the flow of information in medical documentation. Methods: This is a multihospital nonrandomized prospective improvement study conducted on the inpatient general internal medicine service across 3 hospital campuses at the New York University Langone Health System. A group of physician leaders representing each campus met biweekly for 6 months. The output of these meetings included (1) a conceptualization of the note bloat problem as a dysfunction in information flow, (2) a set of guiding principles for organizational documentation improvement, (3) the design and build of novel electronic templates that reduced the flow of extraneous information into provider notes by providing link outs to best practice data visualizations, and (4) a documentation improvement curriculum for inpatient medicine providers. Prior to go-live, pragmatic usability testing was performed with the new progress note template, and the overall user experience was measured using the System Usability Scale (SUS). Primary outcome measures after go-live include template utilization rate and note length in characters. Results: In usability testing among 22 medicine providers, the new progress note template averaged a usability score of 90.6 out of 100 on the SUS. A total of 77% (17/22) of providers strongly agreed that the new template was easy to use, and 64% (14/22) strongly agreed that they would like to use the template frequently. In the 3 months after template implementation, general internal medicine providers wrote 67% (51,431/76,647) of all inpatient notes with the new templates. During this period, the organization saw a 46% (2768/6191), 47% (3505/7819), and 32% (3427/11,226) reduction in note length for general medicine progress notes, consults, and history and physical notes, respectively, when compared to a baseline measurement period prior to interventions. Conclusions: A bundled intervention that included the deployment of novel templates for inpatient general medicine providers significantly reduced average note length on the clinical service. Templates designed to reduce the flow of extraneous information into provider notes performed well during usability testing, and these templates were rapidly adopted across all hospital campuses. Further research is needed to assess the impact of novel templates on note quality, provider efficiency, and patient outcomes.
SCOPUS:85154550880
ISSN: 2561-326x
CID: 5499932

Cross-Sectional Characteristics of Pediatric-Onset Discoid Lupus Erythematosus: Results of a Multicenter, Retrospective Cohort Study

Ezeh, N; Ardalan, K; Buhr, K A; Nguyen, C; Al Ahmed, O; Ardoin, S P; Barton, V; Bell, S; Brandling-Bennett, H; Castelo-Soccio, L; Chiu, Y E; Chong, B F; Lara-Corrales, I; Cintosun, A; Curran, M L; Diaz, L Z; Elman, S A; Faith, E Fernandez; Garcia-Romero, M T; Grossman-Kranseler, J; Hogeling, M; Hudson, A D; Hunt, R D; Ibler, E M; Marques, M C; Monir, R L; Oza, V; Paller, A S; Putterman, E; Rodriguez-Salgado, P; Schoch, J J; Truong, A; Wang, J; Lee, L Wine; Vleugels, R A; Klein-Gitelman, M S; von Scheven, E; Werth, V P; Arkin, L M
• Discoid lupus may be associated with SLE. In this study, most children with discoid lupus did not have systemic disease. Concurrent SLE was highest in female adolescents (>10 years of age) with generalized discoid lupus, who had clinically aggressive disease. • Discoid lupus in adolescence should prompt thorough evaluation for SLE.
PMID: 35487332
ISSN: 1097-6787
CID: 5217732

Experiences from the deployment of non-hospitalist physician volunteers during the 2020 covid pandemic [Meeting Abstract]

Hauck, K; Hochman, K; Pochapin, M; Zabar, S; Wilhite, J; Glynn, G; Bosworth, B
BACKGROUND: New York City was the epicenter of the COVID pandemic in the US during early 2020. NYU Langone Medical Center was one of many New York medical centers that experienced an unprecedented influx of patients. During the onset of the pandemic, clinic leadership identified, oriented, and rapidly deployed a COVID Army, consisting of non-hospitalist physicians, to meet the needs of this patient influx. Orientation and training included an hour-long session with an emphasis on the inpatient electronic medical record system and a plan for at the elbow assistance from senior hospitalists. Here, we share feedback from our providers on our capacity building process and use information gathered to offer specific lessons learned in planning for workforce mobilization.
METHOD(S): A 32-item survey was distributed from March-June of 2020 in order to assess the experiences of these ancillary physicians, all of which were NYU Langone providers. Items included a mix of Likert and open-ended questions on demographics and attitudes toward experiences on the COVID team.
RESULT(S): All 272 volunteers received a survey. 67% (n=183) responded. 84 (46%) were from the Department of Medicine, the remainder were primarily from surgical, pediatrics or obstetrics/gynecology. Respondents worked in combination ambulatory/inpatient practices (n=94; 52%) or outpatient only (n=85; 47%) (Mean years in practice: 7.18). 76% felt that the number of patients they were in charge of felt Just Right (average: 7). 10% rated the experience as challenging (n=17). On their perception of support and training, 94% and 63% rated the support and training they received as somewhat or very effective, respectively. 89% (n=99) and 96% (n=107) of supplemental attendings felt valued and valuable to their team, respectively. 87% of respondents identified as being willing to volunteer again. In review of open-ended feedback, we identified a series of themes surrounding areas for improvement. These include the need to 1) invest time into orientations, including training on EHR use, (2) clarify roles and workflow within each team up front, (3) balance team workload if possible, (4) keep teams updated on evolving policies and recommendations, (5) make team members feel valued and supported, and (6) ensure they have the right tools available.
CONCLUSION(S): Given what we have learned from our survey, the continued waxing and waning of community infection, and the unknown length and extent of the COVID pandemic, we recommend providing transparent leadership, frequent communication, and an educational series to ensure everyone is learning together. In addition, clarity is essential, and it is important to be specific in defining the exact roles of ancillary physicians. It is our hope that the lessons learned from our needs assessment can be applied to other hospitals currently in the throes of a surge of COVID inpatients. LEARNING OBJECTIVE #1: Identify best practices for preparing an ancillary workforce for patient surge. LEARNING OBJECTIVE #2: Understand tools for quality patient care
EMBASE:635796789
ISSN: 1525-1497
CID: 4984912

Hemorrhagic stroke and anticoagulation in COVID-19

Dogra, Siddhant; Jain, Rajan; Cao, Meng; Bilaloglu, Seda; Zagzag, David; Hochman, Sarah; Lewis, Ariane; Melmed, Kara; Hochman, Katherine; Horwitz, Leora; Galetta, Steven; Berger, Jeffrey
BACKGROUND AND PURPOSE/OBJECTIVE:Patients with the Coronavirus Disease of 2019 (COVID-19) are at increased risk for thrombotic events and mortality. Various anticoagulation regimens are now being considered for these patients. Anticoagulation is known to increase the risk for adverse bleeding events, of which intracranial hemorrhage (ICH) is one of the most feared. We present a retrospective study of 33 patients positive for COVID-19 with neuroimaging-documented ICH and examine anticoagulation use in this population. METHODS:Patients over the age of 18 with confirmed COVID-19 and radiographic evidence of ICH were included in this study. Evidence of hemorrhage was confirmed and categorized by a fellowship trained neuroradiologist. Electronic health records were analyzed for patient information including demographic data, medical history, hospital course, laboratory values, and medications. RESULTS:We identified 33 COVID-19 positive patients with ICH, mean age 61.6 years (range 37-83 years), 21.2% of whom were female. Parenchymal hemorrhages with mass effect and herniation occurred in 5 (15.2%) patients, with a 100% mortality rate. Of the remaining 28 patients with ICH, 7 (25%) had punctate hemorrhages, 17 (60.7%) had small- moderate size hemorrhages, and 4 (14.3%) had a large single site of hemorrhage without evidence of herniation. Almost all patients received either therapeutic dose anticoagulation (in 22 [66.7%] patients) or prophylactic dose (in 3 [9.1] patients) prior to ICH discovery. CONCLUSIONS:Anticoagulation therapy may be considered in patients with COVID-19 though the risk of ICH should be taken into account when developing a treatment regimen.
PMCID:7245254
PMID: 32689588
ISSN: 1532-8511
CID: 4535542

COVID-19 related neuroimaging findings: A signal of thromboembolic complications and a strong prognostic marker of poor patient outcome

Jain, Rajan; Young, Matthew; Dogra, Siddhant; Kennedy, Helena; Nguyen, Vinh; Jones, Simon; Bilaloglu, Seda; Hochman, Katherine; Raz, Eytan; Galetta, Steven; Horwtiz, Leora
OBJECTIVE:To investigate the incidence and spectrum of neuroimaging findings and their prognostic role in hospitalized COVID-19 patients in New York City. METHODS:This is a retrospective cohort study of 3218 COVID-19 confirmed patients admitted to a major healthcare system (three hospitals) in New York City between March 1, 2020 and April 13, 2020. Clinical data were extracted from electronic medical records, and particularly data of all neurological symptoms were extracted from the imaging reports. Four neuroradiologists evaluated all neuroimaging studies for acute neuroimaging findings related to COVID-19. RESULTS:14.1% of admitted COVID-19 patients had neuroimaging and this accounted for only 5.5% of the total imaging studies. Acute stroke was the most common finding on neuro-imaging, seen in 92.5% of patients with positive neuro-imaging studies, and present in 1.1% of hospitalized COVID-19 patients. Patients with acute large ischemic and hemorrhagic stroke had much higher mortality risk adjusted for age, BMI and hypertension compared to those COVID-19 patients without neuroimaging. (Odds Ratio 6.02 by LR; Hazard Ratio 2.28 by CRR). CONCLUSIONS:Our study demonstrates acute stroke is the most common neuroimaging finding among hospitalized COVID-19 patients. Detection of an acute stroke is a strong prognostic marker of poor outcome. Our study also highlights the fact there is limited use of neuroimaging in these patients due to multiple logistical constraints.
PMCID:7236667
PMID: 32447193
ISSN: 1878-5883
CID: 4451432

Using a patient-engaged approach to identify cross-cutting disease factors impacting mental health in youth with rheumatologic disease [Meeting Abstract]

Danguecan, A; Fawole, O; Reed, M; Harris, J; Hersh, A; Rodriquez, M; Onel, K; Lawson, E; Rubinstein, T; Ardalan, K; Morgan, E; Paul, A; Barlin, J; Daly, R P; Dave, M; Malloy, S; Hume, S; Schrandt, S; Marrow, L; Chapson, A; Napoli, D; Napoli, M; Moyer, M; Del, Gaizo V; Von, Scheven E; Knight, A
Background/Purpose: Mental health problems are common and often untreated in youth with rheumatologic disease, yet their relationship with disease features is poorly understood. We engaged patients and parents on the research team to identify cross-cutting disease factors impacting mental health in this population.
Method(s): An anonymous cross-sectional online survey examined mental health experiences of patients with juvenile arthritis, juvenile dermatomyositis, or systemic lupus erythematosus. Youth ages 14-24 years and parents of youth 8-24 years were eligible. The survey was developed with patient and parent advisors, the Childhood Arthritis & Rheumatology Research Alliance (CARRA), and the Patients, Advocates, and Rheumatology Teams Network for Research and Service (PARTNERS). Participants were recruited through the Arthritis Foundation, Lupus Foundation of America, and Cure JM Foundation. Primary outcome was the presence of any clinician or self-diagnosed mental health problem. Exposures of interest included several cross-cutting disease factors: disease duration, active disease status, current steroid medication, history of disease flare following remission, and appearance-altering comorbidities (psoriasis, stretch marks, alopecia, skin ulceration, visible scarring). We used logistic regression models to examine the association between any clinician or self-diagnosed mental health problems and disease factors for the combined youth/parent sample, and for youth and parents separately. Secondarily, we examined results by mental health problem (depression, anxiety, self-harm/ suicidal ideation). Alpha values < .05 were considered significant.
Result(s): See Table 1 for sample characteristics. 447 respondents included 123 youth and 324 parents; they were not required to be dyads. Combining youth and parent responses, 210 had juvenile arthritis, 173 had juvenile dermatomyositis, and 64 had systemic lupus erythematosus. Those with and without mental health problems were comparable on many demographic and disease factors, although patients with appearance altering comorbidities were more likely to report mental health problems. Rates of clinician and self-diagnosed depression, anxiety, suicidal thoughts, and self-harm are shown in Figure 1. Adjusted logistic regression models (Table 2) indicate that having appearance altering comorbidities predicted the presence of a mental health problem in the combined youth/parent sample and in the parent-only sample. In the combined sample, appearance altering comorbidities also predicted depression and anxiety problems, whereas history of flare following remission predicted reported suicidal ideation or self-harm. Within the youth responses, there was a trend for depression to be more likely among those taking steroids (p=.053).
Conclusion(s): Certain cross-cutting rheumatologic disease factors such as appearance-altering comorbidities are predictive of mental health problems such as depression or anxiety. These findings are helpful for identifying targets for mental health screening in youth with rheumatologic disease, and should be addressed in screening recommendations.(Figure Presented)
EMBASE:632792241
ISSN: 2326-5205
CID: 4603032

Baseline clinical and serological findings in pediatric-onset discoid lupus erythematosus: Analysis of a multicenter retrospective cohort study [Meeting Abstract]

Ezeh, N; Buhr, K; Nguyen, C; Al, Ahmed O; Ardoin, S; Barton, V; Bell, S; Brandling-Bennett, H; Castelo-Soccio, L; Chiu, Y; Chong, B; Co, D; Lara-Corrales, I; Cintosun, A; Diaz, L; Elman, S A; Faith, E F; Garcia-Romero, M T; Grossman-Kranseler, J; Hersh, A; Hogeling, M; Hudson, A; Hunt, R; Ibler, E; Marques, M; Monir, R; Oza, V; Paller, A; Putterman, E; Rodriguez-Salgado, P; Schoch, J; Truong, A; Wang, J; Lee, L W; Vleugels, R A; Klein-Gitelman, M; Von-Scheven, E; Werth, V; Ardalan, K; Arkin, L
Background/Purpose : DLE is a rare, disfiguring disorder in children. Small retrospective studies suggest 20-25% of patients progress to SLE. Progression risk factors are poorly understood, but DLE has been associated with delay in SLE diagnosis and reduced access to care. This multicenter retrospective cohort study aimed to describe baseline characteristics and clinical phenotypes of pediatric DLE patients at diagnosis. Methods : Medical records at eighteen sites were reviewed for pediatric dermatology and rheumatology patients with DLE. For inclusion, patients required clinical and/or histopathologic findings consistent with DLE. Baseline data were collected at the first documented visit including sociodemographic data, ACR/SLICC SLE criteria (i.e. DLE+SLE), date of DLE onset/diagnosis, DLE distribution, family history, comorbidities, and treatment. Outcome variables included ACR (primary outcome) /SLICC SLE criteria. Rates of progression from skin-limited DLE (DLE) to SLE (DLE+SLE) were evaluated. Analysis included descriptive statistics, chi-square and Wilcoxon tests. Results : Out of >1,000 patients reviewed, 441 met inclusion criteria. The cohort was predominantly female (72%) and racially/ethnically diverse (Table 1). A minority presented at baseline with SLE based on ACR and SLICC criteria, respectively (n=165, 37%; n=183, 42%). DLE+SLE patients were older (median 13.7y vs 10.2y) with shorter time from DLE onset to diagnosis (median 2 mo vs 7 mo), compared to DLE patients (p< 0.001). DLE patients presented with low incidence of renal involvement, serositis, seizures or psychosis (p< 0.001, Table 2). DLE+SLE patients had more positive serologies and higher-titer ANAs (p< 0.001, Table 3), although 5% were ANA negative. Among 231 DLE patients with31 follow up visit, median follow-up was 2.7 y (range 0-13.9y) with 747 total subject-years. Progression to SLE occurred in 20% and 25% of patients based on ACR and SLICC criteria, respectively. Conclusion : To date, this is the largest investigation of pediatric DLE. Patients with DLE+SLE were most likely to present in adolescence with abnormal serologies and end-organ disease. Progression of DLE to SLE occurred at rates consistent with previous literature. All patients with DLE require SLE surveillance at diagnosis and regular follow-up, particularly during adolescence. Limitations include the retrospective study design with potential for misclassification, and analysis restricted to the baseline visit. Further analysis of follow up visits will evaluate for baseline risk factors and biomarkers of evolving SLE, as well as timing of progression, identifying DLE patients at highest risk for systemic disease
EMBASE:633058753
ISSN: 2326-5205
CID: 4633682

An experiential faculty orientation to set communication standards

Wallach, Andrew; McCrickard, Mara; Eliasz, Kinga L; Hochman, Katherine
PMID: 30916360
ISSN: 1365-2923
CID: 5230102

Optimize Your Electronic Medical Record to Increase Value: Reducing Laboratory Overutilization

Iturrate, Eduardo; Jubelt, Lindsay; Volpicelli, Frank; Hochman, Katherine
PURPOSE: To decrease overutilization of laboratory testing by eliminating a feature of the electronic ordering system that allowed providers to order laboratory tests to occur daily without review. METHODS: We collected rates of utilization of a group of commonly ordered laboratory tests (number of tests per patient per day) throughout the entire hospital from June 10th, 2013 through June 10th, 2015. Our intervention which eliminated the ability to order daily recurring tests was implemented on June 11th, 2014. We compared pre and post-intervention rates in order to assess the impact and surveyed providers about their experience with the intervention. RESULTS: We examined 1,296,742 laboratory tests performed on 92,799 unique patients over 434,059 patient days. Prior to the intervention, the target tests were ordered using this daily recurring mechanism 33% of the time. After the intervention we observed between an 8.5% (p <0.001) to 20.9% (p <0.001) reduction in tests per patient per day. The reduction in rate for some of the target tests persisted during the study period but not for the two most commonly ordered tests. We estimated an approximate reduction in hospital costs of $300,000 due to the intervention. CONCLUSION: A simple modification to the order entry system significantly and immediately altered provider practices throughout a large tertiary care academic center. This strategy is replicable by the many hospitals that use the same electronic health record system and possibly by users of other systems. Future areas of study include evaluating the additive effects of education and real-time decision support.
PMID: 26475957
ISSN: 1555-7162
CID: 1803832