Faculty Bibliography

The transitional period between hospital discharge and primary care follow-up is a vulnerable time for patients that can result in adverse health outcomes and preventable hospital readmissions. This is especially true for patients of safety-net hospitals (SNHs) who often struggle to secure primary care access when leaving the hospital due to social, economic and cultural barriers. In this study, we describe a resident-led postdischarge clinic that serves patients discharged from NYU Langone Hospital-Brooklyn, an urban safety-net academic hospital. In our multivariable analysis, there was no statistical difference in the readmission rate between those who completed the transitional care management and those who did not (OR 1.32 (0.75-2.36), p=0.336), but there was a statistically significant increase in primary care provider (PCP) engagement (OR 0.53 (0.45-0.62), p<0.001). Overall, this study describes a postdischarge clinic model embedded in a resident clinic in an urban SNH that is associated with increased PCP engagement, but no reduction in 30-day hospital readmissions.

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.

OBJECTIVES/OBJECTIVE:Predictive studies play important roles in the development of models informing care for patients with COVID-19. Our concern is that studies producing ill-performing models may lead to inappropriate clinical decision-making. Thus, our objective is to summarise and characterise performance of prognostic models for COVID-19 on external data. METHODS:We performed a validation of parsimonious prognostic models for patients with COVID-19 from a literature search for published and preprint articles. Ten models meeting inclusion criteria were either (a) externally validated with our data against the model variables and weights or (b) rebuilt using original features if no weights were provided. Nine studies had internally or externally validated models on cohorts of between 18 and 320 inpatients with COVID-19. One model used cross-validation. Our external validation cohort consisted of 4444 patients with COVID-19 hospitalised between 1 March and 27 May 2020. RESULTS:Most models failed validation when applied to our institution's data. Included studies reported an average validation area under the receiver-operator curve (AUROC) of 0.828. Models applied with reported features averaged an AUROC of 0.66 when validated on our data. Models rebuilt with the same features averaged an AUROC of 0.755 when validated on our data. In both cases, models did not validate against their studies' reported AUROC values. DISCUSSION/CONCLUSIONS:Published and preprint prognostic models for patients infected with COVID-19 performed substantially worse when applied to external data. Further inquiry is required to elucidate mechanisms underlying performance deviations. CONCLUSIONS:Clinicians should employ caution when applying models for clinical prediction without careful validation on local data.

LEARNING OBJECTIVE #1: Recognize hemoptysis as a symptom of alveolar hemorrhage in COVID19 LEARNING OBJECTIVE #2: Recognize the complexity of managing simultaneous pulmonary embolism and hemoptysis in worsening COVID19 pneumonia CASE: A 69-year-old man with hypertension, mild emphysema and gastritis presented for a week of fatigue, dyspnea and fever. On arrival to ED, T 100.4F, tachycardic, hypoxic to 86% on room air and improved to 94% on nasal cannula (NC). No cough, anosmia/ageusia or gastrointestinal (GI) symptoms. Nasopharyngeal swab detected SARS-CoV-2. Chest xray showed bilateral multifocal patchy airspace opacities and prominent interstitial markings. Ddimer was 470. 'Do not intubate (DNI)' status was affirmed. The next day, he required 100% fraction of inspired oxygen with high-flow NC despite initiation of high-dose dexamethasone and remdesivir. Twice-daily proton pump inhibitor (PPI) was begun in tandem with steroid. Procalcitonin of 0.31 prompted addition of ceftriaxone and azithromycin. On day 4, Ddimer jump from 861 to 3099 raised suspicion for pulmonary embolism (PE). CT confirmed bilateral PE. Heparin drip was started and later changed to apixaban. On day 18, he had a large episode of hemoptysis. No hemoglobin (Hgb) drop. Repeat CT showed decreased clot burden but increased bilateral airspace opacity consistent with atypical pneumonia, ARDS and hemorrhage. Interventional Radiology (IR) did not intervene due to lack of target on CT. Once hemodynamically stable with no further bleed, heparin drip was restarted. On day 22, he had another episode of moderate hemoptysis with an isolated episode of melena. Repeat Hgb was again stable, but a unit of packed red blood cells was given preemptively. IMPACT/DISCUSSION: COVID19 is associated with hypercoagulability and increased risk for thrombotic events such as PE. Hemoptysis occurs in 13% of PE cases but has so far rarely been reported in COVID19. There are a few case reports of COVID19 pneumonia, acute PE and underlying emphysema that developed hemoptysis and had worse outcomes. Our case is unique in that his hemoptyses were on hospital days 18 and 22 after starting therapeutic anticoagulation. So, his hemoptysis was unlikely to be caused by PE. Upper GI bleed (GIB) was also less likely; he was on a PPI, and Hgb was low but stable throughout. The most likely etiology was alveolar hemorrhage and ARDS secondary to COVID19. Concurrence of venous thromboembolism and alveolar hemorrhage can create a therapeutic dilemma. Our patient's DNI status precluded procedures requiring general anesthesia, e.g. endoscopy to visualize GIB or bronchoscopy to identify vessels for IR embolization. Apixaban reversal with andexanet alfa was deferred given his known PE. IVC filter was considered in case he could not tolerate anticoagulation. Heparin drip was restarted for easier anticoagulant reversal.
CONCLUSION(S): Hemoptysis can present as a late-onset complication of COVID19 in the hospitalized patient. Heparin drip for pulmonary embolism in COVID19 can be easily discontinued if hemoptysis develops

Purpose: Appropriateness criteria (AC) are important tools that could help inform decision making for elective surgical procedures. Available AC for elective total knee replacement (TKR) focus on pre-operative factors only. With recent availability of longitudinal outcome data on thousands of patients from patient registries and administrative databases, we aimed to develop new AC that also included predicted outcomes.
Method(s): To update the AC, we expanded these 16 hypothetical scenarios of the validated modified Escobar AC to include 3 predicted outcome factors: risk of serious complications (0%, 1-2%, 3-5%), time to revision (<5, 5-15, >15 years), and improvement in pain and function 2 years after surgery (little, some, a lot). The modified Escobar AC are based on 5 clinical factors: age, osteoarthritis radiographic severity, knee stability, symptoms severity, and number of knee compartments with osteoarthritis). A panel of clinician experts (3 orthopedic surgeons, 2 rheumatologists, 2 internists, 1 physical therapist, 1 experienced nurse practitioner) rated 432 written clinical scenarios for appropriateness on a 1-9 scale (1 being least appropriate and 9 being most appropriate), and the median score for each scenario was classified into one of 3 categories: inappropriate 1-3, maybe appropriate 4-6, and appropriate 7-9. Classification and Regression Tree (CART) analysis was applied to the TKR AC appropriateness categories to determine the contribution of the predicted outcomes variables to appropriateness classification.
Result(s): After orthopedic surgeons ruled out clinically implausible scenarios, the remaining 279 scenarios were classified as 71 inappropriate, 112 maybe appropriate, and 96 appropriate. Figure below shows the results of the CART analyses classification tree with the branches labeled with the key variables that discriminated among the classifications. The terminal nodes of each branch (highlighted in grey) indicate the final distribution of the ratings of appropriate (App), may be appropriate ( Maybe App) and inappropriate (Inapp). CART analyses showed that all 3 predicted outcome factors and 2 of the clinical presentation factors (knee symptom severity and X-ray findings) were the variables that discriminated among the classifications.
Conclusion(s): Our Results showed that predicted outcomes were utilized by clinicians when determining appropriateness for TKR. How these data influence the decision making of patients contemplating TKR should be investigated further. [Formula presented]
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Objective: To compare morbidity and mortality of Acute Coronary Syndrome (ACS) patients, with hemoglobin level above 7g/dl in transfused or not transfused groups.
Method(s): We conducted a retrospective cohort study of patients admitted with ACS to both campuses of NYU Langone Hospital. Of 1080 patients screened in, 82 met inclusion criteria and were included in our analysis. Patients with hemoglobin less than 7 g/dL or greater than 10 g/dL during their ischemic event were excluded. The outcomes of interest were length of stay (LOS) and negative clinical events as ascertained by physician chart review. The Mann-Whitney U test, was used to compare continuous variables, and the chi-squared test compared categorical variables.
Result(s): 54 patients were transfused, and 28 were not transfused. Mean age (72.5 vs 74.4 years), and race did not differ significantly between groups. Proportion with heart failure, known anemia and mean baseline hemoglobin of anemic patients prior to admission were similar between both groups. ACS diagnosis and proportion of patients receiving medical management were similar between groups as well. However, transfused patients were more likely to be male, have Chronic Kidney Disease (51.9% vs 28.6%), have known Coronary Artery Disease (77.8 vs 42.6%) and those with Congestive Heart Failure had a lower baseline ejection fraction (34.5 vs 57.5%). For outcomes, blood transfusion was associated with a longer LOS (mean 11.48 vs 6.36 days, p=0.002). Furthermore, transfusion was associated with a higher likelihood to have a combined negative outcome which included new or worsening respiratory distress, hypoxia, volume overload, upgrade to the Intensive Care Unit and death (79% vs 24%, RR=3.29, P<0.001), driven by a significant increase in volume overload (40.7 vs 4.0% P<0.001) and a non-significant tendency towards increased mortality (16.7 vs 4.0%, p=0.12).
Conclusion(s): ACS patients who underwent blood transfusion had worse outcomes, namely longer LOS, increased risk for volume overload and a pronounced but not significant trend towards increased mortality. This effect was confounded by more severe comorbidities in the transfused group. However, given the size and significance of this harmful association, it is possible or perhaps even likely that transfusion itself was a factor in the worsened outcomes in the transfused group. Though transfusion for a hemoglobin > 7g/dl and even > 8g/dl is common in ACS patients, the harms associated with blood transfusions may outweigh the possible risk of worsened myocardial ischemia in the setting of lower oxygen carrying capacity

Statement of Problem Or Question (One Sentence): As communication among patient care team members is often dangerously fragmented and effective collaboration becomes essential to provide safe hospital care for patients, we implemented the Daily Medicine Rounding Tool (DMeRT) that improved collaboration between the physician and nurse. Objectives of Program/Intervention (No More Than Three Objectives): 1. We aimed to promote a patient-centered, highly reliable rounding tool to reduce hospital adverse events by streamlining real time communication between nurses and physicians. 2. We hypothesize that this tool will decrease the need for frequent calls throughout the day, ultimately improving team productivity and overall staff satisfaction. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): In our institution, the Epic's default patient dashboard columns included patient name, venous thromboemboli (VTE) prophylaxis, Medical Orders for Life Sustaining Treatment (MOLST) completion, glycemic control, and medication reconciliation completion. Expanding upon these prior default columns, we partnered with information technology and nursing to create a customized dashboard that included additional informational columns extracted from the documentation in the charts, to include the administration of intravenous fluids, oxygen supplementation, last bowel movement recorded and high risk medications (anti-coagulants, anti-epileptics, furosemide, opioids, and benzo-diazepines). We then trained the physicians and nurses to discuss each patient using the customized DMeRT dashboard during interdisciplinary rounds. The average time spent on the DMeRT is 15 minutes for a total 10 patients. This helps as a reminder and the identification of potential pitfalls and safety concerns. The DMeRT was instituted on a 30 bed medical unit (5500) on June 1, 2018 with iterative improvements to content. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): We will analyze data pre and post intervention to assess for impact on reducing medication errors during hospitalization, hospital acquired VTE events and improvement in glycemic control. Finally we will track MOLST completion, medication reconciliation compliance, constipation and fluid overload events added to the patient's problem list 48 hours prior to discharge. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): To date, the unit which implemented the intervention had an improvement in the Quality Hyperglycemia Scores (method used to evaluate inpatient glycemic management) from 56 in 4/2018 to 95 in 12/2018. There was an improved MOLST completion from 14% in 4/2018 to 83% in 12/2018. A Preliminary survey of 15 nurses on unit 5500 showed that 80% reported that they rarely need to call house staff within 2 hours of completing the rounding tool and 66% of nurses were satisfied with the DMeRT. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): During hospitalization, multiple aspects of patient care are overlooked while we focus on the admitting diagnosis, necessary diagnostics and treatments. Medication errors during hospitalization are commonly caused by breakdowns in communication and associated with substantial risk. This is a simple tool that utilizes information technology to efficiently and systematically review standardized aspects of care