Faculty Bibliography

BACKGROUND: Medical errors occur following handoff-related miscommunication. Data regarding the effect on patient-centered outcomes, specifically mortality, are lacking. Our objective was to investigate handoff-related mortality and the effect of duty-hour regulations. METHODS: Retrospective cohort study of adult medical patients at a public, university-affiliated hospital from 2010 to 2012. Patients were divided into 2 cohorts: handoff group (discharged within 7 days following a change in resident physician team) vs control group (discharged the 3 weeks of each 4-week rotation before resident service change). The primary outcome was unadjusted and adjusted hospital mortality rate. As a secondary prespecified analysis, we examined the effect of 2011 Accreditation Council for Graduate Medical Education (ACGME) duty-hour changes. RESULTS: Among 23,736 patients, unadjusted hospital mortality during the handoff group was higher than the control group (2.68% vs 2.08%, respectively; P = .007; odds ratio [OR] 1.30; 95% confidence interval [CI], 1.08-1.57). Following adjustment, this association remained statistically significant (adjusted OR 1.34; P = .003; 95% CI, 1.10-1.62). Similarly, pre-duty-hour unadjusted hospital mortality was higher in the handoff group vs control group (2.87% vs 2.01%, respectively; P = .006; OR 1.44; 95% CI, 1.11-1.86), which remained statistically significant following adjustment (adjusted OR 1.50; P = .002; 95% CI, 1.16-1.95). However, this association lost statistical significance following duty-hour revision with respect to both unadjusted (2.48% vs 2.15%, respectively; P = .30; OR 1.16; 95% CI, 0.88-1.53) and adjusted mortality (OR 1.18; P = .26; 95% CI, 0.89-1.56). CONCLUSIONS: Resident transition in care was significantly associated with an increase in unadjusted and adjusted hospital mortality. Although improved by 2011 ACGME duty-hour amendments, a trend toward higher mortality remained following resident handoff.

PURPOSE: Many medical errors occur due to miscommunication surrounding transitions in care or "handoffs" Mandated resident duty-hour restrictions have increased the total number of handoffs, yet data regarding the effect of these changes on patient-centered outcomes is lacking. We investigated mortality rates during periods of resident handoff and the effect of duty-hour rule implementation. METHODS: We reviewed 24,739 adult discharges from medical services at a public, university-affiliated hospital in New York City from July 1, 2010 to June 30, 2012. The primary exposure of interest was hospital discharge during the 7 days following a change in resident physician team "handoff period" The primary study outcome was unadjusted and adjusted mortality rate in "handoff periods" compared to "control periods" (the three weeks of each 4-week long rotation prior to resident transition of care). Sub-analysis examined the effect of 2011 ACGME duty-hour changes on mortality. RESULTS: Over the 2-year study period, unadjusted all-cause hospital mortality during the handoff period was significantly higher than the control period (2.74% vs. 2.12%, respectively; p=0.004, OR 1.30 [95%CI 1.09-1.57]). This association persisted after adjustment for age, sex, length of stay, calendar month, and Elixhauser Comorbidity Index (adjusted OR 1.29, p=0.01, [95%CI 1.05-1.57]). On sub-analysis, pre-duty hour unadjusted mortality rate was significantly higher in the handoff period versus control period (2.91% vs. 2.05%, respectively; p=0.003, OR 1.44 [95%CI 1.13-1.84]) with a similar finding in the adjusted mortality rate (adjusted OR 1.42, p=0.01, [95%CI 1.08-1.86]). However, this association lost statistical significance following duty-hour revision with respect to both unadjusted mortality (2.57% vs. 2.19%, respectively; p=0.33, OR 1.15 [95%CI 0.87-1.52]) and adjusted mortality (OR 1.15, p=0.33, [95%CI 0.86-1.54]). CONCLUSIONS: Over a two-year time period, resident handoff was significantly associated with an increase in both unadjusted and adjusted all-cause hospital mortality the week following resident transition in care. Although improved by the 2011 ACGME duty-hour amendments, there remains a trend towards higher mortality during times of resident handoff. CLINICAL IMPLICATIONS: These findings demonstrate a potential patient-centered outcome measure not previously reported that may be affected by enactment of a structured handoff system

RATIONALE/BACKGROUND:To evaluate factors associated with palliative care consultation (PCC) in an urban public hospital. METHODS:A retrospective chart review of patients who died on inpatient medical services. RESULTS:Patients with a PCC were more likely to have a "do not resuscitate" (DNR) order at the time of death (p<0.001) and had a decreased likelihood of death in the ICU (p<0.001). Factors associated with PCC in a multivariate analysis included: cancer diagnosis (p=0.01), at least a high school education (p=0.04), older age (p=.003), and birth outside the US (p=0.03). CONCLUSION/CONCLUSIONS:The increased PCC utilization for immigrants is in contrast to previously reported literature. This increased use may be because access to services in a municipal hospital is not driven by demographic and socioeconomic factors.

Introduction: Massive hemoptysis is a rare but life-threatening complication in patients with bronchiectasis. Bronchial artery embolization is an established first-line therapy in massive hemoptysis, and has greatly reduced the need for lung-resection surgery in these patients. However, bronchial artery embolization may be unsuccessful if the culprit vessel cannot be identified or is not amenable to intervention. Case Presentation: An 89 year-old female with a history of remote pulmonary tuberculosis complicated by bronchiectasis, chronic mycobacterium avium-complex infection, and recurrent hemoptysis was admitted to our hospital with increasing hemoptysis for 24 hours. She reported an abrupt onset of bright-red, moderate volume hemoptysis without preceding fever, cough, dyspnea, or change in sputum. She was admitted and empirically treated with systemic antibacterials and corticosteroids. Despite these interventions, she had repeated episodes of bright-red hemoptysis culminating in an episode of massive hemoptysis. She was emergently intubated and fiberoptic bronchoscopy demonstrated bright-red blood and oozing in the lingular segment of the left upper lobe. She was taken emergently to the interventional radiology department, where arteriography failed to demonstrate any abnormality in the bronchial arteries supplying the lingula. However, delayed imaging of this area revealed extravasated contrast. The source was localized to an enlarged and tortuous left inferior phrenic artery. The vessel arose from the abdominal aorta, crossed the diaphragm, and supplied the lingula. The artery was embolized using a mixture of contrast and avitene collagen hemostat. There was an excellent angiographic outcome, and hemostasis was considered complete. The patient tolerated the procedure well and was soon extubated. She was subsequently discharged and reported no recurrence of hemoptysis at 3 month follow up. Discussion: Our case highlights the importance of a multidisciplinary approach to the management of massive hemoptysis. If the bleeding segment had not been localized bronchoscopically, the angiographer may not have obtained delayed imaging in this area. The source of bleeding would not have been immediately identified and embolized. This may have led to an unnecessary lung-resection surgery in a patient with multiple co-morbidities. Hemoptysis from vessels arising outside the bronchial tree occurs more frequently in patients with bronchiectasis. These vessels may arise from the subclavian, costocervical, left gastric, inferior phrenic, or lower intercostal arteries. It is postulated that chronic inflammation releases angiogenic factors, stimulating the development of these anomalous, ectatic vessels. A multi-disciplinary approach and high level of suspicion for atypical sources of bleeding are essential in the management of massive hemoptysis, particularly in patients with bronchiectasis. (Figure Presented)

Rationale: Nearly 50% of Americans die in an acute care hospital and many experience significant pain, anxiety, and dyspnea at the end of life. A palliative care consultation (PCC) service addresses these issues, potentially leading to improved comfort at the end of life. Data suggest that there is variation in end-of-life care among patients from different racial and ethnic backgrounds. This may be due to differences in access to care, but may also represent variations in PCC utilization. Methods: We reviewed deaths between October 2008 and April 2010 on the inpatient medical service of Bellevue Hospital, a large urban municipal hospital in New York City. Data collected included: patient demographics, co-morbidities, PCC, duration of hospitalization, DNR status, intensive care unit (ICU) length of stay, and use of analgesics and anxiolytics in the final 72 hours of life. We examined patient factors associated with PCC and the effect of PCC on end of life care. Results: Two hundred seventeen in-patient deaths were reviewed. Patient characteristics are described in Table 1. Over 80% of the study population was non-white, 34% was non-English speaking, and 34% was uninsured. 36% of patients had a diagnosis of cancer. Patients who received a PCC during the terminal hospitalization were younger than those who did not (mean age 60.4 years +/- 15.7 compared to 66.2 +/- 16.3, p<0.001). Factors associated with increased likelihood of receiving a PCC included: a diagnosis of cancer, having at least a high school education, speaking a language other than English, and immigration status. Patients who received a PCC were more likely to receive opiates in the 72 hours preceding death, although median dose was not significantly different when compared to those who did not receive a PCC (Table 2). PCC was associated with decreased likelihood of dying in an ICU. Conclusions: Among patients who died on the medical service in an urban public hospital in New York City, those who were non-English speaking and those who were immigrants were more likely to receive PCC in this univariate analysis. This is in contrast to previously reported literature suggesting these patients were less likely to receive palliative care services. One possible explanation is that access to care amongst inpatients in a municipal hospital is less influenced by demographic and socioeconomic factors. In this context, providers may be more likely to seek specialized palliative care when patient-provider communication is more challenging. (Table presented)