Faculty Bibliography

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.

BACKGROUND: Late afternoon hospital discharges are thought to contribute to admission bottlenecks. We previously described an intervention that resulted in a statistically significant increase in the discharge before noon (DBN) rate on 2 inpatient medicine units. OBJECTIVE: To evaluate (1) the effect of an increased DBN rate on the admission arrival time and the number of admissions per hour and (2) the sustainability of our DBN initiative. DESIGN: Pre-/postintervention retrospective analysis. SETTING: Two acute-care inpatient medicine units in a tertiary care, urban, academic medical center. PATIENTS: For the admission arrival time and admissions per hour analysis, all inpatients admitted to the medical units from June 1, 2011 to June 31, 2013. For the sustainability analysis, all patients discharged from July 1, 2013 to December 31, 2014. INTERVENTION: A multidisciplinary intervention to increase the DBN rate. MEASUREMENTS: Date and time of arrival to all inpatient sites, and discharge date and time of all patients from 2 inpatient medicine units. RESULTS: Concurrent with our increase in DBN rate, we found a statistically significant change in the median arrival time of emergency department (ED) admissions and transfers from 5 pm to 4 pm. High-frequency admission peaks were statistically significantly reduced for ED admissions. The statistically significant increase in DBN rate is sustained at 35%. CONCLUSIONS: Increasing the DBN rate correlates with admissions arriving earlier in the day and reductions in high-frequency peaks of ED admissions. Statistically significant improvements in DBN rates are sustainable. Journal of Hospital Medicine 2015. (c) 2015 Society of Hospital Medicine.

A 49-year-old woman with cholangiocarcinoma metastatic to the lungs presented with new-onset unrelenting headaches. A lumbar puncture revealed malignant cells consistent with leptomeningeal metastasis from her cholangiocarcinoma. Magnetic resonance imaging (MRI) of the brain revealed leptomeningeal enhancement. An intrathecal (IT) catheter was placed and IT chemotherapy was initiated with methotrexate. Her case is notable for the rarity of cholangiocarcinoma spread to the leptomeninges, the use of IT chemotherapy with cytologic and potentially symptomatic response, and a possible survival benefit in comparison to previously reported cases of leptomeningeal carcinomatosis secondary to cholangiocarcinoma.

Case Presentation: A 65-year-old female with metastatic breast cancer, glioblastoma multiforme, bilateral pulmonary emboli diagnosed 4 days prior to admission started on enoxaparin, presented with syncope. On the day of admission the patient collapsed on the street suddenly without any prodrome. She reported abdominal pain for the prior 2-3 days, no other new symptoms, and no change in her baseline fatigue. On presentation to the emergency department (Figure presented) she was afebrile with a blood pressure of 105/72, and a heart rate of 92. Her physical exam was notable for conjunctival pallor and a firm, very tender 6 centimeter mass right of the midline slightly inferior to the umbilicus. Fothergill's sign was present. Her hemoglobin was 5.7 gm/dl (it was 12 gm/dl 4 days prior to admission). On CT scan of the abdomen and pelvis a large rectus sheath hematoma (RSH) was found that extended into the preperitoneal space inferiorly, as well as into the pelvis. The patient was transfused, enoxaparin was stopped and she had a retrievable inferior vena cava (IVC) filter placed. Upon further questioning, the patient reported that she had been injecting herself with enoxaparin intramuscularly rather than subcutaneously. Discussion: RSH is an uncommon cause of abdominal pain and is usually not associated with hemodynamically significant hemorhage. It is caused by rupture of the epigastric arteries or trauma to smaller vessels in the rectus muscle often due to vigorous contraction of the abdominal wall muscles from coughing, retching or straining from constipation. In this case, repeated direct intramuscular trauma from needles as well as the effect of the enoxaparin caused the hematoma. Mortality is reported at 4% for RSH but increases to 25% when anticoagulation plays a role. The patient presented with Fothergill's sign which is a painful abdominal mass that does not cross the midline and remains palpable with rectus muscle contraction thus differentiating it from an intra-abdominal mass. In light of her short term contraindication to receiving anticoagulation, an IVC filter was placed (supported by ACC/AHA guidelines issued in April 2011). The indications for placement of IVC filters are not robustly supported by evidence with only one prospective randomized study and a large populationbased retrospective analysis serving as the basis for recommendations. Because the RSH was caused by incorrect injection of enoxaparin, I recommended attempting to reinitiate anticoagulation in a monitored setting and if tolerated, removal of the retrievable IVC filter. The patient remained hemodynamically stable with an unfluctuating hemoglobin level and was transferred to the hospital where she was receiving her oncological treatment. Conclusions: RSH is often associated with the use of anticoagulation and on occasion can cause significant hemorrhage. IVC filters have a role in protecting patients with known proximal deep venous thrombosis or pulmonary embolism who have a contraindication against the use of anticoagulation