Faculty Bibliography

Early reports showed high mortality from coronavirus disease 2019 (COVID-19). Mortality rates have recently been lower; however, patients are also now younger, with fewer comorbidities. We explored 28-day mortality for patients hospitalized for COVID-19 in England over a 5-month period, adjusting for a range of potentially mitigating variables, including sociodemographics and comorbidities. Among 102,610 hospitalizations, crude mortality decreased from 33.4% (95% CI, 32.9-34.0) in March 2020 to 15.5% (95% CI, 14.1-17.0) in July. Adjusted mortality decreased from 33.4% (95% CI, 32.8-34.1) in March to 17.4% (95% CI, 11.3-26.9) in July. The relative risk of mortality decreased from a reference of 1 in March to 0.52 (95% CI, 0.34-0.80) in July. This demonstrates that the reduction in mortality is not solely due to changes in the demographics of those with COVID-19.

BACKGROUND:Safely and effectively discharging a patient from the hospital requires working within a multidisciplinary team. However, little is known about how perceptions of responsibility among the team impact discharge communication practices. OBJECTIVE:Our study attempts to understand residents' perceptions of who is primarily responsible for discharge education, how these perceptions affect their own reported communication with patients, and how residents envision improving multidisciplinary communication around discharges. DESIGN/METHODS:A multi-institutional cross-sectional survey. PARTICIPANTS/METHODS:Internal medicine (IM) residents from seven US residency programs at academic medical centers were invited to participate between March and May 2019, via email of an electronic link to the survey. MAIN MEASURES/METHODS:Data collected included resident perception of who on the multidisciplinary team is primarily responsible for discharge communication, their own reported discharge communication practices, and open-ended comments on ways discharge multidisciplinary team communication could be improved. KEY RESULTS/RESULTS:Of the 613 resident responses (63% response rate), 35% reported they were unsure which member of the multidisciplinary team is primarily responsible for discharge education. Residents who believed it was either the intern's or the resident's primary responsibility had 4.28 (95% CI, 2.51-7.30) and 3.01 (95% CI, 1.66-5.71) times the odds, respectively, of reporting doing discharge communication practices frequently compared to those who were not sure who was primarily responsible. To improve multidisciplinary discharge communication, residents called for the following among team members: (1) clarifying roles and responsibilities for communication with patients, (2) setting expectations for communication among multidisciplinary team members, and (3) redefining culture around discharges. CONCLUSIONS:Residents report a lack of understanding of who is responsible for discharge education. This diffusion of ownership impacts how much residents invest in patient education, with more perceived responsibility associated with more frequent discharge communication.

Introduction/UNASSIGNED:Reports from the United States suggest that acute kidney injury (AKI) frequently complicates COVID-19, but understanding of AKI risks and outcomes is incomplete. Additionally, whether kidney outcomes have evolved during the course of the pandemic is unknown. Methods/UNASSIGNED:We used electronic records to identify COVID-19 patients with and without AKI admitted to 3 New York Hospitals between March 2 and August 25, 2020. Outcomes included AKI overall and according to admission week, AKI stage, the requirement for new renal replacement therapy (RRT), mortality and recovery of kidney function. Logistic regression was utilized to assess associations of patient characteristics and outcomes. Results/UNASSIGNED:Out of 4732 admissions 1386 (29.3%) patients had AKI. Among those with AKI, 717 (51.7%) had Stage 1, 132 (9.5%) Stage 2, 537 (38.7%) stage 3, and 237 (17.1%) required RRT initiation. In March 536/1648 (32.5%) of patients developed AKI compared with 15/87 (17.2%) in August (P<0.001 for monthly trend) whereas RRT initiation was required in 6.9% and 0% of admission, in March and August respectively. Mortality was higher with than without AKI (51.6% vs 8.6%) and was 71.9% in individuals requiring RRT. However, most patients with AKI who survived hospitalization (77%) recovered to within 0.3 mg/dL of baseline creatinine. Among those surviving to discharge, 62% discontinued RRT. Conclusions/UNASSIGNED:AKI impacts a high proportion of admitted COVID-19 patients and is associated with high mortality, particularly when RRT is required. AKI incidence appears to be decreasing over time and kidney function frequently recovers in those who survive.

BACKGROUND:Little is known about long-term recovery from severe COVID-19 disease. Here, we characterize overall health, physical health, and mental health of patients 1 month after discharge for severe COVID-19. METHODS:This was a prospective single health system observational cohort study of patients ≥ 18 years hospitalized with laboratory-confirmed COVID-19 disease who required at least 6 l of oxygen during admission, had intact baseline cognitive and functional status, and were discharged alive. Participants were enrolled between 30 and 40 days after discharge. Outcomes were elicited through validated survey instruments: the PROMIS® Dyspnea Characteristics and PROMIS® Global Health-10. RESULTS:A total of 161 patients (40.6% of eligible) were enrolled; 152 (38.3%) completed the survey. Median age was 62 years (interquartile range [IQR], 50-67); 57 (37%) were female. Overall, 113/152 (74%) participants reported shortness of breath within the prior week (median score 3 out of 10 [IQR 0-5]), vs 47/152 (31%) pre-COVID-19 infection (0, IQR 0-1), p < 0.001. Participants also rated their physical health and mental health as worse in their post-COVID state (43.8, standard deviation 9.3; mental health 47.3, SD 9.3) compared to their pre-COVID state, (54.3, SD 9.3; 54.3, SD 7.8, respectively), both p < 0.001. Physical and mental health means in the general US population are 50 (SD 10). A total of 52/148 (35.1%) patients without pre-COVID oxygen requirements needed home oxygen after hospital discharge; 20/148 (13.5%) reported still using oxygen at time of survey. CONCLUSIONS:Patients with severe COVID-19 disease typically experience sequelae affecting their respiratory status, physical health, and mental health for at least several weeks after hospital discharge.

Early reports showed high mortality from coronavirus disease 2019 (COVID-19). Mortality rates have recently been lower, raising hope that treatments have improved. However, patients are also now younger, with fewer comorbidities. We explored whether hospital mortality was associated with changing demographics at a 3-hospital academic health system in New York. We examined in-hospital mortality or discharge to hospice from March through August 2020, adjusted for demographic and clinical factors, including comorbidities, admission vital signs, and laboratory results. Among 5,121 hospitalizations, adjusted mortality dropped from 25.6% (95% CI, 23.2-28.1) in March to 7.6% (95% CI, 2.5-17.8) in August. The standardized mortality ratio dropped from 1.26 (95% CI, 1.15-1.39) in March to 0.38 (95% CI, 0.12-0.88) in August, at which time the average probability of death (average marginal effect) was 18.2 percentage points lower than in March. Data from one health system suggest that mortality from COVID-19 is decreasing even after accounting for patient characteristics.

Purpose/UNASSIGNED:To evaluate pulmonary embolism (PE) prevalence at CT pulmonary angiography in patients testing positive for coronavirus disease 2019 (COVID-19) and factors associated with PE severity. Materials and Methods/UNASSIGNED:value < .05 was considered significant. Results/UNASSIGNED:< .001). One additional patient with negative results at CT pulmonary angiography had deep venous thrombosis, thus resulting in 38.7% with PE or deep venous thrombosis, despite 40% receiving prophylactic anticoagulation. Other factors did not demonstrate significant PE association. Conclusion/UNASSIGNED:© RSNA, 2020.

BACKGROUND: Safely and effectively discharging a patient from the hospital requires working within a multidisciplinary team. However, with multiple stakeholders responsible for the discharge and competing clinical duties, diffusion of responsibility may result in relinquished ownership, particularly as mandated administrative discharge tasks are often prioritized over taking the time to communicate discharge plans with patients. Residents are uniquely positioned to offer insight on the workings of multidisciplinary teams at discharge, since residents play a central role in the transitions of care process within academic hospital systems. Learning from residents' perspectives on discharge roles and responsibilities can shed light on gaps in order to improve accountability to the patient and increase communication efficacy among team members.
METHOD(S): Internal Medicine residents at 7 academic institutions completed a cross-sectional survey that asked them who they felt was primarily responsible to perform discharge education with patients, and at what frequency they themselves completed six key discharge communication practices with patients. Using multiple linear regression, we examined the relationship between who residents report is primarily responsible for discharge education and their own reported proportion of communication practice domains done frequently (>60% of time). We used content analysis to assess free response comments on ways in which discharge multidisciplinary team communication could be improved.
RESULT(S): Among the 613/966 resident responses (62% response rate), 35% reported they were not sure which member of the multidisciplinary team is primarily responsible for discharge education with patients If residents believed educating patients at discharge was the primary responsibility of the intern, that resident had a 19.5% (95% CI 13.2%, 25.9%) higher proportion of reported discharge communication domains addressed frequently versus those that were not sure who was responsible. To improve multidisciplinary discharge communication, residents called for explicit expectations among team members: 1) What should be communicated to the patient and by whom? 2) How do we communicate discharge plans effectively to each other? 3) What kind of discharge culture allows the patient and care team to thrive?
CONCLUSION(S): Residents report lack of clarity on who is responsible for key patient communication practices at discharge. This diffusion of ownership impacts how much residents invest in patient education, with more perceived responsibility associated with more key discharge communication practices reportedly done on a regular basis. Our results suggest we need to create and explicitly operate under a shared mental model of each team player's responsibility for communication to the patient, to each other and examine the hospital system's priorities and incentives and its impact of the discharge culture

BACKGROUND: Hospital discharge is a vulnerable time for patients, which can lead to adverse outcomes and hospital readmissions. Suboptimal communication with patients and their caregivers, as well as inadequate understanding of post-discharge plans contribute to readmissions. Prior health services research and national society guidelines have identified key components to be addressed with patients on the day of discharge. Yet, we don't know whether residents are using these best practices, or if existing transitions of care curricula are effective in fostering these practices. Critically assessing types of educational instruction and communication practices residents report using at discharge is critical to informing how we train physicians to be transitions of care champions within our fragmented healthcare system.
METHOD(S): Internal Medicine residents at seven large academic medical centers completed a cross- sectional survey characterizing the types of education on transitions of care they received and the self- reported frequency of using six communication practices at discharge. We calculated the proportion of each communication domain done frequently (>60% of the time) for each respondent. Using multiple linear regression, we explored which types of educational exposures were associated with residents using best communication practices frequently. A content analysis was done to examine a free-response question on which factors residents reported as motivation for changing their discharge practices.
RESULT(S): The response rate was 63% (613/966). The majority of residents (82.3%) received some form of instruction around transitions of care, although only about one in five (18.9%) reported being observed and getting feedback on their discharge education with patients. Resident discharge communication practices were variable, with less than half of residents reporting frequently addressing symptom expectations or selfmanagement of disease. Notably, less than a fifth of residents (17.0%) reported routinely asking patients to teach back their understanding of the discharge plans. Workplace-based learning, such as explicit teaching on rounds and direct observation and feedback on discharge education, was associated with increased proportion of discharge communication practices reported being done frequently. In open-ended comments, residents pointed to adverse events after the post-discharge continuum as their impetus for practice change.
CONCLUSION(S): This study exposes the gaps in resident discharge communication practices with patients, the impact of adverse events as a source of hidden curriculum, and the benefits of workplace-based training on discharge communication skills. Our results suggest that developing faculty to incorporate transitions of care in their rounds teaching and integrating experiences across the post-discharge continuum will foster systems-minded physicians-in-training