Faculty Bibliography

Statement of Problem Or Question (One Sentence): The increasing complexity of admitted patients, shorter hospital stays and post-acute care adverse events demand a more sophisticated and effective coordination of care between hospitalists and Primary care providers (PCPS). Objectives of Program/Intervention (No More Than Three Objectives): 1. Standardizing communication between Hospitalist and PCP during hospitalization will lower the rate of readmission due to lack of PCP follow up and post-acute care adverse events. 2. Implementing this practice into our daily workflow will improve PCP satisfaction and increase referrals to our institution. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): We reviewed a root-cause survey of 30 day readmissions between 1/2018-4/2018 as well as readmission rates for each of our hospitalists. We surveyed our PCPS' satisfaction with communication experiences with our hospitalist group. Finally, we conducted a semi-structured interview of the hospitalist with the lowest readmission (8% vs 12% average for other hospitalists) and highest PCP satisfaction rates, Dr. A, to develop best practices for closed loop communication. Based on this data, we designed a protocol and piloted on 5/1/2018, where the hospitalist contacts the PCP via phone call on admission and delivers a discharge narrative to the PCP via our EMR's routing capability. We used a trackable smart phrase to document the communication. For the prospective phase, we will operationalize these best practices in a study group, Family Health Center PCPS. A control group (community PCPS) will receive usual practice. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): We will compare readmission rates between the study group and control group, monitoring the proportion and absolute number of readmissions attributed to no PCP follow up or medication errors. Follow up satisfaction surveys will be sent to the PCPS 6 months after our revised communication practice. Finally, we will monitor the hospitalists' compliance with the smart phrase. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): A review of our institution's 30 day readmissions between 1/2018-4/2018 found that 19% were attributed to lack of PCP/outpatient provider follow-up. Surveys of our community PCPS showed 70% reported being contacted by the hospitalist group in less than 25% of the time. Results from Dr. A's interview revealed that after her encounter with the patient, she calls the patient's PCP highlighting the admitting diagnosis, significant events, pertinent labs, imaging and medications. Dr. A then delivers a discharge narrative to the PCP on the day of discharge highlighting any medication changes, incidental findings and follow up. On a random audit of 100 charts between 5/1/2018-10/30/2018 our preliminary data show that there was 88% compliance with using the smart phrase by the hospitalists. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): Using a "positive deviance" approach, we identified best practices for hospitalist-PCP closed loop communication to develop an intervention to improve this aspect of care. If we are successful in reducing readmission rates and improving PCP satisfaction, we will expand to all of our PCPS and ultimately expand to other services to implement this program as best practice

Statement of Problem Or Question (One Sentence): As the lack of a 'face-to-face' interaction between the full team and the patient led to a downtrend in patient experience scores, we were inspired to design a patient centered communication tool that standardizes the multi-disciplinary bedside rounds. Objectives of Program/Intervention (No More Than Three Objectives): 1. To improve our patients' hospital experience in regards to care transitions and discharge planning by implementing standard bedside rounds that center around the patient's health care needs. 2. To create a daily scheduled opportunity for the patient to be involved in medical decisions and discharge planning which enhances patients' understanding of their own care plan. Description of Program/Intervention, Including Organizational Context (E.G. Inpatient Vs. Outpatient, Practice or Community Characteristics): Our medical-surgical units did not have a standardized approach to ensure clear communication from a patient's multidisciplinary team, comprised of physicians, nurses, case managers and social workers. To this end, we implemented a communication plan based on the acronym "WE CARE" 1) Who was present (who was at bedside in addition to the patient); 2) Everyone on same page (language and literacy barriers); 3) Connect with patient and family (promote patient-centeredness and compassionate care through eye contact, introducing the full team); 4) Assessing understanding (explanation of changes to medications, key lab and test Results, and post-discharge plans); 5) Response from patient and/or caregivers (ensuring understanding); 6) Educate/empathy/end of conversation. Centered on the WE CARE model, we gathered all members of the care team and visited each patient at a standardized time every day. The intervention was started on one medical-surgical, unit 5600 on July 2018. Measures of Success (Discuss Qualitative And/Or Quantitative Metrics Which Will Be Used To Evaluate Program/Intervention): HCAPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores for care transitions and discharge information pre and post intervention will be evaluated for the study group (unit 5600). We will also compare these scores to med/surg units who did not receive the intervention. Findings To Date (It Is Not Sufficient To State Findings Will Be Discussed): We compared our pre-intervention 1/1/2018-4/31/2018 (approximately 54 surveys) and post-intervention (approximately 42 surveys) scores. In the domain of care transitions, e. g., patient had a good understanding of things patient was responsible for in managing his/her health; patient had a good understanding of purpose of each medication; staff consideration of patient and caregiver preferences post-discharge, there was an increase from 28% in our top-box (an answer of always) composite HCAHPS score to 58%. Scores for "discharge information delivered" remained high with a top-box response above 85% both pre-and post-intervention. In addition, during the post-intervention time, the study group unit had the highest "care transition" and "discharge information" top box responses compared to all control units. Key Lessons For Dissemination (What Can Others Take Away For Implementation To Their Practice Or Community?): A focused, structured communication tool WE CARE, implemented as a part of daily standardized multidisciplinary bedside rounds led to an improvement in patient satisfaction scores around care transitions and discharge information delivered

Needs and Objectives: Residents often fail to escalate care due to uncertainty resulting in delays of care and possible harm. Multiple studies have identified trainee self-reported barriers to escalation, but none have evaluated the impact of a multi-faceted curriculum aimed to reduce perceived escalation barriers. Our objective was to identify, address, and improve residents' perceived barriers to escalation. Setting and Participants: This study was conducted at an urban, academic medical center within the Internal Medicine residency program over one year. Description: A baseline Likert-scale survey categorized residents' perceived escalation issues. A four-lecture curriculum about common causes of patient deterioration and an objective structured clinical examination (OSCE) were created to address the found issues. In the OSCE PGY1 residents first entered the room with the option to escalate to a PGY2 or a PGY3 acting as the rapid response team (RRT) leader with an attending physician creating pushback/intimidation throughout. Debrief focused on both knowledge and collapsing hierarchies. A retrospective pre-post Likert-scale survey evaluated for change in resident attitudes after the interventions in three areas: Communication Skills, Awareness/proper knowledge base of the problem, and Self-assertiveness/handling intimidation from superiors. Evaluation: A total of 54/77 of IM residents completed the baseline survey. Only the PGY1,2 received intervention, and 34/54 completed the pre-post survey. Baseline survey Results Identified barriers included feeling intimidated when escalating (33% rated this as at least a fairly common problem), feeling pushback when escalating (31%), worrying others will view them negatively (10%), gaps in knowledge (12%)/awareness (32%), and misunderstanding severity of the problem (11%). Retrospective Pre-Post Results Paired T-tests were conducted on pre and post summary scores. All post-intervention summary scores rose compared to pre scores, and the Awareness scale approached significance (p=.08). The seven most targeted questions were examined using Wilcoxin Sign tests. Three questions showed statistically significant improvement: improved frequency of being told information needing escalation (p=0.004), less feelings of self-blame (p=0.035), less limitation of autonomy with mandatory RRTs (p=0.009). The other four questions including comfort with, worries about repercussions for, feeling intimidated about, and viewing self negatively if needing to escalate showed change in the positive direction without reaching statistical significance. Discussion/Reflection/Lessons Learned: This study demonstrates the implementation of a year-long curriculum and OSCE can lead to significant change in resident attitudes about perceived escalation barriers. It is likely this study was hindered by a small sample size due to the number of near-significant findings. Future studies are needed involving larger numbers of residents and looking at changes in RRT instances and outcomes to determine if clinical change accompanies the found perceptual change

Learning Objective #1: Avoid premature closure when a patient presents with classic lymphoma symptoms. Our case was given a diagnosis of lymphoma by the emergency department and the hematologist oncologist consulted on the case. While the first impression was lympho-ma, there is a very rare, locally invasive neoplasm of the lymphatic vascular origin called papillary intralymphatic angioendothelioma (PILA), also referred to as Dabska tumor. Recognize that although PILA commonly presents as a slowly growing, asymptomatic (without B symptoms), violaceous patch or nodule, arising from a preexisting lymphatic or vascular anomaly that occurs typically in young adults, it may also affect the elderly and present with typical B symptoms. CASE: A 36 year-old otherwise healthy female presented with six days of acute flu-like symptoms, myalgias, persistent fever and chills associated with abdominal bloating and vomiting for three days. Physical exam was notable for temperature of 103 F, sinus tachycardia and mild tenderness at the left upper quadrant on deep palpation. Labs were notable for a normal WBC count, mildly elevated alkaline phosphatase and total bilirubin. The flu swab was negative. All infectious workup including a quantiferon-TB gold test was negative. The Chest CTshowed confluent 9 x 5 cm anterior mediastinal and 2 x 2 cm sub carinal lymphadenopathy extending to the aortopulmonary window. On abdominal CT abdomen and pelvis there was marked diffuse, bulky and confluent upper abdominal, mesenteric and retroperitoneal adenopathy. The patient underwent mediastinal video assisted thoracoscopic surgery (VATS) which showed papillary intralymphatic angioendothelioma (PILA). The patient was referred to a vascular anomalies' specialist and was prescribed Sirolimus for prophylaxis immunosuppressant therapy. IMPACT/DISCUSSION: To our knowledge, less than 40 cases of PILA have been described in literature. Presently, there are diagnostic challenges for pathologists and providers given PILA's rarity and histological complexity to distinguish it from other vascular lesions and lymphoma. We present a new and unusual case of PILAwith typical B symptoms and multifocal intra-abdominal lesions. Most case reports describe asymptomatic and external presentations. It is important to rely on final pathology prior to assuming lymphoma is the most likely diagnosis.
Conclusion(s): Premature closure is failure to consider alternative diagnoses after the initial impression is formed. This leads to diagnostic errors that can have substantial effects on our patients lives. Rare diseases are often overlooked and we need to recognize PILA as a differential diagnosis for neoplasms of the lymphatic vascular origin

Background: Stethoscopes are recognized as a culprit of microbes that has been conclusively demonstrated to transmit microbes from one patient to another and from health care worker to patient. To curb infections, hospitals need to set more rigorous hygiene standards, identify Methods to interrupt transmission and develop strategies on sterilizing the diaphragms of the stethoscopes. Furthermore, studies have shown that providers infrequently clean their stethoscopes. In one study, only 48% of providers cleaned their stethoscopes daily or weekly, 37% monthly and 7% reported that they had never cleaned their stethoscope. The objective of this study was to conduct a pilot study comparing efficacy of disposable diaphragm covers to no intervention, defined as their ability to reduce colony count of Methicillin Resistant Staphylococcus Aureus (MRSA) and reduce bacterial contamination on stethoscope diaphragm surfaces.
Method(s): This was a prospective pilot study using a randomized, controlled, single-blinded, crossover trial design, evaluating the effect of daily stethoscope disposable diaphragm covers vs. uncovered stethoscopes. Upon recruitment, residents on clinical rotations were randomized to receive one of two sealed opaque boxes. If a resident was randomized to the intervention arm, the package included instructions to begin with the covers. If a resident was randomized to the control arm, instructions were to begin with no covers. We instructed the participants to switch arms at 7 days. Laboratory Methods: A sterile swab was rolled over the surface of the stethoscope's diaphragm from side to side in a streaking method. We used the chromagar MRSA plates (MRSASelectTM II agar plates) to grow oxacillin resistant, non-enterococal gram positives and the non-selective blood agar plate. Cultures were obtained from each resident's stethoscope diaphragm at the end of every 7 day period. We performed a colony count in 24 hours and 48 hours of incubation.
Result(s): We enrolled 37 residents, of whom 29 (70%) completed both weeks of the trial. On the log-10 scale, the mean (range) colony count on plain agar was 1.5 (0.0-3.7) during control and 1.6 (0.0-3.0) using covers. For MRSA, the mean (range) log-10 colony count during control was 0.1 (0.0-2.7) and 0.1 (0.0-1.2) under covers. Overall, 7 (11%) cultures were positive for MRSA during control and 6 (9%) using covers. Using mixed models to account for within-subject and within-culture correlation, the covers increased colony count by 0.47 (95% confidence interval,-0.37-1.31) in mean log-10 overall colony count, and increased risk of MRSA+ culture by 0.2 percent (95% confidence interval,-10.0-10.3).
Conclusion(s): This well designed study shows disposable diaphragm covers inadequate in reducing bacterial load. It is likely that this study was hindered by a small sample size, therefore a larger study to evaluate the ability of other Methods to prevent cross transmission of MRSA and subsequent infections from the stethoscope diaphragm is needed

Learning Objectives: Radiologist interpretations contribute to anchoring bias. Differentiating problems with similar presentations requires thorough exams and detailed patient histories. Correct management often requires a patient-centered approach. Case Information: A 48 year old woman developed a limp from pain in the ball of the right foot while training for her fifth half marathon. A radiologist diagnosed Freiberg's Disease Stage 2, a rare avascular necrosis of the metatarsal head, based on an x-ray ordered by her podiatrist. X-ray findings include flattening of the metatarsal head, which is a normal variant in 10% of people. The podiatrist prescribed a fracture boot. The patient consulted an orthopedist who changed management to a metatarsal pad for her insole after reviewing the x-ray without an alternative diagnosis. Doubting her diagnosis, the patient consulted a physiatrist who confirmed Freiberg's Disease. After 6 weeks of pain, her orthopedist ordered an MRI that ruled out Freiberg's and showed a partial plantar plate tear with significant localized bursitis. She was taught to tape her toe, but pain persisted with the metatarsal pad. A new podiatrist noticed that the metatarsal pad was creating gait problems and he altered her running shoe insole instead. After two weeks, she was running again.
Discussion(s): Metatarsalgia has many causes, yet three doctors anchored their diagnosis on an incorrect radiology report. Listening to the nuances of the patient's story and performing an extensive exam may have expedited the correct diagnosis. Many doctors use metatarsal pads, but this management may cause harm in some patients. (Figure Presented)

Although there are many analytical methods available for estimation of metformin in biological samples and pharmaceutical preparations, to our knowledge there is no specific spectrophotometric method using its derivatization by the Mannich reaction. A simple spectrophotometric method was developed by studying the UV evolution of the complex obtained between metformin, formaldehyde and uranine using the Mannich reaction. Measurements of metformin were achieved at 437 nm using UV-visible spectroscopy. To assess the validity of the method in a clinical situation the extraction was adapted to extract metformin from human urine that had been tested by our method. The spectrometric correlation coefficient (R²) was found to be 0.98 over metformin concentrations of 5- 30 mug/mL. This range includes the clinical levels reached during treatment. The method was validated for linearity, accuracy, and precision. The within-assay limit of detection and quantification (sensitivity) were found to be 0.001 mug/mL. This method for quantification of metformin is simple, precise and accurate. It is suitable as an alternative to existing clinical methods and for the analysis of metformin in pharmacodynamic studies of urinary excretion as well as pharmaceutical formulations and in vitro dissolution studies