Indications for the Use of Proton Pump Inhibitors for Stress Ulcer Prophylaxis and Peptic Ulcer Bleeding in Hospitalized Patients
Proton pump inhibitors are widely used throughout the world for the treatment of gastrointestinal disorders that are related to acid secretion, such as peptic ulcer disease and dyspepsia. Another common indication for proton pump inhibitors is stress ulcer prophylaxis. Proton pump inhibitors have proven efficacy for the treatment of acid-related gastrointestinal disorders, but there is concern that their use may be associated with the development of significant complications, such as fractures, Clostridium difficile infection, acute kidney injury, chronic kidney disease, and hypomagnesemia. Proton pump inhibitors are overused in the hospital setting, both for stress ulcer prophylaxis and gastrointestinal bleeding, and then they are often inappropriately continued after discharge from the hospital. This narrative review article outlines the evidence surrounding appropriate proton pump inhibitor use for stress ulcer prophylaxis and peptic ulcer bleeding.
Reducing Overuse of Proton Pump Inhibitors for Stress Ulcer Prophylaxis and Nonvariceal Gastrointestinal Bleeding in the Hospital: A Narrative Review and Implementation Guide
Proton pump inhibitors (PPIs) are among the most commonly used medications in the world; however, these drugs carry the risk of patient harm, including acute and chronic kidney disease, Clostridium difficile infection, hypomagnesemia, and fractures. In the hospital setting, PPIs are overused for stress ulcer prophylaxis and gastrointestinal bleeding, and PPI use often continues after discharge. Numerous multifaceted interventions have demonstrated safe and effective reduction of PPI use in the inpatient setting. This narrative review and the resulting implementation guide summarize published interventions to reduce inappropriate PPI use and provide a strategy for quality improvement teams.
Collaborating Across Private, Public, Community, and Federal Hospital Systems: Lessons Learned from the Covid-19 Pandemic Response in NYC
SARS2-CoV-2 and Stroke in a New York Healthcare System
BACKGROUND AND PURPOSE/OBJECTIVE:With the spread of coronavirus disease 2019 (COVID-19) during the current worldwide pandemic, there is mounting evidence that patients affected by the illness may develop clinically significant coagulopathy with thromboembolic complications including ischemic stroke. However, there is limited data on the clinical characteristics, stroke mechanism, and outcomes of patients who have a stroke and COVID-19. METHODS:We conducted a retrospective cohort study of consecutive patients with ischemic stroke who were hospitalized between March 15, 2020, and April 19, 2020, within a major health system in New York, the current global epicenter of the pandemic. We compared the clinical characteristics of stroke patients with a concurrent diagnosis of COVID-19 to stroke patients without COVID-19 (contemporary controls). In addition, we compared patients to a historical cohort of patients with ischemic stroke discharged from our hospital system between March 15, 2019, and April 15, 2019 (historical controls). RESULTS:<0.001). When compared with contemporary controls, COVID-19 positive patients had higher admission National Institutes of Health Stroke Scale score and higher peak D-dimer levels. When compared with historical controls, COVID-19 positive patients were more likely to be younger men with elevated troponin, higher admission National Institutes of Health Stroke Scale score, and higher erythrocyte sedimentation rate. Patients with COVID-19 and stroke had significantly higher mortality than historical and contemporary controls. CONCLUSIONS:We observed a low rate of imaging-confirmed ischemic stroke in hospitalized patients with COVID-19. Most strokes were cryptogenic, possibly related to an acquired hypercoagulability, and mortality was increased. Studies are needed to determine the utility of therapeutic anticoagulation for stroke and other thrombotic event prevention in patients with COVID-19.
The Financial and Clinical Impact of an Electronic Health Record Integrated Pathway in Elective Colon Surgery
BACKGROUND:â€ƒEnhanced Recovery after Surgery (ERAS) pathways have been shown to reduce length of stay, but there have been limited evaluations of novel electronic health record (EHR)-based pathways. Compliance with ERAS in real-world settings has been problematic. OBJECTIVE:â€ƒThis article evaluates a novel ERAS electronic pathway (E-Pathway) activity integrated with the EHR for patients undergoing elective colorectal surgery. METHODS:â€ƒWe performed a retrospective cohort study of surgical patients age â‰¥ 18 years hospitalized from March 1, 2013 to August 31, 2016. The primary cohort consisted of patients admitted for elective colon surgery. We also studied a control group of patients undergoing other elective procedures. The E-Pathway was implemented on March 2, 2015. The primary outcome was variable costs per case. Secondary outcomes were observed to expected length of stay and 30-day readmissions. RESULTS:â€‰=â€‰0.231) decrease in monthly costs of 0.57% (95% CI 1.51 to - 0.37%) postintervention. For the 30-day readmission rates, there were no statistically significant changes in either cohort. CONCLUSION/CONCLUSIONS:â€ƒOur study is the first to report on the reduced costs after implementation of a novel sophisticated E-Pathway for ERAS. E-Pathways can be a powerful vehicle to support ERAS adoption.
Can Appreciative Inquiry Improve Interdisciplinary Experiences [Meeting Abstract]
Ouch! Addressing Microaggressions on the Interdisciplinary Team [Meeting Abstract]
Bending the cost curve: time series analysis of a value transformation programme at an academic medical centre
BACKGROUND:Reducing costs while increasing or maintaining quality is crucial to delivering high value care. OBJECTIVE:To assess the impact of a hospital value-based management programme on cost and quality. DESIGN/METHODS:Time series analysis of non-psychiatric, non-rehabilitation, non-newborn patients discharged between 1 September 2011 and 31 December 2017 from a US urban, academic medical centre. INTERVENTION/METHODS:NYU Langone Health instituted an institution-wide programme in April 2014 to increase value of healthcare, defined as health outcomes achieved per dollar spent. Key features included joint clinical and operational leadership; granular and transparent cost accounting; dedicated project support staff; information technology support; and a departmental shared savings programme. MEASUREMENTS/METHODS:Change in variable direct costs; secondary outcomes included changes in length of stay, readmission and in-hospital mortality. RESULTS:The programme chartered 74 projects targeting opportunities in supply chain management (eg, surgical trays), operational efficiency (eg, discharge optimisation), care of outlier patients (eg, those at end of life) and resource utilisation (eg, blood management). The study cohort included 160â€‰434 hospitalisations. Adjusted variable costs decreased 7.7% over the study period. Admissions with medical diagnosis related groups (DRG) declined an average 0.20% per month relative to baseline. Admissions with surgical DRGs had an early increase in costs of 2.7% followed by 0.37% decrease in costs per month. Mean expense per hospitalisation improved from 13% above median for teaching hospitals to 2% above median. Length of stay decreased by 0.25% per month relative to prior trends (95%â€‰CI -0.34 to 0.17): approximately half a day by the end of the study period. There were no significant changes in 30-day same-hospital readmission or in-hospital mortality. Estimated institutional savings after intervention costs were approximately $53.9â€‰million. LIMITATIONS/CONCLUSIONS:Observational analysis. CONCLUSION/CONCLUSIONS:A systematic programme to increase healthcare value by lowering the cost of care without compromising quality is achievable and sustainable over several years.
Implementing a daily medicine rounding tool to promote patient safety and improve communication between physician and nurse during hospital-ization [Meeting Abstract]
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
Bedside rounds improve patient satisfaction and care transitions [Meeting Abstract]
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