Faculty Bibliography

INTRODUCTION: Rapid response teams (RRTs) have been shown to reduce cardiopulmonary arrests outside the intensive care unit (ICU). Yet the utility of RRTs remains in question, as most large studies have failed to demonstrate a significant reduction in hospital-wide mortality after RRT implementation. METHODS: A cohort design with historical controls was used to determine the effect on hospital-wide mortality of an RRT in which clinical judgment, in addition to vital-signs criteria, was widely promoted as a key trigger for activation. All nonprisoner patients admitted to a tertiary referral public teaching hospital from 2003 through 2008 were included. In total, 77, 021 admissions before RRT implementation (2003 through 2005) and 79, 013 admissions after RRT implementation (2006 through 2008) were evaluated. The a priori primary outcome was unadjusted hospital-wide mortality. A Poisson regression model was then used to adjust for hospital-wide mortality trends over time. Secondary outcomes defined a priori were unadjusted out-of-ICU mortality and out-of-ICU cardiopulmonary-arrest codes. RESULTS: In total, 855 inpatient RRTs (10.8 per 1, 000 hospital-wide discharges) were activated during the 3-year postintervention period. Forty-seven percent of RRTs were activated for reasons of clinical judgment. Hospital-wide mortality decreased from 15.50 to 13.74 deaths per 1, 000 discharges after RRT implementation (relative risk, 0.887; 95% confidence interval (CI), 0.817 to 0.963; P = 0.004). After adjusting for inpatient mortality trends over time, the reduction in hospital-wide mortality remained statistically significant (relative risk, 0.825; 95% CI, 0.694 to 0.981; P = 0.029). Out-of-ICU mortality decreased from 7.08 to 4.61 deaths per 1, 000 discharges (relative risk, 0.651; 95% CI, 0.570 to 0.743; P < 0.001). Out-of-ICU cardiopulmonary-arrest codes decreased from 3.28 to 1.62 codes per 1, 000 discharges (relative risk, 0.493; 95% CI, 0.399 to 0.610; P < 0.001). CONCLUSIONS: Implementation of an RRT in which clinical judgment, in addition to vital-signs criteria, was widely cited as a rationale for activation, was associated with a significant reduction in hospital-wide mortality, out-of-ICU mortality, and out-of-ICU cardiopulmonary-arrest codes. The frequent use of clinical judgment as a criterion for RRT activation was associated with high RRT utilization.

The top one percent of Americans reaped 70 percent of income growth during a period of economic expansion, average people became over-leveraged, and stocks soared.

South Asian immigrants are a large, rapidly growing community in the United States. The rate of cardiovascular disease in immigrants from India, Pakistan, and Bangladesh is disproportionately high. We conducted focus groups with diverse South Asian community members in New York City to elucidate hypertension knowledge, and screening and treatment practices. Focus groups were conducted in partnership with community-based organizations. 47 participants across Bangladeshi, Pakistani and Indian immigrants participated in three focus groups. Participants hesitated accessing services because of immigration fears, financial concerns, scheduling constraints, and dissatisfaction with their interactions with doctors. Discussions detailed knowledge about, and barriers to following, advice on diet and exercise. The findings compel further development of culturally- and linguistically-tailored research and interventions to address the specific needs of this large at-risk community. Potential culturally appropriate approaches are discussed to bridge barriers faced by the community.

Background: Hospital discharge is a critical transition in care, yet recent data show much room for improvement: 1 in 5 patients experiences an adverse event or readmission within 30 days of discharge. Presently, metrics for the quality of discharge care are limited, and little is known about factors affecting the quality of hospital discharge from the perspective of physicians. Residents' perceptions are particularly important given their unique viewpoint of the discharge process as trainees and their role as primary care givers at teaching hospitals, which collectively provide 20% of all hospital care in the United States. Methods: We employed qualitative methods to describe the dischargeprocess from the resident's perspective and generate hypotheses about quality-limiting factors and key strategies for improvement through in-depth in-person interviews. We developed a purposeful sample of participants with attention to postgraduate year and experience in different hospital settings. Our study design included 2 internal medicine training programs-Yale and New York University (NYU)-to ensure a wide breadth of experiences. To date, we have completed 17 interviews with Yale residents and have begun enrollment at NYU. Interviews were professionally transcribed and independently coded by 2 investigators, and discrepancies were resolved by consensus. Thematic analysis was performed by a diverse research team using the constant comparative method. Results: We have analyzed interviews with 17 Yale residents to date: 10 (59%) were seniors (PGY-2 or PGY-3), 7 were interns (41%), and 10 were female (59%). Based on these interviews, we have identified 5 unifying themes representing factors perceived to limit the quality of discharge care: (1) competing priorities of timely versus thorough discharge, (2) lack of communication between discharge team members, (3) uncertainty about provider roles and patient readiness for discharge, (4) lack of standardization in discharge procedures, and (5) poor patient communication and postdischarge feedback. Representative excerpts from interview transcripts will be presented to illustrate conceptual variations of these quality-limiting factors as well as to support the overall consistency and robustness of each theme above. Conclusions: Quality-limiting factors identified by residents may generate hypotheses to develop novel quantitative measures of quality that are grounded in the experiences of physicians providing discharge care. Residents' insights on this topic may also help shape training and practice to improve the quality of discharge care at teaching hospitals

OBJECTIVES: This retrospective study analyzed a primary care depression screening initiative in a large urban university health center. Depression detection, treatment status, and engagement data are presented. PARTICIPANTS: Participants were 3,713 graduate and undergraduate students who presented consecutively for primary care services between January and April 2006. METHODS: A standardized 2-tiered screening approach for an inception cohort of students utilizing primary services. Primary care providers were trained to triage students with depressive symptoms. RESULTS: Six percent of participants had clinically significant depressive symptoms (CSD). Severe depressive symptoms were found in less than 1.0% of participants. Male rates of severe depressive symptoms were more than double that of females. Only 35.7% of untreated depressed participants started treatment within 30 days following identification. CONCLUSIONS: Systematic primary care depression screening in a college health center is a promising approach to identify untreated students with depression. More study is needed to improve rates of treatment engagement.