Amit Uppal

Increased Mortality Rates During Resident Handoff Periods and the Effect of ACGME Duty Hour Regulations

BACKGROUND Medical errors occur following handoff-related miscommunication. Data regarding the effect on patient-centered outcomes, specifically mortality, are lacking. Our objective was to investigate handoff-related mortality and the effect of duty-hour regulations. METHODS Retrospective cohort study of adult medical patients at a public, university-affiliated hospital from 2010 to 2012. Patients were divided into 2 cohorts: handoff group (discharged within 7 days following a change in resident physician team) vs control group (discharged the 3 weeks of each 4-week rotation before resident service change). The primary outcome was unadjusted and adjusted hospital mortality rate. As a secondary prespecified analysis, we examined the effect of 2011 Accreditation Council for Graduate Medical Education (ACGME) duty-hour changes. RESULTS Among 23,736 patients, unadjusted hospital mortality during the handoff group was higher than the control group (2.68% vs 2.08%, respectively; P = .007; odds ratio [OR] 1.30; 95% confidence interval [CI], 1.08-1.57). Following adjustment, this association remained statistically significant (adjusted OR 1.34; P = .003; 95% CI, 1.10-1.62). Similarly, pre-duty-hour unadjusted hospital mortality was higher in the handoff group vs control group (2.87% vs 2.01%, respectively; P = .006; OR 1.44; 95% CI, 1.11-1.86), which remained statistically significant following adjustment (adjusted OR 1.50; P = .002; 95% CI, 1.16-1.95). However, this association lost statistical significance following duty-hour revision with respect to both unadjusted (2.48% vs 2.15%, respectively; P = .30; OR 1.16; 95% CI, 0.88-1.53) and adjusted mortality (OR 1.18; P = .26; 95% CI, 0.89-1.56). CONCLUSIONS Resident transition in care was significantly associated with an increase in unadjusted and adjusted hospital mortality. Although improved by 2011 ACGME duty-hour amendments, a trend toward higher mortality remained following resident handoff.

A 61-Year-Old-Man With Massive Intravascular Hemolysis

A 61-year-old man with a history of hepatitis C infection and cirrhosis, type II diabetes mellitus, and coronary artery disease presented to the ED with a chief complaint of abdominal pain and hematuria. He reported a flu-like illness that had begun approximately 1 week prior to presentation. His symptoms included abdominal cramping, nausea, and diarrhea. On the day of presentation, hematuria and lethargy developed. There was no history of urinary problems, no unusual ingestions, and no family contacts with similar symptoms. In the ED, he was confused and complained of chest pain.

Factors Associated With Utilization of an Inpatient Palliative Care Consultation Service in an Urban Public Hospital

Rationale: To evaluate factors associated with palliative care consultation (PCC) in an urban public hospital. Methods: A retrospective chart review of patients who died on inpatient medical services. Results: Patients with a PCC were more likely to have a “do not resuscitate” (DNR) order at the time of death (p<0.001) and had a decreased likelihood of death in the ICU (p<0.001). Factors associated with PCC in a multivariate analysis included: cancer diagnosis (p=0.01), at least a high school education (p=0.04), older age (p=.003), and birth outside the US (p=0.03). Conclusion: The increased PCC utilization for immigrants is in contrast to previously reported literature. This increased use may be because access to services in a municipal hospital is not driven by demographic and socioeconomic factors.

Treatment of Viral Hemorrhagic Fever in a Well-Resourced Environment

Evaluation and management of a patient with a potentially highly infectious disease, such as Ebola Virus Disease, requires a structured and thoughtful approach. The differential diagnosis in such cases will include potentially life-threatening diseases that require rapid diagnosis and early initiation of therapy. However, these goals must be balanced with the need to preserve the safety of providers and other patients.