Archana Roy

Optimizing Screening for Osteoporosis in Patients With Fragility Hip Fracture

BackgroundOsteoporosis, the underlying cause of most hip fractures, is underdiagnosed and undertreated. The 2008 Joint Commission report Improving and Measuring Osteoporosis Management showed only an average of 20% of patients with low-impact fracture are ever tested or treated for osteoporosis. We developed an integrated model utilizing hospitalists and orthopaedic surgeons to improve care of osteoporosis in patients with hip fracture.Questions/purposesDoes our integrated model combining hospitalists and orthopaedic surgeons improve the frequency of evaluation for osteoporosis, screening for secondary causes, and patients’ education on osteoporosis?Patients and MethodsOur Hospitalist-Orthopaedic Surgeon Integrated Model of Care was implemented in September 2009. We compared the rate of evaluation and treatment of osteoporosis in 140 patients admitted with fragility hip fracture at our institution before (70 patients) and after (70 patients) implementation of the care plan.ResultsEvaluation of patients for osteoporosis was higher in the postimplementation group compared to the preimplementation group (89% versus 24%). Screening of patients for secondary causes of osteoporosis was also improved in the postimplementation group (89% versus 0%), as was the proportion of patients who received education for osteoporosis management (89% versus 0%).ConclusionOur model of integrated care by hospitalists and orthopaedic surgeons resulted in improvement in the evaluation for osteoporosis, screening for secondary causes of osteoporosis, and education on osteoporosis management in patients with hip fracture at our institution. This may have important implications for treatment of these patients.Level of Evidence Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Mayo registry for telemetry efficacy in arrest study: An evaluation of the feasibility of the do not intubate code status

ABSTRACT Introduction: Guidelines recommend discussing code status with patients on hospital admission. No study has evaluated the feasibility of a full code with do not intubate (DNI) status. Methods: A retrospective analysis of patients who experienced a cardiopulmonary arrest was performed between May 1, 2008 and June 20, 2014. A descriptive analysis was created based on whether patients required mechanical ventilatory support during the hospitalization and comparisons were made between both patient subsets. Results: A total of 239 patients were included. Almost all (n = 218, 91.2%) required intubation during the hospitalization. Over half (n = 117, 53.7%) were intubated on the same day as the cardiopulmonary arrest and 91 patients (41.7%) were intubated at the time of arrest. Comparisons between intubated and non-intubated patients showed little differences in clinical characteristics, except for a higher proportion of medical cardiac etiology for admission in patients who did not require intubation (n = 10, 47.6% versus n = 55, 25.2%; p = 0.18) and initial arrest rhythm of ventricular tachycardia/fibrillation (n = 8, 38.1% versus n = 50, 22.9%; p = 0.37). No differences in 24-hour and posthospital survivals were present. Conclusion: Mechanical ventilatory support is commonly utilized in patients who experience a cardiopulmonary arrest. The DNI status may not be a feasible code status option for most patients.

Violent behavior by emergency department patients with an involuntary hold status

Background: Violence against health care workers has been increasing. Health care workers in emergency departments (EDs) are highly vulnerable because they provide care for patients who may have mental illness, behavioral problems, or substance use disorders (alone or in combination) and who are often evaluated during an involuntary hold. Our objective was to identify factors that may be associated with violent behavior in ED patients during involuntary holds. Methods: Retrospective review of patients evaluated during an involuntary hold at a suburban acute care hospital ED from January 2014 through November 2015. Results: Of 251 patients, 22 (9%) had violent incidents in the ED. Violent patients were more likely to have a urine drug screen positive for tricyclic antidepressants (18.2% vs 4.8%, P = 0.03) and to present with substance misuse (68.2% vs 39.7%, P = 0.01), specifically with marijuana (22.7% vs 9.6%, P = 0.06) and alcohol (54.5% vs 24.9%, P = 0.003). ED readmission rates were higher for violent patients (18.2% vs 3.9%, P = 0.02). No significant difference was found between violent patients and nonviolent patients for sex, race, marital status, insurance status, medical or psychiatric condition, reason for involuntary hold, or length of stay. Conclusion: Violent behavior by patients evaluated during an involuntary hold in a suburban acute care hospital ED was associated with tricyclic antidepressant use, substance misuse, and higher ED readmission rates.

USING BETA-BLOCKERS TO CUT PERIOPERATIVE RISK IN CAD Cardioprotective strategies for noncardiac surgery Prophylactic use of beta-blockers, illustrated here in four cases, is a relatively simple and low-cost way of preventing perioperative adverse events.

Postoperative adverse myocardial ischemic events, such as infarction, unstable angina, and cardiac death, are common in patients with coronary artery disease (CAD). These events can be prevented in many patients with strategies such as the perioperative use of beta-blockers. In this article, the authors present four cases and discuss perioperative evaluation of patients having a noncardiac operation to determine risk of an adverse cardiac event after the procedure. Evidenced-based approaches to reducing the chances of an undesirable outcome in high-risk patients, such as preoperative testing and procedures and the use of beta-blockers, are presented.