Christopher L. Roy

Murine CD1d-Restricted T Cell Recognition of Cellular Lipids

NKT cells are associated with immunological control of autoimmune disease and cancer and can recognize cell surface mCD1d without addition of exogenous antigens. Cellular antigens presented by mCD1d have not been identified, although NKT cells can recognize a synthetic glycolipid, alpha-GalCer. Here we show that after addition of a lipid extract from a tumor cell line, plate-bound mCD1d molecules stimulated an NKT cell hybridoma. This hybridoma also responded strongly to three purified phospholipids, but failed to recognize alpha-GalCer. Seven of sixteen other mCD1d restricted hybridomas also showed a response to certain purified phospholipids. These findings suggest NKT cells can recognize cellular antigens distinct from alpha-GalCer and identify phospholipids as potential self-antigens presented by mCD1d.

Patient Safety Concerns Arising from Test Results That Return after Hospital Discharge

Context Poor communication between inpatient and outpatient providers precedes many preventable adverse events that occur shortly after discharge. Contribution Forty-one percent of 2644 patients on the hospitalist services of 2 academic hospitals had pending laboratory or radiology results at discharge. Physician-reviewers deemed approximately 9% of these results potentially actionable. Physician surveys done 14 days after results were first available showed that physicians were unaware of many results and thought that about 13% of them required urgent action. Cautions Findings may not apply to nonacademic or nonhospitalist settings. Implications We need good integrated systems to assure follow-up of tests that are pending at discharge. The Editors Good communication between inpatient and outpatient physicians at the transition from hospital to home is critical to patient safety. However, the amount and complexity of information that must be relayed at hospital discharge are often overwhelming. Unfortunately, when communication breaks down, patients are at risk: More than half of all preventable adverse events occurring soon after hospital discharge have been related to poor communication among providers (1). Recently, the challenges to high-quality transitions of care have been increasingly recognized (2), and several factors may be contributing to communication failures at discharge. Although the introduction of hospitalist programs across the United States has produced positive results (3-5), the discontinuity of care inherent in the hospitalist model increases the likelihood of communication failures and makes thorough communication at discharge essential (6). Discontinuity is also an issue in teaching hospitals, where physicians-in-training may be responsible for some or all of the communication at discharge and, under new work-hour restrictions, may frequently change services or work in shifts. Whatever the cause, discontinuity of care at the inpatient-to-outpatient transition has been shown to be associated with medical errors (7). Among these errors is a failure to follow up on the results of laboratory tests and radiologic studies that return after discharge. Although timely follow-up on test results has received attention from the Agency for Healthcare Research and Quality (8) and failure to follow up on results has been recognized by a large malpractice insurer (9) as accounting for one quarter of diagnosis-related malpractice cases, few studies have addressed follow-up on test results pending at hospital discharge. Moore and colleagues (7) studied test follow-up errors, which were defined as having a test result noted as pending at discharge in the inpatient medical record but not acknowledged in the outpatient chart. Using retrospective chart review, they found this type of error in the records of 8% of all discharged patients and 41% of all patients discharged with pending test results, but their study design did not allow them to determine 1) whether clinicians were aware of the results and did not document them or 2) the clinical consequences of these errors. To our knowledge, no other studies have prospectively examined the prevalence and characteristics of test results that return after discharge or physician awareness of them. We hypothesized that test results pending at discharge are frequently overlooked in the handoff from the inpatient physician to the outpatient physician and that some of these results might have important clinical consequences for patients. Accordingly, we sought to prospectively determine the prevalence and characteristics of these potentially actionable results, to determine how often physicians are unaware of these results, and to evaluate the satisfaction of inpatient physicians with current systems for following up on results returning after discharge. Methods We carried out our study on the general medicine hospitalist services at 2 academic tertiary care centers in Boston, Massachusetts (hospitals A and B). The human research committee for both hospitals reviewed and approved the study design. The hospitals belong to the same integrated care-delivery network and share a common electronic clinical data repository that includes test results, discharge orders and summaries, ambulatory notes, and medication and problem lists. These data are accessible at all inpatient and outpatient sites through the same electronic medical record. In addition, all physicians use the same e-mail system. Hospital A has 3 hospitalist inpatient teams that each consist of 1 hospitalist attending physician, 1 internal medicine resident, and 2 interns. At hospital A, the hospitalist attending physician is usually responsible for all communication to outpatient physicians at discharge, as well as for follow-up on all pending test results that return after discharge. Hospital B has 2 types of hospitalist services. One is nonhousestaff and is staffed only by hospitalist and nonhospitalist attending physicians; the nonhospitalist attending physicians care for their own patients on this service, but for the purposes of the study, we categorized them as inpatient physicians. The other hospitalist service at hospital B is a teaching service of 4 teams, each with 1 hospitalist attending physician, 1 junior resident, and 3 interns. On these teams at hospital B, the junior resident is responsible for communication at discharge and follow-up on all pending test results. During the study, 16 hospitalists were responsible for patient discharges at hospital A, 15 hospitalist and 93 nonhospitalist attending physicians were responsible for discharges on the nonhousestaff service at hospital B, and 54 junior residents were responsible for discharges on the teaching service at hospital B. Patient Selection and Identification of Results Returning after Discharge Using the hospital computer systems, we prospectively identified 2644 consecutive patients discharged from February to June 2004. Shortly after each patients discharge, a research assistant entered into a database the patients identifying information, discharge diagnosis, and times and dates of hospital admission and discharge. He or she then tracked each patients pending test results by entering the patient on a watch list using a feature in a results-management system called Results Manager. Results Manager is a computer application that is fully integrated into the electronic medical record and is able to cull pending and final test results from the clinical data repository and to prioritize them on the basis of type of result and degree of abnormality. It was originally developed to track test results in the outpatient setting, and it has been evaluated and tested extensively in that setting but has not been used for inpatients (10). Data Collection We tracked test results with Results Manager for 14 days after patient discharge. A research assistant screened all laboratory and radiologic test results returning after discharge and excluded the results of tests done after discharge. Normal, near-normal, and stable results were excluded by using a predefined algorithm (Figure 1). If a result was abnormal, it was sent to 1 of 4 physician-reviewers who, using the electronic medical record, reviewed the discharge diagnosis; any related test results; and the discharge order, note, or summary (when available) to determine whether the result was potentially actionable. Any result mentioned in the discharge summary was excluded (these were most often final radiologic test results that did not differ from the preliminary results available to the inpatient team). Figure 1. Identifying results for physician review At both hospitals, the discharge order (including discharge diagnoses, medications, and follow-up appointments) was entered into the electronic medical record on the day of discharge and therefore was always available at the time of physician review. Of the 671 results that we reviewed, 525 (78%) were for patients who also had a dictated or typed discharge summary available at the time of review. When discharge summaries are completed after hospital discharge, inpatient physicians have access to the electronic medical record, including any test results that were not available on the day of discharge. The physician-reviewers are board-certified internists; 2 are hospitalists, and 2 are primary care physicians. If a physician-reviewer was involved in the care of a patient who had a result that required review, that result was sent to one of the other 3 reviewers. After reviewing the discharge order, the discharge summary, and related test results, the physician-reviewer used clinical judgment to determine whether the result required clinical action on the basis of the available information. A result was considered potentially actionable if it could change the management of the patient by requiring a new treatment or diagnostic test (or repeated testing), modification or discontinuation of a treatment or diagnostic testing, scheduling of an earlier follow-up appointment, or referral of the patient to another physician or specialist. The reviewer rated the result as definitely actionable, probably actionable, probably not actionable, or definitely not actionable. The reviewer also rated the urgency of the required action according to how soon it should occur: within 1 hour, 8 hours, 24 hours, 72 hours, 1 week, or 1 month. Surveys If the physician-reviewer defined a result as definitely actionable or probably actionable, either the inpatient physician or the primary care physician was surveyed by e-mail to determine whether he or she was aware of the result. At hospital A, the attending hospitalist was the inpatient physician surveyed; on the teaching service at hospital B, the junior resident was surveyed. On the nonhousestaff service at hospital B, the hospitalist or nonhospitalist attending physician was surveyed as the inpatient physician. The

Implementation of a physician assistant/hospitalist service in an academic medical center: Impact on efficiency and patient outcomes

BACKGROUND Accreditation Council on Graduate Medical Education (ACGME) duty hour restrictions have led to the widespread implementation of non-house staff services in academic medical centers, yet little is known about the quality and efficiency of patient care on such services. OBJECTIVE To evaluate the quality and efficiency of patient care on a physician assistant/hospitalist service compared with that of traditional house staff services. DESIGN Retrospective cohort study. SETTING Inpatient general medicine service of a 747-bed academic medical center. PATIENTS A total of 5194 consecutive patients admitted to the general medical service from July 2005 to June 2006, including 992 patients on the physician assistant/hospitalist service and 4202 patients on a traditional house staff service. INTERVENTION A geographically localized service staffed with physician assistants and supervised by hospitalists. MEASUREMENTS Length of stay (LOS), cost of care, inpatient mortality, intensive care unit (ICU) transfers, readmissions, and patient satisfaction. RESULTS Patients admitted to the study service were younger, had lower comorbidity scores, and were more likely to be admitted at night. After adjustment for these and other factors, and for clustering by attending physician, total cost of care was marginally lower on the study service (adjusted costs 3.9% lower; 95% confidence interval [CI] -7.5% to -0.3%), but LOS was not significantly different (adjusted LOS 5.0% higher; 95% CI, -0.4% to +10%) as compared with house staff services. No difference was seen in inpatient mortality, ICU transfers, readmissions, or patient satisfaction. CONCLUSIONS For general medicine inpatients admitted to an academic medical center, a service staffed by hospitalists and physician assistants can provide a safe alternative to house staff services, with comparable efficiency.

Factors Associated With Radiologists' Adherence to Fleischner Society Guidelines for Management of Pulmonary Nodules

PURPOSE In 2005, the Fleischner Society guidelines (FSG) for managing pulmonary nodules detected on CT scans were published. The aim of this study was to evaluate adherence to the FSG, adjusting for demographic and clinical variables that may contribute to adherence. METHODS Radiology reports were randomly obtained for 1,100 chest and abdominal CT scans performed between January and June 2010 in a tertiary hospitals emergency department and outpatient clinics. An automated document retrieval system using natural language processing was used to identify patients with pulmonary nodules from the data set. Features relevant to evaluating variation in adherence to the FSG, including age, sex, race, nodule size, and scan site (eg, the emergency department) and type, were extracted by manual review from reports retrieved using natural language processing. All variables were entered into a logistic regression model. RESULTS Three hundred fifteen reports were identified to have pulmonary nodules, 75 of which were for patients with concurrent malignancies or aged < 35 years. Of the remaining 240 reports, 34% of recommendations for pulmonary nodules were adherent to the FSG. Nodule size demonstrated an association with guideline adherence, with adherence highest in the >4-mm to 6-mm nodule group (P = .04) and progressively diminishing for smaller and bigger nodules. CONCLUSIONS Pulmonary nodules are prevalent findings on chest and abdominal CT scans. Although most radiologists recommend follow-up imaging for these findings, recommendations for pulmonary nodules were consistent with the FSG in 34% of radiology reports. Nodule size demonstrated an association with guideline adherence, after adjusting for key variables.

Impact of Automated Alerts on Follow-Up of Post-Discharge Microbiology Results: A Cluster Randomized Controlled Trial

ABSTRACTBACKGROUNDFailure to follow up microbiology results pending at the time of hospital discharge can delay diagnosis and treatment of important infections, harm patients, and increase the risk of litigation. Current systems to track pending tests are often inadequate.OBJECTIVETo design, implement, and evaluate an automated system to improve follow-up of microbiology results that return after hospitalized patients are discharged.DESIGNCluster randomized controlled trial.SUBJECTSInpatient and outpatient physicians caring for adult patients hospitalized at a large academic hospital from February 2009 to June 2010 with positive and untreated or undertreated blood, urine, sputum, or cerebral spinal fluid cultures returning post-discharge.INTERVENTIONAn automated e-mail-based system alerting inpatient and outpatient physicians to positive post-discharge culture results not adequately treated with an antibiotic at the time of discharge.MAIN MEASURESOur primary outcome was documented follow-up of results within 3 days. Secondary outcomes included physician awareness and assessment of result urgency, impact on clinical assessments and plans, and preferred alerting scenarios.KEY RESULTSWe evaluated the follow-up of 157 post-discharge microbiology results from patients of 121 physicians. We found documented follow-up in 27/97 (28%) results in the intervention group and 8/60 (13%) in the control group [aOR 3.2, (95% CI 1.3-8.4); p = 0.01]. Of all inpatient physician respondents, 32/82 (39%) were previously aware of the results, 45/77 (58%) felt the results changed their assessments and plans, 43/77 (56%) felt the results required urgent action, and 67/70 (96%) preferred alerts for current or broader scenarios.CONCLUSIONOur alerting system improved the proportion of important post-discharge microbiology results with documented follow-up, though the proportion remained low. The alerts were well received and may be expanded in the future.

Four-year impact of an alert notification system on closed-loop communication of critical test results.

OBJECTIVE One of the patient safety goals proposed by the Joint Commission urges hospitals to develop a policy for communicating critical test results and to measure adherence to that policy. We evaluated the impact of an alert notification system on policy adherence for communicating critical imaging test results to referring providers and assessed system adoption over the first 4 years after implementation. MATERIALS AND METHODS This study was performed in a 753-bed academic medical center. The intervention, an automated alert notification system for critical results, was implemented in January 2010. The primary outcome was adherence to institutional policy for timely closed-loop communication of critical imaging results, and the secondary outcome was system adoption. Policy adherence was determined through manual review of a random sample of radiology reports from the first 4 years after the intervention (n = 37,604) compared with baseline outcomes 1 year before the intervention (n = 9430). Adoption was evaluated by quantifying the use of the system overall and the proportion of alerts that used noninterruptive communication as a percentage of all reports generated by 320 radiologists (n = 1,538,059). A statistical analysis of the trend at 6-month intervals over 4 years was performed using a chi-square trend test. RESULTS Adherence to the policy increased from 91.3% before the intervention to 95.0% after the intervention (p < 0.0001). There was a ninefold increase in the critical results communicated via the system (chi-square trend test, p < 0.0001). During the first 4 years after the intervention, 41,445 alerts (41% of the total number of alerts) used the systems noninterruptive process for communicating less urgent critical results, which was substantially unchanged over the 4 years postintervention, thus reducing unnecessary paging interruptions. CONCLUSION An automated alert notification system for communicating critical imaging results was successfully adopted and was associated with increased adherence to institutional policy for communicating critical test results and with reduced workflow interruptions.

Design and implementation of an automated email notification system for results of tests pending at discharge

Physicians are often unaware of the results of tests pending at discharge (TPADs). The authors designed and implemented an automated system to notify the responsible inpatient physician of the finalized results of TPADs using secure, network email. The system coordinates a series of electronic events triggered by the discharge time stamp and sends an email to the identified discharging attending physician once finalized results are available. A carbon copy is sent to the primary care physicians in order to facilitate communication and the subsequent transfer of responsibility. Logic was incorporated to suppress selected tests and to limit notification volume. The system was activated for patients with TPADs discharged by randomly selected inpatient-attending physicians during a 6-month pilot. They received approximately 1.6 email notifications per discharged patient with TPADs. Eighty-four per cent of inpatient-attending physicians receiving automated email notifications stated that they were satisfied with the system in a brief survey (59% survey response rate). Automated email notification is a useful strategy for managing results of TPADs.

Impact of an automated email notification system for results of tests pending at discharge: a cluster-randomized controlled trial

BACKGROUND AND OBJECTIVE Physician awareness of the results of tests pending at discharge (TPADs) is poor. We developed an automated system that notifies responsible physicians of TPAD results via secure, network email. We sought to evaluate the impact of this system on self-reported awareness of TPAD results by responsible physicians, a necessary intermediary step to improve management of TPAD results. METHODS We conducted a cluster-randomized controlled trial at a major hospital affiliated with an integrated healthcare delivery network in Boston, Massachusetts. Adult patients with TPADs who were discharged from inpatient general medicine and cardiology services were assigned to the intervention or usual care arm if their inpatient attending physician and primary care physician (PCP) were both randomized to the same study arm. Patients of physicians randomized to discordant study arms were excluded. We surveyed these physicians 72 h after all TPAD results were finalized. The primary outcome was awareness of TPAD results by attending physicians. Secondary outcomes included awareness of TPAD results by PCPs, awareness of actionable TPAD results, and provider satisfaction. RESULTS We analyzed data on 441 patients. We sent 441 surveys to attending physicians and 353 surveys to PCPs and received 275 and 152 responses from 83 different attending physicians and 112 different PCPs, respectively (attending physician survey response rate of 63%). Intervention attending physicians and PCPs were significantly more aware of TPAD results (76% vs 38%, adjusted/clustered OR 6.30 (95% CI 3.02 to 13.16), p<0.001; 57% vs 33%, adjusted/clustered OR 3.08 (95% CI 1.43 to 6.66), p=0.004, respectively). Intervention attending physicians tended to be more aware of actionable TPAD results (59% vs 29%, adjusted/clustered OR 4.25 (0.65, 27.85), p=0.13). One hundred and eighteen (85%) and 43 (63%) intervention attending physician and PCP survey respondents, respectively, were satisfied with this intervention. CONCLUSIONS Automated email notification represents a promising strategy for managing TPAD results, potentially mitigating an unresolved patient safety concern. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (NCT01153451).

Incidence and predictors of microbiology results returning postdischarge and requiring follow‐up

BACKGROUND Failure to follow up microbiology results pending at discharge can delay appropriate treatment, increasing the risk of patient harm and litigation. Limited data describe the frequency of postdischarge microbiology results requiring a treatment change. OBJECTIVE To determine the incidence and predictors of postdischarge microbiology results requiring follow-up. DESIGN Cross-sectional. SETTING Large academic hospital during 2007. MEASUREMENTS We evaluated blood, urine, sputum, and cerebrospinal fluid (CSF) cultures ordered for hospitalized patients. We identified cultures that returned postdischarge and determined which were clinically important and not treated by an antibiotic to which they were susceptible. We reviewed a random subset to assess the potential need for antibiotic change. Using logistic regression, we identified significant predictors of results requiring follow-up. RESULTS Of 77,349 inpatient culture results, 8668 (11%) returned postdischarge. Of these, 385 (4%) were clinically important and untreated at discharge. Among 94 manually reviewed cases, 53% potentially required a change in therapy. Urine cultures were more likely to potentially require therapy change than non-urine cultures (OR 2.8, 95% CI 1.1-7.2; P = 0.03). Also, 76% of 25 results from surgical services potentially required a therapy change, compared with 59% of 29 results from general medicine, 38% of 16 results from oncology, and 33% of 24 results from medical subspecialties. Overall, 2.4% of postdischarge cultures potentially necessitated an antibiotic change. CONCLUSIONS Many microbiology results return postdischarge and some necessitate a change in treatment. These results arise from many specialties, suggesting the need for a hospital-wide system to ensure effective communication of these results.

Clinical utility of lipid and lipoprotein levels during hospitalization for acute myocardial infarction.

The management of dyslipidemia after myocardial infarction (MI) is an important aspect of post-myocardial infarction care. However, acute changes in the lipid profile immediately following myocardial infarction have resulted in uncertainty regarding the clinical utility of lipid levels assessed during hospitalization for MI. We studied the effect of the timing of plasma lipid assessment among 294 patients who presented with MI to determine whether the differences between the serum lipid values in-hospital when compared with post-discharge values (generally 2-3 months after MI) would have a substantial impact on the decision to initiate lipid-lowering therapy. We found that the mean total and LDL cholesterol levels were significantly lower in-hospital when compared with generally 2-3 months later. However, patients whose lipids were measured within 48 h of presentation did not have significantly different values compared with generally 2-3 months post-discharge. Moreover, despite slightly lower in-hospital levels, 83.7% of patients were above the National Cholesterol Education Program target LDL for secondary prevention and 57.6% met the criteria for drug therapy based on in-hospital assessment. Total and LDL cholesterol levels fall modestly after an acute MI; however, from a clinical perspective, in-hospital levels can be used to guide decisions regarding lipid-lowering therapy which can begin in the immediate post-MI setting. In-hospital levels approximate post-MI levels, particularly if drawn within 48 h of presentation. All patients with acute myocardial infarction should have complete lipid profiles measured prior to discharge.