Mahesh Krishnamurthy

Modified Early Warning System improves patient safety and clinical outcomes in an academic community hospital

Background and objective Severe adverse events such as cardiac arrest and death are often heralded by abnormal vital signs hours before the event. This necessitates an organized track and trigger approach of early recognition and response to subtle changes in a patients condition. The Modified Early Warning System (MEWS) is one of such systems that use temperature, blood pressure, pulse, respiratory rate, and level of consciousness with each progressive higher score triggering an action. Root cause analysis for mortalities in our institute has led to the implementation of MEWS in an effort to improve patient outcomes. Here we discuss our experience and the impact of MEWS implementation on patient care at our community academic hospital. Methods MEWS was implemented in a protocolized manner in June 2013. The following data were collected from non-ICU wards on a monthly basis from January 2010 to June 2014: 1) number of rapid response teams (RRTs) per 100 patient-days (100PD); 2) number of cardiopulmonary arrests ‘Code Blue’ per 100PD; and 3) result of each RRT and Code Blue (RRT progressed to Code Blue, higher level of care, ICU transfer, etc.). Overall inpatient mortality data were also analyzed. Results Since the implementation of MEWS, the number of RRT has increased from 0.24 per 100PD in 2011 to 0.38 per 100PD in 2013, and 0.48 per 100PD in 2014. The percentage of RRTs that progressed to Code Blue, an indicator of poor outcome of RRT, has been decreasing. In contrast, the numbers of Code Blue in non-ICU floors has been progressively decreasing from 0.05 per 100PD in 2011 to 0.02 per 100PD in 2013 and 2014. These improved clinical outcomes are associated with a decline of overall inpatient mortality rate from 2.3% in 2011 to 1.5% in 2013 and 1.2% in 2014. Conclusions Implementation of MEWS in our institute has led to higher rapid response system utilization but lower cardiopulmonary arrest events; this is associated with a lower mortality rate, and improved patient safety and clinical outcomes. We recommend the widespread use of MEWS to improve patient outcomes.

Recurrent syncope, orthostatic hypotension and volatile hypertension: think outside the box

The baroreceptors in the neck and aortic arch are important regulators of sudden blood pressure changes. They are innervated by CN IX and X and synapse in the brainstem. Baroreceptor failure is an under-recognized cause of recurrent syncope, orthostatic hypotension, and volatile hypertension, which is refractory to and may in fact worsen with conventional treatments. Baroreflex failure can be the result of neck and chest radiation, head and neck surgery, and cerebrovascular accidents involving the brainstem nuclei. The management of baroreflex failure is a challenge since patient education, lifestyle changes, and family support are extremely important in managing blood pressure. Leg exercises and Thrombo-Embolic Deterrent Stockings (TED) stockings are important in treating orthostatic hypotension. Clonidine is the antihypertensive of choice for supine hypertension. Low-dose benzodiazepines are helpful in suppressing sympathetic surges. We have encountered two patients with baroreflex failure after chemotherapy and radiation to the neck or upper chest. Temporal relationship between symptoms onset and the history of head, neck, and upper chest radiation or trauma is important in reaching a diagnosis.

The alarming reality of medication error: a patient case and review of Pennsylvania and National data

Case description A 71-year-old female accidentally received thiothixene (Navane), an antipsychotic, instead of her anti-hypertensive medication amlodipine (Norvasc) for 3 months. She sustained physical and psychological harm including ambulatory dysfunction, tremors, mood swings, and personality changes. Despite the many opportunities for intervention, multiple health care providers overlooked her symptoms. Discussion Errors occurred at multiple care levels, including prescribing, initial pharmacy dispensation, hospitalization, and subsequent outpatient follow-up. This exemplifies the Swiss Cheese Model of how errors can occur within a system. Adverse drug events (ADEs) account for more than 3.5 million physician office visits and 1 million emergency department visits each year. It is believed that preventable medication errors impact more than 7 million patients and cost almost

Work Hour Regulations: Do We Need Further Changes Now? A Survey of Internal Medicine Faculty and Residents

21 billion annually across all care settings. About 30% of hospitalized patients have at least one discrepancy on discharge medication reconciliation. Medication errors and ADEs are an underreported burden that adversely affects patients, providers, and the economy. Conclusion Medication reconciliation including an ‘indication review’ for each prescription is an important aspect of patient safety. The decreasing frequency of pill bottle reviews, suboptimal patient education, and poor communication between healthcare providers are factors that threaten patient safety. Medication error and ADEs cost billions of health care dollars and are detrimental to the provider–patient relationship.

An unusual cause of pancytopenia: Whipple's disease.

BACKGROUND In 2003, the Accreditation Council for Graduate Medical Education standardized and regulated work hours for physicians in training in the United States. In December 2008, the Institute of Medicine (IOM) recommended further reductions in duty hours to ensure safer conditions for patients and residents and fellows. Significantly, the IOM committee acknowledged that there are barriers to implementing its recommendations. METHODS IN THE WAKE OF THE IOM PROPOSALS, WE CHOSE TO SURVEY A REFERENCE CLOSER TO HOME: residency program directors, faculty, and residents. Our survey allowed them the opportunity to express their opinions regarding the IOM proposals. RESULTS The majority of the faculty oppose the proposed IOM changes, arguing that there is no definite evidence to support the hypothesis that fewer work hours mean better outcomes in patient safety and education. First-year residents and residents who moonlight were more likely to experience stress and to support decreased work hours. CONCLUSIONS The thoughts and opinions of faculty and residents collected through this survey, in combination with evidence-based studies from trial implementation of these standards, will contribute real answers to the challenging questions on resident work hours.

Oscillating hypothyroidism and hyperthyroidism - a case-based review

Whipples disease is a systemic infectious disease caused by the bacteria Tropheryma whipplei. The most common clinical manifestations of Whipples disease are weight loss (92%), hypoalbuminemia and steatorrhea (91%, respectively), diarrhea (72%), arthralgia (67%), and abdominal pain (55%). Neurological signs and symptoms from dementia to oculomasticatory myorhythmia or oculofacioskeletal myorhythmia (pathognomonic of Whipples disease), lymphadenopathy, and fatigue can also be present. Pancytopenia is a rare and less recognized clinical feature in Whipples disease patients. We are describing a case where a middle-aged Caucasian male diagnosed with Whipples disease was found to have pancytopenia. Etiology of pancytopenia is postulated to be due to the invasion of bone marrow by T. whipplei. It is important to recognize that bone marrow involvement by the Whipple bacillus is not uncommon. In the presence of lymphadenopathy and pancytopenia, clinicians should think of Whipples disease as a differential diagnosis apart from lymphoma or other non-specific granulomatous reticuloendothelial disorders.

Necessity is the mother of invention: an innovative hospitalist-resident initiative for improving quality and reducing readmissions from skilled nursing facilities

Objective/Background To discuss a unique clinical entity where inappropriate activity of inhibitory and stimulatory thyroid antibodies resulted in alternating hypothyroidism and hyperthyroidism. Methods We report the clinical history, laboratory data, and results of imaging studies, along with the pathophysiological mechanism and the subsequent treatment in a patient with fluctuating thyroid functional status. Results A 52-year-old female was treated for hypothyroidism for more than two decades. She started having symptoms of hyperthyroidism along with a suppressed thyroid-stimulating hormone (TSH). She continued to have persistent symptoms despite stopping her levothyroxine. Her free T3 and T4 were elevated along with an increased radioactive uptake scan. She was diagnosed with Graves’ disease and started on methimazole, which relieved her symptoms for a few months. Subsequently, her TSH began to rise beyond expected level, her hypothyroid symptoms reappeared, and methimazole was discontinued. Following this, she again developed symptoms of hyperthyroidism and thyroid values revealed an undetectable TSH. She had at least two such documented cycles of hyperthyroidism alternating with hypothyroidism. She was eventually treated with radioactive iodine ablation followed by levothyroxine replacement. Swinging dominance of TSH-blocking autoantibodies (TBAb) and thyroid-stimulating autoantibodies (TSAb) triggered by methimazole and levothyroxine, respectively, is likely the underlying mechanism. Conclusions Physicians should be vigilant to the phenomenon of spontaneous conversion of hypothyroidism to hyperthyroidism, or vice versa, in a subset of patients with autoimmune thyroid disease. Repeated assessment of thyroid function along with measurement of TBAb and TSAb are invaluable in identifying this rare clinical entity.

Left lower quadrant pain: an unlikely diagnosis in a case of acute abdomen

ABSTRACT Background: Hospital readmissions have been a major challenge to the US health system. Medicare data shows that approximately 25% of Medicare skilled nursing facility (SNF) residents are readmitted back to the hospital within 30 days. Some of the major reasons for high readmission rates include fragmented information exchange during transitions of care and limited access to physicians round-the-clock in SNFs. These represent safety, quality, and health outcome concerns. Aim: The goal of the project was to reduce hospital readmission rates from SNFs by improving transition of care and increasing physician availability in SNFs (five to seven days a week physical presence with 24/7 accessibility by phone). Methods: We proposed a model whereby a hospitalist-led team, including the resident on the geriatrics rotation, followed patients discharged from the hospital to one SNF. Readmission rates pre- and post-implementation were compared. Study results: The period between January 2014 and June 2014 served as the baseline and showed readmission rate of 32.32% from the SNF back to the hospital. After we implemented the new hospitalist SNF model in June 2014, readmission rates decreased to 23.96% between July 2014 and December 2014. From January 2015 to June 2015, the overall readmission rate from the SNF reduced further to 16.06%. Statistical analysis revealed a post-intervention odds ratio of 0.403 (p < 0.001). Conclusion: The government is piloting several care models that incentivize value- based behavior. Our study strongly suggests that the hospitalist-resident continuity model of following patients to the SNFs can significantly decrease 30-days hospital readmission rates.

Determining the role of intravenous hydration on hospital readmissions for acute congestive heart failure

ABSTRACT Splenic infarct is an incredibly rare diagnosis for abdominal pain. One study involving two hospitals over ten years describes only 0.0037% of all hospital admissions presenting with splenic infarction. Our report describes a case of massive splenomegaly causing pain in a different location compared to the normal anatomical location of the spleen with an unexpected cause, lymphoma. High clinical suspicion for lymphoma as a cause of splenic infarction is critical because this disease can otherwise be clinically silent. This case emphasizes the importance of a thorough clinical workup and persistence in diagnostic pursuit.

Palpitations as a presenting feature of multisystem sarcoidosis

The role of intravenous hydration on hospital readmissions due to acute exacerbation of congestive heart failure (CHF) has not been studied sufficiently to the best of our knowledge. We sought to determine the possible role of intravenous hydration on hospital readmissions for acute CHF and fluid overload and explain how an intravenous fluid (IVF) restriction strategy may help reduce hospital readmission rates. We retrospectively studied the electronic medical records of 98-patient cohort who had hospital readmission due to acute decompensated congestive heart failure (ADHF) during the period of January 1, 2016 to July 9, 2016. These patients were admitted with reasons other than ADHF during the index admission. The patients were divided into two groups; those with ADHF readmissions within 15 days of index admission (group A) and those after 15 days (group B). Various factors affecting CHF readmissions as outlined in the results were compared between these two groups. Cohort of 98 patients (53 females, 54.1%; 76.4±11.6 years) re-admitted during the study period of 1/1/2016 to 7/9/2016 were analyzed. 71 patients had only received IVF during index admission. These were subdivided into group A (12 females, 54.5 %; mean age 75.9±12.9 years) and group B (25 females, 51.02%; mean age 76.08±11.90 years) based on readmission ≤15 days or >15 days from the index admission. There was no statistically significant difference (P=0.97) in amount of IVF prescribed between two subgroups but the duration of prescribed IVF significantly affected readmission in group A compared to group B (P=0.03). While the drop in albumin and rise in creatinine were not significant, the mean hemoglobin (Hb) drop in group A compared to group B was significant at P=0.008. Type of IVF and nature of CHF (heart failure with reduced ejection fraction, HFrEF/heart failure with preserved ejection fraction, HFpEF) were not found to significantly affect early readmissions associated with IV hydration. In patients with history of CHF, duration of IVF prescribed during the index admission seems to play important role in early CHF readmission (defined as <15 days in our study).