PURPOSE: Chronic obstructive pulmonary disease (COPD) readmissions pose a significant burden on patients as well as hospitalization costs. Centers for Medicare and Medicaid Services (CMS) penalizes hospitals for excess all cause readmissions within the 30 days following discharge. Between 10 to 20% of COPD patients are admitted within 30 days of discharge. Multidisciplinary team approach (MDT) has been proposed as a tool to reduce readmission, and was implemented at Harlem Hospital Center (HHC) since July of 2017 (1). We discuss the results and lessons learnt following its implementation. METHODS: MDT at HHC consists of pulmonologist, internist, respiratory therapist (RT), nurses, case manager ,social worker and pharmacist. All working in concert to implement a safer hospital discharge of COPD patients.
Introduction:Death from prescription opioids quadrupled from 1999 to 2010, far exceeding the combined death toll from illicit cocaine and heroin overdoses (1). Inpatient drug overdoses secondary to illicit drug use while hospitalized are rare and tend not to be considered. We describe such a case. Case Study:A 73-year-old male with history of HIV and heroin use was admitted to the inpatient service for management of multi-lobar pneumonia and pulmonary tuberculosis (AFB smear positive). The patient was first treated in an isolation room and then was moved to the general medical floors. The ICU team was called to see this patient after he suffered a cardiopulmonary arrest. Cardio-pulmonary resuscitation (CPR) resulted in return of pulse after 20 minutes and the patient was transferred to the medical ICU. ICU ultrasonography was not consistent with a pulmonary embolism. Soon after arriving in the ICU the patient coded again. The ICU code was unsuccessful and the patient was pronounced dead. While the nurse was getting the body ready for the morgue she found a bottle of white pills rolled in the patient's socks. The pills were given to the hospital police. A urine toxicology screen (UTOX) was then sent after death and came back positive for opiates. UTOX testing for opiates generally detects the metabolites of heroin and morphine. Review of the electronic medical record did not reveal any orders for any narcotic medication while the patient was hospitalized. Evidently, the patient took his own opiates while hospitalized which precipitated the cardiac arrest. Discussion:The etiology of inpatient cardiac arrests is felt secondary to a given patient's underlying comorbidities. Death from a patient-induced cardiac arrest is unusual. Most likely some of the patient's friends gave heroin to the patient after he was admitted. One other treatment one can use during a cardiac arrest is to consider giving naloxone emergently in patients who might abuse narcotics. Conclusion:Considering a cardiac arrest and its causes during ongoing CPR, one should include the possibility of patient-induced drug overdoses as well. Our patient had a previous history of polysubstance abuse and considering this possibility might have saved the patient's life.
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