and training. We will present a care strategy and pathway to address these three areas. Conclusion: Patients with dementia who are admitted to acute care hospitals may have better outcomes with attention to three elements of care. These three elements should form the basis for improvement efforts for these patients.Background:Intermountain Healthcare is the largest healthcare system in the Intermountain West, delivering care in 185 clinics and 22 hospitals across Utah and the surrounding regions. Queries of our electronic medical record indicated that prevalence of dementia was below expectations based on population-based estimates. Thus, we suspected underreporting of cognitive impairment and wide variation in clinical care. The Neurosciences Cognitive Care Development Team created a system-wide approach to diagnosing and treating mild cognitive impairment and dementia. Our aim was to determine whether a primary-care focused protocol would improve both the detection of cognitive impairment as well as the quality of care provided. Methods: The cognitive care team invited stakeholder participation from neurology, psychology, mental health, geriatrics, primary care, nursing, home care, hospice, care management, radiology, administration, patients, caregivers, and local community and governmental organizations. Our team was supported with a data manager, outcomes analyst, and technical writer. Data for analysis was retrieved from the Intermountain Enterprise Data Warehouse. We developed a standardized protocol to evaluate cognitive impairment, including how primary care providers screen for dementia at the Medicare annual wellness visit (AWV). A positive Mini-Cog at the AWV or physician, patient, or family concern about cognitive impairment prompt a diagnostic workup that includes focused history from the patient and a knowledgeable informant, objective cognitive exam (Montreal Cognitive Assessment), functional assessment, medication reconciliation, and screening for delirium. Guidance regarding diagnosis, neuroimaging, indications for specialty referral, and non-pharmacologic treatment for mild cognitive impairment and dementia, as well as pharmacologic treatment by specific diagnosis was provided as part of the protocol. We created tools to record results of screenings, assessments, and interventions in the electronic medical record such that pre-and post-implementation comparisons could be made. We disseminated the new protocol via trainings at the leadership, regional, and clinic levels. Adherence to the cognitive care protocol, increase in detection rate of dementia, and primary care provider satisfaction will be analyzed. Conclusions: By standardizing our primary care approach to cognitive disorders, we leveraged limited resources to improve cognitive care delivery to one third of patients aged 65 and older in Utah.
Introduction: Beginning January 2014, a 245-bed Intermountain Healthcare primary stroke center was using a private Telestroke (SOC) service. On April 1, 2015, Intermountain implemented its own centralized, internal Telestroke service to provide coverage at this primary stroke center and five other hospitals. The Intermountain Telestroke service uses an internal telemedicine platform with employed physicians providing coverage. To clarify, the Intermountain system has a physician answer calls directly; the SOC model uses an intermediary before connecting to the physician. Hypothesis: Implementation of a centralized, internal Telestroke service will result in improved physician response and improved time to treatment compared to the private service. Methods: The Intermountain Healthcare enterprise data warehouse and SOC summary reports provided the data for this analysis. Wilcoxon-Mann-Whitney test was used to compare physician response time, DTN time, and door to CT time in patients treated during the 15-month SOC era to patients treated by the in house telestroke service. Results: From Jan 2014-Mar 2015, 27 patients received IV TPA at the facility, but only 2/27 had door to needle (DTN) time of <60m. The median DTN time in 2014 was 84 min and the median door to CT time was 18 min, strongly suggesting that the neurologist response time of this service was too long to meet AHA standards. Since implementing the Intermountain service, there has been a statistically significant improvement in DTN time. During the SOC time period, the median DTN time was 92.5 min (N = 35). After implementation, the Intermountain service provided a significantly lower median DTN time of 62.5 min (N=4; p = 0.03). The SOC median technician call-back time was 9.2 min (N=85), with an average physician video response time of 32 min (N=79). Intermountain median physician response time is 4 min (N=91). The door to CT time was not significantly different (Jan 2014-March 2015 was 18 min. vs Mar-May 2015, 14 min, N=31). Conclusions: The Intermountain Telestroke service outperformed SOC in response time and times to treatment. For healthcare systems that have the resources and expertise, an internal Telestroke service may result in faster times to treatment and better patient outcomes.
A. M., aged 56, born in Glasgow, Scotland, a line of the angle of the scapula. The nodule at the site of the punctures grew in the sixteen ,weeks preceding death to the size of a large walnut, but did not involve the skin.Cough, though fairly persistent through the illness, was never troublesome. During the last few weeks a peculiar sputum was noted, odourless, clear, viscid, amber-coloured, jelly-like, very slightly frothy if at all, and changed in a few minutes by the carbolic acid solution in the sputum bowl into a dead-white opaque nummular mass, evidently highly fibrinous, and probably largely from the tubes of the compressed right lung. The wasted cachectic look of malignant disease did not appear. The colour never resembled that usually seen, though emaciation was distinct.Throughout the whole five months the subjective condition of the patient varied very little. His temperature ran during the last five weeks almost entirely a subnormal course, and lit was never at any time anything over IO0°F., and seldom so high. His pulse, to the last, seldom exceeded ioo, and never fell below 8o.About one month before death mild icedema of the lower limbs and a slight ascites were noted, both cardiac in origin.Death was due to asthenia, heart failure coming, on as he sat in his chair, and not very suddenly.The points of interest foundpost mortem-are as follows:I.-THE ABDOMEN.(a) Kidneys.-Both cirrhotic and with adherent capsule. Atrophy of both cortex and medulla, with hardening. Stellate scarring and fibrosis specially marked at upper end of left kidney, beneath which scar was found a rough uric acid calculus one-half by one-third by one-quarter inch] in size, with two smaller ones as large as wheat grains.(b) Liver.-Much enlarged, left lobe touching left side, and appearing during life as smooth firm mass in epigastrium. Its exact nature had not been determined during life from the disturbance of conditions usually discoverable by percussion and palpation, from the fact that the colon lay in front of the anterior surface of the liver, and had formed a permanent groove across it with marked ante-mortem coloration. The dislocation of the liver had been concealed by this cause, though the gall bladder was found to lie an inch and a-half to left of median line. The downward dislocation of the liver was as much as 34 inches, the highest point of the dome of the diaphragm being at the level of the sixth rib. The organ was much enlarged, slightly pale, and friable.To the right of the broad ligament lay a string of about twenty small white flattish nodules, the size of a split pea, under Glisson's capsule. A similar condition was found in the apposed area of the diaphragm, though there was no adhesion between diaphragm andliver, an instance of what has been noted by other observers that cancer can spread by apposition of tissues without the formation of adhesions.The greater part of the right half of the dome of the diaphragm was thickened, fixed, and adherent to the growth in the thorax. The abdomen contained about a pi...
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