H ospital discharges frequently occur in the afternoon or evening hours. 1-5 Late discharges can adversely affect patient flow throughout the hospital, 3,6-9 which, in turn, can result in delays in care, 10-16 more medication errors, 17 increased mortality, 18-20 longer lengths of stay, 20-22 higher costs, 23 and lower patient satisfaction. 24 Various interventions have been employed in the attempts to find ways of moving discharge times to earlier in the day, including preparing the discharge paperwork and medications the previous night, 25 using checklists, 1,25 team huddles, 2 providing real-time feedback to unit staff, 1 and employing multidisciplinary teamwork. 1,2,6,25,26 The purpose of this study was to identify and determine the relative frequency of barriers to writing discharge orders in the hopes of identifying issues that might be addressed by targeted interventions. We also assessed the effects of daily team census, patients being on teaching versus nonteaching services, and how daily rounds were structured at the time that the discharge orders were written. METHODS Study Design, Setting, and Participants We conducted a prospective, cross-sectional survey of housestaff and attending physicians on general medicine teaching and nonteaching services from November 13, 2014, through

Endovascular treatment of dural arteriovenous fistulae of the superior petrosal sinus can result in cure when access to the site of the fistula can be achieved. Preoperative embolization is a safe and effective adjunct to minimize bleeding during open neurosurgery.

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Introduction Fluid replacement therapy is often used as a primary treatment modality in vaso-occlusive crises for sickle cell disease. However, aggressive intravenous fluid administration can lead to complications, including pulmonary vascular congestion and acute chest syndrome. Data is limited on the safety, efficacy, and variability of fluid replacement therapy in this context. This study describes the extent of and outcomes associated with receiving fluid replacement therapy for vaso-occlusive episodes at a single institution. Methods We performed a retrospective analysis on 157 unique patient encounters from 49 sickle cell patients hospitalized with a vaso-occlusive episode at the University of California Los Angeles between 2013 and 2017. Fluid administration measurements were derived from documented intakes (both oral and intravenous fluids) in the medical record. The association between fluid administration and outcomes were analyzed using chi-squared and Fisher's exact tests followed by univariate and multivariate logistic regression. Results The mean age of the patient cohort at the time of hospital admission was 36.0 years (Std 7.9). Most encounters were from patients with hemoglobin SS disease (147 encounters, 93.6%). Twenty-two of the encounters (14.0%) were from patients on hemodialysis prior to admission. The majority of admissions were to an observation unit (99 encounters, 63.1%), whereas 53 admissions (33.8%) were to an inpatient service and 5 encounters (3.2%) were solely in the emergency room. The median length of hospital stay was 4 days (IQR 2-7). The mean total amount of intravenous fluid administered during the hospitalization was 7.4 L (Std 9.6). The mean total amount of fluid intake including intravenous fluids, blood transfusions, and oral fluids was 6.5 L (Std 10.0) (Table 1). The most common clinical outcome that occurred during the hospitalizations was a new oxygen requirement in 28 encounters (17.8%). Other clinical outcomes noted were acute chest syndrome (12 encounters, 7.6%), an aspiration event (2 encounters, 1.3%), other type of hospital-acquired infection (2 encounters, 1.3%, which included Clostridium difficile colitis and Staphylococcus epidermidis bacteremia), acute kidney injury (3 encounters, 1.9%), and intensive care unit transfer (3 encounters, 1.9%). There was a significant association between receiving more than 3 L of intravenous fluid and the development of any of the adverse events listed (p = 0.029) but no association between fluid administration and each individual adverse event (Table 2). Logistic regression analysis confirmed that patients with higher fluid intake were more likely to develop any adverse event (Table 3, Table 4). In multivariable analysis, each component including oral intake during hospitalization (p = 0.041, OR 1.065, 95% CI 1.003-1.132), intravenous fluid administered in the first 24 hours (p = 0.001, OR 1.899, 95% CI 1.319-2.733), total amount of intravenous fluid administered (p = 0.005, OR 1.081, 95% CI 1.023-1.141), and total amount of fluid intake (p = 0.040, OR 1.065, 95% CI 1.003-1.132) all revealed a statistically significant association between higher fluid administration and the development of any adverse event. Other factors found to be significantly associated with any adverse event were dialysis dependence prior to admission (p = 0.000, OR 8.686, 95% CI 2.881-26.190) and admission to inpatient service versus emergency room or observation unit (p = 0.018, OR 2.758, 95% CI 1.186-6.416). Conclusions There was a statistically significant association between higher fluid intake (both oral and intravenous) and the development of any adverse event during hospitalization for sickle cell vaso-occlusive crisis including a new oxygen requirement, acute chest syndrome, aspiration event, other hospital-acquired infection, acute kidney injury, and intensive care unit transfer. While fluid administration may theoretically slow the sickling process, our data suggests that excessive fluid administration during a vaso-occlusive episode may be harmful. Further study is necessary to further elucidate the relationships between exogenous fluids, vaso-occlusion, and adverse events in sickle cell patients. *Equal contribution from Daria Gaut and Jennifer Jones for this work. Disclosures No relevant conflicts of interest to declare.

We surveyed internal medicine residents regarding how they approach febrile patients in cross-cover settings. Residents frequently use the term “full fever work-up,” and rely on this for sign-out. Despite this, residents felt fever work-ups were not evidenced-based, and definitions of when and how to respond to a fever varied.

Background Scant data exists to guide the work-up for fever in hospitalized patients, and little is known about what diagnostic tests medicine residents order for such patients. We sought to analyze how cross-covering medicine residents address fever and how sign-out systems affect their response. Methods We conducted a prospective cohort study to evaluate febrile episodes that residents responded to overnight. Primary outcomes included diagnostic tests ordered, if an in-person evaluation occurred, and the effect of sign-out instructions that advised a “full fever work-up” (FFWU). Results Investigators reviewed 253 fevers in 155 patients; sign-out instructions were available for 204 fevers. Residents evaluated the patient in person in 29 (11%) episodes. The most common tests ordered were: blood cultures (48%), urinalysis (UA) with reflex culture (34%), and chest X-ray (30%). If the sign-out advised an FFWU, residents were more likely to order blood cultures [odds ratio (OR) 14.75, 95% confidence interval (CI) 7.52–28.90], UA with reflex culture (OR 12.07, 95% CI 5.56–23.23), chest X-ray (OR 16.55, 95% CI 7.03–39.94), lactate (OR 3.33, 95% CI 1.47–7.55), and complete blood count (CBC) (OR 3.16, 95% CI 1.17–8.51). In a multivariable regression, predictors of the number of tests ordered included hospital location, resident training level, timing of previous blood culture, in-person evaluation, escalation to a higher level of care, and sign-out instructions. Conclusions Sign-out instructions and a few patient factors significantly impacted cross-cover resident diagnostic test ordering for overnight fevers. This practice can be targeted in resident education to improve diagnostic reasoning and stewardship.

BackgroundResidents at our institution rely heavily on the terminology “Full Fever Work Up” (FFWU) as a cognitive tool for cross-covering patients with a fever. Prior survey data revealed that residents vary considerably in how they respond to fevers and what FFWU means. We sought to determine what tests are included in the FFWU, how often the term is adhered to, and if it significantly changes clinical outcomes.MethodsFor 3 months, study investigators collected FFWU instructions for patients who experienced a fever at night. For each febrile episode, investigators reviewed chart data on patient factors, circumstances surrounding the fever, tests ordered, etiologies of the fever, and outcomes (immediately and 30-days after the fever). The UCLA Institutional Review Board approved this study.ResultsWe reviewed 253 fever episodes. For 204 episodes, written sign-out by the primary team was available. 59% of the fevers were in male patients and the mean age was 59 years. 12% had an organ transplant and 45% qualified as highly immunocompromised. 79% met SIRS criteria, whereas only 3% met qSOFA criteria and 2% required escalation of care.The cross-covering physician wrote a note in 4% of the cases and evaluated the patient in-person in 12% of the cases per chart review. Residents most often ordered bacterial blood cultures (48%), followed by urinary tests (34%) and chest X-rays (30%). These tests, as well as fungal blood cultures, lactate and CBC, were significantly more likely to be ordered by the cross-covering resident if the sign-out instructed to perform a FFWU. The mean number of diagnostic tests ordered was 2 and residents started or changed antibiotics in 14% of cases. 88% of the time patients were alive 30 days after their fever. 11% had an antibiotic-related complication and 8% of blood cultures drawn were positive.ConclusionOrdering practices overnight were significantly influenced by the FFWU sign-out instructions, yet evaluating the patient in-person was rare. We hypothesize that the FFWU standardization has replaced a more individualized evaluation overnight. Fortunately, poor outcomes including death, bacteremia, escalation of care, or antibiotic-related complications were low in this population.Disclosures All authors: No reported disclosures.

Personal Genomics Companies are an emerging form of biotechnology startup that bring rapidly advancing whole genome technologies to a variety of commercial venues. With a combination of direct-to-consumer marketing, social media, and Web 2.0 applications these companies seek to create novel uses, including entertainment, for what is described as predictive medicine -that is the use of genetic marketers to create health forecasts that would allow individual's healthcare to be tailored to their individual genomic data. In this brief piece, the authors use a critical cultural approach to question how this combination of genomics research, marketing, and communications technologies may alter both patient experiences and research processes. In it we argue these companies radically expand the definition of a patient by claiming all consumers are simply pre-symptomatic patients. Moreover, by placing genomic data on both the marketplace and cyberspace, personal genomic companies seek to create new avenues of research that alter how we define (and access) research agendas and human subjects. Therefore, beyond commonly discussed issues of ethics and privacy rights, Personal Genomics has the potential to alter both healthcare priorities and distribution.