Acid-Base Balance and Electrolyte Management

Perhaps the most ubiquitous set of interlinked clinical issues to be addressed in inpatient medicine is fluids, electrolytes, and acid-base balance. Decision making for the first two directly and measurably impacts the latter. Unlike most other critical therapies whose management is tied to a specific skill set and competency, every practitioner is empowered to prescribe and direct fluid and electrolyte management and, secondarily, pH. Downstream consequences in terms of compensation, both pulmonary and renal, may be singularly important for those with preexisting conditions that impact organ function and drive the need for unanticipated monitoring and therapy, including organ support. Therefore, the basics of fluid and electrolyte management are essential to be mastered, as is specific knowledge of the consequences of that prescription to enhance recovery and avoid preventable errors with important sequelae. Accordingly, current different but complementary methods of assessing acid-base balance are presented so that the reader may have a systematic approach to determining pH before intervention as well as after the initiation of fluid and electrolyte therapy. This review contains 12 figures, 7 tables, and 38 references Keywords: acid, base, electrolyte disturbances, Henderson-Hasselbach, maintenance, proton, resuscitation, Stewart methodology

Advanced HIV Disease Management Practices within Inpatient Medicine Units at a Referral Hospital in Zambia: A Retrospective Chart Review

Background Zambia recently achieved UNAIDS 90-90-90 treatment targets for HIV epidemic control; however, inpatient facilities continue to face a large burden of patients with advanced HIV disease and HIV-related mortality. Management of advanced HIV disease, following guidelines from outpatient settings, may be more difficult within complex inpatient settings. We evaluated adherence to HIV guidelines during hospitalization, including opportunistic infection (OI) screening, treatment, and prophylaxis. Methods We reviewed inpatient medical records of people living with HIV (PLHIV) admitted to the University Teaching Hospital in Lusaka, Zambia between December 1, 20218 and April 30, 2019. We collected data on patient demographics, antiretroviral therapy (ART), HIV biomarkers, and OI screening and treatment – including tuberculosis (TB), Cryptococcus, and OI prophylaxis with cotrimoxazole (CTX). Screening and treatment cascades were constructed based on the 2017 WHO Advanced HIV Guidelines. Results We reviewed files from 200 charts of patients with advanced HIV disease; of these 92% (184/200) had been on ART previously; 58.1% (107/184) for more than 12 months. HIV viral load (VL) testing was uncommon but half of VL results were high. 39% (77/200) of patients had a documented CD4 count result. Of the 172 patients not on anti-TB treatment (ATT) on admission, TB diagnostic tests (either sputum Xpert MTB/RIF MTB/RIF or urine TB-LAM) were requested for 105 (61%) and resulted for 60 of the 105 (57%). Nine of the 14 patients (64%) with a positive lab result for TB died before results were available. Testing for Cryptococcosis was performed predominantly in patients with symptoms of meningitis. Urine TB-LAM testing was rarely performed. Conclusions Inconsistent CD4 testing reduced recognition of advanced HIV and OI screening was suboptimal, in part due to laboratory challenges. HIV programs can potentially reduce mortality and identify PLHIV with retention and adherence issues through strengthening inpatient activities, including VL testing.

102 Virtual family-centered rounds: A collaborative necessity during COVID-19 and beyond

Primary Subject area Hospital Paediatrics Background Family-centered rounds (FCR) are the cornerstone of pediatric hospital care and have many proven benefits including improved patient outcomes, satisfaction, communication and safety. Traditionally, FCR take place in the patient’s room; however, due the COVID-19 pandemic, entering patient rooms was no longer advisable in order to maintain physical distancing and preserve personal protective equipment (PPE). Therefore, it became clear early in our pandemic response that a new process was required to ensure the benefits of FCR were maintained given their paramount importance to safe and quality patient care. Objectives The objective of this study was to virtualize the in-person FCR process used by our pediatric inpatient medicine teams to improve safety and reduce PPE costs during the COVID-19 pandemic. Design/Methods We quickly identified available hardware (laptops, tablets) and video conferencing software, assembled a multidisciplinary project team and secured administrative and quality improvement support. Quality improvement methodology and participatory design were used to develop and refine our virtual family-centered rounds (vFCR) standard work, and on April 6, 2020 we launched our first vFCR. Over the next 3 months we engaged in a series of plan-do-study-act (PDSA) cycles to iteratively improve our process: nurse auditors attended vFCR daily then met with our project team to review data and observations, and real-time feedback was sought from patients and caregivers. Results Data collected on 1792 vFCR between April 6 and July 31, 2020 revealed 74% of nurses, physicians and trainees were satisfied or very satisfied with vFCR and 88% felt they had a good understanding of the patient care plan after vFCR. 79% of patients and caregivers were satisfied or very satisfied with vFCR and 88% of caregivers felt like a valued member of their child’s care team. We met our target of 10 minutes per patient in 74% of vFCR with an average transition time of <3 minutes between patients. Patients and caregivers felt vFCR were collaborative, more private and less intimidating than in-person FCR, and some even preferred the virtual approach. Conclusion During this pilot, we achieved a standardized vFCR workflow that is safe, feasible, efficient and confidential, with high levels of stakeholder satisfaction and support. vFCR was highly valued by families and yielded unanticipated benefits. Based on current usage, vFCR are saving ~$36,000 monthly in PPE. The importance of this work during the COVID-19 pandemic is clear, but also has benefits in non-pandemic times, including allowing caregivers to participate in FCR when they cannot be at the bedside, enhancing FCR confidentiality, and improving communication and care for isolated patients. Furthermore, the vFCR process is easily adaptable to other inpatient workflows such as consults and multi-disciplinary meetings. We believe this virtual care model is both highly relevant and transferable to a variety of health care settings across Canada and beyond.

The Impact of an Educational Intervention on Nursing Staff Attitudes Toward Patients Experiencing Homelessness and Mental Illness

OBJECTIVE Patients who experience homelessness and have mental illness can have frequent and challenging hospitalizations. Nurses caring for this vulnerable population may have negative attitudes, which can be mitigated by education and improved for the benefit of patients. This study aimed to assess the impact of an educational intervention on the attitudes of nursing staff toward individuals experiencing homelessness and mental illness. METHOD Using a pre–post design, a revised version of the Health Professionals’ Attitudes Toward the Homeless Inventory (HPATHI) assessed 23 nursing staff working on inpatient medicine units surrounding a brief educational session about persons experiencing homelessness and mental illness. Data were also collected from open-ended questions. RESULTS There was a small positive increase in mean HPATHI scores postintervention (74.783 [ SD = 5.485] to 77.13 [ SD = 6.312]) indicating more positive participant attitudes toward homeless individuals. The HPATHI also revealed a 6% increase in score for participant comfortability providing care for homeless persons with major mental illness postintervention. Some participants likely interpreted their answers as displaying more positive and less cynical attitudes based on their comments, while the HPATHI scored them as more negative. Qualitative feedback revealed both positive and negative attitudes toward this patient population, and various associated barriers to care. CONCLUSIONS Nursing staff will likely provide care for patients who experience homelessness with concomitant mental illness. Educating nurses about the needs of this population is feasible and could be beneficial for patient care.

Discharge Clinical Characteristics and Post-Discharge Events in Patients with Severe COVID-19: A Descriptive Case Series

ABSTRACT Background As the SARS-CoV-2 pandemic continues, little guidance is available on clinical indicators for safely discharging patients with severe COVID-19. Objective To describe the clinical courses of adult patients admitted for COVID-19 and identify associations between inpatient clinical features and post-discharge need for acute care. Design Retrospective chart reviews were performed to record laboratory values, temperature, and oxygen requirements of 99 adult inpatients with COVID-19. Those variables were used to predict emergency department (ED) visit or readmission within 30 days post-discharge. Patients (or Participants) Age ≥ 18 years, first hospitalization for COVID-19, admitted between March 1 and May 2, 2020, at University of California, Los Angeles (UCLA) Medical Center, managed by an inpatient medicine service. Main Measures Ferritin, C-reactive protein, lactate dehydrogenase, D-dimer, procalcitonin, white blood cell count, absolute lymphocyte count, temperature, and oxygen requirement were noted. Key Results Of 99 patients, five required ED admission within 30 days, and another five required readmission. Fever within 24 h of discharge, oxygen requirement, and laboratory abnormalities were not associated with need for ED visit or readmission within 30 days of discharge after admission for COVID-19. Conclusion Our data suggest that neither persistent fever, oxygen requirement, nor laboratory marker derangement was associated with need for acute care in the 30-day period after discharge for severe COVID-19. These findings suggest that physicians need not await the normalization of laboratory markers, resolution of fever, or discontinuation of oxygen prior to discharging a stable or improving patient with COVID-19.

Comparison of Resident, Advanced Practice Clinician, and Hospitalist Teams in an Academic Medical Center: Association with Clinical Outcomes and Resource Utilization

BACKGROUND: Academic medical centers have expanded their inpatient medicine services with advanced practice clinicians (APCs) or nonteaching hospitalists in response to patient volumes, residency work hour restrictions, and recently, COVID-19. Reports of clinical outcomes, cost, and resource utilization differ among inpatient team structures. OBJECTIVE: Directly compare outcomes among resident, APC, and solo hospitalist inpatient general medicine teams. DESIGN: Retrospective cohort study using multivariable analysis adjusted for time of admission, interhospital transfer, and comorbidities that compares clinical outcomes, cost, and resource utilization. SUBJECTS: Patients 18 years or older discharged from an inpatient medicine service between July 2015 and July 2018 (N = 12,716). MAIN MEASURES: Length of stay (LOS), 30-day readmission, inpatient mortality, normalized total direct cost, discharge time, and consultation utilization. KEY RESULTS: Resident teams admitted fewer patients at night (32.0%; P < .001) than did APC (49.5%) and hospitalist (48.6%) teams. APCs received nearly 4% more outside transfer patients (P = .015). Hospitalists discharged patients 26 minutes earlier than did residents (mean hours after midnight [95% CI], 14.58 [14.44-14.72] vs 15.02 [14.97-15.08]). Adjusted consult utilization was 15% higher for APCs (adjusted mean consults per admission [95% CI], 1.00 [0.96-1.03]) and 8% higher for residents (0.93 [0.90-0.95]) than it was for hospitalists (0.85 [0.80-0.90]). No differences in LOS, readmission, mortality, or cost were observed between the teams. CONCLUSION: We observed similar costs, LOS, 30-day readmission, and mortality among hospitalist, APC, and resident teams. Our results suggest clinical outcomes are not significantly affected by team structure. The addition of APC or hospitalist teams represent safe and effective alternatives to traditional inpatient resident teams.

The association between biomarkers and clinical outcomes in novel coronavirus pneumonia in a US cohort

Aim: To describe the association between D-dimer, CRP, IL-6, ferritin, LDH and the clinical outcomes in a cohort of 299 COVID-19 patients treated on the inpatient medical service at a university hospital in the District of Columbia (DC, USA). Methodology & results: In this retrospective study, we included all laboratory confirmed COVID-19 adults admitted to the inpatient medicine service at the George Washington University Hospital between 12 March 2020 and 9 May 2020. We analyzed the association of biomarkers on intensive care unit transfer, intubation and mortality. Threshold values for all biomarkers were found to be statistically significant and independently associated with higher odds of clinical deterioration and death. Conclusion: Laboratory markers of inflammation and coagulopathy can help clinicians identify patients who are at high risk for clinical deterioration in COVID-19.

Listening and question-asking behaviors in resident and nurse handoff conversations: a prospective observational study

Objective To characterize interactivity during resident and nurse handoffs by investigating listening and question-asking behaviors during conversations. Materials and Methods Resident (n = 149) and nurse (n = 126) handoffs in an inpatient medicine unit were audio-recorded. Handoffs were coded based on listening behaviors (active and passive), question types (patient status, coordination of care, clinical reasoning, and framing and alignment), and question responses. Comparisons between residents and nurses for listening and question-asking behaviors were performed using the Wilcoxon rank-sum tests. A Poisson regression model was used to investigate differences in the question-asking behaviors between residents and nurses, and the association between listening and question-asking behaviors. Results There were no significant differences between residents and nurses in their active (18% resident vs 39% nurse handoffs) or passive (88% resident vs 81% nurse handoffs) listening behaviors. Question-asking was common in resident and nurse handoffs (87% vs 98%) and focused primarily on patient status, co-ordination, and framing and alignment. Nurses asked significantly more questions than residents (Mresident = 2.06 and Mnurse = 5.52) by a factor of 1.76 (P &lt; 0.001). Unit increase in listening behaviors was associated with an increase in the number of questions during resident and nurse handoffs by 7% and 12%, respectively. Discussion and Conclusion As suggested by the Joint Commission, question-asking behaviors were common across resident and nurse handoffs, playing a critical role in supporting resilience in communication and collaborative cross-checks during conversations. The role of listening in initiating question-asking behaviors is discussed.