Background: Cardiogenic shock (CS) is a highly fatal condition characterized by cardiac dysfunction leading to inadequate tissue perfusion.Few studies have sought to clarify the rate of mortality among different patient populations hospitalized with CS, and none have investigated CS patients transferred for a higher level of care.Hypothesis: We hypothesized that transfer patients would experience a higher mortality rate compared to inpatients initially admitted to an academic medical center.Methods: Studied patients were hospitalized at an academic medical center with an ICD-9/10 discharge diagnosis of CS between 12/2015 and 8/2017.A chart review identified admission status: to the academic medical center or transferred from a referring facility.Mortality was defined as death in the hospital or as a discharge to hospice.Patient characteristics stratified by admission status were compared.Univariate and multivariate logistic regression analysis were performed.All variables reported as significant had a two-sided p-value ≤0.01, unless otherwise stated.Results: 508 patients were included in this analysis: 62% were male, 73% were Caucasian and mean age was 63 years.Presentation with STEMI was seen in 13% and ACS in 25% of patients.31% of patients were transferred from another facility.Transfer patients had a higher rate of mortality than non-transfer patients (43.6% vs 33.5%, p=0.03).Univariate predictors of mortality included admission post cardiac arrest, respiratory failure, acute renal failure, need for dialysis, lower SBP or MAP and elevated direct bilirubin, lactic acid or creatinine.Multivariate regression analysis identified admission post cardiac arrest, respiratory failure, acute renal failure, need for dialysis and elevated lactic acid as predictors of mortality.Transfer status was not an independent predictor when adjusted for comorbidities.Conclusion: In the study population, transfer patients have a higher severity of illness.This explains the increased mortality observed in this group, and indicates the need for early aggressive therapy in this population.A-2 Prolonged Impella 5.0 support is Safe and Used as a Bridge to Clinical Decision Making

Introduction Cardiogenic shock (CS) is a highly fatal condition characterized by cardiac dysfunction leading to inadequate tissue perfusion. Prior studies of STEMI-related CS patients have shown mortality rates approaching 50%. However, few studies have sought to clarify the rate of mortality among different patient populations hospitalized with this diagnosis, and none have investigated CS patients transferred for a higher level of care. We hypothesized that transferred patients would experience a higher mortality rate compared to inpatients initially admitted to an academic medical center. Methods The study population included patients hospitalized at an academic medical center with an ICD-9/10 discharge diagnosis of CS between 12/2015 and 8/2017. A chart review was performed to identify admission status: either initially to the academic medical center or transferred from a referring facility. Mortality was defined as death in the hospital or as a discharge to hospice. Baseline demographics, comorbid conditions, vital signs, echocardiographic data, hemodynamic and laboratory values were also obtained. Patient characteristics stratified by admission status were compared. Univariate and multivariate logistic regression analysis was performed to identify characteristics associated with mortality. All variables reported as significant had a two-sided p-value Results A total of 508 patients were included in this analysis. Patients were 62% male, 73% were Caucasian and mean age was 63 years. Presentation with STEMI was seen in 13%, ACS in 25% of patients and 31% of patients were transferred from another facility. Transferred patients had a higher rate of mortality than non-transfer patients (43.6% vs 33.5%, p=0.03). These patients were younger, had lower systolic blood pressure (SBP), higher heart rate, elevated troponin and were more likely to be in acute renal failure. Univariate predictors of mortality included admission post cardiac arrest, respiratory failure, acute renal failure or need for dialysis, lower SBP, elevated direct bilirubin, lactic acid and creatinine. Independent risk factors associated with mortality identified by multivariate regression analysis included admission post cardiac arrest, respiratory failure, need for dialysis and elevated lactic acid. Transfer status was not an independent predictor when adjusted for comorbidities. Conclusion Patients with CS transferred to an academic care center suffered a higher mortality rate than patients initially admitted to the academic center. Transferred patients are generally younger but represent a population with a higher severity of illness. While this explains the increased mortality observed in this group, it also indicates the need for early aggressive therapy for this population.

IntroductionHeart Failure (HF) readmissions remain a critical issue for health care systems. HF Navigators (HFN) can streamline care transitions. Thus, we used an inpatient HFN to establish early follow up and "hand off" HF pts to an OP Care Coordinator (CC).MethodsAt our hospital, HF pts can be admitted to multiple IP units. A HF Unit (HFU) primarily admits higher risk pts. A single HFN was recruited to staff the HFU M-F. The HFN linked HF pts to a CC to at discharge. Most HF pts were referred to the OP CC although some pts received only HFN services and no CC due to difficulty identifying HF pts prior to discharge. Over the 14-month period, the HFN established early follow-up and the CC made regular telephone contact post discharge. The incremental contributions of the HFN and CC were evaluated to test the independent impact of each of these roles based on the serial implementation of these roles in distinct hospital units and based on whether or not a particular HF pt was cared for by the HFN and/or the CC.ResultsThirty (30) day readmission rates were measured for pts admitted between October 17, 2016 and December 31, 2017. Patients with a primary, discharge diagnosis of HF were analyzed. HFN services were provided on the dedicated HF unit (HFU) as part of a pilot program and were not available on other IP units during this period. Concurrent 30-day all-cause readmission data were stratified and reported based on admitting unit, involvement of the HFN with or without CC. Of the 757 pts (non LVAD or Transplant) who were admitted to units other than the HFU, there were 160 pts readmitted (21.1%). There were 254 high risk (Includes LVAD and transplant pts) HF pts admitted to the HFU, and there were 75 pts readmitted (29.5%) in this cohort. There were 33 (non LVAD or transplant) pts admitted to the HFU with care provided by HFN but who did not receive a referral to CC, and 6 pts were readmitted (18.9%). Finally, of the 169 HF pts were admitted to the HFU and had access to a HFN and CC, with only 9 pts readmitted (5.33%).ConclusionsIn this analysis, there was a synergistic effect noted to drastically reduce HF readmission rates when an IP HFN and OP CC were involved in the care of hospitalized HF pts. The 5.33% 30 day all cause readmission rates noted is significantly better than rates reported in the literature and reflects the critical role of combining HFN care with care coordination in the OP setting. These data have solidified an interest to expand access to HFN and CC to all IP units and can serve as a model for care delivery to improve readmission rates for this high-risk population.

Introduction With a 30-day all cause readmission rate around 23%, individuals with heart failure (HF) are a medically high risk and costly patient population. Though predictive models have been developed for readmission based on descriptive variables, many of these tools are cumbersome and limited in prognosticative capacity. A few studies have examined the role of the six-minute walk test (6MWT) and found good predictive ability for both 30-day and 1-3-year readmission rates. The goal of this study was to further elucidate the prognostic ability of the 6MWT in stage C/D HF patients with NYHA class IIIb-VI symptoms. Methods We prospectively enrolled 97 patients who from our step-down units with a primary diagnosis of heart failure between October 2016 and March 2017. Every patient who was enrolled had a standardized 6MWT prior to discharge. Multivariate logistic regression analysis was constructed to determine relationships between 6MW distance and 30-day survival free of readmission. Results Baseline characteristics were compared between the 6-minute walk test distance groups using Wilcoxon rank-sum tests for continuous variables and Fisher's exact tests for categorical variables, and no significant differences were found between the patients. The 135-meter cut-point was selected as the threshold which maximizes the sum of sensitivity and specificity of a logistic regression model for 30-day readmission with 6-minute walk test distance as a continuous predictor. Approximately 25.7% of the patients walked less than 135 meters. Out of these about 32% were admitted within 30 days [p= .026]. Among the patients who walked > 135 meters, 11.1% were admitted within 30 days [p= 0.026]. Furthermore, patients who walked Conclusions 6MWT distance less than 135m was associated with not only increased risk of 30 day readmission but also correlated with increased frequency of admissions in patients admitted with stage C/D heart failure.

Introduction: Heart failure is one of the most common causes of hospital readmission with almost 25% of patients being readmitted within the first 30 days. However, there has been little literature looking at indicators which could predict readmission risk and could be used to help optimize patients before discharge. Our observations suggest that many of these patients have not had adequate diuresis. Increases in creatinine and return to dry weight are some of the most often used measures of adequate diuresis. However, based on the lack of improvement in readmission rates, these measures are not proving to be effective. In our personal observations, net weight change during admission, has shown to be an indicator of readmission risk. We believe that heart failure patients who undergo more adequate inpatient diuresis, as measured by clinically measured weight loss, would have better outcomes than those patients without measurable weight loss. Methods: To test this hypothesis, a retrospective analysis was performed on all Froedtert hospital admissions from July 2015 to July 2016. Patients who were admitted with a primary discharge diagnosis of acute decompensated heart failure were eligible to be part of the analysis. Patients were treated according to attending discretion. Admission and discharge weights were obtained for each patient and net weight loss was obtained. Patients were divided into two groups, one group of patients with net negative weight loss during admission and a second group of patients without weight loss (0 weight change or net positive). For these two groups, 30 day all cause unplanned readmission %'s were calculated. In addition, in hospital mortality as well as length of stay (LOS) index (observed LOS/expected LOS) were also calculated (Expected values calculated using Vizient AMC Hospital Risk Models). Results: A total of 302 patients were analyzed in this study and no patients were excluded. 250 patients were in the weight loss group and 52 were in the no net weight loss group. Thirty day unplanned readmission rates were 19.6% in the weight loss group and 25%. Length of stay index was longer in the weight loss group (0.92) vs non weight loss group (0.76) while in hospital mortality was lower in the weight loss group (0.27) vs non weight loss group (0.49). Conclusion: Based on this initial data, there appears to be a trend toward lower readmission rates and lower mortality with measured weight loss at the cost of longer LOS. This suggests that during admissions, diuresis to a net weight loss is more indicative of more adequate diuresis and therefore lower readmission risk. Given costs of readmission, this trend could indicate that increased LOS could be beneficial at reducing costs by reducing readmissions. Currently we are looking further into the data to see specifically how many readmissions were strictly for heart failure. We are also looking into a cost analysis comparing readmission costs vs the increased LOS to determine if there is cost savings.

The integrity of epithelial monolayers depends on the formation of tight junctions (TJ) and adherens junctions (AJ). TJ and AJ associate with underlying actomyosin bundles that are critical for their stability and function. Our previous in vitro studies have identified nonmuscle myosin II A (NM IIA) as a unique regulator of AJ/TJ structure and barrier properties in the intestinal epithelium. In this study, we investigated the roles of NM IIA in the maintenance of the intestinal epithelial barrier in vivo. Mice carrying a floxed allele of NM IIA were crossed with villin‐cre mice. The progeny demonstrated Mendelian inheritance, suggesting that this NM IIA conditional knockout (cKO) is not embryonically lethal. Immunoblotting indicated that NM IIA expression was specifically ablated solely in the intestinal epithelium, but not in the brain, lung, kidney or liver. NM IIA cKO showed an increased baseline mucosal permeability and exaggerated dextran sodium sulfate (DSS)‐induced breakdown of the intestinal barrier. Furthermore, NM IIA cKO animals demonstrated increased body weight loss, amplified disease activity and epithelial damage during DSS colitis. These findings highlight NM IIA as an important regulator of barrier properties of normal and inflamed intestinal mucosa in vivo. Supported by the Crohn’s and Colitis Foundation of America (NGN) and NIH grants DK083968 and DK084953 to AII.Grant Funding Source: Supported by the Crohn’s and Colitis Foundation of America (NGN) and NIH grants DK083968 and DK08495

BACKGROUND Localization of general medical inpatient teams is an attractive way to improve inpatient care but has not been adequately studied. OBJECTIVE To evaluate the impact of localizing general medical teams to a single nursing unit. DESIGN Quasi-experimental study using historical and concurrent controls. SETTING A 490-bed academic medical center in the midwestern United States. PATIENTS Adult, general medical patients, other than those with sickle cell disease, admitted to medical teams staffed by a hospitalist and a physician assistant (PA). INTERVENTION Localization of patients assigned to 2 teams to a single nursing unit. MEASUREMENTS Length of stay (LOS), 30-day risk of readmission, charges, pages to teams, encounters, relative value units (RVUs), and steps walked by PAs. RESULTS Localized teams had 0.89 (95% confidence interval [CI], 0.37-1.41) more patient encounters and generated 2.20 more RVUs per day (CI, 1.10-3.29) compared to historical controls; and 1.02 (CI, 0.46-1.58) more patient encounters and generated 1.36 more RVUs per day (CI, 0.17-2.55) compared to concurrent controls. Localized teams received 51% (CI, 48-54) fewer pages during the workday. LOS may have been approximately 10% higher for localized teams. Risk of readmission within 30 days and charges incurred were no different. PAs possibly walked fewer steps while localized. CONCLUSION Localization of medical teams led to higher productivity and better workflow, but did not significantly impact readmissions or charges. It may have had an unintended negative impact on hospital efficiency; this finding deserves further study.

BACKGROUND Residency reform in the form of work hour restrictions has forced academic medical centers to develop alternate models of care to provide inpatient care. One such model is the use of physician assistants (PAs) with hospitalists. However, these models of care have not been widely evaluated. OBJECTIVE To compare the outcomes of inpatient care provided by a hospitalist-PA (H-PA) model with the traditional resident based model. DESIGN, SETTING AND PATIENTS We conducted a retrospective cohort study of 9681 general medical (GM) hospitalizations between January 2005 and December 2006 using a hospital administrative database. We used multivariable mixed models to adjust for a wide variety of potential confounders and account for multiple patient visits to the hospital to compare the outcomes of 2171 hospitalizations to H-PA teams with those of 7510 hospitalizations to resident teams (RES). MEASUREMENTS Length of stay (LOS), charges, readmission within 7, 14, and 30 days and inpatient mortality. RESULTS Inpatient care provided by H-PA teams was associated with a 6.73% longer LOS (P = 0.005) but charges, risk of readmission at 7, 14, and 30 days and inpatient mortality were similar to resident-based teams. The increase in LOS was dependent on the time of admission of the patients. CONCLUSIONS H-PA team-based GM inpatient care was associated with a higher LOS but similar charges, readmission rates, and inpatient mortality to traditional resident-based teams, a finding that persisted in sensitivity analyses.

OBJECT:The aim of this study was to examine the variables influencing the mode and location of death in patients admitted to a neurosurgical intensive care unit (NICU), including the participation of a newly appointed neurointensivist (NI).METHODS:Data from all patients admitted to a university hospital NICU were prospectively collected and compared between 2 consecutive 19-month periods before and after the appointment of an NI.RESULTS:One thousand eighty-seven patients were admitted before and 1279 after the NI's appointment. The withdrawal of life support (WOLS) occurred in 52% of all cases of death. Death following WOLS compared with survival was independently associated with an older patient age (OR 1.04/year, 95% CI 1.03-1.05), a higher University Hospitals Consortium (UHC) expected mortality rate (OR 1.05/%, 95% CI 1.04-1.07), transfer from another hospital (OR 3.7, 95% CI 1.6-8.4) or admission through the emergency department (OR 5.3, 95% CI 2.4-12), admission to the neurosurgery service (OR 7.5, 95% CI 3.2-17.6), and diagnosis of an ischemic stroke (OR 5.4, 95% CI 1.4-20.8) or intracerebral hemorrhage (OR 5.7, 95% CI 1.9-16.7). On discharge from the NICU, 54 patients died on the hospital ward (2.7% mortality rate). A younger patient age (OR 0.94/year, 95% CI 0.92-0.96), higher UHC-expected mortality rate (OR 1.01/%, 95% CI 1-1.03), and admission to the neurosurgery service (OR 9.35, 95% CI 1.83-47.7) were associated with death in the NICU rather than the ward. There was no association between the participation of an NI and WOLS or ward mortality rate.CONCLUSIONS:The mode and location of death in NICU-admitted patients did not change after the appointment of an NI. Factors other than the participation of an NI-including patient age and the severity and type of neurological injury-play a significant role in the decision to withdraw life support in the NICU or dying in-hospital after discharge from the NICU.

INTRODUCTION:Stroke Units improve the outcome in patients with mild to moderate severity strokes. We sought to examine the role that a full-time neurointensivist (NI) might play on the outcomes of patients with more severe strokes admitted to a Neurosciences Intensive Care Unit (NICU).METHODS:Data regarding 433 stroke patients admitted to a 10-bed university hospital NICU were prospectively collected in two 19-month periods, before and after the appointment of a NI. Outcomes and disposition of patients with ischemic stroke (IS), intracerebral hemorrhage (ICH) or subarachnoid hemorrhage (SAH) were compared between the two periods, using univariate and multivariate analyses.RESULTS:One hundred and seventy-four patients with strokes were admitted in the period before and 259 in the period after the NI. Observed mortality did not differ between the two periods. More patients were discharged home in the after period (75% vs. 54% in the before period (P = 0.003). After adjusting for covariates, the NICU and hospital LOS were shorter for each type of stroke in the after period (Cox proportional hazard ratios, 95% CI were 2.37, 1.4-4.1 and 1.8, 1.04-3 for IS, 1.98, 1.3-3 and 1.2, 0.8-1.9 for ICH, and 1.6, 1.1-2.3 and 1.4, 1.01-2 for SAH, respectively) or for all strokes (1.92, 1.52-2.43 and 1.7, 1.28-2.25 for the first 12 days of hospital admission).CONCLUSION:The direct patient care offered and the organizational changes implemented by a NI shortened the NICU and hospital LOS and improved the disposition of patients with strokes admitted to a NICU.