Study Objective: Pneumonia accounts for over 1.2 million US hospitalizations annually resulting i... more Study Objective: Pneumonia accounts for over 1.2 million US hospitalizations annually resulting in $10.2 billion in health care costs. Unnecessary hospitalizations put patients at risk and strain the limited resources of an already taxed medical system. Currently, tools to assess pneumonia severity have limited applicability to emergency department (ED) disposition decisions because they were developed using only data from patients admitted to the hospital. This study describes current ED admission practices for patients with community-acquired pneumonia (CAP) based on the CURB-65 severity index, and reports on CURB-65's ability to predict 30-day mortality for a cohort of patients discharged and hospitalized from the ED. Methods: A retrospective, observational study of all adult CAP encounters in 14 community EDs from July 2009 to June 2012. We calculated CURB-65 scores based on the established severity scoring system (0-5) to describe all encounters, as well as stratified by those hospitalized and discharged. Each score was used as a cutoff to calculate sensitivity, specificity, positive predictive value, and negative predictive value for predicting 30-day mortality. We described the use of hospitalization for ED CAP encounters and identified discharged patients returning for admission within 7 days. Results: The sample included 21,183 ED encounters for CAP (7,952 discharged and 13,231 admitted). The C-statistic describing the accuracy of CURB-65 at predicting 30day mortality in the full sample was 0.761 (95% CI, 0.747-0.774). Among patients discharged from the ED it performed better (0.864, 95% CI, 0.821-0.906) than for those admitted from the ED (0.689, 95% CI, 0.672-0.705). Among all encounters a CURB-65 threshold 1 was 92.8% sensitive and 38.0% specific with a 99.0% NPV. Among all encounters, 62.5% were admitted, 36.2% of those at lowest risk (CURB-65¼0). Overall, discharged CAP patients had a 5.7% chance of returning for hospital admission within 7 days of the encounter. When stratified by CURB-65 score, 4.2%, 7.7%, 7.5%, and 12.8% were hospitalized within 7 days for scores 0-2 and 3 respectively. If a low-risk threshold of CURB-65 1 had been the only factor used to determine ED discharge vs. admission, then only 34.3% of patients (versus 62.5%) would have been hospitalized. This would have avoided 6,936 (52.4%) of our observed low-risk admissions, and conversely increased admissions for high-risk (CURB-65 2) by 970 admissions (7.3%), resulting in a net decrease of 5,966 (45.1%) hospitalizations. Conclusion: CURB-65 has very good accuracy for predicting 30-day mortality for patients with CAP discharged from the ED, even better than previous reports of hospitalized cohorts (C-statistic 0.87 vs 0.80). This severity tool may be used when assessing ED patients with CAP to assist providers and patients with disposition decisions. Discharging the lowest risk patients could provide substantial savings to the US health system while maintaining acceptable patient safety.
Background The calcium sensing receptor (CASR) regulates parathyroid hormone secretion in respons... more Background The calcium sensing receptor (CASR) regulates parathyroid hormone secretion in response to extracellular calcium concentration. A gain-of-function mutation of the CASR lowers the set point for extracellular calcium sensing, resulting in both reduced parathyroid hormone secretion and increased urinary calcium excretion compared to other causes of hypoparathyroidism. Clinical Case After presenting with hypocalcemia-associated seizures at the age of two years, our patient had an undetectable serum parathyroid hormone level. He was started on calcitriol and calcium supplementation, however continued to have recurrent seizures throughout childhood. On ultrasound at age four, he exhibited nephrocalcinosis. DNA sequence analysis revealed a heterozygous T383G mutation nucleotide substitution on exon 3, resulting in the replacement of phenylalanine with cysteine at amino acid position 128. Our patient's base substitution likely represents a de novo mutation as we have confirme...
Background: During hospital discharge, patients are at high risk for medication discrepancies as ... more Background: During hospital discharge, patients are at high risk for medication discrepancies as they transition from hospital to home. This study aims to evaluate the prevalence of medication errors at hospital discharge for diabetes medications in patients who received an endocrinology consultation for diabetes and explore interventions to improve the accuracy of discharge medication reconciliation. Methods: All patients (n=3018) who received an endocrinology consultation for diabetes at a tertiary care medical center from October 2017 to December 2019 were included. A retrospective chart review was performed to collect the following information on each patient: primary service from which the patient was discharged, hospital site, month and year of discharge date, and whether each patient’s medication reconciliation for diabetes medications at hospital discharge was in agreement with the inpatient diabetes team’s recommendations. Patients who were discharged on medications discord...
Purpose – This study aims to explain how the process of organizational socialization of newcomers... more Purpose – This study aims to explain how the process of organizational socialization of newcomers occurs in a public faculty.Design/methodology/approach – This qualitative and interpretativist research was conducted under an interactionist approach. We interviewed 14 newcomers and also experienced government employees from a state public faculty in São Paulo. The content of the interviews was analyzed by a categorization process.Findings – The findings show that socialization of newcomers is self-motivated, informal, non-institutionalized, influenced by the normative nature of work and insufficient support given by the group. Newcomers’ admission into the workplace does not cause serious conflicts or tensions that could lead to changes in the workplace. It is the proactive behavior of the newcomers that allows them to adapt to work and know traditions, beliefs and history of the organization.Research limitations/implications – The limitation of this study is the context of a public ...
Study Objective: Pneumonia accounts for over 1.2 million US hospitalizations annually resulting i... more Study Objective: Pneumonia accounts for over 1.2 million US hospitalizations annually resulting in $10.2 billion in health care costs. Unnecessary hospitalizations put patients at risk and strain the limited resources of an already taxed medical system. Currently, tools to assess pneumonia severity have limited applicability to emergency department (ED) disposition decisions because they were developed using only data from patients admitted to the hospital. This study describes current ED admission practices for patients with community-acquired pneumonia (CAP) based on the CURB-65 severity index, and reports on CURB-65's ability to predict 30-day mortality for a cohort of patients discharged and hospitalized from the ED. Methods: A retrospective, observational study of all adult CAP encounters in 14 community EDs from July 2009 to June 2012. We calculated CURB-65 scores based on the established severity scoring system (0-5) to describe all encounters, as well as stratified by those hospitalized and discharged. Each score was used as a cutoff to calculate sensitivity, specificity, positive predictive value, and negative predictive value for predicting 30-day mortality. We described the use of hospitalization for ED CAP encounters and identified discharged patients returning for admission within 7 days. Results: The sample included 21,183 ED encounters for CAP (7,952 discharged and 13,231 admitted). The C-statistic describing the accuracy of CURB-65 at predicting 30day mortality in the full sample was 0.761 (95% CI, 0.747-0.774). Among patients discharged from the ED it performed better (0.864, 95% CI, 0.821-0.906) than for those admitted from the ED (0.689, 95% CI, 0.672-0.705). Among all encounters a CURB-65 threshold 1 was 92.8% sensitive and 38.0% specific with a 99.0% NPV. Among all encounters, 62.5% were admitted, 36.2% of those at lowest risk (CURB-65¼0). Overall, discharged CAP patients had a 5.7% chance of returning for hospital admission within 7 days of the encounter. When stratified by CURB-65 score, 4.2%, 7.7%, 7.5%, and 12.8% were hospitalized within 7 days for scores 0-2 and 3 respectively. If a low-risk threshold of CURB-65 1 had been the only factor used to determine ED discharge vs. admission, then only 34.3% of patients (versus 62.5%) would have been hospitalized. This would have avoided 6,936 (52.4%) of our observed low-risk admissions, and conversely increased admissions for high-risk (CURB-65 2) by 970 admissions (7.3%), resulting in a net decrease of 5,966 (45.1%) hospitalizations. Conclusion: CURB-65 has very good accuracy for predicting 30-day mortality for patients with CAP discharged from the ED, even better than previous reports of hospitalized cohorts (C-statistic 0.87 vs 0.80). This severity tool may be used when assessing ED patients with CAP to assist providers and patients with disposition decisions. Discharging the lowest risk patients could provide substantial savings to the US health system while maintaining acceptable patient safety.
Background The calcium sensing receptor (CASR) regulates parathyroid hormone secretion in respons... more Background The calcium sensing receptor (CASR) regulates parathyroid hormone secretion in response to extracellular calcium concentration. A gain-of-function mutation of the CASR lowers the set point for extracellular calcium sensing, resulting in both reduced parathyroid hormone secretion and increased urinary calcium excretion compared to other causes of hypoparathyroidism. Clinical Case After presenting with hypocalcemia-associated seizures at the age of two years, our patient had an undetectable serum parathyroid hormone level. He was started on calcitriol and calcium supplementation, however continued to have recurrent seizures throughout childhood. On ultrasound at age four, he exhibited nephrocalcinosis. DNA sequence analysis revealed a heterozygous T383G mutation nucleotide substitution on exon 3, resulting in the replacement of phenylalanine with cysteine at amino acid position 128. Our patient's base substitution likely represents a de novo mutation as we have confirme...
Background: During hospital discharge, patients are at high risk for medication discrepancies as ... more Background: During hospital discharge, patients are at high risk for medication discrepancies as they transition from hospital to home. This study aims to evaluate the prevalence of medication errors at hospital discharge for diabetes medications in patients who received an endocrinology consultation for diabetes and explore interventions to improve the accuracy of discharge medication reconciliation. Methods: All patients (n=3018) who received an endocrinology consultation for diabetes at a tertiary care medical center from October 2017 to December 2019 were included. A retrospective chart review was performed to collect the following information on each patient: primary service from which the patient was discharged, hospital site, month and year of discharge date, and whether each patient’s medication reconciliation for diabetes medications at hospital discharge was in agreement with the inpatient diabetes team’s recommendations. Patients who were discharged on medications discord...
Purpose – This study aims to explain how the process of organizational socialization of newcomers... more Purpose – This study aims to explain how the process of organizational socialization of newcomers occurs in a public faculty.Design/methodology/approach – This qualitative and interpretativist research was conducted under an interactionist approach. We interviewed 14 newcomers and also experienced government employees from a state public faculty in São Paulo. The content of the interviews was analyzed by a categorization process.Findings – The findings show that socialization of newcomers is self-motivated, informal, non-institutionalized, influenced by the normative nature of work and insufficient support given by the group. Newcomers’ admission into the workplace does not cause serious conflicts or tensions that could lead to changes in the workplace. It is the proactive behavior of the newcomers that allows them to adapt to work and know traditions, beliefs and history of the organization.Research limitations/implications – The limitation of this study is the context of a public ...
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