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Heart failure decompensations accounts for over one million hospitalizations annually and are the most common cause of US hospital admission in patients over 65. While this results in a reduced quality of life for patients, hospital admissions within 30 days of discharge for heart failure are not reimbursed, making this patient population incredibly expensive for hospitals to treat. US expenditure on heart failure exceeds $30 billion annually and is projected to rise by 127% to nearly $70 billion by 2030 as the population ages. Scheduling a follow up appointment within one week of discharge has been shown to reduce rates of readmission. This quality improvement initiative is aimed at improving post-discharge follow up rates in a tertiary referral hospital. The affiliated follow up clinic uses a different electronic medical record (EMR) system, so a system of cross-communication is key. The initial intervention introduced an EMR order that, once placed in the inpatient setting, created an appointment request in the follow up clinic. The cardiology consult nurse practitioner was assigned and educated about the task of entering this follow up order. With this intervention, an increase the number of confirmed follow up appointments scheduled by discharge for patients admitted with acute decompensated heart failure was expected. The initial intervention of introducing an EMR order resulted in a median of 18 patient referrals per month over a period of 5 months. The intervention of introducing a dedicated nurse practitioner the task of placing the order resulted in an increase to 25 orders in the next month. Similarly, the percentage of completed referrals increased from 29% over 5 months to 44% in the last month when a dedicated nurse practitioner was tasked with placing the order for follow up. In recognizing the delicate process of discharging patients with heart failure decompensations, a unified process to organize follow up in a tertiary referral hospital was necessary to communicate with the affiliated clinic. This initial intervention shows promise that continuity of care can be established in an intricate medical system. Further interventions include better equipping the cardiology clinic with personnel to accommodate for the bolus of new post-discharge follow up appointments.

Study Objective Primary ovarian insufficiency (POI) in adolescents not due to cytotoxic therapy has not been well studied. Causes of POI have been described in adults, but adolescents might represent a unique subset necessitating a targeted approach to diagnosis, workup, and treatment. We sought to better characterize adolescent POI through a descriptive multicenter study. Design Case series of patients with POI. Setting Six tertiary care institutions. Participants Patients presenting from 2007 to 2014 aged 13-21 years diagnosed with noncytotoxic POI, with exclusions for those who received gonadotoxic therapy, with 46XY gonadal dysgenesis, or lack of evidence of hypergonadotropic hypogonadism on chart review. Interventions Review and data extraction of records identified according to International Classification of Diseases Ninth or Tenth Revision codes. Main Outcome Measures Data were analyzed for signs and symptoms, workup, and treatments. Complete workup was on the basis of American College of Obstetricians and Gynecologists guidelines. Characteristics of patients with POI who presented with delayed puberty/primary amenorrhea vs secondary amenorrhea were compared. Results One hundred thirty-five records were identified. Those who had received cytotoxic therapy (n = 52), 46XY gonadal dysgenesis (n = 7), or on review did not have POI (n = 19) were excluded. Of 57 remaining cases, 16 were 45X, 2 had galactosemia, and 4 had X-chromosome abnormalities. Most did not undergo full etiologic evaluation. Girls diagnosed after primary amenorrhea/delayed puberty were less symptomatic and more likely to receive an estrogen patch than those diagnosed after secondary amenorrhea. Conclusion Noncytotoxic POI in adolescents is an uncommon condition with, to our knowledge, only 64 cases in 6 institutions over 7 years. These patients might not undergo complete etiological workup. Aside from 45X, the most common etiologies were X-chromosome abnormalities or galactosemia.