Background: Suggested mechanisms for SARS-CoV-2 direct liver infection have been proposed by others to involve both cholangiocytes and hepatocytes. Early clinical studies have highlighted abnormal liver biochemistry with COVID-19 infection as often not being severe, with elevated liver enzymes <5X the upper limit of normal. Methods: Liver enzymes were evaluated and compared in patients admitted with a diagnosis of COVID-19 in a deidentified Internal Medicine-Medical Teaching Unit/hospitalist admission laboratory database. Comparisons in the incidence of severe liver injury (alanine aminotransferase >10 times upper limit of normal) were made for patients with pre-Omicron SARS-CoV-2 (November 30, 2019, to December 15, 2021) and Omicron SARS-CoV-2 (December 15, 2021, to April 15, 2022). Comprehensive hospital health records were also reviewed for the 2 patient cases discussed. One patient had a liver biopsy that was evaluated with H&E and immunohistochemistry staining using an antibody against COVID-19 spike protein. Results: The evaluation of a deidentified admissions laboratory database found the incidence of severe liver injury was 0.42% with Omicron versus 0.30% with pre-Omicron variants of COVID-19. In both patient cases discussed, abnormal liver biochemistry and a negative comprehensive workup strongly suggest COVID-19 as the cause of severe liver injury. In the one patient with liver biopsy, immunohistochemistry staining suggests SARS-CoV-2 presence in the portal and lobular spaces in association with immune cell infiltration. Conclusions: The Omicron variant of SARS-CoV-2 should be considered in the differential diagnosis of severe acute liver injury. Our observation suggests that this new variant, either through direct liver infection and/or mediating immune dysfunction, can result in severe liver injury.

BackgroundLow-value use of laboratory tests is a global challenge. Our objective was to evaluate an intervention bundle to reduce repetitive use of routine laboratory testing in hospitalised patients.MethodsWe used a stepped-wedge design to implement an intervention bundle across eight medical units. Our intervention included educational tools and social comparison reports followed by peer-facilitated report discussion sessions. The study spanned October 2020–June 2021, divided into control, feasibility testing, intervention and a follow-up period. The primary outcomes were the number and costs of routine laboratory tests ordered per patient-day. We used generalised linear mixed models, and analyses were by intention to treat.ResultsWe included a total of 125 854 patient-days. Patient groups were similar in age, sex, Charlson Comorbidity Index and length of stay during the control, intervention and follow-up periods. From the control to the follow-up period, there was a 14% (incidence rate ratio (IRR)=0.86, 95% CI 0.79 to 0.92) overall reduction in ordering of routine tests with the intervention, along with a 14% (β coefficient=−0.14, 95% CI −0.07 to –0.21) reduction in costs of routine testing. This amounted to a total cost savings of $C1.15 per patient-day. There was also a 15% (IRR=0.85, 95% CI 0.79, 0.92) reduction in ordering of all common tests with the intervention and a 20% (IRR=1.20, 95% CI 1.10 to 1.30) increase in routine test-free patient-days. No worsening was noted in patient safety endpoints with the intervention.ConclusionsA multifaceted intervention bundle using education and facilitated multilevel social comparison was associated with a safe and effective reduction in use of routine daily laboratory testing in hospitals. Further research is needed to understand how system-level interventions may increase this effect and which intervention elements are necessary to sustain results.

T ransitions of patient care through hand-offs between health care teams are ubiquitous, particularly in hospitals. Hospitalists, usually internists, provide most of the general medical care to patients admitted to hospital. They typically work contiguous days, handing off patients at the end of their block, such that patients are likely to see more than 1 internist during their hospital admission. 1,2 Data on the association between breaks in continuity of care in hospitals and patient outcomes are limited. 3,4 A 2021 cross-sectional study that assessed care hand-offs among hospitalist physicians in the United States found no difference in postdischarge 30-day mortality. 5 However, an exploratory analysis within this study found that patients with higher illness severity had a higher 30-day mortality with increased physician hand-offs. A 2020 retrospective cohort study involving patients cared for by hospitalists in the top quartile of continuous schedules in Texas had significantly lower postdischarge mortality, readmission rates, costs and higher rates of discharge home than patients who were cared for by hospitalists with discontinuous schedules. 1 In Canada, the clinical teaching unit (CTU) is a teambased structure that delivers care to general medical patients in academic hospitals. 6 The attending physician serves as the most responsible physician for patient care, while simultaneously teaching learners of various skill levels and leading multidisciplinary teams of health care providers. 7 The attending physicians instruct and act as role models for the future physician workforce. 8 This role requires the execution of professional competence and is vulnerable to several unpredictable contextual factors. 9 Given the complexity of this role, an individual physician works a limited number of contiguous days to prevent burnout. 4 The prevalence of discontinuity of care by attending physicians on CTUs makes it important to understand its impact on patient outcomes. We aimed to evaluate the association between the number of Association between physician continuity of care and patient outcomes in clinical teaching units: a cohort analysis