Showing papers in "Journal of Hospital Medicine in 2007"

Promoting effective transitions of care at hospital discharge: A review of key issues for hospitalists

Abstract: The period following discharge from the hospital is a vulnerable time for patients. About half of adults experience a medical error after hospital discharge, and 19%-23% suffer an adverse event, most commonly an adverse drug event. This article reviews several important challenges to providing high-quality care as patients leave the hospital. These include the discontinuity between hospitalists and primary care physicians, changes to the medication regimen, new self-care responsibilities that may stress available resources, and complex discharge instructions. We also discuss approaches to promoting more effective transitions of care, including improvements in communication between inpatient and outpatient physicians, effective reconciliation of prescribed medication regimens, adequate education of patients about medication use, closer medical follow-up, engagement with social support systems, and greater clarity in physician-patient communication. By understanding the key challenges and adopting strategies to improve patient care in the transition from hospital to home, hospitalists could significantly reduce medical errors in the postdischarge period.

Barriers to mobility during hospitalization from the perspectives of older patients and their nurses and physicians.

Abstract: BACKGROUND Low mobility is common during hospitalization and is associated with adverse outcomes. Understanding barriers to the maintenance or improvement of mobility is important to the development of successful interventions. OBJECTIVES To identify barriers to mobility during hospitalization from the perspectives of older patients and their primary nurses and physicians, to compare and contrast the perceived barriers among these groups, and to make a conceptual model. DESIGN Qualitative interviews analyzed and interpreted using a grounded theory approach. SETTING Medical wards of a university hospital. PARTICIPANTS Twenty-nine participants—10 patients ≥ 75 years, 10 nurses, and 9 resident physicians. MEASUREMENTS Participants were interviewed using a semistructured interview guide, with similar questions for patients and health care providers. Interviews were audiotaped, transcribed, and reviewed for common themes by independent reviewers. Perceived barriers to mobility were identified, and their nature and frequency were examined for each respondent group. RESULTS Content analysis identified 31 perceived barriers to increased mobility during hospitalization. Barriers most frequently described by all 3 groups were: having symptoms (97%), especially weakness (59%), pain (55%), and fatigue (34%); having an intravenous line (69%) or urinary catheter (59%); and being concerned about falls (79%). Lack of staff to assist with out-of-bed activity was mentioned by patients (20%), nurses (70%), and physicians (67%). Unlike patients, health care providers attributed low mobility among hospitalized older adults to lack of patient motivation and lack of ambulatory devices. CONCLUSIONS Recognizing and understanding perceived barriers to mobility during hospitalization of older patients is an important first step toward developing successful interventions to minimize low mobility. Journal of Hospital Medicine 2007;2:305–313. © 2007 Society of Hospital Medicine.

Diabetes care in hospitalized noncritically ill patients: More evidence for clinical inertia and negative therapeutic momentum.

Abstract: BACKGROUND Little is known about management of hyperglycemia in inpatients. OBJECTIVE To gain insight into caring for hospitalized patients with hyperglycemia. DESIGN Retrospective analysis. SETTING Teaching hospital. PATIENTS Data on all patients discharged between January 1, 2001, and December 31, 2004 with a diagnosis of diabetes or hyperglycemia were extracted and linked to laboratory and pharmacy databases. Only the data on patients who did not require intensive care and who were hospitalized for at least 3 days were analyzed. MEASUREMENTS Average bedside glucose during the first and last 24 hours of hospital stay and for the entire length of stay; assessment of changes in insulin regimen and dose. RESULTS The average age of patients included in the study (n = 2916) was 69 years. Fifty-seven percent of the patients were men, 90% were white, and average length of stay was 5.7 days. More than 20% of the patients had evidence of sustained hyperglycemia. Forty-two percent of the patients who showed poor control of glycemia (glucose > 200 mg/dL) during the first 24 hours were discharged in poor control. The frequency of hypoglycemia was low (only 2.2 of 100 measurements per person) compared with hyperglycemia (25.5 of 100 measurements per person). Most patients (72%) received insulin during hospitalization, but there was high use of short-acting insulin and less than optimal intensification of therapy (clinical inertia); many patients had insulin therapy decreased despite persistent hyperglycemia (negative therapeutic momentum). CONCLUSIONS Glycemic control in the hospital was frequently poor, and there was suboptimal use of insulin, even among patients with sustained hyperglycemia. Educational programs directed at practitioners should focus on the importance of inpatient glucose control and provide guidelines on how and when to change therapy. Journal of Hospital Medicine 2007;2:203–211. © 2007 Society of Hospital Medicine.

Effects of rapid response systems on clinical outcomes: systematic review and meta-analysis

Abstract: BACKGROUND A rapid response system (RRS) consists of providers who immediately assess and treat unstable hospitalized patients. Examples include medical emergency teams and rapid response teams. Early reports of major improvements in patient outcomes led to widespread utilization of RRSs, despite the negative results of a subsequent cluster-randomized trial. PURPOSE To evaluate the effects of RRSs on clinical outcomes through a systematic literature review. DATA SOURCES MEDLINE, BIOSIS, and CINAHL searches through August 2006, review of conference proceedings and article bibliographies. STUDY SELECTION Randomized and nonrandomized controlled trials, interrupted time series, and before-after studies reporting effects of an RRS on inpatient mortality, cardiopulmonary arrests, or unscheduled ICU admissions. DATA EXTRACTION Two authors independently determined study eligibility, abstracted data, and classified study quality. DATA SYNTHESIS Thirteen studies met inclusion criteria: 1 cluster-randomized controlled trial (RCT), 1 interrupted time series, and 11 before-after studies. The RCT showed no effects on any clinical outcome. Before-after studies showed reductions in inpatient mortality (RR = 0.82, 95% CI: 0.74-0.91) and cardiac arrest (RR = 0.73, 95% CI: 0.65-0.83). However, these studies were of poor methodological quality, and control hospitals in the RCT reported reductions in mortality and cardiac arrest rates comparable to those in the before-after studies. CONCLUSIONS Published studies of RRSs have not found consistent improvement in clinical outcomes and have been of poor methodological quality. The positive results of before-after trials likely reflects secular trends and biased outcome ascertainment, as the improved outcomes they reported were of similar magnitude to those of the control group in the RCT. The effectiveness of the RRS concept remains unproven. Journal of Hospital Medicine 2007;2:422–432. © 2007 Society of Hospital Medicine.

Understanding rehospitalization risk: can hospital discharge be modified to reduce recurrent hospitalization?

Abstract: Background A high rate of unnecessary rehospitalization has been shown to be related to a poorly managed discharge processes. Objective A qualitative study was conducted in order to understand the phenomenon of frequent rehospitalization from the perspective of discharged patients and to determine if activities at the time of discharge could be designed to reduce the number of adverse events and rehospitalization. Design Semistructured, open-ended interviews were conducted with 21 patients during their hospital stay at Boston Medical Center. Interviews assessed continuity of care after discharge, need for and availability of social support, and ability to obtain follow-up medical care. Results Difficult life circumstances posed a greater barrier to recuperation than lack of medical knowledge. All participants were able to describe their medical condition, the reasons they were admitted to the hospital, and the discharge instructions they received. All reported the types of medications being taken or the conditions for which the medications were prescribed. Recuperation was compromised by factors that contribute to undermining the ability of patients to follow their doctors' recommendations including support for medical and basic needs, substance use, and limitations in the availability of transportation to medical appointments. Distress, particularly depression, further contributed to poor health and undermined the ability to follow doctors' recommendations and the discharge plans. Conclusions Discharge interventions that assess the need for social support and provide access and services have the potential to reduce chronic rehospitalization.

Hypoglycemia in hospitalized patients treated with antihyperglycemic agents.

Abstract: OBJECTIVE To determine the incidence and manifestations of hypoglycemia in hospitalized patients receiving antihyperglycemic therapy. RESEARCH DESIGN AND METHODS The study was a 3-month prospective review of consecutive medical records of all adult, nonpregnant hospitalized patients at a 675-bed university hospital who experienced at least 1 blood glucose (BG) ≤ 60 mg/dL within 48 hours of receiving an antihyperglycemic agent. MEASUREMENTS AND RESULTS Of 2174 patients receiving antihyperglycemic agents, 206 (9.5%) experienced 484 hypoglycemic episodes. Of these episodes, 29% occurred in patients with type 1 diabetes, 23% in the ICU, and 72% in patients receiving only insulin for hyperglycemia. More than 1 episode was experienced by 44% of the 206 patients. Furthermore, 4% (20 of 484) of the hypoglycemic episodes were associated with a hypoglycemia-related adverse event, defined as symptoms, signs, or injury. The mean BG of these episodes was 43.0 mg/dL, significantly lower than the mean BG of 50.9 mg/dL for the 464 episodes without adverse events (P = .01). One-third of the adverse events occurred with a BG between 50 and 60 mg/dL; half the adverse events, 10 episodes or 2% of all hypoglycemic episodes, were serious, involving seizures or an unresponsive patient. A decrease in enteral intake accounted for 40% of the episodes; none was attributed to medication error. Less than half the hypoglycemic patients had documented euglycemia within 2 hours. Sulfonylurea agents were associated with higher rates of hypoglycemia than were other oral agents. CONCLUSIONS Hypoglycemia in hospitalized patients taking antihyperglycemic agents is common; 1 in 25 episodes is associated with an adverse event. Opportunities exist to improve care, particularly around discontinuation of feeding. Journal of Hospital Medicine 2007;2:234–240. © 2007 Society of Hospital Medicine.

Effects of a hospitalist care model on mortality of elderly patients with hip fractures.

Abstract: BACKGROUND We previously demonstrated that a hospitalist service created to medically manage patients with hip fracture reduced time to surgery and length of hospital stay, with no difference in inpatient mortality, compared with patients who received standard care. Whether this improved efficiency affects long-term mortality is unknown. OBJECTIVE This study examined the effects of this hospitalist service versus standard care on mortality up to 1 year and identified predictors of mortality in patients with hip fracture. DESIGN Retrospective cohort study. SETTING Tertiary care center. PATIENTS Four hundred and sixty-six consecutive patients admitted for surgical repair of a hip fracture in 2000–2002 with 93% 1-year follow-up. RESULTS There was no significant difference in survival of the patients between those on the hospitalist care service and those on the standard care service (70.5% [CI: 64.8%, 76.7%] vs. 70.6% [CI: 64.9%, 76.8%]; P = .36), despite the shortened time to surgery and decreased length of stay in the hospitalist group. Predictors of mortality included: admission from a nursing home (hazard ratio [HR] 2.24, [CI: 1.73, 2.90]); age at admission (HR 1.17 [CI: 0.99, 1.38]); inpatient complications, including ICU admission, myocardial infarction, or acute renal failure (HR 1.85 [CI: 1.45, 2.35]); and ASA class III or IV compared with ASA class II (HR 4.20 [CI: 2.21, 7.99]). CONCLUSIONS The improved efficiency in reducing length of stay and time to surgery in the hospitalist group did not adversely affect long-term mortality of this patient population. Journal of Hospital Medicine 2007;2:219–225. © 2007 Society of Hospital Medicine.

Executing high-quality care transitions: A call to do it right

Abstract: As a hospital practitioner, you have undoubtedly experienced the frustration of witnessing how easily the excellent care you provide can unravel as the patient goes out the door. Patients are admitted acutely ill, and largely attributed to your clinical acumen, they are discharged “tuned up” and stable to return home. Days later, however, you may learn that your best-laid discharge plans were not properly executed, and the patient returned with yet another exacerbation. Clearly this scenario represents a major setback for the patient and family caregivers. Possibly dismissed as another episode of “patient noncompliance,” such readmissions are now being recognized as system failures and reflect a discharge process that has been described as “random events connected to highly variable actions with only a remote possibility of meeting implied expectations” (Roger Resar, MD, Senior Fellow, Institute for Healthcare Improvement). Once an area that received relatively little attention, transitions out of the hospital has been identified as a priority area in need of action by a confluence of recent research and national activities. Recognizing the expanding evidence for lapses in quality and safety, many esteemed organizations, including the Joint Commission, the Centers for Medicare and Medicaid Services and their accompanying Quality Improvement Organizations, the Institute for Healthcare Improvement, the Institute of Medicine, National Quality Forum, the Medicare Payment Advisory Committee, the American Board of Internal Medicine Foundation, the National Transitions of Care Coalition, the American College of Physicians, the Society for General Medicine, and the Society for Hospital Medicine, are currently focusing their efforts on how to optimize transitions. All have articulated the need for further clinical investigation that can offer greater insight into the nature of the problems that arise during this vulnerable period and what the potential solutions are. In this edition of the Journal of Hospital Medicine, 3 teams of investigators have responded to this need, making timely, important, and unique contributions to advance the field. Specifically, each of these articles further raises awareness that a patient’s transition out of the hospital often unfolds quickly in a fast-paced, chaotic manner, placing many competing demands on clinicians, patients, and family caregivers. Not surprisingly, such competing demands can contribute to deficits in quality and safety. The authors of these studies all directly identify the central role of communication among clinicians as well as between patients and clinicians in ensuring successful handoffs, further affirming the Joint Commission’s finding that inadequate communication is the leading cause of sentinel events. In this respect, E D I T O R I A L

Conflicting measures of hospital quality: ratings from "Hospital Compare" versus "Best Hospitals".

Abstract: BACKGROUND In April 2005 the Centers for Medicare and Medicaid Services launched “Hospital Compare,” the first government-sponsored hospital quality scorecard. We compared the ranking of U.S. News and World Report's “Best Hospitals” with Hospital Compare performance ratings. METHODS We examined Hospital Compare scores for core measures related to care for acute myocardial infarction (AMI), congestive heart failure (CHF), and community-acquired pneumonia (CAP). We calculated composite scores for the disease-specific sets of core measures and a composite combined score for the 14 core measures (across 3 diseases) and determined national score quartile cut points for each set. We then characterized the quartile distribution of Hospital Compare scores for the Best Hospitals for care of cardiac conditions and respiratory disorders in each year, as well as for the Best Hospital “Honor Roll” institutions. RESULTS AMI scores were available for 2165 hospitals, CHF scores for 3130, and CAP scores for 3462. In both 2004 and 2005, fewer than 50% of the Best Hospitals for cardiac care rated in the top quartile of Hospital Compare scores for AMI and CHF. Among the Best Hospitals for care of respiratory disorders, fewer than 15% scored in the top Hospital Compare quartile for CAP. Among Honor Roll institutions, only 5 (of 14 hospitals in 2004; of 16 in 2005) ranked in the top quartile for the combined core measure score. CONCLUSIONS Hospital Compare scores are frequently discordant with Best Hospital rankings, which is likely attributable to the markedly different methods each rating approach employs. Such discordance between major quality rating systems paints a conflicting picture of institutional performance for the public to interpret. Journal of Hospital Medicine 2007;2:128–134. © 2007 Society of Hospital Medicine.

Linezolid- and vancomycin-resistant Enterococcus faecium endocarditis: successful treatment with tigecycline and daptomycin.

Abstract: University of Calfornia, San Diego Enterococci are a leading cause of endocarditis and nosocomial infections. Vancomycin-resistant enterococci (VRE) emerged in the 1980s and now represent most nosocomial isolates in the United States. The first case of VRE endocarditis was reported in 1996. Although increasing enterococcal antibiotic resistance has prompted increasing reliance on newer antibiotics, a recent review of VRE endocarditis noted that survival rates were similar to those for vancomycin-sensitive enterococcal endocarditis. Cure was achieved in several patients with bacteriostatic agents in the absence of valve replacement, but no patients were infected with truly linezolid-resistant organisms. This case of linezolid-resistant VRE endocarditis represents the first reported cure of infective endocarditis with a tigecycline-containing regimen.

Hospital discharge information and older patients: Do they get what they need?

Abstract: BACKGROUND Ineffective communication of hospital discharge instructions may have important implications for future health, function, and quality of life. OBJECTIVE To describe patient recall of predischarge communication of discharge instructions by hospital staff, and to demonstrate the feasibility a posthospitalization survey in this urban, public hospital population. METHODS Cross-sectional telephone survey of 269 patients age 70 years or older who were discharged from an academically affiliated urban public hospital between September 7, 2004, and January 19, 2005. RESULTS The mean length of stay of the respondents was 5.6 days (range, 0–56 days), and the mean number of admissions over the study period was 1.6 (range, 1–7 times). The respondents were interviewed a average of 3 days after discharge (range, 1–10 days). Only 43.7% of the respondents replied yes when asked, “Did anyone talk with you about how to care for yourself at home after this hospitalization?” Among those who recalled how they received care instructions (n = 103), approximately 66.0% (n = 68) reported receiving instructions “verbally,” 10.7% (n = 11) reported receiving written instructions, and 23.3% (n = 24) reported receiving both. More than half the respondents (54.2%) did not recall anyone talking with them about how to care for themselves after hospitalization. Other significant gaps in important patient information were identified. CONCLUSIONS We found that a posthospitalization survey was both feasible and revealing in this urban, public hospital population. Furthermore, interviewee recall of predischarge communication of discharge instructions by hospital staff demonstrated significant gaps in communication between these patients and the hospital care team at time of discharge. Journal of Hospital Medicine 2007;2:291–296. © 2007 Society of Hospital Medicine.

Pediatric hospitalist comanagement of spinal fusion surgery patients.

Abstract: BACKGROUND: There are no published studies of hospitalist comanagement of pediatric surgical patients. OBJECTIVES: (1) To describe comanagement activities; (2) to determine the association of hospitalist comanagement with length of stay (LOS) following spinal fusion surgery DESIGN: Retrospective analysis of the surgeons' log. SETTING: Tertiary-care pediatric hospital. PATIENTS: Patients who underwent initial spinal fusion surgery (n = 759) between July 2000 and October 2005. INTERVENTION: Hospitalist pre- and perioperative evaluation and management of medically complex patients (from December 2004 to October 2005). MEASUREMENTS: Log-transformed LOS and trend in LOS by piecewise regression were measured, adjusting for patient covariates and clustering by surgeon. RESULTS: After December 2004, 12% of all spinal fusion surgery patients (14 of 115) were comanaged by a hospitalist. Nine-three percent (13 of 14) of comanaged patients had neuromuscular scoliosis, and comanaged patients represented 37% (13 of 35) of all neuromuscular patients. Mean LOS for all spinal fusion surgeries decreased from 6.5 days (95% CI: 6.2–6.7) to 4.8 days (95% CI: 4.5–5.1) after December 2004. Mean LOS decreased more for neuromuscular patients (8.6 days [95% CI: 8.0– 9.2] to 6.2 days [95% CI: 5.5–6.9]) than for idiopathic patients (5.2 days [95% CI: 5.0–5.4] to 4.1 days [95% CI: 3.9–4.4]). Variability in LOS also decreased significantly for both groups. Prior to hospitalist comanagement, there was no change in adjusted LOS over time. After December 2004, there was a significant decline in average adjusted LOS (neuromuscular slope = −0.23 to −0.31 days/month, P = .0075; idiopathic slope = −0.10 to −0.12 days/month; P = .0007). CONCLUSIONS: The introduction of selective hospitalist comanagement of pediatric spinal fusion surgery patients was associated with significant decreases in LOS and variability in LOS. Journal of Hospital Medicine 2007;2:23–30. © 2007 Society of Hospital Medicine.

Quality of life of children with neurological impairment who receive a fundoplication for gastroesophageal reflux disease

Abstract: BACKGROUND Children with neurological impairment (NI) commonly have gastroesophageal reflux disease (GERD) treated with a fundoplication. The impact of this procedure on quality of life is poorly understood. OBJECTIVES To examine the quality of life of children with NI who have received a fundoplication for GERD and of their caregivers. METHODS The study was a prospective cohort study of children with NI and GERD who underwent a fundoplication at a children's hospital between January 1, 2005, and July 7, 2006. Quality of life of the children was assessed with the Child Health Questionnaire (CHQ) and of the caregivers with the Short-Form Health Survey Status (SF-36) and Parenting Stress Index (PSI), both at baseline and 1 month after fundoplication. Functional status was assessed using the WeeFIM®. Repeated-measures analyses were performed. RESULTS Forty-four of the 63 parents (70%) were enrolled. The median WeeFIM® score was 31.2 versus the age-normal score of 83 (P = .001). Compared with the baseline scores, mean CHQ scores improved over 1 month in the domains of bodily pain (32.8 vs. 47.5, P = .01), role limitations–physical (30.6 vs. 56.6, P = .01), mental health (62.7 vs. 70.6, P = .01), family limitation of activities (43.3 vs. 55.1, P = .03), and parental time (43.0 vs. 55.3, P = .03). The parental SF-36 domain of vitality improved from baseline over 1 month (41.3 vs. 48.2, P = .001), but there were no changes from baseline in Parenting Stress scores. CONCLUSIONS Parents reported that the quality of life of children with NI who receive a fundoplication for GERD was improved from baseline in several domains 1 month after surgery. The quality of life and stress of caregivers did not improve in nearly all domains, at least in the short term. Journal of Hospital Medicine 2007;2:165–173. © 2007 Society of Hospital Medicine.

Comparison of resource utilization and clinical outcomes between teaching and nonteaching medical services

Abstract: PURPOSE To compare the resource utilization and clinical outcomes of medical care delivered on general internal medicine inpatient services at teaching and nonteaching services at an academic hospital. METHODS From February to October 2002, 2189 patients admitted to a 450-bed university-affiliated community hospital were assigned either to a resident-staffed teaching service (n = 1637) or to a hospitalist- or clinic-based internist nonteaching service (n = 552). We compared total hospital costs per patient, length of hospital stay (LOS), hospital readmission within 30 days, in-hospital mortality, and costs for pharmacy, laboratory, radiology, and others between teaching and nonteaching services. RESULTS Care on a teaching service was not associated with increased overall patient care costs ($5572 vs. $5576; P = .99), LOS (4.92 days vs. 5.10 days; P = .43), readmission rate (12.3% vs. 10.3%; P = .21), or in-hospital mortality (3.7% vs. 4.5%; P = .40). Mean laboratory and radiology costs were higher on the teaching service, but costs for the pharmacy and for speech therapy, occupational therapy, physical therapy, respiratory therapy, pulmonary function testing, and GI endoscopy procedures were not statistically different between the 2 services, and residents did not order more tests or procedures. Case mix and illness severity, as reflected by the distribution of the most frequent DRGs and mean number of secondary diagnoses per patient and DRG-specific LOS, were similar on the 2 services. CONCLUSIONS At our academic hospital, admission to a general internal medicine teaching service resulted in patient care costs and clinical outcomes comparable to those admitted to a nonteaching service. Journal of Hospital Medicine 2007;2:150–157. © 2007 Society of Hospital Medicine.

Discontinuation of antiplatelet therapy prior to low‐risk noncardiac surgery in patients with drug‐eluting stents: A retrospective cohort study

Abstract: BACKGROUND Drug-eluting coronary stents (DESs) pose a challenge in the perioperative period. Sirolimus and paclitaxel may inhibit reendothelialization of the traumatized vessel, making it vulnerable to platelet-mediated thrombosis. Given the anecdotal evidence and case series suggesting that DESs may be more vulnerable to thrombosis on discontinuation of antiplatelet agents than are bare-metal stents, we sought to quantify this risk. METHODS We linked the Cleveland Clinic Heart Center database with the Cleveland Clinic Internal Medicine Preoperative Assessment Consultation and Treatment (IMPACT) Center database to identify all patients who had undergone DES placement at the Cleveland Clinic and subsequently were evaluated for noncardiac surgery between July 2003 and July 2005. Outcome measures included 30-day rate of postoperative myocardial infarction (MI), DES thrombosis, major bleeding, and all-cause mortality. RESULTS We identified 114 patients who underwent noncardiac surgery a median of 236 days (IQR 125–354) after stent placement. Forty-five patients (40%) underwent surgery within 180 days of stenting, 15 of whom (13%) underwent surgery within 90 days of stenting. Eighty-eight patients (77%) discontinued all antiplatelet agents a median of 10 days before surgery. No patients died. Two patients (1.8%, 95% CI 0.5%–6.2%) suffered postoperative MIs, but postoperative catheterization showed neither had DES thrombosis (0%, 95% CI 0%–3.3%). One patient developed major bleeding (0.9%, CI 0.2%–4.8%). CONCLUSIONS These data suggest that the overall risk of stent thrombosis is low in low-risk noncardiac surgery patients with DESs, particularly those who have undergone at least 180 days of antiplatelet therapy, even after complete discontinuation of antiplatelet agents. Journal of Hospital Medicine 2007;2:378–384. © 2007 Society of Hospital Medicine.

Breaking bad news: a practical approach for the hospitalist.

Abstract: Communicating bad news to patients and their families is a difficult but routine responsibility for hospitalists. Most practitioners have little or no formal training for this task. Preparation for, delivery of, and follow-up to these conversations should be deliberately planned in order to meet patients' needs. In this article, we review the literature that guides this process and, with a case example, describe steps practitioners can take to effectively deliver bad news and pitfalls that should be avoided. As competency in this skill set is necessary for effective patient care, hands-on training should be part of the core curriculum for all health care practitioners. Hospitalists should be proficient in this area and may serve as role models and instructors for colleagues and trainees. Journal of Hospital Medicine 2007;2:415–421. © 2007 Society of Hospital Medicine

Stress-ulcer prophylaxis for general medical patients: a review of the evidence.

Abstract: BACKGROUND Gastric stress ulceration and bleeding are common occurrences in the critically ill and prophylactic acid-suppression is used almost universally in this population. Evidence suggests that general medical patients hospitalized outside of the intensive care unit often receive similar therapy. PURPOSE To determine how frequently general medical patients are prescribed stress ulcer prophylaxis and what evidence exists for doing so. DATA SOURCE The MEDLINE database (1966 to October 2005), the Cochrane Central Register of Controlled Trials (4th Quarter 2005), and the bibliographies of selected articles. STUDY SELECTION Studies that contained significant data about either the frequency of use of stress ulcer prophylaxis in general medical patients or gastrointestinal bleeding outcomes in patients given prophylaxis. DATA EXTRACTION The primary author extracted prevalence and outcome data. DATA SYNTHESIS Descriptive studies suggest that 20–25% of general medical patients receive acid suppression for stress ulcer prophylaxis in the absence of presumed (but not established) risk factors for bleeding. Only two randomized, controlled trials evaluated the effects of prophylaxis in this population. The first found a reduction in clinically significant gastrointestinal bleeding from 6% (3 of 48) with placebo to zero (n = 52) with magaldrate. The second found a reduction in clinically significant bleeding from 3% (2 of 70) with sucralfate to zero (n = 74) with cimetidine. CONCLUSION A significant number of general medical patients are prescribed acid-suppressive therapy for stress ulcer prophylaxis. The literature provides only sparse guidance on this issue with two randomized trials showing a possible benefit for prophylaxis. Further study is needed. Journal of Hospital Medicine 2007;2:86–92. © 2007 Society of Hospital Medicine.

Reporting of estimated glomerular filtration rate: effect on physician recognition of chronic kidney disease and prescribing practices for elderly hospitalized patients.

Abstract: BACKGROUND Physician recognition of chronic kidney disease (CKD) in elderly patients has been noted to be poor. These patients are at increased risk of medication dosing errors and acute renal failure. OBJECTIVE To investigate the effect of reporting estimated glomerular filtration rate (GFR) of elderly hospitalized patients on physician recognition of CKD and physician prescribing behaviors. DESIGN A retrospective combined with a prospective medical record review project. SETTING A large academic medical center. PATIENTS Patients included were 65 years of age or older and had creatinine values within the normal laboratory range (< 1.6 mg/dL). INTERVENTION Reporting a calculated estimate of GFR to physicians. MEASUREMENTS Rates of recognition of CKD were examined before and after the intervention. The effects of the intervention on prescription of renal-dosed antibiotics and nonsteroidal anti-inflammatory drugs (NSAIDS) and cyclooxygenase- 2 inhibitors (COX-2) at hospital discharge were assessed. RESULTS A total of 260 and 198 patients were included before and after the intervention, respectively. Recognition of chronic kidney disease was low in both groups but demonstrated a significant increase following reporting of estimated GFR (3.9% to 12.6%, P < .001). Reporting of GFR was not associated with a significant decrease in prescription of NSAID/COX-2 medications or increased rates of correct dosing of antibiotics (P = .10 and P = .81, respectively). CONCLUSIONS Although reporting of estimated GFR was associated with improved physician recognition of CKD in elderly hospitalized patients, it did not lead to a change in physician prescribing. More extensive interventions are necessary to increase recognition and decrease medication dosing errors. Journal of Hospital Medicine 2007;2:74–78. © 2007 of Hospital Medicine.

Impact of a bedside procedure service on general medicine inpatients: A firm-based trial

Abstract: BACKGROUND Procedure services may improve the training of bedside procedures. However, little is known about how procedure services may affect the demand for and success of procedures performed on general medicine inpatients. OBJECTIVE Determine whether a procedure service affects the number and success of 4 bedside procedures (paracentesis, thoracentesis, lumbar puncture, and central venous catheterization) attempted on general medicine inpatients. DESIGN Prospective cohort study. SETTING Large public teaching hospital. PATIENTS Nineteen hundred and forty-one consecutive admissions to the general medicine service. INTERVENTION A bedside procedure service was offered to physicians from 1 of 3 firms for 4 weeks. This service then crossed over to physicians from the other 2 firms for another 4 weeks. MEASUREMENTS Data on all procedure attempts were collected daily from physicians. We examined whether the number of attempts and the proportion of successful attempts differed based on whether firms were offered the beside procedure service. RESULTS The number of procedure attempts was 48% higher in firms offered the service (90 versus 61 per 1000 admissions; RR 1.48, 95% CI 1.06–2.10; P = .030). More than 85% of the observed increase was a result of procedures with therapeutic indications. There were no differences between firms in the proportions of successful attempts or major complications. CONCLUSIONS The availability of a procedure service may increase the overall demand for bedside procedures. Further studies should refine the indications for and anticipated benefits from these commonly performed invasive procedures. Journal of Hospital Medicine 2007;2:143–149. © 2007 Society of Hospital Medicine.

"Non-heart-beating," or "cardiac death," organ donation: why we should care.

Abstract: BACKGROUND Organ donation after cessation of cardiac pump activity is referred to as non-heart-beating organ donation (NHBOD). NHBOD donors can be neurologically intact; they do not fulfill the brain death criteria prior to cessation of cardiac pump activity. For hospitals to participate in NHBOD, they must comply with a newly introduced federal requirement for ICU patients whose deaths are considered imminent after withdrawal of life support. This report describes issues related to NHBOD. METHODS A nonstructured review of selected publications and Web sites was undertaken. RESULTS Scientific evidence from autoresuscitation and extracorporeal perfusion suggests that verifying cardiorespiratory arrest lasting 2–5 minutes does not uniformly comply with the dead donor rule, so that the process of organ procurement can be the irreversible event defining death in organ donors. The interest of organ procurement organizations and affiliates in maximizing recovery of transplantable organs introduces self-serving bias in gaining consent for organ donation and abandons the basic tenet of obtaining true informed consent. The impact of donor management and procurement protocols on end-of-life (EOL) care and the potential trade-off are not disclosed, raising concern about whether potential donors and their families are fully informed before consenting to donation. CONCLUSIONS The use of comprehensive quality indicators for EOL care can determine the impact of NHBOD on care offered to donors and the effects on families and health care providers. Detailed evaluation of NHBOD will enable the public to make informed decisions about participating in this type of organ donation. Journal of Hospital Medicine 2007;2:324–334. © 2007 Society of Hospital Medicine.

Geriatric syndromes in elderly patients admitted to an inpatient cardiology ward.

Abstract: BACKGROUND Older adults make up an increasing proportion of patients hospitalized with cardiovascular disease. Such patients often have multiple coexisting geriatric syndromes that may affect management and outcomes and are frequently underdiagnosed and untreated. OBJECTIVES To determine the prevalence of geriatric syndromes and incidence of selected adverse events in hospitalized elderly patients with cardiovascular disease. DESIGN A prospective cohort study. SETTING Urban academic medical center. PATIENTS One hundred patients at least 70 years old with cardiovascular disease hospitalized on a cardiology ward. MEASUREMENTS Standard geriatric screens were administered to assess mood, function, and cognitive status. Patients were followed prospectively for adverse events such as falls, urinary tract infection (UTI), and use of restraints. RESULTS The mean age of the patients was 79.2 ± 5.5 years, 61% were female, 68% were white, and mean length of stay was 7 days. Geriatric syndromes were prevalent and included functional impairment (35% dependent in ≥1 activity of daily living), cognitive impairment (19% with abnormal results on the Short Blessed Test), and polypharmacy. Thirty-seven percent of patients were prescribed a potentially inappropriate medication on admission or discharge. Patients receiving a Foley catheter were at increased risk for UTI. CONCLUSIONS These findings suggest that geriatric syndromes are prevalent among older patients hospitalized for cardiovascular disease. Further study is needed to determine if interventions designed to increase recognition and treatment of these syndromes can improve outcomes in this patient population. Journal of Hospital Medicine 2007;2:394–400. © 2007 Society of Hospital Medicine.

Clear writing, clear thinking and the disappearing art of the problem list.

Abstract: My hospital’s electronic medical record helpfully informs me after 1 week on service that there are 524 data available for my attention, a statistic that would be paralyzing without a cognitive framework for organizing and interpreting them in a manner that can be shared among my colleagues. Accurate information flow among clinicians was identified early on as an imperative of hospital medicine. Much attention has been focused on communication during transitions of care, such as that between inpatient and outpatient services and between inpatient teams, taking the form of the discharge summary and the sign-out, respectively. But communication among physicians, consultants, and allied therapists must and inevitably does occur continuously day by day during even the most uneventful hospital stay. On academic services the need to keep multiple and ever-rotating team members on the same page, so to speak, is particularly pressing. The succinct and accurate problem list, formulated at the end of the history and physical examination and propagated through daily progress notes, is a powerful tool for promoting clear diagnostic and therapeutic planning and is ideally suited to meeting the need for continuous information flow among clinicians. Sadly, this inexpensive and potentially elegant device has fallen into disuse and disrepair and is in need of restoration. In the 1960s, Dr. Lawrence Weed, the inventor of the “SOAP” note and a pioneer of medical informatics, wrote of the power of the problem list to impose order on the chaos of clinical information and to aid clear diagnostic thinking, in contrast with the simply chronological record popular in earlier years:

Which observations from the complete blood cell count predict mortality for hospitalized patients

Abstract: Background Information on the prognostic utility of the admission complete blood count (CBC) and differential count is lacking.

SynopSIS: integrating physician sign-out with the electronic medical record.

Abstract: BACKGROUND Safe delivery of care depends on effective communication among all health care providers, especially during transfers of care. The traditional medical chart does not adequately support such communication. We designed a patient-tracking tool that enhances provider communication and supports clinical decision making. AIM To develop a problem-based patient-tracking tool, called Sign-out, Information Retrieval, and Summary (SynopSIS), in order to support patient tracking, transfers of care (ie, sign-outs), and daily rounds. SETTING Tertiary-care, university-based teaching hospital. PROGRAM DESCRIPTION SynopSIS compiles and organizes information from the electronic medical record to support hospital discharge and disposition decisions, daily provider decisions, and overnight or cross-coverage decisions. It reflects the provider's patient-care and daily work-flow needs. PROGRAM EVALUATION We plan to use Web-based surveys, audits of daily use, and interdisciplinary focus groups to evaluate SynopSIS's impact on communication between providers, quality of sign-out, patient continuity of care, and rounding efficiency. CONCLUSIONS We expect SynopSIS to improve care by facilitating communication between care teams, standardizing sign-out, and automating daily review of clinical and laboratory trends. SynopSIS redesigns the clinical chart to better serve provider and patient needs. Journal of Hospital Medicine 2007;2:336–342. © 2007 Society of Hospital Medicine.

Association of ambulatory use of statins and beta‐blockers with long‐term mortality after vascular surgery

Abstract: BACKGROUND The use of drugs to improve postoperative outcomes has focused on short-term end points and centered on beta-blockers. Emerging evidence suggests statins may also improve postoperative outcomes. OBJECTIVE We sought to ascertain if the ambulatory use of statins and/or beta-blockers was associated with a reduction in long-term mortality after vascular surgery. DESIGN Retrospective cohort study with a median follow-up of 2.7 years. SETTING Regional multicenter study at Veterans Affairs medical centers. PATIENTS Three thousand and sixty-two patients presenting for vascular surgery. MEASUREMENTS Patients were categorized as using statins or beta-blockers if they filled a prescription for the study drug within 30 days of surgery. Survival analyses, propensity score methods, and stratifications by the revised cardiac risk index (RCRI) were performed. RESULTS Propensity-adjusted ambulatory use of statins and beta-blockers was associated with a reduction in mortality over the study period compared with nonuse of these medications hazard ratio [HR] = 0.78 [95% CI: 0.67–0.92], P = .0021, and number needed to treat (NNT) = 22 for statins; HR = 0.84 [95% CI: 0.73–0.96], P = .0106, and NNT = 30 for beta-blockers. In addition, for propensity-adjusted use of both statins and beta-blockers compared with neither the HR was 0.56 [95% CI: 0.42–0.74] P < .0001, and NNT was 9. The RCRI confirmed combination statin and beta-blocker use was beneficial at all levels of risk. Use of the combination study drugs by the highest-risk patients was associated with a 33% decrease in mortality after 2 years (P = .0106). CONCLUSIONS The use of ambulatory statins alone or in combination with beta-blockers is associated with a reduction in long-term mortality after vascular surgery, and combination use benefits patients at all levels of risk. Journal of Hospital Medicine 2007;2:241–252. © 2007 Society of Hospital Medicine.

Evaluation of an anonymous system to report medical errors in pediatric inpatients

Abstract: OBJECTIVE To compare reports of medical errors in hospitalized children submitted using an electronic, anonymous reporting system with those submitted via traditional incident reports. STUDY DESIGN During the 3-month study period in 2003, reports of medical errors from 2 units at a large children's hospital were made using an electronic, anonymous system. Three reviewers independently evaluated each report and determined whether the events described constituted a medical error. An identical procedure was used to categorize medical error data collected via incident reports from the 2 study units from 1999 to 2002. RESULTS A total of 146 reports were made using the anonymous system, 131 of which documented medical errors. The rate of reporting medical errors with the anonymous system was 2.41/100 patient-days. The rate of reporting medical errors via incident reports in 1999-2002 was 2.40/100 patient-days. However, 33.8% of all incident reports dealt with mislabeled laboratory specimens; after excluding these reports, the rate of medical errors documented via incident reports was 1.56/100 patient-days. The rate of reporting was significantly higher with the anonymous system (rate ratio 1.54, 95% confidence interval 1.26, 1.90). With the anonymous system, 25.2% of reported medical errors were near-misses compared with 12.6% of the errors reported with the incident report system (P = .001). CONCLUSIONS Implementation of the anonymous reporting system with training was associated with a statistically significant increase in the rate of reported medical errors. The reporting of near-miss events was significantly increased, suggesting this may be a useful format for gathering data on this type of medical error. Journal of Hospital Medicine 2007;2:226–233. © 2007 Society of Hospital Medicine.

Firm‐based trial to improve central venous catheter insertion practices

Abstract: BACKGROUND Central venous catheters placed in femoral veins increase the risk of complications At our institution, residents place most catheters in the femoral vein OBJECTIVE Determine whether a hands-on educational session reduced femoral venous catheterization and improved residents' confidence and adherence to recommendations for infection control DESIGN Firm-based clinical trial between November 2004 and March 2005 SETTING General medical wards of Cook County (Stroger) Hospital (Chicago, IL), a public teaching hospital PARTICIPANTS Internal medicine residents (n = 150) INTERVENTION Before their 4-week rotation, intervention-firm residents received a lecture and practiced placing catheters in mannequins; control-firm residents received the usual training MEASUREMENTS Venous insertion site, adherence to recommendations for infection control, knowledge and confidence about catheter insertion, and catheter-associated complications RESULTS Residents inserted 54 catheters, or 024 insertions per resident per 4-week rotation There was a nonsignificant decrease in femoral insertions for nondialysis catheters in the intervention group compared to the control group (44% vs 58%), difference: −14% (95% CI, −52% to 24%) The intervention significantly increased residents' knowledge of complications related to femoral vein catheterization and temporarily increased their confidence about placing internal jugular or subclavian venous catheters Intervention-group residents were more likely to use masks during catheterization (risk ratio, 22; 95% CI, 13-27), but other practices were similar CONCLUSIONS Our intervention improved residents' knowledge of complications and use of masks during catheter insertion; however, it did not significantly change venous insertion sites Catheter insertions on our general medicine wards are infrequent, and the skills acquired during the skills-building session may have deteriorated given the few clinical opportunities for reinforcement Journal of Hospital Medicine 2007;2:135–142 © 2007 Society of Hospital Medicine

Frequency of New or Worsening Symptoms in the Posthospitalization Period

Abstract: BACKGROUND When patients are discharged from the hospital, they are assumed to be stable until follow-up as outpatients. OBJECTIVE To study the frequency of new or worsening symptoms within 2-5 days of hospital discharge. DESIGN Retrospective analysis of data from telephone calls to patients by centralized call center. SETTING Patients discharged by hospitalists employed by IPC—The Hospitalist Company. PATIENTS 15,767 patients surveyed between May 1, 2003, and October 31, 2003. INTERVENTION Patients discharged home were contacted by a central call center in the first several days after discharge. MEASUREMENTS Patient demographics, self-rated health status, prevalence of new or worsening symptoms, medication issues, home health services issues, and status of scheduled follow-up appointments. RESULTS Of the patients surveyed, 11.9% reported new or worsening symptoms since leaving the hospital. There were no differences by age. Women were more likely than men to be symptomatic. Patients with worse health status were more likely to have new or worse symptoms (P < .0001). Symptomatic patients were minimally more likely to have made a follow-up appointment (61.0% vs. 58.4%, P < .05) and were more likely to have medication issues (22.2% vs. 6.8%, P < .0001) and problems with receiving home health care services (5.8% vs. 3.6%, P < .05). CONCLUSIONS A significant percentage of patients had new or worsening symptoms in the first several days after discharge. These patients were only minimally more likely to have made follow-up appointments. A system to manage the postdischarge transition period is essential to improving posthospitalization outcomes. Journal of Hospital Medicine 2007;2:58–68. © 2007 Society of Hospital Medicine.

In‐room display of day and time patient is anticipated to leave hospital: A “discharge appointment”

Abstract: BACKGROUND: We learned from a focus group that many patients find discharge to be one of the least satisfying elements of the hospital experience. Patients cited insufficient communication about the day and time of the impending discharge as a cause of dissatisfaction. OBJECTIVE: In partnership with the Institute for Healthcare Improvement, Improvement Action Network collaborative, we tested the practicality of an in-room “discharge appointment” (DA) display. SETTING AND PATIENTS: Eight inpatient care units in 2 hospitals at an academic medical center (Mayo Clinic, Rochester, MN). INTERVENTION: DA displayed on a specially designed bedside dry-erase board. MEASUREMENTS: The primary outcome was the proportion of discharged patients who had been given a DA, including same-day DAs. Secondary outcomes were (1) the proportion of DAs scheduled before the actual dismissal day and (2) the timeliness of the actual departure compared with the DA. RESULTS: During the 4-month period, 2046 patients were discharged. Of those, 1256 patients (61%) were given a posted DA, of which 576 (46%) were scheduled at least a day in advance and 752 (60%) departed from the care unit within 30 minutes of the appointed time. CONCLUSIONS: With a program for in-room display of a DA in various hospital units, more than half the patients had a DA set, and most of the DA patients departed on time. Further investigation is needed to determine the effect of DAs on patient and provider satisfaction. Journal of Hospital Medicine 2007;2:13–16. © 2007 Society of Hospital Medicine.

Expanding the roles of hospitalist physicians to include public health

Abstract: Several years after the inception of the hospitalist movement, hospitalist roles have evolved in breadth and sophistication. Although public health is not formally recognized or previously described as an arena for hospitalists, hospitalists are often engaged in public health practice. This article attempts to alert hospitalists to the potential to make contributions to the field of public health and defines the public health skills that can positively affect the lives of their patients and the communities they serve. In a public health role, hospitalists may improve the quality of inpatient care. This article reviews how public health and hospital-based practices have already intersected and proposes further development within this discipline. In our ever-changing health care system, hospitalists play key roles in the central public health domains of assessment, assurance, and policy development. Insightful hospitalists will recognize and embrace these responsibilities in caring for patients and society.