Showing papers in "Journal of Hospital Medicine in 2009"

Use of simulation-based mastery learning to improve the quality of central venous catheter placement in a medical intensive care unit.

Abstract: BACKGROUND: Central venous catheter (CVC) insertions are performed frequently by internal medicine residents. Complications, including arterial puncture and pneumothorax, decrease when operators use fewer needle passes to insert the CVC. In this study, we evaluated the effect of simulation-based mastery learning on CVC insertion skill. DESIGN: This was a cohort study of internal jugular (IJ) and subclavian (SC) CVC insertions by 41 internal medicine residents rotating through the medical intensive care unit (MICU) over a five-month period. Thirteen traditionally-trained residents were surveyed about the number of needle passes, complications, and procedural self-confidence on CVCs inserted in the MICU. Concurrently, 28 residents completed simulation-based training in IJ and SC CVC insertions. Simulator-trained residents were expected to perform CVC insertions to mastery standards on a central line simulator. Simulator-trained residents then rotated through the MICU and were surveyed regarding CVC placement. The impact of simulation training was assessed by comparing group survey results. RESULTS: No resident met the minimum passing score (MPS) (79.1%) for CVC insertion at baseline: mean (M) (IJ) = 48.4%, standard deviation (SD) = 23.1, M(SC) = 45.2%, SD = 26.3. All residents met or exceeded the MPS at testing after simulation training: M(IJ) = 94.8%, SD = 10.0, M(SC) = 91.1%, SD = 17.8 (p < 0.001). In the MICU, simulator-trained residents required fewer needle passes to insert a CVC than traditionally-trained residents: M = 1.79, SD = 1.0 versus M = 2.78, SD = 1.77 (p = 0.04). Simulator-trained residents displayed more self-confidence about their procedural skills: (M = 81, SD = 11 versus M = 68, SD = 20, p = 0.02). CONCLUSIONS: Simulation-based mastery learning increased residents' skills in simulated CVC insertion, decreased the number of needle passes when performing actual procedures, and increased resident self-confidence. Journal of Hospital Medicine 2009;4:397–403. © 2009 Society of Hospital Medicine.

Reduction of 30‐day postdischarge hospital readmission or emergency department (ED) visit rates in high‐risk elderly medical patients through delivery of a targeted care bundle

Abstract: RATIONALE: Care coordination has shown inconsistent results as a mechanism to reduce hospital readmission and postdischarge emergency department (ED) visit rates. OBJECTIVE: To assess the impact of a supplemental care bundle targeting high-risk elderly inpatients implemented by hospital-based staff compared to usual care on a composite outcome of hospital readmission and/or ED visitation at 30 and 60 days following discharge. PATIENTS/METHODS: Randomized controlled pilot study in 41 medical inpatients predisposed to unplanned readmission or postdischarge ED visitation, conducted at Baylor University Medical Center. The intervention group care bundle consisted of medication counseling/reconciliation by a clinical pharmacist (CP), condition specific education/enhanced discharge planning by a care coordinator (CC), and phone follow-up. RESULTS: Groups had similar baseline characteristics. Intervention group readmission/ED visit rates were reduced at 30 days compared to the control group (10.0% versus 38.1%, P = 0.04), but not at 60 days (30.0% versus 42.9%, P = 0.52). For those patients who had a readmission/postdischarge ED visit, the time interval to this event was longer in the intervention group compared to usual care (36.2 versus 15.7 days, P = 0.05). Study power was insufficient to reliably compare the effects of the intervention on lengths of index hospital stay between groups. CONCLUSIONS: A targeted care bundle delivered to high-risk elderly inpatients decreased unplanned acute health care utilization up to 30 days following discharge. Dissipation of this effect by 60 days postdischarge defines reasonable expectations for analogous hospital-based educational interventions. Further research is needed regarding the impacts of similar care bundles in larger populations across a variety of inpatient settings. Journal of Hospital Medicine 2009;4:211–218. © 2009 Society of Hospital Medicine.

Transitions of Care Consensus Policy Statement: American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Abstract: The American College of Physicians, Society of Hospital Medicine, and Society of General Internal Medicine convened a multi-stakeholder consensus conference in July 2007 to address the quality gaps in the transitions between inpatient and outpatient settings and to develop consensus standards for these transitions. Over 30 organizations sent representatives to the Transitions of Care Consensus Conference. Participating organizations included medical specialty societies from internal medicine as well as family medicine and pediatrics, governmental agencies such as the Agency for Healthcare Research and Quality and the Centers for Medicare and Medicaid Services, performance measure developers such as the National Committee for Quality Assurance and the American Medical Association Physician Consortium on Performance Improvement, nurse associations such as the Visiting Nurse Associations of America and Home Care and Hospice, pharmacist groups, and patient groups such as the Institute for Family-Centered Care. The Transitions of Care Consensus Conference made recommendations for standards concerning the transitions between inpatient and outpatient settings for future implementation. The American College of Physicians, Society of Hospital Medicine, Society of General Internal Medicine, American Geriatric Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine all endorsed this document.

Hospitalist Handoffs: A Systematic Review and Task Force Recommendations

Abstract: BACKGROUND: Handoffs are ubiquitous to Hospital Medicine and are considered a vulnerable time for patient safety. PURPOSE: To develop recommendations for hospitalist handoffs during shift change and service change. DATA SOURCES: PubMed (through January 2007), Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network, white papers, and hand search of article bibliographies. STUDY SELECTION: Controlled studies evaluating interventions to improve in-hospital handoffs (n = 10). DATA EXTRACTION: Studies were abstracted for design, setting, target, outcomes (including patient-level, staff-level, or system-level outcomes), and relevance to hospitalists. DATA SYNTHESIS: Although there were no studies of hospitalist handoffs, the existing literature from related disciplines and expert opinion support the use of a verbal handoff supplemented with written documentation in a structured format or technology solution. Technology solutions were associated with a reduction in preventable adverse events, improved satisfaction with handoff quality, and improved provider identification. Nursing studies demonstrate that supplementing verbal exchange with a written medium leads to improved retention of information. White papers characterized effective verbal exchange, as focusing on ill patients and actions required, with time for questions and minimal interruptions. In addition, content should be updated daily to ensure communication of the latest clinical information. Using this literature, recommendations for hospitalist handoffs are presented with corresponding levels of evidence. Recommendations were reviewed by hospitalists at the Society of Hospital Medicine (SHM) Annual Meeting and by an interdisciplinary team of expert consultants and were endorsed by the SHM governing board. CONCLUSIONS: The systematic review and resulting recommendations provide hospitalists a starting point from which to improve in-hospital handoffs. Journal of Hospital Medicine 2009;4:433–440. © 2009 Society of Hospital Medicine.

Inpatient glucose control: a glycemic survey of 126 U.S. hospitals

Abstract: BACKGROUND: Despite increased awareness of the value of treating inpatient hyperglycemia, little is known about glucose control in U.S. hospitals. METHODS: The Remote Automated Laboratory System-Plus (RALS®-Plus Medical Automation Systems, Charlottesville, VA) was used to extract inpatient point-of-care bedside glucose (POC-BG) tests from 126 hospitals for the period January to December 2007. Patient-day-weighted mean POC-BG and hypoglycemia/hyperglycemia rates were calculated for intensive care unit (ICU) and non-ICU areas. The relationship of POC-BG levels with hospital characteristics was determined. RESULTS: A total of 12,559,305 POC-BG measurements were analyzed: 2,935,167 from the ICU and 9,624,138 from the non-ICU. Patient-day-weighted mean POC-BG was 165 mg/dL for ICU and 166 mg/dL for non-ICU. Hospital hyperglycemia (>180 mg/dL) prevalence was 46.0% for ICU and 31.7% for non-ICU. Hospital hypoglycemia (<70 mg/dL) prevalence was low at 10.1% for ICU and 3.5% for non-ICU. For ICU and non-ICU there was a significant relationship between number of beds and patient-day-weighted mean POC-BG levels, with larger hospitals (≥400 beds) having lower patient-day weighted mean POC-BG per patient day than smaller hospitals (<200 beds, P < 0.001). Rural hospitals had higher POC-BG levels compared to urban and academic hospitals (P < 0.05), and hospitals in the West had the lowest values. CONCLUSIONS: POC-BG data captured through automated data management software can support hospital efforts to monitor the status of inpatient glycemic control. From these data, hospital hyperglycemia is common, hypoglycemia prevalence is low, and POC-BG levels vary by hospital characteristics. Increased hospital participation in data collection and reporting may facilitate the creation of a national benchmarking process for the development of best practices and improved inpatient hyperglycemia management. Journal of Hospital Medicine 2009;4:E7–E17. © 2009 Society of Hospital Medicine.

U.S. physician satisfaction: A systematic review

Abstract: INTRODUCTION: There is concern in the US about the burden and potential ramifications of dissatisfaction among physicians. The purpose of this article is to systematically review the literature on US physician satisfaction. METHODS: A MEDLINE search with the medical subject headings (MeSH) phrases: (physicians OR physician's role OR physician's women) AND (job satisfaction OR career satisfaction OR burnout), limited to humans and abstracts, with 1157 abstracts reviewed. After exclusions by 2 independent reviewers, 97 articles were included. Physician type sampled, sample size/response rate, satisfaction type, and satisfaction results were extracted for each study. Satisfaction trends were extracted from those studies with longitudinal or repeated cross sectional design. Variables associated with satisfaction were extracted from those studies that included multivariate analyses. RESULTS: Physician satisfaction was relatively stable, with small decreases primarily among primary care physicians (PCPs). The major pertinent mediating factors of satisfaction for hospitalists include both physician factors (age and specialty), and job factors (job demands, job control, collegial support, income, and incentives). CONCLUSIONS: The majority of factors associated with satisfaction are modifiable. Tangible recommendations for measuring and diminishing dissatisfaction are given. Journal of Hospital Medicine 2009;4:560–570. © 2009 Society of Hospital Medicine.

Creating a better discharge summary: Improvement in quality and timeliness using an electronic discharge summary

Abstract: BACKGROUND: Deficits in information transfer between inpatient and outpatient physicians are common and potentially dangerous. OBJECTIVE: To evaluate the effect of a newly-created electronic discharge summary. DESIGN AND PARTICIPANTS: Pre-post evaluation of discharge summaries using a survey of outpatient physicians and a medical records review. MEASUREMENTS: Outpatient physicians' ratings of satisfaction with discharge summaries before and after implementation of an electronic discharge summary using a 5-point Likert scale (1 = very dissatisfied; 5 = very satisfied). Additionally, 196 randomly selected discharge summaries before and after implementation were rated for timeliness and presence of 16 key content areas by 3 internists. RESULTS: Two hundred and twenty-six of 416 (54%) and 256 of 397 (64%) outpatient physicians completed the baseline and postimplementation surveys. Satisfaction with quality and timeliness of discharge summaries improved with the use of the electronic discharge summary (mean quality rating 3.04 versus 3.64; P < 0.001, mean timeliness rating 2.59 versus 3.34; P < 0.001). A higher percentage of electronic discharge summaries were completed within 3 days of discharge as compared with dictated discharge summaries (44.8% versus 74.1%; P < 0.001). Several elements of the discharge summary were present more often with the electronic discharge summary, including discussion of follow-up issues (52.0% versus 75.8%; P = 0.001), pending test results (13.9% versus 46.3%; P < 0.001), and information provided to the patient and/or family (85.1% versus 95.8%; P = 0.01). CONCLUSIONS: The use of an electronic discharge summary significantly improved the quality and timeliness of discharge summaries. Journal of Hospital Medicine 2009;4:219–225. © 2009 Society of Hospital Medicine.

Quantification of bedside teaching by an academic hospitalist group.

Abstract: BACKGROUND: Medical educators have raised serious concerns about the decline in bedside teaching and the effect of this decline on trainee skills. We investigated the fraction of time hospitalist attending physicians spend at the bedside during teaching rounds and how often physical examination skills are demonstrated. METHODS: In a prospective, observational study, the authors investigated the rounding behavior of members of Brigham and Women's Hospitalist Service. For 5 weeks from December 2007 to January 2008, interns and residents rotating on the hospitalist service reported in a daily e-mail (1) total time spent with their attending during attending rounds, (2) time spent inside patient rooms during attending rounds, and (3) whether or not a physical examination finding or technique was demonstrated by their hospitalist attending. RESULTS: A total of 61 observations were reported (66% response). Hospitalists spent an average of 101 minutes on teaching rounds and an average of 17 minutes inside patient rooms or 17% of their teaching time at the bedside. Bedside teaching occurred during 61% of teaching sessions and physical examination teaching occurred during 38% of teaching sessions. Rounds that included time spent at the bedside were longer on average than rounds that did not include time spent at the bedside (122 vs. 69 minutes, P < 0.001). CONCLUSIONS: Bedside teaching makes up approximately 17% of the time that hospitalists at this medical center spend on teaching rounds. Physical examination teaching has become infrequent. Research to clarify optimal strategies to improve bedside teaching and its value in patient care is needed. Journal of Hospital Medicine 2009;4:304–307. © 2009 Society of Hospital Medicine.

Improved inpatient use of basal insulin, reduced hypoglycemia, and improved glycemic control: Effect of structured subcutaneous insulin orders and an insulin management algorithm

Abstract: BACKGROUND: Structured subcutaneous insulin order sets and insulin protocols are widely advocated. The intervention effects are not well reported. OBJECTIVE: Assess the impact of these interventions on insulin use patterns, hypoglycemia, and glycemic control. DESIGN: Prospective observational. SETTING: 400-bed academic center. PATIENTS: Adult non-critical care inpatients with diabetes or hyperglycemia and point-of-care (POC) glucose testing. INTERVENTIONS: Structured insulin orders, insulin management algorithm. MEASUREMENTS: Percent of insulin orders with basal insulin. Percent uncontrolled patient-stays (day-weighted mean glucose ≥180 mg/dL) and uncontrolled patient-days (patient-day mean glucose ≥180 mg/dL). Percent of monitored patient-days and patient-stays with hypoglycemia (glucose ≤60 mg/dL) and severe hypoglycemia (glucose ≤40 mg/dL). RESULTS: The percent sliding scale only insulin regimens decreased (72% versus 26% with structured insulin orders, P < 0.0001 chi square). The percent of uncontrolled patient-days was 37.8% versus 33.9% versus 30.1% (P < 0.005) (TP1–Baseline; TP2–Structured insulin orders; TP3–Orders plus Algorithm). Expressed as relative risk with 95% confidence interval (RR with CI), the RR of an uncontrolled patient-stay was reduced from baseline to 0.91 (CI 0.85–0.96) in TP2, and to 0.84 (CI 0.77–0.89) in TP3, with more marked effects in the secondary analysis limited to patients with at least 8 POC values. The percent of patient-days with hypoglycemia was 3.8%, 2.9%, and 2.6% in 3 time periods, representing a RR for hypoglycemic day in TP3:TP1 of 0.68 (CI 0.59-0.78). Similar reductions were seen in risk for hypoglycemic patient-stays. CONCLUSIONS: Hypoglycemia and glycemic control can be improved simultaneously with structured insulin orders and management algorithms. Journal of Hospital Medicine 2009;4:3–15. © 2009 Society of Hospital Medicine.

Optimizing prevention of hospital-acquired venous thromboembolism (VTE): prospective validation of a VTE risk assessment model.

Abstract: BACKGROUND: Hospital-acquired (HA) venous thromboembolism (VTE) is a common source of morbidity/mortality Prophylactic measures are underutilized Available risk assessment models/protocols are not prospectively validated OBJECTIVES: Improve VTE prophylaxis, reduce HA VTE, and prospectively validate a VTE risk-assessment model DESIGN: Observational design SETTING: Academic medical center PATIENTS: Adult inpatients on medical/surgical services INTERVENTIONS: A simple VTE risk assessment linked to a menu of preferred VTE prophylaxis methods, embedded in order sets Education, audit/feedback, and concurrent identification of nonadherence MEASUREMENTS: Randomly sampled inpatient audits determined the percent of patients with “adequate” VTE prevention HA VTE cases were identified concurrently via digital imaging system Interobserver agreement for VTE risk level and judgment of adequate prophylaxis were calculated from 150 random audits RESULTS: Interobserver agreement with 5 observers was high (kappa score for VTE risk level = 081, and for judgment of “adequate” prophylaxis = 090) The percent of patients on adequate prophylaxis improved each of the 3 years (58%, 78%, and 93%; P < 0001) and reached 98% in the last 6 months of 2007; 361 cases of HA VTE occurred over 3 years Significant reductions for the risk of HA VTE (risk ratio [RR] = 069; 95% confidence interval [CI] = 047-079) and preventable HA VTE (RR = 014; 95% CI = 006-031) occurred We detected no increase in heparin-induced thrombocytopenia (HIT) or prophylaxis-related bleeding using administrative data/chart review CONCLUSIONS: We prospectively validated a VTE risk-assessment/prevention protocol by demonstrating ease of use, good interobserver agreement, and effectiveness Improved VTE prophylaxis resulted in a substantial reduction in HA VTE Journal of Hospital Medicine 2010;5:10–18 © 2010 Society of Hospital Medicine

Risk of venous thromboembolism in hospitalized patients with peripherally inserted central catheters.

Abstract: BACKGROUND: Peripherally inserted central catheters (PICC) are increasingly used in hospitalized patients. The benefit can be offset by complications such as upper extremity deep vein thrombosis (UEDVT). METHODS: Retrospective study of patients who received a PICC while hospitalized at the Methodist University Hospital (MUH) in Memphis, TN. All adult consecutive patients who had PICCs inserted during the study period and who did not have a UEDVT at the time of PICC insertion were included in the study. A UEDVT was defined as a symptomatic event in the ipsilateral extremity, leading to the performance of duplex ultrasonography, which confirmed the diagnosis of UEDVT. Pulmonary embolism (PE) was defined as a symptomatic event prompting the performance of ventilation-perfusion lung scan or spiral computed tomography (CT). RESULTS: Among 777 patients, 38 patients experienced 1 or more venous thromboembolisms (VTEs), yielding an incidence of 4.89%. A total of 7444 PICC-days were recorded for 777 patients. This yields a rate of 5.10 VTEs/1000 PICC-days. Compared to patients whose PICC was inserted in the SVC, patients whose PICC was in another location had an increased risk (odds ratio = 2.61 [95% CI = 1.28-5.35]) of VTE. PICC related VTE was significantly more common among patients with a past history of VTE (odds ratio = 10.83 [95% CI = 4.89-23.95]). CONCLUSIONS: About 5% of patients undergoing PICC placement in acute care hospitals will develop thromboembolic complications. Thromboembolic complications were especially common among persons with a past history of VTE. Catheter tip location at the time of insertion may be an important modifiable risk factor. Journal of Hospital Medicine 2009;4:417–422. © 2009 Society of Hospital Medicine.

Effects of a subcutaneous insulin protocol, clinical education, and computerized order set on the quality of inpatient management of hyperglycemia: Results of a clinical trial

Abstract: BACKGROUND: Inpatient hyperglycemia is associated with poor patient outcomes. It is unknown how best to implement glycemic management strategies in the non–intensive care unit (ICU) setting. OBJECTIVE: To determine the effects of a multifaceted quality improvement intervention on the management of medical inpatients with diabetes mellitus or hyperglycemia. DESIGN: Before-after trial. SETTING: Geographically localized general medical service staffed by physician's assistants (PAs) and hospitalists. PATIENTS: Consecutively enrolled patients with type 2 diabetes or inpatient hyperglycemia. INTERVENTION: A detailed subcutaneous insulin protocol, an admission order set built into the hospital's computerized order entry system, and case-based educational workshops and lectures to nurses, physicians, and PAs. MEASUREMENTS: Mean percent of glucose readings per patient between 60 and 180 mg/dL; percent patient-days with hypoglycemia; insulin use patterns; and hospital length of stay. RESULTS: The mean percent of readings per patient between 60 and 180 mg/dL was 59% prior to the intervention and 65% afterward (adjusted effect size 9.7%; 95% confidence interval [CI], 0.6%-18.8%). The percent of patient days with any hypoglycemia was 5.5% preintervention and 6.1% afterward (adjusted odds ratio 1.1; 95% CI, 0.6–2.1). Use of scheduled nutritional insulin increased from 40% to 75% (odds ratio 4.5; 95% CI, 2.0–9.9) and adjusted length of stay decreased by 25% (95% CI, 9%-44%). Daily insulin adjustment did not improve, nor did glucose control beyond hospital day 3. CONCLUSIONS: This multifaceted intervention, which was easy to implement and required minimal resources, was associated with improvements in both insulin ordering practices and glycemic control among non-ICU medical patients. Journal of Hospital Medicine 2009;4:16–27. © 2009 Society of Hospital Medicine.

Trends in catheter ablation for atrial fibrillation in the United States

Abstract: BACKGROUND: There are few data on the use of catheter ablation for atrial fibrillation (AF) in the United States. We analyzed data from the National Hospital Discharge Survey (NHDS) to examine trends in the rate of catheter ablation for hospitalized patients with AF over a 15-year period. OBJECTIVE: To examine rates of catheter ablation in patients with AF over time. DESIGN: All adult patients in the NHDS with an International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code for AF from the years 1990 to 2005 were identified and assessed for the presence of a cardiac catheter ablation procedure code. Clinical characteristics associated with ablation were identified and multivariable logistic regression used to determine trends in the rate of ablation therapy over time. RESULTS: We identified 269,471 adults with AF. The rate of catheter ablation in AF patients increased from 0.06% in 1990 to 0.79% in 2005 (P 75 years, diabetes mellitus, or stroke/transient ischemic attack (37% versus 16%; P < 0.001). Catheter ablation in AF patients increased by 15% per year over the time period (95% confidence interval [CI], 13%-16%) and across all age groups, including in patients age ≥80 years (0.0% in 1990 and 0.26% in 2005; P < 0.001 for trend). CONCLUSIONS: The rate of catheter ablation in patients with AF is increasing significantly over time, even in the oldest patients. Journal of Hospital Medicine 2009;4:E1–E5. © 2009 Society of Hospital Medicine.

PRESsed for time

Abstract: A 36-year-old woman was admitted after new-onset Hseizures. She had been diagnosed with breast cancer 5 years prior to admission. At that time, she underwent left radical mastectomy and lymph node dissection. Lymph nodes were positive for metastatic disease with negative HER-2-Neu and positive estrogen and progesterone receptors. She was treated with docetaxel and tamoxifen but subsequently developed metastatic left hip lesions and was treated with letrozole and anastrozole. Three years later, scans revealed further metastatic disease to the liver, lung, and vertebral column. She was subsequently treated with capecitabine, until further disease progression led to the use of carboplatin and paclitaxel. Seven months prior to admission, her cancer was progressing and she was switched to doxorubicin, gemcitabine, and bevacizumab. Six weeks prior to admission, both positron emission tomography (PET) and computed tomography (CT) scan of her whole body and magnetic resonance imaging (MRI) of the brain illustrated significant improvement. Her last dose of bevacizumab was given 3 weeks prior to her admission. Two weeks prior to admission, patient reported newonset daily headache. These were often localized in the occipital region. She reported some associated nausea and occasional emesis. Subsequently, she developed photophobia and phonophobia. On seeking outpatient treatment for her headache, it was noted that her systolic blood pressure had increased from a baseline of 100 mm Hg to 170 mm Hg. On the day prior to admission, she reported severe headache and several episodes of emesis and later that evening had a witnessed tonic-clonic seizure. The patient presented to an outside hospital and had an unremarkable noncontrast CT scan of her brain. An examination of her cerebrospinal fluid revealed negative gram stain, and a normal white blood cell count and protein level. She was treated with lorazepam, phenytoin, and decadron. On becoming more alert, she insisted on going home, where she later developed recurrent headache and presented to our emergency room. On admission to our service, she was noted to be confused and irritable, and unable to provide any history. Her exam revealed a blood pressure of 143/102 mmHg. No localizing neurologic signs were noted and her laboratory values were normal. After sedation, MRI of the brain was obtained (Figure 1). This revealed diffuse and patchy gyriform hyperintensity of the white matter, most consistent with posterior reversible encephalopathy syndrome (PRES). Upon reflection, the patient had new onset hypertension that coincided with the initiation and dosing of bevacizumab. Bevacizumab, an antineoplastic agent, is a recombinant humanized monoclonal antibody that binds to and neutralizes vascular endothelial growth factor, thereby preventing angiogenesis. It is known to cause grade 3 hypertension in a minority of patients. Therefore, it was postulated that the patient’s persistent blood pressure elevation resulted in vasogenic brain edema, precipitating her seizure. Subsequent to the diagnosis, her blood pressure was aggressively controlled with oral enalapril, metoprolol, triamterene/hydrochlorothiazide, and hydralazine. By hospital day 7, her headache had subsided and her altered mental status had resolved. She had no further episodes of seizures and bevacizumab was discontinued. FIGURE 1. T2-weighted MRI: multiple diffuse parenchymal brain lesions and generalized edema are noted.

Blood cultures for community‐acquired pneumonia: Are they worthy of two quality measures? A systematic review

Abstract: BACKGROUND: Obtaining blood cultures (BCs) for patients hospitalized with community-acquired-pneumonia (CAP) has been recommended by experts and used as a measure of quality of care. However, BCs are infrequently positive in these patients and their effect on clinical management has been questioned. PURPOSE: We performed a systematic review of the literature to determine the impact of BCs on clinical management in CAP requiring hospitalization and thus its appropriateness as a quality measure. DATA SOURCES: We searched MEDLINE, MEDLINE In-Process, and the Cochrane databases for English-language studies that reported the effect of BCs on management of adults hospitalized with CAP. We also searched the reference lists of included studies and background articles and asked experts to review our list for completeness. STUDY SELECTION: Studies were chosen if they included adults admitted to the hospital with CAP, BCs were obtained at admission, and BC-directed management changes were reported. DATA EXTRACTION: We abstracted study design, BC positivity, and frequency of BC-directed management changes. DATA SYNTHESIS: Fifteen studies, all with observational cohort design, were identified and reviewed. Two included only patients with BCs positive for pneumococcus, yielding 13 studies for the primary analysis. BCs were true-positive in 0% to 14% of cases. They led to antibiotic narrowing in 0% to 3% of patients and to antibiotic broadening ultimately associated with a resistant organism in 0% to 1% of patients. CONCLUSIONS: BCs have very limited utility in immunocompetent patients hospitalized with CAP. Pneumonia quality measures that include BCs should be reassessed. Journal of Hospital Medicine 2009;4:112–123. © 2009 Society of Hospital Medicine.

Diagnostic accuracy of hospitalist-performed hand-carried ultrasound echocardiography after a brief training program.

Abstract: BACKGROUND: The duration of training needed for hospitalists to accurately perform hand-carried ultrasound echocardiography (HCUE) is uncertain. OBJECTIVE: To determine the diagnostic accuracy of HCUE performed by hospitalists after a 27-hour training program. DESIGN: Prospective cohort study. SETTING: Large public teaching hospital. PATIENTS: A total of 322 inpatients referred for standard echocardiography (SE) between March and May 2007. INTERVENTION: Blinded to SE results, attending hospitalist physicians performed HCUE within hours of SE. MEASUREMENTS: Diagnostic characteristics of HCUE as a test for 6 cardiac abnormalities assessed by SE: left ventricular (LV) systolic dysfunction; severe mitral regurgitation (MR); moderate or severe left atrium (LA) enlargement; moderate or severe LV hypertrophy; medium or large pericardial effusion; and dilatation of the inferior vena cava (IVC). RESULTS: A total of 314 patients underwent both SE and HCUE within a median time of 2.8 hours (25th to 75th percentiles, 1.4 to 5.1 hours). Positive and negative likelihood ratios for HCUE increased and decreased, respectively, the prior odds by 5-fold or more for LV systolic dysfunction, severe MR regurgitation, and moderate or large pericardial effusion. Likelihood ratios changed the prior odds by 2-fold or more for moderate or severe LA enlargement, moderate or severe LV hypertrophy, and IVC dilatation. Indeterminate HCUE results occurred in 2% to 6% of assessments. CONCLUSIONS: The diagnostic accuracy of HCUE performed by hospitalists after a brief training program was moderate to excellent for 6 important cardiac abnormalities. Journal of Hospital Medicine 2009;4:340–349. © 2009 Society of Hospital Medicine.

Inpatient thromboprophylaxis use in U.S. hospitals: adherence to the seventh American College of Chest Physician's recommendations for at-risk medical and surgical patients.

Abstract: BACKGROUND: The clinical venous thromboembolism (VTE) burden remains high in the United States, despite guidelines recommending that safe and effective VTE prophylaxis be available. This study assesses the real-world rate of appropriate inpatient VTE prophylaxis in hospitalized U.S. medical and surgical patients at risk of VTE, in accordance with the seventh American College of Chest Physicians, (ACCP) guidelines. METHODS: Medical and surgical discharges from Premier's Perspective™ database between January 1, 2005 and December 31, 2006 were considered. Discharges aged ≥40 years, with a length of stay ≥6 days, at risk of VTE due to the presence of ≥1 VTE risk factors identified by the seventh ACCP guidelines, and without contraindications for anticoagulation, were included in the analysis. Appropriate prophylaxis was determined by comparing the daily use, dosage, and duration of anticoagulants and compression devices with the seventh ACCP recommendations for each medical condition or surgical procedure. RESULTS: A total of 390,024 discharges met the inclusion criteria, of which 201,224 (51.6%) were medical discharges and 188,800 (48.4%) were surgical discharges. Overall, 65.9% of medical discharges and 77.7% of surgical discharges received at least 1 order for VTE prophylaxis during hospitalization. However, only 12.7% of medical discharges and 16.4% of surgical discharges received appropriate prophylaxis when the recommended prophylaxis type, dose, and duration from the seventh ACCP guidelines were taken into account. CONCLUSIONS: Few medical and surgical patients at high risk of VTE receive appropriate inpatient prophylaxis in accordance with guideline recommendations. It is important for individual hospitals to improve VTE prophylaxis practices to meet national performance initiatives. Journal of Hospital Medicine 2009;4:E15–E21. © 2009 Society of Hospital Medicine.

Lack of patient knowledge regarding hospital medications

Abstract: BACKGROUND: Patient involvement in preventing inpatient medication errors is predicated upon patient knowledge of their medications. However, there is little published on the accuracy of patient knowledge or understanding of their hospital medications. OBJECTIVE: To assess hospitalized patients' knowledge of their hospital medications and attitudes towards involvement in the medication safety process while hospitalized. METHODS: A cross-sectional study of 50 adult internal medicine inpatients at the University of Colorado Hospital. Patients completed a list of the hospital medications they believed were prescribed to them and a survey of attitudes toward involvement in the medication safety process. The patient-completed hospital medication list was compared to the hospital medication administration record. RESULTS: Ninety-six percent of study patients omitted at least one prescribed hospital medication. On average, patients omitted 6.8 hospital medications. Forty-four percent of patients believed they were receiving at least one hospital medication that was not actually prescribed. Patients < 65 years old omitted 60% of their as needed (PRN) medications whereas patients ≥ 65 years old omitted 88% (P = 0.01). Only 28% reported having seen their hospital medication list, although 81% reported this would improve their satisfaction with hospital care. Ninety percent wanted to review their hospital medication list for accuracy and 94% felt patient review of the hospital medication list had the potential to reduce errors. CONCLUSIONS: Our findings suggest that, in contrast to patient preferences, there are significant deficits in patients' knowledge of hospital medications. These results are a call to reexamine how we educate patients regarding their hospital medications. Journal of Hospital Medicine 2010;5:83–86. © 2010 Society of Hospital Medicine.

Decrease in as-needed sedative use by limiting nighttime sleep disruptions from hospital staff.

Abstract: BACKGROUND: Hospital routines frequently interrupt nighttime sleep. Sedatives promote sleep, but increase the risk of delirium and falls. Few interventional trials have studied sleep promotion in medical-surgical units and little is known about its impact on sedative use. OBJECTIVE: To determine causes of sleep disruption, and assess whether decreasing sleep disruptions lowers sedative use in medical-surgical patients. DESIGN AND SETTING: Interventional trial with historical controls on a medical-surgical unit of a community teaching hospital. Nurses, physicians, and patients were blinded to the measurement of as-needed sedative use. PATIENTS: Consecutive eligible adults (n = 161 preintervention patients, n = 106 intervention patients). INTERVENTION: We developed the “Somerville Protocol,” which included the establishment of an 8-hour “Quiet Time” that began with automated lights-off and lullaby; staff-monitored noise; and avoidance of waking of patients for routine vital signs and medications. MEASUREMENTS: As-needed sedative use, responses to a patient questionnaire, and responses to a modified Verran Snyder-Halpern (VSH) sleep scale. RESULTS: Preintervention, “hospital staff “ was the disturbance most likely to keep patients awake. The intervention decreased the proportion of patients reporting it from 42% to 26%, a 38% reduction (P = 0.009; 95% confidence interval [CI]: 0.0452-0.2765). Preintervention, 32% of patients received as-needed sedatives, compared to 16% with the intervention, a 49% reduction (P = 0.0041; 95% CI: 0.056-0.26), with a 62% decrease in patients over age 64 years (P = 0.005). VSH scores were unchanged. CONCLUSIONS: Small modifications in hospital routines, especially in the timing of vital signs and routine medication administration, can significantly reduce sedative use in unselected hospital patients. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine.

Medical admission order sets to improve deep vein thrombosis prophylaxis rates and other outcomes

Abstract: BACKGROUND: The value of order sets for clinical decision support has not been established. OBJECTIVE: To determine whether introduction of admission order sets increases the proportion of inpatients receiving deep venous thrombosis (DVT) prophylaxis. DESIGN: Before-after study. SETTING: Community hospital. PATIENTS: General medical patients admitted to hospital. INTERVENTION: Paper-based admission order sets (instead of free-text orders) for voluntary use by internists, without any education or behavior change interventions. MEASUREMENTS: Primary outcome was proportion of medical admissions ordered DVT prophylaxis. Secondary outcomes included overall utilization of DVT prophylaxis in medical inpatients and other admission order care quality measures. RESULTS: Prior to introduction of order sets, DVT prophylaxis was ordered in 10.9% of patients. Patients admitted with order sets were more likely to be ordered DVT prophylaxis than patients admitted with free-text orders (44.0% versus 20.6%, by months 14 and 15, P < 0.0001). Hospital-wide DVT prophylaxis in medical inpatients increased from 12.8% to 25.8% of patient-days (P < 0.0001). Order set use improved many other secondary outcomes (P < 0.05 for all), including allied health consultations (62.8% versus 12.7%), use of standardized diabetic diet (17.0% versus 5.1%), insulin sliding scale (19.1% versus 7.6%), potassium replacement protocol (63.8% versus 0.51%), documentation of allergies (54.3% versus 9.6%) and resuscitation status (57.4% versus 10.2%), and reduced orders for inappropriate laboratory tests such as blood urea nitrogen (39.4% versus 59.0%). CONCLUSIONS: The broad impact of order sets and minimal organizational resources required for their implementation suggests that order sets may have wide applicability as a clinical decision support tool. Journal of Hospital Medicine 2009;4:81–89. © 2009 Society of Hospital Medicine.

Perceptions of resident physicians about management of inpatient hyperglycemia in an urban hospital.

Abstract: BACKGROUND: Information regarding practitioner beliefs about inpatient diabetes care is limited. OBJECTIVE: To assess resident physician attitudes about inpatient hyperglycemia and determine perceived barriers to optimal glycemic control in an urban hospital setting. DESIGN: A previously developed questionnaire was modified and administered. Residents were asked about the importance of inpatient glucose control, desirable glucose ranges, and problems encountered when managing hyperglycemia. SETTING: Urban teaching hospital. RESULTS: Of 85 resident physicians, 66 completed the survey (mean age, 31 years; 47% men; 33% in first residency year). Most respondents categorized glucose control as “very important” in critically-ill and perioperative patients but only “somewhat important” in non-critically-ill patients. Most residents said they would target a therapeutic glucose range within the recommended levels. Most residents (88%) also said they felt “very comfortable” or “somewhat comfortable” using subcutaneous insulin therapy, whereas some were “not at all comfortable” with either subcutaneous (11%) or intravenous (18%) administration. In general, respondents were not very familiar with existing institutional policies and preprinted order sets. The most commonly reported barrier to management of inpatient hyperglycemia was lack of knowledge about appropriate insulin regimens and their use. Anxiety about hypoglycemia was only the third most frequent concern. CONCLUSION: Most residents acknowledged the importance of good glucose control in hospitalized patients and chose target glucose ranges consistent with existing guidelines. Lack of knowledge about insulin treatment options was the most commonly cited barrier to ideal management. Educational programs should emphasize inpatient treatment strategies for glycemic control. Journal of Hospital Medicine 2009;4:E1–E8. © 2009 Society of Hospital Medicine.

Evaluation of hospital glycemic control at US academic medical centers.

Abstract: OBJECTIVE: To evaluate contemporary hospital glycemic management in US academic medical centers. DESIGN: This retrospective cohort study was conducted on patients discharged from 37 academic medical centers between July 1 and September 30, 2004; 1,718 eligible adult patients met at least 1 of the inclusion criteria: 2 consecutive blood glucose readings >180 mg/dL within 24 hours, or insulin treatment at any time during hospitalization. We assessed 3 consecutive measurement days of glucose values, glycemic therapy, and additional clinical and laboratory characteristics. RESULTS: In this diverse cohort, 79% of patients had a prior diagnosis of diabetes, and 84.6% received insulin on the second measurement day. There was wide variation in hospital performance of recommended hospital diabetes care measures such as glycosylated hemoglobin (A1C) assessment (range, 3%–63%) and timely admission laboratory glucose measurement (range, 39%–97%). Median glucose was significantly lower for patients in the intensive care unit (ICU) compared to ward/intermediate care. ICU patients treated with intravenous insulin had significantly lower median glucose when compared to subcutaneous insulin. Only 25% of ICU patients on day 3 had estimated 6 AM glucose ≤110 mg/dL. Hyperglycemia was common, 50% of all patients had ≥1 glucose measurement ≥180 mg/dL on measurement days 2 and 3. Severe hypoglycemia (<50 mg/dL) occurred in 2.8% of all patient days. CONCLUSIONS: Despite frequent insulin use, glucose control was suboptimal. Academic medical centers have opportunities to improve care to meet current American Diabetes Association hospital diabetes care standards. Journal of Hospital Medicine 2009;4:35–44. © 2009 Society of Hospital Medicine.

Prevalence of previously unknown elevation of glycosylated hemoglobin in spine surgery patients and impact on length of stay and total cost.

Abstract: BACKGROUND: Elevated levels of glycosylated hemoglobin (HbA1c) among spine surgery patients may have an impact on length of stay (LOS) and healthcare cost. MATERIALS AND METHODS: We retrospectively reviewed the charts of 556 spine surgery patients who underwent 1 of 3 types of surgery: lumbar microdiscectomy (LMD), anterior cervical decompression and fusion (ACDF), and lumbar decompression and fusion (LDF). Information was collected about their diabetes mellitus (DM) history and HbA1c levels. We used HbA1c 6.1% as the screening cutpoint. Percentages of nondiabetic patients, those with subclinical elevation of HbA1c and those with already known DM were calculated and statistical analysis was applied. RESULTS: After excluding the small group of well-controlled DM (n = 14), 72.4% of patients were nondiabetic, 14.3% were subclinical patients with previously unknown HbA1c elevation, and 13.3% were already known, confirmed DM patients. There were significant differences in the LDF group between the “No DM” and “Subclinical” groups (P 0.05) in determining cost. CONCLUSIONS: There is a significant segment of spine surgery patients who were unaware of their elevated HbA1c status before their preoperative visit. These patients seem to utilize more healthcare resources, which is especially evident in the LDF group. We believe that HbA1c should be considered in the routine preoperative workup of spine surgery patients. Journal of Hospital Medicine 2010;5:E10–E14. © 2010 Society of Hospital Medicine.

Retrievable vena cava filters: A clinical review

Abstract: Vena cava filters were developed as a method of preventing pulmonary embolism (PE) in patients with venous thromboembolism (VTE) at risk for bleeding from therapeutic anticoagulation. However, the long-term complications of filter placement, such as caval thrombosis, have mitigated some of the benefits, particularly in those patients with only a temporary contraindication to anticoagulation. Retrievable filters were designed to avoid the long-term risks of a permanent filter while still providing short-term protection against PE. As a result, their use has expanded from patients with known thrombosis to those without VTE who are at high risk for developing PE. In this review, we discuss the different types of retrievable filters, indications for their placement, complications that can occur during and after placement, and their use as prophylaxis in surgical patients. Although the use of retrievable filters in patients with known VTE is clear, further studies are needed to establish their prophylactic efficacy in the surgical patient. Until this evidence is available, we recommend that retrievable filters should be used only in patients with acute VTE who are at risk for recurrent thromboembolism and have a transient risk for bleeding.

Enhanced end-of-life care associated with deploying a rapid response team: a pilot study.

Abstract: HYPOTHESIS: Institution of a rapid response team (RRT) improves patients' quality of death (QOD). SETTING: A 425-bed community teaching hospital. PATIENTS: All medical-surgical patients whose end-of-life care was initiated on the hospital wards during the 8 months before (pre-RRT) and after (post-RRT) actuation. STUDY DESIGN: Retrospective cohort study. METHODS: Medical records of all patients were reviewed using a uniform data abstraction tool. Demographic information, diagnoses, physiologic and laboratory data, and outcomes were recorded. RESULTS: A total of 197 patients died in both the pre-RRT and post-RRT periods. There were no differences in age, sex, advance directives, ethnicity, or religion between groups. Restorative outcomes, including in-hospital mortality (27 vs. 30/1000 admissions), unexpected transfers to intensive care (17 vs. 19/1000 admissions) and cardiac arrests (3 vs. 2.5/1000 admissions) were similar during the 2 periods. Outcomes, including formal comfort care only orders (68 vs. 46%), administration of opioids (68 vs. 43%), pain scores (3.0 ± 3.5 vs. 3.7 ± 3.2), patient distress (26 vs. 62%), and chaplain visits (72 vs. 60%), were significantly better in the post-RRT period compared to the pre-RRT period (all P < 0.05). During the post-RRT period, 61 patients died with RRT care and 136 died without RRT care. End-of-life care outcomes were similar for these groups except more RRT patients had chaplain visits proximate to their deaths (80% vs. 68%; P = 0.0001). CONCLUSIONS: Institution of an RRT in our hospital had negligible impact on outcomes of patients whose goal was restorative care. Deployment of the RRT was associated with generally improved end-of-life pain management and psychosocial care. Journal of Hospital Medicine 2009;4:449–452. © 2009 Society of Hospital Medicine.

Pediatric hospitalists: training, current practice, and career goals.

Abstract: OBJECTIVE: To determine the range and frequency of experiences, clinical and nonclinical roles, training, work expectations, and career plans of practicing pediatric hospitalists. DESIGN: Mail survey study of a national sample of 530 pediatric hospitalists of whom 67% (N 5 338) were from teaching hospitals, 71% (N 5 374) were from children’s hospitals, 43% (N 5 230) were from freestanding children’s hospitals, and 69% (N 5 354) were from hospitals with � 250 beds. RESULTS: The response rate was 84%. The majority (54%; N 5 211) had been practicing as hospitalists for at least 3 years. Most reported that the pediatric inpatient unit (94%) and inpatient consultation service (51%) were a part of their regular clinical assignment. Most did not provide service in the normal newborn nursery (58%), subspecialty inpatient service (52%), transports (85%), outpatient clinics (66%), or as part of an emergency response team (53%). Many participated in quality improvement (QI) initiatives (84%) and practice guideline development (81%). CONCLUSIONS: This study provides the most comprehensive information available regarding the clinical and nonclinical roles, training, work expectations, and career plans of pediatric hospitalists. However, the field is currently a moving target; there is significant flux in the hospitalist workforce and variation in the roles of these professionals in their clinical and nonclinical work environment. Journal of Hospital Medicine 2009;4:179–186. V C 2009 Society of Hospital Medicine.

Communication and information deficits in patients discharged to rehabilitation facilities: An evaluation of five acute care hospitals†

Abstract: BACKGROUND: The quality of discharge documentation in patients discharged to rehabilitation centers and other subacute facilities is less well studied than that of patients discharged home. OBJECTIVE: To evaluate the quality of information transfer among patients discharged from acute hospitals to subacute facilities across an integrated healthcare delivery system. DESIGN: Retrospective evaluation of discharge documentation packets of selected patients. SETTING: Five acute care hospitals of the Partners Healthcare System. MEASUREMENTS: We measured the presence of specific data elements required to safely care for patients after discharge, including all data elements required by the Joint Commission on Accreditation of Healthcare Organizations (TJC). RESULTS: A total of 1501 discharge documentation packets were reviewed from March 2005 through June 2007. Only 1055 (70.3%) discharge summaries had all the information required by TJC, with physical examination at admission and condition at discharge most often missing (in 11.4% and 14.2% of cases, respectively). Other deficiencies not mandated by TJC included a list of preadmission medications (missing in 20.3%) and reasons for changes in these medications at discharge (35.3%), mention of pending test results (47.2%), and postdischarge management and follow-up plans (11.1%). CONCLUSIONS: We found room for improvement in the inclusion of data elements required for the safe transfer of patients from acute hospitals to subacute facilities, especially in areas such as medication reconciliation, pending test results, and adequate follow-up plans. Journal of Hospital Medicine 2009;4:E28–E33. © 2009 Society of Hospital Medicine.

Improving internal medicine residents' performance, knowledge, and confidence in central venous catheterization using simulators

Abstract: BACKGROUND: Efficacy of simulators in teaching central venous catheterization (CVC) in an internal medicine residency program is unknown. OBJECTIVE: To determine whether or not learning CVC on simulators is associated with improvement in performance of CVC, knowledge about the procedure, and self-reported confidence. METHODS: All consenting first-year internal medicine residents who completed training in CVC on simulators were included. Participants were evaluated pre- and post-training by video-recorded CVC insertion and multiple-choice knowledge assessments. Procedural technique was rated in a blinded fashion by two independent adjudicators. Knowledge retention and self-reported confidence were reassessed at 18 months. MEASUREMENTS: Primary outcome of CVC performance was assessed based on global rating score (minimum 1, maximum 5). Secondary measures include checklist score (out of ten), knowledge score and self-reported confidence (6-point Likert scale ranging from “none” to “complete”). RESULTS: Median global rating scores in 30 participants increased from 3.5 (IQR = 3-4) to 4.5 (IQR = 4-4.5) (P < 0.001). Checklist score increased from 9 (IQR = 6-9.5) to 9.5 (IQR = 9-9.5) (P < 0.001). Knowledge score increased from 65.7 ± 11.9% to 81.2 ± 10.7% (P < 0.001). Confidence increased from 3 (“moderate”, IQR = 2-3) to 4 (“good”, IQR=3-4) (P < 0.001). Sixteen participants completed the retention tests. Improvement in knowledge score and confidence at 18 months was retained compared with baseline (P = 0.002 and P < 0.0001 respectively). CONCLUSIONS: Use of simulators in teaching CVC in an internal medicine residency program results in improved procedural performance, knowledge, and self-reported confidence. Improvement in knowledge and confidence was retained at 18 months. Journal of Hospital Medicine 2009;4:410–416. © 2009 Society of Hospital Medicine.

Understanding communication during hospitalist service changes: a mixed methods study.

Abstract: BACKGROUND: Little data exist to inform hospitalist communication during service changes. OBJECTIVE: To characterize hospitalist handoffs during service changes. DESIGN: Serial survey study. SETTING: Single academic medical center. MEASUREMENTS: From May to December 2007, 60 service changes among 17 hospitalists on a nonteaching service were targeted for evaluation using an anonymous 18-item survey that was completed by hospitalists within 48 hours of assuming care for patients. Survey items assessed completeness of handoff communication, certainty of patient care plans, missed information, time spent recovering information, and near misses/adverse events due to incomplete handoffs. The association between completeness of communication and handoff outcomes was examined. Narrative comments were analyzed qualitatively. RESULTS: Ninety-three percent (56/60) of surveys were returned. All 17 hospitalists participated. Thirteen percent of respondents reported incomplete handoffs and 18% were uncertain of care plan on transition day. At least 1 near miss, attributable to incomplete communication was reported by 16%. Hospitalists who reported incomplete handoffs were more likely to report uncertainty about patient care plans on the transition day (71% incomplete vs. 10% complete, P < 0.01), discovery of missing information (71% incomplete vs. 24% complete, P = 0.01), near misses/adverse events (57% incomplete vs. 10% complete, P < 0.01), and more time resolving issues arising from missed information (71% incomplete vs. 22% complete, P < 0.01). Qualitative comments suggest the need for a more systematic, focused, team-based, and patient-centered handoff model. CONCLUSIONS: Incomplete handoffs during service changes are associated with uncertainty and potential patient harm. Suggestions to improve the completeness of hospitalist service change communications are offered. Journal of Hospital Medicine 2009;4:535–540. © 2009 Society of Hospital Medicine.

The devil is in the details.

Abstract: The approach to clinical conundrums by an expert clinician is revealed through presentation of an actual patient's case in an approach typical of morning report. Similar to patient care, sequential pieces of information are provided to the clinician who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant.