Showing papers in "Journal of Hospital Medicine in 2011"
TL;DR: Readmission of general medicine patients within 30 days is common and associated with several easily identifiable clinical and nonclinical factors, which can allow providers to target interventions to reduce potentially avoidable readmissions.
Abstract: Background Readmissions are costly both financially for our healthcare system and emotionally for our patients. Identifying factors that increase risk for readmissions may be helpful to focus resources to optimize the discharge process and reduce avoidable readmissions. Objective To identify factors associated with readmission within 30 days for general medicine patients. Methods We performed a retrospective observational study of an administrative database at an urban 550-bed tertiary care academic medical center. Cohort patients were discharged from the general medicine service over a 2-year period from June 1, 2006, to May 31, 2008. Clinical, operational, and sociodemographic factors were evaluated for association with readmission. Results Our cohort included 10,359 consecutive admissions (6805 patients) discharged from the general medicine service. The 30-day readmission rate was 17.0%. In multivariate analysis, factors associated with readmission included black race (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.24-1.65), inpatient use of narcotics (1.33; 1.16-1.53) and corticosteroids (1.24; 1.09-1.42), and the disease states of cancer (with metastasis 1.61; 1.33-1.95; without metastasis 1.95; 1.54-2.47), renal failure (1.19; 1.05-1.36), congestive heart failure (1.30; 1.09-1.56), and weight loss (1.26; 1.09-1.47). Medicaid payer status (1.15; 0.97-1.36) had a trend toward readmission. Conclusion Readmission of general medicine patients within 30 days is common and associated with several easily identifiable clinical and nonclinical factors. Identification of these risk factors can allow providers to target interventions to reduce potentially avoidable readmissions.
219 citations
TL;DR: A risk-standardized measure of hospital readmission rates derived from administrative claims has similar performance characteristics to one based on medical record review.
Abstract: BACKGROUND:
Readmission following hospital discharge has become an important target of quality improvement.
OBJECTIVE:
To describe the development, validation, and results of a risk-standardized measure of hospital readmission rates among elderly patients with pneumonia employed in federal quality measurement and efficiency initiatives.
DESIGN:
A retrospective cohort study using hospital and outpatient Medicare claims from 2005 and 2006.
SETTING:
A total of 4675 hospitals in the United States.
PATIENTS:
Medicare beneficiaries aged >65 years with a principal discharge diagnosis of pneumonia.
INTERVENTION:
None.
MEASUREMENTS:
Hospital-specific, risk-standardized 30-day readmission rates calculated as the ratio of predicted-to-expected readmissions, multiplied by the national unadjusted rate. Comparison of the areas under the receiver operating curve (ROC) and measurement of correlation coefficient in development and validation samples.
RESULTS:
The development sample consisted of 226,545 hospitalizations at 4675 hospitals, with an overall unadjusted 30-day readmission rate of 17.4%. The median risk-standardized hospital readmission rate was 17.3%, and the odds of readmission for a hospital one standard deviation above average was 1.4 times that of a hospital one standard deviation below average. Performance of the medical record and administrative models was similar (areas under the ROC curve 0.59 and 0.63, respectively) and the correlation coefficient of estimated state-specific standardized readmission rates from the administrative and medical record models was 0.96.
CONCLUSIONS:
Rehospitalization within 30 days of treatment for pneumonia is common, and rates vary across hospitals. A risk-standardized measure of hospital readmission rates derived from administrative claims has similar performance characteristics to one based on medical record review. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine
156 citations
TL;DR: In this high-risk patient group, multiple chronic conditions are common and predict increased risk of readmission, and post-hospital interventions should consider targeting nutritional and mood status in this population.
Abstract: BACKGROUND:
Hospital readmissions are common and costly. A recent previous hospitalization preceding the index admission is a marker of increased risk of future readmission.
OBJECTIVES:
To identify factors associated with an increased risk of recurrent readmission in medical patients with 2 or more hospitalizations in the past 6 months.
DESIGN:
Prospective cohort study.
SETTING:
Australian teaching hospital acute medical wards, February 2006-February 2007.
PARTICIPANTS:
142 inpatients aged ≥50 years with a previous hospitalization ≤6 months preceding the index admission. Patients from residential care, with terminal illness, or with serious cognitive or language difficulties were excluded.
VARIABLES OF INTEREST:
Demographics, previous hospitalizations, diagnosis, comorbidities and nutritional status were recorded in hospital. Participants were assessed at home within 2 weeks of hospital discharge using validated questionnaires for cognition, literacy, activities of daily living (ADL)/instrumental activities of daily living (IADL) function, depression, anxiety, alcohol use, medication adherence, social support, and financial status.
MAIN OUTCOME MEASURE:
Unplanned readmission to the study hospital within 6 months.
RESULTS:
A total of 55 participants (38.7%) had a further unplanned hospital admission within 6 months. In multivariate analysis, chronic disease (adjusted odds ratio [OR] 3.4; 95% confidence interval [CI], 1.3-9.3, P = 0.002), depressive symptoms (adjusted OR, 3.0; 95% CI, 1.3-6.8, P = 0.01), and underweight (adjusted OR, 12.7; 95% CI, 2.3-70.7, P = 0.004) were significant predictors of readmission after adjusting for age, length of stay and functional status.
CONCLUSIONS:
In this high-risk patient group, multiple chronic conditions are common and predict increased risk of readmission. Post-hospital interventions should consider targeting nutritional and mood status in this population. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine.
149 citations
TL;DR: While Joint Commission-accredited hospitals had larger gains over time, and were significantly more likely to have high performance in 2008 on 13 out of 16 standardized clinical performance measures and all summary scores, these differences became significantly more pronounced over 5 years of observation.
Abstract: BACKGROUND:
Evaluations of the impact of hospital accreditation have been previously hampered by the lack of nationally standardized data. One way to assess this impact is to compare accreditation status with other evidence-based measures of quality, such as the process measures now publicly reported by The Joint Commission and the Centers for Medicare and Medicaid Services (CMS).
OBJECTIVES:
To examine the association between Joint Commission accreditation status and both absolute measures of, and trends in, hospital performance on publicly reported quality measures for common diseases.
DESIGN, SETTING, AND PATIENTS:
Performance data for 2004 and 2008 from U.S. acute care and critical access hospitals were obtained using publicly available CMS Hospital Compare data augmented with Joint Commission performance data.
MEASUREMENTS:
Changes in hospital performance between 2004 and 2008, and percent of hospitals with 2008 performance exceeding 90% for 16 measures of quality-of-care and 4 summary scores.
RESULTS:
Hospitals accredited by The Joint Commission tended to have better baseline performance in 2004 than non-accredited hospitals. Accredited hospitals had larger gains over time, and were significantly more likely to have high performance in 2008 on 13 out of 16 standardized clinical performance measures and all summary scores.
CONCLUSIONS:
While Joint Commission-accredited hospitals already outperformed non-accredited hospitals on publicly reported quality measures in the early days of public reporting, these differences became significantly more pronounced over 5 years of observation. Future research should examine whether accreditation actually promotes improved performance or is a marker for other hospital characteristics associated with such performance. Journal of Hospital Medicine 2011;6:458–465. © 2011 Society of Hospital Medicine
128 citations
TL;DR: No statistically significant differences were found in bacterial or methicillin-resistant Staphylococcus aureus contamination of physicians' white coats compared with newly laundered short-sleeved uniforms or in contamination of the skin at the wrists of physicians wearing either garment.
Abstract: BACKGROUND:
Governmental agencies in the United Kingdom and Scotland have recently instituted guidelines banning physicians' white coats and the wearing of long-sleeved garments to decrease nosocomial transmission of bacteria.
OBJECTIVE:
Our aim was to compare the degree of bacterial and methicillin-resistant Staphylococcus aureus contamination of physicians' white coats with that of newly laundered, standardized short-sleeved uniforms after an 8-hour workday and to determine the rate at which bacterial contamination of the uniform ensued.
DESIGN:
The design was a prospective, randomized controlled trial.
SETTING:
The setting was a university-affiliated public safety-net hospital.
PARTICIPANTS:
One hundred residents and hospitalists on an internal medicine service participated.
INTERVENTION:
Subjects wore either a physician's white coat or a newly laundered short-sleeved uniform.
MEASUREMENTS:
Bacterial colony count and the frequency with which methicillin-resistant Staphylococcus aureus was cultured from both garments over time were measured.
RESULTS:
No statistically significant differences were found in bacterial or methicillin-resistant Staphylococcus aureus contamination of physicians' white coats compared with newly laundered short-sleeved uniforms or in contamination of the skin at the wrists of physicians wearing either garment. Colony counts of newly laundered uniforms were essentially zero, but after 3 hours of wear they were nearly 50% of those counted at 8 hours.
CONCLUSIONS:
Bacterial contamination occurs within hours after donning newly laundered short-sleeved uniforms. After 8 hours of wear, no difference was observed in the degree of contamination of uniforms versus infrequently laundered white coats. Our data do not support discarding long-sleeved white coats for short-sleeved uniforms that are changed on a daily basis. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.
119 citations
TL;DR: Evidence suggests that good antimicrobial stewardship can lead to less overall and inappropriate antimicrobial use, lower drug-related costs, reductions in Clostridium difficile-associated disease, and, in some studies, less emergence of antimicrobial resistance.
Abstract: Antibiotic stewardship aims to improve patient care and reduce unwanted consequences of antimicrobial overuse or misuse, including lowered efficacy, emergence of antimicrobial resistance, development of secondary infections, adverse drug reactions, increased length of hospital stay, and additional healthcare costs. Recent guidelines make specific recommendations for the development of institutional programs to enhance antimicrobial stewardship. Optimally, such programs should be comprehensive, multidisciplinary, supported by hospital and medical staff leadership, and should employ evidence-based strategies that best fit local needs and resources. An infectious diseases physician and clinical pharmacist with infectious diseases training are recommended as core members of the multidisciplinary team, although a hospitalist with interest (and perhaps additional training) in antimicrobial therapy may be able to fill the void. Program directors and core members should be compensated for their time. Principal proactive strategies--with evidence supporting their consideration--include prospective audits, with intervention and feedback, formulary restriction, and preauthorization. Other strategies include persistent one-on-one education, guidelines adapted to local needs, and informatics to support clinical decision making. Intervention goals are to prevent unnecessary antimicrobial starts, to streamline or de-escalate therapy early in its course, and to convert from parenteral to oral therapy, optimize dosing, and ensure the appropriate length of therapy. Most community hospitals, if sufficiently resourced, should be able to implement a successful antimicrobial stewardship program. Evidence suggests that good antimicrobial stewardship can lead to less overall and inappropriate antimicrobial use, lower drug-related costs, reductions in Clostridium difficile-associated disease, and, in some studies, less emergence of antimicrobial resistance.
91 citations
TL;DR: SIDR had a positive effect on nurses' ratings of collaboration and teamwork on a hospitalist unit, yet no impact on LOS and cost and further study is required to assess the impact of SIDR on patient safety measures.
Abstract: BACKGROUND:
Effective collaboration and teamwork is essential in providing safe and effective care. Research reveals deficiencies in teamwork on medical units involving hospitalists.
OBJECTIVE:
The aim of this study was to assess the impact of an intervention, Structured Inter-Disciplinary Rounds (SIDR), on nurses' ratings of collaboration and teamwork.
METHODS:
The study was a controlled trial involving an intervention and control hospitalist unit. The intervention, SIDR, combined a structured format for communication with a forum for regular interdisciplinary meetings. We asked nurses to rate the quality of communication and collaboration with hospitalists using a 5-point ordinal scale. We also assessed teamwork and safety climate using a validated instrument. Multivariable regression analyses were used to assess the impact on length of stay (LOS) and cost using both a concurrent and historic control.
RESULTS:
A total of 49 of 58 (84%) nurses completed surveys. A larger percentage of nurses rated the quality of communication and collaboration with hospitalists as high or very high on the intervention unit compared to the control unit (80% vs. 54%; P = 0.05). Nurses also rated the teamwork and safety climate significantly higher on the intervention unit (P = 0.008 and P = 0.03 for teamwork and safety climate, respectively). Multivariable analyses demonstrated no difference in the adjusted LOS and an inconsistent effect on cost.
CONCLUSIONS:
SIDR had a positive effect on nurses' ratings of collaboration and teamwork on a hospitalist unit, yet no impact on LOS and cost. Further study is required to assess the impact of SIDR on patient safety measures. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine.
87 citations
TL;DR: Key barriers to medication reconciliation are unreliable sources of medication information and tasks that compete for providers' time and attention that they consider higher priority that might improve medication reconciliation and its outcomes.
Abstract: BACKGROUND:
Medication reconciliation can prevent medication errors and harm when patients transition between hospital and other care settings. Though a Joint Commission hospital Patient Safety Goal since 2006, organizations continue to have difficulty implementing the process.
OBJECTIVE:
To determine factors that influence performance of medication reconciliation in a hospital setting with a computerized medication reconciliation tool.
DESIGN:
Cognitive task analysis (CTA) and focus group interviews.
SETTING:
Urban, academic, tertiary-care Veterans Affairs medical center.
PARTICIPANTS:
Internal medicine house staff physicians (n = 23) and inpatient staff pharmacists (n = 12).
MEASUREMENTS:
CTA participants verbalized their thoughts while they completed medication reconciliation with the computerized tool. Focus group participants described medication reconciliation's purpose and effectiveness, how they completed the task, and its barriers and facilitators. Interviews were recorded and analyzed using social science methods for analyzing qualitative data.
RESULTS:
Participants agreed that a central goal of medication reconciliation is to prevent prescribing errors, but disagreed about whether it achieves this goal. Computerization facilitated the task, but participants said that computers and patients can be unreliable sources of information. Participants varied in how they sequenced components of the task. When time was limited, physicians considered other responsibilities higher priority. Both physicians and pharmacists expressed low self-efficacy, ie, low perceived capability to achieve the objectives of the process.
CONCLUSION:
Key barriers to medication reconciliation are unreliable sources of medication information and tasks that compete for providers' time and attention that they consider higher priority. Addressing these barriers while increasing providers' self-efficacy might improve medication reconciliation and its outcomes. Journal of Hospital Medicine 2011;6:329–337. © 2011 Society of Hospital Medicine
86 citations
TL;DR: Automated bed history data is employed to examine outcomes of intra-hospital transfers using all hospital admissions as the denominator to find patients transferred to higher level of care following admission to the hospital have excess mortality and LOS.
Abstract: BACKGROUND:
Patients who experience intra-hospital transfers to a higher level of care (eg, ward to intensive care unit [ICU]) are known to have high mortality. However, these findings have been based on single-center studies or studies that employ ICU admissions as the denominator.
OBJECTIVE:
To employ automated bed history data to examine outcomes of intra-hospital transfers using all hospital admissions as the denominator.
DESIGN:
Retrospective cohort study.
SETTING:
A total of 19 acute care hospitals.
PATIENTS:
A total of 150,495 patients, who experienced 210,470 hospitalizations, admitted to these hospitals between November 1st, 2006 and January 31st, 2008.
MEASUREMENTS:
Predictors were age, sex, admission type, admission diagnosis, physiologic derangement on admission, and pre-existing illness burden; outcomes were: 1) occurrence of intra-hospital transfer, 2) death following admission to the hospital, 3) death following transfer, and 4) total hospital length of stay (LOS).
RESULTS:
A total of 7,868 hospitalizations that began with admission to either a general medical surgical ward or to a transitional care unit (TCU) had at least one transfer to a higher level of care. These hospitalizations constituted only 3.7% of all admissions, but accounted for 24.2% of all ICU admissions, 21.7% of all hospital deaths, and 13.2% of all hospital days. Models based on age, sex, preadmission laboratory test results, and comorbidities did not predict the occurrence of these transfers.
CONCLUSIONS:
Patients transferred to higher level of care following admission to the hospital have excess mortality and LOS. Journal of Hospital Medicine 2010;. © 2010 Society of Hospital Medicine.
82 citations
TL;DR: Why unplanned transfers occur, what fraction results from errors in care, whether they are preceded by changes in clinical status and if so, whether earlier or different responses might prevent the transfers.
Abstract: BACKGROUND:
Unplanned intensive care unit (ICU) transfers may result from errors in care but the frequency of their occurrence, and whether these transfers might be prevented, has not been investigated.
OBJECTIVE:
To determine why unplanned transfers occur, what fraction results from errors in care, whether they are preceded by changes in clinical status and if so, whether earlier or different responses might prevent the transfers.
DESIGN:
Retrospective study.
SETTING:
University-affiliated hospital.
PATIENTS:
All patients 18 to 89 years with unplanned transfers to the medical ICU from June 1, 2005 to May 30, 2006.
INTERVENTION:
None.
MEASUREMENTS:
Demographics, admission and transfer diagnoses, clinical triggers preceding the transfer, mortality, judgment by three reviewers about cause of transfer and whether it could have been prevented.
RESULTS:
A total of 152 patients had unplanned transfers. The most common reasons were worsening of the problem for which the patient was admitted (48%) and development of a new problem (39%). Errors in care accounted for 29 transfers (19%), 15 of which were due to incorrect triage at the time of admission, and 14 due to iatrogenic errors. Of the 14 iatrogenic errors, the investigators determined that eight transfers might have been prevented by an earlier intervention. Agreement among the three reviewers was moderate to almost perfect (κ 0.55-0.90).
CONCLUSIONS:
Although 19% of unplanned transfers to medical ICUs are associated with errors in care, almost 80% of these seem to be preventable. Most of the preventable errors resulted from inappropriate admission triage. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine.
67 citations
TL;DR: The risk of symptomatic VTE in general medical patients is low and a risk factor model can identify those at sufficient risk to warrant pharmacologic prophylaxis.
Abstract: BACKGROUND:
The Joint Commission requires that all medical inpatients be assessed for venous thromboembolism (VTE) risk, but available risk stratification tools have never been validated.
METHODS:
We conducted a retrospective cohort study of patients age ≥18 years, admitted to 374 US hospitals in 2004–2005, with a primary diagnosis of pneumonia, heart failure, chronic obstructive pulmonary disease (COPD), stroke, and urinary tract infection, and length of stay ≥3 days. Subjects were randomly assigned (80/20) to a derivation or validation set. We then assessed VTE (International Classification of Diseases, Ninth Revision [ICD-9] code plus diagnostic test plus treatment), patient demographics, 21 potential risk factors, and other comorbidities. We created a VTE risk stratification tool using multivariable regression modeling and applied it to the validation sample.
RESULTS:
Of 242,738 patients, 612 (0.25%) patients fulfilled our criteria for VTE during hospitalization, and an additional 440 (0.18%) were readmitted for VTE within 30 days (overall incidence of 0.43%). In the multivariable model, age, sex, and 10 additional risk factors were associated with VTE. The strongest risk factors were inherited thrombophilia (OR 4.00), length of stay ≥6 days (OR 3.22), inflammatory bowel disease (OR 3.11), central venous catheter (OR 1.87), and cancer. In the validation set, the model had a c-statistic of 0.75 (95% CI 0.71, 0.78). Deciles of predicted risk ranged from 0.11% to 1.46% with observed risk over the same deciles from 0.17% to 1.81%.
CONCLUSIONS:
The risk of symptomatic VTE in general medical patients is low. A risk factor model can identify those at sufficient risk to warrant pharmacologic prophylaxis. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.
TL;DR: A possible direct dose response relationship between SPS and the reduction in serum potassium concentration was found and should be evaluated prospectively.
Abstract: Background:
Limited data exist on the precise dose of sodium polystyrene sulfonate (SPS) needed for specific potassium concentrations in the management of mild to moderate hyperkalemia in an inpatient hospital setting.
Methods:
A retrospective cohort study involving a review of electronic medical records of inpatients receiving SPS for the treatment of hyperkalemia was conducted at the Jesse Brown Veteran Affairs Medical Center, between January 1, 2006 and December 31, 2006. Hyperkalemia was defined as a serum potassium concentration >5.1 mmol/L. The primary endpoint was the mean change in potassium concentration associated with specific SPS dosage administration.
Results:
A total of 122 patients were selected for inclusion in the analysis. The mean potassium concentrations before SPS administration were 5.40 ± 0.18 mmol/L, 5.51 ± 0.30, 5.83 ± 0.46, and 5.92 ± 0.30 in the 15, 30, 45, and 60 gm groups, respectively. The mean potassium concentration decreased by 0.82 ± 0.48 mmol/L in the 15 gm group, 0.95 ± 0.47 in the 30 gm group, 1.11 ± 0.58 in the 45 gm group, and 1.40 ± 0.42 in the 60 gm group. After a single dose of SPS, the mean potassium concentration was within normal range in 115 patients (94%).
Conclusions:
A possible direct dose response relationship between SPS and the reduction in serum potassium concentration was found and should be evaluated prospectively. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.
TL;DR: Implementation of a inpatient Pharmacist-Directed Anticoagulation Service provides a net improvement in quality of care for the patient taking warfarin in the inpatient setting.
Abstract: BACKGROUND:
Warfarin is implicated in approximately 30% of reported anticoagulant-related errors. In order to improve anticoagulation management and safety, our institution implemented an inpatient Pharmacist-Directed Anticoagulation Service (PDAS).
OBJECTIVE:
To evaluate the impact of this service on both transition of care and safety of patients receiving warfarin anticoagulation.
DESIGN:
Cluster randomized trial.
SETTING:
Large, urban teaching hospital and level 1 trauma center.
PATIENTS:
All patients receiving warfarin on two medical and two cardiology units.
INTERVENTION:
A PDAS provided dosing, monitoring, and coordination of transition from the inpatient-to-outpatient setting.
MEASUREMENTS:
Endpoints were assessed during hospitalization and 30 days after discharge. Transition of care was considered effective if compliance with all of the transition of care metrics occurred. The transition of care metrics included: appropriate enrollment in the anticoagulation clinic, documented inpatient-to-outpatient provider contact, documented inpatient provider-to-anticoagulation clinic communication and patient follow-up with the anticoagulation clinic within five days of discharge. Safety was measured by the composite endpoint of thromboembolism, major bleeding, or international normalized ratio (INR) ≥5.
RESULTS:
This study included 500 patients. Transition of care metric compliance occurred in 73% more patients in the PDAS group (P < 0.001). There was also a 32% reduction in the composite safety endpoint in the PDAS group (P = 0.103). This finding was driven by a reduction in rate of INR ≥5 (P = 0.076).
CONCLUSIONS:
Implementation of a PDAS provides a net improvement in quality of care for the patient taking warfarin in the inpatient setting. Journal of Hospital Medicine 2011;6:322–328. © 2011 Society of Hospital Medicine
TL;DR: In severe sepsis attributed to Gram-negative bacteremia, initial treatment with an antibiotic regimen to which the causative pathogen is resistant was associated with increased hospital mortality, suggesting that rapid determination of bacterial susceptibility could influence treatment choices in patients with severe sePSis potentially improving their clinical outcomes.
Abstract: BACKGROUND:
Gram-negative bacteria are an important cause of severe sepsis. Recent studies have demonstrated reduced susceptibility of Gram-negative bacteria to currently available antimicrobial agents.
METHODS:
We performed a retrospective cohort study of patients with severe sepsis who were bacteremic with Pseudomonas aeruginosa, Acinetobacter species, or Enterobacteriaceae from 2002 to 2007. Patients were identified by the hospital informatics database and pertinent clinical data (demographics, baseline severity of illness, source of bacteremia, and therapy) were retrieved from electronic medical records. All patients were treated with antimicrobial agents within 12 hours of having blood cultures drawn that were subsequently positive for bacterial pathogens. The primary outcome was hospital mortality.
RESULTS:
A total of 535 patients with severe sepsis and Gram-negative bacteremia were identified. Hospital mortality was 43.6%, and 82 (15.3%) patients were treated with an antimicrobial regimen to which the causative pathogen was resistant. Patients infected with a resistant pathogen had significantly greater risk of hospital mortality (63.4% vs 40.0%; P < 0.001). In a multivariate analysis, infection with a pathogen that was resistant to the empiric antibiotic regimen, increasing APACHE II scores, infection with Pseudomonas aeruginosa, healthcare-associated hospital-onset infection, mechanical ventilation, and use of vasopressors were independently associated with hospital mortality.
CONCLUSIONS:
In severe sepsis attributed to Gram-negative bacteremia, initial treatment with an antibiotic regimen to which the causative pathogen is resistant was associated with increased hospital mortality. This finding suggests that rapid determination of bacterial susceptibility could influence treatment choices in patients with severe sepsis potentially improving their clinical outcomes. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine
TL;DR: Clinicians should be aware of these factors when considering the accuracy of patient-reported medication regimens, and counseling patients about safe and effective medication use.
Abstract: Background
Patients’ ability to accurately report their pre-admission medications is a vital aspect of medication reconciliation and may affect subsequent medication adherence and safety. Little is known about predictors of pre-admission medication understanding.
TL;DR: The use of baclofen was associated with a significant reduction in the use of high doses of benzodiazepine (lorazepam) in the management of symptomatic AWS, and reduced dependence on high-dose Benzodiazepines in AWS management could improve patient safety.
Abstract: BACKGROUND:
Abrupt cessation of alcohol intake causes habituated drinkers to experience symptoms of alcohol withdrawal syndrome (AWS).
OBJECTIVE:
To determine the effect of the gamma-aminobutyric acid (GABA)-B agonist baclofen on the course of acute symptomatic AWS.
DESIGN:
Prospective, randomized, double-blind, placebo-controlled clinical study.
SETTING:
Two tertiary-care hospitals in Duluth, Minnesota.
PATIENTS:
Inpatient adults admitted for any reason (including AWS) judged to be at high risk for AWS.
INTERVENTION:
Inpatients who developed symptoms of AWS received symptom-triggered benzodiazepine treatment using lorazepam by standard protocol, and were randomized to receive baclofen 10 mg or placebo, 3 times per day, orally.
MEASUREMENTS:
AWS severity was assessed using the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar); lorazepam dose was monitored.
RESULTS:
Seventy-nine subjects were enrolled. The 44 subjects who developed symptoms of AWS were randomized to baclofen or placebo. Thirty-one subjects (18 baclofen, 13 placebo) completed 72 hours of assessments, either entirely as inpatients or with outpatient follow-up. The need for high doses of benzodiazepines (20 mg or more of lorazepam over 72 hours) to control AWS was less likely in the baclofen treatment group (1 of 18) than in the placebo-treated group (7 of 13) (P = 0.004).
CONCLUSIONS:
We found that the use of baclofen was associated with a significant reduction in the use of high doses of benzodiazepine (lorazepam) in the management of symptomatic AWS. The use of low-dose baclofen in the management of AWS deserves further study, as reduced dependence on high-dose benzodiazepines in AWS management could improve patient safety. Journal of Hospital Medicine 2011;6:474–479. © 2011 Society of Hospital Medicine
TL;DR: Overall, high utilization was difficult to predict, as was its course, and the diagnoses most associated with high utilization indicated more severe sickle cell disease.
Abstract: BACKGROUND:
Although sickle cell disease (SCD) patients typically manage their pain at home, a small subgroup is frequently hospitalized and accounts for the majority of costs.
OBJECTIVES:
1) To identify prospective diagnostic and demographic markers of new periods of high utilization; 2) To identify demographic and diagnostic markers of a persistent rather than moderating course of high utilization; 3) To replicate the finding that high utilization tends to moderate.
DESIGN:
The State Inpatient Databases for California, 2004–2007, were used. Patients with new onset periods of high utilization were compared with non-high utilizers, and new high utilizers who moderated were compared with those who had a persistent course.
SETTING:
All hospitals in the state of California.
PATIENTS:
Patients age 13 years or older in 2004 with a recorded diagnosis of sickle cell disease and at least one hospitalization for crisis during the study period.
MEASURES: METHODS:
Groups from hospitals throughout California were compared on demographics and discharge diagnoses of SCD complications and comorbidities. Patients age 13 years or older in 2004 with a recorded diagnosis of sickle cell disease and at least 1 hospitalization for crisis during the study period were included.
RESULTS:
New periods of high utilization were associated with more prior hospitalizations and previous diagnoses of aseptic necrosis and renal disease. High utilization typically moderated. A persistent course was associated with slightly more hospitalizations during the initial year of high utilization, and, subsequently, by more mentions of septicemia and mood disorders.
CONCLUSIONS:
Overall, high utilization was difficult to predict, as was its course. The diagnoses most associated with high utilization indicated more severe sickle cell disease. Septicemia deserves further investigation as a preventable cause for high utilization, as do mood disorders. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine
TL;DR: In this article, a cross-sectional survey was conducted to determine factors critical to the promotion of successfully promoted hospitalists who have achieved the rank of either associate professor or professor, finding that being a hospitalist was viewed as a hindrance to promotion.
Abstract: BACKGROUND:
Academic hospital medicine is a new and rapidly growing field. Hospitalist faculty members often fill roles not typically held by other academic faculty, maintain heavy clinical workloads, and participate in nontraditional activities. Because of these differences, there is concern about how academic hospitalists may fare in the promotions process.
OBJECTIVE:
To determine factors critical to the promotion of successfully promoted hospitalists who have achieved the rank of either associate professor or professor.
DESIGN:
A cross-sectional survey.
PARTICIPANTS:
Thirty-three hospitalist faculty members at 22 academic medical centers promoted to associate professor rank or higher between 1995 and 2008.
MEASUREMENTS:
Respondents were asked to describe their institution, its promotions process, and the activities contributing to their promotion. We identified trends across respondents.
RESULTS:
Twenty-six hospitalists responded, representing 20 institutions (79% response rate). Most achieved promotion in a nontenure track (70%); an equal number identified themselves as clinician-administrators and clinician educators (40%). While hospitalists were engaged in a wide range of activities in the traditional domains of service, education, and research, respondents considered peer-reviewed publication to be the most important activity in achieving promotion. Qualitative responses demonstrated little evidence that being a hospitalist was viewed as a hindrance to promotion.
CONCLUSIONS:
Successful promotion in academic hospital medicine depends on accomplishment in traditional academic domains, raising potential concerns for academic hospitalists with less traditional roles. This study may provide guidance for early-career academic hospitalists and program leaders. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine
TL;DR: The age-related decline in CSF protein concentration among infants 56 days of age and younger is quantified and accurate, age-specific reference values for neonates and young infants are provided.
Abstract: BACKGROUND:
Cerebrospinal fluid (CSF) protein values decline over the first few months of life as the infant's blood-CSF barrier matures. However, published studies differ in the reported rate, timing, and magnitude of this decline.
OBJECTIVE:
To quantify the age-related changes in CSF protein concentration and to determine accurate, age-specific reference values for neonates and young infants.
DESIGN, SETTING AND PATIENTS:
This cross-sectional study included infants age 56 days or younger who had a lumbar puncture performed in the emergency department of an urban tertiary care children's hospital between January 1, 2005 and June 30, 2007. Infants with conditions associated with elevated CSF protein concentrations, including traumatic lumbar puncture and bacterial or viral meningitis, were excluded.
RESULTS:
Of 1064 infants undergoing lumbar puncture, 375 (35%) met inclusion criteria. The median CSF protein value was 58 mg/dL (interquartile range: 48–72 mg/dL). In linear regression, the CSF protein concentration decreased 6.8% (95% confidence interval [CI], 5.4%-8.1%; P < 0.001) with each 1 week increase in age. The 95th percentile values were 115 mg/dL for infants ≤28 days and 89 mg/dL for infants 29–56 days. The 95th percentile values by age category were as follows: ages 0–14 days, 132 mg/dL; ages 15–28 days, 100 mg/dL; ages 29–42 days, 89 mg/dL; and ages 43–56 days, 83 mg/dL.
CONCLUSIONS:
We quantify the age-related decline in CSF protein concentration among infants 56 days of age and younger and provide age-specific reference values. The values reported here represent the largest series to-date for this age group. Journal of Hospital Medicine 2011. © 2010 Society of Hospital Medicine.
TL;DR: A Hospitalist-ACE service may improve care processes without significantly increasing resource consumption and no impact on key clinical outcomes was observed.
Abstract: BACKGROUND:
Comprehensive care for frail older inpatients may improve selected outcomes and reduce harm.
OBJECTIVE:
To evaluate a Hospitalist-run Acute Care for the Elderly (Hospitalist-ACE) service.
DESIGN:
Quasi-randomized, controlled trial.
SETTING:
Urban academic medical center.
PATIENTS:
Medical inpatients age ≥70 years.
INTERVENTION:
Hospitalist-ACE service components: 1) selected hospitalist attendings; 2) daily interdisciplinary rounds; 3) standardized geriatric assessment; 4) clinical focus on mitigating harm and discharge planning; 5) novel inpatient geriatrics curriculum.
MEASURES:
The primary outcome was recognition of abnormal functional status by the primary medical team. Secondary outcomes included: recognition of abnormal cognitive status and delirium by the primary medical team; use of physical restraints and sleep aids; documentation of code status; hospital charges, length of stay, readmission rates, discharge location, and falls.
RESULTS:
One hundred twenty-two Hospitalist-ACE patients were compared to 95 usual care patients. Hospitalist-ACE patients had significantly greater recognition of abnormal functional status (65% vs 32%, P < 0.0001), and abnormal cognitive status (57% vs 36%, P = 0.02), and greater use of “Do Not Attempt Resuscitation” orders (39% vs 26%, P = 0.04). There were no differences in use of physical restraints, or sleep aids, falls, or discharge location. Hospitalist-ACE patients and usual care patients had similar mean lengths of stay in days (3.4 ± 2.7 vs 3.1 ± 2.7, P = 0.52), mean charges ($24,617 ± $15,828 vs $21,488 ± $13,407, P = 0.12), and 30-day readmission rates (12% vs 10%, P = 0.50).
CONCLUSIONS:
A Hospitalist-ACE service may improve care processes without significantly increasing resource consumption. No impact on key clinical outcomes was observed. Journal of Hospital Medicine 2011;6:313–321. © 2011 Society of Hospital Medicine
TL;DR: Academic hospital medicine groups have an acute need for mentoring and career development programs that target both individual hospitalists and their leaders while also helping to enhance scholarly work.
Abstract: BACKGROUND:
Few data describe the structure, activities, and goals of academic hospital medicine groups.
METHODS:
We carried out a cross sectional email survey of academic hospitalist leaders. Our survey asked about group resources, services, recruitment and growth, as well as mentoring of faculty, future priorities, and general impressions of group stability.
RESULTS:
A total of 57 of 142 (40%) potential hospitalist leaders responded to our email survey. Hospitalist groups were generally young (<5 years old). Hospitalist group leaders worried about adequate mentorship and burnout while placing a high priority on avoiding physician turnover. However, most groups also placed a high priority on expanding nonclinical activities (teaching, research, etc.). Leaders felt financially and philosophically unsupported, a sentiment which seemed to stem from being viewed primarily as a clinical rather than an academic service.
CONCLUSION:
Academic hospital medicine groups have an acute need for mentoring and career development programs. These programs should target both individual hospitalists and their leaders while also helping to enhance scholarly work. Journal of Hospital Medicine 2011;6:5–9. © 2011 Society of Hospital Medicine.
TL;DR: Night or weekend admission was not associated with worse hospitalization-relevant outcomes at the authors' tertiary care hospital.
Abstract: Introduction:
Nights and weekends represent a potentially high-risk time for hospitalized patients. Data regarding night or weekend admission and its impact on outcomes is limited. We studied the association between night or weekend admission and outcomes.
Methods:
We reviewed 857 admissions to the general medicine services from the emergency department (ED) at our tertiary care hospital for demographic information, time and day of admission, and hospitalization-relevant outcomes (length of stay [LOS], hospital charges, intensive care unit [ICU] transfer during hospitalization, repeat ED visit within 30 days, readmission within 30 days, and poor outcome [ICU transfer, cardiac arrest, or death] within the first 24 hours of admission). Outcomes were compared between groups using univariate and multivariate modeling.
Results:
Complete data for analysis were available for 824 patients. A total of 58% of patients were admitted at night and 22% were admitted during the weekend. Patients admitted at night as compared to those admitted during the day had similar a LOS (4.1 vs. 4.3, P = 0.38), hospital charges (25,200 vs. 27,500, P = 0.17), ICU transfer during hospitalization (3% vs. 6%, P = 0.06), 30 day repeat ED visit (22% vs. 20%, P = 0.42), 30 day readmission (20% vs. 17%, P = 0.23), and poor outcomes within 24 hours of admission (1% vs. 2%, P = 0.15). Patients admitted during the weekend as compared to those admitted during the week had lower hospital charges and lower likelihood of an ICU transfer but were otherwise similar.
Conclusion:
Night or weekend admission was not associated with worse hospitalization-relevant outcomes at our tertiary care hospital. Journal of Hospital Medicine 2011. © 2010 Society of Hospital Medicine.
TL;DR: Helping resident physicians with the discharge process improves many aspects of discharge communication and patient follow-up, and saves residents' time, but had no effect on hospital reutilization for a general medicine population.
Abstract: BACKGROUND:
Hospital discharges are vulnerable periods for patient safety, especially in teaching hospitals where discharges are done by residents with competing demands. We sought to assess whether embedding a nurse practitioner on a medical team to help physicians with the discharge process would improve communication, patient follow-up, and hospital reutilization.
METHODS:
A 5-month randomized controlled trial was conducted on the medical service at an academic tertiary-care hospital. A nurse practitioner was randomly assigned to 1 resident team to complete discharge paperwork, arrange follow-up appointments and prescriptions, communicate discharge plans with nursing and primary care physicians, and answer questions from discharged patients.
RESULTS:
Intervention patients had more discharge summaries completed within 24 hours (67% vs 47%, P < 0.001). Similarly, they had more follow-up appointments scheduled by the time of discharge (62% vs 36%, P < 0.0001) and attended those appointments more often within 2 weeks (36% vs 23%, P < 0.0002). Intervention patients knew whom to call with questions (95% vs 85%, P = 0.003) and were more satisfied with the discharge process (97% vs 76%, P < 0.0001). Attending rounds on the intervention team finished on time (45% vs 31%, P = 0.058), and residents signed out on average 46 minutes earlier each day. There was no significant difference between the groups in 30-day emergency department visits or readmissions.
CONCLUSIONS:
Helping resident physicians with the discharge process improves many aspects of discharge communication and patient follow-up, and saves residents' time, but had no effect on hospital reutilization for a general medicine population. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.
TL;DR: In conclusion, audit and feedback sessions were associated with better DS completeness in areas of particular importance to geriatric care.
Abstract: Discharge summaries (DS) communicate important clinical information from inpatient to outpatient settings. Previous studies noted increased adverse events and rehospitalization due to poor DS quality. We postulated that an audit and feedback intervention of DS completed by geriatric medicine fellows would improve the completeness of their summaries. We conducted a preintervention post intervention study. In phase 1 (AUDIT #1 and FEEDBACK) we scored all DS (n = 89) completed by first year fellows between July 2006 to December 2006 using a 21-item checklist. Individual performance scores were reviewed with each fellow in 30-minute feedback sessions. In phase 2 (AUDIT #2) we scored all DS (n = 79) completed after the first phase between February 2007 to July 2007 using the same checklist. Data were analyzed using generalized estimating equations. Fellows were more likely to complete all required DS data after feedback when compared with prior to feedback (91% vs. 71%, P < 0.001). Feedback was also associated with improved admission (93% vs. 70%, P < 0.001), duration of hospitalization (93% vs 78%, P < 0.001), discharge planning (93% vs. 18%, P < 0.02) and postdischarge care (83% vs. 57%., P < 0.001) section-specific information. In conclusion, audit and feedback sessions were associated with better DS completeness in areas of particular importance to geriatric care.
TL;DR: A pilot study in 20 patients with cystic fibrosis–related diabetes (CFRD), after bone marrow or solid organ (liver, kidney, or lung) transplantation, who received methylprednisolone intravenously during admissions to the University of Colorado Hospital, Denver, Colorado, found that point-of-contact glycemia immediately prior to initiation of steroids and for the 3 days of methylpredisonsolone administration was compared.
Abstract: Patients and Methods We conducted a pilot study in 20 patients with cystic fibrosis–related diabetes (CFRD), after bone marrow or solid organ (liver, kidney, or lung) transplantation, who received methylprednisolone intravenously (10-60 mg) during admissions to the University of Colorado Hospital, Denver, Colorado. All patients received basal glargine and premeal lispro insulins. A total of 10 patients (randomized 1:1) received neutral protamine Hagedorn (NPH) insulin at the time of administration of methylprednisolone between 8 and 11 am (Group 1). The dose of NPH insulin was selected as follows: 1 unit (U) for 1 mg methylprednisolone for the first 20 mg of steroid; 0.5 U of insulin for 1 mg of methylprednisolone for the next 20 mg of steroid; and 0.25 U of insulin for each subsequent milligram of steroid. The average dose of NPH was 23 6 5 U. In the remaining 10 patients, the doses of glargine and lispro were increased according to the University of Colorado Hospital’s standard protocols for use of subcutaneous insulin to achieve the best possible control (Group 2). Point-of-contact glycemia immediately prior to initiation of steroids and for the 3 days of methylprednisolone administration was compared. Results are expressed as mean 6 standard deviation and compared using the Student t test with P value < 0.05 considered significant.
TL;DR: The study points to the multifactorial nature of interventions needed to prevent readmissions, the tradeoffs between hospital length of stay and readmission, and the importance of fostering a culture of optimism and engagement to outpatient components of the health system to reduce hospital readmissions.
Abstract: BACKGROUND:
Hospital readmissions are receiving increasing attention as an indicator of health care quality and waste. Hospitalists provide a unique perspective on the underlying processes that result in acute care readmissions and the extent to which readmissions can be prevented.
OBJECTIVE:
The study assessed the views of hospitalists on the preventability of readmissions and the most important ways to prevent future readmissions.
DESIGN AND MEASUREMENTS:
A group of 17 hospitalists serving four community hospitals reviewed the details of 300 consecutive 21-day readmissions. Each used a structured data collection form to code information from inpatient and outpatient charts on patient characteristics, process measures, preventability, and potential interventions.
RESULTS:
Overall, 15% of readmissions were rated as overtly preventable, but with wide variation among hospitalists in their ratings of preventability. Perceptions of preventability appear to be a function of readmission timing, the similarity of diagnoses between admissions, medication issues, and the presence of certain chronic diseases (eg, chronic obstructive pulmonary disease [COPD]). Hospitalists were more likely to recommend familiar interventions under their control for a readmissions termed preventable, such as extending the initial hospital stay or addressing medications and patient education at discharge. They less often identified outpatient case management, home services, or physician nursing home visits as viable prevention strategies.
CONCLUSIONS:
The study points to the multifactorial nature of interventions needed to prevent readmissions, the tradeoffs between hospital length of stay and readmission, and the importance of fostering a culture of optimism and engagement to outpatient components of the health system to reduce hospital readmissions. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine
TL;DR: H-PA team-based GM inpatient care was associated with a higher LOS but similar charges, readmission rates, and inpatient mortality to traditional resident-based teams, a finding that persisted in sensitivity analyses.
Abstract: BACKGROUND:
Residency reform in the form of work hour restrictions has forced academic medical centers to develop alternate models of care to provide inpatient care. One such model is the use of physician assistants (PAs) with hospitalists. However, these models of care have not been widely evaluated.
OBJECTIVE:
To compare the outcomes of inpatient care provided by a hospitalist-PA (H-PA) model with the traditional resident based model.
DESIGN, SETTING and PATIENTS:
We conducted a retrospective cohort study of 9681 general medical (GM) hospitalizations between January 2005 and December 2006 using a hospital administrative database. We used multivariable mixed models to adjust for a wide variety of potential confounders and account for multiple patient visits to the hospital to compare the outcomes of 2171 hospitalizations to H-PA teams with those of 7510 hospitalizations to resident teams (RES).
MEASUREMENTS:
Length of stay (LOS), charges, readmission within 7, 14, and 30 days and inpatient mortality.
RESULTS:
Inpatient care provided by H-PA teams was associated with a 6.73% longer LOS (P = 0.005) but charges, risk of readmission at 7, 14, and 30 days and inpatient mortality were similar to resident-based teams. The increase in LOS was dependent on the time of admission of the patients.
CONCLUSIONS:
H-PA team-based GM inpatient care was associated with a higher LOS but similar charges, readmission rates, and inpatient mortality to traditional resident-based teams, a finding that persisted in sensitivity analyses. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.
Children's Hospital of Philadelphia1, University of Pennsylvania2, University of Missouri–Kansas City3, University of Washington4, Monroe Carell Jr. Children's Hospital at Vanderbilt5, Primary Children's Hospital6, Eastern Virginia Medical School7, University of Pittsburgh8, University of Colorado Denver9, Cincinnati Children's Hospital Medical Center10
TL;DR: There is variability in the treatment and outcomes of children with complicated pneumonia, and initial chest tube without fibrinolysis was the least costly strategy.
Abstract: Objective
To determine the comparative effectiveness of common pleural drainage procedures for treatment of pneumonia complicated by parapneumonic effusion (i.e., complicated pneumonia).
TL;DR: Building FD programs can be effective to foster the development and satisfaction of new faculty while also creating a shared commitment towards an academic mission.
Abstract: Background:
Academic hospital medicine (AHM) groups continue to grow rapidly, driven largely by clinical demands. While new hospitalist faculty usually have strong backgrounds in clinical medicine, they often lack the tools needed to achieve excellence in the other aspects of a faculty career, including teaching, research, quality improvement, and leadership skills.
Objective:
To develop and implement a Faculty Development (FD) Program that improves the knowledge, skills, attitudes, and scholarly output of first-year faculty.
Intervention:
We created a vision and framework for FD that targeted our new faculty but also engaged our entire Division of Hospital Medicine. New faculty participated in a dedicated coaching relationship with a more senior faculty member, a core curriculum, a teaching course, and activities to meet a set of stated scholarly expectations. All faculty participated in newly established divisional Grand Rounds, a lunch seminar series, and venues to share scholarship and works in progress.
Results:
Our FD programmatic offerings were rated highly overall on a scale of 1 to 5 (5 highest): Core Seminars 4.83 ± 0.41, Coaching Program 4.5 ± 0.84, Teaching Course 4.5 ± 0.55, Grand Rounds 4.83 ± 0.41, and Lunch Seminars 4.5 ± 0.84. Compared to faculty hired in the 2 years prior to our FD program implementation, new faculty reported greater degrees of work satisfaction, increased comfort with their skills in a variety of areas, and improved academic output.
Conclusion:
Building FD programs can be effective to foster the development and satisfaction of new faculty while also creating a shared commitment towards an academic mission. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine.
TL;DR: There are important differences between infants with bronchiolitis having short and prolonged hospital stays, including several clinical markers identifiable on hospital day 2, and this model may be a useful prediction tool for targeting early interventions for high-risk infants.
Abstract: BACKGROUND:
Prior prediction models for length of stay (LOS) in bronchiolitis have focused more on birth- and disease-related risk factors than on early hospital course factors, particularly common clinical markers including respiratory status and caloric intake.
OBJECTIVES:
1) Study the associations of various clinical markers and LOS; and 2) develop a LOS prediction model.
DESIGN:
Retrospective cohort study.
SETTING:
Children's Hospital of Wisconsin.
PATIENTS:
Inclusion criteria were: age <365 days old; admission between November 1, 2004 and April 15, 2005; final diagnosis of bronchiolitis; placement on the bronchiolitis treatment protocol; and lack of concurrent condition impacting LOS.
RESULTS:
During the study period, 272/347 infants admitted with bronchiolitis met inclusion criteria. On hospital day 2, infants in the prolonged LOS group (≥108 hours) had a significantly greater number of hours on supplemental oxygen, maximum supplemental oxygen use, minimum supplemental oxygen use, maximum respiratory rate, mean respiratory score, and number of times suctioned. They had significantly lower minimum oxygen saturation and caloric intake. Recursive partitioning demonstrated five variables (hours of supplemental oxygen, maximum respiratory rate, minimum supplemental oxygen use, gestation, and caloric intake) to predict short or prolonged LOS with an area under the receiver-operator characteristic curve of 0.89/0.72 in the learning/test trees; sensitivity, 0.85; and specificity, 0.82.
CONCLUSIONS:
There are important differences between infants with bronchiolitis having short and prolonged hospital stays, including several clinical markers identifiable on hospital day 2. This model may be a useful prediction tool for targeting early interventions for high-risk infants. Journal of Hospital Medicine 2011. © 2011 Society of Hospital Medicine