Showing papers in "Journal of Hospital Medicine in 2014"

Opioid utilization and opioid-related adverse events in nonsurgical patients in US hospitals

Abstract: BACKGROUND Recent studies in the outpatient setting have demonstrated high rates of opioid prescribing and overdose-related deaths. Prescribing practices in hospitalized patients are unexamined. OBJECTIVE To investigate patterns and predictors of opioid utilization in nonsurgical admissions to US hospitals, variation in use, and the association between hospital-level use and rates of severe opioid-related adverse events. DESIGN, SETTING, AND PATIENTS Adult nonsurgical admissions to 286 US hospitals. MEASUREMENTS Opioid exposure and severe opioid-related adverse events during hospitalization, defined using hospital charges and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. RESULTS Of 1.14 million admissions, opioids were used in 51%. The mean ± standard deviation daily dose received in oral morphine equivalents was 68 ± 185 mg; 23% of exposed received a total daily dose of ≥100 mg oral morphine equivalents. Opioid-prescribing rates ranged from 5% in the lowest-prescribing hospital to 72% in the highest-prescribing hospital (mean, 51% ± 10%). After adjusting for patient characteristics, the adjusted opioid-prescribing rates ranged from 33% to 64% (mean, 50% ± standard deviation 4%). Among exposed, 0.60% experienced severe opioid-related adverse events. Hospitals with higher opioid-prescribing rates had higher adjusted relative risk of a severe opioid-related adverse event per patient exposed (relative risk: 1.23 [1.14-1.33] for highest-prescribing compared with lowest-prescribing quartile). CONCLUSIONS The majority of hospitalized nonsurgical patients were exposed to opioids, often at high doses. Hospitals that used opioids most frequently had increased adjusted risk of a severe opioid-related adverse event per patient exposed. Interventions to standardize and enhance the safety of opioid prescribing in hospitalized patients should be investigated. Journal of Hospital Medicine 2014;9:73–81. © 2013 Society of Hospital Medicine

Association of impaired functional status at hospital discharge and subsequent rehospitalization.

Abstract: Federally mandated pay-for-performance initiatives promote minimizing 30-day hospital readmissions to improve healthcare quality and reduce costs. Although the reasons for readmissions are multifactorial, many patients are readmitted for a condition other than their initial hospital admitting diagnosis.1 Impairments in functional status experienced during acute care hospitalization contribute to patients being discharged in a debilitated state and being vulnerable to postdischarge complications and potentially hospital read-mission.2 As such, decreased functional status may be an important and potentially modifiable risk factor for acute care hospital readmission.3 Previous studies have suggested that impaired functional status may be an important predictor of rehospitalization.4–7 However, inferences from existing studies are limited because they did not consider functional status as their primary focus, they only considered specific patient populations (eg, stroke) or readmissions occurring well beyond the 30-day period defined by federal pay-for-performance standards.4–6,8–10 Our objective was to evaluate the association between functional status near the time of discharge from acute care hospital and 30-day readmission for patients admitted to an acute inpatient rehabilitation facility. As a secondary objective, we sought to investigate the relationship between functional status and readmission by diagnostic category (medical, neurologic, or orthopedic).

Impact of extended‐spectrum β‐lactamase–producing organisms on clinical and economic outcomes in patients with urinary tract infection

Abstract: OBJECTIVE To compare clinical and economic outcomes between patients with urinary tract infection (UTI) due to extended-spectrum β-lactamase–producing Escherichia coli and Klebsiella species (ESBL-EK) versus patients with non-ESBL-EK UTI. PATIENTS AND METHODS Eighty-four (3.6%) of 2345 patients admitted between September 1, 2011 and August 31, 2012 with UTI were positive for ESBL-EK. Fifty-five ESBL-EK UTI (cases) and matched controls (non–ESBL-EK UTI) were included in the analysis. Clinical and economic outcomes were compared between cases and controls for statistical significance. RESULTS Cases were more likely to have diabetes mellitus, a history of recurrent UTIs, recently received antibiotics, recently been hospitalized, and had previous isolation of an ESBL-producing organism compared with controls. Failure of initial antibiotic regimen (62% vs 6%; P < 0.001) and time to appropriate antibiotic therapy (51 vs 2.5 hours; P < 0.001) were greater in cases. The median cost of care was greater (additional $3658; P = 0.02) and the median length of stay (LOS) prolonged for cases (6 vs 4 days; P = 0.02) despite similar hospital reimbursement (additional $469; P = 0.56). Although not significant, infection-related mortality (7.2% vs 1.8%) and 30-day UTI readmission (7.2% vs 3.6%) were higher in ESBL-EK cases. CONCLUSIONS UTI caused by ESBL-EK is associated with significant clinical and economic burden. The cost of care and LOS of patients with ESBL-EK UTI were 1.5 times those caused by non–ESBL-EK. Importantly, the additional cost of care is a liability to the hospital, as this is not offset by reimbursement. Appropriate and timely initial antibiotics may minimize the ESBL-EK impact on outcomes of patients with UTI. Journal of Hospital Medicine 2014;9:232–238. © 2014 Society of Hospital Medicine

Measuring the modified early warning score and the Rothman Index: Advantages of utilizing the electronic medical record in an early warning system

Abstract: Early detection of an impending cardiac or pulmonary arrest is an important focus for hospitals trying to improve quality of care. Unfortunately, all current early warning systems suffer from high false-alarm rates. Most systems are based on the Modified Early Warning Score (MEWS); 4 of its 5 inputs are vital signs. The purpose of this study was to compare the accuracy of MEWS against the Rothman Index (RI), a patient acuity score based upon summation of excess risk functions that utilize additional data from the electronic medical record (EMR). MEWS and RI scores were computed retrospectively for 32,472 patient visits. Nursing assessments, a category of EMR inputs only used by the RI, showed sharp differences 24 hours before death. Receiver operating characteristic curves for 24-hour mortality demonstrated superior RI performance with c-statistics, 0.82 and 0.93, respectively. At the point where MEWS triggers an alarm, we identified the RI point corresponding to equal sensitivity and found the positive likelihood ratio (LR+) for MEWS was 7.8, and for the RI was 16.9 with false alarms reduced by 53%. At the RI point corresponding to equal LR+, the sensitivity for MEWS was 49% and 77% for RI, capturing 54% more of those patients who will die within 24 hours. Journal of Hospital Medicine 2014;9:116–119. 2013 The Authors. Journal of Hospital Medicine published by Wiley Periodicals, Inc. on behalf of Society of Hospital Medicine

Tablet computers for hospitalized patients: a pilot study to improve inpatient engagement.

Abstract: Inadequate patient engagement in hospital care inhibits high-quality care and successful transitions to home. Tablet computers may provide opportunities to engage patients, particularly during inactive times between provider visits, tests, and treatments, by providing interactive health education modules as well as access to their personal health record (PHR). We conducted a pilot project to explore inpatient satisfaction with bedside tablets and barriers to usability. Additionally, we evaluated use of these devices to deliver 2 specific Web-based programs: (1) an interactive video to improve inpatient education about hospital safety, and (2) PHR access to promote inpatient engagement in discharge planning. We enrolled 30 patients; 17 (60%) were aged 40 years or older, 17 (60%) were women, 17 (60%) owned smartphones, and 6 (22%) owned tablet computers. Twenty-seven (90%) reported high overall satisfaction with the device, and 26 (87%) required ≤ 30 minutes for basic orientation (70% required ≤ 15 minutes). Twenty-five (83%) independently completed an interactive educational module on hospital patient safety. Twenty-one (70%) accessed their personal health record (PHR) to view their medication list, verify scheduled appointments, or send a message to their primary care physician. Next steps include education on high-risk medications, assessment of discharge barriers, and training clinical staff (such as respiratory therapists, registered nurses, or nurse practitioners) to deliver tablet interventions.

Pediatric Hospital Discharge Interventions to Reduce Subsequent Utilization: A Systematic Review

Abstract: BACKGROUND Reducing avoidable readmission and posthospitalization emergency department (ED) utilization has become a focus of quality-of-care measures and initiatives. For pediatric patients, no systematic efforts have assessed the evidence for interventions to reduce these events. PURPOSE We sought to synthesize existing evidence on pediatric discharge practices and interventions to reduce hospital readmission and posthospitalization ED utilization. DATA SOURCES PubMed and the Cumulative Index to Nursing and Allied Health Literature. STUDY SELECTION Studies available in English involving pediatric inpatient discharge interventions with at least 1 outcome of interest were included. DATA EXTRACTION We utilized a modified Cochrane Good Practice data extraction tool and assessed study quality with the Downs and Black tool. DATA SYNTHESIS Our search identified a total of 1296 studies, 14 of which met full inclusion criteria. All included studies examined multifaceted discharge interventions initiated in the inpatient setting. Overall, 2 studies demonstrated statistically significant reductions in both readmissions and subsequent ED visits, 4 studies demonstrated statistically significant reductions in either readmissions or ED visits, and 2 studies found statistically significant increases in subsequent utilization. Several studies were not sufficiently powered to detect changes in either subsequent utilization outcome measure. CONCLUSIONS Interventions that demonstrated reductions in subsequent utilization targeted children with specific chronic conditions, providing enhanced inpatient feedback and education reinforced with postdischarge support. Interventions seeking to reduce subsequent utilization should identify an individual or team to assume responsibility for the inpatient-to-outpatient transition and offer ongoing support to the family via telephone or home visitation following discharge. Journal of Hospital Medicine 2014;9:251–260. © 2013 Society of Hospital Medicine

Hospital readmission and healthcare utilization following sepsis in community settings

Abstract: Background Sepsis, the most expensive cause of hospitalization in the US, is associated with high morbidity and mortality. However, healthcare utilization patterns following sepsis are poorly understood.

Interprofessional simulation training improves knowledge and teamwork in nursing and medical students during internal medicine clerkship

Abstract: Simulation is effective at improving healthcare students' knowledge and communication. Despite increasingly interprofessional approaches to medicine, most studies demonstrate these effects in isolation. We enhanced an existing internal medicine curriculum with immersive interprofessional simulations. For ten months, third-year medical students and senior nursing students were recruited for four, 1-hour simulations. Scenarios included myocardial infarction, pancreatitis/hyperkalemia, upper gastrointestinal bleed, and chronic obstructive pulmonary disease exacerbation. After each scenario, experts in medicine, nursing, simulation, and adult learning facilitated a debriefing. Study measures included pre- and post-tests assessing self-efficacy, communication skills, and understanding of each profession's role. Seventy-two medical students and 30 nursing students participated. Self-efficacy communication scores improved for both (medicine, 18.9 ± 3.3 pretest vs 23.7 ± 3.7 post-test; nursing, 19.6 ± 2.7 pretest vs 24.5 ± 2.5 post-test). Both groups showed improvement in “confidence to correct another healthcare provider in a collaborative manner” (Δ = .97 medicine, Δ = 1.2 nursing). Medical students showed the most improvement in “confidence to close the loop in patient care” (Δ = .93). Nursing students showed the most improvement in “confidence to figure out roles” (Δ = 1.1). This study supports the hypothesis that interdisciplinary simulation improves each discipline's self-efficacy communication skills and understanding of each profession's role. Despite many barriers to interprofessional simulation, this model is being sustained. Journal of Hospital Medicine 2014;9:189–192. © 2014 Society of Hospital Medicine

Smarter hospital communication: secure smartphone text messaging improves provider satisfaction and perception of efficacy, workflow.

Abstract: Pagers, though reliable and familiar technology, can be suboptimal for facilitating healthcare team communication.1,2 Most paging systems utilize single-function pagers and only allow one-way communication, requiring recipients to disrupt workflow to respond to pages. Paging transmissions can also be intercepted, and the information presented on pager displays can be viewed by anyone in possession of the pager. Smartphones allow for instantaneous two-way and group communication through advanced technological features. Their use is widespread; over 81% of American physicians owned a smartphone in 2011.3 Previous studies demonstrate that healthcare providers rate smartphone-based email positively, and that team smartphones can facilitate communication between nurses and physicians.4,5 However, these studies specifically examined the utility of smartphone-based email and voice calls, and did not include text messaging. Limitations of traditional smartphone-based text messaging include Health Insurance Portability and Accountability Act (HIPAA) noncompliance and dependence on in-hospital cellular reception, which can be unreliable. HIPAA is a 1996 US federal law that established a set of privacy and security rules governing not only what is considered protected health information (PHI), but also minimum standards for the protection of such information. HIPAA compliance is defined as meeting these minimum standards for physical, network, and process security.6,7 Though PHI is often transmitted via paging systems and commercial carrier-based text messaging, these modalities are not secure and are thus not HIPAA-compliant. Text messaging applications that address these security and reliability issues have the potential to greatly enhance in-hospital communication. We hypothesized that a smartphone-based HIPAA-compliant group messaging application could improve in-hospital communication on the inpatient medicine service. To our knowledge, our study is the first to examine a HIPAA-compliant text messaging system, and also the first to compare a combination paging/HIPAA-compliant group messaging (HCGM) system with a paging-only system in assessing healthcare provider perception of communication efficiency.

Discharge before noon: An achievable hospital goal

Abstract: BACKGROUND Late afternoon hospital discharges are thought to contribute to admission bottlenecks, overcrowding, and increased length of stay (LOS). In January 2012, the discharge before noon (DBN) percentage on 2 medical units was 7%, below the organizational goal of 30%. OBJECTIVE To sustainably achieve a DBN rate of 30% and to evaluate the effect of this intervention on observed-to-expected (O/E) LOS and 30-day readmission rate. DESIGN Pre-/post-intervention retrospective analysis. SETTING Two acute care inpatient medical units in an urban, academic medical center. PATIENTS All inpatients discharged from the units. INTERVENTION All staff helped create a checklist of daily responsibilities at a DBN kickoff event. We initiated afternoon interdisciplinary rounds to identify next-day DBNs and created a website for enhanced communication. We provided daily feedback on the DBN percentage, rewards for success, and real-time opportunities for case review. MEASUREMENTS Calendar month DBN percentage, O/E LOS, and 30-day readmission rate. RESULTS The DBN percentage increased from 11% in the 8-month baseline period to an average of 38% over the 13-month intervention (P = 0.0002). The average discharge time moved 1 hour and 31 minutes earlier in the day. The O/E LOS declined from 1.06 to 0.96 (P = 0.0001), and the 30-day readmission rate declined from 14.3% to 13.1% (P = 0.1902). CONCLUSIONS Our study demonstrates that increased DBN is an achievable and sustainable goal for hospitals. Future work will allow for better understanding of the full effects of such an intervention on patient outcomes and hospital metrics. Journal of Hospital Medicine 2014;9:210–214. © 2014 Society of Hospital Medicine

A national comparison of burnout and work‐life balance among internal medicine hospitalists and outpatient general internists

Abstract: BACKGROUND General internists suffer higher rates of burnout and lower satisfaction with work-life balance than most specialties, but the impact of inpatient vs outpatient practice location is unclear. METHODS Physicians in the American Medical Association Physician Masterfile were previously surveyed about burnout, depression, suicidal ideation, quality of life, fatigue, work-life balance, career plans, and health behaviors. We extracted and compared data for these variables for the 130 internal medicine hospitalists and 448 outpatient general internists who participated. Analyses were adjusted for age, sex, hours worked, and practice setting. RESULTS There were 52.3% of the hospitalists and 54.5% of the outpatient internists affected by burnout (P = 0.86). High scores on the emotional exhaustion subscale (43.8% vs 48.1%, P = 0.71) and on the depersonalization subscale (42.3% vs 32.7%, P = 0.17) were common but similar in frequency in the 2 groups. Hospitalists were more likely to score low on the personal accomplishment subscale (20.3% vs 9.6%, P = 0.04). There were no differences in symptoms of depression (40.3% for hospitalists vs 40.0% for outpatient internists, P = 0.73) or recent suicidality (9.2% vs 5.8%, P = 0.15). Rates of reported recent work-home conflict were similar (48.4% vs 41.3%, P = 0.64), but hospitalists were more likely to agree that their work schedule leaves enough time for their personal life and family (50.0% vs 42.0%, P = 0.007). CONCLUSIONS Burnout was common among both hospitalists and outpatient general internists, although hospitalists were more satisfied with work-life balance. A better understanding of the causes of distress and identification of solutions for all internists is needed. Journal of Hospital Medicine 2014;9:176–181. © 2014 Society of Hospital Medicine

How do supervising physicians decide to entrust residents with unsupervised tasks? A qualitative analysis

Abstract: BACKGROUND Medical supervisors struggle to find meaningful ways to evaluate the preparedness of trainees to independently perform patient care tasks. The aim of this study was to describe the factors that influence how attending and resident physician perceptions of trust impact decision making. METHODS Internal medicine residents and attending physicians at a tertiary academic medical center were interviewed during a single academic year. Participants were asked to describe, using the critical incident technique, entrustment decisions made during their clinical rotations. A deductive qualitative analysis using the entrustable professional activities framework was used. The inter-rater reliability was calculated using a generalized kappa statistic. RESULTS Eighty-four percent (46/50) of residents and 88% (44/50) of attending physicians participated. The analysis yielded 535 discrete mentions of entrusting factors that were mapped to the following domains deductively, with inductively derived subthemes: trainee factors (eg, confidence, specialty plans), supervisor factors (eg, approachability), task factors (eg, situational characteristics) and systems factors (eg, workload). The inter-rater kappa between the 2 raters was 0.84. CONCLUSIONS Factors influencing trust in a trainee are related to the supervisor, trainee, their relationship, task, and the environment. Attending physicians note early interactions and language cues as markers of trustworthiness. Attending physicians reported using perceived confidence as a gauge of the trainee's true ability and comfort. Attendings noted trainee absences, even those that comply with regulation, negatively affected willingness to entrust. Future studies are needed to develop better assessment instruments to understand how entrustment decisions for independent practice are made. Journal of Hospital Medicine 2014;9:169–175. © 2014 Society of Hospital Medicine

Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis.

Abstract: BACKGROUND Hip fracture surgery and lower extremity arthroplasty are associated with increased risk of both venous thromboembolism and bleeding. The best pharmacologic strategy for reducing these opposing risks is uncertain. PURPOSE To compare venous thromboembolism (VTE) and bleeding rates in adult patients receiving aspirin versus anticoagulants after major lower extremity orthopedic surgery. DATA SOURCES Medline, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Library through June 2013; reference lists, ClinicalTrials.gov, and scientific meeting abstracts. STUDY SELECTION Randomized trials comparing aspirin to anticoagulants for prevention of VTE following major lower extremity orthopedic surgery. DATA EXTRACTION Two reviewers independently extracted data on rates of VTE, bleeding, and mortality. DATA SYNTHESIS Of 298 studies screened, 8 trials including 1408 participants met inclusion criteria; all trials screened participants for deep venous thrombosis (DVT). Overall rates of DVT did not differ statistically between aspirin and anticoagulants (relative risk [RR]: 1.15 [95% confidence interval {CI}: 0.68–1.96]). Subgrouped by type of surgery, there was a nonsignificant trend favoring anticoagulation following hip fracture repair but not knee or hip arthroplasty (hip fracture RR: 1.60 [95% CI: 0.80–3.20], 2 trials; arthroplasty RR: 1.00 [95% CI: 0.49–2.05], 5 trials). The risk of bleeding was lower with aspirin than anticoagulants following hip fracture repair (RR: 0.32 [95% CI: 0.13–0.77], 2 trials), with a nonsignificant trend favoring aspirin after arthroplasty (RR: 0.63 [95% CI: 0.33–1.21], 5 trials). Rates of pulmonary embolism were too low to provide reliable estimates. CONCLUSION Compared with anticoagulation, aspirin may be associated with higher risk of DVT following hip fracture repair, although bleeding rates were substantially lower. Aspirin was similarly effective after lower extremity arthroplasty and may be associated with lower bleeding risk. Journal of Hospital Medicine 2014;9:579–585. © 2014 Society of Hospital Medicine

A randomized trial of real‐time automated clinical deterioration alerts sent to a rapid response team

Abstract: BACKGROUND Episodes of patient deterioration on hospital units are expected to increasingly contribute to morbidity and healthcare costs. OBJECTIVE To determine if real-time alerts sent to the rapid response team (RRT) improved patient care. DESIGN Randomized, controlled trial. SETTING Eight medicine units (Barnes-Jewish Hospital). PATIENTS Five hundred seventy-one patients. INTERVENTION Real-time alerts generated by a validated deterioration algorithm were sent real-time to the RRT (intervention) or hidden (control). MEASUREMENTS Intensive care unit (ICU) transfer, hospital mortality, hospital duration. RESULTS ICU transfer (17.8% vs 18.2%; odds ratio: 0.972; 95% confidence interval [CI]: 0.635–1.490) and hospital mortality (7.3% vs 7.7%; odds ratio: 0.947; 95% CI: 0.509-1.764) were similar for the intervention and control groups. The number of patients requiring transfer to a nursing home or long-term acute care hospital was similar for patients in the intervention and control groups (26.9% vs 26.3%; odds ratio: 1.032; 95% CI: 0.712–1.495). Hospital duration (8.4 ± 9.5 days vs 9.4 ± 11.1 days; P = 0.038) was statistically shorter for the intervention group. The number of RRT calls initiated by the primary care team was similar for the intervention and control groups (19.9% vs 16.5%; odds ratio: 1.260; 95% CI: 0.823-1.931). CONCLUSIONS Real-time alerts sent to the RRT did not reduce ICU transfers, hospital mortality, or the need for subsequent long term care. However, hospital length of stay was modestly reduced. Journal of Hospital Medicine 2014;9:424–429. © 2014 Society of Hospital Medicine

Prevalence and predictors of return visits to pediatric emergency departments

Abstract: OBJECTIVE To determine the rate of return visits to pediatric emergency departments (EDs) and identify patient- and visit-level factors associated with return visits and hospitalization upon return. DESIGN AND SETTING Retrospective cohort study of visits to 23 pediatric EDs in 2012 using data from the Pediatric Health Information System. PARTICIPANTS Patients <18 years old discharged following an ED visit. MEASURES The primary outcomes were the rate of return visits within 72 hours of discharge from the ED and of return visits within 72 hours resulting in hospitalization. Results: 1,415,721 of the 1,610,201 ED visits to study hospitals resulted in discharge. Of the discharges, 47,294 patients (3.3%) had a return visit. Of these revisits, 9295 (19.7%) resulted in hospitalization. In multivariate analyses, the odds of having a revisit were higher for patients with a chronic condition (odds ratio [OR]: 1.91, 95% confidence interval [CI]: 1.86-1.96), higher severity scores (OR: 1.42, 95% CI: 1.40-1.45), and age <1 year (OR: 1.32, 95% CI: 1.22-1.42). The odds of hospitalization on return were higher for patients with higher severity (OR: 3.42, 95% CI: 3.23-3.62), chronic conditions (OR: 2.92, 95% CI: 2.75-3.10), age <1 year (1.7–2.5 times the odds of other age groups), overnight arrival (OR: 1.84, 95% CI: 1.71-1.97), and private insurance (OR: 1.47, 95% CI: 1.39-1.56). Sickle cell disease and cancer patients had the highest rates of return at 10.7% and 7.3%, respectively. CONCLUSIONS Multiple patient- and visit-level factors are associated with revisits. These factors may provide insight in how to optimize care and decrease avoidable ED utilization. Journal of Hospital Medicine 2014;9:779–787. © 2014 Society of Hospital Medicine

Bedside interprofessional rounds: Perceptions of benefits and barriers by internal medicine nursing staff, attending physicians, and housestaff physicians

Abstract: BACKGROUND Interprofessional collaboration improves the quality of care, but integration into workflow is challenging. Although a shared conceptualization regarding bedside interprofessional rounds may enhance implementation, little work has investigated providers' perceptions of this activity. OBJECTIVE To evaluate the perceptions of nurses, attending physicians, and housestaff physicians regarding the benefits/barriers to bedside interprofessional rounds. DESIGN AND PARTICIPANTS Observational, cross-sectional survey of hospital-based medicine nurses, attending physicians, and housestaff physicians. Descriptive, nonparametric Wilcoxon rank sum and nonparametric correlation were used. MAIN MEASURES Bedside interprofessional rounds were defined as “encounters including 2 physicians plus a nurse or other care provider discussing the case at the patient's bedside.” Eighteen items related to “benefits” and 21 items related to “barriers” associated with bedside interprofessional rounds. RESULTS Of 171 surveys sent, 149 were completed (87%). Highest-ranked benefits were related to communication/coordination, including “improves communication between nurses-physicians;” lowest-ranked benefits were related to efficiency, process, and outcomes, including “decreases length-of-stay” and “improves timeliness of consultations.” Nurses reported most favorable ratings for all items (P < 0.05). Rank order for 3 provider groups showed high correlation (r = 0.92, P < 0.001). Highest-ranked barriers were related to time, including “nursing staff have limited time;” lowest-ranked barriers were related to provider- and patient-related factors, including “patient lack of comfort.” Rank order of barriers among all groups showed moderate correlation (r = 0.62–0.82). CONCLUSIONS Although nurses perceived greater benefit for bedside interprofessional rounds than physicians, all providers perceived coordination/teamwork benefits higher than outcomes. To the extent the results are generalizable, these findings lay the foundation for facilitating meaningful patient-centered interprofessional collaboration. Journal of Hospital Medicine 2014;9:646–651. © 2014 Society of Hospital Medicine

US population aging and demand for inpatient services

Abstract: US inpatient capacity increased until the 1970s, then declined. The US Census Bureau expects the population aged ≥65 years to more than double by 2050. The implications for national inpatient capacity requirements have not been quantified. Our objective was to calculate the number of hospital admissions that will be necessitated by population aging, ceteris paribus. We estimated 2011 nationwide age-specific hospitalization rates using data from the Nationwide Inpatient Sample and Census data. We applied these rates to the population expected by the Census Bureau to exist through 2050. By 2050, the US population is expected to increase by 41%. Our analysis suggests that based on expected changes in the population age structure by then, the annual number of hospitalizations will increase by 67%. Thus, inpatient capacity would have to expand 18% more than population growth to meet demand. Total aggregate inpatient days is projected to increase 22% more than population growth. The total projected growth in required inpatient capacity is 72%, accounting for both number of admissions and length of stay. This analysis accounts only for changes in the population's age structure. Other factors could increase or decrease demand, as discussed in the article.

Hospital cardiac arrest resuscitation practice in the United States: a nationally representative survey.

Abstract: BACKGROUND In-hospital cardiac arrest (IHCA) outcomes vary widely between hospitals, even after adjusting for patient characteristics, suggesting variations in practice as a potential etiology. However, little is known about the standards of IHCA resuscitation practice among US hospitals. OBJECTIVE To describe current US hospital practices with regard to resuscitation care. DESIGN A nationally representative mail survey. SETTING A random sample of 1000 hospitals from the American Hospital Association database, stratified into 9 categories by hospital volume tertile and teaching status (major teaching, minor teaching, and nonteaching). SUBJECTS Surveys were addressed to each hospital's cardiopulmonary resuscitation (CPR) committee chair or chief medical/quality officer. MEASUREMENTS A 27-item questionnaire. RESULTS Responses were received from 439 hospitals with a similar distribution of admission volume and teaching status as the sample population (P = 0.50). Of the 270 (66%) hospitals with a CPR committee, 23 (10%) were chaired by a hospitalist. High frequency practices included having a rapid response team (91%) and standardizing defibrillators (88%). Low frequency practices included therapeutic hypothermia and use of CPR assist technology. Other practices such as debriefing (34%) and simulation training (62%) were more variable and correlated with the presence of a CPR committee and/or dedicated personnel for resuscitation quality improvement. The majority of hospitals (79%) reported at least 1 barrier to quality improvement, of which the lack of a resuscitation champion and inadequate training were the most common. CONCLUSIONS There is wide variability among hospitals and within practices for resuscitation care in the United States with opportunities for improvement. Journal of Hospital Medicine 2014;9:353–357. © 2014 Society of Hospital Medicine

Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery.

Abstract: BACKGROUND Patients presenting for surgery with angiotensin axis blockade (AAB) from therapy with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers experience an increased incidence of perioperative hypotension. Acute kidney injury (AKI) in patients receiving preoperative AAB has been demonstrated after lung, vascular, and cardiac surgery. However, there is little literature evaluating the hypotensive and renal effects of preoperative AAB and major orthopedic surgery. METHODS We performed a retrospective chart review of 1154 patients who underwent spinal fusion, total knee arthroplasty, or total hip arthroplasty during the 2010 calendar year in our academic medical center. RESULTS A total of 922 patients met inclusion criteria, 343 (37%) received preoperative AAB. Postinduction hypotension (systolic blood pressure ≤80 mm Hg for 5 minutes) was significantly higher in patients receiving AAB when compared to those not so treated (12.2% vs 6.7%; odds ratio [OR]: 1.93, P = 0.005). Of the 922 patients, 798 had documented measurements of both preoperative and postoperative creatinine. Postoperative AKI was significantly higher in patients receiving AAB therapy (8.3% vs 1.7%; OR: 5.40, P < 0.001), remaining significant after adjusting for covariates including hypotension (OR: 2.60, P = 0.042). Developing AKI resulted in a significantly higher mean length of stay (5.76 vs 3.28 days, P < 0.001) but no difference in 2-year mortality. CONCLUSIONS Patients undergoing major elective orthopedic surgery who receive preoperative AAB therapy,have an associated increased risk of postinduction hypotension and postoperative acute kidney injury resulting in a greater hospital length of stay. Journal of Hospital Medicine 2014;9:283–288. © 2014 Society of Hospital Medicine

Thirty-day mortality risk associated with the postoperative nonresumption of angiotensin-converting enzyme inhibitors: a retrospective study of the Veterans Affairs Healthcare System.

Abstract: BACKGROUND Angiotensin-converting enzyme inhibitors (ACE-Is) are a widely used class of cardiovascular medication. However, limited data exist on the risks of postoperative nonresumption of an ACE-I. OBJECTIVE To evaluate the factors and 30-day mortality risks associated with the postoperative nonresumption of an ACE-I. DESIGN A retrospective cohort study. SETTING Veterans Affairs (VA) Healthcare System. PATIENTS A total of 294,505 admissions in 240,978 patients with multiple preoperative prescription refills (>3) for an ACE-I who underwent inpatient surgery from calendar years 1999 to 2012. INTERVENTION None. MEASUREMENTS We classified surgical admissions based upon the timing of postoperative resumption of an ACE-I prescription from the day of surgery through postoperative days 0 to 14 and 15 to 30, and collected 30-day mortality data. We evaluated the relationship between 30-day mortality and the nonresumption of an ACE-I from postoperative day 0 to 14 using proportional hazard regression models, adjusting for patient- and hospital-level risk factors. Sensitivity analyses were conducted using more homogeneous subpopulations and propensity score models. RESULTS Twenty-five percent of our cohort did not resume an ACE-I during the 14 days following surgery. Nonresumption of an ACE-I within postoperative day 0 to 14 was independently associated with increased 30-day mortality (hazard ratio: 3.44; 95% confidence interval: 3.30-3.60; P < 0.001) compared to the restart group. Sensitivity analyses maintained this relationship. CONCLUSIONS Nonresumption of an ACE-I is common after major inpatient surgery in the large VA Health Care System. Restarting of an ACE-I within postoperative day 0 to 14 is, however, associated with decreased 30-day mortality. Careful attention to the issue of timely reinstitution of chronic medications such as an ACE-I is indicated. Journal of Hospital Medicine 2014;9:289–296. 2014 Society of Hospital Medicine

Comparison of Hospital Consumer Assessment of Healthcare Providers and Systems patient satisfaction scores for specialty hospitals and general medical hospitals: confounding effect of survey response rate.

Abstract: BACKGROUND Specialty hospitals are a subset of acute-care hospitals that provide a narrower set of services than general medical hospitals (GMHs), predominantly in areas such as cardiac disease and surgery. Although specialty hospitals also advertise high patient satisfaction, this has not been examined using national data. We examined the differences in Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) satisfaction scores in a national sample. METHODS HCAHPS results were obtained for July 2007 to June 2010. Specialty hospitals were identified using the American Hospital Association's Annual Survey, the Physician Hospital Association's directory, a name search of hospitals on the HCAHPS database, contact with experts, and online searches. Multiple linear regression was performed to examine the relationship between overall satisfaction and hospital specialty status, survey response rate, and subdomains of patient satisfaction. RESULTS We identified 188 specialty hospitals and 4368 GMHs. Specialty hospitals were disproportionately located in states that do not require Certification Of Need (47.9%), and had a higher overall patient satisfaction score (86.6 vs 67.8%, P 50% (from 18.5 to 8.7) but remained significantly higher (P < 0.0001). Similar results were obtained for patient satisfaction subdomains. CONCLUSION Specialty hospitals have a significantly higher overall HCAHPS patient satisfaction score than GMHs, although more than half of this difference disappears when adjusted for survey response rate. Comparisons among healthcare organizations should take into account survey response rates. Journal of Hospital Medicine 2014;9:590–593. © 2014 Society of Hospital Medicine

Prevalence and characteristics of hospitalized adults on chronic opioid therapy

Abstract: BACKGROUND As chronic opioid therapy (COT) becomes more common, complexity of pain management in the inpatient setting increases; little is known about medical inpatients on COT. OBJECTIVE To determine the prevalence of COT among hospitalized patients and to compare outcomes among these patients relative to those not receiving COT. DESIGN Observational study of inpatient and outpatient administrative data. PARTICIPANTS All veterans with acute medical admissions to 129 Veterans Administration hospitals during fiscal years 2009 to 2011, residing in the community, and with outpatient pharmacy use. MEASUREMENTS We defined COT as 90 or more days of opioids prescribed in the 6 months prior to hospitalization. Patient characteristics included demographic variables and major comorbidities. Outcomes included 30-day readmission and death during hospitalization or within 30 days, with associations ascertained using multivariable logistic regression. RESULTS Of 122,794 hospitalized veterans, 31,802 (25.9%) received COT. These patients differed from comparators in age, sex, race, residence, and presence of chronic noncancer pain, chronic obstructive pulmonary disease, complicated diabetes, cancer, and mental health diagnoses including post-traumatic stress disorder. After adjustment for demographic factors, comorbidities, and admission diagnosis, COT was associated with hospital readmission (odds ratio [OR]: 1.15, 95% confidence interval [CI]: 1.10-1.20) and death (OR: 1.19, 95% CI: 1.10-1.29). CONCLUSIONS COT is common among medical inpatients. Patients on COT differ from patients without COT beyond dissimilarities in pain and cancer diagnoses. Occasional and chronic opioid use are associated with increased risk of hospital readmission, and COT is associated with increased risk of death. Additional research relating COT to hospitalization outcomes is warranted. Journal of Hospital Medicine 2014;9:82–87. © 2013 Society of Hospital Medicine

Development and validation of a recurrent Clostridium difficile risk‐prediction model

Abstract: BACKGROUND Recurrent Clostridium difficile infection (rCDI) affects 10% to 25% of patients with initial CDI (iCDI). Initiation of new therapies that reduce recurrences rests on identifying patients at high risk for rCDI at iCDI onset. OBJECTIVE To develop a predictive model for rCDI based on factors present at iCDI onset. DESIGN Retrospective cohort study. SETTING Large urban academic medical center. PATIENTS All adult patients with an inpatient iCDI from January 1, 2003 to December 31, 2009. INTERVENTION None. MEASUREMENTS Positive toxin assay for C difficile with no C difficile infection in the previous 60 days constituted iCDI. Repeat positive toxin within 42 days of stopping iCDI treatment defined rCDI. Three demographic, 13 chronic, and 12 acute disease characteristics, and 7 processes of care prior to or at the onset of iCDI, were assessed for association with rCDI. A logistic regression model to identify predictors for rCDI was developed and cross-validated. RESULTS Among the 4196 patients enrolled, 425 (10.1%) developed rCDI. Six factors (case status as community-onset healthcare-associated, ≥2 hospitalizations in the prior 60 days, new gastric acid suppression, fluoroquinolone and high-risk antibiotic use at the onset of iCDI, age) predicted rCDI in multivariate analyses, whereas intensive care unit stay appeared protective. The model achieved moderate discrimination (C statistic 0.643) and calibration (Brier score 0.089). Its negative predictive value was 90% or higher across a wide range of risk. CONCLUSIONS Among patients hospitalized with rCDI, multiple factors present at the onset of iCDI increased the risk for rCDI. Recognizing patients at high-risk for rCDI can help clinicians tailor early treatment and prevention. Journal of Hospital Medicine 2014;9:418–423. © 2014 Society of Hospital Medicine

Association of serum sodium with morbidity and mortality in hospitalized patients undergoing major orthopedic surgery

Abstract: BACKGROUND Dysnatremia may predispose to falls and fractures, and serum sodium may influence bone health. Little is known of the association of perioperative dysnatremia and clinical outcomes in those undergoing major orthopedic surgery. OBJECTIVE We examined the association of serum sodium (corrected for glucose) with morbidity and mortality in a sample of hospitalized patients undergoing major orthopedic procedures at 2 large academic medical centers. DESIGN Retrospective observational study. SETTING AND PARTICIPANTS Adult patients admitted to major academic teaching hospitals for a major orthopedic procedure from January 2006 to January 2011. METHODS The association of serum sodium with log-transformed hospital length of stay was assessed by fitting linear regression models. The association with 30-day mortality was assessed by fitting Cox proportional hazards models. RESULTS There were 16,206 unique admissions, of which 44.8% were male, with a mean age of 62.5 years. Mean corrected serum sodium was 138.5 ± 2.9 mmol/L; 1.2% had moderate/severe hyponatremia, 6.4% had mild hyponatremia, and 2.5% were hypernatremic. In adjusted models, compared with normonatremia, moderate/severe hyponatremia, mild hyponatremia, and hypernatremia were associated with a 1.6-, 1.4-, and 1.4-day-longer hospital stay, respectively, and greater risk of 30-day mortality (hazard ratio [HR]: 2.47, 95% confidence interval [CI]: 1.33-4.59 for moderate/severe hyponatremia; HR: 1.80, 95% CI: 1.21-2.66 for mild hyponatremia; and HR: 2.99, 95% CI: 1.79-4.98 for hypernatremia). CONCLUSION AND RELEVANCE Dysnatremia is relatively common in the hospitalized orthopedic population and associated with greater length of stay and 30-day mortality. Future studies should address potential mechanisms underlying these associations and whether correction of perioperative dysnatremia may improve patient outcomes. Journal of Hospital Medicine 2014;9:297–302. © 2014 Society of Hospital Medicine

Nurse practitioner and physician assistant scope of practice in 118 acute care hospitals

Abstract: Background Advanced practice providers (APPs), including nurse practitioners (NPs) and physician assistants (PAs) are cost-effective substitutes for physicians, with similar outcomes in primary care and surgery. However, little is understood about APP roles in inpatient medicine. Objective Describe APPs role in inpatient medicine. Design Observational cross-sectional cohort study. Setting One hundred twenty-four Veterans Health Administration (VHA) hospitals. Participants Chiefs of medicine (COMs) and nurse managers. Measurements Surveys included inpatient medicine scope of practice for APPs and perceived healthcare quality. We conducted bivariate unadjusted and multivariable adjusted analyses. Results One hundred eighteen COMs (95.2%) and 198 nurse managers (75.0%) completed surveys. Of 118 medicine services, 56 (47.5%) employed APPs; 27 (48.2%) used NPs only, 15 (26.8%) PAs only, and 14 (25.0%) used both. Full-time equivalents for NPs was 0.5 to 7 (mean = 2.22) and PAs was 1 to 9 (mean = 2.23). Daily caseload was similar at 4 to 10 patients (mean = 6.5 patients). There were few significant differences between tasks. The presence of APPs was not associated with patient or nurse manager satisfaction. Presence of NPs was associated with greater overall inpatient and discharge coordination ratings by COMs and nurse managers, respectively; the presence of PAs was associated with lower overall inpatient coordination ratings by nurse managers. Conclusions NPs and PAs work on half of VHA inpatient medicine services with broad, yet similar, scopes of practice. There were few differences between their roles and perceptions of care. Given their very different background, regulation, and reimbursement, this has implications for inpatient medicine services that plan to hire NPs or PAs.

Assessing preventability in the quest to reduce hospital readmissions.

Abstract: Hospitals devote significant human and capital resources to eliminate hospital readmissions, prompted most recently by the Centers for Medicare and Medicaid Services (CMS) financial penalties for higher-than-expected readmission rates. Implicit in these efforts are assumptions that a significant proportion of readmissions are preventable, and preventable readmissions can be identified. Yet, no consensus exists in the literature regarding methods to determine which readmissions are reasonably preventable. In this article, we examine strengths and limitations of the CMS readmission metric, explore how preventable readmissions have been defined and measured, and discuss implications for readmission reduction efforts. Drawing on our clinical, research and operational experiences, we offer suggestions to address the key challenges in moving forward to measure and reduce preventable readmissions.

Screening for novel risk factors related to peripherally inserted central catheter-associated complications.

Abstract: BACKGROUND Peripherally inserted central catheters (PICCs) are increasingly utilized. Patient and system factors that increase risk of complications should be identified to avoid preventable patient harm. METHODS A case control analysis of adult inpatients who underwent PICC placement from January 2009 to January 2010 at Scott & White Memorial Hospital was conducted to determine the incidence and risk factors for complications. One hundred seventy cases of inpatients who experienced PICC-related complications were identified. Age- and gender-matched controls were randomly selected among patients who underwent PICC placement without documented complications during this time. RESULTS A total of 1444 PICCs were placed, with a complication rate of 11.77% (95% confidence interval: 10.11%-13.44%). Complications included catheter-associated thrombosis (3%), mechanical complications (4%), catheter-associated bloodstream infections (2%), and cellulitis (1%). In multivariable logistic regression analyses, malnutrition and after-hours placement were significantly associated with increased risk of complications, as was body mass index (BMI) >30 after adjusting for anticoagulation and time of placement. In a secondary multivariable logistic regression analysis, after-hours placement and malnutrition were significantly associated with increased risk of nonmechanical complications. Additionally, in conditional univariate analyses, length of stay, malnutrition, and after-hours placement were associated with increased risk of catheter-associated thrombosis. In our multivariable logistic regression analyses, use of anticoagulation/antiplatelet agents was associated with decreased risk of all-cause complications, nonmechanical complications, and catheter-associated thrombosis. CONCLUSIONS Screening of patients undergoing PICC placement with attention to malnutrition, BMI >30, and length of stay may reduce the risk of PICC-associated complications. Use of anticoagulation/antiplatelet agents and avoiding after-hours placement may reduce complications and enhance patient safety. Journal of Hospital Medicine 2014;9:481–489. © 2014 Society of Hospital Medicine

Inpatient pharmacological sleep aid utilization is common at a tertiary medical center.

Abstract: BACKGROUND Sleep is known to be poor in the hospital. Patients frequently request pharmacological sleep aids, despite the risk of altered mental status (delirium) and falls. Little is known about the scope of pharmacological sleep aid use in hospitalized patients. METHODS We performed a single center, retrospective review of all patients admitted to the general adult (age >18 years) medical and surgical units of a tertiary care center during a recent 2-month period (January 2013–February 2013). Review of the electronic medication administration system was performed to assess for medications administered for sleep. RESULTS Of 642 unique admissions, 168 patients (26.2%) received a medication for sleep. Most (n = 115, 68.5%) had no known history of insomnia or regular prior sleep medication use. Patients most frequently were treated with trazodone (30.4%; median dose, 50 mg; range, 12.5–450 mg), lorazepam (24.4%; median, 0.5 mg; range, 0.25–2 mg), and zolpidem tartrate (17.9%; median, 10 mg; range, 2.5–10 mg). Of the medications given, 36.7% were given early (before 9 pm) or late (after midnight). Of patients not known to be previously taking a pharmacological sleep aid, 34.3% of them were discharged with a prescription for one. CONCLUSIONS Despite increasing evidence of risks such as delirium or falls, pharmacological sleep aid use in general wards remains common, even in elderly patients. Medication administration time is frequently suboptimal. Many previously sleep medication-naive patients leave the hospital with a sleep aid prescription. Further research is needed to understand the factors that contribute to the high rate of sleep medication use in hospitalized patients. Journal of Hospital Medicine 2014;9:652–657. © 2014 Society of Hospital Medicine

Hospital-wide survey of the adequacy in the number of vascular catheters and catheter lumens.

Abstract: BACKGROUND Removal of unnecessary catheters has been proposed as an important measure to reduce catheter-related morbidity. Nevertheless, there is scarce information about the potential magnitude of such intervention. OBJECTIVE The present study was aimed at analyzing the appropriateness of use of vascular catheters and catheter lumens in the inpatient setting. DESIGN Cross-sectional survey. SETTING The entire population of adult inpatients admitted to a 1368-bed tertiary-care hospital in a single day. MEASUREMENTS We used a set of preestablished criteria to evaluate the appropriateness of use of vascular catheters and catheter lumens according to the number and administration regimen of intravenous drugs. RESULTS Out of 834 patients, 575 (68.9%) had ≥1 vascular catheters in place on the day of the survey. The type and distribution of the 703 surveyed catheters were peripheral venous catheter, 80.6%; central venous catheter, 15.8%; and arterial catheter, 3.6%. We found an overall mean of 2.06 ± 0.82 lumens per catheter, with significant differences between intensive care units and conventional wards (P < 0.0001). Based on our criteria, 126 out of 575 patients (21.9%) had an inappropriate number of catheters (medical wards, 20.0%; surgical wards, 23.9%; intensive care units, 26.3%), and 631 out of 14248 nonarterial catheter lumens (43.6%) were considered unnecessary. CONCLUSIONS Significant room exists for improving the adequacy of the number of vascular catheters and catheter lumens as a potentially useful tool for decreasing the incidence of catheter-related bloodstream infection. Journal of Hospital Medicine 2014;9:35–41. © 2013 Society of Hospital Medicine

Impact of pocket ultrasound use by internal medicine housestaff in the diagnosis of dyspnea.

Abstract: Background Recent reports demonstrate high diagnostic accuracy of lung ultrasound for evaluation of dyspnea. We assessed the feasibility of training internal medicine residents in lung ultrasound with a pocket ultrasound device. Methods We performed a prospective, observational trial of residents performing lung ultrasound with a pocket ultrasound. Training consisted of two 90-minute sessions of didactics and supervised bedside performance. Two residents received an additional 2 weeks of training. Residents recorded a clinical diagnosis based on admission data. Following lung ultrasound performance, an ultrasound diagnosis was recorded integrating clinical and sonographic findings. Using receiver operating curve analysis, the area under the curve was calculated for both clinical diagnosis and ultrasound diagnosis using attending physician's final discharge diagnosis as the gold standard. Results Five residents performed 69 exams. The AUC for ultrasound diagnosis was significantly higher than that for clinical diagnosis (0.87 vs 0.81, P Conclusions Lung ultrasound performed by residents with a pocket ultrasound improved the diagnostic accuracy of dyspnea. Two residents undergoing extended training showed a total increase in diagnostic accuracy.