Showing papers in "Journal of Hospital Medicine in 2015"

Development, implementation, and impact of an automated early warning and response system for sepsis.

Abstract: BACKGROUND Early recognition and timely intervention significantly reduce sepsis-related mortality. OBJECTIVE Describe the development, implementation, and impact of an early warning and response system (EWRS) for sepsis. DESIGN After tool derivation and validation, a preimplementation/postimplementation study with multivariable adjustment measured impact. SETTING Urban academic healthcare system. PATIENTS Adult non-ICU patients admitted to acute inpatient units from October 1, 2011 to October 31, 2011 for tool derivation, June 6, 2012 to July 5, 2012 for tool validation, and June 6, 2012 to September 4, 2012 and June 6, 2013 to September 4, 2013 for the preimplementation/postimplementation analysis. INTERVENTION An EWRS in our electronic health record monitored laboratory values and vital signs in real time. If a patient had ≥4 predefined abnormalities at any single time, the provider, nurse, and rapid response coordinator were notified and performed an immediate bedside patient evaluation. MEASUREMENTS Screen positive rates, test characteristics, predictive values, and likelihood ratios; system utilization; and resulting changes in processes and outcomes. RESULTS The tool's screen positive, sensitivity, specificity, and positive and negative predictive values and likelihood ratios for our composite of intensive care unit (ICU) transfer, rapid response team call, or death in the derivation cohort was 6%, 16%, 97%, 26%, 94%, 5.3, and 0.9, respectively. Validation values were similar. The EWRS resulted in a statistically significant increase in early sepsis care, ICU transfer, and sepsis documentation, and decreased sepsis mortality and increased discharge to home, although neither of these latter 2 findings reached statistical significance. CONCLUSIONS An automated prediction tool identified at-risk patients and prompted a bedside evaluation resulting in more timely sepsis care, improved documentation, and a suggestion of reduced mortality. Journal of Hospital Medicine 2015;10:26–31. © 2014 Society of Hospital Medicine

International prevalence of the use of peripheral intravenous catheters

Abstract: Over a billion peripheral intravenous catheters (PIVCs) are inserted each year in hospitalized patients worldwide. However, international data on prevalence and management of these devices are lacking. The study assessed the prevalence of PIVCs and their management practices across different regions of the world. This global audit involved 14 hospitals across 13 countries, with 479 patients screened for the presence of a PIVC. We found 59% of patients had at least 1 PIVC in place, and 16% had other types of vascular devices. We also found that overall, 25% of patients had no vascular device in place. The majority of PIVCs were inserted by nursing staff or a specialist team. The prevalence of idle PIVCs in place with no fluid or medication orders was 16%, and 12% of PIVCs had at least 1 symptom of phlebitis.

Ultrasound in the diagnosis and management of pleural effusions.

Abstract: We review the literature on the use of point-of-care ultrasound to evaluate and manage pleural effusions. Point-of-care ultrasound is more sensitive than physical exam and chest radiography to detect pleural effusions, and avoids many negative aspects of computerized tomography. Additionally, point-of-care ultrasound can assess pleural fluid volume and character, revealing possible underlying pathologies and guiding management. Thoracentesis performed with ultrasound guidance has lower risk of pneumothorax and bleeding complications. Future research should focus on the clinical effectiveness of point-of-care ultrasound in the routine management of pleural effusions and how new technologies may expand its clinical utility.

Safety of peripheral intravenous administration of vasoactive medication.

Abstract: BACKGROUND Central venous access is commonly performed to administer vasoactive medication. The administration of vasoactive medication via peripheral intravenous access is a potential method of reducing the need for central venous access. The aim of this study was to evaluate the safety of vasoactive medication administered through peripheral intravenous access. METHODS Over a 20-month period starting in September 2012, we monitored the use of vasoactive medication via peripheral intravenous access in an 18-bed medical intensive care unit. Norepinephrine, dopamine, and phenylephrine were all approved for use through peripheral intravenous access. RESULTS A total of 734 patients (age 72 ± 15 years, male/female 398/336, SAPS II score 75 ± 15) received vasoactive medication via peripheral intravenous access 783 times. Vasoactive medication used was norepinephrine (n = 506), dopamine (n = 101), and phenylephrine (n = 176). The duration of vasoactive medication via peripheral intravenous access was 49 ± 22 hours. Extravasation of the peripheral intravenous access during administration of vasoactive medication occurred in 19 patients (2%) without any tissue injury following treatment, with local phentolamine injection and application of local nitroglycerin paste. There were 95 patients (13%) receiving vasoactive medication through peripheral intravenous access who eventually required central intravenous access. CONCLUSIONS Administration of norepinephrine, dopamine, or phenylephrine by peripheral intravenous access was feasible and safe in this single-center medical intensive care unit. Extravasation from the peripheral intravenous line was uncommon, and phentolamine with nitroglycerin paste were effective in preventing local ischemic injury. Clinicians should not regard the use of vasoactive medication is an automatic indication for central venous access. Journal of Hospital Medicine 2015;10:581–585. © 2015 Society of Hospital Medicine

Association between exposure to nonactionable physiologic monitor alarms and response time in a children's hospital

Abstract: BACKGROUND Alarm fatigue is reported to be a major threat to patient safety, yet little empirical data support its existence in the hospital. OBJECTIVE To determine if nurses exposed to high rates of nonactionable physiologic monitor alarms respond more slowly to subsequent alarms that could represent life-threatening conditions. DESIGN Observational study using video. SETTING Freestanding children's hospital. PATIENTS Pediatric intensive care unit (PICU) patients requiring inotropic support and/or mechanical ventilation, and medical ward patients. INTERVENTION None. MEASUREMENTS Actionable alarms were defined as correctly identifying physiologic status and warranting clinical intervention or consultation. We measured response time to alarms occurring while there were no clinicians in the patient's room. We evaluated the association between the number of nonactionable alarms the patient had in the preceding 120 minutes (categorized as 0–29, 30–79, or 80+ alarms) and response time to subsequent alarms in the same patient using a log-rank test that accounts for within-nurse clustering. RESULTS We observed 36 nurses for 210 hours with 5070 alarms; 87.1% of PICU and 99.0% of ward clinical alarms were nonactionable. Kaplan-Meier plots showed incremental increases in response time as the number of nonactionable alarms in the preceding 120 minutes increased (log-rank test stratified by nurse P < 0.001 in PICU, P = 0.009 in the ward). CONCLUSIONS Most alarms were nonactionable, and response time increased as nonactionable alarm exposure increased. Alarm fatigue could explain these findings. Future studies should evaluate the simultaneous influence of workload and other factors that can impact response time. Journal of Hospital Medicine 2015;10:345–351. © 2015 Society of Hospital Medicine

Bedside diagnosis of dysphagia: A systematic review

Abstract: Dysphagia is associated with aspiration, pneumonia, and malnutrition, but remains challenging to identify at the bedside. A variety of exam protocols and maneuvers are commonly used, but the efficacy of these maneuvers is highly variable. We conducted a comprehensive search of 7 databases, including MEDLINE, Embase, and Scopus, from each database's earliest inception through June 9, 2014. Studies reporting diagnostic performance of a bedside examination maneuver compared to a reference gold standard (videofluoroscopic swallow study or flexible endoscopic evaluation of swallowing with sensory testing) were included for analysis. From each study, data were abstracted based on the type of diagnostic method and reference standard study population and inclusion/exclusion characteristics, design, and prediction of aspiration. The search strategy identified 38 articles meeting inclusion criteria. Overall, most bedside examinations lacked sufficient sensitivity to be used for screening purposes across all patient populations examined. Individual studies found dysphonia assessments, abnormal pharyngeal sensation assessments, dual axis accelerometry, and 1 description of water swallow testing to be sensitive tools, but none were reported as consistently sensitive. A preponderance of identified studies was in poststroke adults, limiting the generalizability of results. No bedside screening protocol has been shown to provide adequate predictive value for presence of aspiration. Several individual exam maneuvers demonstrated reasonable sensitivity, but reproducibility and consistency of these protocols was not established. More research is needed to design an optimal protocol for dysphagia detection.

Preliminary development of an ultrabrief two-item bedside test for delirium.

Abstract: Delirium (acute confusion) is common in older adults and leads to poor outcomes, such as death, clinician and caregiver burden, and prolonged cognitive and functional decline.1–4 Delirium is extremely costly, with estimates ranging from $143 to $152 billion annually (2005 US$).5,6 Early detection and management may improve the poor outcomes and reduce costs attributable to delirium,3,7 yet delirium identification in clinical practice has been challenging, particularly when translating research tools to the bedside.8–10As a result, only 12% to 35% of delirium cases are detected in routine care, with hypoactive delirium and delirium superimposed on dementia most likely to be missed.11–15 To address these issues, we recently developed and published the three-dimensional Confusion Assessment Method (3D-CAM), the 3-minute diagnostic assessment for CAM-defined delirium.16 The 3D-CAM is a structured assessment tool that includes mental status testing, patient symptom probes, and guided interviewer observations for signs of delirium. 3D-CAM items were selected through a rigorous process to determine the most informative items for the 4 CAM diagnostic features.17 The 3D-CAM can be completed in 3 minutes, and has 95% sensitivity and 94% specificity relative to a reference standard.16 Despite the capabilities of the 3D-CAM, there are situations when even 3 minutes is too long to devote to delirium identification. Moreover, a 2-step approach in which a sensitive ultrabrief screen is administered, followed by the 3D-CAM in “positives,” may be the most efficient approach for large-scale delirium case identification. The aim of the current study was to use the 3D-CAM database to identify the most sensitive single item and pair of items in the diagnosis of delirium, using the reference standard in the diagnostic accuracy analysis. We hypothesized that we could identify a single item with greater than 80% sensitivity and a pair of items with greater than 90% sensitivity for detection of delirium.

Improving patient satisfaction through physician education, feedback, and incentives

Abstract: BACKGROUND Patient satisfaction has been associated with improved outcomes and become a focus of reimbursement. OBJECTIVE Evaluate an intervention to improve patient satisfaction. DESIGN Nonrandomized, pre-post study that took place from 2011 to 2012. SETTING Large tertiary academic medical center. PARTICIPANTS Internal medicine (IM) resident physicians, non-IM resident physicians, and adult patients of the resident physicians. INTERVENTION IM resident physicians were provided with patient satisfaction education through a conference, real-time individualized patient satisfaction score feedback, monthly recognition, and incentives for high patient-satisfaction scores. MAIN MEASURES Patient satisfaction on physician-related and overall satisfaction questions on the HCAHPS survey. We conducted a difference-in-differences regression analysis comparing IM and non-IM patient responses, adjusting for differences in patient characteristics. KEY RESULTS In our regression analysis, the percentage of patients who responded positively to all 3 physician-related Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) questions increased by 8.1% in the IM and 1.5% in the control cohorts (absolute difference 6.6%, P = 0.04). The percentage of patients who would definitely recommend this hospital to friends and family increased by 7.1% in the IM and 1.5% in the control cohorts (absolute difference 5.6%, P = 0.02). The national average for the HCAHPS outcomes studied improved by no more than 3.1%. LIMITATIONS This study was nonrandomized and was conducted at a single site. CONCLUSION To our knowledge, this is the first intervention associated with a significant improvement in HCAHPS scores. This may serve as a model to increase patient satisfaction, hospital revenue, and train resident physicians. Journal of Hospital Medicine 2015;10:497–502. © 2015 Society of Hospital Medicine

Reorganizing a hospital ward as an accountable care unit

Abstract: Traditional hospital wards are not specifically designed as effective clinical microsystems. The feasibility and sustainability of doing so are unclear, as are the possible outcomes. To reorganize a traditional hospital ward with the traits of an effective clinical microsystem, we designed it to have 4 specific features: (1) unit-based teams, (2) structured interdisciplinary bedside rounds, (3) unit-level performance reporting, and (4) unit-level nurse and physician coleadership. We called this type of unit an accountable care unit (ACU). In this narrative article, we describe our experience implementing each feature of the ACU. Our aim was to introduce a progressive approach to hospital care and training.

Diagnostic accuracy and effectiveness of automated electronic sepsis alert systems: A systematic review

Abstract: Background Although timely treatment of sepsis improves outcomes, delays in administering evidence-based therapies are common.

Demographic factors and hospital size predict patient satisfaction variance—implications for hospital value‐based purchasing

Abstract: BACKGROUND Hospital Value-Based Purchasing (HVBP) incentivizes quality performance-based healthcare by linking payments directly to patient satisfaction scores obtained from Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys. Lower HCAHPS scores appear to cluster in heterogeneous population-dense areas and could bias Centers for Medicare & Medicaid Services (CMS) reimbursement. OBJECTIVE Assess nonrandom variation in patient satisfaction as determined by HCAHPS. DESIGN Multivariate regression modeling was performed for individual dimensions of HCAHPS and aggregate scores. Standardized partial regression coefficients assessed strengths of predictors. Weighted Individual (hospital) Patient Satisfaction Adjusted Score (WIPSAS) utilized 4 highly predictive variables, and hospitals were reranked accordingly. SETTING A total of 3907 HVBP-participating hospitals. PATIENTS There were 934,800 patient surveys by the most conservative estimate. MEASUREMENTS A total of 3144 county demographics (US Census) and HCAHPS surveys. RESULTS Hospital size and primary language (non–English speaking) most strongly predicted unfavorable HCAHPS scores, whereas education and white ethnicity most strongly predicted favorable HCAHPS scores. The average adjusted patient satisfaction scores calculated by WIPSAS approximated the national average of HCAHPS scores. However, WIPSAS changed hospital rankings by variable amounts depending on the strength of the predictive variables in the hospitals’ locations. Structural and demographic characteristics that predict lower scores were accounted for by WIPSAS that also improved rankings of many safety-net hospitals and academic medical centers in diverse areas. CONCLUSIONS Demographic and structural factors (eg, hospital beds) predict patient satisfaction scores even after CMS adjustments. CMS should consider WIPSAS or a similar adjustment to account for the severity of patient satisfaction inequities that hospitals could strive to correct. Journal of Hospital Medicine 2015;10:503–509. © 2015 Society of Hospital Medicine

A multifaceted hospitalist quality improvement intervention: Decreased frequency of common labs.

Abstract: PURPOSE Common labs such as a daily complete blood count or a daily basic metabolic panel represent possible waste and have been targeted by professional societies and the Choosing Wisely campaign for critical evaluation. We undertook a multifaceted quality-improvement (QI) intervention in a large community hospitalist group to decrease unnecessary common labs. METHODS The QI intervention was composed of academic detailing, audit and feedback, and transparent reporting of the frequency with which common labs were ordered as daily within the hospitalist group. We performed a pre-post analysis, comparing a cohort of patients during the 10-month baseline period before the QI intervention and the 7-month intervention period. Demographic and clinical data were collected from the electronic medical record. The primary endpoint was number of common labs ordered per patient-day as estimated by a clustered multivariable linear regression model clustering by ordering hospitalist. Secondary endpoints included length of stay, hospital mortality, 30-day readmission, blood transfusion, amount of blood transfused, and laboratory cost per patient. RESULTS The baseline (n = 7824) and intervention (n = 5759) cohorts were similar in their demographics, though the distribution of primary discharge diagnosis-related groups differed. At baseline, a mean of 2.06 (standard deviation 1.40) common labs were ordered per patient-day. Adjusting for age, sex, and principle discharge diagnosis, the number of common labs ordered per patient-day decreased by 0.22 (10.7%) during the intervention period compared to baseline (95% confidence interval [CI], 0.34 to 0.11; P < 0.01). There were nonsignificant reductions in hospital mortality in the intervention period compared to baseline (2.2% vs 1.8%, P = 0.1) as well as volume of blood transfused in patients who received a transfusion (127.2 mL decrease; 95% CI, −257.9 to 3.6; P = 0.06). No effect was seen on length of stay or readmission rate. The intervention decreased hospital direct costs by an estimated $16.19 per admission or $151,682 annualized (95% CI, $119,746 to $187,618). CONCLUSION Implementation of a multifaceted QI intervention within a community-based hospitalist group was associated with a significant, but modest, decrease in the number of ordered lab tests and hospital costs. No effect was seen on hospital length of stay, mortality, or readmission rate. This intervention suggests that a community-based hospitalist QI intervention focused on daily labs can be effective in safely reducing healthcare waste without compromising quality of care. Journal of Hospital Medicine 2015;10:390–395. © 2015 Society of Hospital Medicine

A matter of priorities? Exploring the persistent gender pay gap in hospital medicine

Abstract: BACKGROUND Gender earnings disparities among physicians exist even after considering differences in specialty, part-time status, and practice type. Little is known about the role of job satisfaction priorities on earnings differences. OBJECTIVE To examine gender differences in work characteristics and job satisfaction priorities, and their relationship with gender earnings disparities among hospitalists. DESIGN Observational cross-sectional survey study. PARTICIPANTS US hospitalists in 2010. MEASUREMENTS Self-reported income, work characteristics, and priorities among job satisfaction domains. RESULTS On average, women compared to men hospitalists were younger, less likely to be leaders, worked fewer full-time equivalents, worked more nights, reported fewer daily billable encounters, more were pediatricians, worked in university settings, worked in the Western United States, and were divorced. More hospitalists of both genders prioritized optimal workload among the satisfaction domains. However, substantial pay ranked second in prevalence by men and fourth by women. Women hospitalists earned $14,581 less than their male peers in an analysis adjusting for these differences. CONCLUSIONS The gender earnings gap persists among hospitalists. A portion of the disparity is explained by the fewer women hospitalists compared to men who prioritize pay. Journal of Hospital Medicine 2015;10:486–490. © 2015 Society of Hospital Medicine

Changes in patient satisfaction related to hospital renovation: Experience with a new clinical building

Abstract: IMPORTANCE There is an increasing trend toward designing hospitals with patient-centered features like reduced noise, improved natural light, visitor friendly facilities, well-decorated rooms, and hotel-like amenities It has also been suggested that because patients cannot reliably distinguish positive experiences with the physical environment from positive experience with care, an improved hospital environment leads to higher satisfaction with physicians, nursing, food service, housekeeping, and higher overall satisfaction OBJECTIVE To characterize changes in patient satisfaction that occurred when clinical services (comprised of stable nursing, physician, and unit teams) were relocated to a new clinical building with patient-centered features We hypothesized that new building features would positively impact provider, ancillary staff, and overall satisfaction, as well as improved satisfaction with the facility DESIGN Natural experiment utilizing a pre-post design with concurrent controls SETTING Academic tertiary care hospital PARTICIPANTS We included all patients discharged from 12 clinical units that relocated to the new clinical building who returned surveys in the 75-month period following the move Premove baseline data were captured from the year prior to the move Patients on unmoved clinical units who returned satisfaction surveys served as concurrent controls EXPOSURE Patient-centered design features incorporated into the new clinical building All patients during the baseline period and control patients during the study period were located in usual patient rooms with standard hospital amenities MAIN OUTCOMES AND MEASURES The primary outcome was satisfaction scores on the Press Ganey and Hospital Consumer Assessment of Healthcare Providers and Systems survey, dichotomized at highest category versus lower categories We performed logistic regression to identify predictors of “top-box” scores RESULTS The move was associated with improved room- and visitor-related satisfaction without significant improvement in satisfaction with clinical providers, ancillary staff, and only 1 of 4 measures of overall satisfaction improved The most prominent increase was with pleasantness of decor (336% vs 648%) and visitor accommodation and comfort (500% vs 703%) CONCLUSION AND RELEVANCE Patients responded positively to pleasing surroundings and comfort, but were able to discriminate their experiences with the hospital environment from those with physicians and nurses The move to a new building had significant impact on only 1 of the 4 measures of overall patient satisfaction, as clinical care is likely to be the most important determinant of this outcome Hospital administrators should not use outdated facilities as an excuse for suboptimal provider satisfaction scores Journal of Hospital Medicine 2015;10:165–171 © 2014 Society of Hospital Medicine

Association of clinical practice guidelines with emergency department management of febrile infants ≤56 days of age

Abstract: BACKGROUND Differences among febrile infant institutional clinical practice guidelines (CPGs) may contribute to practice variation and increased healthcare costs. OBJECTIVE Determine the association between pediatric emergency department (ED) CPGs and laboratory testing, hospitalization, ceftriaxone use, and costs in febrile infants. DESIGN Retrospective cross-sectional study in 2013. SETTING Thirty-three hospitals in the Pediatric Health Information System. PATIENTS Infants aged ≤56 days with a diagnosis of fever. EXPOSURES The presence and content of ED-based febrile infant CPGs assessed by electronic survey. MEASUREMENTS Using generalized estimating equations, we evaluated the association between CPG recommendations and rates of urine, blood, cerebrospinal fluid (CSF) testing, hospitalization, and ceftriaxone use at ED discharge in 2 age groups: ≤28 days and 29 to 56 days. We also assessed CPG impact on healthcare costs. RESULTS We included 9377 ED visits; 21 of 33 EDs (63.6%) had a CPG. For neonates ≤28 days, CPG recommendations did not vary and were not associated with differences in testing, hospitalization, or costs. Among infants 29 to 56 days, CPG recommendations for CSF testing and ceftriaxone use varied. CSF testing occurred less often at EDs with CPGs recommending limited testing compared to hospitals without CPGs (adjusted odds ratio: 0.5, 95% confidence interval: 0.3-0.8). Ceftriaxone use at ED discharge varied significantly based on CPG recommendations. Costs were higher for admitted and discharged infants 29 to 56 days old at hospitals with CPGs. CONCLUSIONS CPG recommendations for febrile infants 29 to 56 days old vary across institutions for CSF testing and ceftriaxone use, correlating with observed practice variation. CPGs were not associated with lower healthcare costs. Journal of Hospital Medicine 2015;10:358–365. © 2015 Society of Hospital Medicine

Development and Validation of an Algorithm to Identify Planned Readmissions From Claims Data

Abstract: BACKGROUND It is desirable not to include planned readmissions in readmission measures because they represent deliberate, scheduled care. OBJECTIVES To develop an algorithm to identify planned readmissions, describe its performance characteristics, and identify improvements. DESIGN Consensus-driven algorithm development and chart review validation study at 7 acute-care hospitals in 2 health systems. PATIENTS For development, all discharges qualifying for the publicly reported hospital-wide readmission measure. For validation, all qualifying same-hospital readmissions that were characterized by the algorithm as planned, and a random sampling of same-hospital readmissions that were characterized as unplanned. MEASUREMENTS We calculated weighted sensitivity and specificity, and positive and negative predictive values of the algorithm (version 2.1), compared to gold standard chart review. RESULTS In consultation with 27 experts, we developed an algorithm that characterizes 7.8% of readmissions as planned. For validation we reviewed 634 readmissions. The weighted sensitivity of the algorithm was 45.1% overall, 50.9% in large teaching centers and 40.2% in smaller community hospitals. The weighted specificity was 95.9%, positive predictive value was 51.6%, and negative predictive value was 94.7%. We identified 4 minor changes to improve algorithm performance. The revised algorithm had a weighted sensitivity 49.8% (57.1% at large hospitals), weighted specificity 96.5%, positive predictive value 58.7%, and negative predictive value 94.5%. Positive predictive value was poor for the 2 most common potentially planned procedures: diagnostic cardiac catheterization (25%) and procedures involving cardiac devices (33%). CONCLUSIONS An administrative claims-based algorithm to identify planned readmissions is feasible and can facilitate public reporting of primarily unplanned readmissions. Journal of Hospital Medicine 2015;10:670–677. © 2015 Society of Hospital Medicine.

Maximizing teaching on the wards: Review and application of the One‐Minute Preceptor and SNAPPS models

Abstract: Hospitalist educators face a number of challenges in teaching clinical reasoning to residents and medical students. Helping to develop trainees' clinical acumen is an essential and highly nuanced process, yet complex patients, documentation requirements, and productivity goals compete with teaching time. Workplace-based assessment is particularly important for residents with the institution of the developmental milestones for meeting Accreditation Council for Graduate Medical Education competencies. Two frameworks for facilitating the clinical reasoning discussion-the One-Minute Preceptor preceptor and SNAPPS-have been well studied in the outpatient setting with positive results. Both models show promise for use in the inpatient teaching environment with little modification. This narrative review compares and contrasts these 2 teaching frameworks and discusses their application to the inpatient teaching environment. These models can provide opportunities for hospitalist educators to better assess trainees, integrate regular feedback, and encourage self-directed learning. These teaching frameworks can also allow hospitalists to provide more focused education to trainees without taking additional valuable time.

A smartphone‐enabled communication system to improve hospital communication: Usage and perceptions of medical trainees and nurses on general internal medicine wards

Abstract: BACKGROUND There is increasing interest in the use of information and communication technologies to improve how clinicians communicate in hospital settings. METHODS We implemented a communication system with support for physician handover and secure messaging on 2 general internal medicine wards. We measured usage and surveyed physicians and nurses on perceptions of the system's effects on communication. RESULTS Between May 2011 and August 2012, a clinical teaching team received, on average, 14.8 messages per day through the system. Messages were typically sent as urgent (69.1%) and requested a text reply (76.5%). For messages requesting a text reply, 8.6% did not receive a reply. For those messages that did receive a reply, the median response time was 2.3 minutes, and 84.5% of messages received a reply within 15 minutes. Of those who completed the survey, 95.3% were medical residents (82 of 86) and 81.7% were nurses (83 of 116). Medical trainees (82.8%) and nursing staff (78.3%) agreed or strongly agreed that the system helped to speed up their daily work tasks. Overall, 67.1% of the trainees and 73.2% of nurses agreed or strongly agreed that the system made them more accountable in their clinical roles. Only 35.8% of physicians and 26.3% of nurses agreed or strongly agreed that the system was useful for communicating complex issues. CONCLUSIONS In summary, with a system designed to improve communication, we found that there was high uptake and that users perceived that the system improved efficiency and accountability but was not appropriate for communicating complex issues. Journal of Hospital Medicine 2015;10:83–89. © 2014 Society of Hospital Medicine

Implementing hospital-based baby boomer hepatitis C virus screening and linkage to care: Strategies, results, and costs.

Abstract: BACKGROUND/OBJECTIVE The US Preventive Services Task Force recommends 1-time hepatitis C virus (HCV) screening of all baby boomers (born 1945–1965). However, little is known about optimal ways to implement HCV screening, counseling, and linkage to care. We developed strategies following approaches used for HIV to implement baby boomer HCV screening in a hospital setting and report results as well as costs. DESIGN/PATIENTS Prospective cohort of 6140 baby boomers admitted to a safety-net hospital in South Texas from December 1, 2012 to January 31, 2014 and followed to December 10, 2014. PROCEDURES/MEASUREMENTS The HCV screening program included clinician/staff education, electronic medical record algorithm for eligibility and order entry, opt-out consent, anti-HCV antibody test with reflex HCV RNA, personalized inpatient counseling, and outpatient case management. Outcomes were anti-HCV antibody-positive and HCV RNA–positive results. RESULTS Of 3168 eligible patients, 240 (7.6%) were anti-HCV positive, which was more likely (P < 0.05) for younger age, men, and uninsured. Of 214 (89.2%) patients tested for HCV RNA, 134 (4.2% of all screened) were positive (chronic HCV). Among patients with chronic HCV, 129 (96.3%) were counseled, 108 (80.6%) received follow-up primary care, and 52 (38.8%) received hepatology care. Five patients initiated anti-HCV therapy. Total costs for start-up and implementation for 14 months were $286,482. CONCLUSIONS This inpatient HCV screening program diagnosed chronic HCV infection in 4.2% of tested patients and linked >80% to follow-up care. Yet access to therapy is challenging for largely uninsured populations, and most programmatic costs of the program are not currently covered. Journal of Hospital Medicine 2015;10:510–516. © 2015 Society of Hospital Medicine

Characteristics associated with clinician diagnosis of aspiration pneumonia: a descriptive study of afflicted patients and their outcomes.

Abstract: Background Aspiration pneumonia is a common disease, although less well characterized than other pneumonia syndromes.

Gender disparities in leadership and scholarly productivity of academic hospitalists.

Abstract: BACKGROUND Gender disparities still exist for women in academic medicine but may be less evident in younger cohorts. Hospital medicine is a new field, and the majority of hospitalists are <41 years of age. OBJECTIVE To determine whether gender disparities exist in leadership and scholarly productivity for academic hospitalists and to compare the findings to academic general internists. DESIGN Prospective and retrospective observational study. SETTING University programs in the United States. MEASUREMENTS Gender distribution of (1) academic hospitalists and general internists, (2) division or section heads for both specialties, (3) speakers at the 2 major national meetings of the 2 specialties, and (4) first and last authors of articles from the specialties' 2 major journals RESULTS We found equal gender representation of hospitalists and general internists who worked in university hospitals. Divisions or sections of hospital medicine and general internal medicine were led by women at 11/69 (16%) and 28/80 (35%) of university hospitals, respectively (P = 0.008). Women hospitalists and general internists were listed as speakers on 146/557 (26%) and 291/580 (50%) of the presentations at national meetings, respectively (P < 0.0001), first authors on 153/464 (33%) and 423/895 (47%) publications, respectively (P < 0.0001), and senior authors on 63/305 (21%) and 265/769 (34%) articles, respectively (P < 0.0001). CONCLUSIONS Despite hospital medicine being a newer field, gender disparities exist in leadership and scholarly productivity. Journal of Hospital Medicine 2015;10:481–485. © 2015 Society of Hospital Medicine

The highest utilizers of care: Individualized care plans to coordinate care, improve healthcare service utilization, and reduce costs at an academic tertiary care center

Abstract: BACKGROUND High utilizers are medically and psychosocially complex, have high rates of emergency department (ED) visits and hospital admissions, and contribute to rising healthcare costs. OBJECTIVE Develop individualized care plans to reduce unnecessary healthcare service utilization and hospital costs for complex, high utilizers of inpatient and ED care. DESIGN Quality-improvement intervention with a retrospective pre/post intervention analysis. SETTING Nine hundred twenty-four–bed tertiary academic medical center. PATIENTS Twenty-four medically and psychosocially complex patients with the highest rates of inpatient admissions and ED visits from August 1, 2012 to August 31, 2013. INTERVENTION A multidisciplinary team developed individualized care plans integrated into our electronic medical record (EMR) that summarize patient histories, utilization patterns, and management strategies. MEASUREMENTS Primary outcomes included inpatient admissions, ED visits, and corresponding variable direct costs 6 and 12 months after care-plan implementation. Secondary outcomes include inpatient length of stay (LOS) and 30-day readmissions. RESULTS Hospital admissions decreased by 56% (P < 0.001) and 50.5% (P = 0.003), 6 and 12 months after care-plan implementation. Thirty-day readmissions decreased by 66% (P < 0.001) and 51.5% (P = 0.002), 6 and 12 months after care-plan implementation. ED visits, ED costs, and inpatient LOS did not significantly change. Inpatient variable direct costs were reduced by 47.7% (P = 0.001) and 35.8% (P = 0.052), 6 and 12 months after care-plan implementation. CONCLUSIONS Individualized care plans developed by a multidisciplinary team and integrated with the existing healthcare workforce and EMR reduce hospital admissions, 30-day readmissions, and hospital costs for complex, high-utilizing patients. Journal of Hospital Medicine 2015;10:419–424. © 2015 Society of Hospital Medicine

A nurse-driven screening tool for the early identification of sepsis in an intermediate care unit setting.

Abstract: BACKGROUND Use of a screening tool as a decision support mechanism for early detection of sepsis has been widely advocated, yet studies validating tool performance are scarce, especially in non–intensive care unit settings.

Diagnostic point-of-care ultrasound for hospitalists

Abstract: We review the literature on diagnostic point-of-care ultrasound applications most relevant to hospital medicine and highlight gaps in the evidence base. Diagnostic point-of-care applications most relevant to hospitalists include cardiac ultrasound for left ventricular systolic function, pericardial effusion, and severe mitral regurgitation; lung ultrasound for pneumonia, pleural effusion, pneumothorax, and pulmonary edema; abdominal ultrasound for ascites, aortic aneurysm, and hydronephrosis; and venous ultrasound for central venous volume assessment and lower extremity deep venous thrombosis. Hospitalists and other frontline providers, as well as physician trainees at various levels of training, have moderate to excellent diagnostic accuracy after brief training programs for most of these applications. Despite the evidence supporting the diagnostic accuracy of point-of-care ultrasound, experimental evidence supporting its clinical use by hospitalists is limited to cardiac ultrasound.

Use of provider-level dashboards and pay-for-performance in venous thromboembolism prophylaxis.

Abstract: BACKGROUND Despite safe and cost-effective venous thromboembolism (VTE) prevention measures, VTE prophylaxis rates are often suboptimal. Healthcare reform efforts emphasize transparency through programs to report performance and payment incentives through pay-for-performance programs. OBJECTIVE To sequentially examine an individualized physician dashboard and pay-for-performance program to improve VTE prophylaxis rates among hospitalists. DESIGN Retrospective analysis of 3144 inpatient admissions. After a baseline observation period, VTE prophylaxis compliance was compared during both interventions. SETTING A 1060-bed tertiary care medical center. PARTICIPANTS Thirty-eight part-time and full-time academic hospitalists. INTERVENTIONS A Web-based hospitalist dashboard provided VTE prophylaxis feedback. After 6 months of feedback only, a pay-for-performance program was incorporated, with graduated payouts for compliance rates of 80% to 100%. MEASUREMENTS Prescription of American College of Chest Physicians' guideline-compliant VTE prophylaxis and subsequent pay-for-performance payments. RESULTS Monthly VTE prophylaxis compliance rates were 86% (95% confidence interval [CI]: 85–88), 90% (95% CI: 88–93), and 94% (95% CI: 93–96) during the baseline, dashboard, and combined dashboard/pay-for-performance periods, respectively. Compliance significantly improved with the use of the dashboard (P = 0.01) and addition of the pay-for-performance program (P = 0.01). The highest rate of improvement occurred with the dashboard (1.58%/month; P = 0.01). Annual individual physician performance payments ranged from $53 to $1244 (mean $633; standard deviation ±$350). CONCLUSIONS Direct feedback using dashboards was associated with significantly improved compliance, with further improvement after incorporating an individual physician pay-for-performance program. Real-time dashboards and physician-level incentives may assist hospitals in achieving higher safety and quality benchmarks. Journal of Hospital Medicine 2015;10:172–178. © 2014 Society of Hospital Medicine

Stepping toward discharge: Level of ambulation in hospitalized patients

Abstract: Little information is available on how active adult patients are during their hospitalization. The purpose of this study is to describe the level of ambulation in hospitalized patients. This was a cohort study of ambulatory patients from 3 hospital medical-surgical units conducted March 2014 through July 2014. Patients wore an accelerometer upon admission to the unit until discharge to home. Sensor placement and data review were performed as part of routine care. Step counts were merged with administrative and clinical data for analysis. Data were available on 777 patients who had at least 24 hours of monitoring prior to discharge. The sample included 57% females, and 55% were nonwhite. The median total step count over 24 hours was 1158 (interquartile range: 636–2238). Patients who were older accrued fewer steps compared to younger patients (962 vs 1294, P < 0.0001). For patients who had at least 48 hours of monitoring (n = 378), there was an increase from 811 steps in the first 24 hours to 1188 steps in the final 24 hours prior to discharge. More frequent documentation was associated with higher step counts (P ≤ 0.001). We found that a diverse sample of hospitalized adult patients accrued over 1000 steps in the 24 hours prior to discharge home. Journal of Hospital Medicine 2015;10:384–389. © 2015 Society of Hospital Medicine

Patient preferences regarding pharmacologic venous thromboembolism prophylaxis.

Abstract: BACKGROUND The 2012 American College of Chest Physicians venous thromboembolism prevention guidelines emphasized the importance of considering patient preferences when ordering venous thromboembolism prophylaxis. OBJECTIVE Determine patient preferences regarding pharmacologic venous thromboembolism prophylaxis. DESIGN Single-center, mixed-methods survey. SETTING Academic medical center. PATIENTS Consecutive hospitalized patients on surgical and medical units. MEASUREMENTS Patients were asked about their preferences regarding the route of administration for pharmacologic venous thromboembolism prophylaxis and the rationale for their preference. Qualitative analyses of themes were determined from patient rationale. RESULTS Of the 227 patients, a majority (60.4%) preferred an oral medication, if equally effective to subcutaneous options. Dislike of needles (30.0%) and pain from injection (27.7%) were identified as rationales for their preference. Patients favoring subcutaneous administration (27.5%) identified a presumed faster onset of action (40.3%) as the primary reason for their preference. Patients with a preference for subcutaneous injections were less likely to refuse prophylaxis than patients who preferred an oral route of administration (37.5% vs 51.3%, P < 0.0001). LIMITATION Only medical and surgical patients participated. CONCLUSION In a sample of consecutive medical and surgical patients, a majority preferred an oral route of administration for prophylaxis. Patients preferring subcutaneous injections were less likely to refuse doses of ordered pharmacologic prophylaxis. These results indicate use of an oral agent for venous thromboembolism prophylaxis may improve adherence and that integrating patient preferences into care may increase delivery of effective prophylaxis and reduce the incidence of venous thromboembolism. Journal of Hospital Medicine 2015;10:108–111. © 2014 Society of Hospital Medicine

Reduction of inappropriate exit prescriptions for proton pump inhibitors: A before-after study using education paired with a web-based quality-improvement tool

Abstract: BACKGROUND Proton pump inhibitors (PPIs) are overprescribed despite concerns regarding associated adverse drug events OBJECTIVE To reduce inappropriate PPI prescriptions using hospitalization as the point of contact to effect meaningful change DESIGN Before-after study design SETTING Forty-six–bed medical clinical teaching unit in a 417-bed university teaching hospital in Montreal, Canada PATIENTS Four hundred sixty-four consecutively admitted patients in the preintervention control group, and 640 consecutively admitted patients in the intervention group INTERVENTION A monthly educational intervention paired with a Web-based quality improvement tool MEASUREMENTS We determined the proportion of patients admitted on PPIs, their indications, and appropriateness of use We then compared the proportion of patients whose PPIs were discontinued at discharge before and after our intervention RESULTS Forty-four percent of patients were already using a PPI prior to their hospitalization In evaluated patients, only 54% of these patients had an evidence-based indication for ongoing use The proportion of PPIs discontinued at hospital discharge increased from 77% per month in the 6 months prior to intervention, to 185% per month postintervention (P = 003) CONCLUSIONS Strategies to combat PPI overuse are needed to improve the overall quality of patient care We significantly reduced discharge prescriptions for PPIs through the implementation of an educational initiative paired with a Web-based quality improvement tool An active interventional strategy is likely required considering the increasingly recognized and preventable adverse events associated with PPI misuse Journal of Hospital Medicine 2015;10:281–286 © 2015 Society of Hospital Medicine

Discharge before noon: Effect on throughput and sustainability.

Abstract: BACKGROUND Late afternoon hospital discharges are thought to contribute to admission bottlenecks. We previously described an intervention that resulted in a statistically significant increase in the discharge before noon (DBN) rate on 2 inpatient medicine units. OBJECTIVE To evaluate (1) the effect of an increased DBN rate on the admission arrival time and the number of admissions per hour and (2) the sustainability of our DBN initiative. DESIGN Pre-/postintervention retrospective analysis. SETTING Two acute-care inpatient medicine units in a tertiary care, urban, academic medical center. PATIENTS: For the admission arrival time and admissions per hour analysis, all inpatients admitted to the medical units from June 1, 2011 to June 31, 2013. For the sustainability analysis, all patients discharged from July 1, 2013 to December 31, 2014. INTERVENTION A multidisciplinary intervention to increase the DBN rate. MEASUREMENTS: Date and time of arrival to all inpatient sites, and discharge date and time of all patients from 2 inpatient medicine units. RESULTS Concurrent with our increase in DBN rate, we found a statistically significant change in the median arrival time of emergency department (ED) admissions and transfers from 5 pm to 4 pm. High-frequency admission peaks were statistically significantly reduced for ED admissions. The statistically significant increase in DBN rate is sustained at 35%. CONCLUSIONS Increasing the DBN rate correlates with admissions arriving earlier in the day and reductions in high-frequency peaks of ED admissions. Statistically significant improvements in DBN rates are sustainable. Journal of Hospital Medicine 2015;10:664–669. © 2015 Society of Hospital Medicine

Outcomes associated with a mandatory gastroenterology consultation to improve the quality of care of patients hospitalized with decompensated cirrhosis.

Abstract: Background & Aims Patients with decompensated cirrhosis (DC) have significant morbidity, and resource utilization. In a cohort of patients with DC undergoing usual care (UC) in 2009, we demonstrated that quality indicators (QI) were met less than 50% of the time. We established a mandatory gastroenterology consultation (MC) to improve the care of patients with DC. We sought to evaluate the impact of the MC intervention on adherence to QI, and compared outcomes to UC.