Showing papers in "Journal of Hospital Medicine in 2018"

Use of short peripheral intravenous catheters: characteristics, management, and outcomes worldwide

Abstract: BACKGROUND: Peripheral intravenous catheter (PIVC) use in health care is common worldwide. Failure of PIVCs is also common, resulting in premature removal and replacement. OBJECTIVE: To investigate the characteristics, management practices, and outcomes of PIVCs internationally. SETTING/PATIENTS: Cross-sectional study. Hospitalized patients from rural, regional, and metropolitan areas internationally. MEASUREMENTS: Hospital, device, and inserter characteristics were collected along with assessment of the catheter insertion site. PIVC use in different geographic regions was compared. RESULTS: We reviewed 40,620 PIVCs in 51 countries. PIVCs were used primarily for intravenous medication (n = 28,571, 70%) and predominantly inserted in general wards (n = 22,167, 55%). Two-thirds of all devices were placed in non-recommended sites such as the hand, wrist, or antecubital veins. Nurses inserted most PIVCs (n = 28,575, 71%); although there was wide regional variation (26% to 97%). The prevalence of iIn this study, we found that many PIVCs were placed in areas of flexion, were symptomatic or idle, had suboptimal dressings, or lacked adequate documentation. This suggests inconsistency between recommended management guidelines for PIVCs and current practice.dle PIVCs was 14% (n = 5,796). Overall, 10% (n = 4,204) of PIVCs were painful to the patient or otherwise symptomatic of phlebitis; a further 10% (n = 3,879) had signs of PIVC malfunction; and 21% of PIVC dressings were suboptimal (n = 8,507). Over one-third of PIVCs (n = 14,787, 36%) had no documented daily site assessment and half (n = 19,768, 49%) had no documented date and time of insertion. CONCLUSIONS: In this study, we found that many PIVCs were placed in areas of flexion, were symptomatic or idle, had suboptimal dressings, or lacked adequate documentation. This suggests inconsistency between recommended management guidelines for PIVCs and current practice.

Development of Hospitalization Resource Intensity Scores for Kids (H-RISK) and Comparison across Pediatric Populations.

Abstract: Background In the Medicare population, measures of relative severity of illness (SOI) for hospitalized patents have been used in prospective payment models. Similar measures for pediatric populations have not been fully developed. Objective To develop hospitalization resource intensity scores for kids (H-RISK) using pediatric relative weights (RWs) for SOI and to compare hospital types on case-mix index (CMI). Design/methods Using the 2012 Kids' Inpatient Database (KID), we developed RWs for each All Patient Refined Diagnosis Related Group (APR-DRG) and SOI level. RW corresponded to the ratio of the adjusted mean cost for discharges in an APR-DRG SOI combination over adjusted mean cost of all discharges in the dataset. RWs were applied to every discharge from 3,117 hospitals in the database with at least 20 discharges. RWs were then averaged at the hospital level to provide each hospital's CMI. CMIs were compared by hospital type using Kruskal- Wallis tests. Results The overall adjusted mean cost of weighted discharges in Healthcare Cost and Utilization Project KID 2012 was $6,135 per discharge. Solid organ and bone marrow transplantations represented 4 of the 10 highest procedural RWs (range: 35.5 to 91.7). Neonatal APRDRG SOIs accounted for 8 of the 10 highest medical RWs (range: 19.0 to 32.5). Free-standing children's hospitals yielded the highest median (interquartile range [IQR]) CMI (2.7 [2.2-3.1]), followed by urban teaching hospitals (1.8 [1.3-2.6]), urban nonteaching hospitals (1.1 [0.9-1.5]), and rural hospitals (0.8 [0.7-0.9]; P Conclusions H-RISK for populations of pediatric admissions are sensitive to detection of substantial differences in SOI by hospital type.

Shorter Versus Longer Courses of Antibiotics for Infection in Hospitalized Patients: A Systematic Review and Meta-Analysis.

Abstract: Background Infection is a leading cause of hospitalization with high morbidity and mortality, but there are limited data to guide the duration of antibiotic therapy. Purpose Systematic review to compare outcomes of shorter versus longer antibiotic courses among hospitalized adults and adolescents. Data sources MEDLINE and Embase databases, 1990-2017. Study selection Inclusion criteria were human randomized controlled trials (RCTs) in English comparing a prespecified short course of antibiotics to a longer course for treatment of infection in hospitalized adults and adolescents aged 12 years and older. Data extraction Two authors independently extracted study characteristics, methods of statistical analysis, outcomes, and risk of bias. Data synthesis Of 5187 unique citations identified, 19 RCTs comprising 2867 patients met our inclusion criteria, including the following: 9 noninferiority trials, 1 superiority design trial, and 9 pilot studies. Across 13 studies evaluating 1727 patients, no significant difference in clinical efficacy was observed (d = 1.6% [95% confidence interval (CI), -1.0%-4.2%]). No significant difference was detected in microbiologic cure (8 studies, d = 1.2% [95% CI, -4.1%-6.4%]), short-term mortality (8 studies, d = 0.3% [95% CI, -1.2%-1.8%]), longer-term mortality (3 studies, d = -0.4% [95% CI, -6.3%-5.5%]), or recurrence (10 studies, d = 2.1% [95% CI, -1.2%-5.3%]). Heterogeneity across studies was not significant for any of the primary outcomes. Conclusions Based on the available literature, shorter courses of antibiotics can be safely utilized in hospitalized patients with common infections, including pneumonia, urinary tract infection, and intra-abdominal infection, to achieve clinical and microbiologic resolution without adverse effects on mortality or recurrence.

"We've Learned It's a Medical Illness, Not a Moral Choice": Qualitative Study of the Effects of a Multicomponent Addiction Intervention on Hospital Providers' Attitudes and Experiences.

Abstract: Background Substance use disorders (SUD) represent a national epidemic with increasing rates of SUD-related hospitalizations. However, most hospitals lack expertise or systems to directly address SUD. Healthcare professionals feel underprepared and commonly hold negative views toward patients with SUD. Little is known about how hospital interventions may affect providers' attitudes and experiences toward patients with SUD. Objective To explore interprofessional hospital providers' perspectives on how integrating SUD treatment and care systems affect providers' attitudes, beliefs, and experiences. Design In-depth semi-structured interviews and focus groups. The study was part of a formative evaluation of the Improving Addiction Care Team (IMPACT), an interprofessional hospital-based addiction medicine service with rapid-access pathways to post-hospital SUD treatment. Setting Single urban academic hospital in Portland, Oregon. Participants Multidisciplinary hospital providers. Measurements We conducted a thematic analysis using an inductive approach at a semantic level. Results Before IMPACT, participants felt that hospitalization did not address addiction, leading to untreated withdrawal, patients leaving against medical advice, chaotic care, and staff "moral distress." Participants felt that IMPACT "completely reframes" addiction as a treatable chronic disease, improving patient engagement and communication, and humanizing care. Participants valued post-hospital SUD treatment pathways and felt having systems to address SUD reduced burnout and provided relief. Providers noted that IMPACT had limited ability to address poverty or engage highly ambivalent patients. Conclusions Providers' distress of caring for patients with SUD is not inevitable. Hospital-based SUD interventions can reframe providers' views of addiction and may have significant implications for clinical care and providers' well-being.

Implementation of a Process for Initiating Naltrexone in Patients Hospitalized for Alcohol Detoxification or Withdrawal.

Abstract: BACKGROUND Naltrexone trials have demonstrated improved outcomes for patients with alcohol use disorders. Hospital initiation of naltrexone has had limited study. OBJECTIVE To describe the implementation and impact of a process for counseling hospitalized patients with alcohol withdrawal about naltrexone. DESIGN A pre-post study analysis. SETTING A tertiary academic center. PATIENTS Patients hospitalized for alcohol withdrawal. INTERVENTION (1) Provider education about the efficacy and contraindications of naltrexone and (2) algorithms for evaluating patients for naltrexone. MEASUREMENTS The percentages of patients counseled about and prescribed naltrexone before discharge and the percentages of pre- and postintervention patients with 30-day emergency department (ED) revisits and rehospitalizations. RESULTS We identified 128 patient encounters before and 114 after implementation. The percentage of patients counseled about naltrexone rose from 1.6% preimplementation to 63.2% postimplementation (P<.001); the percentage of patients prescribed naltrexone rose from 1.6% to 28.1% (P<.001). Comparing preintervention versus postintervention groups, there were no unadjusted differences in 30-day ED revisits (25.8% vs 19.3%; P=.23) or rehospitalizations (10.2% vs 11.4%; P=.75). When adjusted for demographics and comorbidities, postintervention patients had lower odds of 30-day ED revisits (odds ratio [OR]=0.47; 95% confidence interval [CI], 0.24-0.94) but no significant difference in rehospitalizations (OR=0.76; 95% CI, 0.30-1.92). In subgroup analysis, postintervention patients counseled versus those not counseled about naltrexone were less likely to have 30-day ED revisits (9.7% vs 35.7%; P=.001) and rehospitalizations (2.8% vs 26.2%; P<.001). CONCLUSIONS The implementation of a process for counseling patients hospitalized for alcohol withdrawal about using naltrexone for the maintenance of sobriety was associated with lower 30-day ED revisits but no statistically significant difference in rehospitalizations.

Hospital Readmissions in Patients with Cirrhosis: A Systematic Review

Abstract: Background Hospital readmission is a significant problem for patients with complex chronic illnesses such as liver cirrhosis. Purpose We aimed to describe the range of readmission risk in patients with cirrhosis and the impact of the model for end-stage liver disease (MELD) score. Data sources We conducted a systematic review of studies identified in Ovid MEDLINE, PubMed, EMBASE, CINAHL, the Cochrane Library, Scopus, Google Scholar, and ClinicalTrials.gov from 2000 to May 2017. Study selection We examined studies that reported early readmissions (up to 90 days) in patients with cirrhosis. Studies were excluded if they did not examine the association between readmission and at least 1 variable or intervention. Data extraction Two reviewers independently extracted data on study design, setting, population, interventions, comparisons, and detailed information on readmissions. Data synthesis Of the 1363 records reviewed, 26 studies met the inclusion and exclusion criteria. Of these studies, 21 were retrospective, and there was significant variation in the inclusion and exclusion criteria. The pooled estimate of 30-day readmissions was 26%(95% confidence interval [CI], 22%-30%). Few studies examined readmission preventability or the relationship between readmissions and social determinants of health. Reasons for readmission were highly variable. An increased MELD score was associated with readmissions in most studies. Readmission was associated with increased mortality. Conclusions Hospital readmissions frequently occur in patients with cirrhosis and are associated with liver disease severity. The impact of functional and social factors on readmissions is unclear.

Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement From the Society of Hospital Medicine.

Abstract: Hospital-based clinicians frequently treat acute, noncancer pain. Although opioids may be beneficial in this setting, the benefits must be balanced with the risks of adverse events, including inadvertent overdose and prolonged opioid use, physical dependence, or development of opioid use disorder. In an era of epidemic opioid use and related harms, the Society of Hospital Medicine (SHM) convened a working group to develop a consensus statement on opioid use for adults hospitalized with acute, noncancer pain, outside of the palliative, end-of-life, and intensive care settings. The guidance is intended for clinicians practicing medicine in the inpatient setting (eg, hospitalists, primary care physicians, family physicians, nurse practitioners, and physician assistants). To develop the Consensus Statement, the working group conducted a systematic review of relevant guidelines, composed a draft Statement based on extracted recommendations, and obtained feedback from external experts in hospital-based opioid prescribing, SHM members, the SHM Patient-Family Advisory Council, other professional societies, and peer-reviewers. The iterative development process resulted in a final Consensus Statement consisting of 16 recommendations covering 1) whether to use opioids in the hospital, 2) how to improve the safety of opioid use during hospitalization, and 3) how to improve the safety of opioid prescribing at hospital discharge. As most guideline recommendations from which the Consensus Statement was derived were based on expert opinion alone, the working group identified key issues for future research to support evidence-based practice.

Is Posthospital Syndrome a Result of Hospitalization-Induced Allostatic Overload?

Abstract: After discharge from the hospital, patients face a transient period of generalized susceptibility to disease as well as an elevated risk for adverse events, including hospital readmission and death. The term posthospital syndrome (PHS) has been used to describe this time of enhanced vulnerability. Based on data from bench to bedside, this narrative review examines the hypothesis that hospitalrelated allostatic overload is a plausible etiology of PHS. Resulting from extended exposure to stress, allostatic overload is a maladaptive state driven by overuse and dysregulation of the hypothalamic-pituitary-adrenal axis and the autonomic nervous system that ultimately generates pathophysiologic consequences to multiple organ systems. Markers of allostatic overload, including elevated levels of cortisol, catecholamines, and inflammatory markers, have been associated with adverse outcomes after hospital discharge. Based on the evidence, we suggest a possible mechanism for postdischarge vulnerability, encourage critical contemplation of traditional hospital environments, and suggest interventions that might improve outcomes.

The Adoption of an Online Journal Club to Improve Research Dissemination and Social Media Engagement Among Hospitalists.

Abstract: Background Twitter-based journal clubs are intended to connect clinicians, educators, and researchers to discuss recent research and aid in dissemination of results. The Journal of Hospital Medicine (JHM) began producing a Twitter-based journal club, #JHMChat, in 2015. Objective To describe the implementation and assess the impact of a journal-sponsored, Twitter-based journal club on Twitter and journal metrics. Intervention Each #JHMChat focused on a recently published JHM article, was moderated by a social media editor, and included one study author or guest. Measurements The total number of participants, tweets, tweets/participant, impressions, page views, and change in the Altmetric score were assessed after each session. Thematic analysis of each article was conducted, and post-chat surveys of participating authors and participant responses to continuing medical education surveys were reviewed. Results Seventeen Twitter-based chats were held: seven (47%) focused on value, six (40%) targeted clinical issues, and four (27%) focused on education. On average, we found 2.17 (±0.583 SD) million impressions/session, 499 (± 129 SD) total tweets/session, and 73 (±24 SD) participants/session. Value-based care articles had the greatest number of impressions (2.61 ± 0.55 million) and participants (90 ± 12). The mean increase in the Altmetric score was 14 points (±12), with medical education-themed articles garnering the greatest change (mean increase of 32). Page views were noted to have increased similarly to levels of electronic Table of Content releases. Authors and participants believed #JHMChat was a valuable experience and rated it highly on post-chat evaluations. Conclusions Online journal clubs appear to increase awareness and uptake of journal article results and are considered a useful tool by participants.

Predictors of Long-Term Opioid Use After Opioid Initiation at Discharge From Medical and Surgical Hospitalizations.

Abstract: Opioid analgesics may be initiated following surgical and medical hospitalization or in ambulatory settings; rates of subsequent long-term opioid (LTO) use have not been directly compared. This retrospective cohort study of the Veterans Health Administration (VHA) included all patients receiving a new outpatient opioid prescription from a VHA provider in fiscal year 2011. If a new outpatient prescription was filled within 2 days following hospital discharge, the initiation was considered a discharge prescription. LTO use was defined as an episode of continuous opioid supply lasting a minimum of 90 days and beginning within 30 days of the initial prescription. We performed bivariate and multivariate analyses to identify the factors associated with LTO use following surgical and medical discharges. Following incident prescription, 5.3% of discharged surgical patients, 15.2% of discharged medical patients, and 19.3% of outpatient opioid initiators received opioids long term. Medical and surgical patients differed; surgical patients were more likely to receive shorter prescription durations. Predictors of LTO use were similar in medical and surgical patients; the most robust predictor in both groups was the number of days' supply of the initial prescription (odds ratio [OR] = 1.24 and 95% confidence interval [CI], 1.12-1.37 for 8-14 days; OR = 1.56 and 95% CI, 1.39-1.76 for 15-29 days; and OR = 2.59 and 95% CI, 2.35-2.86 for >30 days) compared with the reference group receiving =7days. Rates of subsequent LTO use are higher among discharged medical patients than among surgical patients. Characteristics of opioid prescribing within the initial 30 days, including initial dose and days prescribed, were strongly associated with LTO use.

Numeracy, Health Literacy, Cognition, and 30-Day Readmissions among Patients with Heart Failure

Abstract: Background Numeracy, health literacy, and cognition are important for chronic disease management. Prior studies have found them to be associated with poorer selfcare and worse clinical outcomes, but limited data exists in the context of heart failure (HF), a condition that requires patients to monitor their weight, fluid intake, and dietary salt, especially in the posthospitalization period. Objective To examine the relationship between numeracy, health literacy, and cognition with 30-day readmissions among patients hospitalized for acute decompensated HF (ADHF). Design, setting, patients The Vanderbilt Inpatient Cohort Study is a prospective longitudinal study of adults hospitalized with acute coronary syndromes and/or ADHF. We studied 883 adults hospitalized with ADHF. Measurements During their hospitalization, a baseline interview was performed in which demographic characteristics, numeracy, health literacy, and cognition were assessed. Through chart review, clinical characteristics were determined. The outcome of interest was 30-day readmission to any acute care hospital. To examine the association between numeracy, health literacy, cognition, and 30-day readmissions, multivariable Poisson (log-linear) regression was used. Results Of the 883 patients admitted for ADHF, 23.8% (n = 210) were readmitted within 30 days; 33.9% of the study population had inadequate numeracy skills, 24.6% had inadequate/marginal literacy skills, and 53% had any cognitive impairment. Numeracy and cognition were not associated with 30-day readmissions. Though (objective) health literacy was associated with 30-day readmissions in unadjusted analyses, it was not in adjusted analyses. Conclusions Numeracy, health literacy, and cognition were not associated with 30-day readmission among this sample of patients hospitalized with ADHF.

Interventions to Reduce the Overuse of Imaging for Pulmonary Embolism: A Systematic Review.

Abstract: Background Imaging use in the diagnostic workup of pulmonary embolism (PE) has increased markedly in the last 2 decades. Low PE prevalence and diagnostic yields suggest a significant problem of overuse. Purpose The purpose of this systematic review is to summarize the evidence associated with the interventions aimed at reducing the overuse of imaging in the diagnostic workup of PE in the emergency department and hospital wards. Data sources PubMed, MEDLINE, Embase, and EBM Reviews from 1998 to March 28, 2017. Study selection Experimental and observational studies were included. The types of interventions, their efficacy and safety, the impact on healthcare costs, the facilitators, and barriers to their implementation were assessed. Data synthesis Seventeen studies were included assessing clinical decision support (CDS), educational interventions, performance and feedback reports (PFRs), and institutional policy. CDS impact was most comprehensively documented. It was associated with a reduction in imaging use, ranging from 8.3% to 25.4%, and an increase in diagnostic yield, ranging from 3.4% to 4.4%. The combined implementation of a CDS and PFR resulted in a modest but significant increase in the adherence to guidelines. Few studies appraised the safety of interventions. There was a lack of evidence concerning economic aspects, facilitators, and barriers. Conclusions A combined implementation of an electronic CDS and PFRs is more effective than purely educational or policy interventions, although evidence is limited. Future studies of high-methodological quality would strengthen the evidence concerning their efficacy, safety, facilitators, and barriers.

The Role of Hospital Medicine in Emergency Preparedness: A Framework for Hospitalist Leadership in Disaster Preparedness, Response, and Recovery.

Abstract: Recent high-profile mass casualty events illustrate the unique challenges that such occurrences pose to normal hospital operations. These events create patient surges that overwhelm hospital resources, space, and staff. However, in most healthcare systems, hospitalists currently show no integration within emergency planning or incident response. This review aims to provide hospitalists with an overview of disaster management principles so that they can engage their hospitals' disaster management system with a working fluency in emergency management and the incident command system. This review also proposes a framework for hospitalist involvement in preparation, response, and coordination during periods of crisis.

Patterns and Predictors of Short-Term Peripherally Inserted Central Catheter Use: A Multicenter Prospective Cohort Study.

Abstract: Background The guidelines for peripherally inserted central catheters (PICCs) recommend avoiding insertion if the anticipated duration of use is =5 days. However, short-term PICC use is common in hospitals. We sought to identify patient, provider, and device characteristics and the clinical outcomes associated with short-term PICCs. Methods Between January 2014 and June 2016, trained abstractors at 52 Michigan Hospital Medicine Safety (HMS) Consortium sites collected data from medical records of adults that received PICCs during hospitalization. Patients were prospectively followed until PICC removal, death, or 70 days after insertion. Multivariable logistic regression models were fit to identify factors associated with short-term PICCs, defined as dwell time of =5 days. Complications associated with short-term use, including major (eg, venous thromboembolism [VTE] or central lineassociated bloodstream infection [CLABSI]) or minor (eg, catheter occlusion, tip migration) events were assessed. Results Of the 15,397 PICCs placed, 3902 (25.3%) had a dwell time of =5 days. Most (95.5%) short-term PICCs were removed during hospitalization. Compared to PICCs placed for >5 days, variables associated with short-term PICCs included difficult venous access (odds ratio [OR], 1.54; 95% confidence interval [CI], 1.40-1.69), multilumen devices (OR, 1.53; 95% CI, 1.39-1.69), and teaching hospitals (OR, 1.25; 95% CI, 1.04-1.52). Among those with short-term PICCs, 374 (9.6%) experienced a complication, including 99 (2.5%) experiencing VTE and 17 (0.4%) experiencing CLABSI events. The most common minor complications were catheter occlusion (4%) and tip migration (2.2%). Conclusion Short-term use of PICCs is common and associated with patient, provider, and device factors. As PICC placement, even for brief periods, is associated with complications, efforts targeted at factors underlying such use appear necessary.

Improving Teamwork and Patient Outcomes with Daily Structured Interdisciplinary Bedside Rounds: A Multimethod Evaluation.

Abstract: Background Previous research has shown that interdisciplinary ward rounds have the potential to improve team functioning and patient outcomes. Design A convergent parallel multimethod approach to evaluate a hospital interdisciplinary ward round intervention and ward restructure. Setting An acute medical unit in a large tertiary care hospital in regional Australia. Participants Thirty-two clinicians and inpatients aged 15 years and above, with acute episode of care, discharged during the year prior and the year of the intervention. Intervention A daily structured interdisciplinary bedside round combined with a ward restructure. Measurements Qualitative measures included contextual factors and measures of change and experiences of clinicians. Quantitative measures included length of stay (LOS), monthly "calls for clinical review," and cost of care delivery. Results Clinicians reported improved teamwork, communication, and understanding between and within the clinical professions, and between clinicians and patients, after the intervention implementation. There was no statistically significant difference between the intervention and control wards in the change in LOS over time (Wald ?2 = 1.05; degrees of freedom [df] = 1; P = .31), but a statistically significant interaction for cost of stay, with a drop in cost over time, was observed in the intervention group, and an increase was observed in the control wards (Wald ?2 = 6.34; df = 1; P = .012). The medical wards and control wards differed significantly in how the number of monthly "calls for clinical review" changed from prestructured interdisciplinary bedside round (SIBR) to during SIBR (F (1,44) = 12.18; P = .001). Conclusions Multimethod evaluations are necessary to provide insight into the contextual factors that contribute to a successful intervention and improved clinical outcomes.

Credentialing of hospitalists in ultrasound-guided bedside procedures: A position statement of the society of hospital medicine

Abstract: Ultrasound guidance is used increasingly to perform the following 6 bedside procedures that are core competencies of hospitalists: abdominal paracentesis, arterial catheter placement, arthrocentesis, central venous catheter placement, lumbar puncture, and thoracentesis Yet most hospitalists have not been certified to perform these procedures, whether using ultrasound guidance or not, by specialty boards or other institutions extramural to their own hospitals Instead, hospital privileging committees often ask hospitalist group leaders to make ad hoc intramural certification assessments as part of credentialing Given variation in training and experience, such assessments are not straightforward "sign offs" We thus convened a panel of experts to conduct a systematic review to provide recommendations for credentialing hospitalist physicians in ultrasound guidance of these 6 bedside procedures Pathways for initial and ongoing credentialing are proposed A guiding principle of both is that certification assessments for basic competence are best made through direct observation of performance on actual patients

You Can't Have It All: The Experience of Academic Hospitalists During Pregnancy, Parental Leave, and Return to Work

Abstract: Background The United States lags behind most other countries regarding the support for working mothers and parental leave. Data are limited to describe the experience of female hospital medicine physicians during pregnancy, parental leave, and their return to work in academic hospital medicine. Methods We conducted a qualitative descriptive study including interviews with 10 female academic hospitalists chosen from institutions across the country that are represented in Society of Hospital Medicine (SHM) Committees. Interview guides were based on the following domains: experience in pregnancy, parental leave, and return to work. Interviews were recorded, transcribed verbatim, and analyzed using a general inductive approach to theme analysis using the ATLAS.ti software (Scientific Software Development GmbH, Berlin, Germany). Primary outcome Women in hospital medicine experience the following six common challenges in their experience as new parents, each of which has the potential to impact their career trajectory, wellness, and are associated with areas for institutional improvement: (1) access to paid parental leave, (2) physical challenges, (3) breastfeeding, (4) career opportunities, (5) colleague responses, and (6) empathy in patient care.

Physiologic Monitor Alarm Rates at 5 Children’s Hospitals

Abstract: Alarm fatigue has been linked to patient morbidity and mortality in hospitals due to delayed or absent responses to monitor alarms. We sought to describe alarm rates at 5 freestanding children's hospitals during a single day and the types of alarms and proportions of patients monitored by using a point-prevalence, cross-sectional study design. We collected audible alarms on all inpatient units and calculated overall alarm rates and rates by alarm type per monitored patient per day. We found a total of 147,213 alarms during the study period, with 3-fold variation in alarm rates across hospitals among similar unit types. Across hospitals, onequarter of monitored beds were responsible for 71%, 61%, and 63% of alarms in medical-surgical, neonatal intensive care, and pediatric intensive care units, respectively. Future work focused on addressing nonactionable alarms in patients with the highest alarm counts may decrease alarm rates.

The Design and Evaluation of the Comprehensive Hospitalist Assessment and Mentorship with Portfolios (CHAMP) Ultrasound Program.

Abstract: BACKGROUND Literature supports the use of point-ofcare ultrasound performed by the treating hospitalist in the diagnosis of common diseases. There is no consensus on the training paradigm or the evaluation of skill retention for hospitalists. OBJECTIVE To evaluate the effectiveness of a comprehensive bedside ultrasound training program with postcourse competency assessments for hospitalists. DESIGN A retrospective report of a training program with 53 hospitalists. The program consisted of online modules, a 3-day in-person course, portfolios, 1-day refresher training, monthly scanning, and assessments. Hospitalists were rated by using similar pre- and postcourse competency assessments and self-rating parameters during the 3-day and refresher courses. SETTING A large tertiary-care center. RESULTS Skills increased after the 3-day course from a median preassessment score of 15% correct (interquartile range [IQR] 10%-25%) to a median postassessment score of 90% (IQR 80%-95%; P < .0001). At the time of the refresher course, the median precourse skills score had decreased to 65% correct (IQR 35%-90%), which improved to 100% postcourse (IQR 85%-100%; P < .0001). Skills scores decreased significantly less between the post 3-day course assessment and pre 1-day refresher course for hospitalists who completed portfolios (mean decrease 13.6% correct; P < .0001) and/or monthly scanning sessions (mean decrease 7.3% correct; P < .0001) compared with hospitalists who did not complete these items. CONCLUSIONS A comprehensive longitudinal ultrasound training program including competency assessments improved ultrasound acquisition skills with hospitalists. Skill retention remained high in those who completed portfolios and/or monthly scanning sessions along with a 1-day in-person refresher course.

Prospective Randomized Evaluation of Preoperative Angiotensin-Converting Enzyme Inhibition (PREOP-ACEI).

Abstract: Background Intraoperative hypotension is associated with an increased risk of end organ damage and death. The transient preoperative interruption of angiotensinconverting enzyme inhibitor (ACEI) therapy prior to cardiac and vascular surgeries decreases the occurrence of intraoperative hypotension. Objective We sought to compare the effect of two protocols for preoperative ACEI management on the risk of intraoperative hypotension among patients undergoing noncardiac, nonvascular surgeries. Design Prospective, randomized study. Setting Midwestern urban 489-bed academic medical center. Patients Patients taking an ACEI for at least six weeks preoperatively were considered for inclusion. Interventions Randomization of the final preoperative ACEI dose to omission (n = 137) or continuation (n = 138). Measurements The primary outcome was intraoperative hypotension, which was defined as any systolic blood pressure (SBP) > 180 mm Hg) episodes were also recorded. Outcomes were compared using Fisher's exact test. Results Intraoperative hypotension occurred less frequently in the omission group (76 of 137 [55%]) than in the continuation group (95 of 138 [69%]) (RR: 0.81, 95% CI: 0.67 to 0.97, P = .03, NNH 7.5). Postoperative hypotensive events were also less frequent in the ACEI omission group (RR: 0.49, 95% CI: 0.28 to 0.86, P = .02) than in the continuation group. However, postoperative hypertensive events were more frequent in the omission group than in the continuation group (RR: 1.95, 95%: CI: 1.14 to 3.34, P = .01). Conclusions The transient preoperative interruption of ACEI therapy is associated with a decreased risk of intraoperative hypotension. Registration ClinicalTrials.gov: NCT01669434.

Safe Opioid Prescribing for Acute Noncancer Pain in Hospitalized Adults: A Systematic Review of Existing Guidelines.

Abstract: Background Pain is common among hospitalized patients. Inpatient prescribing of opioids is not without risk. Acute pain management guidelines could inform safe prescribing of opioids in the hospital and limit associated unintended consequences. Purpose To evaluate the quality and content of existing guidelines for acute, noncancer pain management. Data sources The National Guideline Clearinghouse, MEDLINE via PubMed, websites of relevant specialty societies and other organizations, and selected international search engines. Study selection Guidelines published between January 2010 and August 2017 addressing acute, noncancer pain management among adults were considered. Guidelines that focused on chronic pain, specific diseases, and the nonhospital setting were excluded. Data extraction Quality was assessed using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) instrument. Data synthesis Four guidelines met the selection criteria. Most recommendations were based on expert consensus. The guidelines recommended restricting opioids to severe pain or pain that has not responded to nonopioid therapy, using the lowest effective dose of short-acting opioids for the shortest duration possible, and co-prescribing opioids with nonopioid analgesics. The guidelines generally recommended checking the prescription drug monitoring program when prescribing opioids, developing goals for patient recovery, and educating patients regarding the risks and side effects of opioid therapy. Additional recommendations included using an opioid dose conversion guide, avoidance of co-administration of parenteral and oral opioids, and using caution when co-prescribing opioids with other central nervous system depressants. Conclusions Guidelines, based largely on expert opinion, recommend judicious prescribing of opioids for severe, acute pain. Future work should assess the implications of these recommendations on hospital-based pain management.

How Does Your PICCOMPARE? A Pilot Randomized Controlled Trial Comparing Various PICC Materials in Pediatrics.

Abstract: Despite the popularity of peripherally inserted central catheters (PICCs), recent literature highlights their potential injurious complications Innovative PICC materials have been developed to prevent thrombosis and infection formation (Endexo®) and antireflux valves to prevent occlusion (pressure-activated safety valve®) No large randomized controlled trial has assessed these technologies Our primary aim was to evaluate the feasibility of a large randomized controlled efficacy trial of PICC materials and design to reduce PICC complication in pediatrics A randomized controlled feasibility trial was undertaken at the Lady Cilento Children's Hospital in South Brisbane, Australia, between March 2016 and November 2016 Consecutive recruitment of 150 pediatric participants were randomly assigned to receive either (1) polyurethane PICC with a clamp or (2) BioFlo® PICC (AngioDynamics Inc, Queensbury, NY) Primary outcomes were trial feasibility, including PICC failure (thrombosis, occlusion, infection, breakage, or dislodgement) Secondary outcomes were PICC complications during use Protocol feasibility was established, including staff and patient acceptability, timely recruitment, no missing primary outcome data, and 0% attrition PICC failure was 22% (16 of 74, standard care) and 11% (8 of 72, BioFlo®) corresponding to 126 and 73 failures per 1000 hours (risk ratio 058; 95% confidence interval, 021-143; P = 172) PICC failures were primarily due to thrombosis (standard care 7% versus BioFlo® 3%) and complete occlusion (standard care 7% versus BioFlo® 1%) No blood stream infections occurred Significantly fewer patients with BioFlo® had PICC complications during use (15% vs 34%; P = 009) BioFlo® PICCs appear potentially safer for pediatrics than traditional standard care PICCs with a clamp Further research is required to definitively identify clinical, cost-effective methods to prevent PICC failure and improve reliability

Does Patient Experience Predict 30-Day Readmission? A Patient-Level Analysis of HCAHPS Data.

Abstract: BACKGROUND Hospital-level studies have found an inverse relationship between patient experience and readmissions. However, based on typical survey response time, it is unclear if patients are able to respond to surveys before they get readmitted and whether being readmitted might be a driver of poor experience scores (reverse causation). OBJECTIVE Using patient-level Hospital Consumer Assessment of Healthcare Providers and Systems (HCHAPS) and Press Ganey data to examine the relationship between readmissions and experience scores and to distinguish between patients who responded before or after a subsequent readmission. DESIGN Retrospective analysis of 10-year HCAHPS data. SETTING Single tertiary care academic hospital. PARTICIPANTS Patients readmitted within 30 days of an index hospitalization who received an HCAHPS survey linked to index admission comprised the exposure group. This group was divided into those who responded prior to readmission and those who responded after readmission. Nonreadmitted patients comprised the control group. ANALYSIS Multivariable-logistic regression to analyze the association between HCHAPS and Press Ganey scores and 30-readmission status, adjusted for patient factors. RESULTS Only 15.8% of the readmitted patients responded to the survey prior to readmission, and their scores were not significantly different from the nonreadmitted patients. The patients who responded after readmission were significantly more dissatisfied with physicians (doctors listened 73.0% vs 79.2%, aOR 0.75, P < .0001), staff responsiveness, (call button 50.0% vs 59.1%, aOR 0.71, P < .0001) pain control, discharge plan, noise, and cleanliness of the hospital. CONCLUSIONS Our findings suggest that poor patient experience may be due to being readmitted, rather than being predictive of readmission.

Focused Ethnography of Diagnosis in Academic Medical Centers.

Abstract: BACKGROUND: Approaches of trainees to diagnosis in teaching hospitals are poorly understood. Identifying cognitive and system-based barriers and facilitators to diagnosis may improve diagnosis in these settings. METHODS: We conducted a focused ethnography of trainees at 2 academic medical centers to understand the barriers and facilitators to diagnosis. Field notes regarding the diagnostic process (eg, information gathering, integration and interpretation, working diagnosis) and the work system (eg, team members, organization, technology and tools, physical environment, tasks) were recorded. Following observations, focus groups and interviews were conducted to understand the viewpoints, problems, and solutions to improve diagnosis. RESULTS: Between January 2016 and May 2016, four teaching teams (4 attendings, 4 senior residents, 9 interns, and 12 medical students) were observed for 168 hours. Observations of diagnosis during care led to identification of the following four key themes: (1) diagnosis is a social phenomenon, (2) data necessary to make diagnoses are fragmented, (3) distractions interfere with the diagnostic process, and (4) time pressures impede diagnostic decision-making. These themes suggest that specific interventions tailored to the academic setting such as team-based discussions of diagnostic workups, scheduling diagnostic time-outs during the day, and strategies to “protect” learners from interruptions might prove to be useful in improving the process of diagnosis. Future studies that implement these ideas (either alone or within a multimodal intervention) appear to be necessary. CONCLUSION: Diagnosis in teaching hospitals is a unique process that requires improvement. Contextual insights gained from this ethnography may be used to inform future interventions.

Transitioning from General Pediatric to Adult-Oriented Inpatient Care: National Survey of US Children's Hospitals.

Abstract: Background Hospital charges and lengths of stay may be greater when adults with chronic conditions are admitted to children's hospitals. Despite multiple efforts to improve pediatric-adult healthcare transitions, little guidance exists for transitioning inpatient care. Objective This study sought to characterize pediatricadult inpatient care transitions across general pediatric services at US children's hospitals. Design, setting and participants National survey of inpatient general pediatric service leaders at US children's hospitals from January 2016 to July 2016. Measurements Questionnaires assessed institutional characteristics, presence of inpatient transition initiatives (having specific process and/or leader), and 22 inpatient transition activities. Scales of highly correlated activities were created using exploratory factor analysis. Logistic regression identified associations between institutional characteristics, transition activities, and presence of an inpatient transition initiative. Results Ninety-six of 195 children's hospitals responded (49.2% response rate). Transition initiatives were present at 38% of children's hospitals, more often when there were dual-trained internal medicine-pediatrics providers or outpatient transition processes. Specific activities were infrequent and varied widely from 2.1% (systems to track youth in transition) to 40.5% (addressing potential insurance problems). Institutions with initiatives more often consistently performed the majority of activities, including using checklists and creating patient-centered transition care plans. Of remaining activities, half involved transition planning, the essential step between readiness and transfer. Conclusions Relatively few inpatient general pediatric services at US children's hospitals have leaders or dedicated processes to shepherd transitions to adultoriented inpatient care. Across institutions, there is a wide variability in performance of activities to facilitate this transition. Feasible process and outcome measures are needed.

Immunotherapy-Induced Colitis: An Emerging Problem for the Hospitalist.

Abstract: Since their introduction for melanoma treatment, the use of immune checkpoint inhibitors (ICIs) has rapidly expanded. Though their impact on survival is irrefutable, these medications have been associated with autoimmune-like adverse events related to their ability to induce the immune system. One of the most commonly affected organ systems is the gastrointestinal (GI) tract, in which manifestations range from mild diarrhea to severe colitis with intestinal perforation. Because of the increased use of ICIs, hospitalists are caring for an increasing number of patients experiencing their adverse events. We present a case-oriented review of the GI adverse events associated with the use of ICIs to familiarize the hospitalist with their mechanism of action and potential complications and to emphasize the importance of early diagnosis and treatment to decrease morbidity and mortality.

Shared Decision-Making During Inpatient Rounds: Opportunities for Improvement in Patient Engagement and Communication.

Abstract: BACKGROUND Shared decision-making (SDM) improves patient engagement and may improve outpatient health outcomes Little is known about inpatient SDM OBJECTIVE To assess overall quality, provider behaviors, and contextual predictors of SDM during inpatient rounds on medicine and pediatrics hospitalist services DESIGN A 12-week, cross-sectional, single-blinded observational study of team SDM behaviors during rounds, followed by semistructured patient interviews SETTING Two large quaternary care academic medical centers PARTICIPANTS Thirty-five inpatient teams (18 medicine, 17 pediatrics) and 254 unique patient encounters (117 medicine, 137 pediatrics) INTERVENTION Observational study MEASUREMENTS We used a 9-item Rochester Participatory Decision-Making Scale (RPAD) measured team-level SDM behaviors Same-day interviews using a modified RPAD assessed patient perceptions of SDM RESULTS Characteristics associated with increased SDM in the multivariate analysis included the following: service, patient gender, timing of rounds during patient's hospital stay, and amount of time rounding per patient (P < 05) The most frequently observed behaviors across all services included explaining the clinical issue and matching medical language to the patient's level of understanding The least frequently observed behaviors included checking understanding of the patient's point of view, examining barriers to follow-through, and asking if the patient has any questions Patients and guardians had substantially higher ratings for SDM quality compared to peer observers (72 vs 44 out of 9) CONCLUSIONS Important opportunities exist to improve inpatient SDM Team size, number of learners, patient census, and type of decision being made did not affect SDM, suggesting that even large, busy services can perform SDM if properly trained

Accuracy Comparisons between Manual and Automated Respiratory Rate for Detecting Clinical Deterioration in Ward Patients

Abstract: Respiratory rate is the most accurate vital sign for predicting adverse outcomes in ward patients.1,2 Though other vital signs are typically collected by using machines, respiratory rate is collected manually by caregivers counting the breathing rate. However, studies have shown signi cant discrepancies between a patient’s respiratory rate documented in the medical record, which is often 18 or 20, and the value measured by counting the rate over a full minute.3 Thus, despite the high accuracy of respiratory rate, it is possible that these values do not represent true patient physiology. It is unknown whether a valid automated measurement of respiratory rate would be more predictive than a manually collected respiratory rate for identifying patients who develop deterioration. The aim of this study was to compare the distribution and predictive accuracy of manually and automatically recorded respiratory rates.

Barriers to Early Hospital Discharge: A Cross-Sectional Study at Five Academic Hospitals.

Abstract: Background Understanding the issues delaying hospital discharges may inform efforts to improve hospital throughput. Objective This study was conducted to identify and determine the frequency of barriers contributing to delays in placing discharge orders. Design This was a prospective, cross-sectional study. Physicians were surveyed at approximately 8:00 AM, 12:00 PM, and 3:00 PM and were asked to identify patients that were "definite" or "possible" discharges and to describe the specific barriers to writing discharge orders. Setting This study was conducted at five hospitals in the United States. Participants The study participants were attending and housestaff physicians on general medicine services. Primary outcomes and measures Specific barriers to writing discharge orders were the primary outcomes; the secondary outcomes included discharge order time for high versus low team census, teaching versus nonteaching services, and rounding style. Results Among 1,584 patient evaluations, the most common delays for patients identified as "definite" discharges (n = 949) were related to caring for other patients on the team or waiting to staff patients with attendings. The most common barriers for patients identified as "possible" discharges (n = 1,237) were awaiting patient improvement and for ancillary services to complete care. Discharge orders were written a median of 43-58 minutes earlier for patients on teams with a smaller versus larger census, on nonteaching versus teaching services, and when rounding on patients likely to be discharged first (all P Conclusions Discharge orders for patients ready for discharge are most commonly delayed because physicians are caring for other patients. Discharges of patients awaiting care completion are most commonly delayed because of imbalances between availability and demand for ancillary services. Team census, rounding style, and teaching teams affect discharge times.