Showing papers in "Journal of Hospital Medicine in 2022"

Effectiveness of the rural transitions nurse program for Veterans: A multicenter implementation study.

Abstract: BACKGROUND Veterans are often transferred from rural areas to urban VA Medical Centers for care. The transition from hospital to home is vulnerable to postdischarge adverse events. OBJECTIVE To evaluate the effectiveness of the rural Transitions Nurse Program (TNP). DESIGN, SETTING, AND PARTICIPANTS National hybrid-effectiveness-implementation study, within site propensity-matched cohort in 11 urban VA hospitals. 3001 Veterans were enrolled in TNP from April 2017 to September 2019, and 6002 matched controls. INTERVENTION AND OUTCOMES The intervention was led by a transitions nurse who assessed discharge readiness, provided postdischarge communication with primary care providers (PCPs), and called the Veteran within 72 h of discharge home to assess needs, and encourage follow-up appointment attendance. Controls received usual care. The primary outcomes were PCP visits within 14 days of discharge and all-cause 30-day readmissions. Secondary outcomes were 30-day emergency department (ED) visits and 30-day mortality. Patients were matched by length of stay, prior hospitalizations and PCP visits, urban/rural status, and 32 Elixhauser comorbidities. RESULTS The 3001 Veterans enrolled in TNP were more likely to see their PCP within 14 days of discharge than 6002 matched controls (odds ratio = 2.24, 95% confidence interval [CI] = 2.05-2.45). TNP enrollment was not associated with reduced 30-day ED visits or readmissions but was associated with reduced 30-day mortality (hazard ratio = 0.33, 95% CI = 0.21-0.53). PCP and ED visits did not have a significant mediating effect on outcomes. The observational design, potential selection bias, and unmeasurable confounders limit causal inference. CONCLUSIONS TNP was associated with increased postdischarge follow-up and a mortality reduction. Further investigation to understand the reduction in mortality is needed.

Discontinuation of atorvastatin use in hospital is associated with increased risk of mortality in COVID‐19 patients

Abstract: Abstract Background Statins are a commonly used class of drugs, and reports have suggested that their use may affect COVID‐19 disease severity and mortality risk. Objective The purpose of this analysis was to determine the effect of discontinuation of previous atorvastatin therapy in patients hospitalized for COVID‐19 on the risk of mortality and ventilation. Methods Data from 146,413 hospitalized COVID‐19 patients were classified according to statin therapy. Home + in hospital atorvastatin use (continuation of therapy); home + no in hospital atorvastatin use (discontinuation of therapy); no home + no in hospital atorvastatin use (no statins). Logistic regression was performed to assess the association between atorvastatin administration and either mortality or use of mechanical ventilation during the encounter. Results Continuous use of atorvastatin (home and in hospital) was associated with a 35% reduction in the odds of mortality compared to patients who received atorvastatin at home but not in hospital (odds ratio [OR]: 0.65, 95% confidence interval [CI]: 0.59–0.72, p < .001). Similarly, the odds of ventilation were lower with continuous atorvastatin therapy (OR: 0.70, 95% CI: 0.64–0.77, p < .001). Conclusions Discontinuation of previous atorvastatin therapy is associated with worse outcomes for COVID‐19 patients. Providers should consider maintaining existing statin therapy for patients with known or suspected previous use.

Child Opportunity Index 2.0 and acute care utilization among children with medical complexity.

Abstract: BACKGROUND Disproportionately high acute care utilization among children with medical complexity (CMC) is influenced by patient-level social complexity. OBJECTIVE The objective of this study was to determine associations between ZIP code-level opportunity and acute care utilization among CMC. DESIGN, SETTING, AND PARTICIPANTS This cross-sectional, multicenter study used the Pediatric Health Information Systems database, identifying encounters between 2016-2019. CMC aged 28 days to <16 years with an initial emergency department (ED) encounter or inpatient/observation admission in 2016 were included in primary analyses. MAIN OUTCOME AND MEASURES We assessed associations between the nationally-normed, multi-dimensional, ZIP code-level Child Opportunity Index 2.0 (COI) (high COI = greater opportunity), and total utilization days (hospital bed-days + ED discharge encounters). Analyses were conducted using negative binomial generalized estimating equations, adjusting for age and distance from hospital and clustered by hospital. Secondary outcomes included intensive care unit (ICU) days and cost of care. RESULTS A total of 23,197 CMC were included in primary analyses. In unadjusted analyses, utilization days decreased in a stepwise fashion from 47.1 (95% confidence interval: 45.5, 48.7) days in the lowest COI quintile to 38.6 (36.9, 40.4) days in the highest quintile (p < .001). The same trend was present across all outcome measures, though was not significant for ICU days. In adjusted analyses, patients from the lowest COI quintile utilized care at 1.22-times the rate of those from the highest COI quintile (1.17, 1.27). CONCLUSIONS CMC from low opportunity ZIP codes utilize more acute care. They may benefit from hospital and community-based interventions aimed at equitably improving child health outcomes.

Healthcare quality during pediatric mental health boarding: A qualitative analysis.

Abstract: BACKGROUND Following initial evaluation and management, youth requiring inpatient psychiatric care often experience boarding, defined as being held in the emergency department or another location while awaiting inpatient care. Although mental health boarding is common, little research has examined the quality of healthcare delivery during the boarding period. OBJECTIVE This study aimed to explore the perspectives and experiences of multidisciplinary clinicians and parents regarding mental health boarding and to develop a conceptual model to inform quality improvement efforts. DESIGN, SETTING, & PARTICIPANTS We conducted semistructured interviews with clinicians and parents of youth experiencing boarding. Interviews focused on experiences of care and perceived opportunities for improvement were continued until thematic saturation was reached. Interviews were recorded, transcribed, and analyzed to identify emergent themes using a general inductive approach. Axial coding was used to inform conceptual framework development. RESULTS Interviews were conducted with 19 clinicians and 11 parents. Building on the Donabedian structure-process-outcome model of quality evaluation, emergent domains, and associated themes included: (1) infrastructure for healthcare delivery, including clinician training, healthcare team composition, and the physical environment; (2) processes of healthcare delivery, including clinician roles and responsibilities, goals of care, communication with families, policies/procedures, and logistics of inter-facility transfer; and (3) measurable outcomes, including patient safety, family experience, mental health status, timeliness of care, and clinician moral distress. CONCLUSION This qualitative study summarizes clinician and family perspectives about care for youth experiencing boarding. The conceptual model resulting from this analysis can be applied to implement and evaluate quality improvement endeavors to support this vulnerable population.

Forgotten frontline workers: Environmental health service employees' perspectives on working during the COVID‐19 pandemic

Abstract: Abstract Background Environmental Health Service employees (EVS) sanitize healthcare facilities and are critical to preventing infection, but are under‐resourced during the COVID‐19 pandemic and at risk of burnout. Objective Understand demands on EVS’ work and strain on resources during COVID‐19. Design Qualitative descriptive study conducted in winter 2020–2021. Setting One quaternary care academic medical center in Colorado. Participants A convenience sample of 16 EVS out of 305 eligible at the medical center. Fifty percent identified as Black, 31% as Hispanic, 6% as Asian, and 6% as White (another 6% identified as mixed race). Sixty‐nine percent were female, and half were born in a country outside the United States. Measures Semistructured telephone interviews. Interviews were audio‐recorded and transcribed, and thematic analysis was used to identify key themes. Results Four themes illustrate EVS experiences with job strain and support during COVID‐19: (1) Needs for ongoing training/education, (2) Emotional challenges of patient care, (3) Resource/staffing barriers, and (4) Lack of recognition as frontline responders. Despite feeling unrecognized during the pandemic, EVS identified structural supports with potential to mitigate job strain, including opportunities for increased communication with interdisciplinary colleagues, intentional acknowledgment, and education for those who speak languages other than English. Strategies that can increase physical and emotional resources and reduce job demands have potential to combat EVS burnout. Conclusions As the surge of COVID‐19 cases continues to overwhelm healthcare facilities, healthcare systems and interdisciplinary colleagues can adopt policies and practices that ensure lower‐wage healthcare workers have access to resources, education, and emotional support.

Reducing unnecessary routine laboratory testing for noncritically ill patients with COVID‐19

Abstract: Abstract Background Reducing unnecessary routine laboratory testing is a Choosing Wisely® recommendation, and new areas of overuse were noted during the COVID‐19 pandemic. Objective To reduce unnecessary repetitive routine laboratory testing for patients with COVID‐19 during the pandemic across a large safety net health system. Designs, Settings and Participants This quality improvement initiative was initiated by the System High‐Value Care Council at New York City Health + Hospitals (H + H), the largest public healthcare system in the United States consisting of 11 acute care hospitals. Intervention four overused laboratory tests in noncritically ill hospitalized patients with COVID‐19 were identified: C‐reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), and procalcitonin. A two‐pronged electronic health record intervention was implemented consisting of (1) nonintrusive, informational nudge statements placed on selected order sets, and (2) a forcing function of one consecutive day limit on ordering. Main Outcome and Measures The average of excess tests per encounter days (ETPED) for each of four target laboratory testing only in patients with COVID‐19. Objective Interdisciplinary System High‐Value Care Council identified four overused laboratory tests (inflammatory markers) in noncritically ill hospitalized patients with COVID‐19: C‐reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), and procalcitonin. Within an 11‐hospital safety net health system, a two‐pronged electronic health record intervention was implemented consisting of (1) nonintrusive, informational nudge statements placed on selected order sets, and (2) a forcing function of one consecutive day limit on ordering. The preintervention period (March 16, 2020 to January 24, 2021) was compared to the postintervention period (January 25, 2021 to March 22, 2022). Results Time series linear regression showed decreases in CRP (−17.9%, p < .05), ferritin (−37.6%, p < .001), and LDH (−30.1%, p < .001). Slope differences were significant (CRP, ferritin, and LDH p < 0.001; procalcitonin p < 0.05). Decreases were observed across weekly averages: CRP (−19%, p < .01), ferritin (−37.9%, p < .001), LDH (−28.7%, p < .001), and procalcitonin (−18.4%, p < .05). Conclusion This intervention was associated with reduced routine inflammatory marker testing in non‐intensive care unit COVID‐19 hospitalized patients across 11 hospitals. Variation was high among individual hospitals.

Implementation of a comprehensive hospitalist‐led initiative to improve care for patients with opioid use disorder

Abstract: Abstract Background As opioid‐related hospitalizations rise, hospitals must be prepared to evaluate and treat patients with opioid use disorder (OUD). We implemented a hospitalist‐led program, Project Caring for patients with Opioid Misuse through Evidence‐based Treatment (COMET) to address gaps in care for hospitalized patients with OUD. Objective Implement evidence‐based treatment for inpatients with OUD and refer to postdischarge care. Design, Setting, and Participants Project COMET launched in July 2019 at Duke University Hospital (DUH), an academic medical center in Durham, NC. Intervention, Main Outcomes, and Measures We engaged key stakeholders, performed a needs assessment, and secured health system funding. We developed protocols to standardize OUD treatment and employed a social worker to facilitate postdischarge care. Electronic health records were utilized for data analysis. Results COMET evaluated 512 patients for OUD during their index hospitalization from July 1, 2019 through June 30, 2021. Seventy‐one percent of patients received medication for OUD (MOUD) during admission. Of those who received buprenorphine during admission, 64% received a discharge prescription. Of those who received methadone during admission, 83% of eligible patients were connected to a methadone clinic. Among all patients at DUH with OUD, MOUD use during hospitalization and at discharge increased in the post‐COMET period compared to the pre‐COMET period (p < .001 for both). Conclusion Our program is one of the first to demonstrate successful implementation of a hospitalist‐led, comprehensive approach to caring for hospitalized patients with OUD and can serve as an example to other institutions seeking to implement life‐saving, evidence‐based treatment in this population.

Current use, training, and barriers in point-of-care ultrasound in hospital medicine: A national survey of VA hospitals.

Abstract: BACKGROUND Point-of-care ultrasound (POCUS) can reduce procedural complications and improve the diagnostic accuracy of hospitalists. Currently, it is unknown how many practicing hospitalists use POCUS, which applications are used most often, and what barriers to POCUS use exist. OBJECTIVE This study aimed to characterize current POCUS use, training needs, and barriers to use among hospital medicine groups (HMGs). DESIGN, SETTING, AND PARTICIPANTS A prospective observational study of all Veterans Affairs (VA) medical centers was conducted between August 2019 and March 2020 using a web-based survey sent to all chiefs of HMGs. These data were compared to a similar survey conducted in 2015. RESULT Chiefs from 117 HMGs were surveyed, with a 90% response rate. There was ongoing POCUS use in 64% of HMGs. From 2015 to 2020, procedural POCUS use decreased by 19%, but diagnostic POCUS use increased for cardiac (8%), pulmonary (7%), and abdominal (8%) applications. The most common barrier to POCUS use was lack of training (89%), and only 34% of HMGs had access to POCUS training. Access to ultrasound equipment was the least common barrier (57%). The proportion of HMGs with ≥1 ultrasound machine increased from 29% to 71% from 2015 to 2020. An average of 3.6 ultrasound devices per HMG was available, and 45% were handheld devices. CONCLUSION From 2015 to 2020, diagnostic POCUS use increased, while procedural use decreased among hospitalists in the VA system. Lack of POCUS training is currently the most common barrier to POCUS use among hospitalists.

Management of opioid use disorder and associated conditions among hospitalized adults: A Consensus Statement from the Society of Hospital Medicine.

Abstract: Hospital-based clinicians frequently care for patients with opioid withdrawal or opioid use disorder (OUD) and are well-positioned to identify and initiate treatment for these patients. With rising numbers of hospitalizations related to opioid use and opioid-related overdose, the Society of Hospital Medicine convened a working group to develop a Consensus Statement on the management of OUD and associated conditions among hospitalized adults. The guidance statement is intended for clinicians practicing medicine in the inpatient setting (e.g., hospitalists, primary care physicians, family physicians, advanced practice nurses, and physician assistants) and is intended to apply to hospitalized adults at risk for, or diagnosed with, OUD. To develop the Consensus Statement, the working group conducted a systematic review of relevant guidelines and composed a draft statement based on extracted recommendations. Next, the working group obtained feedback on the draft statement from external experts in addiction medicine, SHM members, professional societies, harm reduction organizations and advocacy groups, and peer reviewers. The iterative development process resulted in a final Consensus Statement consisting of 18 recommendations covering the following topics: (1) identification and treatment of OUD and opioid withdrawal, (2) perioperative and acute pain management in patients with OUD, and (3) methods to optimize care transitions at hospital discharge for patients with OUD. Most recommendations in the Consensus Statement were derived from guidelines based on observational studies and expert consensus. Due to the lack of rigorous evidence supporting key aspects of OUD-related care, the working group identified important issues necessitating future research and exploration.

Disparities in the allocation of inpatient physical and occupational therapy services for patients with COVID‐19

Abstract: Abstract Background Survivors of the novel coronavirus (COVID‐19) experience significant morbidity with reduced physical function and impairments in activities of daily living. The use of in‐hospital rehabilitation therapy may reduce long‐term impairments. Objective To determine the frequency of therapy referral and treatment amongst hospitalized COVID‐19 patients, assess for disparities in referral and receipt of therapy, and identify potentially modifiable factors contributing to disparities in therapy allocation. Design, Setting and Participants Retrospective cohort study using data collected from the University of Colorado Health Data Compass data warehouse assessing therapy referral rates and estimated delivery based on available administrative billing. Measurements Multivariable logistic regression was used to determine the association between sex and/or underrepresented minority race with therapy referral or delivery. Results Amongst 6239 COVID‐19‐related hospitalization, a therapy referral was present in 3952 patients (51.9%). Hispanic ethnicity was independently associated with lower odds of receipt of therapy referral (adjusted OR [aOR]: 0.78, 95% confidence interval [CI]: 0.67–0.93, p = .001). Advanced age (aOR: 1.53, 95% CI: 1.46–1.62, p < .001), greater COVID illness severity (aOR for intensive care unit admission: 1.63, 95% CI: 1.37–1.94, p < .01) and hospital stay (aOR: 1.14, 95% CI: 1.12–1.15, p < .01) were positively associated with referral. Conclusions and Relevance In a cohort of patients hospitalized for COVID‐19 across a multicenter healthcare system, we found that referral rates and delivery of physical therapy and/or occupational therapy sessions were significantly reduced for patients of Hispanic identity compared with patients of non‐Hispanic, Caucasian identity after adjustment for potential confounding by available demographic and illness severity variables.

Declines in the utilization of hospital‐based care during COVID‐19 pandemic

Abstract: Abstract The disruptions of the coronavirus disease 2019 (COVID‐19) pandemic impacted the delivery and utilization of healthcare services with potential long‐term implications for population health and the hospital workforce. Using electronic health record data from over 700 US acute care hospitals, we documented changes in admissions to hospital service areas (inpatient, observation, emergency room [ER], and same‐day surgery) during 2019−2020 and examined whether surges of COVID‐19 hospitalizations corresponded with increased inpatient disease severity and death rate. We found that in 2020, hospitalizations declined by 50% in April, with greatest declines occurring in same‐day surgery (−73%). The youngest patients (0−17) experienced largest declines in ER, observation, and same‐day surgery admissions; inpatient admissions declined the most among the oldest patients (65+). Infectious disease admissions increased by 52%. The monthly measures of inpatient case mix index, length of stay, and non‐COVID death rate were higher in all months in 2020 compared with respective months in 2019.

Lessons learned from the COVID‐19 pandemic blood supply crisis

Abstract: In the United States, a blood transfusion occurs every 2 s with a total of 30 million blood components transfused per year. Globally, there are more than 100 million blood donations annually, with significant disparities between supply and demand in high‐ and low‐resource countries, resulting in ongoing challenges to ration this critical resource. Despite many advances in medicine, there remains no manufactured substitute for blood. Meeting the unpredictable and continuous needs for blood products relies upon a steady and reliable donor pool able to replenish the supply to keep a positive balance in the blood “bank.” Even in times of plenty in a high‐resource setting such as the United States, blood products are a limited resource with tremendous work by the American Red Cross and local blood centers to recruit and encourage donors and share the limited resources across regions, depending on local need. As in many areas of medicine, the COVID‐19 pandemic has further stressed an already stressed system, resulting in a critical shortage of blood products. This has led to difficult clinical considerations of who really needed blood and how much blood they truly needed. While it appears, for the moment, that we have weathered this storm, it is important to reflect upon how we got there in the first place and how we can use this experience to improve our stewardship of this precious resource

Patients' and caregivers' experiences of hospitalization under COVID‐19 visitation restrictions

Abstract: Abstract Background During the COVID‐19 pandemic, hospitals did not allow caregiver visitation. Little is known about how caregivers' absence affected patients' care. Objective This study aimed to describe visitation restrictions' impact on patients and their caregivers experiences. Design We used a sequential explanatory mixed‐methods study design. First, we randomly selected 200 adult patients with cancer or heart failure hospitalized before (n = 100) and during visitor restrictions (n = 100) and abstracted data from the electronic medical record on communication between medical teams and caregivers and the topics discussed. Results from the quantitative analysis guided our thematic analysis of semi‐structured interviews conducted with a subsample of patients hospitalized during visitor restrictions and their caregivers to understand the impact of visitor restrictions on their experiences. Results Compared to prerestrictions, caregivers under visitation restrictions communicated less frequently with the medical team (29% vs. 37% of hospitalized days; p = .04), fewer received discharge counseling (37% vs. 52%; p = .04), and disproportionately more had no contact with the medical team (36% vs. 17%; p < .01). Video conferencing was documented for caregivers of only five patients. Qualitative analysis revealed that both caregivers and patients experienced emotional distress, increased conflict, and decreased perception of quality of care because of visitation restrictions. Conclusions Hospital visitor restrictions significantly reduced caregivers' communication with patients' medical team, causing caregivers and patients emotional distress. Protocols that facilitate communication between caregivers and care teams may benefit caregivers who cannot be physically present at care facilities, including distance caregivers.

Trends in all‐cause mortality and inpatient and outpatient visits for ambulatory care sensitive conditions during the first year of the COVID‐19 pandemic: A population‐based study

Abstract: Abstract Background The impact of the COVID‐19 pandemic on the management of ambulatory care sensitive conditions (ACSCs) remains unknown. Objectives To compare observed and expected (projected based on previous years) trends in all‐cause mortality and healthcare use for ACSCs in the first year of the pandemic (March 2020 to March 2021). Design, Setting and Participants We conducted a population‐based study using provincial health administrative data on general adul population (Ontario, Canada). Outcomes and Measures Monthly all‐cause mortality, and hospitalizations, emergency department (ED) and outpatient visit rates (per 100,000 people at‐risk) for seven combined ACSCs (asthma, chronic obstructive pulmonary disease, angina, congestive heart failure, hypertension, diabetes, and epilepsy) during the first year were compared with similar periods in previous years (2016–2019) by fitting monthly time series autoregressive integrated moving‐average models. Results Compared to previous years, all‐cause mortality rates increased at the beginning of the pandemic (observed rate in March to May 2020 of 79.98 vs. projected of 71.24 [66.35–76.50]) and then returned to expected in June 2020—except among immigrants and people with mental health conditions where they remained elevated. Hospitalization and ED visit rates for ACSCs remained lower than projected throughout the first year: observed hospitalization rate of 37.29 versus projected of 52.07 (47.84–56.68); observed ED visit rate of 92.55 versus projected of 134.72 (124.89–145.33). ACSC outpatient visit rates decreased initially (observed rate of 4299.57 vs. projected of 5060.23 [4712.64–5433.46]) and then returned to expected in June 2020.

Growth trends of the adult hospitalist workforce between 2012 and 2019

Abstract: Background Accurately identifying the number of practicing hospitalists across the United States continues to be a challenge. Characterizing the workforce is important in the context of healthcare reforms and public reporting. Objective We sought to estimate the number of adult hospitalists practicing in the United States over an 8-year period, to examine patterns in growth, and begin to explore billing patterns. Design, Settings, and Participants Retrospective study using national Medicare Part B claims datasets. We applied a commonly used 90% threshold of billing hospital visit-associated Healthcare Common Procedure Coding System codes to identify adult hospitalists in publicly available Medicare Provider Utilization and Payment data for 2012–2019. We then analyzed billing patterns for those identified hospitalists. Main Outcomes and Measures Identify trends in the number of identified adult hospitalists, including those self-identified. Compare hospitalists' billing to that of non-hospitalist Internal Medicine and Family Medicine physicians. Results We saw more than a 50% growth rate of practicing adult hospitalists between 2012 and 2019. In 2019, we identified 44,037 adult hospitalists. Conclusions The number of adult hospitalists continued to grow at a consistent rate, such that hospitalists are in the top five largest physician specialties in the United States. In the absence of more formal identification and consistent use by hospitalists, a threshold continues to be a meaningful tool to characterize the workforce.

Advance directives completion and hospital out‐of‐pocket expenditures

Abstract: Abstract Introduction Health care costs remain high at the end of life. It is not known if there is a relationship between advance directive (AD) completion and hospital out‐of‐pocket costs. This analysis investigated whether AD completion was associated with lower hospital out‐of‐pocket costs at end of life. Methods We used Health and Retirement Study participants who died between 2000 and 2014 (N = 9228) to examine the association between AD completion status and hospital out‐of‐pocket spending in the last 2 years of life through the use of a two‐part model controlling for socioeconomic status, death‐related characteristics and health insurance coverage. Results About 44% of decedents had completed ADs. Having an AD was significantly associated with $673 lower hospital out‐of‐pocket costs, with a higher magnitude of savings among younger decedents. Decedents who completed ADs 3 months or less before death had higher out‐of‐pocket costs ($1854 on average) than those who completed ADs more than 3 months before death ($1176 on average). Conclusions AD completion was significantly associated with lower hospital out‐of‐pocket costs, with greater out‐of‐pocket savings among younger decedents. Early AD completers experienced lower costs than decedents who completed ADs closer to death.

Management of opioid use disorder, opioid withdrawal, and opioid overdose prevention in hospitalized adults: A systematic review of existing guidelines.

Abstract: BACKGROUND Hospitalizations related to the consequences of opioid use are rising. National guidelines directing in-hospital opioid use disorder (OUD) management do not exist. OUD treatment guidelines intended for other treatment settings could inform in-hospital OUD management. OBJECTIVE Evaluate the quality and content of existing guidelines for OUD treatment and management. DATA SOURCES OVID MEDLINE, PubMed, Ovid PsychINFO, EBSCOhost CINHAL, ERCI Guidelines Trust, websites of relevant societies and advocacy organizations, and selected international search engines. STUDY SELECTION Guidelines published between January 2010 to June 2020 addressing OUD treatment, opioid withdrawal management, opioid overdose prevention, and care transitions among adults. DATA EXTRACTION We assessed quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument. DATA SYNTHESIS Nineteen guidelines met the selection criteria. Most recommendations were based on observational studies or expert consensus. Guidelines recommended the use of nonstigmatizing language among patients with OUD; to assess patients with unhealthy opioid use for OUD using the Diagnostic Statistical Manual of Diseases-5th Edition criteria; use of methadone or buprenorphine to treat OUD and opioid withdrawal; use of multimodal, nonopioid therapy, and when needed, short-acting opioid analgesics in addition to buprenorphine or methadone, for acute pain management; ensuring linkage to ongoing methadone or buprenorphine treatment; referring patients to psychosocial treatment; and ensuring access to naloxone for opioid overdose reversal. CONCLUSIONS Included guidelines were informed by studies with various levels of rigor and quality. Future research should systematically study buprenorphine and methadone initiation and titration among people using fentanyl and people with pain, especially during hospitalization.

Methodological progress note: A clinician's guide to propensity scores.

Abstract: Journal of Hospital MedicineVolume 17, Issue 4 p. 283-286 PROGRESS NOTES: CLINICAL PRACTICE UPDATE OR METHODOLOGICAL UPDATE Methodological progress note: A clinician's guide to propensity scores Lilliam Ambroggio PhD, Corresponding Author Lilliam Ambroggio PhD Lilliam.Ambroggio@childrenscolorado.org orcid.org/0000-0002-6242-607X Department of Pediatrics, Section of Emergency Medicine, Children's Hospital of Colorado, University of Colorado, Denver, Colorado, USA Department of Pediatrics, Section of Hospital Medicine, Children's Hospital of Colorado, University of Colorado, Denver, Colorado, USA Correspondence Lilliam Ambroggio, PhD, 13123 East 16th Ave., B251, Aurora, CO 80045, USA. Email: Lilliam.Ambroggio@childrenscolorado.orgSearch for more papers by this authorJillian M. Cotter MD, MSCS, Jillian M. Cotter MD, MSCS Department of Pediatrics, Section of Hospital Medicine, Children's Hospital of Colorado, University of Colorado, Denver, Colorado, USASearch for more papers by this authorMatthew Hall PhD, Matthew Hall PhD orcid.org/0000-0001-7778-5887 Children's Hospital Association, Lenexa, Kansas, USASearch for more papers by this author Lilliam Ambroggio PhD, Corresponding Author Lilliam Ambroggio PhD Lilliam.Ambroggio@childrenscolorado.org orcid.org/0000-0002-6242-607X Department of Pediatrics, Section of Emergency Medicine, Children's Hospital of Colorado, University of Colorado, Denver, Colorado, USA Department of Pediatrics, Section of Hospital Medicine, Children's Hospital of Colorado, University of Colorado, Denver, Colorado, USA Correspondence Lilliam Ambroggio, PhD, 13123 East 16th Ave., B251, Aurora, CO 80045, USA. Email: Lilliam.Ambroggio@childrenscolorado.orgSearch for more papers by this authorJillian M. Cotter MD, MSCS, Jillian M. Cotter MD, MSCS Department of Pediatrics, Section of Hospital Medicine, Children's Hospital of Colorado, University of Colorado, Denver, Colorado, USASearch for more papers by this authorMatthew Hall PhD, Matthew Hall PhD orcid.org/0000-0001-7778-5887 Children's Hospital Association, Lenexa, Kansas, USASearch for more papers by this author First published: 14 February 2022 https://doi.org/10.1002/jhm.12791Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat Volume17, Issue4April 2022Pages 283-286 RelatedInformation

Integrated versus nonintegrated peripheral intravenous catheter in hospitalized adults (OPTIMUM): A randomized controlled trial

Abstract: Abstract Background One‐third of peripheral intravenous catheters (PIVCs) fail from inflammatory or infectious complications, causing substantial treatment interruption and replacement procedures. Objectives We aimed to compare complications between integrated PIVCs (inbuilt extension sets, wings, and flattened bases) and traditional nonintegrated PIVCs. Designs, Settings and Participants A centrally randomized, controlled, superiority trial (with allocation concealment until study entry) was conducted in three Australian hospitals. Medical–surgical patients (one PIVC each) requiring intravenous therapy for >24 h were studied. Main Outcome Measures The primary outcome was device failure (composite: occlusion, infiltration, phlebitis, dislodgement, local, or bloodstream infection). Infection endpoints were assessor‐masked. The secondary outcomes were: failure type, first‐time insertion success, tip colonization, insertion pain, dwell time, mortality, costs, health‐related quality of life, clinician, and patient satisfaction. Results Out of 1759 patients randomized (integrated PIVC, n = 881; nonintegrated PIVC, n = 878), 1710 (97%) received a PIVC and were in the modified intention‐to‐treat analysis (2269 PIVC‐days integrated; 2073 PIVC‐days nonintegrated). Device failure incidence was 35% (145 per 1000 device‐days) nonintegrated, and 33% (124 per 1000 device‐days) integrated PIVCs. Intervention Integrated PIVCs had a significantly lower failure risk (adjusted [sex, infection, setting, site, gauge] hazard ratio [HR]: 0.82 [95% confidence interval, CI: 0.69–0.96], p = .015). The per‐protocol analysis was consistent (adjusted HR: 0.80 [95% CI: 0.68–0.95], p = .010). Integrated PIVCs had significantly longer dwell (top quartile ≥ 95 vs. ≥84 h). Mean per‐patient costs were not statistically different. Conclusions PIVC failure is common and complex. Significant risk factors include sex, infection at baseline, care setting, insertion site, catheter gauge, and catheter type. Integrated PIVCs can significantly reduce the burden of PIVC failure on patients and the health system.

Associations between hospitalist physician workload, length of stay, and return to the hospital.

Abstract: BACKGROUND Hospitalist physicians' workload-the total number of patients they care for daily-is rising in the U.S. Hospitalists report that increased workload negatively affects patients care. OBJECTIVE Measure the associations between hospitalist physicians' workload and clinical outcomes. DESIGN, SETTINGS, AND PARTICIPANTS Observational study, using electronic health record (EHR) data, of adults hospitalized on the hospitalist service at Yale-New Haven Hospital from 2015-2018. MAIN OUTCOME AND MEASURES We defined hospitalists' workload as the number of patients they cared for on the first full hospital day of a given patient's encounter. We used multilevel Poisson and logistic regression to examine associations between workload and length of stay (LOS), return to the Emergency Department (ED), and readmission. We adjusted for sociodemographic factors, patient complexity and severity of illness, and weekend admission (for LOS) or discharge (for ED visits or readmission). RESULTS We analyzed 38,141 hospitalizations. Median patient age was 64 years (IQR 51-78 years), 53% were female, and 34% were nonwhite. Mean workload was 15 patients (SD 3 patients; range 10-34 patients). LOS was prolonged by 0.05 days (95% CI 0.02, 0.08; p(0.001) when comparing the 75th workload percentile (16 patients) to the 25th workload percentile (13 patients). There were no associations between workload and ED visits or readmission within 7 and 30 days. CONCLUSIONS There was a statistically significant but modest relationship between workload and LOS; workload was not associated with ED visits or readmissions.Given clinical reports of the deleterious effects of increased hospitalist workload, there is a need for prospective research assessing a range of outcomes, beyond those measurable in contemporary EHR data.

Interventions for malnutrition in hospitalized adults: A systematic review and meta-analysis.

Abstract: BACKGROUND Malnutrition is associated with poor outcomes in hospitalized adults. We aimed to assess the effectiveness of hospital-initiated interventions for patients with malnutrition. METHODS Data sources included MEDLINE, Embase, Cochrane Library from January 1, 2000 to June 3, 2021. We included randomized controlled trials (RCTs) assessing interventions for hospitalized adults diagnosed or identified as at-risk for malnutrition using malnutrition screening and diagnostic assessment tools. Individual reviewers extracted study data and performed quality checks for accuracy. Meta-analysis was conducted using a random-effects model with variance correction. We assessed the overall strength of evidence at the outcome level. The risk of bias was assessed using the Cochrane Risk of Bias 2.0 tool. RESULTS We found 11 RCTs that assessed two types of interventions: specialized nutrition care (8 RCTs) and increased protein provision (3 RCTs). The pooled findings of 11 RCTs found moderate strength of evidence that specialized nutrition care and increased protein provision reduced mortality by 21% (relative risk [RR]: 0.79, 95% confidence interval [CI]: 0.63-0.98; absolute risk reduction [ARR]: -0.02, 95% CI: -0.03 to -0.00). Pooled estimates indicated a nonsignificant decrease of 0.18 days in the length of stay (9 RCTs) and a 10% reduction in readmissions (7 RCTs). No eligible RCTs assessed parenteral or enteral nutrition. CONCLUSION Certain malnutrition-focused hospital-initiated interventions (e.g., specialized nutrition care and increased protein provision) reduce mortality and may improve the quality of life among patients at risk for or diagnosed with malnutrition. Future trials are needed to assess the effectiveness of parenteral and enteral nutrition.

What's in a name? Laypeople's understanding of medical roles and titles.

Abstract: BACKGROUND Physicians regularly use jargon in patient communication, which can lead to confusion and misunderstanding. OBJECTIVE To assess the general public's understanding of names and roles of medical specialties and job seniority titles. DESIGNS Volunteer participants completed an electronic survey, filling-in-the-blanks for 14 medical specialties (e.g., "pediatricians are doctors who take care of _____"), and ranked physician titles in order of experience (medical student, intern, senior resident, fellow, attending). SETTING The 2021 Minnesota State Fair. PARTICIPANTS Volunteers >18 years old without medical or nursing training. MAIN OUTCOME AND MEASURES We summarized responses with descriptive statistics. Two researchers coded open-ended answers as correct, partially correct, or incorrect, with a third researcher for coding discrepancies. RESULTS Two hundred and four participants completed the survey (55% female; mean age 43; 67% of respondents with a bachelor's degree or higher). Of 14 medical specialties listed on the survey, respondents most accurately identified dermatologists (94%) and cardiologists (93%). Six specialties were understood by less than half of the respondents: neonatologists (48%), pulmonologists (43%), hospitalists (31%), intensivists (29%), internists (21%), and nephrologists (20%). Twelve percent of participants correctly identified medical roles in rank order. Most participants (74%) correctly identified medical students as the least experienced. Senior residents were most often identified as the most experienced (44%), with just 27% of respondents correctly placing the attending there. We conclude that medical professionals should recognize that titles are a common source of misunderstanding among the general public and should describe their role when introducing themselves to minimize confusion.

Death among patients hospitalized with symptomatic COVID‐19: Implications for high‐risk patients

Abstract: Abstract Background We aimed to examine the role played by the COVID‐19 infection in patients' death and to determine the proportion of patients for whom it was a major contributor to death. Methods We included patients ≥50 years old who were hospitalized with COVID‐19 infection and died between March 1, 2020 and September 30, 2020 in a tertiary medical center. We considered COVID‐19 infection to be a major cause for death if the patient had well‐controlled medical conditions and death was improbable without coronavirus infection, and a minor cause for death if the patient had serious illnesses and had an indication for palliative care. Results Among 243 patients, median age was 80 (interquartile intervals: 72–86) and 40% were female. One in two had moderate or severe frailty and 41% had dementia. Nearly 60% of the patients were classified as having advanced, serious illnesses present prior to the hospitalization, with death being expected within 12 months, and among this group 39% were full code at admission. In the remaining 40% of patients, deaths were classified as unexpected based on patients' prior conditions, suggesting that COVID‐19 infection complications were the primary contributor to death. Conclusions For slightly less than half (40%) of patients who died of complications of COVID‐19, death was an unexpected event. Among the 60% of patients for whom death was not a surprise, our findings identify opportunities to improve end‐of‐life discussions and implement shared decision‐making in high‐risk patients early on or prior to hospitalization.

Acute medical workup for new-onset psychosis in children and adolescents: A retrospective cohort.

Abstract: No consensus exists about which medical testing is indicated for youth with new-onset psychotic symptoms. We conducted a chart review of youths aged 7-21 years who were medically hospitalized for workup of new-onset psychotic symptoms from January 2017 through September 2020 in a free-standing children's hospital. The sample included 131 patients. At discharge, 129 (98.5%; 95% confidence interval [CI]: 94.5-99.8) were diagnosed with a primary psychiatric condition, 1 was diagnosed with levetiracetam-induced psychosis, and 1 with seronegative autoimmune encephalitis. Notably, 33 (25.2%; 95% CI: 18.0-33.5) had incidental findings unrelated to psychosis, 14 (10.7%; 95% CI: 6.0-17.3) had findings that required medical intervention but did not explain the psychosis, 12 (9.2%; 95% CI: 4.8-15.5) had a positive urine drug screen, and 4 (3.1%; 95% CI: 0.8-7.6) had a neurological exam consistent with conversion disorder. In conclusion, extensive medical testing in the acute setting for psychosis had a low yield for identifying medical etiologies of new-onset psychotic symptoms.

Defining existing practices to support the sleep of hospitalized patients: A mixed‐methods study of top‐ranked hospitals

Abstract: Abstract The objective of this study was to understand the existing practices and attitudes regarding inpatient sleep at the 2020 US News and World Report (USNWR) Honor Roll pediatric (n = 10) and adult (n = 20) hospitals. Section chiefs of Hospital Medicine from these institutions were surveyed and interviewed between June and August 2021. Among 23 of 30 surveyed physician leaders (response rate = 77%), 96% (n = 22) rated patient sleep as important, but only 43% (n = 10) were satisfied with their institutions' efforts. A total of 96% (n = 22) of institutions lack sleep equity practices. Fewer than half (48%) of top hospitals have sleep‐friendly practices, with the most common practices including reducing overnight vital sign monitoring (43%), decreasing ambient light in the wards (43%), adjusting lab and medication schedules (35%), and implementing quiet hours (30%). Major themes from qualitative interviews included: importance of universal sleep‐friendly cultures, environmental changes, and external incentives to improve patient sleep.

The impact of clinical decision support systems on provider behavior in the inpatient setting: A systematic review and meta-analysis.

Abstract: BACKGROUND Clinical decision support systems (CDSS) are used to improve processes of care. CDSS proliferation may have unintended consequences impacting effectiveness. OBJECTIVE To evaluate the effectiveness of CDSS in altering clinician behavior. DESIGN Electronic searches were performed in EMBASE, PubMed, and Cochrane Central Register of Control Trials for randomized controlled trials testing the impacted of CDSS on clinician behavior from 2000-2021. Extracted data included study design, CDSS attributed and outcomes, user characteristics, settings, and risk of bias. Eligible studies were analyzed qualitatively to describe CDSS types. Studies with sufficient outcome data were included in the meta-analysis. SETTING AND PARTICIPANTS Adult inpatients in the United States. INTERVENTION Clinical decision support system versus non-clinical decision support system. MAIN OUTCOME AND MEASURE A random-effects model measured the pooled risk difference (RD) and odds ratio of clinicians' adherence to CDSS; subgroup analyses tested differences in CDSS effectiveness over time and by CDSS type. RESULTS Qualitative synthesis included 22 studies. Eleven studies reported sufficient outcome data for inclusion in the meta-analysis. CDSS did not result in a statistically significant increase in clinician adoption of desired practicies (RD = 0.04 [95% confidence interval {CI} 0.00, 0.07]). CDSS from 2010-2015 (n = 5) did not increase clinician adoption of desired practice [RD -0.01, (95% CI -0.04, 0.02)].CDSS from 2016-2021 (n = 6) were associated with an increase in targeted practices [RD 0.07 (95% CI0.03, 0.12)], pInteraction = 0.004. EHR [RD 0.04 (95% CI 0.00, 0.08)] vs. non-EHR [RD 0.01 (95% CI -0.01, 0.04)] based CDSS interventions did not result in different adoption of desired practices(pInteraction = 0.27). The meta-analysis did not find an overall positive impact of CDSS on clinician behavior in the inpatient setting.

Bedspacing and clinical outcomes in general internal medicine: A retrospective, multicenter cohort study.

Abstract: BACKGROUND Admitting hospitalized patients to off-service wards ("bedspacing") is common and may affect quality of care and patient outcomes. OBJECTIVE To compare in-hospital mortality, 30-day readmission to general internal medicine (GIM), and hospital length-of-stay among GIM patients admitted to GIM wards or bedspaced to off-service wards. DESIGN, PARTICIPANTS, AND MEASURES Retrospective cohort study including all emergency department admissions to GIM between 2015 and 2017 at six hospitals in Ontario, Canada. We compared patients admitted to GIM wards with those who were bedspaced, using multivariable regression models and propensity score matching to control for patient and situational factors. KEY RESULTS Among 40,440 GIM admissions, 10,745 (26.6%) were bedspaced to non-GIM wards and 29,695 (73.4%) were assigned to GIM wards. After multivariable adjustment, bedspacing was associated with no significant difference in mortality (adjusted hazard ratio 0.95, 95% confidence interval [CI]: 0.86-1.05, p = .304), slightly shorter median hospital length-of-stay (-0.10 days, 95% CI:-0.20 to -0.001, p = .047) and lower 30-day readmission to GIM (adjusted OR 0.89, 95% CI: 0.83-0.95, p = .001). Results were consistent when examining each hospital individually and outcomes did not significantly differ between medical or surgical off-service wards. Sensitivity analyses focused on the highest risk patients did not exclude the possibility of harm associated with bedspacing, although adverse outcomes were not significantly greater. CONCLUSIONS Overall, bedspacing was associated with no significant difference in mortality, slightly shorter hospital length-of-stay, and fewer 30-day readmissions to GIM, although potential harms in high-risk patients remain uncertain. Given that hospital capacity issues are likely to persist, future research should aim to understand how bedspacing can be achieved safely at all hospitals, perhaps by strengthening the selection of low-risk patients.

Understanding the roots of mistrust in medicine: Learning from the example of sickle cell disease

Abstract: Department of Pediatrics, Indiana University School of Medicine, Indianapolis, Indiana, USA Division of Pediatric Hematology/Oncology, Riley Hospital for Children, Indianapolis, Indiana, USA Department of Graduate Medical Education, Indiana University School of Medicine, Indianapolis, Indiana, USA Center of Pediatric and Adolescent Comparative Effectiveness Research, Indiana University, Indianapolis, Indiana, USA

The angels and heroes of health care: Justified and appropriate, or harmful and destructive?

Abstract: Faculty of Health Science and Medicine, Bond University, Gold Coast, Queensland, Australia Faculty of Health, Southern Cross University, Gold Coast, Queensland, Australia Faculty of Science, Medicine and Health, University of Wollongong, New South Wales, Australia Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital and Centre for Nursing and Midwifery Research, Northern Sydney Local Health District, St Leonards, New South Wales, Australia Faculty of Health, University of Technology, Ultimo, New South Wales, Australia