A Quality Improvement Project to Reduce Rapid Response System Inequities for Patients with Limited English Proficiency at a Quaternary Academic Medical Center.

BACKGROUND: Recognition of clinically deteriorating hospitalized patients with activation of rapid response (RR) systems can prevent patient harm. Patients with limited English proficiency (LEP), however, experience less benefit from RR systems than do their English-speaking counterparts. OBJECTIVE: To improve outcomes among hospitalized LEP patients experiencing clinical deteriorations. DESIGN: Quasi-experimental pre-post design using quality improvement (QI) statistics. PARTICIPANTS: All adult hospitalized non-intensive care patients with LEP who were admitted to a large academic medical center from May 2021 through March 2023 and experienced RR system activation were included in the evaluation. All patients included after May 2022 were exposed to the intervention. INTERVENTIONS: Implementation of a modified RR system for LEP patients in May 2022 that included electronic dashboard monitoring of early warning scores (EWSs) based on electronic medical record data; RR nurse initiation of consults or full RR system activation; and systematic engagement of interpreters. MAIN MEASURES: Process of care measures included monthly rates of RR system activation, critical response nurse consultations, and disease severity scores prior to activation. Main outcomes included average post-RR system activation length of stay, escalation of care, and in-hospital mortality. Analyses used QI statistics to identify special cause variation in pre-post control charts based on monthly data aggregates. KEY RESULTS: In total, 222 patients experienced at least one RR system activation during the study period. We saw no special cause variation for process measures, or for length of hospitalization or escalation of care. There was, however, special cause variation in mortality rates with an overall pre-post decrease in average monthly mortality from 7.42% (n = 8/107) to 6.09% (n = 7/115). CONCLUSIONS: In this pilot study, prioritized tracking, utilization of EWS-triggered evaluations, and interpreter integration into the RR system for LEP patients were feasible to implement and showed promise for reducing post-RR system activation mortality.

A Natural Language Processing and Machine Learning Approach to Identification of Incidental Radiology Findings in Trauma Patients Discharged from the Emergency Department.

STUDY OBJECTIVE: Patients undergoing diagnostic imaging studies in the emergency department (ED) commonly have incidental findings, which may represent unrecognized serious medical conditions, including cancer. Recognition of incidental findings frequently relies on manual review of textual radiology reports and can be overlooked in a busy clinical environment. Our study aimed to develop and validate a supervised machine learning model using natural language processing to automate the recognition of incidental findings in radiology reports of patients discharged from the ED. METHODS: We performed a retrospective analysis of computed tomography (CT) reports from trauma patients discharged home across an integrated health system in 2019. Two independent annotators manually labeled CT reports for the presence of an incidental finding as a reference standard. We used regular expressions to derive and validate a random forest model using open-source and machine learning software. Final model performance was assessed across different ED types. RESULTS: The study CT reports were divided into derivation (690 reports) and validation (282 reports) sets, with a prevalence of incidental findings of 22.3%, and 22.7%, respectively. The random forest model had an area under the curve of 0.88 (95% confidence interval [CI], 0.84 to 0.92) on the derivation set and 0.92 (95% CI, 0.88 to 0.96) on the validation set. The final model was found to have a sensitivity of 92.2%, a specificity of 79.4%, and a negative predictive value of 97.2%. Similarly, strong model performance was found when stratified to a dedicated trauma center, high-volume, and low-volume community EDs. CONCLUSION: Machine learning and natural language processing can classify incidental findings in CT reports of ED patients with high sensitivity and high negative predictive value across a broad range of ED settings. These findings suggest the utility of natural language processing in automating the review of free-text reports to identify incidental findings and may facilitate interventions to improve timely follow-up.

Choosing Wisely in Adult Hospital Medicine: Co-creation of New Recommendations for Improved Healthcare Value by Clinicians and Patient Advocates.

BACKGROUND: The American Board of Internal Medicine Foundation's Choosing Wisely campaign has resulted in a vast number of recommendations to reduce low-value care. Implementation of these recommendations, in conjunction with patient input, remains challenging. OBJECTIVE: To create updated Society of Hospital Medicine Adult Hospitalist Choosing Wisely recommendations that incorporate patient input from inception. DESIGN AND PARTICIPANTS: This was a multi-phase study conducted by the Society of Hospital Medicine's High Value Care Committee from July 2017 to January 2020 involving clinicians and patient advocates. APPROACH: Phase 1 involved gathering low-value care recommendations from patients and clinicians across the USA. Recommendations were reviewed by the committee in phase 2. Phase 3 involved a modified Delphi scoring in which 7 committee members and 7 patient advocates voted on recommendations based on strength of evidence, potential for patient harm, and relevance to either hospital medicine or patients. A patient-friendly script was developed to allow advocates to better understand the clinical recommendations. KEY RESULTS: A total of 1265 recommendations were submitted by clinicians and patients. After accounting for similar suggestions, 283 recommendations were categorized. Recommendations with more than 10 mentions were advanced to phase 3, leaving 22 recommendations for the committee and patient advocates to vote upon. Utilizing a 1-5 Likert scale, the top combined recommendations were reducing use of opioids (4.57), improving sleep (4.52), minimizing overuse of oxygen (4.52), reducing CK-MB use (4.50), appropriate venous thromboembolism prophylaxis (4.43), and decreasing daily chest x-rays (4.43). CONCLUSIONS: Specific voting categories, along with the use of patient-friendly language, allowed for the successful co-creation of recommendations.

Incidental Radiology Findings on Computed Tomography Studies in Emergency Department Patients: A Systematic Review and Meta-Analysis.

STUDY OBJECTIVE: An incidental finding is defined as a newly discovered mass or lesion detected on imaging performed for an unrelated reason. The identification of an incidental finding may be an opportunity for the early detection of a serious medical condition, including a malignancy. However, little is known about the prevalence of incidental findings in the emergency department (ED) setting and the strategies that can be used to mitigate the risk associated with them in the ED. This study aimed to estimate the overall prevalence of incidental findings and to summarize the currently described measures to mitigate the risks associated with incidental findings. METHODS: On November 22, 2020, a systematic literature search of PubMed, EMBASE, and Scopus was performed for studies that were published in peer-reviewed journals and reported the prevalence of incidental findings in computed tomography (CT) scans in patients in the ED. Patients who received CT scans that included the head, neck, chest, or abdomen/pelvis were included. The study characteristics, overall prevalence of incidental findings, prevalence of incidental findings by body region, and prespecified subgroups were extracted. The criteria used for risk stratification within individual studies were also extracted. Pooled estimates were calculated using a random-effects meta-analysis. RESULTS: A total of 1,385 studies were identified, and 69 studies met the inclusion criteria. The included studies represented 147,763 ED encounters or radiology reports across 16 countries, and 83% of studies were observational, cross-sectional studies. A total of 35 studies (50.7%) were in trauma patients. A large degree of heterogeneity was observed across the included studies. The overall pooled prevalence estimate for any incidental finding was 31.3% (95% confidence interval 24.4% to 39.1%). We found great variation in the methods described to mitigate the risk associated with incidental findings, including a lack of standardized risk stratification, inconsistent documentation practices, and only a small subset of studies describing prospective interventions aimed at improving the recognition and management of incidental findings from the ED. CONCLUSION: In patients in the ED receiving CT scans, incidental findings are commonly encountered across a broad range of ED chief complaints. This review highlights the existence of great heterogeneity in the definitions used to classify incidental findings. Future studies are needed to determine a clinically feasible categorization standard or terminology for commonly encountered incidental findings in the ED setting to standardize classification and documentation.

Frequency and yield of blood cultures for observation patients with skin and soft tissue infections.

OBJECTIVES: 1) To measure frequency and yield of blood cultures obtained for observation status adult patients with skin and soft tissue infection (SSTI), 2) describe how often blood cultures were performed according to Infectious Diseases Society of America (IDSA) SSTI guideline indications, 3) identify proportion of patients meeting Center for Medicare Services (CMS) sepsis criteria. DESIGN: Retrospective cohort. SETTING: Tertiary academic center. PATIENTS: Consecutive adult observation status patients hospitalized with SSTI between July 2017 and July 2018. METHODS: We measured the proportion and results of blood cultures obtained among the study cohort and proportion of obtained cultures that satisfied IDSA indications. RESULTS: We identified 132 observation status patients with SSTI during the study period; 67 (50.8%) had blood cultures drawn. Only 14 (10.6%) patients met IDSA indications for culture; 51 (38.%) met Center for Medicare Services definition for sepsis. We identified two (3.0%) cases of bacteremia and two (3.0%) cases of skin bacteria contamination. In multivariable analysis, only temperature > 38 °C (OR 3.84, 95%CI 1.09-13.60) and white race (OR 2.71, 95%CI 1.21-6.20) were associated with blood culture obtainment; neither meeting IDSA SSTI guideline indications nor meeting CMS sepsis criteria was associated with culture. CONCLUSIONS: Among observation status patients with SSTI, over half had blood cultures drawn, though 10% satisfied guideline indications for culture. The proportion of cultures with bacterial growth was low and yielded as many skin contaminants as cases of bacteremia. Our study highlights the need for further quality improvement efforts to reduce unnecessary blood cultures in routine SSTI cases.

Was This Readmission Preventable? Qualitative Study of Patient and Provider Perceptions of Readmissions.

OBJECTIVES: Readmissions are a costly, burdensome, and potentially preventable occurrence in the healthcare system. With the renewed national focus on the cost and quality of health care, readmissions have become a major target for improvement; however, in general, the viewpoints of patients and healthcare providers have not been considered in these discussions. We aimed to compare provider and patient perspectives on the preventability of hospital readmissions. We also aimed to compare the factors that patients and providers perceive as contributing to readmissions. METHODS: We conducted descriptive statistics of readmissions using provider chart reviews (N = 213) on all readmissions to the University of North Carolina hospitalist service during a 6-month span. We also performed a qualitative analysis of those provider chart reviews, in addition to interviews with those readmitted patients (n = 23). We compared the percentage of providers versus patients who believed the readmission was preventable, and we explored the factors to which each group attributed the readmission. RESULTS: Providers stated that 30% of the readmissions were preventable, compared with only 13% of patients. Key contributing factors differed between providers and patients. Providers cited medical problems in 45% of readmissions, pain (24%), follow-up problems (22%), substance abuse (20%), and nonadherence (17%). Patients believed nothing could have been done to prevent them in 35% of readmissions, but they also cited medical problems (35%), incomplete diagnosis or treatment (22%), medication issues (17%), and system concerns (13%) as contributing to readmissions. CONCLUSIONS: These data suggest that patients and providers view the issue of readmissions differently and highlight potential areas for improvement.

Feedback on Bounce Backs: Real-Time Notification of Readmissions and the Impact on Readmission Rates and Physician Perceptions.

OBJECTIVES: Readmissions are an increasing area of focus for quality improvement initiatives. Widely variable estimates exist on preventability and impact of multipronged readmission interventions. Given the rotating nature of attending physicians in academic centers, physicians often are unaware of readmissions. We present a before-and-after (uncontrolled) trial evaluating timely feedback of readmissions to hospitalist physicians. METHODS: A daily list of patients (inpatient, observation, procedure, or emergency department) who are registered as receiving care within University of North Carolina hospitals was filtered to include only inpatients within the last 30 days and cared for by a faculty member from the hospital medicine program, and readmissions were tracked. A hospitalist physician performed an in-depth review of readmissions using a readmission diagnostic worksheet developed by the Institute for Healthcare Improvement STate Action on Avoidable Rehospitalizations Initiative. Physicians were surveyed on their perception of readmissions in general and their preventability. Outcomes of interest were 30-day readmission rates, physician perspectives and estimates of preventability, patient factors from the STate Action on Avoidable Rehospitalizations tool, and length of stay. RESULTS: Compared with the previous 18 months, the readmission rate was reduced modestly during the 6 months of our intervention (12% to 10%, t test + 0.071). The average length of stay increased from 4.73 days during the prior 18 months to 5.01 for the 4 months since the intervention (t test 0.1). Based on the attending physician survey, 13% of attending physicians believed that fewer than 10% of readmissions were preventable; this increased to 30% after 6 months of timely notification and chart reviews. At baseline, the top three contributors to readmissions were believed to be patient understanding, medication nonadherence, and substance abuse/addiction. After 6 months of the intervention, the top three contributors were believed to be substance abuse/addiction, medication nonadherence, and lack of primary care. CONCLUSIONS: Our intervention of real-time feedback regarding readmissions and enforced chart review led to a modest reduction in readmission rates without significant changes in length of stay. Physicians continued to believe that a readmission event was multifactorial and largely not preventable. Real-time notification did increase physician involvement in prevention initiatives, in particular with high-use patients.

The role of language barriers on efficacy of rapid response teams.

OBJECTIVES: Rapid response (RR) systems are associated with decreased hospital mortality. Systemic biases and inequities can negatively impact RR outcomes. Language barriers between patients and providers are associated with worse outcomes, but it is unknown if language barriers are associated with RR outcomes. METHODS: We analyzed all adult hospitalized patients who experienced a RR over one year (January 2020 to December 2020) at a tertiary care academic medical center. We used an objective scoring system to establish disease severity at the time of the event. We then compared disease severity and outcomes for patients who are primary language Spanish (PLS) and primary language English (PLE) using both univariable and multivariable analyses. RESULTS: Of 1133 patients, 42 identified as PLS and 1091 as PLE. In multivariable analyses, PLS patients had significantly higher disease severity scores, as measured by deterioration index score (8.2, p = 0.021) at the time of their rapid responses. PLS patients also had 18.5% increase in length of stay (LOS) after RRs and this disparity was not mitigated when controlling for disease severity at the time of RRs. PLS was not a significant predictor for hospital mortality after RRs. CONCLUSIONS: Our study found that PLS patients had increased disease severity at the time of RRs and increased LOS after RRs. However, the disparity in LOS was not mitigated when controlling for disease severity at the time of RRs. These findings suggest that language barriers may cause both delays in activation of RR systems, as well as the care provided during and after RRs.

Safety and predictors of the success of lumbar punctures performed by a medicine procedure service.

BACKGROUND: Medicine procedure services (MPS) increasingly perform bedside procedures, including lumbar punctures (LPs). Success rates and factors associated with LP success performed by MPS have not been well described. OBJECTIVE: We identified patients undergoing LP by an MPS September 2015 to December 2020. We identified demographic and clinical factors, including patient position, body mass index (BMI), use of ultrasound, and trainee participation. We performed multivariable analysis to identify factors associated with LP success and complications. MAIN OUTCOME AND MEASURES: We identified 1065 LPs among 844 patients. Trainees participated in 82.2%; ultrasound guidance was used in 76.7% of LPs. The overall success rate was 81.3% with 7.8% minor and 0.1% major complications. A minority of LPs were referred to radiology (15.2%) or were traumatic (11.1%). In multivariable analysis, BMI > 30 kg/m2 (odds ratio [OR] 0.32, 95% confidence interval [CI] 0.21-0.48), prior spinal surgery (OR 0.50, 95% CI 0.26-0.87), and Black race (OR 0.62, 95% CI 0.41-0.95) were associated with decreased odds of successful LP; trainee participation (OR 2.49, 95% CI 1.51-4.12) was associated with increased odds. Ultrasound guidance (OR 0.53, 95% CI 0.31-0.89) was associated with lower odds of traumatic LP. RESULTS: In a large cohort of patients undergoing LP by an MPS, we identified high success and low complication rates. Trainee participation was associated with increased odds of success, while obesity, prior spinal surgery, and Black race were associated with decreased odds of success. Ultrasound guidance was associated with lower odds of a traumatic LP. Our data may help proceduralists in planning and assist in shared decision-making.

Building High-Performance Team Dynamics for Rapid Response Events in a US Tertiary Hospital: A Quality Improvement Model for Sustainable Process Change.

Hospital rapid response systems are designed to reduce unmet patient needs and prevent clinical deterioration. Rapid response teams are the principal component of a rapid response system and require teamwork to function optimally; poor communication among team members can result in substandard patient care. The authors describe a process for developing and implementing standardized communication and a teamwork structure for rapid response events (RREs) at a large academic hospital. The multidisciplinary team developed a project charter and key driver diagram, developed a "communication bundle," used quality improvement methodology, monitored adherence to the changes, and reported these data to key stakeholders on a weekly basis. By project end, the team met the goal of having 70% or more of adult RREs include the use of the "communication bundle." The balancing measure demonstrated that the introduction of a formalized communication framework did not significantly increase the duration of RREs.

Use of troponins in the classification of myocardial infarction from electronic health records. The Atherosclerosis Risk in Communities (ARIC) Study.

OBJECTIVE: Electronic health record (EHR) data are underutilized for abstracting classification criteria for heart disease. We compared extraction of EHR data on troponin I and T levels with human abstraction. METHODS: Using EHR for hospitalizations identified through the Atherosclerosis Risk in Communities (ARIC) Study in four US hospitals, we compared blood levels of troponins I and T extracted from EHR structured data elements with levels obtained through data abstraction by human abstractors to 3 decimal places. Observations were divided randomly 50/50 into training and validation sets. Bayesian multilevel logistic regression models were used to estimate agreement by hospital in first and maximum troponin levels, troponin assessment date, troponin upper limit of normal (ULN), and classification of troponin levels as normal (< ULN), equivocal (1-2× ULN), abnormal (>2× ULN), or missing. RESULTS: Estimated overall agreement in first measured troponin level in the validation data was 88.2% (95% credible interval: 65.0%-97.5%) and 95.5% (91.2-98.2%) for the maximum troponin level observed during hospitalization. The largest variation in probability of agreement was for first troponin measured, which ranged from 66.4% to 95.8% among hospitals. CONCLUSION: Extraction of maximum troponin values during a hospitalization from EHR structured data is feasible and accurate.

Prognostic value of labs ordered on patients hospitalized with COVID-19.

Background: Hospitalists at our institution have taken on most non-intensive care unit (ICU) coronavirus disease 2019 (COVID-19) care. Based on sparse research, our institution developed a protocol for ordering labs for this patient population, including routine admission labs in addition to eight COVID-19-specific daily labs. The study goal is to determine if COVID-19-specific admission labs have any prognostic value beyond that provided by routine admission labs and vitals, and costs of labs with no prognostic value.Methods: We retrospectively reviewed adult patients admitted with COVID-19 from 3/2020 to 7/2020. Outcomes were mortality, ICU stay, and length of hospitalization. Multivariable logistic and linear regression were used to determine if COVID-19-specific admission labs have any prognostic value beyond that provided by vitals and routine admission labs. COVID-19-specific labs were d-Dimer, fibrinogen, ferritin, LDH, CK, pro-BNP, troponin, and CRP. Multivariable models included all routine admission labs and vitals. COVID-19-specific admission labs were included in the multivariable models if the p-value was <0.05 in the univariable analysis.Results: 331 patients met study criteria, inpatient mortality was 13.0%, 52.4% of patients required ICU stays and the average length of hospitalization was 8.9 days. COVID-19-specific labs showed no additional prognostic value for mortality. CRP, LDH, and d-Dimer provided additional prognostic information for ICU stay. CRP≥100 mg/dL and LDH≥900 U/L were associated with increased length of hospitalization.Conclusion: Only 3 of 8 admission COVID-19-specific labs recommended by our institution's protocol had additional prognostic value beyond that provided by routine labs and vitals. The total cost of non-prognostic COVID-19-specific labs during the study period was $75,874.

Ascertaining Framingham heart failure phenotype from inpatient electronic health record data using natural language processing: a multicentre Atherosclerosis Risk in Communities (ARIC) validation study.

OBJECTIVES: Using free-text clinical notes and reports from hospitalised patients, determine the performance of natural language processing (NLP) ascertainment of Framingham heart failure (HF) criteria and phenotype. STUDY DESIGN: A retrospective observational study design of patients hospitalised in 2015 from four hospitals participating in the Atherosclerosis Risk in Communities (ARIC) study was used to determine NLP performance in the ascertainment of Framingham HF criteria and phenotype. SETTING: Four ARIC study hospitals, each representing an ARIC study region in the USA. PARTICIPANTS: A stratified random sample of hospitalisations identified using a broad range of International Classification of Disease, ninth revision, diagnostic codes indicative of an HF event and occurring during 2015 was drawn for this study. A randomly selected set of 394 hospitalisations was used as the derivation dataset and 406 hospitalisations was used as the validation dataset. INTERVENTION: Use of NLP on free-text clinical notes and reports to ascertain Framingham HF criteria and phenotype. PRIMARY AND SECONDARY OUTCOME MEASURES: NLP performance as measured by sensitivity, specificity, positive-predictive value (PPV) and agreement in ascertainment of Framingham HF criteria and phenotype. Manual medical record review by trained ARIC abstractors was used as the reference standard. RESULTS: Overall, performance of NLP ascertainment of Framingham HF phenotype in the validation dataset was good, with 78.8%, 81.7%, 84.4% and 80.0% for sensitivity, specificity, PPV and agreement, respectively. CONCLUSIONS: By decreasing the need for manual chart review, our results on the use of NLP to ascertain Framingham HF phenotype from free-text electronic health record data suggest that validated NLP technology holds the potential for significantly improving the feasibility and efficiency of conducting large-scale epidemiologic surveillance of HF prevalence and incidence.

Implementation of a fracture liaison service for patients with hip fracture cared for on a hospital medicine service.

OBJECTIVE: Hip fracture is a common and morbid condition. Prior studies have shown that the majority of patients with fragility fracture are not treated for underlying osteoporosis. Our hospitalist-led co-management service for patients with acute hip fracture had no system for evaluating and treating osteoporosis in this cohort. Our objective was to implement a fracture liaison service (FLS) to assist patients with acute hip fracture and assess subsequent impact on diagnosis and treatment of osteoporosis. METHODS: We conducted a pre-post study design at our tertiary academic center, including patients >50 years old hospitalized with acute hip fracture. We implemented a FLS, whereby all patients received endocrinology consultation. Outcome measures included the proportion of patients evaluated for osteoporosis by time of hospital discharge, comparing pre-implementation (12 months) and post-implementation (9 months) cohorts. We also measured the proportions of patients evaluated for and offered treatment for osteoporosis within 3 months of discharge for patients with post-discharge encounters visible in the medical record. RESULTS: We identified 167 patients before and 124 after FLS implementation. In univariate analysis, the proportion of patients evaluated for osteoporosis before discharge increased from 0.6% to 72.6% (p < 0.001) pre- vs. post-implementation. The proportion of patients offered osteoporosis treatment within 3 months after discharge increased from 25.3% to 46.3% (p = 0.01). In multivariate analysis, post-implementation patients had higher odds of osteoporosis evaluation while hospitalized (OR = 470.4, p < 0.001) and higher odds of being offered osteoporosis treatment within 3 months (OR = 2.8, p = 0.008). CONCLUSIONS: Establishment of an FLS partnered with a hospitalist-led co-management service for patients with hip fracture was associated with significant improvements in the proportions of patients evaluated and offered treatment for osteoporosis. Wider adoption of this model has the potential to improve care for patients with hip fracture by narrowing the osteoporosis treatment gap.

Using Safety Barrier Analysis to Facilitate Quality Improvement in Health Care: Improving Venous Thromboembolism Prophylaxis as a Proof of Concept.

Effective quality improvement is a key factor in optimizing the care of hospitalized patients. Unfortunately, the US health care system has a poor safety record when compared to other major industries. For example, at 250 000 per year, medical errors are the third leading cause of death in the United States. Safety barrier management, a widely used methodology in high-risk industries such as commercial airline transportation and oil drilling, has not been widely used in traditional quality improvement efforts in health care, which rely more on standard lean Six Sigma quality approaches. The authors describe a quality improvement project that uses safety barrier analysis to help inform solutions to improve venous thromboembolism prophylaxis in hospitalized patients. This study found that safety barrier analysis helped inform solutions to improve venous thromboembolism prophylaxis at the study institution and can be a useful adjunct to standard lean Six Sigma methodologies for quality improvement in health care.

Association of the Usability of Electronic Health Records With Cognitive Workload and Performance Levels Among Physicians.

Importance: Current electronic health record (EHR) user interfaces are suboptimally designed and may be associated with excess cognitive workload and poor performance. Objective: To assess the association between the usability of an EHR system for the management of abnormal test results and physicians' cognitive workload and performance levels. Design, Setting, and Participants: This quality improvement study was conducted in a simulated EHR environment. From April 1, 2016, to December 23, 2016, residents and fellows from a large academic institution were enrolled and allocated to use either a baseline EHR (n = 20) or an enhanced EHR (n = 18). Data analyses were conducted from January 9, 2017, to March 30, 2018. Interventions: The EHR with enhanced usability segregated in a dedicated folder previously identified critical test results for patients who did not appear for a scheduled follow-up evaluation and provided policy-based decision support instructions for next steps. The baseline EHR displayed all patients with abnormal or critical test results in a general folder and provided no decision support instructions for next steps. Main Outcomes and Measures: Cognitive workload was quantified subjectively using NASA-Task Load Index and physiologically using blink rates. Performance was quantified according to the percentage of appropriately managed abnormal test results. Results: Of the 38 participants, 25 (66%) were female. The 20 participants allocated to the baseline EHR compared with the 18 allocated to the enhanced EHR demonstrated statistically significantly higher cognitive workload as quantified by blink rate (mean [SD] blinks per minute, 16 [9] vs 24 [7]; blink rate, -8 [95% CI, -13 to -2]; P = .01). The baseline group showed statistically significantly poorer performance compared with the enhanced group who appropriately managed 16% more abnormal test results (mean [SD] performance, 68% [19%] vs 98% [18%]; performance rate, -30% [95% CI, -40% to -20%]; P < .001). Conclusions and Relevance: Relatively basic usability enhancements to the EHR system appear to be associated with better physician cognitive workload and performance; this finding suggests that next-generation systems should strip away non-value-added EHR interactions, which may help physicians eliminate the need to develop their own suboptimal workflows.

Who You Gonna Call? Outcomes of a Team-Based Approach to Respond to Disruptive Behavioral Issues in Hospitalized Patients.

BACKGROUND: The behavioral response system (BRS) at one institution is designed to bring immediate resources to bear when hospitalized patients experience acute episodes of disruptive behavior. The goal of this study was to describe the patient population, inciting events, and outcomes of the BRS. METHODS: The researchers identified all patients admitted to the institution from July 2016 to June 2017 for whom the BRS was activated. Descriptive statistics were calculated, and logistic regression was used to evaluate associations between demographic and clinical characteristics and use of physical and/or chemical restraints. RESULTS: There were 271 BRS calls (range: 0-9 per day). One injury every month occurred for patients and hospital staff. Men, African Americans, and older patients were significantly overrepresented in BRS calls when compared to the overall hospital population. Either chemical or physical restraints were used in 68.7% of cases: 53.9% of patients (or visitors) received chemical restraints, 28.8% were placed in physical restraints, and 17.7% were placed in manual holds. In multivariate analyses, use of physical and chemical restraints were correlated with age ≥ 65 years. Having a dementia/delirium diagnosis was the only significant predictor of chemical restraints, and threatening harm to staff or self was a significant predictor of the use of physical restraints. CONCLUSION: Our study adds to the growing body of knowledge describing how BRSs interact with patients and hospital staff at large academic medical centers. Future studies should focus on investigating if implicit bias influences provider activation of the BRS and reducing the need for patient restraints.

Impact of hospitalist vs. non-hospitalist services on length of stay and 30-day readmission rate in hip fracture patients.

OBJECTIVES: Hip fracture is a common and morbid condition, affecting a patient population with significant medical co-morbidities. A number of medical co-management models have been studied, with conflicting reports of effect on patient outcomes. Our objective was to compare outcomes for patients with hip fracture managed by hospitalist vs. non-hospitalist services at an academic medical center. METHODS: We conducted a retrospective cohort study of patients with hip fracture over 1 year, comparing those on hospitalist vs. non-hospitalist services. Outcomes included 30-day readmission and hospitalization ≤7 days, with comparison between patients admitted to hospitalist vs. non-hospitalist services. We performed multivariate analysis, adjusting for age, gender, race/ethnicity, insurance type, ASA score, and blood transfusion during hospitalization and days from admission to surgery. RESULTS: We identified 124 hospitalist and 53 non-hospitalist patients. In unadjusted analysis, hospitalist patients were more likely to have hospitalization ≤7 days (84.7% vs. 67.9%, p = 0.01). In adjusted analysis, hospitalist patients had lower odds of 30-day readmissions (OR 0.2, 95% CI 0.04-0.97) but no difference in odds of hospitalization ≤7 days (OR 2.1, 95% CI 0.82-5.66). CONCLUSIONS: Patients with hip fracture managed by hospitalist vs. non-hospitalist services had lower odds of 30-day readmission after discharge. Our results suggest benefit to hospitalist co-management of hip fracture patients.

Tying up loose ends: discharging patients with unresolved medical issues.

BACKGROUND: Patients are increasingly being discharged from the hospital with unresolved medical problems requiring outpatient follow-up. This study evaluates the frequency with which hospital physicians recommend outpatient workups to address patients' unresolved medical problems and the impact that availability of discharge summaries has on workup completion. METHODS: We conducted a retrospective cohort study of patients discharged from the medicine or geriatrics service of a large teaching hospital between June 1, 2002, and December 31, 2003. Each subject's inpatient medical record was reviewed to determine if the hospital physician recommended an outpatient workup. Subjects' outpatient medical records were then reviewed to determine if the workups were completed. RESULTS: Of 693 hospital discharges, 191 discharged patients (27.6%) had 240 outpatient workups recommended by their hospital physicians. The types of workups were diagnostic procedures (47.9%), subspecialty referrals (35.4%), and laboratory tests (16.7%). The most common diagnostic procedures were computed tomographic scans to follow up abnormalities seen on previous radiographic studies and endoscopic procedures to follow up gastrointestinal tract bleeding. Of recommended workups, 35.9% were not completed. Increasing time to the initial postdischarge primary care physician visit decreased the likelihood that a recommended workup was completed (odds ratio, 0.77; P=.002), and availability of a discharge summary documenting the recommended workup increased the likelihood of workup completion (odds ratio, 2.35; P=.007). CONCLUSIONS: Noncompletion of recommended outpatient workups after hospital discharge is common. Primary care physicians' access to discharge summaries documenting the recommended workup is associated with better completion of recommendations. Future research should focus on interventions to improve the quality and dissemination of discharge information to primary care physicians.

Patients discharged from the emergency department after referral for hospitalist admission.

OBJECTIVES: To describe the characteristics and outcomes of patients discharged from the emergency department (ED) by hospitalist physicians. STUDY DESIGN: Retrospective cohort study at a tertiary academic medical center. METHODS: We used consultation Current Procedural Technology codes to identify patients discharged from the ED after referral for hospitalist admission from April 2011 to April 2014. We report patient demographics and primary diagnoses. Main outcome measures included return to the ED, hospitalization, or mortality, all within 30 days. RESULTS: There were 710 discharges from the ED for 670 patients referred for hospitalist admission; 21.7% returned to the ED, 12.3% were hospitalized, and 0.4% died within 30 days. Chest pain was the most common diagnosis (38.2%); 18.1% of these patients returned to the ED within 30 days. Patients with the following 3 diagnoses returned to the ED most frequently: sickle cell disease (82.4%), alcohol-related diagnoses (43.5%), and abdominal pain (35.7%). In multivariate analysis, abdominal pain (odds ratio [OR], 3.2; P <.001) and alcohol dependence (OR, 3.1; P = .003) increased the odds of ED revisits, whereas syncope (OR, 0.23; P = .049) reduced the odds. Chest pain reduced the odds of hospitalization (OR, 0.37; P = .005). CONCLUSIONS: A majority of patients discharged from the ED after referral for hospitalist admission did not return to the ED within 30 days, and the 30-day hospitalization rate was low. Our data suggest that hospitalists can safely aid patients by reducing the costs and adverse outcomes associated with unnecessary hospitalization.