Family Perceptions of Virtual Family-Centered Rounds in a Quaternary Cardiac Intensive Care Unit.

Background: Family-centered rounds (FCR) reduce the risk of psychological comorbidities of family members and improve the quality of communication between providers and families. Materials and methods: We conducted a pilot quality improvement study analyzing family perceptions of virtual FCR. Family members of previously admitted cardiac ICU patients who participated in at least one session of virtual FCR between April 2020 and June 2021 at Massachusetts General Hospital were surveyed post-ICU discharge. Results: During the study, 82 family members enrolled and participated in virtual FCR with 29 completing the post-admission telephone survey. Many cardiac ICU patients were male (n = 53), and a majority were discharged home (43%) with the patient's wives being the most common respondents to the questionnaire (n = 18). Across all questions in the survey, more than 75% of the respondents perceived the highest level of care in trust, communication, relationship, and compassion with their provider. Participants perceived the highest level of care in trust (96%), explanation (88%), as well as care and understanding (89%). Conclusions: Family members of cardiac ICU patients positively rated the quality of communication and perceived a high level of trust and communication between their providers on the virtual format.

Adapting the serious illness conversation guide for use in the emergency department by social workers.

OBJECTIVE: Although important treatment decisions are made in the Emergency Department (ED), conversations about patients' goals and values and priorities often do not occur. There is a critical need to improve the frequency of these conversations, so that ED providers can align treatment plans with these goals, values, and priorities. The Serious Illness Conversation Guide has been used in other care settings and has been demonstrated to improve the frequency, quality, and timing of conversations, but it has not been used in the ED setting. Additionally, ED social workers, although integrated into hospital and home-based palliative care, have not been engaged in programs to advance serious illness conversations in the ED. We set out to adapt the Serious Illness Conversation Guide for use in the ED by social workers. METHODS: We undertook a four-phase process for the adaptation of the Serious Illness Conversation Guide for use in the ED by social workers. This included simulated testing exercises, pilot testing, and deployment with patients in the ED. RESULTS: During each phase of the Guide's adaptation, changes were made to reflect both the environment of care (ED) and the clinicians (social workers) that would be using the Guide. A final guide is presented. SIGNIFICANCE OF RESULTS: This report presents an adapted Serious Illness Conversation Guide for use in the ED by social workers. This Guide may provide a tool that can be used to increase the frequency and quality of serious illness conversations in the ED.

A Novel Model for Predicting Rehospitalization Risk Incorporating Physical Function, Cognitive Status, and Psychosocial Support Using Natural Language Processing.

BACKGROUND: With the increasing focus on reducing hospital readmissions in the United States, numerous readmissions risk prediction models have been proposed, mostly developed through analyses of structured data fields in electronic medical records and administrative databases. Three areas that may have an impact on readmission but are poorly captured using structured data sources are patients' physical function, cognitive status, and psychosocial environment and support. OBJECTIVE OF THE STUDY: The objective of the study was to build a discriminative model using information germane to these 3 areas to identify hospitalized patients' risk for 30-day all cause readmissions. RESEARCH DESIGN: We conducted clinician focus groups to identify language used in the clinical record regarding these 3 areas. We then created a dataset including 30,000 inpatients, 10,000 from each of 3 hospitals, and searched those records for the focus group-derived language using natural language processing. A 30-day readmission prediction model was developed on 75% of the dataset and validated on the other 25% and also on hospital specific subsets. RESULTS: Focus group language was aggregated into 35 variables. The final model had 16 variables, a validated C-statistic of 0.74, and was well calibrated. Subset validation of the model by hospital yielded C-statistics of 0.70-0.75. CONCLUSIONS: Deriving a 30-day readmission risk prediction model through identification of physical, cognitive, and psychosocial issues using natural language processing yielded a model that performs similarly to the better performing models previously published with the added advantage of being based on clinically relevant factors and also automated and scalable. Because of the clinical relevance of the variables in the model, future research may be able to test if targeting interventions to identified risks results in reductions in readmissions.

Clinical implementation of an emergency department coronary computed tomographic angiography protocol for triage of patients with suspected acute coronary syndrome.

OBJECTIVES: To evaluate the efficiency and safety of emergency department (ED) coronary computed tomography angiography (CTA) during a 3-year clinical experience. METHODS: Single-center registry of coronary CTA in consecutive ED patients with suspicion of acute coronary syndrome (ACS). The primary outcome was efficiency of coronary CTA defined as the length of hospitalization. Secondary endpoints of safety were defined as the rate of downstream testing, normalcy rates of invasive coronary angiography (ICA), absence of missed ACS, and major adverse cardiac events (MACE) during follow-up, and index radiation exposure. RESULTS: One thousand twenty two consecutive patients were referred for clinical coronary CTA with suspicion of ACS. Overall, median time to discharge home was 10.5 (5.7-24.1) hours. Patient disposition was 42.7 % direct discharge from the ED, 43.2 % discharge from emergency unit, and 14.1 % hospital admission. ACS rate during index hospitalization was 9.1 %. One hundred ninety two patients underwent additional diagnostic imaging and 77 underwent ICA. The positive predictive value of CTA compared to ICA was 78.9 % (95 %-CI 68.1-87.5 %). Median CT radiation exposure was 4.0 (2.5-5.8) mSv. No ACS was missed; MACE at follow-up after negative CTA was 0.2 %. CONCLUSIONS: Coronary CTA in an experienced tertiary care setting allows for efficient and safe management of patients with suspicion for ACS. KEY POINTS: • ED Coronary CTA using advanced systems is associated with low radiation exposure. • Negative coronary CTA is associated with low rates of MACE. • CTA in ED patients enables short median time to discharge home. • CTA strategy is characterized by few downstream tests including unnecessary ICA.

Project BOOST implementation: lessons learned.

OBJECTIVES: Enhancing care coordination and reducing hospital readmissions have been a focus of multiple quality improvement (QI) initiatives. Project BOOST (Better Outcomes by Optimizing Safe Transitions) aims to enhance the discharge transition from hospital to home. Previous research indicates that QI initiatives originating externally often face difficulties gaining momentum or effecting lasting change in a hospital. We performed a qualitative evaluation of Project BOOST implementation by examining the successes and failures experienced by six pilot sites. We also evaluated the unique physician mentoring component of this program. Finally, we examined the impact of intensification of the physician mentoring model on adoption of BOOST interventions in two later Illinois cohorts (27 hospitals). METHODS: Qualitative analysis of six pilot hospitals used a process of methodological triangulation and analysis of the BOOST enrollment applications, the listserv, and content from telephone interviews. Evaluation of BOOST implementation at Illinois hospitals occurred via mid-year and year-end surveys. RESULTS: The identified common barriers included inadequate understanding of the current discharge process, insufficient administrative support, lack of protected time or dedicated resources, and lack of frontline staff buy-in. Facilitators of implementation included the mentor, a small beginning, teamwork, and proactive engagement of the patient. Notably, hospitals viewed their mentors as essential facilitators of change. Sites consistently commented that the individualized mentoring was extremely helpful and provided significant accountability and stimulated creativity. In the Illinois cohorts, the improved mentoring model showed more complete implementation of BOOST interventions. CONCLUSIONS: The implementation of Project BOOST was well received by hospitals, although sites faced substantial barriers consistent with other QI research reports. The unique mentorship element of Project BOOST proved extremely valuable in helping sites overcome their distinctive challenges and identify facilitators for success. The findings from this qualitative study should contribute to future BOOST implementation success and others' efforts to optimize hospital discharge transitions.

Rationale and design of the Multicenter Medication Reconciliation Quality Improvement Study (MARQUIS).

BACKGROUND: Unresolved medication discrepancies during hospitalization can contribute to adverse drug events, resulting in patient harm. Discrepancies can be reduced by performing medication reconciliation; however, effective implementation of medication reconciliation has proven to be challenging. The goals of the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) are to operationalize best practices for inpatient medication reconciliation, test their effect on potentially harmful unintentional medication discrepancies, and understand barriers and facilitators of successful implementation. METHODS: Six U.S. hospitals are participating in this quality improvement mentored implementation study. Each hospital has collected baseline data on the primary outcome: the number of potentially harmful unintentional medication discrepancies per patient, as determined by a trained on-site pharmacist taking a "gold standard" medication history. With the guidance of their mentors, each site has also begun to implement one or more of 11 best practices to improve medication reconciliation. To understand the effect of the implemented interventions on hospital staff and culture, we are performing mixed methods program evaluation including surveys, interviews, and focus groups of front line staff and hospital leaders. DISCUSSION: At baseline the number of unintentional medication discrepancies in admission and discharge orders per patient varies by site from 2.35 to 4.67 (mean=3.35). Most discrepancies are due to history errors (mean 2.12 per patient) as opposed to reconciliation errors (mean 1.23 per patient). Potentially harmful medication discrepancies averages 0.45 per patient and varies by site from 0.13 to 0.82 per patient. We discuss several barriers to implementation encountered thus far. In the end, we anticipate that MARQUIS tools and lessons learned have the potential to decrease medication discrepancies and improve patient outcomes. TRIAL REGISTRATION: Clinicaltrials.gov identifier NCT01337063.

Aging is not an Illness: Exploring Geriatricians' Resistance to Serious Illness Conversations.

CONTEXT: Serious illness conversations help clinicians align medical decisions with patients' goals, values, and priorities and are considered an essential component of shared decision-making. Yet geriatricians at our institution have expressed reluctance about the serious illness care program. OBJECTIVES: We sought to explore geriatricians' perspectives on serious illness conversations. METHODS: We conducted focus groups with interprofessional stakeholders in geriatrics. RESULTS: Three key themes emerged that help explain the reluctance of clinicians caring for older patients to have or document serious illness conversations: 1) aging in itself is not a serious illness; 2) geriatricians often focus on positive adaptation and social determinants of health and in this context, the label of "serious illness conversations" is perceived as limiting; and 3) because aging is not synonymous with illness, important goals-of-care conversations are not necessarily documented as serious illness conversations until an acute illness presents itself. CONCLUSION: As institutions work to create system-wide processes for documenting conversations about patients' goals and values, the unique communication preferences of older patients and geriatricians should be specifically considered.

Assessing the Acceptability and Feasibility of Leveraging Emergency Department Social Workers' Advanced Communication Skills to Assess Elderly Patients' Goals and Values.

Background: The Emergency Department (ED) has increasingly been recognized as an important site of care for older adults with unmet palliative care needs. Despite this, no clear model of care delivery has emerged. Aim: To assess the acceptability and feasibility of a scripted palliative care communication intervention in the ED directed by social workers. We hypothesized that the intervention would be feasible, acceptable to patients and ED social workers, and that the collection of patient outcomes would be possible. Design: A prospective, unblinded, pilot randomized clinical trial of older adults with serious illness presenting to the ED. Patients were randomized to either receive a social worker-directed palliative care intervention (n-65), which consisted of a conversation focused on patients' goals, values, hopes and worries, or to usual care (n-52). The intervention was evaluated for feasibility and acceptability. Results: Of patients randomized to the intervention arm, 66% (43/65) completed a conversation with the social worker. Focus group feedback with the social workers further demonstrated the feasibility of these conversations. There was minimal (12%) loss to follow-up. Of the patients who received the intervention, the majority reported that they appreciated the social workers bringing up their goals for the future (77%), their social workers asking about their fears and worries (72%), and they liked the way the conversation was set up (81%). Social workers administered 95% of the conversation components. Conclusions: This pilot trial demonstrated the feasibility and acceptability of a social worker-directed, scripted palliative care communication intervention in a single urban, academic ED.

2011 John M. Eisenberg Patient Safety and Quality Awards. Mentored implementation: building leaders and achieving results through a collaborative improvement model. Innovation in patient safety and quality at the national level.

BACKGROUND: The Society of Hospital Medicine (SHM) created "Mentored Implementation" (MI) programs with the dual aims of educating and mentoring hospitalists and their quality improvement (QI) teams and accelerating improvement in the inpatient setting in three signature programs: Venous Thromboembolism (VTE) Prevention, Glycemic Control, and Project BOOST (Better Outcomes for Older adults through Safe Transitions). METHODS: More than 300 hospital improvement teams were enrolled in SHM MI programs in a series of cohorts. Hospitalist mentors worked with individual hospitals/health systems to guide local teams through the life cycle of a QI project. Implementation Guides and comprehensive Web-based "Resource Rooms," as well as the mentor's own experience, provided best-practice definitions, practical implementation tips, measurement strategies, and other tools. E-mail interactions and mentoring were augmented by regularly scheduled teleconferences; group webinars; and, in some instances, a site visit. Performance was tracked in a centralized data tracking center. RESULTS: Preliminary data on all three MI programs show significant improvement in patient outcomes, as well as enhancements of communication and leadership skills of the hospitalists and their QI teams. CONCLUSIONS: Although objective data on outcomes and process measures for the MI program's efficacy remain preliminary at this time, the maturing data tracking system, multiple awards, and early results indicate that the MI programs are successful in providing QI training and accelerating improvement efforts.

Factors associated with false-positive results from fingerstick OraQuick ADVANCE rapid HIV 1/2 antibody test.

OBJECTIVE: Identify factors associated with false-positive rapid HIV antibody tests. DESIGN: This retrospective cohort study with nested case-controls involved patients tested for HIV by Boston Medical Center (BMC) affiliates. METHODS: Cases had a reactive fingerstick OraQuick ADVANCE rapid HIV 1/2 antibody test and a negative Western blot. Controls had nonreactive rapid tests. We compared the prevalence of HIV risk factors between cases and the total nonreactive population and the prevalence of other clinical factors between cases and controls. RESULTS: Of the 15 094 tests, 14 937 (98.9%) were negative and 11 (0.07%) were false positives (specificity of 99.9%). Cases were more likely to have had an HIV-infected sex partner and to be tested at certain sites compared to true negatives. More cases than controls had O-negative blood type. CONCLUSION: O-negative blood type and sex with an HIV-infected person may increase false-positive HIV fingerstick results. More targeted studies should examine these risk factors.

One Hospital's Response to the Institute of Medicine Report, "Dying in America".

BACKGROUND: In response to the Institute of Medicine (IOM) report, Dying in America, we undertook an institution wide effort to improve the experience of patients and families facing serious illness by engaging leadership and developing a program to promote the practice of generalist palliative care. MEASURES: The impact of the program was measured with process measures related to its' three parts. INTERVENTION: We developed a three-part generalist palliative care program that focuses on 1) instructional design, 2) advance care planning, and 3) engagement. OUTCOMES: Over four years, the program trained 51 interprofessional clinicians in a two-week intensive palliative care course and 1,541 interprofessional clinicians in a 90-150 min skills-based training. Clinicians documented 15,791 serious illness conversations. Zoom community engagement sessions were attended by 411 live viewers, and subsequently, 1918 YouTube views. Additionally, we report on the impact of the COIVD-19 crisis on our efforts. Early in the pandemic, over two months, 464 interprofessional clinicians documented 5,168 conversations with patients. CONCLUSION/LESSONS LEARNED: A broad based strategy resulted wide institutional engagement with serious illness care.

Making Space to Save Lives: A Critical Role for the Hospitalist During Mass Casualty Incidents.

OBJECTIVE: An effective hospital response to mass casualty incidents (MCIs) requires rapid mobilization of personnel capable of caring for critically ill trauma patients and availability of resuscitation resources. METHODS: Hospitals facing an MCI wrestle with the challenge of immediately adjusting their overextended clinical operations to resuscitate a large number of rapidly arriving patients without compromising the care of existing patients. RESULTS: Hospitalists are well positioned to add significant value by off-loading the emergency department (ED) given their broad clinical expertise. We describe our institution's protocol to generate immediate and sustained surge capacity by integrating our hospitalist service into MCI response. CONCLUSIONS: Our protocol details the safe and rapid transfer of care of existing ED patients to hospitalist teams to make ED staff and space available to care for incoming MCI patients.

Improving Quality and Safety for Patients After Hospital Discharge: Primary Care as the Lead Integrator in Postdischarge Care Transitions.

To understand current and idealized primary care-based care transition workflow processes for hospitalized patients, we conducted 133 interviews with staff at 9 primary care sites; community agency staff (n = 18); recently discharged patients (n = 33); and primary care thought leaders (n = 9). Current postdischarge workflows in primary care vary widely across settings, are often implemented inconsistently, and rarely involve communications with the patient or inpatient team during hospitalization. Based on these findings, we propose 5 principles for primary care practices to facilitate active involvement in postdischarge care, beginning during the hospital admission and extending until after the initial postdischarge primary care visit.

Effective multilevel teaching techniques on attending rounds: a pilot survey and systematic review of the literature.

BACKGROUND: While numerous authors acknowledge the challenge of teaching simultaneously to medical students, interns, and residents, few offer specific advice on how to meet that challenge, and none have studied which techniques are most effective. AIMS: The purpose of this study was to determine whether multilevel teaching is challenging for attendings, whether trainees feel that teaching on rounds is appropriate to their level, and to define multilevel teaching techniques. METHODS: We surveyed attendings and trainees on the internal medicine services at two academic medical centers. RESULTS: Attendings were divided about whether teaching to multiple levels posed a challenge. Trainees reported that the teaching they received was usually appropriate to their level of training. The most effective techniques for multilevel teaching were Broadening (asking "what if" questions), Targeting (directing questions at specific team members), and Novelty (teaching newly published information), while the least effective were techniques that taught advanced material unfamiliar to most or all of the team. A systematic literature review yielded no studies that focused on multilevel teaching techniques. CONCLUSIONS: This article is the first to define and evaluate specific techniques for multilevel instruction in a medical setting and identifies certain techniques as more effective at engaging multiple levels of learners simultaneously.