Design of MARQUIS2: study protocol for a mentored implementation study of an evidence-based toolkit to improve patient safety through medication reconciliation.

BACKGROUND: The first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) demonstrated that implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals. We sought to implement the MARQUIS toolkit in more diverse hospitals, incorporating lessons learned from MARQUIS1. METHODS: MARQUIS2 is a pragmatic, mentored implementation QI study which collected clinical and implementation outcomes. Sites implemented a revised toolkit, which included interventions from these domains: 1) best possible medication history (BPMH)-taking; 2) discharge medication reconciliation and patient/caregiver counseling; 3) identifying and defining clinician roles and responsibilities; 4) risk stratification; 5) health information technology improvements; 6) improved access to medication sources; 7) identification and correction of real-time discrepancies; and, 8) stakeholder engagement. Eight hospitalists mentored the sites via one site visit and monthly phone calls over the 18-month intervention period. Each site's local QI team assessed opportunities to improve, implemented at least one of the 17 toolkit components, and accessed a variety of resources (e.g. implementation manual, webinars, and workshops). Outcomes to be assessed will include unintentional medication discrepancies per patient. DISCUSSION: A mentored multi-center medication reconciliation QI initiative using a best practices toolkit was successfully implemented across 18 medical centers. The 18 participating sites varied in size, teaching status, location, and electronic health record (EHR) platform. We introduce barriers to implementation and lessons learned from MARQUIS1, such as the importance of utilizing dedicated, trained medication history takers, simple EHR solutions, clarifying roles and responsibilities, and the input of patients and families when improving medication reconciliation.

Hospital Strategies for Reducing Emergency Department Crowding: A Mixed-Methods Study.

STUDY OBJECTIVE: Emergency department (ED) crowding and patient boarding are associated with increased mortality and decreased patient satisfaction. This study uses a positive deviance methodology to identify strategies among high-performing, low-performing, and high-performance improving hospitals to reduce ED crowding. METHODS: In this mixed-methods comparative case study, we purposively selected and recruited hospitals that were within the top and bottom 5% of Centers for Medicare & Medicaid Services case-mix-adjusted ED length of stay and boarding times for admitted patients for 2012. We also recruited hospitals that showed the highest performance improvement in metrics between 2012 and 2013. Interviews were conducted with 60 key leaders (physicians, nurses, quality improvement specialists, and administrators). RESULTS: We engaged 4 high-performing, 4 low-performing, and 4 high-performing improving hospitals, matched on hospital characteristics including geographic designation (urban versus rural), region, hospital occupancy, and ED volume. Across all hospitals, ED crowding was recognized as a hospitalwide issue. The strategies for addressing ED crowding varied widely. No specific interventions were associated with performance in length-of-stay metrics. The presence of 4 organizational domains was associated with hospital performance: executive leadership involvement, hospitalwide coordinated strategies, data-driven management, and performance accountability. CONCLUSION: There are organizational characteristics associated with ED decreased length of stay. Specific interventions targeted to reduce ED crowding were more likely to be successfully executed at hospitals with these characteristics. These organizational domains represent identifiable and actionable changes that other hospitals may incorporate to build awareness of ED crowding.

Transapical Endovascular Repair of an Ascending Aortic Pseudoaneurysm.

Proximal aortic pathology provides a technical challenge for endovascular repair. We present a case of successful transapical endovascular aortic repair in a patient with a proximal suture line pseudoaneurysm who was not a candidate for open surgical repair. doi: 10.1111/jocs.12766 (J Card Surg 2016;31:456-460).

Clinical Communities at Johns Hopkins Medicine: An Emerging Approach to Quality Improvement.

BACKGROUND: Clinical communities are an emerging approach to quality improvement (QI) to which several large-scale projects have attributed some success. In 2011 the Armstrong Institute for Patient Safety and Quality established clinical communities as a core strategy to connect frontline providers from six different hospitals to improve quality of care, patient safety, and value across the health system. CLINICAL COMMUNITIES: Fourteen clinical communities that presented great opportunity for improvement were established. A community could focus on a clinical area, a patient population, a group, a process, a safety-related issue, or nearly any health care issue. The collaborative spirit of the communities embraced interdisciplinary membership and representation from each hospital in each community. Communities engaged in team-building activities and facilitated discussions, met monthly, and were encouraged to meet in person to develop relationships and build trust. After a community was established, patients and families were invited to join and share their perspectives and experiences. ENABLING STRUCTURES: The clinical community structure provided clinicians access to resources, such as technical experts and safety and QI researchers, that were not easily otherwise accessible or available. Communities convened clinicians from each hospital to consider safety problems and their resolution and share learning with workplace peers and local unit safety teams. CONCLUSION: The clinical communities engaged 195 clinicians from across the health system in QI projects and peer learning. Challenges included limited financial support and time for clinicians, timely access to data, limited resources from the health system, and not enough time with improvement experts.

Comportment and Communication Patterns among Hospitalist Physicians: Insight Gleaned Through Observation.

OBJECTIVES: By 2014, there were more than 40,000 hospitalists delivering the majority of inpatient care in US hospitals. No empiric research has characterized hospitalist comportment and communication patterns as they care for patients. METHODS: The chiefs of hospital medicine at five different hospitals were asked to identify their best hospitalists. These hospitalists were watched during their routine clinical care of patients. An observation tool was developed that focused on elements believed to be associated with excellent comportment and communication. One observer watched the physicians, taking detailed quantitative and qualitative field notes. RESULTS: A total of 26 hospitalists were shadowed. The mean age of the physicians was 38 years, and their average experience in hospital medicine was 6 years. The hospitalists were observed for a mean of 5 hours, during which time they saw an average of 7 patients (patient encounters observed N = 181). Physicians spent an average of 11 minutes with each patient. There was large variation in the extent to which desirable behaviors were performed. For example, most physicians (76%) started encounters with an open-ended question, and relatively few (30%) attempted to integrate nonmedical content into conversation with patients. CONCLUSIONS: This study represents a first step in trying to characterize comportment and communication in hospital medicine. Because hospitalists spend only a small proportion of their clinical time in direct patient care, it is imperative that excellent comportment and communication are clearly defined and established as a goal for every encounter.

Neutrophil gelatinase-associated lipocalin: ready for routine clinical use? An international perspective.

Acute kidney injury (AKI) remains a challenge in terms of diagnosis and classification, its morbidity and mortality remaining high in the face of improving clinical protocols. Current clinical criteria use serum creatinine (sCr) and urine output to classify patients. Ongoing research has identified novel biomarkers that may improve the speed and accuracy of patient evaluation and prognostication, yet the route from basic science to clinical practice remains poorly paved. International evidence supporting the use of plasma neutrophil gelatinase-associated lipocalin (NGAL) as a valuable biomarker of AKI and chronic kidney disease (CKD) for a number of clinical scenarios was presented at the 31st International Vicenza Course on Critical Care Nephrology, and these data are detailed in this review. NGAL was shown to be highly useful alongside sCr, urinary output, and other biomarkers in assessing kidney injury; in patient stratification and continuous renal replacement therapy (CRRT) selection in paediatric AKI; in assessing kidney injury in conjunction with sCr in sepsis; in guiding resuscitation protocols in conjunction with brain natriuretic peptide in burn patients; as an early biomarker of delayed graft function and calcineurin inhibitor nephrotoxicity in kidney transplantation from extended criteria donors; as a biomarker of cardiovascular disease and heart failure, and in guiding CRRT selection in the intensive care unit and emergency department. While some applications require further clarification by way of larger randomised controlled trials, NGAL nevertheless demonstrates promise as an independent biological marker with the potential to improve earlier diagnosis and better assessment of risk groups in AKI and CKD. This is a critical element in formulating quick and accurate decisions for individual patients, both in acute scenarios and in long-term care, in order to improve patient prognostics and outcomes.

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.

Implementation of the I-PASS handoff program in diverse clinical environments: A multicenter prospective effectiveness implementation study.

BACKGROUND: Handoff miscommunications are a leading source of medical errors. Harmful medical errors decreased in pediatric academic hospitals following implementation of the I-PASS handoff improvement program. However, implementation across specialties has not been assessed. OBJECTIVE: To determine if I-PASS implementation across diverse settings would be associated with improvements in patient safety and communication. DESIGN: Prospective Type 2 Hybrid effectiveness implementation study. SETTINGS AND PARTICIPANTS: Residents from diverse specialties across 32 hospitals (12 community, 20 academic). INTERVENTION: External teams provided longitudinal coaching over 18 months to facilitate implementation of an enhanced I-PASS program and monthly metric reviews. MAIN OUTCOME AND MEASURES: Systematic surveillance surveys assessed rates of resident-reported adverse events. Validated direct observation tools measured verbal and written handoff quality. RESULTS: 2735 resident physicians and 760 faculty champions from multiple specialties (16 internal medicine, 13 pediatric, 3 other) participated. 1942 error surveillance reports were collected. Major and minor handoff-related reported adverse events decreased 47% following implementation, from 1.7 to 0.9 major events/person-year (p < .05) and 17.5 to 9.3 minor events/person-year (p < .001). Implementation was associated with increased inclusion of all five key handoff data elements in verbal (20% vs. 66%, p < .001, n = 4812) and written (10% vs. 74%, p < .001, n = 1787) handoffs, as well as increased frequency of handoffs with high quality verbal (39% vs. 81% p < .001) and written (29% vs. 78%, p < .001) patient summaries, verbal (29% vs. 78%, p < .001) and written (24% vs. 73%, p < .001) contingency plans, and verbal receiver syntheses (31% vs. 83%, p < .001). Improvement was similar across provider types (adult vs. pediatric) and settings (community vs. academic).

What works in medication reconciliation: an on-treatment and site analysis of the MARQUIS2 study.

BACKGROUND: The second Multicenter Medication Reconciliation Quality Improvement Study demonstrated a marked reduction in medication discrepancies per patient. The aim of the current analysis was to determine the association of patient exposure to each system-level intervention and receipt of each patient-level intervention on these results. METHODS: This study was conducted at 17 North American Hospitals, the study period was 18 months per site, and sites typically adopted interventions after 2-5 months of preintervention data collection. We conducted an on-treatment analysis (ie, an evaluation of outcomes based on patient exposure) of system-level interventions, both at the category level and at the individual component level, based on monthly surveys of implementation site leads at each site (response rate 65%). We then conducted a similar analysis of patient-level interventions, as determined by study pharmacist review of documented activities in the medical record. We analysed the association of each intervention on the adjusted number of medication discrepancies per patient in admission and discharge orders, based on a random sample of up to 22 patients per month per site, using mixed-effects Poisson regression with hospital site as a random effect. We then used a generalised linear mixed-effects model (GLMM) decision tree to determine which patient-level interventions explained the most variance in discrepancy rates. RESULTS: Among 4947 patients, patient exposure to seven of the eight system-level component categories was associated with modest but significant reductions in discrepancy rates (adjusted rate ratios (ARR) 0.75-0.97), as were 15 of the 17 individual system-level intervention components, including hiring, reallocating and training personnel to take a best possible medication history (BPMH) and training personnel to perform discharge medication reconciliation and patient counselling. Receipt of five of seven patient-level interventions was independently associated with large reductions in discrepancy rates, including receipt of a BPMH in the emergency department (ED) by a trained clinician (ARR 0.40, 95% CI 0.37 to 0.43), admission medication reconciliation by a trained clinician (ARR 0.57, 95% CI 0.50 to 0.64) and discharge medication reconciliation by a trained clinician (ARR 0.64, 95% CI 0.57 to 0.73). In GLMM decision tree analyses, patients who received both a BPMH in the ED and discharge medication reconciliation by a trained clinician experienced the lowest discrepancy rates (0.08 per medication per patient). CONCLUSION AND RELEVANCE: Patient-level interventions most associated with reductions in discrepancies were receipt of a BPMH of admitted patients in the ED and admission and discharge medication reconciliation by a trained clinician. System-level interventions were associated with modest reduction in discrepancies for the average patient but are likely important to support patient-level interventions and may reach more patients. These findings can be used to help hospitals and health systems prioritise interventions to improve medication safety during care transitions.

Signet ring cell primary cutaneous CD30+ lymphoproliferative disorder presenting as a monomorphic T-cell posttransplant lymphoproliferative disease.

T-cell posttransplant lymphoproliferative disorders are rare, with peripheral T-cell lymphoma not otherwise specified being the most common type. Although cases of the signet ring cell variant of primary cutaneous CD30+ lymphoproliferative disorder have been reported, such cases have not been described in the posttransplant setting. We describe a case with emphasis on the special contextual differential diagnostic considerations.

Peer assessment of professional performance by hospitalist physicians.

BACKGROUND: The clinical collaborations among hospitalist physicians create opportunities for peer evaluation. We conducted this study to generate validity evidence for a scale that allows for peer assessment of professional performance. METHODS: All of the hospitalist physicians working for >1 year at our hospital were asked to assess each of their physician colleagues along eight domains and name three colleagues whom they would choose to care for a loved one needing hospitalization. A mean composite clinical performance score was generated for each provider. Statistical analyses using the Pearson coefficient were performed. RESULTS: The 22 hospitalist physician participants were confident in their ability to assess their peers' clinical skills. There were strong correlations between the domains of clinical excellence (r > 0.5, P < 0.05). Being selected as a doctor whom colleagues would choose to take care of their loved ones was highly correlated with high scores in the domains of humanism, diagnostic acumen, signouts/handoffs, and passion for clinical medicine, and higher composite clinical performance scores (all r > 0.5, P < 0.05). High scores on the Press Ganey questions correlated with peer assessment of humanism (r = .78, P = 0.06). CONCLUSIONS: The correlation among scale items, the composite clinical performance score, and the variable "a doctor whom you would choose to care for a loved one" provides validity evidence to our assessment scale. Such measurements may allow hospitalist groups to identify top performers who could be recognized, rewarded, and held up as role models and weaker performers who may need focused training or remediation.

Growth trends of the adult hospitalist workforce between 2012 and 2019.

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.

Strategies for sustaining high-quality pediatric asthma care in community hospitals.

OBJECTIVE: To identify strategies associated with sustained guideline adherence and high-quality pediatric asthma care in community hospitals. DATA SOURCES: Primary qualitative data from clinicians in hospitals across the United States (collected December 2019-February 2021). STUDY DESIGN: Pathways for Improving Pediatric Asthma Care (PIPA) was a national quality improvement (QI) intervention. In a prior quantitative study, data from 23 community hospitals in PIPA were analyzed to identify sites with the highest and lowest performance in sustaining improvements for 2 years. In this qualitative study, we conducted semi-structured interviews with multidisciplinary clinicians from these hospitals to identify strategies associated with sustainability. DATA COLLECTION/EXTRACTION METHODS: We purposefully sampled and interviewed participants involved in clinical care of children hospitalized with asthma at the identified hospitals (those with the highest/lowest sustainability performance). We transcribed and analyzed interview data using constant comparative methods. PRINCIPAL FINDINGS: Clinicians (n = 19) from five higher- and three lower-performing hospitals participated. In higher-performing hospitals, dedicated local champions more consistently provided reminders of evidence-based practices and delivered ongoing education. They also modified/developed electronic health record (EHR) tools (e.g., order sets with decision support). Higher-performing hospitals had a collaborative culture receptive to practice change and set firm expectations that evidence-based practices would be followed without exception. In lower-performing hospitals, participants described unique barriers, including delays in modifying the EHR and lack of automation of EHR tools (requiring clinicians to remember new EHR tasks without automated prompts). Barriers to sustainability for all hospitals included challenges with quality monitoring, decreasing focus of local champions over time, and ongoing difficulties developing consensus around evidence-based practices. CONCLUSIONS: To better ensure sustained high-quality care for children with asthma and greater returns on QI investments, QI leaders should prioritize: designating long-term local champions to continue reminders and educational efforts and developing electronic order sets to provide ongoing decision support.

Effects of a refined evidence-based toolkit and mentored implementation on medication reconciliation at 18 hospitals: results of the MARQUIS2 study.

BACKGROUND: The first Multicenter Medication Reconciliation Quality Improvement (QI) Study (MARQUIS1) demonstrated that mentored implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals, but results varied by site. The objective of this study was to determine the effects of a refined toolkit on a larger group of hospitals. METHODS: We conducted a pragmatic quality improvement study (MARQUIS2) at 18 North American hospitals or hospital systems from 2016 to 2018. Incorporating lessons learnt from MARQUIS1, we implemented a refined toolkit, offering 17 system-level and 6 patient-level interventions. One of eight physician mentors coached each site via monthly calls and performed one to two site visits. The primary outcome was number of unintentional medication discrepancies in admission or discharge orders per patient. Time series analysis used multivariable Poisson regression. RESULTS: A total of 4947 patients were sampled, including 1229 patients preimplementation and 3718 patients postimplementation. Both the number of system-level interventions adopted per site and the proportion of patients receiving patient-level interventions increased over time. During the intervention, patients experienced a steady decline in their medication discrepancy rate from 2.85 discrepancies per patient to 0.98 discrepancies per patient. An interrupted time series analysis of the 17 sites with sufficient data for analysis showed the intervention was associated with a 5% relative decrease in discrepancies per month over baseline temporal trends (adjusted incidence rate ratio: 0.95, 95% CI 0.93 to 0.97, p<0.001). Receipt of patient-level interventions was associated with decreased discrepancy rates, and these associations increased over time as sites adopted more system-level interventions. CONCLUSION: A multicentre medication reconciliation QI initiative using mentored implementation of a refined best practices toolkit, including patient-level and system-level interventions, was associated with a substantial decrease in unintentional medication discrepancies over time. Future efforts should focus on sustainability and spread.

Capturing the Rest: Inpatient Mammography for Nonadherent Hospitalized Women.

INTRODUCTION: More than a third of hospitalized women are overdue or nonadherent to breast cancer screening guidelines, and almost a third of them are also at high risk for developing breast cancer. The purpose of this study is to evaluate the feasibility of coordinating inpatient breast cancer screening mammography for these women before their discharge from the hospital. METHODS: A prospective intervention study was conducted among 101 nonadherent women aged 50-74 years who were hospitalized to a general medicine service. Sociodemographic, reproductive history, family history of breast cancer, and medical comorbidities data were collected for all patients from January 2015 to October 2016. The data were analyzed in March 2018. Fisher's exact tests and unpaired t-tests were utilized to compare the characteristics of the study population. RESULTS: Of the 101 women enrolled who were nonadherent to breast cancer screening recommendations, their mean age was 59.3 (SD=6) years, the mean 5-year Gail risk score was 1.63 (SD=0.69), and 29% of the women were African American. Almost 80% (n=79) underwent inpatient screening mammography. All women who underwent screening mammography during their inpatient stay were extremely satisfied with the experience. The convenience of having screening mammography while hospitalized was reported to be a major facilitator of completing the overdue screening. All nurses (100%) taking care of these women believed that this practice should become part of the standard of care, and most hospitalist physicians (66%) agreed that this practice is feasible. CONCLUSIONS: This study shows that it is possible to coordinate mammography for hospitalized women who were overdue for screening and at high risk for developing breast cancer. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT04164251.

Retrospective Quality Improvement Study of Insulin-Induced Hypoglycemia and Implementation of Hospital-Wide Initiatives.

BACKGROUND: Hospitalized patients who are receiving antihyperglycemic agents are at increased risk for hypoglycemia. Inpatient hypoglycemia may lead to increased risk for morbidity, mortality, prolonged hospitalization, and readmission within 30 days of discharge, which in turn may lead to increased costs. Hospital-wide initiatives targeting hypoglycemia are known to be beneficial; however, their impact on patient care and economic measures in community nonteaching hospitals are unknown. METHODS: This retrospective quality improvement study examined the effects of hospital-wide hypoglycemia initiatives on the rates of insulin-induced hypoglycemia in a community hospital setting from January 1, 2016, until September 30, 2019. The potential cost of care savings has been calculated. RESULTS: Among 49 315 total patient days, 2682 days had an instance of hypoglycemia (5.4%). Mean ± SD hypoglycemic patient days/month was 59.6 ± 16.0. The frequency of hypoglycemia significantly decreased from 7.5% in January 2016 to 3.9% in September 2019 (P = .001). Patients with type 2 diabetes demonstrated a significant decrease in the frequency of hypoglycemia (7.4%-3.8%; P < .0001), while among patients with type 1 diabetes the frequency trended downwards but did not reach statistical significance (18.5%-18.0%; P = 0.08). Based on the reduction of hypoglycemia rates, the hospital had an estimated cost of care savings of $98 635 during the study period. CONCLUSIONS: In a community hospital setting, implementation of hospital-wide initiatives targeting hypoglycemia resulted in a significant and sustainable decrease in the rate of insulin-induced hypoglycemia. These high-leverage risk reduction strategies may be translated into considerable cost savings and could be implemented at other community hospitals.

Active bed management by hospitalists and emergency department throughput.

BACKGROUND: When emergency departments are overcrowded, ambulances are diverted. Interventions focused primarily on emergency departments have had limited success. OBJECTIVE: To discover whether an active bed management, quality improvement initiative could reduce ambulance diversion hours and emergency department throughput times. DESIGN: Pre-post study that compared institutional data from November 2006 to February 2007 (intervention period) with data from November 2005 to February 2006 (control period). SETTING: Johns Hopkins Bayview Medical Center, Baltimore, Maryland. PATIENTS: All adult patients registered in the emergency department during the study periods. INTERVENTION: Active bed management is a hospitalist-led, multifaceted intervention that consists of proactive management of hospital and departmental resources, including twice-daily bed management rounds in the intensive care unit and regular visits to the emergency department to assess congestion and flow; assignment of all admissions to the department of medicine and facilitating transfer from the emergency department to the appropriate care setting; and support from the "bed director," who can mobilize additional resources in real time to augment hospital capacity to address emergency department throughput problems. MEASUREMENTS: Emergency department throughput times and ambulance diversion hours. RESULTS: The emergency department census was 8.8% higher during the intervention period than in the control period (17 573 patients vs. 16 148 patients). Throughput for patients who were admitted decreased by 98 minutes (SD, 10) (from 458 minutes in the control period to 360 minutes during the intervention period). Throughput for patients who were not admitted did not change (274 minutes vs. 269 minutes). The percentage of hours that the emergency department was on "yellow alert" (ambulance diversion because of emergency department crowding) decreased 6%, and the percentage of hours on "red alert" (ambulance diversion due to lack of intensive care unit beds in the hospital) decreased 27%. Staffing, length of stay, case-mix index, intensive care unit transfer rates, and mortality rates were stable across the 2 periods. LIMITATIONS: Pre-post designs are less effective than randomized, controlled trials on the study design hierarchy, and unidentified external forces may have influenced the results. The study was done at a single hospital, and the findings may not be generalizable to other institutions. CONCLUSION: Emergency department throughput and diversion status improved with the implementation of an active bed management process coordinated by hospitalists.

Flying Around in the Genome: Characterization of LINE-1 in Chiroptera.

L1s are transposable elements that move by a copy-and-paste mechanism that continuously increases their copy number in the genome, such that each genome has a record of the L1 history in that host lineage. They make up about 20% of the genomes of eutherian mammals and have played a major role in shaping genome evolution. Chiroptera has the lowest average genome size among mammalian orders and the only documented case of L1 extinction affecting an entire mammalian family. Herein, L1 activity and extinction are characterized in all families of the order Chiroptera using a method that enriches for the youngest lineages of L1s in the genome. In addition to the previously reported L1 extinction in Pteropodidae, L1 extinction was documented to occur in Mormoops blainvilli, but this event did not affect all species of Mormoopidae. Further, there was no evidence of concordance between the evolution of L1s and their chiropteran host. There were two L1 lineages present before the divergence of all extant bats. Both lineages are extinct in the Pteropodidae. One or the other L1 lineage is extinct in almost all bat families, but Taphozous melanopogon maintains active members of both. Most intriguingly, some families within the Rhinolophoidea retain one active L1 lineage whereas other families retain the other, creating a deep discontinuity between L1 phylogeny and chiropteran phylogeny. These results indicate that there have been numerous losses of active L1 lineages over the history of chiropteran evolution, but that all chiropteran families except Pteropodidae have retained L1 activity.

Retrospective study of inpatient diabetes management service, length of stay and 30-day readmission rate of patients with diabetes at a community hospital.

Background: Hospitalized patients with diabetes are at risk of complications and longer length of stay (LOS). Inpatient Diabetes Management Services (IDMS) are known to be beneficial; however, their impact on patient care measures in community, non-teaching hospitals, is unknown. Objectives: To evaluate whether co-managing patients with diabetes by the IDMS team reduces LOS and 30-day readmission rate (30DR). Methods: This retrospective quality improvement cohort study analyzed LOS and 30DR among patients with diabetes admitted to a community hospital. The IDMS medical team consisted of an endocrinologist, nurse practitioner, and diabetes educator. The comparison group consisted of hospitalized patients with diabetes under standard care of attending physicians (mostly internal medicine-trained hospitalists). The relationship between study groups and outcome variables was assessed using Generalized Estimating Equation models. Results: 4,654 patients with diabetes (70.8 ± 0.2 years old) were admitted between January 2016 and May 2017. The IDMS team co-managed 18.3% of patients, mostly with higher severity of illness scores (p < 0.0001). Mean LOS in patients co-managed by the IDMS team decreased by 27%. Median LOS decreased over time in the IDMS group (p = 0.046), while no significant decrease was seen in the comparison group. Mean 30DR in patients co-managed by the IDMS decreased by 10.71%. Median 30DR decreased among patients co-managed by the IDMS (p = 0.048). Conclusions: In a community hospital setting, LOS and 30DR significantly decreased in patients co-managed by a specialized diabetes team. These changes may be translated into considerable cost savings.

Pilot study comparing patients' valuation of health-care services with Medicare's relative value units.

BACKGROUND AND AIMS: Physician reimbursement for services and thus income are largely determined by the Medicare Resource-Based Relative Value Scale. Patients' assessment of the value of physician services has never been considered in the calculation. This study sought to compare patients' valuation of health-care services to Medicare's relative value unit (RVU) assessments and to discover patients' perceptions about the relative differences in incomes across physician specialties. DESIGN: Cross-sectional survey. PARTICIPANTS AND SETTING: Individuals in select outpatient waiting areas at Johns Hopkins Bayview Medical Center. METHODS: Data collection included the use of a visual analog 'value scale' wherein participants assigned value to 10 specific physician-dependent health-care services. Informants were also asked to estimate the annualized incomes of physicians in specialties related to the above-mentioned services. Comparisons of (i) the 'patient valuation RVUs' with actual Medicare RVUs, and (ii) patients' estimations of physician income with actual income were explored using t-tests. OUTCOMES: Of the 206 eligible individuals, 186 (90%) agreed to participate. Participants assigned a significantly higher mean value to 7 of the 10 services compared with Medicare RVUs (P<0.001) and the range in values assigned by participants was much smaller than Medicare's (a factor of 2 vs. 22). With the exception of primary care, respondents estimated that physicians earn significantly less than their actual income (all P<0.001) and the differential across specialties was thought to be much smaller (estimate: $88,225, actual: $146,769). CONCLUSION: In this pilot study, patients' estimations of the value health-care services were markedly different from the Medicare RVU system. Mechanisms for incorporating patients' valuation of services rendered by physicians may be warranted.