General Internists as Change Agents: Opportunities and Barriers to Leadership in Health Systems and Medical Education Transformation.

Health systems are increasingly engaging in mission development around the quadruple aim of patient experience of care, population health, cost of care, and work-life balance of clinicians. This integrated approach is closely aligned with the education principles and competencies of health systems science (HSS), which includes population health, high-value care, leadership, teamwork, collaboration, and systems thinking. Influenced by health outcomes research, the systems-based practice competency, and the Clinical Learning Environment Review, many medical schools and residency programs are taking on the challenge of comprehensively incorporating these HSS competencies into the education agenda. General internal medicine physicians, inclusive of hospitalists, geriatricians, and palliative and primary care physicians, are at the frontlines of this transformation and uniquely positioned to contribute to and lead health system transformation, role model HSS competencies for trainees, and facilitate the education of a new workforce equipped with HSS skills to accelerate change in healthcare. Although GIM faculty are positioned to be early adopters and leaders in evolving systems of care and education, professional development and changes with academic health systems are required. This Perspective article explores the conceptualization and opportunities to effectively link GIM with healthcare and medical education transformation.

Interprofessional collaborative care characteristics and the occurrence of bedside interprofessional rounds: a cross-sectional analysis.

BACKGROUND: Interprofessional collaboration improves the quality of medical care, but integration into inpatient workflow has been limited. Identification of systems-based factors promoting or diminishing bedside interprofessional rounds (BIR), one method of interprofessional collaboration, is critical for potential improvements in collaboration in hospital settings. The objective of this study was to determine whether the percentage of bedside interprofessional rounds in 18 hospital-based clinical units is attributable to spatial, staffing, patient, or nursing perception characteristics. METHODS: A prospective, cross-sectional assessment of data obtained from nursing audits in one large academic medical center on a sampling of hospitalized pediatric and adult patients in 18 units from November 2012 to October 2013 was performed. The primary outcome was the percentage of bedside interprofessional rounds, defined as encounters including one attending-level physician and a nurse discussing the case at the patient's bedside. Logistic regression models were constructed with four covariate domains: (1) spatial characteristics (unit type, bed number, square feet per bed), (2) staffing characteristics (nurse-to-patient ratios, admitting services to unit), (3) patient-level characteristics (length of stay, severity of illness), and (4) nursing perceptions of collegiality, staffing, and use of rounding scripts. RESULTS: Of 29,173 patients assessed during 1241 audited unit-days, 21,493 patients received BIR (74 %, range 35-97 %). Factors independently associated with increased occurrence of bedside interprofessional rounds were: intensive care unit (odds ratio 9.63, [CI 5.30-17.42]), intermediate care unit (odds ratio 2.84, [CI 1.37-5.87]), hospital length of stay 5-7 days (odds ratio 1.89, [CI, 1.05-3.38]) and >7 days (odds ratio 2.27, [CI, 1.28-4.02]), use of rounding script (odds ratio 2.20, [CI 1.15-4.23]), and perceived provider/leadership support (odds ratio 3.25, [CI 1.83-5.77]). CONCLUSIONS: Variation of bedside interprofessional rounds was more attributable to unit type and perceived support rather than spatial or relationship characteristics amongst providers. Strategies for transforming the value of hospital care may require a reconfiguration of care delivery toward more integrated practice units.

Hospital at home: emergence of a high-value model of care delivery.

Background: With increasing healthcare demands for acute illness in patients especially in the times of pandemic, healthcare organizations require modern solutions. Hospital at home (HaH) is one such tool that has the potential to solve these problems without compromising the care of the patients. Main body: Hospitals have been the conventional setting for managing acute sickness patients; however, it could be a very challenging environment for a few patients, especially for the older population who are highly susceptible to hospital-acquired infections. Health care in a hospital setting can also be very expensive, as it often involves a lot of healthcare professionals providing care. HaH service can provide the same quality of care expected in traditional settings. Conclusions: The median length of stay and the rate of readmissions were lower in people under HaH care. Compared with patients in a hospital setting, patients in HaH had better clinical outcomes. HaH unit provides an integrated, flexible, easy-to-scale platform that can be cost-effectively adapted to high-demand situations.

Using Standardized Whiteboards to Improve Patient Engagement.

Whiteboards are ubiquitous fixtures in hospital rooms that may represent a ready-made patient engagement tool; yet, their use has only been minimally explored. This study examined the relationship between a standardized whiteboard communication process and patient activation by using the Patient Activation Measure (PAM®). Participants (N = 172) that were optimally involved in whiteboard communication had significantly higher PAM® scores compared to those who were suboptimally involved. PAM® scores also correlated with self-reported role, with those endorsing active participation scoring higher than passive listeners. Accordingly, this study establishes a positive association between the structured use of whiteboards and patient activation.

Papering over the cracks: COVID-19's amplification of the failures of employer-based health insurance coverage.

Background: COVID-19 has altered numerous lives and accounted for significant mortality and morbidity throughout the world and, especially, the USA. During the pandemic, from mid-March to July 2020, around one-fourth of the US population filed for unemployment benefits. Objective: In this article, we discuss the economic ramifications exposed in the American healthcare system's current model by the COVID-19 crisis. Methods: In this review, we analyze 18 articles to look at how access to health insurance has affected how Americans receive medical care during the coronavirus pandemic. Results: The large-scale job losses related to the pandemic translates directly into millions of Americans also losing employer-sponsored health insurance (ESI) coverage. With the pandemic disproportionately affecting minority populations, these communities now bear the additional toll of not receiving appropriate care. Conclusion: Due to the pandemic, it is probable that a significant portion of Americans that are uninsured are less likely to seek medical care for COVID-19 symptoms. While the disease can manifest as a mild respiratory illness in most, others can experience more severe disease and require acute, intensive medical care. The lack of health insurance in this instance can be potentially fatal. Given that COVID-19 has disproportionately affected minority communities across the USA, it is important to highlight the correlation between access to medical care and COVID-19 infection rates. Communities that are of lower socioeconomic status are less likely to have health insurance and follow up with medical care due to out-of-pocket costs, which in turn leads to a higher case fatality rate due to COVID-19.

A Multidisciplinary Approach to Expedite Surgical Hip Fracture Care.

INTRODUCTION: In 2014, we implemented a geriatric hip fracture patient care pathway at our institution which was designed to improve outcomes and decrease time to surgery. MATERIALS AND METHODS: We analyzed retrospective data from 463 patients, aged greater than 50, who had surgical treatment for a closed hip fracture due to a low-energy injury between 2013 and 2016 at an academic institution. Objective outcome measures included time to surgery, mortality rate, and total hospital length of stay. Our primary goal was to decrease the time to surgery for definitive fracture fixation to within 24 hours of admission to the hospital for patients who were medically fit for surgery. RESULTS: We implemented a multidisciplinary, collaborative approach to address the needs of this specific patient population. Prior to implementing the pathway in 2013, our baseline time to surgery within 24 hours was 74.67%. After implementation, we had incremental yearly increases in the percentage of patients operated on within 24 hours, 82.31% in 2014 (P = .10) and 84.14% in 2015 (P = .04). During the study period, our overall time to surgery was reduced by 27% with an initial average of 20.22 hours in 2013, decreasing to 15.33 hours in 2014, and 14.63 hours in 2015. Our mortality rate at 1 year was 16% in 2013, 17% in 2014, and 15% in 2015. CONCLUSION: With implementation of the pathway, we were able to expedite surgical care for our patients and demonstrate a 10% improvement in the percentage of patients able to have surgery within 24 hours over a 3-year period. Our mortality and hospital length of stay, however, remained the same. Through this collaborative process and system standardization, we believe we have significantly improved not only direct patient care but their overall hospital experience. We continue to make improvements in our pathway.

Cryptococcal Meningitis in an Apparent Immunocompetent Patient.

Cryptococcal meningitis is an uncommon and severe infection that tends to affect immunocompromised hosts worldwide and in the United States. Annually it is estimated that there are 200 000 cases of cryptococcal meningitis, with the most recent estimate of 3400 cases per year in the United States alone. However, despite the low incidence, 1-year mortality is estimated at 20% to 30% even with long-term consolidation antifungal therapy. A 37-year-old man presented to the emergency department with headaches, dysarthria, hallucinations, and acute worsening of altered mental status, and he was found to have increased intracranial pressure, cerebrospinal fluid leukocytosis, and few encapsulated yeasts consistent with Cryptococcus neoformans meningitis in addition to radiologic evidence consistent with a cryptococcoma of the lungs. This report highlights the occurrence of Cryptococcus neoformans meningitis in a presumed immunocompetent host. The clinician should be aware of sources of minor immunosuppression, as they may contribute to development of Cryptococcus neoformans meningitis. Mortality in this condition remains high due to subacute presentations and delayed diagnosis in non-immunocompromised patients.

Inversion of excreted intravenous contrast-fluid levels in the urinary bladder on computed tomography.

Fluid-fluid levels occur on computed tomography due to differences in density between the 2 fluids. For example, intravenous (IV) contrast excreted into the urinary bladder layers posterior with gravity in the supine patient with normal, unopacified urine layering anterior, due to their differing densities. The rare presence of inverted fluid-contrast levels in the bladder calls attention to the existence of pathology such as microscopic hematuria, infectious debris, glycosuria, and purulent fluid. In such instances, the hypodense, nonopacified urine is the abnormality and is often only recognized due to the excreted IV contrast "floating" on top of it within the bladder. Here, we describe a case in which the development of inverted fluid-contrast levels in the urinary bladder on computed tomography during a patient's hospital stay heralded further investigation with urinalysis and urinary culture, with the known, worrisome causes able to be excluded.