Preventability of 30-Day Hospital Revisits Following Admission with COVID-19 at an Academic Medical Center.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic may have affected the preventability of 30-day hospital revisits, including readmissions and emergency department (ED) visits without admission. This study was conducted to examine the preventability of 30-day revisits for patients admitted with COVID-19 in order to inform the design of interventions that may decrease preventable revisits in the future. METHODS: The study team retrospectively reviewed a cohort of adults admitted to an academic medical center with COVID-19 between March 21 and June 29, 2020, and discharged alive. Patients with a 30-day revisit following hospital discharge were identified. Two-physician review was used to determine revisit preventability, identify factors contributing to preventable revisits, assess potential preventive interventions, and establish the influence of pandemic-related conditions on the revisit. RESULTS: Seventy-six of 576 COVID-19 hospitalizations resulted in a 30-day revisit (13.2%), including 21 ED visits without admission (3.6%) and 55 readmissions (9.5%). Of these 76 revisits, 20 (26.3%) were potentially preventable. The most frequently identified factors contributing to preventable revisits were related to the choice of postdischarge location and to patient/caregiver understanding of the discharge medication regimen, each occurring in 25.0% of cases. The most frequently cited potentially preventive intervention was "improved self-management plan at discharge," occurring in 65.0% of cases. Five of the 20 preventable revisits (25.0%) had contributing factors that were thought to be directly related to the COVID-19 pandemic. CONCLUSION: Although only approximately one quarter of 30-day hospital revisits following admission with COVID-19 were potentially preventable, these results highlight opportunities for improvement to reduce revisits going forward.

A Model for Electronic Handoff Between the Emergency Department and Inpatient Units.

BACKGROUND: Patient handoffs between units can introduce risk and time delays. Verbal communication is the most common mode of handoff, but requires coordination between different parties. OBJECTIVE: We present an asynchronous patient handoff process supported by a structured electronic signout for admissions from the emergency department (ED) to the inpatient medicine service. METHODS: A retrospective review of patients admitted to the medical service from July 1, 2011 to June 30, 2015 at a tertiary referral center with 520 inpatient beds and 57,000 ED visits annually. We developed a model for structured electronic, asynchronous signout that includes an option to request verbal communication after review of the electronic handoff information. RESULTS: During the 2010 academic year (AY) all admissions used verbal communication for signout. The following academic year, electronic signout was implemented and 77.5% of admissions were accepted with electronic signout. The rate increased to 87.3% by AY 2014. The rate of transfer from floor to an intensive care unit within 24 h for the year before and 4 years after implementation of the electronic signout system was collected and calculated with 95% confidence interval. There was no statistically significant difference between the year prior and the years after the implementation. CONCLUSIONS: Our handoff model sought to maximize the opportunity for asynchronous signout while still providing the opportunity for verbal signout when deemed necessary. The process was rapidly adopted with the majority of patients being accepted electronically.

Patient care transitions from the emergency department to the medicine ward: evaluation of a standardized electronic signout tool.

OBJECTIVE: To evaluate the impact of a new electronic handoff tool for emergency department to medicine ward patient transfers over a 1-year period. DESIGN: Prospective mixed-methods analysis of data submitted by medicine residents following admitting shifts before and after eSignout implementation. SETTING: University-based, tertiary-care hospital. PARTICIPANTS: Internal medicine resident physicians admitting patients from the emergency department. INTERVENTION: An electronic handoff tool (eSignout) utilizing automated paging communication and responsibility acceptance without mandatory verbal communication between emergency department and medicine ward providers. MAIN OUTCOME MEASURES: (i) Incidence of reported near misses/adverse events, (ii) communication of key clinical information and quality of verbal communication and (iii) characterization of near misses/adverse events. RESULTS: Seventy-eight of 80 surveys (98%) and 1058 of 1388 surveys (76%) were completed before and after eSignout implementation. Compared with pre-intervention, residents in the post-intervention period reported similar number of shifts with a near miss/adverse event (10.3 vs. 7.8%; P = 0.27), similar communication of key clinical information, and improved verbal signout quality, when it occurred. Compared with the former process requiring mandatory verbal communication, 93% believed the eSignout was more efficient and 61% preferred the eSignout. Patient safety issues related to perceived sufficiency/accuracy of diagnosis, treatment or disposition, and information quality. CONCLUSIONS: The eSignout was perceived as more efficient and preferred over the mandatory verbal signout process. Rates of reported adverse events were similar before and after the intervention. Our experience suggests electronic platforms with optional verbal communication can be used to standardize and improve the perceived efficiency of patient handoffs.

Accuracy of residents' retrospective perceptions of 16-hour call admitting shift compliance and characteristics.

BACKGROUND: The Accreditation Council for Graduate Medical Education Resident-Fellow Survey measurement of compliance with duty hours uses remote retrospective resident report, the accuracy of which has not been studied. We investigated residents' remote recall of 16-hour call-shift compliance and workload characteristics at 1 institution. METHODS: We sent daily surveys to second- and third-year internal medicine residents immediately after call shifts from July 2011 to June 2012 to assess compliance with 16-hour shift length and workload characteristics. In June 2012, we sent a survey with identical items to assess residents' retrospective perceptions of their call-shift compliance and workload characteristics over the preceding year. We used linear models to compare on-call data to residents' retrospective data. RESULTS: We received a survey response from residents after 497 of 648 call-shifts (77% response). The end-of-year perceptions survey was completed by 87 of 95 residents (92%). Compared with on-call data, the recollections of 5 (6%) residents were accurate; however, 48 (56%) underestimated and 33 (38%) overestimated compliance with the 16-hour shift length requirement. The average magnitude of under- and overestimation was 18% (95% confidence interval  =  13-23). Using a greater than 10% absolute difference to define under- and overestimation, 39 (45%) respondents were found to be accurate, 27 (31%) underestimated compliance, and 20 (23%) overestimated compliance. Residents overestimated census size, long call admissions, and admissions after 5 pm. CONCLUSIONS: Internal medicine residents' remote retrospective reporting of compliance with the 16-hour limit on continuous duty and workload characteristics was inaccurate compared with their immediate recall and included errors of underestimation and overestimation.

Systems-based content in medical morbidity and mortality conferences: a decade of change.

BACKGROUND: Following the Accreditation Council for Graduate Medical Education recommendations in 1999 to foster education in the systems-based practice (SBP) competency by examining adverse clinical events, institutions have modified the morbidity and mortality conference (MMC) to increase SBP-related discussion. We sought to examine the extent to which SBP-related content has increased in our department's MMCs compared with MMCs 10 years prior. METHOD: We qualitatively analyzed audio recordings of our MMCs during 2 academic years, 1999-2000 (n  =  30) and 2010-2011 (n  =  30). We categorized comments and questions from moderators and faculty as SBP or non-SBP and characterized conferences by whether adverse events were presented and which systems issues were discussed. RESULTS: Compared with MMCs in 1999-2000, present-day MMCs included a greater average percentage of SBP comments stated (69% versus 12%; P ≤ .001) and questions asked (13% versus 1%; P  =  .001) by the moderator, SBP comments stated (44% versus 4%; P ≤ .001) and questions asked (19% versus 1%; P ≤ .001) by faculty, and were more likely to present adverse events (87% versus 13%; P < .001). Interrater reliability for the distinction between SBP and non-SBP content was good (κ  =  0.647). Most common categories of systems issues discussed in 2010-2011 were critical laboratory value processing and reporting, institutional policies, and hospital-based factors. CONCLUSIONS: Over the past decade, our MMC has transformed to include more discussion of SBP-related content and adverse events. The MMC can be used to educate residents in SBP and can also serve as a cornerstone for departmental quality and safety initiatives.

Combining clinical microsystems and an experiential quality improvement curriculum to improve residency education in internal medicine.

Beth Israel Deaconess Medical Center's internal medicine residency program was admitted to the new Education Innovation Project accreditation pathway of the Accreditation Council of Graduate Medical Education to begin in July 2006. The authors restructured the inpatient medical service to create clinical microsystems in which residents practice throughout residency. Program leadership then mandated an active curriculum in quality improvement based in those microsystems. To provide the experience to every graduating resident, a core faculty in patient safety was trained in the basics of quality improvement. The authors hypothesized that such changes would increase the number of residents participating in quality improvement projects, improve house officer engagement in quality improvement work, enhance the culture of safety the residents perceive in their training environment, improve work flow on the general medicine ward rotations, and improve the overall educational experience for the residents on ward rotations.The authors describe the first 18 months of the intervention (July 2006 to January 2008). The authors assessed attitudes and the educational experience with surveys and evaluation forms. After the intervention, the authors documented residents' participation in projects that overlapped with hospital priorities. More residents reported roles in designing and implementing quality improvement changes. Residents also noted greater satisfaction with the quality of care they deliver. Fewer residents agreed or strongly agreed that the new admitting system interfered with communication. Ongoing residency program assessment showed an improved perception of workload, and educational ratings of rotations improved. The changes required few resources and can be transported to other settings.