Association of 48-h net fluid status with change in renal function and dyspnea among patients with decompensated heart failure: A pooled cohort analysis of three acute heart failure trials.

BACKGROUND: Acute heart failure (AHF) exacerbations are a leading cause of hospitalization in the United States. Despite the frequency of AHF hospitalizations, there are inadequate data or practice guidelines on how quickly diuresis should be achieved. OBJECTIVE: To study the association of 48-h net fluid change and (A) 72-h change in creatinine and (B) 72-h change in dyspnea among patients with acute heart failure. DESIGNS, SETTINGS, AND PARTICIPANTS: This is a retrospective, pooled cohort analysis of patients from the DOSE, ROSE, and ATHENA-HF trials. INTERVENTIONS: The primary exposure was 48-h net fluid status. MAIN OUTCOMES AND MEASURES: The co-primary outcomes were 72-h change in creatinine and 72-h change in dyspnea. The secondary outcome was risk of 60-day mortality or rehospitalization. RESULTS: Eight hundred and seven patients were included. The mean 48-h net fluid status was -2.9 L. A nonlinear association was observed with net fluid status and creatinine change, such that creatinine improved with each liter net negative up to 3.5 L (-0.03 mg/dL per liter negative [95% confidence interval [CI]: -0.06 to -0.01) and remained stable beyond 3.5 L (-0.01 [95% CI: -0.02 to 0.001], p = .17). Net fluid loss was associated with a monotonic improvement of dyspnea (1.4-point improvement per liter negative [95% CI: 0.7-2.2], p = .0002). Each liter net negative by 48 h was also associated with 12% decreased odds of 60-day rehospitalization or death (odds ratio: 0.88; 95% CI: 0.82-0.95; p = .002). CONCLUSION: Aggressive net fluid targets within the first 48 h are associated with effective relief of patient self-reported dyspnea and improved long-term outcomes without adversely affecting renal function.

Characteristics of adult hospital medicine fellowships in the United States: A cross-sectional survey study.

BACKGROUND: Hospitalists who seek academic careers are interested in developing skills in research, education, and quality improvement (QI). Since these are not major foci of residency programs, hospitalists may pursue a hospital medicine fellowship to acquire these skill sets. OBJECTIVE: We sought to characterize the current state of hospital medicine fellowships in the United States, including demographics, clinical requirements, curricular focus, financial structure, and scholarly outputs. DESIGNS, SETTINGS, AND PARTICIPANTS: This was a cross-sectional study of 32 hospital medicine fellowship programs across the United States in 2020-2021. An electronic survey was emailed to program leaders. RESULTS: Out of 32 eligible programs contacted, 19 (59.4%) programs responded, representing 22 fellowship tracks. Most (63.2%) programs have been in existence for 5 years or less. Fourteen (63.6%) of the tracks had multiple focus areas, while 8 (36.4%) had a single focus. Of the 14 fellowship tracks with multiple focus areas, 6 (42.8%) reported research, QI and medical education as curricular elements. All 14 reported research as one of the curricular elements. The majority (68.4%) of programs offered opportunities to obtain a master's degree, though the field of degree varied widely. A median of 50% (IQR 0) of fellows' time was spent in clinical activities. Considerable heterogeneity exists among adult hospital medicine fellowship programs. The majority focus on research, QI, and/or medical education. Hospital medicine fellowships offer opportunities for intesive faculty development and unique career pathways.

Engineering a Clinical Microsystem to Decrease Workplace Violence for Medically and Psychiatrically Concurrently Decompensated Patients.

BACKGROUND: Hospitalized medical patients with concurrently decompensated psychiatric and medical conditions experience worse clinical outcomes. Health care providers caring for this patient population are at increased risk of workplace violence. The authors sought to understand the effects of a clinical microsystem specifically designed to care for patients too psychiatrically ill for medical units and too medically ill for psychiatry units. METHODS: The research team performed a quality improvement study in which a medicine-psychiatry co-managed clinical microsystem incorporating high performance teamwork principles was engineered in an urban academic medical center to improve patient and staff safety, as well as operational outcomes. Poisson regression was performed to determine differences between workplace violence events, falls, 30-day emergency department (ED) revisits, and hospital readmissions, comparing the baseline period to the intervention period. RESULTS: There were 321 patients discharged in the baseline period and 310 during the intervention period. Workplace violence events decreased by 65.6% (incidence rate ratio [IRR] 0.34, 95% confidence interval [CI] 0.20-0.57, p < 0.001) after implementation of the clinical microsystem when compared to the baseline period. The rate of ED utilization at 30 days postdischarge also decreased from 30.6% at baseline to 21.0% postintervention (adjusted odds ratio [aOR] 0.60, 95% CI 0.42-0.87, p = 0.006). No differences were detected in falls and 30-day readmissions. CONCLUSION: For patients with concurrently decompensated medical and psychiatric conditions, the incidence of workplace violence and postdischarge ED utilization can be improved by creating a clinical microsystem that integrates changes to both the physical environment and teamwork processes.

Empowering telemetry technicians and enhancing communication to improve in-hospital cardiac arrest survival.

Delays in treatment of in-hospital cardiac arrests (IHCAs) are associated with worsened survival. We sought to assess the impact of a bundled intervention on IHCA survival in patients on centralised telemetry. A retrospective quality improvement study was performed of a bundled intervention which incorporated (1) a telemetry hotline for telemetry technicians to reach nursing staff; (2) empowerment of telemetry technicians to directly activate the IHCA response team and (3) a standardised escalation system for automated critical alerts within the nursing mobile phone system. In the 4-year study period, there were 75 IHCAs, including 20 preintervention and 55 postintervention. Cox proportional hazard regression predicts postintervention individuals have a 74% reduced the risk of death (HR 0.26, 95% CI 0.08 to 0.84) during a code and a 55% reduced risk of death (HR 0.45, 95% CI 0.23 to 0.89) prior to hospital discharge. Overall code survival improved from 60.0% to 83.6% (p=0.031) with an improvement in ventricular tachycardia/ventricular fibrillation (VT/VF) code survival from 50.0% to 100.0% (p=0.035). There was no difference in non-telemetry code survival preintervention and postintervention (71.4% vs 71.3%, p=0.999). The bundled intervention, including improved communication between telemetry technicians and nurses as well as empowerment of telemetry technicians to directly activate the IHCA response team, may improve IHCA survival, specifically for VT/VF arrests.

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.

The inpatient experience of emerging adults in the United States.

OBJECTIVES: Emerging adults transitioning from pediatric to adult care experience worse outcomes including increased mortality. Improved patient experience (PEX) correlates with decreased inpatient mortality and better adherence to quality guidelines. We aimed to evaluate trends in the PEX of inpatients aged 14-29 years in the United States (US). METHODS: We performed a retrospective cohort study using a national, de-identified PEX survey obtained from hospitalized patients aged 14-29 years between 2017 and 2019. We described and compared survey responses across 10 domains. Composite mean scores for each health facility were converted to percentile rankings, which were then compared by age group to determine differences in percentile ranking (ΔPR). RESULTS: We evaluated the results of 174,174 PEX surveys across a national sample of 1519 US hospitals. The PEX percentile rankings for ages 18-21 were lower than ages 14-17 in almost every domain including experience with nurses (ΔPR = 43.4, p < 0.001), physicians (ΔPR = 31.1, p < 0.001), treatment (ΔPR = 12.3, p < 0.001), and overall experience (ΔPR = 26.5, p < 0.001). Similarly, 22-25-year-olds reported a worse PEX across nearly all domains when compared to 26-29-year-olds. CONCLUSION: In a national sample of PEX surveys, hospitalized emerging adults aged 18-25 reported worse PEX when compared to both older children and established adults. These lower ratings were most strongly attributed to people, processes, and relationships as opposed to differences in the hospital environment. By ages 26-29, PEX returned to levels similar to those reported by ages 14-17. These results suggest that further investigation to elucidate the unique needs of hospitalized emerging adults may be warranted.

Scholarly productivity and growth of academic hospital medicine full professors.

BACKGROUND: Scholarship remains the principal currency for faculty promotion in academic medicine. Reference points for scholarly growth and productivity at academic medical centers (AMCs) are lacking. METHODS: We identified hospital medicine full professors (HMFPs) at AMCs ranked in research by US News & World Report. Scopus was used to identify each HMFP's publications, citations, and Hirsch-index (H-index). Publications; citations; and first, middle, and senior author papers were measured in 3-year intervals postresidency. Scholarly productivity was analyzed by quintile based on publications, AMC research ranking, years postresidency, and grant funding. RESULTS: Data were extracted for 128 HMFPs from 54 AMCs. HMFPs were a mean of 20.5 (SD: 5.4) years postresidency. The median H-index was 7.0 (interquartile range [IQR]: 2.0-16.0); the median number of publications was 15.0 (IQR: 4.0-51.0). Top quintile HMFPs had a median of 175.5 (IQR: 101.5-248.0) publications, whereas fifth quintile HMFPs had a median of 0.0 (IQR: 0.0-1.0) (p < .001). HMFPs on faculty at the top 20 AMCs had a median of 35.5 (IQR: 11.0-108.0) publications, whereas HMFPs in AMCs ranked 81-122 had a median of 3.0 (IQR: 1.0-9.0) (p < .001). Grant-funded HMFPs had a median of 177.0 (IQR: 71.0-278.0) publications, while nongrant-funded HMFPs had a median of 11.0 (IQR: 3.0-25.0) (p < .001). At 3, 6, and 9 years postresidency, HMFPs had a median of 0.0 (IQR: 0.0-1.0), 1.5 (IQR: 0.0-5.0), and 3.5 (IQR: 0.0-11.0) publications. Fellowship training, additional degrees, and top 25 residency programs correlated with the top half of scholarly productivity. CONCLUSIONS: Scholarly productivity among HMFPs varies considerably. At 3, 6, and 9 years postresidency, it is minimal to modest. Grant funding and AMC research rank may establish separate frames of reference for scholarly growth.

The Inpatient Experience of Emerging Adults: Transitioning From Pediatric to Adult Care.

The pediatric-to-adult care transition has been correlated with worse outcomes, including increased mortality. Emerging adults transitioning from child-specific healthcare facilities to adult hospitals encounter marked differences in environment, culture, and processes of care. Accordingly, emerging adults may experience care differently than other hospitalized adults. We performed a retrospective cohort study of patients admitted to a large urban safety net hospital and compared all domains of patient experience between patients in 3 cohorts: ages 18 to 21, 22 to 25, and 26 years and older. We found that patient experience for emerging adults aged 18 to 21, and, to a lesser extent, aged 22 to 25, was significantly and substantially worse as compared to adults aged 26 and older. The domains of worsened experience were widespread and profound, with a 38-percentile difference in overall experience between emerging adults and established adults. While emerging adults experienced care worse in nearly all domains measured, the greatest differences were found in those pertinent to relationships between patients and care providers, suggesting a substantial deficit in our understanding of the preferences and values of emerging adults.

What the Baby Formula and Medical Contrast Material Shortages Have in Common: Insights and Recommendations for Managing the Iodinated Contrast Media Shortage.

The impact of supply chain and supply chain logistics, including personnel directly and indirectly related to the movement of supplies, has come to light in a variety of industries since the global COVID-19 pandemic. Acutely, the experience with baby formula and iodinated contrast material exposes key vulnerabilities to supply chains. The rather sudden diminished availability of iodinated contrast material has forced health care systems to engage in more judicious use of product through catalyzing the adoption of behaviors that had been recommended and deemed reasonable prior to the shortage. The authors describe efforts at a large, academic safety net county health system to conserve iodinated contrast media by optimizing contrast media use in the CT department and changing ordering patterns of referring providers. Special attention is given to opportunities to conserve contrast material in cardiothoracic imaging, including low kV and dual-energy CT techniques. A values-based leadership philosophy and collaboration with key stakeholders facilitate effective response to the critical shortage and rapid deployment of iodinated contrast media conservation strategies. Last, while the single-supplier model is efficient and cost-effective, its application to critically necessary services such as health care must be questioned considering disruptions related to the COVID-19 pandemic. Keywords: CT, Intravenous Contrast Agents, CT-Spectral Imaging (Dual Energy) ©RSNA, 2022.

Implementation of a Medication Reconciliation Risk Stratification Tool Integrated within an electronic health record: A Case Series of Three Academic Medical Centers.

Medication errors during transitions of care are common, dangerous and costly. Medication reconciliation can help mitigate this risk, but it is a complex and time-consuming process when performed properly. Increasingly, pharmacy staff have been engaged to help improve medication reconciliation. However, many organizations lack the resources and staff required to perform accurate medication histories and other reconciliation tasks on all patients. We describe how three academic medical centers implemented risk scoring systems to allocate limited pharmacy resources to patients with the highest likelihood of medication reconciliation related errors. We found that (1) development of a tailored medication risk scoring system and integration into the electronic health record is feasible, (2) workflow around the risk calculator is critical to the success of the implementation, and (3) the complex coordination of professional disciplines during the medication reconciliation process remains an ongoing challenge at all three institutions.

Polydipsia and hyponatremia in a woman with anorexia nervosa.

OBJECTIVE: Hyponatremia is infrequently reported in the constellation of metabolic abnormalities in patients with eating disorders. We sought to identify the etiology and describe the management of a patient with anorexia nervosa and hyponatremia. METHOD: We report the case of a 23-year-old woman with anorexia nervosa who suffered with severe hyponatremia. RESULTS: The etiology of hyponatremia in this case, as in most patients with eating disorders, was multifactorial, encompassing both hypovolemic and euvolemic categories of hyponatremia. Multiple impairments in the ability to clear free water are responsible for a heightened risk for hyponatremia in patients with anorexia nervosa. DISCUSSION: This case underscores the importance of careful scrutiny of fluid intake, an awareness of medications that lead to hyponatremia, and the need for regular monitoring of serum electrolytes, even in patients with anorexia nervosa, to allow for an early diagnosis and to assist in the formulation of an effective treatment and prevention strategy.

Abuse and clinical value of diuretics in eating disorders therapeutic applications.

OBJECTIVE: Diuretic abuse as a means of purging is common in patients with bulimia nervosa. We sought to illustrate the pathophysiologic effects of diuretics and purging on a patient with bulimia nervosa's fluid and electrolyte status and to clarify the role of diuretics in the management of volume status during refeeding. METHOD: We reviewed the literature pertaining to diuretic abuse, purging, bulimia nervosa, and diuretic therapy. RESULTS: Purging behaviors lead to volume depletion and a state of heightened aldosterone production. Patients with bulimia nervosa commonly undergo rapid rehydration with intravenous fluid administration. In the setting of hyperaldostreronism, aggressive rehydration leads to avid salt retention and the development of marked amounts of edema. DISCUSSION: Providers should understand both the background renal pathophysiology of the patient with bulimia nervosa and the mechanisms of action of diuretics to correctly use diuretics as focused therapeutic agents for this patient population.

Scholarly Productivity and Rank in Academic Hospital Medicine.

Despite the rapid growth of academic hospital medicine, scholarly productivity remains poorly characterized. In this cross-sectional study, distribution of academic rank and scholarly output of academic hospital medicine faculty are described. We extracted data for 1,554 hospitalists on faculty at the top 25 internal medicine residency programs. Only 11.7% of faculty had reached associate (9.0%) or full professor (2.7%). The median number of publications was 0.0 (interquartile range [IQR], 0.0-4.0), with 51.4% without a single publication. Faculty 6 to 10 years post residency had a median of 1.0 (IQR, 0.0-4.0) publication, with 46.8% of these faculty without a publication. Among men, 54.3% had published at least one manuscript, compared to 42.7% of women (P < .0001). Predictors of promotion included H-index, number of years post residency graduation, completion of chief residency, and graduation from a top 25 medical school. Promotion remains uncommon in academic hospital medicine, which may be partially due to low rates of scholarly productivity.

The use of thrombelastography to determine coagulation status in severe anorexia nervosa: a case series.

OBJECTIVE: Hospitalized patients with severe anorexia nervosa (AN) frequently have a complex coagulation profile, with elements of hypocoagulability--thrombocytopenia and elevated international normalized ratio (INR) and elements of hypercoagulability--usually manifested as immobility, which is either due to their marked weakness or from enforced degrees of bed rest to minimize energy expenditure. Hospitalized medical patients have been shown to have appropriate prophylaxis for venous thromboembolic (VTE) disease in only 40% of cases. METHOD: A simple test that could evaluate the overall coagulation profile of these patients would help guide appropriate VTE prophylaxis. The thrombelastogram is a blood test that evaluates the full dynamic process of hemostasis. RESULTS: The study of patients did not reveal evidence of being hypocoagulable and thus should be considered for VTE prophylaxis. DISCUSSION: We report on three cases of young women with severe AN and weakness, hospitalized for closely monitored refeeding, in whom the thromboelastogram was used to evaluate the coagulation status of the patient and assist in guiding therapy.

Clinical triggers: an alternative to a rapid response team.

DHMC's clinical triggers program is a promising approach that addresses an unmet patient need. We have seen dramatic reductions in our non-ICU cardiopulmonary arrest rates, along with our ICU bounceback rates. In the context of our hospital, this program aligns well with our teaching mission while maximizing the resources that are currently available. RRTs are certainly one way to prevent the unnoticed deterioration of patients, but programs such as ours, which focus on prevention of ongoing deterioration, may yield more benefit for the patients in institutions similar to DHMC. Although our study does not alter the weight of evidence in the literature, it does offer a new focus on the afferent limb by clarifying the expectations of the primary responders. This was the essence of the deficiency in the aforementioned case study. Death is the natural, albeit sad, endpoint of all lives; the overarching goal of DHMC's clinical triggers system is to prevent the premature death of a hospitalized patient and thereby improve patient safety.

Preoperative evaluation of the patient with pulmonary disease.

Preoperative pulmonary evaluation is important in the management of patients with lung disease who are undergoing elective cardiothoracic or noncardiothoracic surgery. In some instances, preoperative pulmonary evaluations may also contribute to the management of patients being considered for urgent surgery. The incidence of postoperative pulmonary complications (PPCs) is high and is associated with substantial morbidity and mortality, and prolonged hospital stays. Perioperative pulmonary complications in patients undergoing elective noncardiothoracic surgery can be more accurately predicted than in patients undergoing elective cardiothoracic surgery. Effective strategies to prevent complications in the postoperative period are few. Incentive spirometry and continuous positive airway pressure are the only modalities of proven benefit. Identifying patients who are at risk for the development of PPCs and managing their underlying modifiable risk factors aggressively prior to surgery is essential.

ACUTE center for eating disorders.

BACKGROUND: While patients with anorexia nervosa have a high mortality rate, more are living into adulthood. Patients with severe malnutrition secondary to anorexia nervosa often require hospitalization for medical stabilization prior to treatment in eating disorders programs. METHODS: We developed the ACUTE Center at Denver Health Medical Center to medically stabilize adults with the medical complications of severe malnutrition due to an eating disorder. The first 2 years of patient characteristics and outcomes are reported. RESULTS: From October 2008 through December 2010, the ACUTE unit had 76 admissions of which 62 were for medical stabilization, comprising 54 patients. Eighty-nine percent of patients were female. The mean age was 27 years old (range 17-65). The mean body mass index on admission was 12.9 kg/m(2) (standard deviation [SD] 2.0). At admission, patients were hyponatremic, anemic, and leukopenic, with low bone density, but had normal albumin levels. The mean body mass index on discharge was 13.1 ± 1.9 kg/m(2). Median length of stay was 16 days (interquartile range [IQR] 9-29 days). Eighteen percent were discharged to home and eighty-two percent were discharged to inpatient psychiatric eating disorder units. Inpatient mortality was zero. DISCUSSION: Patients with this degree of severe malnutrition due to eating disorders are medically complex and relatively uncommon. Regionalized subspecialty centers of excellence, in which a multidisciplinary team is led by practitioners of hospital medicine who have developed expertise in a rare condition, may improve clinical outcomes, optimize healthcare resources, and provide unique professional and academic opportunities for the clinicians involved.