Hospital Capacity Command Centers: A Benchmarking Survey on an Emerging Mechanism to Manage Patient Flow.

BACKGROUND: Delayed hospital and emergency department (ED) patient throughput, which occurs when demand for inpatient care exceeds hospital capacity, is a critical threat to safety, quality, and hospital financial performance. In response, many hospitals are deploying capacity command centers (CCCs), which co-locate key work groups and aggregate real-time data to proactively manage patient flow. Only a narrow body of peer-reviewed articles have characterized CCCs to date. To equip health system leaders with initial insights into this emerging intervention, the authors sought to survey US health systems to benchmark CCC motivations, design, and key performance indicators. METHODS: An online survey on CCC design and performance was administered to members of a hospital capacity management consortium, which included a convenience sample of capacity leaders at US health systems (N = 38). Responses were solicited through a targeted e-mail campaign. Results were summarized using descriptive statistics. RESULTS: The response rate was 81.6% (31/38). Twenty-five respondents were operating CCCs, varying in scope (hospital, region of a health system, or entire health system) and number of beds managed. The most frequent motivation for CCC implementation was reducing ED boarding (n = 24). The most common functions embedded in CCCs were bed management (n = 25) and interhospital transfers (n = 25). Eighteen CCCs (72.0%) tracked financial return on investment (ROI); all reported positive ROI. CONCLUSION: This survey addresses a gap in the literature by providing initial aggregate data for health system leaders to consider, plan, and benchmark CCCs. The researchers identify motivations for, functions in, and key performance indicators used to assess CCCs. Future research priorities are also proposed.

Emergency department provider in triage: assessing site-specific rationale, operational feasibility, and financial impact.

Emergency department (ED) crowding is recognized as a critical threat to patient safety, while sub-optimal ED patient flow also contributes to reduced patient satisfaction and efficiency of care. Provider in triage (PIT) programs-which typically involve, at a minimum, a physician or advanced practice provider conducting an initial screening exam and potentially initiating treatment and diagnostic testing at the time of triage-are frequently endorsed as a mechanism to reduce ED length of stay (LOS) and therefore mitigate crowding, improve patient satisfaction, and improve ED operational and financial performance. However, the peer-reviewed evidence regarding the impact of PIT programs on measures including ED LOS, wait times, and costs (as variously defined) is mixed. Mechanistically, PIT programs exert their effects by initiating diagnostic work-ups earlier and, sometimes, by equipping triage providers to directly disposition patients. However, depending on local contextual factors-including the co-existence of other front-end interventions and delays in ED throughput not addressed by PIT-we demonstrate how these features may or may not ultimately translate into reduced ED LOS in different settings. Consequently, site-specific analysis of the root causes of excessive ED LOS, along with mechanistic assessment of potential countermeasures, is essential for appropriate deployment and successful design of PIT programs at individual EDs. Additional motivations for implementing PIT programs may include their potential to enhance patient safety, patient satisfaction, and team dynamics. In this conceptual article, we address a gap in the literature by demonstrating the mechanisms underlying PIT program results and providing a framework for ED decision-makers to assess the local rationale for, operational feasibility of, and financial impact of PIT programs.

Use of Electronic Medical Records to Estimate Changes in Pregnancy and Birth Rates During the COVID-19 Pandemic.

Importance: The influence of the COVID-19 pandemic on fertility rates has been suggested in the lay press and anticipated based on documented decreases in fertility and pregnancy rates during previous major societal and economic shifts. Anticipatory planning for birth rates is important for health care systems and government agencies to accurately estimate size of economy and model working and/or aging populations. Objective: To use projection modeling based on electronic health care records in a large US university medical center to estimate changes in pregnancy and birth rates prior to and after the COVID-19 pandemic societal lockdowns. Design, Setting, and Participants: This cohort study included all pregnancy episodes within a single US academic health care system retrospectively from 2017 and modeled prospectively to 2021. Data were analyzed September 2021. Exposures: Pre- and post-COVID-19 pandemic societal shutdown measures. Main Outcomes and Measures: The primary outcome was number of new pregnancy episodes initiated within the health care system and use of those episodes to project birth volumes. Interrupted time series analysis was used to assess the degree to which COVID-19 societal changes may have factored into pregnancy episode volume. Potential reasons for the changes in volumes were compared with historical pregnancy volumes, including delays in starting prenatal care, interruptions in reproductive endocrinology and infertility services, and preterm birth rates. Results: This cohort study documented a steadily increasing number of pregnancy episodes over the study period, from 4100 pregnancies in 2017 to 4620 in 2020 (28 284 total pregnancies; median maternal [interquartile range] age, 30 [27-34] years; 18 728 [66.2%] White women, 3794 [13.4%] Black women; 2177 [7.7%] Asian women). A 14% reduction in pregnancy episode initiation was observed after the societal shutdown of the COVID-19 pandemic (risk ratio, 0.86; 95% CI, 0.79-0.92; P < .001). This decrease appeared to be due to a decrease in conceptions that followed the March 15 mandated COVID-19 pandemic societal shutdown. Prospective modeling of pregnancies currently suggests that a birth volume surge can be anticipated in summer 2021. Conclusions and Relevance: This cohort study using electronic medical record surveillance found an initial decline in births associated with the COVID-19 pandemic societal changes and an anticipated increase in birth volume. Future studies can further explore how pregnancy episode volume changes can be monitored and birth rates projected in real-time during major societal events.

Interventions to curb the overuse of Acid-suppressive medications on an inpatient general medicine service.

PURPOSE: We conducted a study to measure the impact of three sequential levels of intervention on prescribing patterns of acid-suppressive medications (ASMs) on an inpatient internal medicine service at a university hospital. METHODS: THIS RETROSPECTIVE REVIEW COMPARED PRESCRIBING PATTERNS ON FOUR DIFFERENT TIERS: a phase 1 study, conducted one year before the phase 2 intervention study; and three phase 2 interventions. Each group was assessed for the percentage of all patients receiving ASMs and the percentage of patients receiving these drugs with an inappropriate indication. The three phase 2 studies are described in this article. RESULTS: Intervention A (a beginning-of-year lecture to all interns) was not enough to decrease total in-hospital use of these medications, compared with the phase 1 historical controls (62% vs. 66%, respectively); however, it did decrease the rate of inappropriate use from 59% to 37% (P < 0.001). When Intervention B (an early-in-the-month rotation "reminder lecture") was added, the volume of agents used was significantly reduced to 53% (P = 0.025) and the number of inappropriate prescriptions was reduced to 32% (P < 0.001), compared with rates in phase 1. Finally, when Intervention C (a clinical pharmacist making rounds with the health care team on most post-call days) was added to Interventions A and B, the total volume of drug use in the hospital declined to 53% (P = 0.025) and the number of inappropriate prescriptions fell to 19%, compared with rates in phase 1 (P < 0.001). CONCLUSION: Providing educational lectures for interns was helpful in curbing the inappropriate prescribing of ASMs, but the benefit was augmented when a clinical pharmacist was added to the team.

Evaluating the impact of emergency department crowding on disposition patterns and outcomes of discharged patients.

BACKGROUND: Crowding is a major challenge faced by EDs and is associated with poor outcomes. OBJECTIVES: Determine the effect of high ED occupancy on disposition decisions, return ED visits, and hospitalizations. METHODS: We conducted a retrospective analysis of electronic health records of patients evaluated at an adult, urban, and academic ED over 20 months between the years 2012 and 2014. Using a logistic regression model predicting admission, we obtained estimates of the effect of high occupancy on admission disposition, adjusted for key covariates. We then stratified the analysis based on the presence or absence of high boarder patient counts. RESULTS: Disposition decisions during a high occupancy hour decreased the odds of admission (OR = 0.93, 95% CI: [0.89, 0.98]). Among those who were not admitted, high occupancy was not associated with increased odds of return in the combined (OR = 0.94, 95% CI: [0.87, 1.02]), with-boarders (OR = 0.96, 95% CI: [0.86, 1.09]), and no-boarders samples (OR = 0.93, 95% CI: [0.83, 1.04]). Among those who were not admitted and who did return within 14 days, disposition during a high occupancy hour on the initial ED visit was not associated with a significant increased odds of hospitalization in the combined (OR = 1.04, 95% CI: [0.87, 1.24]), the with-boarders (OR = 1.12, 95% CI: [0.87, 1.44]), and the no-boarders samples (OR = 0.98, 95% CI: [0.77, 1.24]). CONCLUSION: ED crowding was associated with reduced likelihood of hospitalization without increased likelihood of 2-week return ED visit or hospitalization. Furthermore, high occupancy disposition hours with high boarder patient counts were associated with decreased likelihood of hospitalization.

Tried and true: a survey of successfully promoted academic hospitalists.

BACKGROUND: Academic hospital medicine is a new and rapidly growing field. Hospitalist faculty members often fill roles not typically held by other academic faculty, maintain heavy clinical workloads, and participate in nontraditional activities. Because of these differences, there is concern about how academic hospitalists may fare in the promotions process. OBJECTIVE: To determine factors critical to the promotion of successfully promoted hospitalists who have achieved the rank of either associate professor or professor. DESIGN: A cross-sectional survey. PARTICIPANTS: Thirty-three hospitalist faculty members at 22 academic medical centers promoted to associate professor rank or higher between 1995 and 2008. MEASUREMENTS: Respondents were asked to describe their institution, its promotions process, and the activities contributing to their promotion. We identified trends across respondents. RESULTS: Twenty-six hospitalists responded, representing 20 institutions (79% response rate). Most achieved promotion in a nontenure track (70%); an equal number identified themselves as clinician-administrators and clinician educators (40%). While hospitalists were engaged in a wide range of activities in the traditional domains of service, education, and research, respondents considered peer-reviewed publication to be the most important activity in achieving promotion. Qualitative responses demonstrated little evidence that being a hospitalist was viewed as a hindrance to promotion. CONCLUSIONS: Successful promotion in academic hospital medicine depends on accomplishment in traditional academic domains, raising potential concerns for academic hospitalists with less traditional roles. This study may provide guidance for early-career academic hospitalists and program leaders.

Competence in patient safety: a multifaceted experiential educational intervention for resident physicians.

BACKGROUND: The need to provide efficient, effective, and safe patient care is of paramount importance. However, most physicians receive little or no formal training to prepare them to address patient safety challenges within their clinical practice. METHODS: We describe a comprehensive Patient Safety Learning Program (PSLP) for internal medicine and medicine-pediatrics residents. The curriculum is designed to teach residents key concepts of patient safety and provided opportunities to apply these concepts in the "real" world in an effort to positively transform patient care. Residents were assigned to faculty expert-led teams and worked longitudinally to identify and address patient safety conditions and problems. The PSLP was assessed by using multiple methods. RESULTS: Resident team-based projects resulted in changes in several patient care processes, with the potential to improve clinical outcomes. However, faculty evaluations of residents were lower for the Patient Safety Improvement Project rotation than for other rotations. Comments on "unsatisfactory" evaluations noted lack of teamwork, project participation, and/or responsiveness to faculty communication. Participation in the PSLP did not change resident or faculty attitudes toward patient safety, as measured by a comprehensive survey, although there was a slight increase in comfort with discussing medical errors. CONCLUSIONS: Development of the PSLP was intended to create a supportive environment to enhance resident education and involve residents in patient safety initiatives, but it produced lower faculty evaluations of resident for communication and professionalism and did not have the intended positive effect on resident or faculty attitudes about patient safety. Further research is needed to design or refine interventions that will develop more proactive resident learners and shift the culture to a focus on patient safety.

Teaching internal medicine residents quality improvement and patient safety: a lean thinking approach.

Patient safety (PS) and quality improvement (QI) are among the highest priorities for all health systems. Resident physicians are often at the front lines of providing care for patients. In many instances, however, QI and PS initiatives exclude trainees. By aligning the goals of the health system with those of the residency program to engage residents in QI and PS projects, there is a unique opportunity to fulfill both a corporate and educational mission to improve patient care. Here, the authors briefly describe one residency program's educational curriculum to provide foundational knowledge in QI and PS to all its trainees and highlight a resident team-based project that applied principles of lean thinking to evaluate the process of responding to an in-hospital cardiopulmonary arrest. This approach provided residents with a practical experience but also presented an opportunity for trainees to align with the health system's approach to improving quality and safety.

Hospitalists as emerging leaders in patient safety: lessons learned and future directions.

OBJECTIVE: To examine the results of a multi-institution, hospitalist-centered consortium designed to disseminate knowledge of best practices relevant to patient safety and to facilitate institutional innovation around such practices. METHODS: The Hospitalists as Emerging Leaders in Patient Safety (HELPS) consortium consisted of a hospitalist lead and a patient safety representative from each of 9 health care systems in southeastern Michigan. The consortium's aim was to provide rapid dissemination of best practices in patient safety through regular group meetings and to facilitate implementation and analysis of hospitalist-led patient safety initiatives. Key safety targets included prevention of device-related infections, creating a culture of safety, care transitions, medication safety, fall prevention, perioperative care, intensive care unit safety, and end-of-life care. Participating institutions were free to implement any of the best practices and had access to the expertise of the HELPS coordinating site. Surveys were used to assess knowledge dissemination among participants. RESULTS: Participating institutions described their patient safety initiative and identified several key barriers and facilitators encountered during implementation. Common themes emerged among both barriers and facilitators. In postmeeting surveys to measure dissemination, consortium participants answered a mean of 84.2% (SD = 19.2) of the questions correctly. CONCLUSIONS: The HELPS consortium successfully disseminated knowledge regarding best practices and identified common barriers and facilitators faced by hospitalists and institutions attempting to improve safety. The next step is to transform the consortium into a robust quality collaborative that leverages key facilitators and prospectively addresses barriers to implementing high-impact interventions in a multihospital setting.

Non-housestaff medicine services in academic centers: models and challenges.

Non-housestaff medicine services are growing rapidly in academic medical centers (AMCs), partly driven by efforts to comply with resident duty hour restrictions. Hospitalists have emerged as a solution to providing these services given their commitment to delivering efficient and high-quality care and the field's rapid growth. However, limited evidence is available on designing these services, including the similarities and differences of existing ones. We describe non-housestaff medicine services at 5 AMCs in order to share our experiences and outline important considerations in service development. We discuss common challenges in building and sustaining these models along with local institutional factors that affect decision making. Keys to success include ensuring an equitable system for scheduling and staffing, fostering opportunities for scholarly activities and academic promotion (defining the "academic hospitalist"), and providing compensation that supports recruitment and retention of hospitalists. With further work hour restrictions expected in the future and increased requests for surgical comanagement, the relationship between AMCs and hospitalists will continue to evolve. To succeed in developing hospitalist faculty who follow long careers in hospital medicine, academic leadership must carefully plan for and evaluate the methods of providing these clinical services while expanding on our academic mission.