Juntos: A Model for Language Congruent Care to Better Serve Spanish-Speaking Patients with COVID-19.

Coronavirus disease 2019 (COVID-19) exacerbated pre-existing health disparities and disproportionately affected the Latino community. Clinicians identified communication barriers as a major challenge in care for COVID-19 Latino patients with limited English proficiency (LEP). To address these challenges, Juntos (Together) consult service was established to promote language-congruent care with cultural sensitivity, identify barriers to safe discharge, and facilitate referral to appropriate resources. Spanish speaking volunteer health care providers worked synergistically with medical teams caring for LEP Latino patients. Volunteers were trained on consultant responsibilities and discharge planning resources. The program was evaluated by a satisfaction survey distributed to providers who requested a Juntos consult and Juntos volunteers. Between May 5 and July 30, 2020, 19 individuals volunteered time to the Juntos consult service, 12 (63%) Latinos, 14 (74%) physicians, and 5 (26%) staff. The service supported 127 patients, 76 (60%) males, mean age 42 (±16), 83 (65%) uninsured, and 91 (72%) without primary care. The most common referral sources were medical units (52, 41%) and intensive care units (47, 37%). The most common services offered were family engagement (55, 43%), goals of care (35, 28%), and mental status assessment (26, 20%). The majority of providers who consulted Juntos were very satisfied (48/59, 81%) with the care delivered. The Juntos service offered critical support tailored to the patients' and primary teams' needs. The experience reinforced the need for cultural-based communication to provide optimal care to LEP patients. The Juntos consult service could be a model for providing language-congruent care even beyond COVID-19, but to do so will require institutional investment and rigorous outcomes evaluation.

Relative impact of a patient blood management program on utilization of all three major blood components.

BACKGROUND: Although patient blood management (PBM) programs clearly reduce transfusion overuse, the relative impact on red blood cell (RBC), plasma, and platelet (PLT) utilization is unclear. STUDY DESIGN AND METHODS: A retrospective analysis of electronic records was conducted at a medium-sized academic hospital to assess blood utilization for all inpatients admitted during 1-year periods before (n = 20,531) and after (n = 19,477) PBM efforts began in September 2014. Transfusion guideline compliance and overall utilization were assessed for RBCs, plasma, and PLTs. The primary PBM efforts included education on evidence-based transfusion guidelines, decision support in the computerized provider order entry system, and distribution of provider-specific reports showing comparison to peers for guideline compliance. Cost avoidance was determined by two methods (acquisition cost and activity-based cost), and clinical outcomes were compared during the two periods. RESULTS: For RBCs, orders outside hospital guidelines decreased (from 23.9% to 17.1%, p < 0.001), and utilization decreased by 12% (p < 0.035). For plasma and PLTs, both orders outside guidelines and utilization changed minimally. Overall cost avoidance was $181,887/year by acquisition cost (and from $582,039 to $873,058/year by activity-based cost), 93% of which was attributed to reduction in RBC utilization. Length of stay, morbidity, and mortality were unchanged. CONCLUSIONS: Our findings demonstrate a greater opportunity for reducing RBC compared to plasma and PLT utilization. A properly implemented PBM program has potential to reduce unnecessary transfusions and their associated risk and costs, without compromising clinical outcomes.

Impact of an educational intervention on the frequency of daily blood test orders for hospitalized patients.

OBJECTIVES: During hospitalizations, blood is drawn for diagnostic laboratory tests to help guide patient care. Often, blood tests continue to be ordered even in the face of clinical and laboratory stability. Blood draws are painful and costly, and they may be associated with anemia. We hypothesized that provider education could reduce the frequency of daily blood tests ordered for hospitalized patients. METHODS: During a 2-month intervention period, internal medicine providers were educated through flyers displayed in providers' offices and periodic email communications reminding them to order daily blood tests only if the results would change patient care. Two-month preintervention data from 982 patients and 2-month postintervention data from 988 patients were analyzed. The primary outcome measured was the number of daily blood tests ordered per patient per day. RESULTS: Mean orders of CBC decreased from 1.46 to 1.37 tests per patient per day (P < .05) after the intervention. Basic metabolic panel orders were reduced from 0.91 to 0.83 tests per patient per day (P < .05). Cost analyses showed a reduction of $6.33 per patient day based on the decrease in the number of daily laboratory tests ordered. CONCLUSIONS: Provider education and reminders can reduce the frequency of daily blood tests ordered by providers for hospitalized patients. This can decrease health care costs and may reduce the risk of complications such as anemia.

Reducing excess cardiac biomarker testing at an academic medical center.

BACKGROUND: Elimination of wasteful diagnostic testing will improve value for the United States health care system. OBJECTIVE: Design and implement a multimodal intervention to improve evidence-based ordering of cardiac biomarkers for the diagnosis of acute coronary syndrome (ACS). DESIGN: Interrupted times series. SUBJECTS: A total of 60,494 adult inpatient admissions from January 2009 through July 2011 (pre-intervention) and 24,341 admissions from November 2011 through October 2012 (post-intervention) at an academic medical center in Baltimore, Maryland. INTERVENTION: Multimodal intervention introduced August through October 2011 that included dissemination of an institutional guideline and changes to the computerized provider order entry system. MAIN MEASURES: The primary outcome was percentage of patients with guideline-concordant ordering of cardiac biomarkers, defined as three or fewer troponin tests and zero CK-MB tests in patients without a diagnosis of ACS. Secondary outcomes included counts of tests ordered per patient, incidence of diagnosis of ACS, and estimated change in charges for cardiac biomarker tests in the post-intervention period. KEY RESULTS: Twelve months following the intervention, we estimated that guideline-concordant ordering of cardiac biomarkers increased from 57.1 % to 95.5 %, an absolute increase of 38.4 % (95 % CI, 36.4 % to 40.4 %). We estimated that the intervention led to a 66 % reduction in the number of tests ordered, and a $1.25 million decrease in charges over the first year. At 12 months, there was an estimated absolute increase in incidence of primary diagnosis of ACS of 0.3 % (95 % CI, 0.0 % to 0.5 %) compared with the expected baseline rate. CONCLUSIONS: We implemented a multimodal intervention that significantly increased guideline-concordant ordering of cardiac biomarker testing, leading to substantial reductions in tests ordered without impacting diagnostic yield. A trial of this approach at other institutions and for other diagnostic tests is warranted and if successful, would represent a framework for eliminating wasteful diagnostic testing.

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.

Qualitative assessment of the long-term impact of a faculty development programme in teaching skills.

CONTEXT: The long-term impact of faculty development programmes (FDPs) is poorly understood, and most assessments of them have been quantitative in nature. OBJECTIVE: This study aimed to use qualitative methods to better understand the long-term impact of an FDP in teaching skills (FDP/TS). METHODS: A survey was carried out in July 2002 of the 242 faculty members and fellows who had participated in a 9-month FDP/TS at any time from 1987 through 2000. The survey included 2 quantitative questions and an open-ended qualitative question about the impact of the programme on the participants' professional and personal lives. RESULTS: A total of 200 past participants (83%) responded to the survey. Participants from early and recent cohorts were similarly represented. In all, 82% of respondents said programme participation had had 'a moderate' or 'a lot' of impact on their professional life, and 49% said their personal life had been affected to this degree. Four major domains, each containing at least 3 subcategories, emerged from qualitative analysis. The domain intrapersonal development included changes participants reported in themselves and in their approach to self-management. Interpersonal development contained subcategories relating to how participants interact with others. Subcategories in the domain development as a teacher related to increased teaching ability and enjoyment. The domain career development included professional growth and career opportunities attributed to programme participation. CONCLUSIONS: Longitudinal FDPs can have broad and sustained positive effects on the professional and personal lives of participants. Qualitative evaluation methods may result in a richer and deeper understanding of the impact of these programmes.