Attention Among Health Care Professionals : A Scoping Review.

BACKGROUND: The concept of attention can provide insight into the needs of clinicians and how health systems design can impact patient care quality and medical errors. PURPOSE: To conduct a scoping review to 1) identify and characterize literature relevant to clinician attention; 2) compile metrics used to measure attention; and 3) create a framework of key concepts. DATA SOURCES: Cumulated Index to Nursing and Allied Health Literature (CINAHL), Medline (PubMed), and Embase (Ovid) from 2001 to 26 February 2024. STUDY SELECTION: English-language studies addressing health care worker attention in patient care. At least dual review and data abstraction. DATA EXTRACTION: Article information, health care professional studied, practice environment, study design and intent, factor type related to attention, and metrics of attention used. DATA SYNTHESIS: Of 6448 screened articles, 585 met inclusion criteria. Most studies were descriptive (n = 469) versus investigational (n = 116). More studies focused on barriers to attention (n = 387; 342 descriptive and 45 investigational) versus facilitators to improving attention (n = 198; 112 descriptive and 86 investigational). We developed a framework, grouping studies into 6 categories: 1) definitions of attention, 2) the clinical environment and its effect on attention, 3) personal factors affecting attention, 4) relationships between interventions or factors that affect attention and patient outcomes, 5) the effect of clinical alarms and alarm fatigue on attention, and 6) health information technology's effect on attention. Eighty-two metrics were used to measure attention. LIMITATIONS: Does not synthesize answers to specific questions. Quality of studies was not assessed. CONCLUSION: This overview may be a resource for researchers, quality improvement experts, and health system leaders to improve clinical environments. Future systematic reviews may synthesize evidence on metrics to measure attention and on the effectiveness of barriers or facilitators related to attention. PRIMARY FUNDING SOURCE: None.

Characterizing electronic messaging use among hospitalists and its association with patient volumes.

BACKGROUND: Secure electronic messaging is increasingly being utilized for communications in healthcare settings. While it likely increases efficiency, it has also been associated with interruptions, high message volumes, and risk of errors due to multitasking. OBJECTIVES: We aimed to characterize patterns of secure messaging among hospitalists to understand the volume of messages, message patterns, and impact on hospitalist workload. METHODS: This was a retrospective cross-sectional study of Epic Secure Chat secure electronic messages received and sent by hospitalists from April 1 to April 30, 2023 at a large academic medical center. Number of conversations per day, number of chats sent and accessed per hour, and average minutes between when a chat was sent and accessed (lag time) were analyzed using a Pearson correlation coefficient test. Measures were plotted against patient volume and time of day. RESULTS: Hospitalists sent or received an average of 130 messages per day with an average of 13 messages sent or received per hour. The median lag time was 39 s. There was a statistically significant correlation between hospital medicine morning census and number of conversations per day, number of chats sent per hour, and number of chats accessed per hour, but census did not impact lag time. CONCLUSION: Secure messaging volumes may be higher than previously reported, which may affect hospitalist workload and workflow and have unintended effects on interruptions, multitasking, and medical errors. Additional work should be done to better understand local messaging patterns and opportunities to optimize volume of work and distractions.

Virtual hospital care development and deployment: A rapid qualitative study of frontline clinicians and leaders.

BACKGROUND: Virtual hospitalist programs are rapidly growing in popularity due to worsening clinician shortages and increased pressure for flexible work options. These programs also have the potential to establish sustainable staffing models across multiple hospitals optimizing cost. We aimed to explore the current state of virtual hospitalist services at various health systems, challenges and opportunities that exist in providing virtual care, and future opportunities for these types of services. OBJECTIVES: To identify perspectives on design and implementation of virtual hospitalist programs from academic hospitalist leaders. METHODS: We conducted focus groups with United States academic hospitalist leaders. Semistructured interviews explored experiences with virtual hospitalist programs. Using rapid qualitative methods including templated summaries and matrix analysis, focus group recordings were analyzed to identify key themes. RESULTS: We conducted four focus groups with 13 participants representing nine hospital systems across six geographic regions and range of experience with virtual hospital medicine care. Thematic analysis identified three themes: (1) a broad spectrum of virtual care delivery; (2) adoption and acceptance of virtual care models followed the stages of diffusion of innovation; and (3) sustainability and scalability of programs were affected by unclear finances. CONCLUSIONS: Hospitalist leader perspectives revealed complex factors influencing virtual care adoption and implementation. Addressing concerns about care quality, financing, and training may accelerate adoption. Further research should clarify the best practices for sustainable models optimized for access, hospitalist experience, patient safety, and financial viability.

Academic hospitalist perspectives on the benefits and challenges of secure messaging: A mixed methods analysis.

BACKGROUND: Hospitals and patients rely on effective clinician communication. Asynchronous electronic secure messaging (SM) systems are a common way for hospitalists to communicate, but few studies have evaluated how hospitalists are navigating the adoption of SM and the benefits and challenges they are encountering. OBJECTIVES: The objective of this study is to assess academic hospitalist perspectives on SM to guide future research and quality improvement initiatives. METHODS: This was a mixed methods study utilizing an embedded REDCap survey and six virtual semistructured focus groups. It took place during a Hospital Medicine ReEngineering Network Zoom meeting on October 13, 2023. Rapid qualitative methods were used to define major themes. RESULTS: There were 28 hospitalists and one patient representative across 24 separate academic institutions. There was a 71% survey completion rate (N = 20). SM was felt to be an effective and efficient communication modality but was associated with a large amount of multitasking and interruptions. Perspectives around SM clustered around three main themes: SM has been widely but variably adopted; there is a lack of institutional guidance about how to best engage with SM; and SM is changing the landscape of hospitalist work by increasing ease but decreasing depth of communication, increasing cognitive load, and changing interpersonal relationships. Recommendations for SM improvements included the need for institutions to work with frontline workers to develop and implement clear usage guidelines. CONCLUSION: SM is likely contributing to both positive and negative effects for clinicians and patients. Understanding hospitalist perspectives on SM will help guide future research and quality improvement initiatives.

Decreasing Inappropriate Telemetry Use via Nursing-Driven Checklist and Electronic Health Record Order Set.

INTRODUCTION: Telemetry is ubiquitous in many hospitals despite widely acknowledged limitations, waste, and potential harm associated with inappropriate use. To curb overuse, guidelines such as the 2017 American Heart Association/American College of Cardiology (AHA/ACC) continuous telemetry monitoring practice standards have outlined appropriate telemetry use standards. This study aimed to perform two "plan-do-study-act" (PDSA) cycles and assess whether a nursing (RN)-driven checklist addressing appropriate telemetry use, combined with just-in-time education delivered via an electronic health record (EHR) order set modification, was efficacious in reducing inappropriate telemetry use within a level 1a Veterans Health Administration hospital. METHODS: This is a quality improvement intervention study that took place between March 2019 and August 2020. Three cohorts were sequentially studied: a control cohort without any intervention (n = 100), a cohort with only the RN-driven checklist (n = 100), and a cohort with both the RN-driven checklist and an EHR order set modification that provided just-in-time education about telemetry indications (n = 100). Telemetry records were reviewed by a physician to determine indication, duration for each telemetry order, and appropriateness. An order was deemed "appropriate" if it met AHA/ACC classification grade I (telemetry recommended) or IIa/b (telemetry may be considered) and "inappropriate" if it fell under class III (telemetry not recommended). Data were compared between the control cohort and the two intervention cohorts, as well as between intervention cohorts, using Pearson chi-square analysis. A p-value < 0.05 was considered statistically significant. RESULTS: Within the control group, 37% of telemetry orders were deemed inappropriate. After implementation of the RN checklist, a non-statistically significant lower proportion (26%) of orders was deemed inappropriate (p = 0.09). Implementation of the RN checklist, along with the EHR order set, was associated with a significantly lower proportion of inappropriate orders (17%) in comparison to the control cohort (p = 0.001) but not in comparison to the RN checklist cohort (p = 0.12). There was no significant difference in the duration of telemetry use across cohorts. CONCLUSIONS: An RN-driven checklist and EHR telemetry order set modification were associated with a decrease in inappropriate telemetry use from 37% to 17%. By prompting the review of telemetry orders via a daily nursing checklist reviewed during bedside interdisciplinary rounds, clinicians received reinforcement regarding appropriate telemetry indications. This education was strengthened by the just-in-time training provided via the EHR order set.

Pain Control Disparities in Acute Pancreatitis.

Background and objective Patient treatments and outcomes have historically differed based on age, sex, race/ethnicity, and social factors, and there is a growing awareness that such disparities still exist. While prior studies have found that patients belonging to minority groups have their pain undertreated, few studies have evaluated pain control based on age, sex, body mass index (BMI), or presence of a substance use disorder (SUD). The studies that do exist have inconsistent results. This study aimed to evaluate pain control in patients admitted to a Denver academic safety net hospital for acute pancreatitis. Pancreatitis is an inherently painful condition involving pancreatic inflammation and for which adequate pain control is a cornerstone of treatment; this makes it an ideal disease state for an exploratory analysis into the experience of pain within different patient groups. Methods This was a retrospective cohort study of patients treated at the Denver Health Medical Center from January 1, 2017, through December 31, 2019, for acute pancreatitis; 659 patients met the inclusion criteria and were included in the study. Pain control during the first 24 hours of hospital admission was analyzed by comparing controlled vs. uncontrolled reports of pain and mean pain scores. Patients were stratified by age, sex, self-reported race/ethnicity, BMI, and presence of SUD at the time of admission. Achievement of "controlled pain," as defined by a pain score below the patient's stated functional pain goal, was then analyzed. Chi-squared analysis was employed to look into differences within and between groups. Additionally, a t-test was used to compare mean pain scores between groups with controlled and uncontrolled pain. Results A statistically significant difference in pain control was found when stratified by age or the presence of SUD (p<0.001). Within these groups, 39% of those aged 18-40 years achieved pain control, compared with 49% of those aged 41-64 years and 66% of those aged 65 years and older. Among those with active SUD, only 41% were able to achieve pain control compared with 58% of those without SUD. Among those who achieved pain control, the average mean pain score was 5, which decreased to 4 within 24 hours. Among those who did not achieve pain control, the average mean pain score was 7, which remained at 7 at 24 hours (p<0.001). Conclusions We did not find significant differences in the ability to achieve tolerable pain control based on sex or BMI. We were unable to appropriately analyze differences based on race/ethnicity due to an inability to differentiate between White Hispanic and White non-Hispanic populations within Epic. However, we did find significantly poorer pain control in younger patients and those with an active SUD.

Gram-Negative Pyomyositis in an Immunocompetent Patient.

Pyomyositis is an acute or sub-acute primary infection of the striated muscles. It is commonly misdiagnosed in its early stages due to its nonspecific presentation and lower suspicion among physicians when it comes to diagnosis. It has been historically associated with tropical climates but is being seen with increasing incidence in temperate regions. In both tropical and temperate areas, Staphylococcus aureus is the most common causative organism; gram-negative organisms are rare and traditionally only seen in immunocompromised patients. We report a case of Klebsiella pneumoniae pyomyositis in an immunocompetent patient with no risk factors. The awareness of the possibility of gram-negative pyomyositis in immunocompetent patients will broaden initial empiric antibiotic treatment, especially in those patients not responding to traditional empiric treatment.

Does Osteopathic Manipulative Treatment Make a Neuropsychological Difference in Adults With Pain? A Rationale for a New Approach.

Cognitive impairment is common in patients with pain. While symptoms of pain are effectively treated with osteopathic manipulative treatment (OMT), the cognitive complaint is vastly ignored. Pain-induced cognitive dysfunction can be severe and is particularly apparent in working memory and attention. There is good reason to expect cognitive responsiveness to OMT. Previous research has reported the effects of OMT on related psychiatric outcomes, including relief from depression and anxiety, suggesting that OMT may produce more cortical benefits than is currently thought. The rationale to link OMT to cognition comes from the tenets of osteopathic medicine: body unity, homeostasis, and the structure-function relationship. The present article provides background evidence to support the hypothetical link between OMT and cognitive benefits and proposes a physiological mechanism of how OMT could exert its effect on cognition. Research strategies are discussed to test the hypotheses that are generated from the proposed theoretical framework.