Providing Structured Real-Time Feedback on Postdischarge Outcomes Using Electronic Health Record Data.

OBJECTIVES: Most trainees do not receive information about postdischarge outcomes, despite the importance of external feedback for accurate self-assessment and improvement in discharge planning skills. We aimed to design an intervention to foster reflection and self-assessment by trainees regarding how they can improve transitions of care with minimal investment of program resources. METHODS: We developed a low-resource session delivered near the end of an internal medicine inpatient rotation. Faculty, medical students, and internal medicine residents reviewed and reacted to postdischarge outcomes of their patients, explored understanding of the reasons for these outcomes, and developed goals for future practice. The intervention required minimal resources given that it was conducted during scheduled teaching time, did not require additional staff, and used already available data. Forty internal medicine resident and medical student participants completed pre- and postintervention surveys that evaluated their understanding of causes for poor patient outcomes, sense of responsibility for postdischarge outcomes, degree of self-reflection, and goals for future practice. RESULTS: Trainee understanding of the causes for poor patient outcomes was significantly different in several areas after completing the session. Trainees were less likely to believe that their responsibility for patients ends at the time of discharge, indicating an increase in sense of responsibility for postdischarge outcomes. After the session, 52.6% of trainees planned to change their approach to discharge planning, and 57.1% of attending physicians planned to change their approach to discharge planning with trainees. Through free-text responses, trainees noted that the intervention facilitated reflection and discussion about discharge planning and led to the development of goals to adopt specific behaviors for future practice. CONCLUSIONS: Meaningful information about postdischarge outcomes from the electronic health record can be used to provide feedback to trainees in a brief, low-resource session during an inpatient rotation. This feedback significantly affects trainee sense of responsibility for and understanding of postdischarge outcomes, which may lead to improved trainee ability to orchestrate transitions of care.

Utilization of an Internal Medicine Triaging Resident in the Emergency Department Reduces Preventable Admissions and Improves Trainee Experiences.

OBJECTIVE: Increasing patient care requirements and suboptimal communication between emergency department (ED) and Internal Medicine (IM) services may lead to inefficient hospital utilization, lapses in transitions of care, and reduced trainee satisfaction in the inpatient setting. Furthermore, a lack of triaging roles for IM trainees has been a common limitation in graduate medical education. We aimed to demonstrate that the addition of an IM triaging resident (TR) in the ED may represent an innovative solution to these problems. METHODS: A single-center pilot study was performed. An IM trainee served as the TR at a tertiary Veterans Affairs hospital for 2 weeks. The TR evaluated medical patients in a parallel manner with ED physicians and assisted in the initial management, disposition, and transitions of care under the supervision of an IM attending physician. Hospital utilization and patient safety were tracked using electronic records, and trainee satisfaction was measured using daily surveys administered to IM resident teams. RESULTS: Of the 62 cases evaluated by the TR for medical admission, 26 (42%) represented preventable admissions; 12 (46%) of those patients were discharged from the ED, representing a 19% overall reduction. There were statistically significant improvements in trainee experiences relating to patient flow (P < 0.01) and initial patient management (P < 0.02), and our intervention did not have a negative impact on ED performance metrics or patient safety. CONCLUSIONS: Expansion of this model in select integrated health systems may improve graduate medical education and healthcare system performance. Future iterations of this study can aim to improve transitions of care between ambulatory and inpatient providers and limit the overuse of antimicrobial agents, radiography, and consultative services.

Improving the Quality of Inpatient Discharge Instructions: An Evaluation and Implementation of Best Practices.

OBJECTIVES: Little is known about whether improving the quality of written discharge instructions can result in improved readmission rates and whether there are differences in the quality of discharge instructions based on provider and patient characteristics. We set out to determine provider characteristics associated with high quality discharge instructions and whether redesigned discharge instructions would lead to improvement in their quality and reduce hospital readmission rates. METHODS: We instituted sequential interventions of educational outreach and a redesigned discharge instructions template and evaluated their quality using 11 metrics based on established best practices and subsequent 30-day readmission rates. RESULTS: In total, 225 randomly selected charts were reviewed during a 15-month period. An average of 5.36 quality metrics were completed before our interventions, which increased to 5.61 after educational outreach and 7.16 after the template was redesigned. The risk standardized 30-day readmission rate fluctuated from a baseline of 10.48% to 12.71% and 10.97% following each intervention, respectively. Medical students completed significantly more quality metrics than interns, residents, or attendings (P < 0.05 for all) and residents completed significantly more than attendings (P = 0.014). CONCLUSIONS: Although an education intervention was ineffective in improving discharge instruction quality, a redesigned discharge instructions template did improve the quality of patient discharge instructions. Neither intervention led to a meaningful change in readmission rates. We also found significant differences in the quality of discharge instructions based on the level of training of the author of the discharge instructions.

Rate of Preventable Mortality in Hospitalized Patients: a Systematic Review and Meta-analysis.

BACKGROUND: The number of preventable inpatient deaths in the USA is commonly estimated as between 44,000 and 98,000 deaths annually. Because many inpatient deaths are believed to be preventable, mortality rates are used for quality measures and reimbursement. We aimed to estimate the proportion of inpatient deaths that are preventable. METHODS: A systematic literature search of Medline, Embase, Web of Science, and the Cochrane Library through April 8, 2019, was conducted. We included case series of adult patients who died in the hospital and were reviewed by physicians to determine if the death was preventable. Two reviewers independently performed data extraction and study quality assessment. The proportion of preventable deaths from individual studies was pooled using a random-effects model. RESULTS: Sixteen studies met inclusion criteria. Eight studies of consecutive or randomly selected cohorts including 12,503 deaths were pooled. The pooled rate of preventable mortality was 3.1% (95% CI 2.2-4.1%). Two studies also reported rates of preventable mortality limited to patients expected to live longer than 3 months, ranging from 0.5 to 1.0%. In the USA, these estimates correspond to approximately 22,165 preventable deaths annually and 7150 deaths for patients with greater than 3-month life expectancy. DISCUSSION: The number of deaths due to medical error is lower than previously reported and the majority occur in patients with less than 3-month life expectancy. The vast majority of hospital deaths are due to underlying disease. Our results have implications for the use of hospital mortality rates for quality reporting and reimbursement. STUDY REGISTRATION: PROSPERO registration number CRD42018095140.

Symptom-Triggered Therapy for Alcohol Withdrawal Syndrome: a Systematic Review and Meta-analysis of Randomized Controlled Trials.

BACKGROUND: Benzodiazepines are the standard medication class for treating alcohol withdrawal. Guidelines recommend dosing based on objectively measured symptoms (symptom-triggered therapy) rather than fixed dose regimens. However, the superiority of symptom-triggered therapy has been questioned, and concerns have been raised about its inappropriate use and safety. We aimed to assess whether symptom-triggered therapy is superior to fixed dose schedules in terms of mortality, delirium, seizures, total benzodiazepine dose, and duration of therapy. METHODS: A systematic literature search using Medline, Embase, and the Cochrane Registry through February 2018 was conducted for randomized controlled trials of patients with alcohol withdrawal syndrome comparing fixed dose benzodiazepine schedules to symptom-triggered therapy. Risk of bias was assessed using the Cochrane Risk of Bias Tool. Outcomes were pooled using random effects meta-analysis. Heterogeneity was estimated using the I2 statistic. Strength of evidence was assessed using methods outlined by the Agency for Healthcare Research and Quality. RESULTS: Six studies involving 664 patients were included. There were no deaths and only one seizure in each group. Four studies reported delirium, which occurred in 4 out of 164 patients randomized to symptom-triggered therapy compared to 6 out of 164 randomized to fixed dose therapy (odds ratio, 0.64 [95% CI, 0.17-2.47]). Three studies reported duration of therapy, which was 60.4 h less with symptom-triggered therapy (95% CI, 39.7-81.1 h; p < 0.001). Six studies reported total benzodiazepine dosage, which was 10.5 mg in lorazepam-equivalent dosing less with symptom-triggered therapy (95% CI, 7.1-13.9 mg; p = 0.011). DISCUSSION: Moderate strength evidence suggests that symptom-triggered therapy improved duration of therapy and total benzodiazepine dose in specialized detoxification settings of low-risk patients but the applicability of this evidence in general hospital settings is low. There was insufficient evidence for any conclusions about symptom-triggered therapy for the major outcomes of mortality, seizure, and delirium in any setting. PROSPERO REGISTRATION: CRD42017073426.

Bedside Rounds Valued But Not Preferred: Perceptions of Internal Medicine Residents and Attending Physicians in a Diverse Academic Training Program.

OBJECTIVES: Bedside rounds/rounding (BDR) is an important tool for patient-centered care and trainee education. This study aimed at understanding the attitudes toward BDR among residents and attending physicians. METHODS: A survey was conducted using the Qualtrics survey tool. Responses were measured using a five-point Likert scale. RESULTS: The survey was sent to 301 attending physicians and 195 residents. Attending physicians conducted BDR 19% of the time. The preferred mode of rounding for residents was hallway and/or conference room rounding (67%). The major barriers to BDR were concern for causing confusion in or alarm to patients (attending physicians 49%, residents 77%) and prolongation of rounds (attending physicians 47%, residents 72%). The major advantages to BDR were increased likelihood of using patient-friendly language (attending physicians 84%, residents 69%) and the potential to improve trainees' oral presentations and physical examination skills (attending physicians 71%, residents 54%). Attending physicians reported having adequate skills to conduct BDR (95%) and potential opportunity to be better teachers with this mode of rounding (69%). Residents reported having some previous experience with BDR (46%) and agreed that BDR is an important skill for residents (62%). Only 34% of residents agreed that BDR allowed them to learn more about patient care compared with other modes of rounding, however. CONCLUSIONS: Our study showed that our participants perceive BDR positively. Endorsed benefits include the ability to use patient-friendly language, the potential to improve trainees' clinical skills, and an opportunity to become better teachers. The reported major barriers to BDR were potential concern for patient confusion and prolongation of rounds. Despite some prior exposure reported by residents and adequate attending skills, the frequency and preference for BDR remains low and the residents remain uncertain about the educational value of BDR. The evaluation of other factors that contribute to the low frequency of BDR needs further consideration. Furthermore, each residency program may differ in the patterns of perception toward BDR and these should be formally assessed before implementing this patient-centered mode of rounding.

The "Hand-in" Project: Jump-starting Communication Between Inpatient and Outpatient Providers.

OBJECTIVES: Communication between hospitalists and primary care providers (PCPs) upon discharge has been much discussed, but the transition from outpatient to inpatient has received less attention. We questioned whether a brief, standardized e-mail from the hospitalist to the PCP upon admission could facilitate information exchange, increase communication, elucidate PCP preferences, and improve outcomes. METHODS: This prospective single-center study with a preintervention-to-postintervention design involved 300 inpatient admissions from June 2015 through October 2015 in the Veterans Affairs Connecticut Healthcare System. Hospitalists e-mailed an encrypted notification of admission along with standardized questions to PCPs within 1 day of admission. Measurements included the number of communications between PCPs and hospitalists, length of stay (LOS), 30-day readmissions, 30-day emergency department (ED) utilization rates, PCP preferences with regard to communication, and follow-up. RESULTS: Preintervention data for 94 patients during a 6-week period revealed 0.11 communications per patient, an LOS of 4.18 days, 30-day readmissions of 28.7%, and 30-day ED visits of 32%. Postintervention data on 206 patients during the next 12 weeks showed statistically significant increased communications per patient (0.5), and a nonsignificant decrease in LOS (3.96 days), 30-day readmissions (22.3%), and 30-day ED visits (31%). P values were <0.001, 0.67, 0.4, and 0.79, respectively. PCPs preferred e-mail communication upon discharge (40%) to telephone (25%) or instant messaging (13%), and 39% wanted a follow-up appointment within 2 weeks, regardless of what transpired. CONCLUSIONS: A hospitalist-led transition-of-care intervention designed to improve communication and information exchange between PCPs and hospitalists at the time of admission demonstrated that encrypted e-mail could be used as a tool to obtain useful additional medical and psychosocial information and to better understand PCP attitudes and preferences. The increased level of communication did not yield statistically significant decreases in LOS, 30-day readmission rates, or 30-day post-discharge ED visits, however.

Creating a Process for the Implementation of Tiered Huddles in a Veterans Affairs Medical Center.

INTRODUCTION: In 2019, the Veteran's Health Administration began its journey in pursuit of becoming an enterprise-wide High Reliability Organization (HRO). Improving the delivery of safe, high quality patient care is a central focus of HROs. Requisite to meeting this goal is the timely identification and resolution of problems. This is best achieved by empowering and engaging both clinical and non-clinical staff across the healthcare organization through the promotion of robust collaboration and communication between various disciplines. Improved care coordination and increased accountability are two important subsequent outcomes. One method for accomplishing this is through the implementation of tiered huddles. MATERIALS AND METHODS: An extensive review of the current literature from 2013 until June 2021 was conducted for evidence highlighting the experiences of other healthcare organizations during implementation of huddles. Following the review, a tiered huddle proposal was developed and presented to the executive leadership team of a healthcare system for approval. Pilot testing of the tiered huddle implementation plan began in October 2021 over a 12-week period with three services. On average, the pilot services had between three to four tiers from frontline staff to the executive level of leadership. RESULTS: Over the 12-week period, out of the possible 120 tiered huddles that could have been conducted, 68% (n = 81) were completed. Of the tiered huddles conducted, 99% (n = 80) started and ended on time. During the pilot test, seven issues were identified by frontline staff: coordination of pre-procedural coronavirus testing, equipment/computer issues, rooms out of service, staffing levels, and lack of responsiveness from other departments. Issues related to staffing, unresponsiveness from other departments, and equipment concerns required elevation to a higher-level tier with no issues remaining open. Delays in patient care, or prolongation of shift hours for staff because of tiered huddles, was low at 2.5% (n = 2). For the duration of the pilot test, a total of 75 minutes accounted for shifts being extended among five staff members. CONCLUSIONS: The success of this initiative demonstrates the importance of thoughtfully creating a robust process when planning for the implementation of tiered huddles. The findings from this initiative will be of immense value with the implementation of tiered huddles across our healthcare system. We believe that this approach can be used by other healthcare institutions along their journey to improving patient safety and quality.

Building Resident Quality Improvement Knowledge and Engagement Through a Longitudinal, Mentored, and Experiential Learning-Based Quality Improvement Curriculum.

Introduction: Quality improvement (QI) training is an essential component of resident medical education and a part of the ACGME core competencies. We present our residency's evidence-based QI curriculum, which outlines key components identified in the literature for successful QI education. Methods: Our curriculum included a mandatory five-part longitudinal educational series during ambulatory education sessions for second-year residents. Modeled after the Institute for Healthcare Improvement model for improvement and taught by a chief resident, our curriculum introduced residents to key QI concepts through case-based, just-in-time didactics and applied experiential learning via concurrent resident-led longitudinal QI projects. Residents received structured, multilayer mentorship from a faculty mentor in their field of interest and the chief resident of quality and patient safety. Their work-in-progress projects were presented to faculty QI experts and institutional leadership for additional feedback and mentorship. Results: Since 2016, a total of 234 internal medicine residents have completed our QI curriculum and developed 67 QI projects, which have been presented at various local, regional, and national conferences. In the 2 most recent academic years, Quality Improvement Knowledge Application Tool Revised (QIKAT-R) scores significantly increased from 4.6 precurriculum to 6.3 postcurriculum (p < .001). Discussion: A longitudinal, experiential, and mentored QI curriculum teaches residents QI skill sets through incorporating mechanisms associated with successful educational initiatives and adult learning theory. Our QIKAT-R results and project output show that our curriculum is associated with improved trainee QI knowledge and systems-level improvements.

Hospitalisations for heart failure: increased palliative care referrals - a veterans affairs hospital initiative.

OBJECTIVES: Heart failure (HF) portends significant morbidity and mortality. Integrating palliative care (PC) with HF management improves quality of life and preparedness planning. At a Veterans Affairs hospital, PC was used in 6.5% of patients admitted for HF from October 2019 to September 2020. We sought to increase the percentage of referrals to PC to 20%. METHODS: PC referral guidelines were developed and used to screen all HF admissions between October 2020 and May 2021. Point-of-care education on the benefits of PC was delivered to teams caring for patients who met PC referral criteria. Changes were tested using Plan-Do-Study-Act (PDSA) cycles. Results were analysed using run charts. RESULTS: During the study period, there were 109 HF admissions in patients who were not already followed by PC. Thirty-one (28%) received a new PC consult. The mean age was 81±9.5 years, median B-type natriuretic peptide was 1202 pg/mL, and mean length of stay was 8±5 days. After our intervention, there was an upward shift in the percentage of new referrals to PC with 6 values above the baseline median, which represents a significant change. CONCLUSIONS: Through multiple PDSA cycles, referrals to PC for patients admitted with HF increased from 6.5% to 28%. Point-of-care education was an effective tool to teach medical teams about the benefits of PC. Inpatient teams more consistently and independently considered PC for patients with HF, representing a cultural shift. This quality improvement model may serve as a paradigm to improve the care of HF patients.

Room of Hazards: A Comparison of Differences in Safety Hazard Recognition Among Various Hospital-Based Healthcare Professionals and Trainees in a Simulated Patient Room.

OBJECTIVES: Adverse events in hospitals are common. While studies have used simulated patient rooms to assess healthcare trainees' skills in detecting safety hazards, few have explored the characteristics of safety hazards that make them more or less identifiable to healthcare workers. We sought to determine differences in hospital-based safety hazard identification among physicians, nurses, and other staff members. METHODS: Healthcare workers were invited to identify safety hazards in a simulated patient room with intentionally placed hazards. Responses were transcribed and compared between physicians (MD), nurses (RN), and other hospital-based healthcare professionals and trainees (other). Data were analyzed using nonparametric statistical analysis. RESULTS: Twelve physicians, 29 nurses, and 26 other staff members participated in this study. Different professions identified different numbers of total hazards with nurses identifying more hazards than other professions (RN: 9.59, MD: 9.17, other: 6.35; P = 0.001). All professions had difficulty identifying hazards associated with omission (e.g., no precaution sign: MD: 8.3%, RN: 3.4%, other: 0%) or hazards requiring 2-step logical thinking (e.g., intravenous heparin for patient with head laceration: MD: 0%, RN: 6.9%, other: 0%). CONCLUSIONS: Physicians, nurses, and others identified different numbers of total hazards, and few participants identified hazards associated with omission or 2-step logical thinking. While previous studies have found differences in types of hazards identified among different healthcare members, we identified hazards that were collectively challenging for all participants to identify. Future studies should target identification of these types of hazards, using human factor engineering to decrease risk of patient harm.

Room of Hazards: An Interprofessional Evaluation of Safety Risks in a Simulated Patient Room.

OBJECTIVES: Approximately 3.7% of patients experience adverse events in health care facilities, many of which are preventable. Patient safety requires effective training and an interprofessional culture of safety, but few studies compare the safety skills of different hospital professions. We sought to assess skills in safety hazards identification among staff from different health care disciplines with a pilot study. METHODS: An exercise with a simulated room of an inpatient ward with a patient mannequin in a hospital bed with 34-intentionally planted safety hazards was set up. Health care staff members from various professions walked around the room and independently documented observed safety hazards. Identified hazards were separated based on staff disciplines, grouped into 5 categories (patient, medications, equipment, environment, care processes), and analyzed using analysis of variance. Because participants identified more hazards than the 34 intentionally planted hazards, these were analyzed separately. RESULTS: The study included 111 staff: nurses (n = 68), nursing students (n = 5), medical students (n = 3), physicians (n = 11), social workers (n = 5), pharmacists (n = 6), certified nursing assistants (n = 9), and psychologists (n = 4). There were significant differences among professions in the following categories: medications, equipment, and total number of safety hazards (P < 0.05 for all). Nurses found more intended equipment hazards than did social workers (38.8% versus 4.4%, P < 0.001), pharmacists (38.8% versus 11.1%, P = 0.004), medical students (38.8% versus 7.4%, P = 0.021), and psychologists (38.8% versus 8.3%, P = 0.001) and more medication hazards than nursing students (20.3% versus 16.7%, P = 0.008), whereas certified nursing assistants also found more equipment hazards than did social workers (25.9% versus 4.4%, P = 0.016). CONCLUSIONS: There were significant differences in patterns of safety hazards identified among health care professions, with nurses identifying more hazards than several other professions. This finding suggests that each health care profession's unique training and responsibilities result in varying ability to identify safety hazards and that interdisciplinary safety teams may be more effective than those from only a single profession. Our study provides a starting point to encourage diversification of hospital professions in simulation-based safety trainings, although further work is needed to validate these findings moving forward.

A High-reliability Organization Mindset.

In 2020, the US Department of Veterans Affairs Connecticut Healthcare System began its journey to becoming a high-reliability organization as part of Veterans Affairs efforts to become an enterprise-wide high-reliability organization through the Veterans Health Administration. The initiative was launched to create safe enterprise-wide health care systems and environments with robust continuous process improvements as a method for providing patients with safer and higher quality care. In this article, the authors describe a continuous process improvement initiative aimed at implementing system-wide initiatives along the journey to becoming a high-reliability organization. The initiatives are described from the perspectives of individuals representing staff from the frontline to executive leadership. The authors believe that the processes, strategies, and example initiatives described can be readily adopted and implemented in other health care organizations along the journey to high reliability.

Tylenol or acetaminophen: a recurrent fixed drug eruption perpetuated through the use of inconsistent drug terminology.

An 87-year-old man with a history of osteoarthritis presented with worsening knee pain. He was prescribed acetaminophen with codeine. A few days later, he developed a rash on his right buttock and proximal thigh, similar to a rash he experienced in the past when he took over-the-counter (OTC) acetamenophen and an unknown lozenge to treat a presumed viral illness. A fixed drug eruption (FDE) was diagnosed and the patient was asked to avoid Tylenol and other OTC lozenges. Tylenol was entered as an allergy in the electronic medical records. However, since Tylenol, not acetaminophen was listed in the allergy profile, the order for acetaminophen and codeine did not generate an alert for the prescribing physician. Additionally, the dispensing pharmacist did not question the prescribing physician and the patient, unaware that acetaminophen in the pain medication is the same drug as Tylenol, took it and developed recurrent FDE.

Atypical case of Miller-Fisher syndrome presenting with severe dysphagia and weight loss.

A 71-year-old man developed dysphagia, bilateral lower extremity muscle weakness and weight loss. He was admitted to the hospital after a failed formal swallow evaluation, nearly 3 weeks after symptom onset. In addition to dysphagia and weakness, physical examination was notable for hypophonia, dysarthria, diplopia, horizontal ophthalmoparesis, ptosis, ataxia and hyporeflexia. Cerebrospinal fluid was notable for albuminocytological dissociation and serum anti-GQ1b antibody titre was elevated (1:200). A diagnosis of Miller-Fisher syndrome (MFS) was made, and the patient was treated with intravenous immunoglobulin (0.4 g/kg/day) for 5 days, which resulted in resolution of symptoms. This is an atypical case of MFS, in that the presenting symptom was progressive dysphagia rather than the ophthalmoplegia and ataxia that are normally seen in MFS. Patients who present with dysphagia should receive a thorough neurological examination, with particular attention to extraocular movements, reflexes and gait stability, to rule out MFS as a potential cause.

Stethoscope hygiene: Using cultures and real-time feedback with bioluminescence-based adenosine triphosphate technology to change behavior.

BACKGROUND: Stethoscope hygiene is rarely done despite guideline recommendations. We wanted to determine whether demonstrating what is growing on the stethoscopes of providers via culture or bioluminescence technology alters perceptions and improves compliance. METHODS: Providers were given the opportunity to (1) culture their stethoscopes before and after disinfection with alcohol pads, alcohol-based hand rub, or hydrogen peroxide disinfectant wipes and (2) swab stethoscopes for bioluminescence-based adenosine triphosphate testing before and after disinfection. Outcomes were observed for hand and stethoscope hygiene rates and before and after intervention survey responses. The bacteria that were isolated, colony-forming units (CFU), and bioluminescence scores were tracked. RESULTS: A total of 1,245 observed hand hygiene opportunities showed that compliance improved from 72.5%-82.3% (P < .001). In addition, 590 observed patient-provider encounters revealed no significant change in stethoscope hygiene rates of 10% initially and 5% afterward (P = .08), although self-reported rates trended from 56%- 67% postintervention (P = .06). Perceptions regarding stethoscope hygiene importance improved (8.5/10 to 9.3/10; P = .04). Disinfection with alcohol pads, alcohol-based hand rub, and hydrogen peroxide disinfectant wipes were equivalent in CFU reduction (P = .21). CONCLUSIONS: Showing providers what is growing on their stethoscopes via cultures and bioluminescence technology before and after disinfection improved "buy in" regarding stethoscope hygiene importance. Both methods were rated as having an equal impact, however, objective observations failed to show improvement.