Prevalence of homelessness among hospitalized patients: A point-in-time survey.

Although homelessness is associated with increased acute healthcare utilization and poorer health outcomes, the prevalence of homelessness and housing insecurity in hospitalized patients is poorly characterized. We conducted an in-person survey to determine the prevalence of housing insecurity and homelessness among hospitalized patients at two hospitals in metropolitan Denver in conjunction with the Housing and Urban Development point-in-time count on January 24, 2022. Of the 271 surveyed patients, 79 (29.2%) reported experiencing either housing insecurity (17.3%) or homelessness (11.8%). Of those experiencing housing insecurity or homelessness, 69.6% reported chronic health conditions, 55.7% reported multiple hospitalizations in the preceding year, 38% reported mental health concerns and 39.2% reported substance use. The prevalence of homelessness among a hospitalized patient population was over 20-fold higher than community prevalence estimates. Housing insecurity also impacted a substantial proportion of hospitalized patients and was associated with high rates of co-morbid conditions.

Hospitalization and Housing: A Qualitative Study Exploring the Perspectives of Hospitalized Patients Experiencing Housing Insecurity.

Although housing insecurity has clear negative impacts on health, little is known about how it impacts patients' experience of hospitalization. In this qualitative study, we interviewed 22 hospitalized patients experiencing housing insecurity. The following three major themes emerged: 1) adverse social and environmental factors directly contribute to hospitalization, 2) lack of tailored care during hospitalization leaves patients unprepared for discharge, and 3) patients have difficulty recuperating after a hospital stay, leading to the risk of rehospitalization. Within these themes, participants described the roles of extreme physical and psychological hardship, chaotic interpersonal relationships, substance use, and stigma affecting participants' experiences before, during, and following hospitalization. Our results, based directly on the patient experience, suggest a need for hospital systems to invest in universal in-hospital screening for housing insecurity, incorporation of trauma-informed care, and robust partnerships with community organizations. Future research should explore the feasibility and impact of these interventions.

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.

A Case-Based Critical Care Curriculum for Internal Medicine Residents Addressing Social Determinants of Health.

Introduction: Graduate medical education on social determinants of health (SDOH) is limited. Residents often directly care for vulnerable populations at safety-net hospitals, yet curricula thus far are based in the ambulatory setting. Methods: We developed a case-based curriculum integrating SDOH with critical care topics to standardize knowledge and improve skills and attitudes of internal medicine residents working with these patients. We conducted a needs assessment, identified systematic social risk domains, and modified a published curriculum to develop the content. Case-based discussions were conducted weekly in the medical intensive care unit, while knowledge, attitudes, and skills were assessed daily during multidisciplinary rounds. A 360-degree assessment was completed with pre- and postcurriculum surveys and self-reflection. Results: Eleven residents completed postcurriculum surveys. Both pre- and postcurriculum, residents reported confidence in identifying and describing how SDOH affect care. After the curriculum, residents could name more resources for patients experiencing health disparities due to substance abuse (pre: 47%, post: 73%) and financial constraints (pre: 50%, post:64%). This curriculum was recognized as the first training many residents received (pre: 31%, post: 91%) with formal feedback (pre: 16%, post: 64%). Discussion: Implementing a curriculum of social risk assessment in critically ill patients was difficult due to competition with clinical care. Participating residents said they "loved the open dialogue" to reflect on their experiences; this became an avenue to "debrief on specific patient encounters and [how] SDOH brought [patients] to the ICU." Future directions include qualitative analysis of reflections and assessment of curricular impact on trainee resiliency.

Prospective comparison of curbside versus formal consultations.

BACKGROUND: Curbside consultations are commonly requested during the care of hospitalized patients, but physicians perceive that the recommendations provided may be based on inaccurate or incomplete information. OBJECTIVE: To compare the accuracy and completeness of the information received from providers requesting a curbside consultation of hospitalists with that obtained in a formal consultation on the same patients, and to examine whether the recommendations offered in the 2 consultations differed. DESIGN: Prospective cohort. SETTING: University-affiliated, urban safety net hospital. MAIN OUTCOME MEASURES: Proportion of curbside consultations with inaccurate or incomplete information; frequency with which recommendations in the formal consultation differed from those in the curbside consultation. RESULTS: Curbside consultations were requested for 50 patients, 47 of which were also evaluated in a formal consultation performed on the same day by a hospitalist other than the one performing the curbside consultation. Based on information collected in the formal consultation, information was either inaccurate or incomplete in 24/47 (51%) of the curbside consultations. Management advice after formal consultation differed from that given in the curbside consultation for 28/47 patients (60%). When inaccurate or incomplete information was received, the advice provided in the formal versus the curbside consultation differed in 22/24 patients (92%, P < 0.0001). CONCLUSIONS: Information presented during inpatient curbside consultations of hospitalists is often inaccurate or incomplete, and this often results in inaccurate management advice.

Decreased antibiotic utilization after implementation of a guideline for inpatient cellulitis and cutaneous abscess.

BACKGROUND: Cellulitis and cutaneous abscess are among the most common infections leading to hospitalization, yet optimal management strategies have not been adequately studied. We hypothesized that implementation of an institutional guideline to standardize and streamline the evaluation and treatment of inpatient cellulitis and abscess would decrease antibiotic and health care resource utilization. METHODS: A retrospective preintervention-postintervention study was performed to compare management before and after implementation of the guideline (January 1, 2007-December 31, 2007, and July 9, 2009-July 8, 2010). RESULTS: A total of 169 patients (66 with cellulitis, 103 with abscess) were included in the baseline cohort, and 175 (82 with cellulitis, 93 with abscess) were included in the intervention cohort. The intervention led to a significant decrease in use of microbiological cultures (80% vs 66%; P = .003) and fewer requests for inpatient consultations (46% vs 30%; P = .004). The median duration of antibiotic therapy decreased from 13 days (interquartile range [IQR], 10-15 days) to 10 days (IQR, 9-12 days) (P < .001). Fewer patients received antimicrobial agents with broad aerobic gram-negative activity (66% vs 36%; P < .001), antipseudomonal activity (28% vs 18%; P = .02), or broad anaerobic activity (76% vs 49%; P < .001). Clinical failure occurred in 7.7% and 7.4% of cases (P = .93), respectively. CONCLUSION: Implementation of a guideline for the management of inpatient cellulitis and cutaneous abscess led to shorter durations of more targeted antibiotic therapy and decreased use of resources without adversely affecting clinical outcomes.

Skin and soft-tissue infections requiring hospitalization at an academic medical center: opportunities for antimicrobial stewardship.

BACKGROUND: Although complicated skin and soft-tissue infections (SSTIs) are among the most common infections requiring hospitalization, their clinical spectrum, management, and outcomes have not been well described. METHODS: We report a cohort of consecutive adult patients hospitalized for SSTI from 1 January through 31 December 2007 at an academic medical center. Cases meeting inclusion criteria were reviewed and classified as cellulitis, cutaneous abscess, or SSTI with additional complicating factors. RESULTS: In total, 322 patients were included; 66 (20%) had cellulitis, 103 (32%) had cutaneous abscess, and 153 (48%) had SSTI with additional complicating factors. Injection drug use, diabetes mellitus, and alcohol abuse were common comorbidities. Serum inflammatory markers were routinely measured and blood cultures and imaging studies were routinely performed in each group. Of 150 patients with a positive culture result for an abscess, deep tissue, or blood, Staphylococcus aureus or streptococci were identified in 145 (97%). Use of antibiotics with broad aerobic gram-negative activity (61%-80% of patients) or anaerobic activity (73%-83% of patients) was frequent in each group. The median duration of therapy for cellulitis, cutaneous abscess, and SSTI with additional complicating factors was 13 (interquartile range [IQR], 10-14), 13 (IQR, 10-16), and 14 (IQR, 11-17) days, respectively. Treatment failure, recurrence, or rehospitalization due to SSTI within 30 days occurred in 12.1%, 4.9%, and 9.2% of patients, respectively. CONCLUSIONS: Hospitalizations for SSTI were common; more than half were due to cellulitis or cutaneous abscess. Frequent use of potentially unnecessary diagnostic studies, broad-spectrum antibiotic therapy, and prolonged treatment courses in these patients suggest targets for antimicrobial stewardship programs.

Effectiveness of a course designed to teach handoffs to medical students.

INTRODUCTION: Handoffs of patient care are increasingly common and are known to contribute to medical errors. A significant number, if not the large majority, of first-year Internal Medicine residents have not received formal education pertaining to handoffs during medical school. AIM: To develop a program designed to teach handoffs to medical students entering their fourth year of training. SETTING: University of Colorado Denver School of Medicine. PROGRAM DESCRIPTION: Our Handoff Selective was first offered in April 2007 as part of a 2-week Integrated Clinician's Course conducted once yearly between the third and fourth years of medical school. The Selective consisted of a didactic session in which communication theory and elements were discussed and a practicum in which students used faculty-developed case scenarios to practice both giving and receiving handoffs. PROGRAM EVALUATION: Sixty (the maximum number of spots available) out of 150 students participated in the course, although many more students chose the course than spots available. Prior to taking the Selective, medical students' confidence in performing handoffs was poor, but it improved after the course (P < 0.001); 92% of students felt the Handoff Selective was "useful" or "extremely useful." While both components of the course were thought to be useful to the large majority of students, the practicum portion was thought to be more useful (P < 0.001). DISCUSSION: Formal education on handoffs is well received by medical students and improves their self-perceived understanding and performance of handoffs.