From the hospital to the streets: Bringing care to the unsheltered homeless in Los Angeles.

Homelessness is a neglected crisis throughout the United States. In Los Angeles (L.A.) County, nearly 59,000 residents are homeless, and the vast majority are unsheltered. An academic institution and L.A county's largest public hospital formed a partnership to launch a Street Medicine (SM) program. SM assists the inpatient team with discharge planning and builds rapport with the patient experiencing homelessness. After discharge, the SM team follows up and brings care to the patient on the streets, often developing a trusting relationship and establishing continuity of primary care. During a 12-month period, SM provided inpatient consults for 206 unsheltered homeless patients.

A randomized trial of a behavioral intervention to decrease hospital length of stay by decreasing bedrest.

BACKGROUND: Approximately half of hospitalized patients suffer functional decline due to spending the vast majority of their time in bed. Previous studies of early mobilization have demonstrated improvement in outcomes, but the interventions studied have been resource-intensive. We aimed to decrease the time hospital inpatients spend in bed through a pragmatic mobilization protocol. METHODS: This prospective, non-blinded, controlled clinical trial assigned inpatients to the study wards per routine clinical care in an urban teaching hospital. All subjects on intervention wards were provided with a behavioral intervention, consisting of educational handouts, by the nursing staff. Half of the intervention wards were supplied with recliner chairs in which subjects could sit. The primary outcome was hospital length of stay. The secondary outcome was the '6-Clicks' functional score. RESULTS: During a 6-month study period, 6082 patient encounters were included. The median length of stay was 84 hours (IQR 44-175 hours) in the control group, 80 hours (IQR 44-155 hours) in the group who received the behavioral intervention alone, and 88 hours (IQR 44-185 hours) in the group that received both the behavioral intervention and the recliner chair. In the multivariate analysis, neither the behavioral intervention nor the provision of a recliner chair was associated with a significant decrease in length of stay or increase in functional status as measured by the '6-Clicks' functional score. CONCLUSION: The program of educational handouts and provision of recliner chairs to discourage bed rest did not increase functional status or decrease length of stay for inpatients in a major urban academic center. Education and physical resources must be supplemented by other active interventions to reduce time spent in bed, functional decline, and length of stay. TRIAL REGISTRATION: ClinicalTrials.gov, HS-16-00804.

The effect of a resident-led quality improvement project on improving communication between hospital-based and outpatient physicians.

This article reports on a resident-led quality improvement program to improve communication between inpatient internal medicine residents and their patients' primary care physicians (PCPs). The program included education on care transitions, standardization of documentation, audit and feedback of documented PCP communication rates with public reporting of performance, rapid-cycle data analysis and improvement projects, and a financial incentive. At baseline, PCP communication was documented in 55% of patients; after implementation of the intervention, communication was documented in 89.3% (2477 of 2772) of discharges during the program period. The program was associated with a significant increase in referring PCP satisfaction with communication at hospital admission (baseline, 27.7% "satisfied" or "very satisfied"; postintervention, 58.2%; P < .01) but not at discharge (baseline, 14.9%; postintervention, 21.8%; P = .41). Residents cited the importance of PCP communication for patient care and audit and feedback of their performance as the principal drivers of their engagement in the project.

Hospitalist experiences, practice, opinions, and knowledge regarding peripherally inserted central catheters: a Michigan survey.

BACKGROUND: Peripherally inserted central catheters (PICCs) are commonly inserted during hospitalization for a variety of clinical indications. OBJECTIVE: To understand hospitalist experience, practice, knowledge, and opinions as they relate to PICCs. DESIGN AND SETTING: Web-based survey of hospitalists in 5 healthcare systems (representing a total of 10 hospitals) across Michigan. RESULTS: The overall response rate was 63% (227 hospitalists received invitations; 144 responded). Compared with central venous catheters, hospitalists felt that PICCs were safer to insert (81%) and preferred by patients (74%). Although 84% of respondents reported that placing a PICC solely to obtain venous access was appropriate, 47% also indicated that 10%-25% of PICCs inserted in their hospitals might represent inappropriate placement. Hospitalist knowledge regarding PICC-related venous thromboembolism was poor, with only 4% recognizing that PICC-tip verification was performed principally to prevent thrombosis. Furthermore, several potential practice-related concerns were identified: one-third of hospitalists indicated that they never examine PICCs for externally evident problems, such as exit-site infection; 48% responded that once inserted, they did not remove PICCs until a patient was ready for discharge; and 51% admitted that, at least once, they had "forgotten" that their patient had a PICC. CONCLUSIONS: Hospitalist experiences, practice, opinions, and knowledge related to PICCs appear to be variable. Because PICC use is growing and is often associated with complications, examining the impact of such variation is necessary. Hospitals and health systems should consider developing and implementing mechanisms to monitor PICC use and adverse events.

Changes in the amplitude and timing of the hemodynamic response associated with prepulse inhibition of acoustic startle.

Disruption of the early stages of information processing in limbic brain circuits may underlie symptoms of severe neuropsychiatric disorders. Prepulse inhibition of acoustic startle (PPI) is diminished in many of these disorders and may reflect the disruption of this CNS function. PPI is associated with brain activity in many of the same regions in humans as it is in laboratory animals, suggesting that neuroimaging studies in humans may help localize deficits that can then be elucidated in animal models. In this article, we employed a rapid presentation event-related design during continuous EPI BOLD scanning to examine hemodynamic response functions (HRFs) associated with PPI. Fourteen healthy participants listened to 100 pulse alone and 100 prepulse combined with pulse (prepulse-pulse) trials. PPI is the normalized difference in the startle response to the two trial types. Following the prepulse-pulse trials, the amplitudes of the HRFs in auditory cortices and in the anterior insula were increased, while in the cerebellum, thalamus and anterior cingulate, they were decreased, relative to the pulse alone trials. In addition, the timing of the prepulse-pulse responses was delayed in the auditory cortices, anterior insula and cerebellum. Finally, PPI measured outside the scanner was predicted by the difference in BOLD responses between trial types in the anterior insula and in the cerebellum. The results suggest that prepulse inhibition, and by extension early stages of information processing, modulate both the amplitude as well as timing of neural activity.