Decreasing Hypoglycemia following Insulin Administration for Inpatient Hyperkalemia.

BACKGROUND: Acute hyperkalemia (serum potassium ≥ 5.1 mEq/L) is often treated with a bolus of IV insulin. This treatment may result in iatrogenic hypoglycemia (glucose < 70 mg/dl). OBJECTIVES: The aims of this study were to accurately determine the frequency of iatrogenic hypoglycemia following insulin treatment for hyperkalemia, and to develop an electronic health record (EHR) orderset to decrease the risk for iatrogenic hypoglycemia. DESIGN: This study was an observational, prospective study. SETTING: The setting for this study was a university hospital. PATIENTS: All nonobstetric adult inpatients in all acute and intensive care units were eligible. INTERVENTION: Implementation of a hyperkalemia orderset (Orderset 1.1) with glucose checks before and then one, two, four, and six hours after regular intravenous insulin administration. Based on the results from Orderset 1.1, Orderset 1.2 was developed and introduced to include weight-based dosing of insulin options, alerts identifying patients at higher risk of hypoglycemia, and tools to guide decision-making based on the preinsulin blood glucose level. MEASUREMENTS: Patient demographics, weight, diabetes history, potassium level, renal function, and glucose levels were recorded before, and then glucose levels were measured again at one, two, four, and six hours after insulin was administered. RESULTS: The iatrogenic hypoglycemia rate identified with mandatory glucose checks in Orderset 1.1 was 21%; 92% of these occurred within three hours posttreatment. Risk factors for hypoglycemia included decreased renal function (serum creatinine >2.5 mg/dl), a high dose of insulin (>0.14 units/kg), and re-treatment with blood glucose < 140 mg/dl. After the introduction of Orderset 1.2, the rate of iatrogenic hypoglycemia decreased to 10%. CONCLUSIONS: The use of an EHR orderset for treating hyperkalemia may reduce the risk of iatrogenic hypoglycemia in patients receiving insulin while still adequately lowering their potassium.

Keeping Time: Implementing Appointment-based Family-centered Rounds.

BACKGROUND: Family-centered rounds (FCRs) provide many benefits over traditional rounds, including higher patient satisfaction, and shared mental models among staff. These benefits can only be achieved when key members of the care team are present and engaged. We aimed to improve patient engagement and satisfaction with our existing bedside rounds by designing a new FCR process. METHODS: We conducted a needs assessment and formed a multidisciplinary FCR committee that identified appointment-based family-centered rounds (aFCRs) as a primary intervention. We designed, implemented, and iteratively refined an aFCR process. We tracked process metrics (rounds attendance by key participants), a balancing metric (time per patient), and outcome metrics (patient satisfaction domains) during the intervention and follow-up periods. RESULTS: After implementing aFCR, 65% of patients reported positive experience with rounds and communication. Rounds duration per patient was similar (9 versus 9.4 min). Nurse, subspecialist, and interpreter attendance on rounds was 72%, 60%, and 90%, respectively. We employed a Rounding Coordinator to complete the scheduling and communication required for successful aFCR. DISCUSSION: We successfully improved our rounding processes through the introduction of aFCR with the addition of a rounding coordinator. Our experience demonstrates one method to increase multidisciplinary team member attendance on rounds and patient satisfaction with physician communication in the inpatient setting.

Thinking Outside the Checkbox.

A 34-year-old, previously healthy Japanese man developed a dry cough. He did not have dyspnea, nasal discharge, sore throat, facial pain, nasal congestion, or postnasal drip. His symptoms persisted despite several courses of antibiotics (from different physicians), including clarithromycin, minocycline, and levofl oxacin. A chest x-ray after 2 months of symptoms and a noncontrast chest computed tomography (CT) after 4 months of symptoms were normal, and bacterial and mycobacterial sputum cultures were sterile. Treatment with salmeterol and fl uticasone was ineffective.

Letter to the Editor, The Authors Reply, "What Can Be Done to Maintain Positive Patient Experience and Improve Residents' Satisfaction?" and vStandardized Attending Rounds to Improve the Patient Experience: A Pragmatic Cluster Randomized Controlled Trial".

We thank Talrai et al. for their comments in response to our randomized controlled trial evaluating the impact of standardized rounds on patient, attending, and trainee satisfaction. We agree that many factors beyond rounding structure contribute to resident satisfaction, including those highlighted by the authors, and would enthusiastically welcome additional research in this realm.

What's the Purpose of Rounds? A Qualitative Study Examining the Perceptions of Faculty and Students.

BACKGROUND: Rounds are a critical activity on any inpatient service, but there is little literature describing the purpose of rounds from the perspective of faculty and trainees in teaching hospitals. OBJECTIVE: To evaluate and compare the perceptions of pediatric and internal medicine attendings and medical students regarding the purpose of inpatient attending rounds. METHODS: The authors conducted 10 semistructured focus groups with attendings and medical students in the spring of 2014 at 4 teaching hospitals. The protocol was approved by the institutional review boards at all institutions. The authors employed a grounded theory approach to data collection and analysis, and data were analyzed by using the constant- comparative method. Two transcripts were read and coded independently by 2 authors to generate themes. RESULTS: Forty-eight attendings and 31 medical students participated in the focus groups. We categorized 218 comments into 4 themes comprised of 16 codes representing what attendings and medical students believed to be the purpose of rounds. These themes included communication, medical education, patient care, and assessment. CONCLUSIONS: Our results highlight that rounds serve 4 purposes, including communication, medical education, patient care, and assessment. Importantly, both attendings and students agree on what they perceive to be the many purposes of rounds. Despite this, a disconnect appears to exist between what people believe are the purposes of rounds and what is happening during rounds.

Fecal Occult Blood Testing in Hospitalized Patients with Upper Gastrointestinal Bleeding.

A 47-year-old man with a history of alcohol abuse, cirrhosis, and grade II esophageal varices is admitted for treatment of alcohol withdrawal. He reports having some dark-colored stools a week prior to admission, but his stools since then have been normal in color. A repeat hemoglobin is stable, but a fecal occult blood test is positive. What should be done next?

Standardized Attending Rounds to Improve the Patient Experience: A Pragmatic Cluster Randomized Controlled Trial.

BACKGROUND: At academic medical centers, attending rounds (AR) serve to coordinate patient care and educate trainees, yet variably involve patients. OBJECTIVE: To determine the impact of standardized bedside AR on patient satisfaction with rounds. DESIGN: Cluster randomized controlled trial. SETTING: 500-bed urban, quaternary care hospital. PATIENTS: 1200 patients admitted to the medicine service. INTERVENTION: Teams in the intervention arm received training to adhere to 5 AR practices: 1) pre-rounds huddle; 2) bedside rounds; 3) nurse integration; 4) real-time order entry; 5) whiteboard updates. Control arm teams continued usual rounding practices. MEASUREMENTS: Trained observers audited rounds to assess adherence to recommended AR practices and surveyed patients following AR. The primary outcome was patient satisfaction with AR. Secondary outcomes were perceived and actual AR duration, and attending and trainee satisfaction. RESULTS: We observed 241 (70.1%) and 264 (76.7%) AR in the intervention and control arms, respectively, which included 1855 and 1903 patient rounding encounters. Using a 5-point Likert scale, patients in the intervention arm reported increased satisfaction with AR (4.49 vs 4.25; P = 0.01) and felt more cared for by their medicine team (4.54 vs 4.36; P = 0.03). Although the intervention shortened the duration of AR by 8 minutes on average (143 vs 151 minutes; P = 0.052), trainees perceived intervention AR as lasting longer and reported lower satisfaction with intervention AR. CONCLUSIONS: Medicine teams can adopt a standardized, patient-centered, time-saving rounding model that leads to increased patient satisfaction with AR and the perception that patients are more cared for by their medicine team. Journal of Hospital Medicine 2017;12:143-149.

Forging Ahead.

The approach to clinical conundrums by an expert clinician is revealed through the presentation of an actual patient's case in an approach typical of a morning report. Similarly to patient care, sequential pieces of information are provided to the clinician, who is unfamiliar with the case. The focus is on the thought processes of both the clinical team caring for the patient and the discussant. This icon represents the patient's case. Each paragraph that follows represents the discussant's thoughts.

Rounds Today: A Qualitative Study of Internal Medicine and Pediatrics Resident Perceptions.

BACKGROUND: Attending rounds is a key component of patient care and education at teaching hospitals, yet there is an absence of studies addressing trainees' perceptions of rounds. OBJECTIVE: To determine perceptions of pediatrics and internal medicine residents about the current and ideal purposes of inpatient rounds on hospitalist services. METHODS: In this multi-institutional qualitative study, the authors conducted focus groups with a purposive sample of internal medicine and pediatrics residents at 4 teaching hospitals. The constant comparative method was used to identify themes and codes. RESULTS: The study identified 4 themes: patient care, clinical education, patient/family involvement, and evaluation. Patient care included references to activities on rounds that forwarded care of the patient. Clinical education pertained to teaching/learning on rounds. Patient/family involvement encompassed comments about incorporating patients and families on rounds. Evaluation described residents demonstrating skill for attendings. CONCLUSIONS: Resident perceptions of the purposes of rounds aligned with rounding activities described by prior observational studies of rounds. The influence of time pressures and the divergent needs of participants on today's rounds placed these identified purposes in tension, and led to resident dissatisfaction in the achievement of all of them. Suboptimal congruency exists between perceived resident clinical education and specialty-specific milestones. These findings suggest a need for education of multiple stakeholders by (1) enhancing faculty teaching strategies to maximize clinical education while minimizing inefficiencies; (2) informing residents about the value of patient interactions and family-centered rounds; and (3) educating program directors in proper alignment of inpatient rotational objectives to the milestones.

Improving attending rounds: Qualitative reflections from multidisciplinary providers.

BACKGROUND: Attending rounds, the time for the attending physician and the team to discuss the team's patients, take place at teaching hospitals every day, often with little standardization. OBJECTIVE: This hypothesis-generating qualitative study sought to solicit improvement recommendations for standardizing attending rounds from the perspective of a multi-disciplinary group of providers. METHODS: Attending physicians, housestaff (residents and interns), medical students, nurses and pharmacists at an academic medical center participated in a quality improvement initiative between January and April 2013. Participants completed an individual or focus group interview or an e-mail survey with three open-ended questions: (1) What are poor or ineffective practices for attending rounds? (2) How would you change attending rounds structure and function? (3) What do you consider best practices for attending rounds? We undertook content analysis to summarize each clinical stakeholder group's improvement recommendations. RESULTS: Sixty stakeholders participated in our study including 23 attending hospitalists, 24 housestaff, 7 medical students, 2 pharmacists and 4 nurses. Key improvement recommendations included (1) performing a pre-rounds huddle, (2) planning of the visit schedule based on illness or pending discharge, (3) real-time order writing, (4) patient involvement in rounds with shared decision-making, (5) bedside nurse inclusion and (6) minimizing interruption of intern or student presentations. CONCLUSIONS: The practice improvement recommendations identified in this study will require deliberate systems changes and training to implement, and they warrant rigorous evaluation to determine their impact on the clinical and educational goals of rounds.