Reducing ICU Utilization, Length of Stay, and Cost by Optimizing the Clinical Use of Continuous Monitoring System Technology in the Hospital.

BACKGROUND: Continuous monitoring system technology (CMST) aids in earlier detection of deterioration of hospitalized patients, but whether improved outcomes are sustainable is unknown. METHODS: This interrupted time series evaluation explored whether optimized clinical use of CMST was associated with sustained improvement in intensive care unit (ICU) utilization, hospital length of stay, cardiac arrest rates, code blue events, mortality, and cost across multiple adult acute care units. RESULTS: A total of 20,320 patients in the postoptimized use cohort compared with 16,781 patients in the preoptimized use cohort had a significantly reduced ICU transfer rate (1.73% vs 2.25%, P = .026) corresponding to 367.11 ICU days saved over a 2-year period, generating an estimated cost savings of more than $2.3 million. Among patients who transferred to the ICU, hospital length of stay was decreased (8.37 vs 9.64 days, P = .004). Cardiac arrest, code blue, and mortality rates did not differ significantly. CONCLUSION: Opportunities exist to promote optimized adoption and use of CMST at acute care facilities to sustainably improve clinical outcomes and reduce cost.

An Implementation Science Approach to Promote Optimal Implementation, Adoption, Use, and Spread of Continuous Clinical Monitoring System Technology.

OBJECTIVES: This study aimed to apply implementation science tenets to guide the deployment and use of in-hospital Clinical Monitoring System Technology (CMST) and to develop a toolkit to promote optimal implementation, adoption, use, and spread of CMST. METHODS: Six steps were carried out to (1) establish leadership support; (2) identify, educate, and sustain champions; (3) enlist clinical staff users to learn barriers and facilitators; (4) examine initial qualitative data from 11 clinician group interviews; (5) validate barriers/facilitators to CMST use and toolkit content; and (6) propose a toolkit to promote utilization. Clinical Monitoring System Technology output before and after implementation were compared. RESULTS: The top 3 barriers to effective CMST use were as follows: (1) inadequate education/training/support, (2) clinical workflow challenges, and (3) lack of communication. Facilitators to CMST implementation and adoption included the following: (1) providing comprehensive and consistent CMST education, (2) presenting evidence early and often, (3) tailoring device and usage expectations to individual environments, and (4) providing regular feedback about progress. Empirical data drove the development of a CMST implementation toolkit covering 6 areas: (1) why, (2) readiness, (3) readiness and implementation, (4) patient/family introduction, (5) champions, (6) care team saves, and (7) troubleshooting. Clinical Monitoring System Technology positively impacted failure to rescue events. Monthly median cardiac alert responses decreased from 30 to 3.64 minutes (87.9%), and respiratory alert responses decreased from 26 to 4.85 minutes (81.4%). CONCLUSIONS: Using implementation science tenets to concurrently guide deployment and study performance of 2 CMST devices and impact on workload was effective for both learning CMST efficacy at 2 hospital systems and developing a toolkit to promote optimal implementation, adoption, use, and spread.

Does a higher frequency of difficult patient encounters lead to lower quality care?

BACKGROUND: Difficult patient encounters in the primary care office are frequent and are associated with physician burnout. However, their relationship to patient care outcomes is not known. OBJECTIVE: To determine the effect of difficult encounters on patient health outcomes and the role of physician dissatisfaction and burnout as mediators of this effect. DESIGN: A total of 422 physicians were sorted into 3 clusters based on perceived frequency of difficult patient encounters in their practices. Patient charts were audited to assess the quality of hypertension and diabetes management and preventive care based on national guidelines. Summary measures of quality and errors were compared among the 3 physician clusters. RESULTS: Of the 1384 patients, 359 were cared for by high-cluster physicians (those who had a high frequency of difficult encounters), 871 by medium-cluster physicians, and 154 by low-cluster physicians. Dissatisfaction and burnout were higher among physicians reporting higher frequencies of difficult encounters. However, quality of patient care and management errors were similar across all 3 groups. CONCLUSIONS: Physician perception of frequent difficult encounters was not associated with worse patient care quality or more medical errors. Future studies should investigate whether other patient outcomes, including acute care and patient satisfaction, are affected by difficult encounters.

Performance on preventive cancer screening tests in the ambulatory setting by internal medicine resident physicians.

BACKGROUND: Limited information exists about the quality and determinants of ambulatory care by resident physicians. DESCRIPTION: This study investigated whether year of training and primary care versus traditional categorical status for internal medicine residents influenced preventive cancer screening rates. Ambulatory patients cared for by 143 internal medicine residents in one program over a 1-year period were assessed. Patients eligible for breast, cervical, and colorectal cancer screening were identified and test completion status was assessed. Patients who had not yet completed screening and had a visit with the resident physician were prospectively followed for subsequent test completion. Cancer screening rates, overall and among those overdue, were compared controlling for baseline patient characteristics. EVALUATION: Among 3, 729 patients, overall test completion rates for breast (72%), cervical (75%), and colorectal cancer screening (56%) did not differ by year of training or type of training (primary care vs. categorical). Among patients overdue for a screening test, no association was found by resident year of training or primary care versus categorical status: 22% vs. 12% for colorectal (p = .08), 46% versus 28% for breast (p = .69), and 24% versus 19% for cervical cancer (p = .61), respectively. CONCLUSIONS: Neither resident physician type of training nor year of training were found to be associated with cancer screening rates in the ambulatory setting. Future research should seek to identify physician factors and educational strategies to augment system-based efforts to improve the quality of outpatient care by resident physicians.

Part-time physicians...prevalent, connected, and satisfied.

OBJECTIVE: The health care workforce is evolving and part-time practice is increasing. The objective of this work is to determine the relationship between part-time status, workplace conditions, and physician outcomes. DESIGN: Minimizing error, maximizing outcome (MEMO) study surveyed generalist physicians and their patients in the upper Midwest and New York City. MEASUREMENTS AND MAIN RESULTS: Physician survey of stress, burnout, job satisfaction, work control, intent to leave, and organizational climate. Patient survey of satisfaction and trust. Responses compared by part-time and full-time physician status; 2-part regression analyses assessed outcomes associated with part-time status. Of 751 physicians contacted, 422 (56%) participated. Eighteen percent reported part-time status (n = 77, 31% of women, 8% of men, p < .001). Part-time physicians reported less burnout (p < .01), higher satisfaction (p < .001), and greater work control (p < .001) than full-time physicians. Intent to leave and assessments of organizational climate were similar between physician groups. A survey of 1,795 patients revealed no significant differences in satisfaction and trust between part-time and full-time physicians. CONCLUSIONS: Part-time is a successful practice style for physicians and their patients. If favorable outcomes influence career choice, an increased demand for part-time practice is likely to occur.

Urban outpatient views on quality and safety in primary care.

OBJECTIVE: The Minimizing Errors Maximizing Outcomes Study is designed to examine the effect of workplace conditions on quality of care and medical errors. In the first phase of the study, patients were asked to "tell their stories" via focus groups. DESIGN: Moderators used a standard question guide. Researchers read the transcripts independently and reached consensus on major themes. Two coders independently assigned transcript statement to themes. SETTING: Three focus groups were conducted in three cities, including 21 patients from three clinics. PATIENTS: Patients with previously scheduled appointments at participating clinics were invited to join the focus groups. MEASUREMENTS AND MAIN RESULTS: Agreement between the two coders was 77.5% (kappa value 0.66). All but 2% of 187 distinct comments could be grouped into four categories: (1) Systems Issues (44% of comments). Long waits for providers and lack of access were the most common frustrations. Understaffing, underfunding and lack of health insurance were perceived as contributing to poor quality of care; (2) Interpersonal Skills (37%). Physician listening skills were valued. Participants felt patient attitudes affected care. (3) Knowledge and Technical Skills (9%). (4) Errors (7%). Medication errors, errors of inattention and technical errors were discussed. CONCLUSIONS: Patients provide important insights into complex systems issues, which can guide planners in improving quality and reducing errors. According to focus group participants, healthcare could be improved and made safer by increasing timely access to patients' own physicians, decreasing the time patients spend in waiting rooms, and adding staff to double-check prescriptions.

Helping the poor emerge from "urban barbarism to civic civilization": public bathhouses in America, 1890-1915.

In an era when the luxury of private bathrooms had not yet been made widely available to the masses, local charities and municipal governments worked feverishly to construct public bathhouses. Reformers, including city officials, engineers, physicians, and members of the clergy, increased the number of public bath facilities across America from a mere six in 1894 to 49 by 1904. The urban poor took tens of millions of showers at the turn of the century as a result. What the poor may not have realized, however, is that the reformers of the Progressive Era had in mind a form of social engineering. Bathing, they argued, not only assisted in the containment of disease; it also served to instill upper-middle class values of self-respect, morality, and citizenship into the life and practice of the poor.

Constructing and dismantling frameworks of disease etiology: the rise and fall of sewer gas in America, 1870-1910.

For roughly forty years, from 1870 to 1910, Americans recognized and feared gases emanating from sewers, believing that they were responsible for causing an array of diseases. Fears of sewer gas arose from deeper anxieties toward contact with decomposing organic matter and the vapors emitted from such refuse. These anxieties were exacerbated by the construction of sewers across the country during the mid-to-late-nineteenth century, which concentrated waste emanations and connected homes to one another. The result was the birth of sewer gas and the attribution of sickness and death to it, as well as the development of a host of plumbing devices and, especially, bathroom fixtures, to combat sewer gas. The rise of the germ theory, laboratory science, and belief in disease specificity, however, transformed the threat of sewer gas, eventually replacing it (and the larger fear of miasmas) with the threat of germs. The germ theory framework, by 1910, proved more suitable than the sewer gas framework in explaining disease causation; it is this suitability that often shapes the relationship between science and society.