Outcomes of a home telemonitoring program for SARS-CoV-2 viral infection at a large academic medical center.

INTRODUCTION: Telemedicine serves as a viable option during the COVID-19 pandemic to provide in-home care, maintain home isolation precautions, reduce unnecessary healthcare exposures, and de-burden hospitals. METHODS: We created a novel telemedicine program to closely monitor patients infected with SARS-CoV-2 (COVID-19) at home. Adult patients with COVID-19 were enrolled in the program at the time of documented infection. Patients were followed by a team of providers via telephone or video visits at frequent intervals until resolution of their acute illness. Additionally, patients were stratified into high-risk and low-risk categories based on demographics and underlying comorbidities. The primary outcome was hospitalization after enrollment in the home monitoring program, including 30 days after discharge from the program. RESULTS: Over a 3.5-month period, 1128 patients met criteria for enrollment in the home monitoring program. 30.7% were risk stratified as high risk for poor outcomes based on their comorbidities and age. Of the 1128 patients, 6.2% required hospitalization and 1.2% required ICU admission during the outcome period. Hospitalization was more frequent in patients identified as high risk (14.2% vs 2.7%, P < 0.001). DISCUSSION: Enrollment in a home monitoring program appears to be an effective and sustainable modality for the ambulatory management of COVID-19.

An Initiative to Improve 30-Day Readmission Rates Using a Transitions-of-Care Clinic Among a Mixed Urban and Rural Veteran Population.

BACKGROUND/OBJECTIVE: Hospital readmissions in the United States, especially in patients at high-risk, cost more than $17 billion annually. Although care transitions is an important area of research, data are limited regarding its efficacy, especially among rural patients. In this study, we describe a novel transitions-of-care clinic (TOCC) to reduce 30-day readmissions in a Veterans Health Administration setting that serves a high proportion of rural veterans. METHODS: In this quality improvement initiative we conducted a pre-post study evaluating clinical outcomes in adult patients at high risk for 30-day readmission (Care Assessment Needs score > 85) discharged from the Iowa City Veterans Affairs (ICVA) Health Care System from 2017 to 2020. The ICVA serves 184,000 veterans across 50 counties in eastern Iowa, western Illinois, and northern Missouri, with more than 60% of these patients residing in rural areas. We implemented a multidisciplinary TOCC to provide in-person or virtual follow-up to high-risk veterans after hospital discharge. The main purpose of this study was to assess how TOCC follow-up impacted the monthly 30-day patient readmission rate. RESULTS: The TOCC resulted in a 19.2% relative reduction in 30-day readmission rates in the 12-month postimplementation period compared to the preimplementation period (9.2% vs 11.4%, P = .04). Virtual visits were more popular than in-person visits among both urban and rural veterans. There was no difference in outcomes between these two follow-up options, and both groups had reduced readmission rates compared to non-TOCC follow-up. CONCLUSIONS: A multidisciplinary TOCC within the ICVA featuring both virtual and in-person visits reduced the 30-day readmission rate. This reduction was particularly notable among patients with congestive heart failure.

The Virtual Hospitalist: A Single-Site Implementation Bringing Hospitalist Coverage to Critical Access Hospitals.

BACKGROUND: On-site hospitalist care can improve patient care, but it is economically infeasible for small critical access hospitals (CAHs). A telemedicine "virtual hospitalist" may expand CAH capabilities at a fractional cost of an on"site provider. OBJECTIVE: To evaluate the impact of a virtual hospitalist on transfers from a CAH to outside hospitals. DESIGN, SETTING, PATIENTS: A 6-month pilot program providing "virtual hospitalist" coverage to patients at a CAH in rural Iowa. MEASUREMENTS: The primary outcome was the rate of outside transfers from the CAH Emergency Department (ED). The secondary outcomes included transfer from either the ED or the inpatient wards, daily census, length of stay, transfers after admission, virtual hospitalist time commitment, and patient and staff satisfaction. The preceding 24-week baseline was compared with 24 weeks after implementation, excluding a 2-week transition period. RESULTS: At baseline, there were 947 ED visits and 176 combined inpatient and observation encounters, compared to 930 and 176 after implementation, respectively. Outside transfers from the ED decreased from 16.6% to 10.5% (157/947 to 98/930, P < .001), and transfers at any time decreased from 17.3% to 11.9% (164/947 to 111/930, P < .001). Daily census, length of stay, and transfers after admission were unchanged. Time commitment for a virtual hospitalist was 35 minutes per patient per day. The intervention was well received by the CAH staff and patients. CONCLUSIONS: The virtual hospitalist model increased the percentage of ED patients who could safely receive their care locally. A single virtual hospitalist may be able to cover multiple CAHs simultaneously. FUNDING: Development of this project was funded through the University of Iowa Hospitalist group and the Signal Center for Health Innovations at UI Health Ventures. Virtual hospitalist clinical time was paid for by the CAH on a fractional basis of a traditional hospitalist based on projected patient volumes through analysis of baseline data. Patients were not directly billed for virtual hospitalist service but were charged for the services provided by CAH providers.

Residents' Exposure to Educational Experiences in Facilitating Hospital Discharges.

BACKGROUND: There is an incomplete understanding of the most effective approaches for motivating residents to adopt guideline-recommended practices for hospital discharges. OBJECTIVE: We evaluated internal medicine (IM) residents' exposure to educational experiences focused on facilitating hospital discharges and compared those experiences based on correlations with residents' perceived responsibility for safely transitioning patients from the hospital. METHODS: A cross-sectional, multi-center survey of IM residents at 9 US university- and community-based training programs in 2014-2015 measured exposure to 8 transitional care experiences, their perceived impact on care transitions attitudes, and the correlation between experiences and residents' perceptions of postdischarge responsibility. RESULTS: Of 817 residents surveyed, 469 (57%) responded. Teaching about care transitions on rounds was the most common educational experience reported by residents (74%, 327 of 439). Learning opportunities with postdischarge patient contact were less common (clinic visits: 32%, 142 of 439; telephone calls: 12%, 53 of 439; and home visits: 4%, 18 of 439). On a 1-10 scale (10 = highest impact), residents rated postdischarge clinic as having the highest impact on their motivation to ensure safe transitions of care (mean = 7.61). Prior experiences with a postdischarge clinic visit, home visit, or telephone call were each correlated with increased perceived responsibility for transitional care tasks (correlation coefficients 0.12 [P = .004], 0.1 [P = .012], and 0.13 [P = 001], respectively). CONCLUSIONS: IM residents learn to facilitate hospital discharges most often through direct patient care. Opportunities to interact with patients across the postdischarge continuum are uncommon, despite correlating with increased perceived responsibility for ensuring safe transitions of care.

Impact of adding additional providers to resident workload and the resident experience on a medical consultation rotation.

BACKGROUND: Excellence in Graduate Medical Education requires the right clinical environment with an appropriate workload where residents have enough patients to gain proficiency in medicine with optimal time for reflection. The Accreditation Council for Graduate Medical Education (ACGME) has focused more on work hours rather than workload; however, high resident workload has been associated with lower resident participation in education and fatigue-related errors. Recognizing the potential risks associated with high resident workload and being mindful of the costs of reducing resident workload, we sought to reduce residents' workload by adding an advanced practice provider (APP) to the surgical comanagement service (SCM) and study its effect on resident satisfaction and perceived educational value of the rotation. METHODS: In Fiscal Year (FY) 2014 and 2015, an additional faculty member was added to the SCM rotation. In FY 2014, the faculty member was a staff physician, and in FY 2015, the faculty member was an APP.. Resident workload was assessed using billing data. We measured residents' perceptions of the rotation using an anonymous electronic survey tool. We compared FY2014-2015 data to the baseline FY2013. RESULTS: The number of patients seen per resident per day decreased from 8.0(SD 3.3) in FY2013 to 5.0(SD 1.9) in FY2014 (p < 0.001) and 5.7(SD 2.0) in FY2015 (p < 0.001). A higher proportion of residents reported "just right" patient volume (64.4%, 91.7%, 96.7% in FY2013, 2014, 2015 respectively p < 0.001), meeting curricular goals (79.9%, 95.0%, 97.2%, in FY2013, 2014 and 2015 respectively p < 0.001), and overall educational value of the rotation (40.0%, 72.2%, 72.6% in FY2013, 2014, 2015 respectively, p < 0.001). CONCLUSIONS: Decreasing resident workload through adding clinical faculty (both staff physician and APPs) was associated with improvements on resident perceived educational value and clinical experience of a medical consultation rotation.

The Development and Evaluation of a Novel Instrument Assessing Residents' Discharge Summaries.

PURPOSE: To develop and determine the reliability of a novel measurement instrument assessing the quality of residents' discharge summaries. METHOD: In 2014, the authors created a discharge summary evaluation instrument based on consensus recommendations from national regulatory bodies and input from primary care providers at their institution. After a brief pilot, they used the instrument to evaluate discharge summaries written by first-year internal medicine residents (n = 24) at a single U.S. teaching hospital during the 2013-2014 academic year. They conducted a generalizability study to determine the reliability of the instrument and a series of decision studies to determine the number of discharge summaries and raters needed to achieve a reliable evaluation score. RESULTS: The generalizability study demonstrated that 37% of the variance reflected residents' ability to generate an adequate discharge summary (true score variance). The decision studies estimated that the mean score from six discharge summary reviews completed by a unique rater for each review would yield a reliability coefficient of 0.75. Because of high interrater reliability, multiple raters per discharge summary would not significantly enhance the reliability of the mean rating. CONCLUSIONS: This evaluation instrument reliably measured residents' performance writing discharge summaries. A single rating of six discharge summaries can achieve a reliable mean evaluation score. Using this instrument is feasible even for programs with a limited number of inpatient encounters and a small pool of faculty preceptors.

Internal Medicine Residents' Perceived Responsibility for Patients at Hospital Discharge: A National Survey.

BACKGROUND: Medical residents are routinely entrusted with transitions of care, yet little is known about the duration or content of their perceived responsibility for patients they discharge from the hospital. OBJECTIVE: To examine the duration and content of internal medicine residents' perceived responsibility for patients they discharge from the hospital. The secondary objective was to determine whether specific individual experiences and characteristics correlate with perceived responsibility. DESIGN: Multi-site, cross-sectional 24-question survey delivered via email or paper-based form. PARTICIPANTS: Internal medicine residents (post-graduate years 1-3) at nine university and community-based internal medicine training programs in the United States. MAIN MEASURES: Perceived responsibility for patients after discharge as measured by a previously developed single-item tool for duration of responsibility and novel domain-specific questions assessing attitudes towards specific transition of care behaviors. KEY RESULTS: Of 817 residents surveyed, 469 responded (57.4 %). One quarter of residents (26.1 %) indicated that their responsibility for patients ended at discharge, while 19.3 % reported perceived responsibility extending beyond 2 weeks. Perceived duration of responsibility did not correlate with level of training (P = 0.57), program type (P = 0.28), career path (P = 0.12), or presence of burnout (P = 0.59). The majority of residents indicated they were responsible for six of eight transitional care tasks (85.1-99.3 % strongly agree or agree). Approximately half of residents (57 %) indicated that it was their responsibility to directly contact patients' primary care providers at discharge. and 21.6 % indicated that it was their responsibility to ensure that patients attended their follow-up appointments. CONCLUSIONS: Internal medicine residents demonstrate variability in perceived duration of responsibility for recently discharged patients. Neither the duration nor the content of residents' perceived responsibility was consistently associated with level of training, program type, career path, or burnout, suggesting there may be unmeasured factors such as professional role modeling that shape these perceptions.

The effects of advanced age on primary total knee arthroplasty: a meta-analysis and systematic review.

BACKGROUND: Total knee arthroplasty is an effective treatment when nonsurgical treatments fail, but it is associated with risk of complications which may be increased in advanced age. The purpose of this study was to quantify age-related differences in perioperative morbidity and mortality after total knee arthroplasty through systematic review of existing literature. METHODS: PubMed, the Cochrane database of systematic reviews, Scopus, and clinicaltrials.gov, were queried for relevant studies that compared primary total knee arthroplasty outcomes of mortality, myocardial infarction (MI), deep vein thrombosis (DVT), pulmonary embolism (PE) and functional status, of geriatric patients (>75 years old) with a younger control group (<65 years old). Pertinent journals and reference lists were hand searched. Eligibility criteria included all articles except case reports, meta-analyses, and systematic reviews. Two authors independently extracted data from each paper. Article quality was assessed using the Newcastle-Ottawa Scale. RESULTS: Twenty-two studies were included. Geriatric patients had higher rates of mortality, MI, DVT, and length of stay in older compared to younger patients, however the absolute magnitude of these increases were small. The increase in mortality may have reflected decreased life expectancy in the geriatric populations as opposed to mortality specifically due perioperative risk. There were no differences in PE incidence and improvement in pain and functional status was equal in older and younger patients. Existing studies were limited by non-randomized patient selection, as well as variation in definitions and methodology. CONCLUSIONS: Existing data supports offering primary total knee arthroplasty to select geriatric patients, although the risk of complications may be increased. Much of the data was of poor quality. Future prospective studies are needed to better identify risks and benefits of total knee arthroplasty so that patients and surgeons can make informed decisions.

Impact of an Overnight Internal Medicine Academic Hospitalist Program on Patient Outcomes.

BACKGROUND: Many academic hospitals have implemented overnight hospitalists to supervise house staff and improve outcomes, but few studies have described the impact of this role. OBJECTIVE: To investigate the effect of an overnight academic hospitalist program on patient-level outcomes. Secondary objectives were to describe the program's revenue generation and work tasks. DESIGN: Retrospective interrupted time-series analysis of patients admitted to the medicine service before and after implementation of the program. PARTICIPANTS: All patients aged 18 and older admitted to the acute or intermediate care units between 7:00 p.m. and 6:59 a.m. during the period before (April 2011-August 2012) and after (September 2012-April 2014) program implementation. INTERVENTION: An on-site attending-level physician directly supervising medicine house staff overnight, providing clinical care during high-volume periods, and ensuring safe handoffs to daytime providers. MAIN MEASURES: Primary outcomes included in-hospital mortality, 30-day hospital readmissions, length of stay, and upgrades in care on the night of admission and during hospitalization. Multivariable models estimated the effect on outcomes after adjusting for secular trends. Revenue generation and work tasks are reported descriptively. KEY RESULTS: During the study period, 6484 patients were admitted to the medicine service: 2722 (42 %) before and 3762 (58 %) after implementation. No differences were found in mortality (1.1 % vs. 0.9 %, p=0.38), 30-day readmissions (14.8 % vs. 15.6 %, p=0.39), mean length of stay (3.09 vs. 3.08 days, p=0.86), or upgrades to intensive care on the night of admission (0.4 % vs. 0.7 %, p=0.11) or during hospitalization (3.5 % vs. 4.2 %, p=0.20). During the first year, hospitalists billed 1209 patient encounters (3.3/shift) and 63 procedures (0.2/shift), and supervised 1939 patient admissions (6.12/shift) while supervising house staff 3-h/shifts. CONCLUSIONS: Implementation of an overnight academic hospitalist program showed no impact on several important clinical outcomes, and revenue generation was modest. As overnight hospitalist programs develop, investigations are needed to delineate the return on investment and focus on other outcomes that may be more sensitive to change, such as errors and provider/patient satisfaction.

Comparing Resident Self-Report to Chart Audits for Quality Improvement Projects: Accurate Reflection or Cherry-Picking?

BACKGROUND: Resident engagement in quality improvement is a requirement for graduate medical education, but the optimal means of instruction and evaluation of resident progress remain unknown. OBJECTIVE: To determine the accuracy of self-reported chart audits in measuring resident adherence to primary care clinical practice guidelines. METHODS: During the 2010-2011 academic year, second- and third-year internal medicine residents at a single, university hospital-based program performed chart audits on 10 patients from their primary care clinic to determine adherence to 16 US Preventive Services Task Force primary care guidelines. We compared residents' responses to independent audits of randomly selected patient charts by a single external reviewer. RESULTS: Self-reported data were collected by 18 second-year and 15 third-year residents for 330 patients. Independently, 70 patient charts were randomly selected for review by an external auditor. Overall guideline compliance was significantly higher on self-reported audits compared to external audits (82% versus 68%, P < .001). Of 16 guidelines, external audits found significantly lower rates of adherence for 5 (tetanus vaccination, osteoporosis screening, colon cancer screening, cholesterol screening, and obesity screening). Chlamydia screening was more common in audited charts than in self-reported data. Although third-year residents self-reported higher guideline adherence than second-year residents (86% versus 78%, P < .001), external audits for third-year residents found lower overall adherence (64% versus 72%, P  =  .040). CONCLUSIONS: Residents' self-reported chart audits may significantly overestimate guideline adherence. Increased supervision and independent review appear necessary to accurately evaluate resident performance.

The impact of obesity on sepsis mortality: a retrospective review.

BACKGROUND: Recent sepsis guidelines have focused on the early identification and risk stratification of patients on presentation. Obesity is associated with alterations in multiple inflammatory regulators similar to changes seen in sepsis, suggesting a potential interaction between the presence of obesity and the severity of illness in sepsis. METHODS: We performed a retrospective chart review of patients admitted with a primary billing diagnosis of sepsis at a single United States university hospital from 2007 to 2010. Seven hundred and ninety-two charts were identified meeting inclusion criteria. Obesity was defined as a body mass index (BMI) ≥ 30 kg/m2. The data recorded included age, race, sex, vital signs, laboratory values, length of stay, comorbidities, weight, height, and survival to discharge. A modified APACHE II score was calculated to estimate disease severity. The primary outcome variable was inpatient mortality. RESULTS: Survivors had higher average BMI than nonsurvivors (27.6 vs. 26.3 kg/m2, p = 0.03) in unadjusted analysis. Severity of illness and comorbid conditions including cancer were similar across BMI categories. Increased incidence of diabetes mellitus type 2 was associated with increasing BMI (p < 0.01) and was associated with decreased mortality, with an odds ratio of 0.53 compared with nondiabetic patients. After adjusting for age, gender, race, severity of illness, length of stay, and comorbid conditions, the trend of decreased mortality for increased BMI was no longer statistically significant, however diabetes continued to be strongly protective (odds ratio 0.52, p = 0.03). CONCLUSIONS: This retrospective analysis suggests obesity may be protective against mortality in septic inpatients. The protective effect of obesity may be dependent on diabetes, possibly through an unidentified hormonal intermediary. Further prospective studies are necessary to elaborate the specific mechanism of this protective effect.