Nationwide survey on Japanese residents' experience with and barriers to incident reporting.

The ability of any incident reporting system to improve patient care is dependent upon robust reporting practices. However, under-reporting is still a problem worldwide. We aimed to reveal the barriers experienced while reporting an incident through a nationwide survey in Japan. We conducted a cross-sectional survey. All first- and second-year residents who took the General Medicine In-Training Examination (GM-ITE) from February to March 2021 in Japan were selected for the study. The voluntary questionnaire asked participants regarding the number of safety incidents encountered and reported within the previous year and the barriers to reporting incidents. Demographics were obtained from the GM-ITE. The answers of respondents who indicated they had never previously reported an incident (non-reporting group) were compared to those of respondents who had reported at least one incident in the previous year (reporting group). Of 5810 respondents, the vast majority indicated they had encountered at least one safety incident in the past year (n = 4449, 76.5%). However, only 2724 (46.9%) had submitted an incident report. Under-reporting (more safety incidents compared to the number of reports) was evident in 1523 (26.2%) respondents. The most frequently mentioned barrier to reporting an incident was the time required to file the report (n = 2622, 45.1%). The barriers to incident reporting were significantly different between resident physicians who had previously reported and those who had never previously reported an incident. Our study revealed that resident physicians in Japan commonly encounter patient safety incidents but under-report them. Numerous perceived and experienced barriers to reporting remain, which should be addressed if incident reporting systems are to have an optimal impact on improving patient safety. Incident reporting is essential for improving patient safety in an institution, and this study recommends establishing appropriate interventions according to each learner's barriers for reporting.

Quantitative Results of a National Intervention to Prevent Clostridioides difficile Infection: A Pre-Post Observational Study.

Background: Clostridioides difficile infection (CDI) is on the rise. Objective: To evaluate the effect of a tiered, evidence-based intervention to prevent CDI. Design: Pre-post observational evaluation of a prospective, 12-month, national, nonrandomized, clustered quality improvement project to reduce hospital health care-associated infection. Setting: Acute care, long-term acute care, and critical access hospitals working with state partner organizations (state hospital associations and state health departments) to improve health care-associated infection prevention practices. Participants: Targeted hospitals had a high burden of CDI and another health care-associated infection. Other hospitals that did not meet these criteria volunteered to participate. Intervention: Multimodal intervention that consisted of 1) on-demand educational modules and webinars, 2) in-person meetings facilitated by state-level partners, 3) feedback and recommendations for implementation of evidence-based recommendations (including a CDI-specific guide on which interventions to implement), and 4) guided facilitation through infection prevention resources and site visits. Measurements: Pre- and postintervention CDI rates. Results: Between November 2016 and May 2018, 387 hospitals (366 of which reported CDI data) in 23 states and the District of Columbia participated in the intervention. There was a statistically significant decrease in CDI incidence over the study period, from 7.0 cases per 10 000 patient-days in the preintervention period to 5.7 cases per 10 000 patient-days in the postintervention period. However, this decrease appeared to be part of a temporal trend rather than due to the study intervention. Limitations: Commitment to and adherence with recommended infection prevention practices before and after the intervention were not assessed. The intervention period was relatively brief, and patient-level data were not available. Conclusion: Although a statistically significant decline in hospital-onset CDI was observed, this trend appears to be unrelated to the study intervention. Primary Funding Source: Centers for Disease Control and Prevention.

Engaging hospitalists in antimicrobial stewardship: Lessons from a multihospital collaborative.

Inappropriate antimicrobial use in hospitalized patients contributes to antimicrobial-resistant infections and complications. We sought to evaluate the impact, barriers, and facilitators of antimicrobial stewardship best practices in a diverse group of hospital medicine programs. This multihospital initiative included 1 community nonteaching hospital, 2 community teaching hospitals, and 2 academic medical centers participating in a collaborative with the Centers for Disease Control and Prevention and the Institute for Healthcare Improvement. We conducted multimodal physician education on best practices for antimicrobial use including: (1) enhanced antimicrobial documentation, (2) improved quality and accessibility of local clinical guidelines, and (3) a 72-hour antimicrobial "timeout." Implementation barriers included variability in physician practice styles, lack of awareness of stewardship importance, and overly broad interventions. Facilitators included engaging hospitalists, collecting real time data and providing performance feedback, and appropriately limiting the scope of interventions. In 2 hospitals, complete antimicrobial documentation in sampled medical records improved significantly (4% to 51% and 8% to 65%, P < 0.001 for each comparison). A total of 726 antimicrobial timeouts occurred at 4 hospitals, and 30% resulted in optimization or discontinuation of antimicrobials. With careful attention to key barriers and facilitators, hospitalists can successfully implement effective antimicrobial stewardship practices. Journal of Hospital Medicine 2016;11:576-580. © 2016 Society of Hospital Medicine.

Variation in practice patterns among specialties in the acute management of atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) is commonly managed by a variety of specialists. Current guidelines differ in their recommendations leading to uncertainty regarding important clinical decisions. We sought to document practice pattern variation among cardiologists, emergency physicians (EP) and hospitalists at a single academic, tertiary-care center. METHODS: A survey was created containing seven clinical scenarios of patients presenting with AF. We analyzed respondent choices regarding rate vs rhythm control, thromboembolic treatment and hospitalization strategies. Finally, we contrasted our findings with a comparable Australasian survey to provide an international reference. RESULTS: There was a 78% response rate (124 of 158), 37% hospitalists, 31.5% cardiologists, and 31.5% EP. Most respondents chose rate over rhythm control (92.2%; 95% CI, 89.1% - 94.5%) and thromboembolic treatment (67.8%; 95% CI, 63.8% - 71.7%). Compared to both hospitalists and EPs, cardiologists were more likely to choose thromboembolic treatment for new and paroxysmal AF (adjusted OR 2.38; 95% CI, 1.05 - 5.41). They were less likely to favor hospital admission across all types of AF (adjusted OR 0.36; 95% CI, 0.17 - 0.79) but thought cardiology consultation was more important (adjusted OR 1.88, 95% CI, 0.97 - 3.64). Australasian physicians were more aggressive with rhythm control for paroxysmal AF with low CHADS2 score compared to US physicians. CONCLUSIONS: Significant variation exists among specialties in the management of acute AF, likely reflecting a lack of high quality research to direct the provider. Future studies may help to standardize practice leading to decreased rates of hospitalization and overall cost.

Health care-associated infection after red blood cell transfusion: a systematic review and meta-analysis.

IMPORTANCE: The association between red blood cell (RBC) transfusion strategies and health care-associated infection is not fully understood. OBJECTIVE: To evaluate whether RBC transfusion thresholds are associated with the risk of infection and whether risk is independent of leukocyte reduction. DATA SOURCES: MEDLINE, EMBASE, Web of Science Core Collection, Cochrane Central Register of Controlled Trials, Cochrane Database of Sytematic Reviews, ClinicalTrials.gov, International Clinical Trials Registry, and the International Standard Randomized Controlled Trial Number register were searched through January 22, 2014. STUDY SELECTION: Randomized clinical trials with restrictive vs liberal RBC transfusion strategies. DATA EXTRACTION AND SYNTHESIS: Twenty-one randomized trials with 8735 patients met eligibility criteria, of which 18 trials (n = 7593 patients) contained sufficient information for meta-analyses. DerSimonian and Laird random-effects models were used to report pooled risk ratios. Absolute risks of infection were calculated using the profile likelihood random-effects method. MAIN OUTCOMES AND MEASURES: Incidence of health care-associated infection such as pneumonia, mediastinitis, wound infection, and sepsis. RESULTS: The pooled risk of all serious infections was 11.8% (95% CI, 7.0%-16.7%) in the restrictive group and 16.9% (95% CI, 8.9%-25.4%) in the liberal group. The risk ratio (RR) for the association between transfusion strategies and serious infection was 0.82 (95% CI, 0.72-0.95) with little heterogeneity (I2 = 0%; τ2 <.0001). The number needed to treat (NNT) with restrictive strategies to prevent serious infection was 38 (95% CI, 24-122). The risk of infection remained reduced with a restrictive strategy, even with leukocyte reduction (RR, 0.80 [95% CI, 0.67-0.95]). For trials with a restrictive hemoglobin threshold of <7.0 g/dL, the RR was 0.82 (95% CI, 0.70-0.97) with NNT of 20 (95% CI, 12-133). With stratification by patient type, the RR was 0.70 (95% CI, 0.54-0.91) in patients undergoing orthopedic surgery and 0.51 (95% CI, 0.28-0.95) in patients presenting with sepsis. There were no significant differences in the incidence of infection by RBC threshold for patients with cardiac disease, the critically ill, those with acute upper gastrointestinal bleeding, or for infants with low birth weight. CONCLUSIONS AND RELEVANCE: Among hospitalized patients, a restrictive RBC transfusion strategy was associated with a reduced risk of health care-associated infection compared with a liberal transfusion strategy. Implementing restrictive strategies may have the potential to lower the incidence of health care-associated infection.

Functional outcomes of general medical patients with severe sepsis.

BACKGROUND: Severe sepsis is a common cause for admission to the general medical ward. Previous work has demonstrated substantial new long-term disability in patients with severe sepsis, but the short-term functional outcomes of patients admitted to the general medical floor -- where the majority of severe sepsis is treated -- are largely unknown. METHODS: A retrospective cohort study was performed of patients initially admitted to non-ICU medical wards at a tertiary care academic medical center. Severe sepsis was confirmed by three physician reviewers, using the International Consensus Conference definition of sepsis. Baseline functional status, disposition location, and receipt of post-acute skilled care were recorded using a structured abstraction instrument. RESULTS: 3,146 discharges had severe sepsis by coding algorithm; from a random sample of 111 patients, 64 had the diagnosis of severe sepsis confirmed by reviewers. The mean age of the 64 patients was 63.5 years +/- 18.0. Prior to admission, 80% of patients lived at home and 50.8% of patients were functionally independent. Inpatient mortality was 12.5% and 37.5% of patients were discharged to a nursing facility. Of all patients in the cohort, 50.0% were discharged home, and 66.7% of patients who were functionally independent at baseline were discharged to home. CONCLUSIONS: New physical debility is a common feature of severe sepsis in patients initially cared for on the general medical floor. Debility occurs even in those with good baseline physical function. Interventions to improve the poor functional outcomes of this population are urgently needed.

Role of the hospitalist in antimicrobial stewardship: a review of work completed and description of a multisite collaborative.

BACKGROUND: Historically, antimicrobial stewardship programs have been led by infectious-disease physicians and pharmacists. With the growing presence of hospitalists in health and hospital systems, combined with their focus on quality improvement and patient safety, this emerging medical specialty has the potential to fill essential roles in antimicrobial stewardship programs. OBJECTIVE: The goal of this article was to present the reasons hospitalists are ideally positioned to fill antimicrobial-stewardship roles, a narrative review of previously reported hospitalist-led antibiotic-stewardship projects, and a description of an ongoing multisite collaborative by the Institute for Healthcare Improvement (IHI) and the Centers for Disease Control and Prevention (CDC). METHODS: A review of the published literature was performed, including an extensive review of the abstracts submitted to the Society of Hospital Medicine annual meetings. RESULTS: A number of examples of hospitalists developing and leading antimicrobial-stewardship programs are described. The details of a current multisite IHI/CDC hospitalist-focused initiative are discussed in detail. CONCLUSIONS: Hospitalists are actively involved with, and even lead, a variety of antimicrobial-stewardship programs in several different hospital systems. A large, multisite collaborative focused on hospitalist-led antimicrobial stewardship is currently in progress.

The epidemiology of acute organ system dysfunction from severe sepsis outside of the intensive care unit.

BACKGROUND: Severe sepsis is a common, costly, and complex problem, the epidemiology of which has only been well studied in the intensive care unit (ICU). However, nearly half of all patients with severe sepsis are cared for outside the ICU. OBJECTIVE: To determine rates of infection and organ system dysfunction in patients with severe sepsis admitted to non-ICU services. DESIGN: Retrospective cohort study. SETTING: A large, tertiary, academic medical center in the United States. PATIENTS: Adult patients initially admitted to non-ICU medical services from 2009 through 2010. MEASUREMENTS: All International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes were screened for severe sepsis. Three hospitalists reviewed a sample of medical records evaluating the characteristics of severe sepsis. RESULTS: Of 23,288 hospitalizations, 14% screened positive for severe sepsis. A sample of 111 cases was manually reviewed, identifying 64 cases of severe sepsis. The mean age of patients with severe sepsis was 63 years, and 39% were immunosuppressed prior to presentation. The most common site of infection was the urinary tract (41%). The most common organ system dysfunctions were cardiovascular (hypotension) and renal dysfunction occurring in 66% and 64% of patients, respectively. An increase in the number of organ systems affected was associated with an increase in mortality and eventual ICU utilization. Severe sepsis was documented by the treating clinicians in 47% of cases. CONCLUSIONS: Severe sepsis was commonly found and poorly documented on the wards at our medical center. The epidemiology and organ dysfunctions among patients with severe sepsis appear to be different from previously described ICU severe sepsis populations.