Virtual hospital care development and deployment: A rapid qualitative study of frontline clinicians and leaders.

BACKGROUND: Virtual hospitalist programs are rapidly growing in popularity due to worsening clinician shortages and increased pressure for flexible work options. These programs also have the potential to establish sustainable staffing models across multiple hospitals optimizing cost. We aimed to explore the current state of virtual hospitalist services at various health systems, challenges and opportunities that exist in providing virtual care, and future opportunities for these types of services. OBJECTIVES: To identify perspectives on design and implementation of virtual hospitalist programs from academic hospitalist leaders. METHODS: We conducted focus groups with United States academic hospitalist leaders. Semistructured interviews explored experiences with virtual hospitalist programs. Using rapid qualitative methods including templated summaries and matrix analysis, focus group recordings were analyzed to identify key themes. RESULTS: We conducted four focus groups with 13 participants representing nine hospital systems across six geographic regions and range of experience with virtual hospital medicine care. Thematic analysis identified three themes: (1) a broad spectrum of virtual care delivery; (2) adoption and acceptance of virtual care models followed the stages of diffusion of innovation; and (3) sustainability and scalability of programs were affected by unclear finances. CONCLUSIONS: Hospitalist leader perspectives revealed complex factors influencing virtual care adoption and implementation. Addressing concerns about care quality, financing, and training may accelerate adoption. Further research should clarify the best practices for sustainable models optimized for access, hospitalist experience, patient safety, and financial viability.

Increasing and sustaining discharges by noon - a multi-year process improvement project.

High hospital occupancy degrades emergency department performance by increasing wait times, decreasing patient satisfaction, and increasing patient morbidity and mortality. Late discharges contribute to high hospital occupancy by increasing emergency department (ED) patient length of stay (LOS). We share our experience with increasing and sustaining early discharges at a 650-bed academic medical center in the United States. Our process improvement project followed the Institute of Medicine Model for Improvement of successive Plan‒Do‒Study‒Act cycles. We implemented multiple iterative interventions over 41 months. As a result, the proportion of discharge orders before 10 am increased from 8.7% at baseline to 22.2% (p < 0.001), and the proportion of discharges by noon (DBN) increased from 9.5% to 26.8% (p < 0.001). There was no increase in balancing metrics because of our interventions. RA-LOS (Risk Adjusted Length Of Stay) decreased from 1.16 to 1.09 (p = 0.01), RA-Mortality decreased from 0.65 to 0.61 (p = 0.62) and RA-Readmissions decreased from 0.92 to 0.74 (p < 0.001). Our study provides a roadmap to large academic facilities to increase and sustain the proportion of patients discharged by noon without negatively impacting LOS, 30-day readmissions, and mortality. Continuous performance evaluation, adaptability to changing resources, multidisciplinary engagement, and institutional buy-in were crucial drivers of our success.

Effect of a Performance Feedback Dashboard on Hospitalist Laboratory Test Utilization.

BACKGROUND: Healthcare spending continues to be an area of improvement across all forms of medicine. Overtreatment or low-value care, including overutilization of laboratory testing, has an estimated annual cost of waste of $75.7-$101.2 billion annually. Providing performance feedback to hospitalists has been shown to be an effective way to encourage the practice of quality-improvement-focused medicine. There remains limited data regarding the implementation of performance feedback and direct results on hospital laboratory testing spending in the short term. OBJECTIVE: The objective of this project was to identify whether performance-based feedback on laboratory utilization between both hospitalists and resident teams results in more conservative utilization of laboratory testing. DESIGN, SETTING, PARTICIPANTS: This quality improvement project was conducted at a tertiary academic medical center, including both direct-care and house-staff teams. INTERVENTION OR EXPOSURE: A weekly performance feedback report was generated and distributed to providers detailing laboratory test utilization by all hospitalists in a ranked system, normalized by the census of patients, for 3 months. MAIN OUTCOMES AND MEASURES: The outcome measure was cumulative laboratory utilization during the intervention period compared to baseline utilization during the corresponding 3 months in the year prior and the weekly trend in laboratory utilization over 52 weeks. The aggregate laboratory utilization rate during intervention and control time periods was defined as the total number of laboratory tests ordered divided by the total number of patient encounters. Additionally, the cost difference was averaged per quarter and reported. The week-by-week trend in laboratory utilization was evaluated using a statistical process control (SPC) chart. RESULTS: We found that following intervention during January-March 2020, the cumulative complete blood count utilization rate decreased from 5.54 to 4.83 per patient encounter and the basic metabolic panels/CMP utilization rate decreased from 6.65 to 6.11 per patient encounter compared with January-March 2019. This equated to cost savings of ~$42,700 in total for the quarter. Nonrandom variation was seen on SPC charts in weekly laboratory utilization rates for common laboratory tests during the intervention period. CONCLUSIONS: We found that our intervention did result in a decrease in laboratory test utilization rates across direct-care and house-staff teams. This study lays promising groundwork for one tool that can be used to eliminate a source of hospital waste and improve the quality and efficiency of patient care.

Teaching Students to Care (Coordinate): A Randomized Controlled Trial.

INTRODUCTION: Interdisciplinary rounds are a vital part of discharge planning; however, medical students receive little training in how to contribute effectively. Many existing discharge planning curricula are either prohibitively time consuming or narrowly focused. Addressing this gap can help improve interdisciplinary care and enhance the role of medical students on inpatient teams. METHODS: We developed a 30-minute curriculum on the purpose of interdisciplinary rounds, expected presentation content, and team members' roles and conducted a randomized controlled trial among medical students on their inpatient internal medicine rotation. Outcomes were measured using pre- and post-curriculum surveys and comparison of evaluations of student participation in interdisciplinary rounds. RESULTS: Eighty-six medical students participated in the study (59 intervention, 27 control), and we received 142 presentation evaluations (91 intervention, 51 control). There was significant post-curriculum improvement in all students' understanding of and comfort presenting in interdisciplinary rounds and knowledge of team members' roles. Presentation evaluations did not show a significant difference; however, students in the intervention group were better able to answer questions about their patients, with a difference approaching statistical significance (70% vs 57%, P = 0.069). CONCLUSIONS: A brief, just-in-time curriculum improved learners' knowledge of interdisciplinary discharge rounds and showed a trend towards improvement in their ability to answer questions during rounds. Our curriculum can empower medical students to help their inpatient teams by participating in discharge rounds and can be integrated into existing curricula with minimal disruption.

The Impact of Dynamic Real-Time Feedback on Patient Satisfaction Scores.

INTRODUCTION: Providers' communication skills have a significant impact on patients' satisfaction. Improved patients' satisfaction has been positively correlated with various healthcare and financial outcomes. Patients' satisfaction in the inpatient setting is measured using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. In this study, we evaluated the impact of dynamic real-time feedback to the providers on the HCAHPS scores. METHODS: This was a randomized study conducted at our 550-bed level-1 tertiary care center. Twenty-six out of 27 hospitalists staffing our 12 medicine teams (including teams containing advanced practice providers (APPs) and house-staff teams) were randomized into intervention and control groups. Our research assistant interviewed 1110 patients over a period of 7 months and asked them the three provider communication-specific questions from the HCAHPS survey. Our intervention was a daily computer-generated email which alerted providers to their performance on HCAHPS questions (proportions of "always" responses) along with the performance of their peers and Medicare benchmarks. RESULTS: The intervention and control groups were similar with regard to baseline HCAHPS scores and clinical experience. The proportion of "always" responses to the three questions related to provider communication was statistically significantly higher in the intervention group compared to the control group (86% vs 80.5%, p-value 0.00001). It was also noted that the HCAHPS scores were overall lower on the house-staff teams and higher on the teams with APPs. CONCLUSION: Real-time patients' feedback to inpatient providers with peer comparison via email has a positive impact on the provider-specific HCAHPS scores.

The Impact of Asking Medical Students What They Want to Learn on Student Participation in Lectures.

BACKGROUND: The General Internal Medicine Acting Internship (GIM AI) at our school is a compulsory, one-month-long experience. Morning report-style case-based discussions were conducted on a weekly basis as part of the acting internship and were poorly attended. We sought to redesign our academic half day didactic curriculum and increase voluntary student attendance by allowing students to actively participate in determining the content of the acting internship academic half day. INTERVENTION: Prior to the beginning of the acting internship, students were sent an email survey listing seven inpatient topics to rank on a scale of 1-5 (1=not at all interested, 5=very interested). Based on student feedback, one additional topic was added: antibiotic use for common inpatient diagnoses. Topics that received the highest score were selected for topic-based sessions. A total of 32 teaching sessions were conducted over eight months. Twenty-four of these sessions were topic-based and the remainder were case-based. Student attendance at these sessions was voluntary. KEY RESULTS: Case-based discussions had the lowest preference ranking (n=94, mean=2.9), while cross-cover-based discussions (n=94, mean=4.3, p=0.001) and antibiotic use (n=52, mean=4.3, p=0.001) received the highest scores. Thirty-four percent (41/120) of possible learners attended case-based discussions, while 78% (281/360) of possible learners attended topic-based sessions (p<0.001). Learners reported a statistically significant improvement in comfort level in recognizing and managing 73% of sub-topics (29 out of 41) covered in topic-based sessions. CONCLUSIONS: A learner-centered approach to curriculum design led to robust student engagement in our acting internship academic half day. Fourth-year students prefer specific topic-based teaching sessions over case-based, morning report-style sessions.

Discharge When Medically Ready.

QUALITY PROBLEM: The timing and pace of patient discharges are not level-loaded throughout the day at many institutions including ours, an academic medical center and adult Level I trauma center located in Milwaukee, Wisconsin. INITIAL ASSESSMENT: Only 4% of patients were being discharged with rooms marked dirty by 11 AM at our institution. CHOISE OF SOLUTION: We put together a multidisciplinary team of approximately 30 stakeholders to develop a revised process that focused on coordination of discharge activities, plan of care awareness among team members, and communication with patients and families. IMPLEMENTATION: The discharge process was piloted and iteratively adjusted on a single medicine floor. EVALUATION: Our interventions made a noticeable impact on median room "ready to be cleaned" (RTBC) time without having an adverse impact on length of stay. RTBC improved by a median of 39 minutes (P = 0.019), and the proportion of rooms ready to be cleaned by 11 AM increased from 4.19% to 8.13%. LESSONS LEARNED: Having a multidisciplinary team participate in the evaluation and development of a new process was critical. Additionally, implementing solutions on a single unit allowed for rapid iteration of changes.

The Impact of Hospitalist Switch Day on Length of Stay.

BACKGROUND AND OBJECTIVE: Hospitalist practices around the country switch service on different days of the week. It is unclear whether switching clinical service later in the week is associated with an increase in length of stay (LOS). The aim of this study was to examine the association between service switch day for hospitalists at an academic medical center and LOS. METHODS: A single-center, cross-sectional study examined 4284 discharges from hospitalist staffed general internal medicine ward teams over a 1-year period between July 2018 and June 2019. Hospitalist service switch day changed from Tuesday to Thursday on January 1, 2019. The period between July 1, 2018, and December 31, 2018, was defined as the pre-switch time, while January 1, 2019, to June 30, 2019, was defined as the post-switch period. We calculated the LOS in days for patients discharged from hospitalist general internal medicine teams in the 2 periods. Generalized linear models were used to examine the association between attending switch day and LOS while adjusting for demographic factors, payer status, markers of severity of illness, and hospital or discharge-level confounders. RESULTS: There was no difference in mean LOS for patients discharged in the pre-switch time (6 days) period versus patients discharged in the post-switch time (6.03 days) (difference of means 0.03 days, 95% confidence interval -0.04 to 0.09, P value .37). CONCLUSIONS: Change in attending switch day from earlier in the week to later in the week is not associated with an increase in LOS. Other factors such as group preference and institutional needs should drive service switch day selection for hospitalist groups.

Location Matters: Type of Hospital Unit Can Influence Medicine Patients' Satisfaction with Physician Communication.

Payors hold hospitals accountable for patient experience using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. The objective was to determine if hospital unit (medicine versus nonmedicine [ie, cardiology, oncology, urology, physical medicine and rehabilitation, and surgery]) influences HCAHPS scores when care is given by the same providers on different units. This retrospective analysis of adult inpatient data (n = 845), included overall hospital satisfaction, staff communication, care and communication from physicians, and discharge communication. Average overall satisfaction was 8.9 out of 10 and length of stay was 4.6 days. Patients treated on nonmedicine units had higher overall satisfaction than those on medicine units (P = 0.02) and higher scores when asked how often doctors listened to the patient carefully (P = 0.002). The type of inpatient unit can influence overall satisfaction and satisfaction with physician communication. Differences in room environment, amenities, and staffing may explain why medicine patients were more satisfied on nonmedicine versus medicine units.

Creating a culture of quality: our experience with providing feedback to frontline hospitalists.

BACKGROUND: One way to provide performance feedback to hospitalists is through the use of dashboards, which deliver data based on agreed-upon standards. Despite the growing trend on feedback performance on quality metrics, there remain limited data on the means, frequency and content of feedback that should be provided to frontline hospitalists. OBJECTIVE: The objective of our research is to report our experience with a comprehensive feedback system for frontline hospitalists, as well as report the change in our quality metrics after implementation. DESIGN, SETTING AND PARTICIPANTS: This quality improvement project was conducted at a tertiary academic medical centre among our hospitalist group consisting of 46 full-time faculty members. INTERVENTION OR EXPOSURE: A monthly performance feedback report was distributed to provide ongoing feedback to our hospitalist faculty, including an individual dashboard and a peer comparison report, complemented by coaching to incorporate process improvement tactics into providers' daily workflow. MAIN OUTCOMES AND MEASURES: The main outcome of our study is the change in quality metrics after implementation of the monthly performance feedback report RESULTS: The dashboard and rank order list were sent to all faculty members every month. An improvement was seen in the following quality metrics: length of stay index, 30-day readmission rate, catheter-associated urinary tract infections, central line-associated bloodstream infections, provider component of Healthcare Consumer Assessment of Healthcare Providers and Systems scores, attendance at care coordination rounds and percentage of discharge orders placed by 10:00. CONCLUSIONS: Implementation of a monthly performance feedback report for hospitalists, complemented by peer comparison and guidance on tactics to achieve these metrics, created a culture of quality and improvement in the quality of care delivered.

Differences in length of stay by teaching team status in an academic medical center in the Midwestern United States.

Background: Given the high cost of inpatient stays, hospital systems are investigating ways to decrease lengths of stay while ensuring high-quality care. The goal of this study was to determine if patients in teaching teams (hospitalist teams with residents and interns) had a higher length of stay after adjusting for relevant confounders compared to hospitalist-only teams (staffed only by attending physicians).Methods: Using a retrospective design, we investigated differences in length of stay for 17,577 inpatient encounters over a 2-year period. Length of stay was calculated based on the time between hospital admission and hospital discharge with no removal of outliers. Encounters were assigned to teams based on the discharge provider. Teams were grouped based on whether they were teaching teams or nonteaching teams. Since the length of stay was not normally distributed, it was modeled first using generalized linear models with gamma distribution and log link, and secondly by quantile regression. Models were adjusted for age, gender, race, medicine vs. non-medicine unit, MS-DRGs, and comorbidities.Results: Using gamma models to account for the skewed nature of the data, the length of stay for encounters assigned to teaching teams was 0.56 days longer (ß = 0.10 95% CI 0.06 0.14) than for nonteaching teams after adjustment. Using quantile regression, teaching teams had encounters on average 0.63 days longer (95% CI 0.44 0.81) than nonteaching teams at the 75th percentile and 1.19 days longer (95% CI 0.77 1.61) compared to nonteaching teams at the 90th percentile after adjustment.Conclusions: After adjusting for demographics and clinical factors, teaching teams on average had lengths of stay that were over half day longer than nonteaching teams. In addition, for the longest encounters, differences between teaching and nonteaching teams were over 1-day difference. Given these results, process improvement opportunities exist within teaching teams regarding length of stay, particularly for longer encounters.

Two-Year Experience of 14 French Pigtail Catheters Placed by Procedure-Focused Hospitalists.

BACKGROUND: Recent studies show small-bore chest tubes, commonly 14 French pigtail catheters (PCs), are noninferior to large-bore chest tubes for treating various conditions, and they are associated with better patient comfort. The Medical College of Wisconsin implemented a bedside procedure service (BPS) that has been trained in the placement of PCs as an adjunct to its interventional radiology department. METHODS: The data regarding consults for PC placement was collected by the BPS over a 2-year period. Primary outcomes reviewed were insertion-related complications (IRCs), unsuccessful attempts (UAs), and adverse outcomes (AOs) because the authors believe these represent the safety and effectiveness of the group. It was determined which services consulted the BPS for PC placement, the indications for consults, and a brief review of declined PC consults. RESULTS: Of the 124 accepted consults, the service had 3 IRCs (2.4%), 2 UAs (1.6%), and 3 AOs (2.4%). A total of 18 consults were declined. The BPS was consulted by 12 services with 8 primary reasons for PC placement. CONCLUSIONS: At high-volume, tertiary care centers, and with the support of cardiothoracic surgical and interventional radiology services, procedure-focused hospitalists can safely serve as an adjunct service for PC placement in selected hospitalized patients.

A Qualitative Exploration to Understand Hospitalists' Attitude Toward the Patient Experience Scoring System.

Patient's perception of their inpatient experience is measured by the Center for Medical Services' (CMS) administered Hospital Consumer Assessment of Healthcare Providers & Systems (HCAHPS) survey. There is scant existing literature on physicians' perceptions toward the HCAHPS scoring system. Understanding hospitalist knowledge and attitude toward the HCAHPS survey can help guide efforts to impact HCAHPS survey scores by improving the patient's perception of their hospital experience. The goal of this study is to explore hospitalists' knowledge and perspective of the physician communication domain of the HCAHPS survey at an academic medical center. Seven hospitalists at an academic medical center were interviewed for this report using a semistructured interview. Thematic analysis approach was used to analyze data. Open, line-by-line coding was performed on all 7 transcripts. Categories were derived in an inductive fashion. Categories were refined using the techniques of constant comparison and axial coding. We generated themes reflecting hospitalists' knowledge of the HCAHPS scoring system, their perception of the HCAHPS scoring system and the impact of the HCAHPS scoring system on their practice. While hospitalists acknowledged physician-patient communication is a challenging area to study, they are unlikely to embrace the feedback provided by HCAHPS surveys. There is a need to deploy tactics that provide timely and actionable feedback to providers on their bedside communication skills.

Prevalence of fatigue among postgraduate trainees in the United States and Japan.

BACKGROUND: The difference in prevalence of fatigue among postgraduate trainees between the United States and Japan is unknown. METHODS: A cross-sectional survey using Iowa Fatigue Scale was administered on postgraduate trainees in two internal medicine residency programs in New York and five postgraduate residency programs in Japan. RESULTS: Of the 393 trainees, 135 (34%) completed the survey. Seventy-seven (57%) were US trainees. Both fatigue (42% vs 81%) and severe fatigue (4% vs 19%) were more prevalent in Japan (P < .01). US trainees felt more productive during work hours but less fatigued. CONCLUSIONS: Fatigue was more prevalent among postgraduate trainees in Japan.

Self-reflection as a Tool to Increase Hospitalist Participation in Readmission Quality Improvement.

BACKGROUND: Reducing 30-day readmissions is a national priority. Although multipronged programs have been shown to reduce readmissions, the role of the individual hospitalist physician in reducing readmissions is not clear. OBJECTIVES: We evaluated the effect of physicians' self-review of their own readmission cases on the 30-day readmission rate. METHODS: Over a 1-year period, hospitalists were sent their individual readmission rates and cases on a weekly basis. They reviewed their cases and completed a data abstraction tool. In addition, a facilitator led small group discussion about common causes of readmission and ways to prevent such readmissions. RESULTS: Our preintervention readmission rate was 16.16% and postintervention was 14.99% (P = .76). Among hospitalists on duty, nearly all participated in scheduled facilitated discussions. Self-review was completed in 67% of the cases. CONCLUSIONS: A facilitated reflective practice intervention increased hospitalist participation and awareness in the mission to reduce readmissions and this intervention resulted in a nonsignificant trend in readmission reduction.

Effect of a rapid response team on patient outcomes in a community-based teaching hospital.

BACKGROUND: Rapid response teams have been adopted across hospitals to reduce the rate of inpatient cardiopulmonary arrest. Yet, data are not uniform on their effectiveness across university and community settings. OBJECTIVE: The objective of our study was to determine the impact of rapid response teams on patient outcomes in a community teaching hospital with 24/7 resident coverage. METHODS: Our retrospective chart review of preintervention-postintervention data included all patients admitted between January 2004 and April 2006. Rapid response teams were initiated in March 2005. The outcomes of interest were inpatient mortality, unexpected transfer to the intensive care unit, code blue (cardiac or pulmonary arrest) per 1000 discharges, and length of stay in the intensive care unit. RESULTS: Rapid response teams were activated 213 times during the intervention period. There was no statistically significant difference in inpatient mortality (3.13% preintervention versus 2.91% postintervention), code blue calls (3.09 versus 2.89 per 1000 discharges), or unexpected transfers of patients to the intensive care unit (15.8% versus 15.5%). CONCLUSIONS: The implementation of a rapid response team did not appear to affect overall mortality and code blue calls in a community-based hospital with 24/7 resident coverage.

Epidemiology of Clostridium difficile-associated disease (CDAD): a shift from hospital-acquired infection to long-term care facility-based infection.

BACKGROUND: Previous epidemiological studies on Clostridium-difficile-Associated Diarrhea (CDAD) have focused on hospitalized patients with nosocomial transmission. However, increasing numbers of patients with CDAD are being admitted to acute-care hospitals from long-term care facilities (LTCFs) and the local community. The purpose of our study was to study the changing epidemiological trends of CDAD patients admitted to an acute-care hospital and examine factors contributing to this shift in epidemiology. MATERIALS AND METHODS: This IRB-approved retrospective study included 400 randomly selected patients with a diagnosis of CDAD, admitted to an acute-care hospital between January, 2005 and December, 2010. CDAD was defined as ≥3 episodes of loose stools in <24 h with a positive Clostridium difficile stool toxin assay. The patients were divided into three groups: hospital-acquired CDAD, long-term care facility (LTCF)-acquired CDAD, and community-acquired CDAD. The groups were compared in terms of demographics, ICU admissions, hospital length of stay, co-morbidities, presenting complaint, and medication use. Patients who were hospitalized in the preceding 12 weeks or who had history of antibiotic use in the prior 8 weeks were excluded. RESULTS: Final analysis included 258 toxin-positive CDAD patients. Only 53 (20.6%) patients had hospital-acquired CDAD. Patients from LTCFs (n=119, 46.1%) and the community (86 patients, 33.3%) comprised 79.4% of patients. The mean age for LTCF population was significantly higher than the hospital-acquired and community-acquired CDAD groups (p<0.0001). The presenting complaint was categorized as diarrhea or non-diarrheal symptom. Other non-diarrheal symptoms included fever, abdominal pain and altered mental status. Only 15.2% of LTCF patients had diarrhea as their presenting complaint (n=18) as compared to 29.1% of patients from the community (n=25; p<0.05). Most LTCF patients (n=101, 84.8%) had non-diarrheal symptoms as their presenting complaint as compared to only 61 patients from the community (70.9%) (p<0.05). Use of proton pump inhibitor (PPI) was more frequent in LTCF patients (73%) and patients with hospital-acquired CDAD (69.8%) as compared to patients with community-acquired CDAD (43%) (p<0.05). No valid indication was found for PPI use in 24.13% of LTCF patients and 32.1% of patients with community-acquired CDAD as compared to only 12.9% of patients with hospital-acquired CDAD. CONCLUSION: These observations suggest that CDAD originated predominantly in patients from LTCFs (46.1%) and community (33.3%) rather than from hospitalized patients (20.6%). Diarrhea was the presenting complaint in LTCF patients in only 15.2% of cases. Hence, CDAD should be suspected if LTCF patients present with symptoms such as abdominal pain, fever, or altered mental status along with loose stools. Majority of the LTCF patients were found to be on PPIs, a risk factor for CDAD, with as many as 24% of these patients with no valid indication for their use.

Identifying oncological emergencies.

Prompt identification and treatment of life-threatening oncological conditions is of utmost importance and should always be included in the differential diagnosis. Oncological emergencies can have a myriad of presentations ranging from mechanical obstruction due to tumor growth to metabolic conditions due to abnormal secretions from the tumor. Notably, hematologic and infectious conditions may complicate the presentation of oncological emergencies. Advanced testing and imaging is generally required to recognize these serious presentations of common malignancies. Early diagnosis and treatment of these conditions can significantly affect the patient's clinical outcome.