Efficiency of the Japanese Hospitalist System for Patients with Urinary Tract Infection: A Propensity-matched Analysis.

Objective The hospitalist system in the United States has been considered successful in terms of the quality of care and cost effectiveness. In Japan, however, its efficacy has not yet been extensively examined. This study examined the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population using treatment of urinary tract infection as an example. Methods We analyzed 271 patients whose most resource-consuming diagnosis at admission was urinary tract infection between April 2017 and March 2019. Propensity-matched analyses were performed to compare health care economics and the quality of care between the hospitalist system and the conventional system. Results In matched pairs, care by the hospitalist system was associated with a significantly shorter length of stay than that by the conventional system. The quality of care (oral antibiotics switch rate, rate of appropriate antibiotics change based on urine or blood culture results, detection rate of urinary tract infection etiology and the number of laboratory tests) was also considered to be favorably impacted by the hospitalist system. Although not statistically significant, hospital costs tended to be lower with the hospitalist system than with the conventional system. The mortality rate and 30-day readmission were also not significantly different between the groups. Conclusion The hospitalist system had a favorable impact on the quality of care and length of stay without increasing readmission in patients with urinary tract infection. This study is further evidence of the strong potential for the positive impact of an implemented hospitalist system in Japan.

The scope of hospital medicine practice at night: a national survey of night shift hospitalists.

Introduction: Although in-person hospitalist presence, increasingly staffed by dedicated nocturnists, has become the norm overnight in the hospital, the scope of nocturnist practice and typical workload has not been defined. This study examines the clinical responsibilities and patient safety perceptions of hospitalists who work night shifts in the United States.Methods: In the fall of 2019, a cross-sectional, web-based survey was administered to physician and nurse practitioner/physician assistant (NP/PA) hospitalists who work night shifts. The questionnaire assessed night staffing structure, typical responsibilities, patient volume, perceptions of safety overnight, as well as demographic information. The survey was posted on the Society of Hospital Medicine (SHM) Hospital Medicine Exchange (HMX) Online Discussion Forum. Additionally, the survey was distributed by 'snowball method' by respondents to other night hospitalists. Responses were collected anonymously.Results: Of the 167 respondents, 157 reported working night shifts. There was at least one respondent from 32 different states. In addition to performing admissions to medicine services and covering inpatients, night hospitalists cover ICU patients, participate in RRT/Code teams and procedure teams, perform consults, participate in medical education, and take outpatient calls. Across institutions, there was a large distribution in numbers of patients covered in a night shift; however, patient volume fell into typical ranges: 5-10 admissions for physicians, 0-6 admissions for NP/PAs, and 25-75 patient cross-coverage census. When physicians perform more than five admissions per night, hospitalists were less likely to agree that they could provide safe care (88% vs. 63%, p = 0.0006).Conclusions: This is the first national study to examine the clinical responsibilities of hospitalists working overnight. Overnight responsibilities are heterogeneous across institutions. As hospitals are increasingly employing nocturnists, more research is needed to guide night staffing and optimize patient safety.

Role of Technology in Self-Assessment and Feedback Among Hospitalist Physicians: Semistructured Interviews and Thematic Analysis.

BACKGROUND: Lifelong learning is embedded in the culture of medicine, but there are limited tools currently available for many clinicians, including hospitalists, to help improve their own practice. Although there are requirements for continuing medical education, resources for learning new clinical guidelines, and developing fields aimed at facilitating peer-to-peer feedback, there is a gap in the availability of tools that enable clinicians to learn based on their own patients and clinical decisions. OBJECTIVE: The aim of this study was to explore the technologies or modifications to existing systems that could be used to benefit hospitalist physicians in pursuing self-assessment and improvement by understanding physicians' current practices and their reactions to proposed possibilities. METHODS: Semistructured interviews were conducted in two separate stages with analysis performed after each stage. In the first stage, interviews (N=12) were conducted to understand the ways in which hospitalist physicians are currently gathering feedback and assessing their practice. A thematic analysis of these interviews informed the prototype used to elicit responses in the second stage. RESULTS: Clinicians actively look for feedback that they can apply to their practice, with the majority of the feedback obtained through self-assessment. The following three themes surrounding this aspect were identified in the first round of semistructured interviews: collaboration, self-reliance, and uncertainty, each with three related subthemes. Using a wireframe, the second round of interviews led to identifying the features that are currently challenging to use or could be made available with technology. CONCLUSIONS: Based on each theme and subtheme, we provide targeted recommendations for use by relevant stakeholders such as institutions, clinicians, and technologists. Most hospitalist self-assessments occur on a rolling basis, specifically using data in electronic medical records as their primary source. Specific objective data points or subjective patient relationships lead clinicians to review their patient cases and to assess their own performance. However, current systems are not built for these analyses or for clinicians to perform self-assessment, making this a burdensome and incomplete process. Building a platform that focuses on providing and curating the information used for self-assessment could help physicians make more accurately informed changes to their own clinical practice and decision-making.

The Pediatric Hospital Medicine Core Competencies: 2020 Revision.

BACKGROUND: The Pediatric Hospital Medicine (PHM) Core Competencies define the expertise required of practitioners and provide a framework for educational activities. Since initial publication in 2010, the scope of practice for pediatric hospitalists has evolved in clinical, research, administrative, and educational arenas. OBJECTIVE: To describe the methodology utilized in the revision of The PHM Core Competencies to ensure a product reflective of current roles and expectations for pediatric hospitalists across all training pathways and practice settings. METHODS: The Society of Hospital Medicine (SHM) Pediatrics Special Interest Group supported the initiation of the revision. A diverse group of editors and authors was engaged from among members of SHM, the American Academy of Pediatrics and the Academic Pediatrics Association. Editorial roles were expanded to represent all practice settings. More than 80 individuals contributed, representing both university and community sites, and all US geographic regions. Editors conducted a two-part needs assessment; a survey related to content was distributed to the PHM community and content from recent conferences and PHM related publications was reviewed. The final compendium consists of 4 sections and 66 chapters, including 12 new chapters and 36 chapters with substantial changes. Individual chapters and the entire compendium underwent rigorous internal and external review. CONCLUSION: The PHM Core Competencies: 2020 Revision reflects the work of a broad spectrum of PHM practitioners responding to the practice and educational changes in PHM over the past decade. The compendium can inform education, training, and career development for pediatric hospitalists practicing now and in coming years.

Patient Safety Initiative Using Peer Observations and Feedback Inspire Collegial Workplace Culture.

Following Joint Commission recommendations for standardizing patient handoffs, direct peer observations and feedback were utilized in order to improve patient safety related to transitions of care in the Division of Pediatric Hospital Medicine at Kapi'olani Medical Center for Women & Children. All hospitalist attendings were trained in an evidence-based handoff bundle inclusive of team communication and feedback strategies. For the initial project, each hospitalist performed 12 peer observations and feedback sessions using validated tools for verbal and written handoffs over 6 months. For a subsequent "refresher" project, each hospitalist performed 6 handoff observations. Attendings were surveyed several times before, during, and after completion of the multiple iterations of the project. A qualitative interview was conducted 6 years after the initial handoff project. In total, 204 observations were completed by 17 hospitalists during the initial project. The perceived overall quality of the patient handoff improved significantly across shifts (P < .001 for the quality of each of two critical daily handoffs) as did pediatric hospitalists' confidence in providing peer feedback (P < .001). Downstream effects of this activity led to additional benefits towards the cohesive growth of the division. Themes from post-project qualitative interviews regarding the peer observation and feedback portion of the study included that it was "helpful," "collaborative," and inspired "camaraderie" that led to increased comfort and participation during future opportunities for observation and feedback. Performing direct peer observations with feedback strengthened the workplace culture, promoted growth through collaboration, and allowed acceptance and success of future projects involving peer observations and feedback.

Navigating immunosuppression in a pandemic: A guide for the dermatologist from the COVID Task Force of the Medical Dermatology Society and Society of Dermatology Hospitalists.

Dermatologists treating immune-mediated skin disease must now contend with the uncertainties associated with immunosuppressive use in the context of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Although the risk of infection with many commonly used immunosuppressive agents remains low, direct data evaluating the safety of such agents in coronavirus disease 2019 (COVID-19) are scarce. This article reviews and offers guidance based on currently available safety data and the most recent COVID-19 outcome data in patients with immune-mediated dermatologic disease. The interdisciplinary panel of experts emphasizes a stepwise, shared decision-making approach in the management of immunosuppressive therapy. The goal of this article is to help providers minimize the risk of disease flares while simultaneously minimizing the risk of iatrogenic harm during an evolving pandemic.

Collaborative patient- and family-centered care for hospitalized individuals: Best practices for hospitalist care teams.

Traditionally, hospital medicine services have been dominated by the physician and hospital team, with significant barriers to patient- and family-centered care. This article offers principles and associated strategies to reduce those barriers and guide implementation of systemically informed, collaborative, and culturally responsive patient- and family-centered care provided by hospitalist care teams, especially regarding collaborative decision-making for treatment and discharge planning. Such an approach is associated with reduced lengths of stay and hospital costs and lowered rates of medical errors and mortality. It also is linked to improved patient and family cooperation and adherence; enhanced quality of care and clinical outcomes; and increased levels of satisfaction among health care professionals, patients, and families. Such care uses resources wisely and is effective and ethical. We hope articulating and illustrating these principles and strategies will facilitate efforts to shift the health care culture from being physician-centered to truly team-, patient-, and family-centered. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Impact of an Obstetrical Hospitalist Program on the Safety Events in a Mid-Sized Obstetrical Unit.

OBJECTIVE: Because internal medicine hospitalist programs were developed to address issues in medicine such as a need to improve quality, improve efficiency, and decrease healthcare cost, obstetrical (OB) hospitalist models were developed to address needs specific to the obstetrics and gynecology field. Our objective was to compare outcomes measured by occurrence of safety events before and after implementation of an OB hospitalist program in a mid-sized OB unit. METHODS: From July 2012 to September 2014, 11 safety events occurred on the labor and delivery floor. A full-time OB hospitalist program was implemented in October 2014. RESULTS: From October 2014 to December 2016, there was 1 safety event associated with labor and delivery. CONCLUSION: It has been speculated that implementation of an OB hospitalist model would be associated with improved maternal and neonatal outcomes; our regional OB referral hospital demonstrated a statistically significant decrease in OB safety events after the OB hospitalist program implementation.

Hospitalists as Triagists: Description of the Triagist Role across Academic Medical Centers.

From the hospitalist perspective, triaging involves the evaluation of a patient for potential admission to an inpatient service. Although traditionally done by residents, many academic hospitalist groups have assumed the responsibility for triaging. We conducted a cross-sectional survey of 235 adult hospitalists at 10 academic medical centers (AMCs) to describe the similarities and differences in the triagist role and assess the activities and skills associated with the role. Eight AMCs have a defined triagist role; at the others, hospitalists supervise residents/advanced practice providers. The triagist role is generally filled by a faculty physician and shared by all hospitalists.We found significant variability in verbal communication practices (P = .02) and electronic communication practices (P < .0001) between the triagist and the current provider (eg, emergency department, clinic provider), and in the percentage of patients evaluated in person (P < .0001). Communication skills, personal efficiency, and systems knowledge are dominant themes of attributes of an effective triagist.

Clinical Guideline Highlights for the Hospitalist: Initial Management of Acute Pancreatitis in the Hospitalized Adult.

GUIDELINE TITLE: 2018 American Gastroenterological Association (AGA) Institute Guideline on Initial Management of Acute Pancreatitis RELEASE DATE: March 2018 PRIOR VERSION: Not applicable DEVELOPER: AGA Clinical Practice Guideline Committee FUNDING SOURCE: AGA Institute TARGET POPULATION: Patients within first 48-72 hours of admission with acute pancreatitis (AP).

Observing and Identifying Hospitalist Best Communication Practices in Patient Interactions.

This study identifies actual hospitalist best communication practices that optimize patient interactions in a busy hospital context. We observed and rated 36 hospitalists and 206 patient encounters using the Kalamazoo Essential Elements of Communication Checklist-Adapted (KEECC-A). We collected descriptive statistics of checklist scores and thematically analyzed fieldnotes to identify communication patterns. Results show hospitalists score highest and most frequently use three of seven KEECC-A dimensions: builds a relationship, shares information, and gathers information. We first identify exemplar behaviors and then provide statistical comparisons by professional and hospital tenure, gender, and day of rounding observed for these three dimensions. Male hospitalists scored higher than females for shares information and significant differences were found for gender between cross-sex patient-hospitalist interactions. Hospitalists early in their professional and hospital tenure received significantly lower ratings than mid-to-late career hospitalists in the three KEECC dimensions. Hospitalists observed on the first day of rounding received significantly higher ratings than those observed on a middle or last day. We offer interpretations to explain study findings and suggest interventions to help hospitalists with less-than-desirable communication skills.

Evaluation of a multifaceted approach to antimicrobial stewardship education methods for medical residents.

OBJECTIVE: Medical residents are an important group for antimicrobial stewardship programs (ASPs) to target with interventions aimed at improving antibiotic prescribing. In this study, we compared antimicrobial prescribing practices of 2 academic medical teams receiving different ASP training approaches along with a hospitalist control group. DESIGN: Retrospective cohort study comparing guideline-concordant antibiotic prescribing for 3 common infections among a family medicine (FM) resident service, an internal medicine (IM) resident service, and hospitalists. SETTING: Community teaching hospital. PARTICIPANTS: Adult patients admitted between July 1, 2016, and June 30, 2017, with a discharge diagnosis of pneumonia, cellulitis, and urinary tract infections were reviewed. METHODS: All 3 medical teams received identical baseline ASP education and daily antibiotic prescribing audit with feedback via clinical pharmacists. The FM resident service received an additional layer of targeted ASP intervention that included biweekly stewardship-focused rounds with an ASP physician and clinical pharmacist leadership. Guideline-concordant prescribing was assessed based on the institution's ASP guidelines. RESULTS: Of 1,572 patients, 295 (18.8%) were eligible for inclusion (FM, 96; IM, 69; hospitalist, 130). The percentage of patients receiving guideline-concordant antibiotic selection empirically was similar between groups for all diagnoses (FM, 87.5%; IM, 87%; hospitalist, 83.8%; P = .702). No differences were observed in appropriate definitive antibiotic selection among groups (FM, 92.4%; IM, 89.1%; hospitalist, 89.9%; P = .746). The FM resident service was more likely to prescribe a guideline-concordant duration of therapy across all diagnoses (FM, 74%; IM, 56.5%; hospitalist, 44.6%; P < .001). CONCLUSIONS: Adding dedicated stewardship-focused rounds into the graduate medical curriculum demonstrated increased guideline adherence specifically to duration of therapy recommendations.

Impact of the Hospitalist System in Japan on the Quality of Care and Healthcare Economics.

Objective The hospitalist system is considered successful with respect to the quality of care and cost effectiveness in the United States. Studies have consistently demonstrated an improved clinical efficiency with this system. In Japan, however, the efficacy of the hospitalist system has not yet been examined. As a "super-aged society", Japan has a high number of elderly patients with multiple comorbidities who may theoretically receive better care by the hospitalist system than by the conventional system. This study investigates the impact of the hospitalist system on the quality of care and healthcare economics in a Japanese population. Methods We analyzed 274 patients ≥65 years of age in whom the most resource-consuming diagnosis at admission was aspiration pneumonia over a 1-year period. We categorized patients as those managed by hospitalists and those managed by various departments (control group) and compared the groups. Propensity score matching was used to minimize selection bias. Results For matched pairs, the length of hospital stay in the hospitalist group was shorter than that in the control group. Care by the hospitalist system was associated with significantly lower hospital costs. The quality of care (rate of switching from intravenous to oral antibiotics, duration of antibiotics therapy, number of chest X-rays and blood tests during hospitalization) was also considered to be favorably impacted by the hospitalist system. There was no statistically significant difference in the mortality rate or readmission rate between the groups. Conclusion This study showed that the hospitalist system had a favorable impact on the quality of care and cost effectiveness, suggesting the potential utility of its implementation in the Japanese medical system.

Hospitalist-Operated Compression Ultrasonography: a Point-of-Care Ultrasound Study (HOCUS-POCUS).

BACKGROUND: Venous thromboembolism includes deep vein thrombosis (DVT) and pulmonary embolism. Compression ultrasonography is the most common way to evaluate DVT and is typically performed by sonographers and interpreted by radiologists. Yet there is evidence that ultrasound examinations can be safely and accurately performed by clinicians at the bedside. OBJECTIVE: To measure the operating characteristics of hospital medicine providers performing point-of-care ultrasound (POCUS) for evaluation of DVT. DESIGN: This is a prospective cohort study enrolling a convenience sample of patients. Hospital medicine providers performed POCUS for DVT and the results were compared with the corresponding formal vascular study (FVS) interpreted by radiologists. PARTICIPANTS: Hospitalized non-ICU patients at four tertiary care hospitals for whom a DVT ultrasound was ordered. MAIN MEASURES: The primary outcomes were the sensitivity, specificity, and predictive values of the POCUS compression ultrasound compared with a FVS. The secondary outcome was the elapsed time between order and the POCUS study compared with the time the FVS was ordered to when the formal radiology report was finalized. KEY RESULTS: One hundred twenty-five limbs from 73 patients were scanned. The prevalence of DVT was 6.4% (8/125). The sensitivity of POCUS for DVT was 100% (95% CI 74-100%) and specificity was 95.8% (95% CI 91-98%) with a positive predictive value of 61.5% (95% CI 35-84%) and a negative predictive value of 100% (95% CI 98-100%). The median time from order to POCUS completion was 5.8 h versus 11.5 h median time from order until the radiology report was finalized (p = 0.001). CONCLUSION: Hospital medicine providers can perform compression-only POCUS for DVT on inpatients with accuracy similar to other specialties and settings, with results available sooner than radiology. The observed prevalence of DVT was lower than expected. POCUS may be reliable in excluding DVT but further study is required to determine how to incorporate a positive POCUS DVT result into clinical practice.