Development of an Emergency Department Case Management Case-Finding Tool.

PURPOSE OF STUDY: Identifying emergency department (ED) patients who are at high risk for return visits is an important goal for case management to improve patient care. This quality improvement study describes the development and evaluation of the Emergency Department Case Management Priority Score (EDCMPS), an electronic medical record (EMR)-based "case-finding" system, and its ability to identify these high-risk patients. In addition, the authors present data about its acceptability among emergency department case managers (ED CMs). PRIMARY PRACTICE SETTINGS: Emergency departments with case management availability and staffing. METHODOLOGY AND SAMPLE: A retrospective analysis at Duke University Hospital ED compared patient data pre- and postimplementation of the EDCMPS. The tool was developed using the LEAN and Plan-Do-Study-Act (PDSA) quality improvement methodologies, with ED CM participation. ED return and hospitalization rates within 7 and 30 days between both methods were compared, and a survey evaluated CM satisfaction with the EDCMPS. RESULTS: The 2-month preintervention period (July 1, 2022, to August 31, 2022) included 8,677 patients discharged from the ED, with 897 patients (10.3%) identified as at high risk for return based on the previous manual methodology. In the 3-month postintervention period (September 1, 2022, to November 30, 2022), there were 13,566 patients discharged, with 692 patients (5.1%) identified as at high risk for return using the EDCMPS. The EDCMPS outperformed the manual method, yielding a significantly higher odds ratio (OR) for 7- and 30-day ED return or hospitalization (e.g., 30-day any return OR = 4.21 vs. 1.69). The survey showed broad ED CM agreement on the tool's superior performance, especially in organizing outpatient resources and referring to support programs. However, challenges in securing primary care follow-up, housing, and health insurance applications were identified. The tool's collaborative development approach ensured its fit to ED CM needs, contributing to its success. IMPLICATIONS FOR CASE MANAGEMENT PRACTICE: The EDCMPS showcases promise in enhancing ED CM efficiency, with strong frontline staff endorsement. It pinpoints areas needing focus for patient support and has the potential to reduce ED revisits and therefore health care utilization. Its methodology offers insights for similar future implementations in health care institutions.

X + Y = Time for QI: Meaningful Engagement of Residents in Quality Improvement During the Ambulatory Block.

BACKGROUND: Meaningful resident engagement in quality improvement (QI) remains challenging. Barriers include a lack of time and of faculty with QI expertise. We leveraged our internal medicine (IM) residency program's adoption of an "X" (inpatient rotations) plus "Y" (ambulatory block) schedule to implement a QI curriculum for all residents during their ambulatory block. OBJECTIVE: We sought to engage residents in interprofessional QI, improve residents' QI confidence and knowledge and application to practice, and create opportunities for QI scholarship. METHODS: In July 2015, the program provided dedicated time for QI in the ambulatory block. All categorical IM residents and 11 voluntary faculty mentors were divided into 10 teams based on clinic site and "Y" block schedule. Teams participated in resident-led, interprofessional ambulatory QI projects. Resident QI knowledge and confidence were assessed before the curriculum and 11 months after using the Quality Improvement Knowledge Application Tool-Revised (QIKAT-R) and surveys. QI project implementation and scholarship were tracked. RESULTS: All categorical residents (N = 81) participated. Residents reported increased confidence in all QI skills, and they demonstrated increased knowledge, with mean QIKAT-R paired scores improving from 15.8 ± 4.6 to 19.1 ± 5.9 (n = 45 pairs, P < .001). A total of 9 of 10 teams implemented process changes, and 6 team project improvements have been sustained. CONCLUSIONS: This ongoing curriculum engaged IM and IM-psychiatry residents in QI during their ambulatory block using volunteer clinic faculty mentors. Residents demonstrated improved QI confidence and knowledge. The majority of resident projects were sustained and generated scholarship.

HEART Failure? Episodes of Missed Major Cardiac Events When Applying the HEART Pathway to an Observation Unit Population.

OBJECTIVE: The HEART Pathway risk prediction tool (HEART score plus serial troponin measures at 0 and 3 hours post-presentation) is used to identify low-risk patients with chest pain who may qualify for safe, early discharge. We calculated the percentage of patients in our observation unit that qualified as low risk using HEART Pathway, as well as their associated outcomes. METHODS: We retrospectively reviewed charts on 966 consecutive patients admitted to our observation unit for chest pain (January 2015 to February 2016); HEART Pathway scores were retrospectively calculated and serial cardiac troponin values logged. The primary outcome was 42-day major adverse cardiac events (MACE), including acute myocardial infarction, urgent revascularization, and all-cause death. RESULTS: The patients' mean age was 59, 42% were male, 46% white, and 68 (7.7%) had MACE. HEART Pathway defined 384 patients as low risk (39.8%) and eligible for early discharge. Applying HEART Pathway would have missed 1.2% of patients with MACE; however, all adverse cardiac events occurred in patients with a HEART Pathway score of 3 (4 of 193, 2.1%) and none in those with a HEART Pathway score ≤2 (0 of 134). CONCLUSIONS: While the HEART Pathway identifies a pooled population at low risk for MACE, risk is not homogenous within this population. Patients with a score of 3 may have higher risk of 42-day MACE that may be unacceptable to some providers, while scores ≤2 saw no events. Caution is advised for those with HEART Pathway score of 3 until more data is available to accurately estimate risk.

Development assistance for health: what criteria do multi- and bilateral funders use?

After years of unprecedented growth in development assistance for health (DAH), the system is challenged on several fronts: by the economic downturn and stagnation of DAH, by the epidemiological transition and increase in non-communicable diseases, and by the economic transition and rise of the middle-income countries. This raises questions about which countries should receive DAH and how much, and, fundamentally, what criteria that promote fair and effective allocation. Yet, no broad comparative assessment exists of the criteria used today. We reviewed the allocation criteria stated by five multilateral and nine bilateral funders of DAH. We found that several funders had only limited information about concrete criteria publicly available. Moreover, many funders not devoted to health lacked specific criteria for DAH or criteria directly related to health, and no funder had criteria directly related to inequality. National income per capita was emphasised by many funders, but the associated eligibility thresholds varied considerably. These findings and the broad overview of criteria can assist funders in critically examining and revising the criteria they use, and inform the wider debate about what the optimal criteria are.

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.

A 90-year-old patient presenting with postoperative hypotension and a new murmur: a case report.

INTRODUCTION: Hospitalists are frequently consulted on postoperative patients with hypotension. Postoperative hypotension is common and can be due to variety of causes. Systolic anterior motion of the mitral valve leading to left ventricular outflow tract obstruction is a rare cause of postoperative hypotension and can occur without prior structural heart disease. A high index of suspicion can lead to early recognition of this unique condition. CASE PRESENTATION: A 90-year-old Caucasian woman with no known structural heart abnormality was admitted to the intensive care unit with hypotension after a left hip arthroplasty revision. A transthoracic echocardiogram revealed systolic anterior motion of the mitral valve and dynamic left ventricular outflow tract obstruction as the likely cause of her hypotension. Our patient was treated with fluid resuscitation and phenylephrine with improvement in blood pressure. A repeat echocardiogram on postoperative day 5 showed resolution of the left ventricular outflow tract obstruction. Intraoperative vasodilatation and volume loss that caused underfilling of the left ventricle likely led to dynamic outflow tract obstruction in our patient. CONCLUSIONS: Hospitalists should be aware of systolic anterior motion of the mitral valve as a rare peri-operative complication in patients with or without underlying cardiac pathology as it is treated differently than other causes of peri-operative hypotension. Clinical suspicion, early recognition, and prompt treatment can improve clinical outcomes in these patients.

Interventions using electronic medical records improve follow up of infants born to hepatitis C virus infected mothers.

BACKGROUND: The American Academy of Pediatrics recommends hepatitis C virus (HCV) antibody testing for all HCV- exposed infants at age ≥ 18 months. However, many of these infants are not appropriately tested. In 2006, the pediatric infectious disease service (PIDS) at our institution implemented interventions using electronic medical records (EMR) to improve appropriate HCV testing for HCV-exposed infants. METHODS: Two-part study: During the first period (January 1, 1993, to December 31, 2005), medical records of all infants born to mothers with HCV were retrospectively reviewed for patient's demographics and infant's HCV testing. PIDS interventions included contacting the primary care physician through EMR requesting HCV testing for children without proper testing. During the second period (January 1, 2006, to December 31, 2011), interventions using EMR were implemented prospectively, including PIDS consultations during birth hospitalization for all HCV-exposed infants, addition of HCV exposure to the EMR problem list and communication with PCPs via the EMR to assure appropriate HCV testing. RESULTS: About 67,112 infants were born during the study period; 280 had maternal HCV infection and 193 continued to receive medical care at our institution. PIDS interventions using EMR resulted in a significant improvement of appropriate HCV testing among HCV-exposed infants from 8% (10/121) to 50% (36/72); P <0.0001. It also resulted in the identification of 5 new HCV-infected children; 3 of them were born before 2006 and previously undiagnosed. CONCLUSIONS: Interventions using EMR improved the identification and appropriate HCV follow up of infants born to HCV-infected mothers.

Risk factors and outcomes associated with surgical site infections after craniotomy or craniectomy.

OBJECT: Many studies that have evaluated surgical site infections (SSIs) after craniotomy or craniectomy (CRANI) did not use robust methods to assess risk factors for SSIs or outcomes associated with SSIs. The authors conducted the current study to identify risk factors for SSIs after CRANI procedures and to evaluate outcomes attributed to SSIs. METHODS: The authors performed a nested case-control study of patients undergoing CRANI procedures between 2006 and 2010 at the University of Iowa Hospitals and Clinics. They identified 104 patients with SSIs and selected 312 controls. They collected data from medical records and used multivariate analyses to identify risk factors and outcomes associated with SSIs. RESULTS: Thirty-two percent of SSIs were caused by Staphylococcus aureus, 88% were deep incisional or organ space infections, and 70% were identified after discharge. Preoperative length of stay (LOS) ≥ 1 day was the only significant patient-related factor in the preoperative model (OR 2.1 [95% CI 1.2-3.4]) and in the overall model (OR 1.9 [95% CI 1.1-3.3]). Procedure-related risk factors that were significant in the overall model included Gliadel wafer use (OR 6.7 [95% CI 2.5-18.2]) and postoperative CSF leak (OR 3.5 [95% CI 1.4-8.5]). The preoperative SSI risk index, including body mass index, previous brain operation, chemotherapy on admission, preoperative LOS, procedure reason, and preoperative glucose level, had better predictive efficacy (c-statistic = 0.664) than the National Healthcare Safety Network risk index (c-statistic = 0.547; p = 0.004). Surgical site infections were associated with increased LOS during the initial hospitalizations (average increase of 50%) or readmissions (average increase of 100%) and with an increased risk of readmissions (OR 7.7 [95% CI 4.0-14.9]), reoperations (OR 36 [95% CI 14.9-87]), and death (OR 3.4 [95% CI 1.5-7.4]). CONCLUSIONS: Surgeons were able to prospectively assess a patient's risk of SSI based on preoperative risk factors and they could modify some processes of care to lower the risk of SSI. Surgical site infections substantially worsened patients' outcomes. Preventing SSIs after CRANI could improve patient outcomes and decrease health care utilization.

Hospital costs associated with smoking in veterans undergoing general surgery.

BACKGROUND: Approximately 30% of patients undergoing elective general surgery smoke cigarettes. The association between smoking status and hospital costs in general surgery patients is unknown. The objectives of this study were to compare total inpatient costs in current smokers, former smokers, and never smokers undergoing general surgical procedures in Veterans Affairs (VA) hospitals; and to determine whether the relationship between smoking and cost is mediated by postoperative complications. STUDY DESIGN: Patients undergoing general surgery during the period of October 1, 2005 to September 30, 2006 were identified in the VA Surgical Quality Improvement Program (VASQIP) data set. Inpatient costs were extracted from the VA Decision Support System (DSS). Relative surgical costs (incurred during index hospitalization and within 30 days of operation) for current and former smokers relative to never smokers, and possible mediators of the association between smoking status and cost were estimated using generalized linear regression models. Models were adjusted for preoperative and operative variables, accounting for clustering of costs at the hospital level. RESULTS: Of the 14,853 general surgical patients, 34% were current smokers, 39% were former smokers, and 27% were never smokers. After controlling for patient covariates, current smokers had significantly higher costs compared with never smokers: relative cost was 1.04 (95% Cl 1.00 to 1.07; p = 0.04); relative costs for former smokers did not differ significantly from those of never smokers: 1.02 (95% Cl 0.99 to 1.06; p = 0.14). The relationship between smoking and hospital costs for current smokers was partially mediated by postoperative respiratory complications. CONCLUSIONS: These findings complement emerging evidence recommending effective smoking cessation programs in general surgical patients and provide an estimate of the potential savings that could be accrued during the preoperative period.