Analysis of Clinical Criteria for Discharge Among Patients Hospitalized for COVID-19: Development and Validation of a Risk Prediction Model.

BACKGROUND: Patients hospitalized with COVID-19 can clinically deteriorate after a period of initial stability, making optimal timing of discharge a clinical and operational challenge. OBJECTIVE: To determine risks for post-discharge readmission and death among patients hospitalized with COVID-19. DESIGN: Multicenter retrospective observational cohort study, 2020-2021, with 30-day follow-up. PARTICIPANTS: Adults admitted for care of COVID-19 respiratory disease between March 2, 2020, and February 11, 2021, to one of 180 US hospitals affiliated with the HCA Healthcare system. MAIN MEASURES: Readmission to or death at an HCA hospital within 30 days of discharge was assessed. The area under the receiver operating characteristic curve (AUC) was calculated using an internal validation set (33% of the HCA cohort), and external validation was performed using similar data from six academic centers associated with a hospital medicine research network (HOMERuN). KEY RESULTS: The final HCA cohort included 62,195 patients (mean age 61.9 years, 51.9% male), of whom 4704 (7.6%) were readmitted or died within 30 days of discharge. Independent risk factors for death or readmission included fever within 72 h of discharge; tachypnea, tachycardia, or lack of improvement in oxygen requirement in the last 24 h; lymphopenia or thrombocytopenia at the time of discharge; being ≤ 7 days since first positive test for SARS-CoV-2; HOSPITAL readmission risk score ≥ 5; and several comorbidities. Inpatient treatment with remdesivir or anticoagulation were associated with lower odds. The model's AUC for the internal validation set was 0.73 (95% CI 0.71-0.74) and 0.66 (95% CI 0.64 to 0.67) for the external validation set. CONCLUSIONS: This large retrospective study identified several factors associated with post-discharge readmission or death in models which performed with good discrimination. Patients 7 or fewer days since test positivity and who demonstrate potentially reversible risk factors may benefit from delaying discharge until those risk factors resolve.

Effect of Complementary Interventions to Redesign Care on Teamwork and Quality for Hospitalized Medical Patients : A Pragmatic Controlled Trial.

BACKGROUND: Multiple challenges impede interprofessional teamwork and the provision of high-quality care to hospitalized patients. OBJECTIVE: To evaluate the effect of interventions to redesign hospital care delivery on teamwork and patient outcomes. DESIGN: Pragmatic controlled trial. Hospitals selected 1 unit for implementation of interventions and a second to serve as a control. (ClinicalTrials.gov: NCT03745677). SETTING: Medical units at 4 U.S. hospitals. PARTICIPANTS: Health care professionals and hospitalized medical patients. INTERVENTION: Mentored implementation of unit-based physician teams, unit nurse-physician coleadership, enhanced interprofessional rounds, unit-level performance reports, and patient engagement activities. MEASUREMENTS: Primary outcomes were teamwork climate among health care professionals and adverse events experienced by patients. Secondary outcomes were length of stay (LOS), 30-day readmissions, and patient experience. Difference-in-differences (DID) analyses of patient outcomes compared intervention versus control units before and after implementation of interventions. RESULTS: Among 155 professionals who completed pre- and postintervention surveys, the median teamwork climate score was higher after than before the intervention only for nurses (n = 77) (median score, 88.0 [IQR, 77.0 to 91.0] vs. 80.0 [IQR, 70.0 to 89.0]; P = 0.022). Among 3773 patients, a greater percentage had at least 1 adverse event after compared with before the intervention on control units (change, 1.61 percentage points [95% CI, 0.01 to 3.22 percentage points]). A similar percentage of patients had at least 1 adverse event after compared with before the intervention on intervention units (change, 0.43 percentage point [CI, -1.25 to 2.12 percentage points]). A DID analysis of adverse events did not show a significant difference in change (adjusted DID, -0.92 percentage point [CI, -2.49 to 0.64 percentage point]; P = 0.25). Similarly, there were no differences in LOS, readmissions, or patient experience. LIMITATION: Adverse events occurred less frequently than anticipated, limiting statistical power. CONCLUSION: Despite improved teamwork climate among nurses, interventions to redesign care for hospitalized patients were not associated with improved patient outcomes. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Implementation of pharmacogenomics into inpatient general medicine.

Pharmacogenomics is a crucial piece of personalized medicine. Preemptive pharmacogenomic testing is only used sparsely in the inpatient setting and there are few models to date for fostering the adoption of pharmacogenomic treatment in the inpatient setting. We created a multi-institutional project in Chicago to enable the translation of pharmacogenomics into inpatient practice. We are reporting our implementation process and barriers we encountered with solutions. This study, 'Implementation of Point-of-Care Pharmacogenomic Decision Support Accounting for Minority Disparities', sought to implement pharmacogenomics into inpatient practice at three sites: The University of Chicago, Northwestern Memorial Hospital, and the University of Illinois at Chicago. This study involved enrolling African American adult patients for preemptive genotyping across a panel of actionable germline variants predicting drug response or toxicity risk. We report our approach to implementation and the barriers we encountered engaging hospitalists and general medical providers in the inpatient pharmacogenomic intervention. Our strategies included: a streamlined delivery system for pharmacogenomic information, attendance at hospital medicine section meetings, use of physician and pharmacist champions, focus on hospitalists' care and optimizing system function to fit their workflow, hand-offs, and dealing with hospitalists turnover. Our work provides insights into strategies for the initial engagement of inpatient general medicine providers that we hope will benefit other institutions seeking to implement pharmacogenomics in the inpatient setting.

Barriers to Adoption of a Secure Text Messaging System: a Qualitative Study of Practicing Clinicians.

BACKGROUND: Secure text messaging systems (STMS) offer HIPAA-compliant text messaging and mobile phone call functionalities that are more efficient than traditional paging. Although some studies associate improved provider satisfaction and healthcare delivery with STMS use, healthcare organizations continue to struggle with achieving widespread and sustained STMS adoption. OBJECTIVE: To understand the barriers to adoption of an STMS among physicians and advanced practice providers (APPs). DESIGN: We qualitatively analyzed free-text comments that clinicians (physicians and APPs) across a large healthcare organization offered on a survey about STMS perceptions. PARTICIPANTS: A total of 1110 clinicians who provided a free-text comment in response to one of four open-ended survey questions. APPROACH: Data were analyzed using a grounded theory approach and constant comparative method to characterize responses and identify themes. KEY RESULTS: The overall survey response rate was 20.5% (n = 1254). Clinicians familiar with the STMS frequently believed the STMS was unnecessary (existing tools worked well enough) and would overburden them with more communications. They were frustrated that the STMS app had to be downloaded onto their personal mobile device and that it drained their battery. Ambiguity regarding who was reachable in the app led to missed messages and drove distrust of the STMS. Clinicians saw the exclusion of other care team members (e.g., nurses) from the STMS as problematic; however, some clinicians at hospitals with expanded STMS access complained of excessive messages. Secondhand reports of several of these barriers prevented new users from downloading the app and contributed to ongoing low use. CONCLUSIONS: Clinicians are reluctant to adopt an STMS that does not offer a clear and trustworthy communication benefit to offset its potential burden and intrusiveness. Our findings can be incorporated into STMS implementation strategies that maximize active users by targeting and mitigating barriers to adoption.

Prevalence and Causes of Diagnostic Errors in Hospitalized Patients Under Investigation for COVID-19.

BACKGROUND: The COVID-19 pandemic required clinicians to care for a disease with evolving characteristics while also adhering to care changes (e.g., physical distancing practices) that might lead to diagnostic errors (DEs). OBJECTIVE: To determine the frequency of DEs and their causes among patients hospitalized under investigation (PUI) for COVID-19. DESIGN: Retrospective cohort. SETTING: Eight medical centers affiliated with the Hospital Medicine ReEngineering Network (HOMERuN). TARGET POPULATION: Adults hospitalized under investigation (PUI) for COVID-19 infection between February and July 2020. MEASUREMENTS: We randomly selected up to 8 cases per site per month for review, with each case reviewed by two clinicians to determine whether a DE (defined as a missed or delayed diagnosis) occurred, and whether any diagnostic process faults took place. We used bivariable statistics to compare patients with and without DE and multivariable models to determine which process faults or patient factors were associated with DEs. RESULTS: Two hundred and fifty-seven patient charts underwent review, of which 36 (14%) had a diagnostic error. Patients with and without DE were statistically similar in terms of socioeconomic factors, comorbidities, risk factors for COVID-19, and COVID-19 test turnaround time and eventual positivity. Most common diagnostic process faults contributing to DE were problems with clinical assessment, testing choices, history taking, and physical examination (all p < 0.01). Diagnostic process faults associated with policies and procedures related to COVID-19 were not associated with DE risk. Fourteen patients (35.9% of patients with errors and 5.4% overall) suffered harm or death due to diagnostic error. LIMITATIONS: Results are limited by available documentation and do not capture communication between providers and patients. CONCLUSION: Among PUI patients, DEs were common and not associated with pandemic-related care changes, suggesting the importance of more general diagnostic process gaps in error propagation.

Men and Women Pursue Nonlinear Career Paths, but Impacts Differ: a Cross-Sectional Study of Academic Hospitalists.

BACKGROUND: Nonlinear career paths are increasingly common. Women in academia pursuing nonlinear career paths experience negative impacts on career trajectory. No published studies have examined how pursuit of nonlinear career paths might perpetuate gender inequities within academic hospital medicine. OBJECTIVE: (1) Compare the frequency of nonlinear career paths by gender among academic hospitalists; (2) assess the perceived impact of two types of nonlinear career paths-extended leave (EL) and non-traditional work arrangements (NTWA) on hospitalists' personal lives and careers. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional descriptive survey study of adult hospitalist physicians in three academic centers within the USA. INTERVENTION: Electronic survey including closed- and open-ended items assessing respondent utilization of and experiences with nonlinear career paths. MAIN OUTCOMES AND MEASURES: (1) Associations between EL and demographic variables as well as gender differences in leave length and NTWA strategies using Fisher's exact test; 2) grounded theory qualitative analysis of open-text responses. KEY RESULTS: Compared with men, women reported taking EL more often (p = 0.035) and for longer periods (p = 0.002). Men and women reported taking NTWA at similar rates. Women reported negative impacts of EL within domains of personal life, career, well-being, and work-life integration whereas men only reported negative impacts to career. Men and women described positive impacts of NTWA across all domains. CONCLUSIONS: Women academic hospitalists reported taking EL more often than men and experienced disproportionately more adverse impacts to personal lives and careers. Surprisingly, men reported taking NTWA to address burnout and childbirth at similar rates to women. Our findings lay the groundwork for additional exploration of cultural and policy interventions, particularly improved paid leave policies.

An Intensive Intervention to Reduce Readmissions for Frequently Hospitalized Patients: the CHAMP Randomized Controlled Trial.

BACKGROUND: A small number of patients are disproportionally readmitted to hospitals. The Complex High Admission Management Program (CHAMP) was established as a multidisciplinary program to improve continuity of care and reduce readmissions for frequently hospitalized patients. OBJECTIVE: To compare hospital utilization metrics among patients enrolled in CHAMP and usual care. DESIGN: Pragmatic randomized controlled trial. PARTICIPANTS: Inclusion criteria were as follows: 3 or more, 30-day inpatient readmissions in the previous year; or 2 inpatient readmissions plus either a referral or 3 observation admissions in previous 6 months. INTERVENTIONS: Patients randomized to CHAMP were managed by an interdisciplinary team including social work, physicians, and pharmacists. The CHAMP team used comprehensive care planning and inpatient, outpatient, and community visits to address both medical and social needs. Control patients were randomized to usual care and contacted 18 months after initial identification if still eligible. MAIN MEASURES: Primary outcome was number of 30-day inpatient readmissions 180 days following enrollment. Secondary outcomes were number of hospital admissions, total hospital days, emergency department visits, and outpatient clinic visits 180 days after enrollment. KEY RESULTS: There were 75 patients enrolled in CHAMP, 76 in control. Groups were similar in demographic characteristics and baseline readmissions. At 180 days following enrollment, CHAMP patients had more inpatient 30-day readmissions [CHAMP incidence rate 1.3 (95% CI 0.9-1.8) vs. control 0.8 (95% CI 0.5-1.1), p=0.04], though both groups had fewer readmissions compared to 180 days prior to enrollment. We found no differences in secondary outcomes. CONCLUSIONS: Frequently hospitalized patients experienced reductions in utilization over time. Though most outcomes showed no difference, CHAMP was associated with higher readmissions compared to a control group, possibly due to consolidation of care at a single hospital. Future research should seek to identify subsets of patients with persistently high utilization for whom tailored interventions may be beneficial. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03097640; https://clinicaltrials.gov/ct2/show/NCT03097640.

The Effect of Reducing Intravenous Push Opioid Use on Hospital Medicine Patients' Pain Experience During Hospitalization.

OBJECTIVE: To determine the efficacy of a program to limit the use of the intravenous (IV) push route for opioids on the experience of pain by inpatients and on associated safety events. DESIGN: Retrospective cohort study. SETTING: Two inpatient general medicine floor units at an urban tertiary care academic medical center. SUBJECTS: 4,752 inpatient opioid recipients. METHODS: Patients in one unit were exposed to a multidisciplinary intervention to limit the prescription of opioids via the IV push route, with the other unit used as a control unit. The primary study outcome was the mean numeric pain score per patient during the hospital stay. Secondary measures included the hospital length of stay and postdischarge patient satisfaction. Fidelity measures included the percentage of the patient population exposed to each opioid administration route and the amount of opioid administered per route. Safety measures included patient disposition, transfer to intensive care, and incidence of naloxone administration. RESULTS: The intervention was successful in decreasing both the percentage of patients exposed to IV push opioids and the amount of opioid administered via the IV push route, but no associated changes in other study outcomes were identified. CONCLUSIONS: For the treatment of acute pain in medical inpatients, no evidence of benefit or harm was identified in relation to an increase or decrease in the use of the IV push opioid route.

Effect of COVID-19 on the implementation of a multifaceted intervention to improve teamwork and quality for hospitalized patients: a qualitative interview study.

BACKGROUND: Healthcare organizations made major adjustments to deliver care during the COVID pandemic, yet little is known about how these adjustments shaped ongoing quality and safety improvement efforts. We aimed to understand how COVID affected four U.S. hospitals' prospective implementation efforts in an ongoing quality improvement initiative, the REdesigning SystEms to Improve Teamwork and Quality for Hospitalized Patients (RESET) project, which implemented complementary interventions to redesign systems of care for medical patients. METHODS: We conducted individual semi-structured interviews with 40 healthcare professionals to determine how COVID influenced RESET implementation. We used conventional qualitative content analysis to inductively code transcripts and identify themes in MAXQDA 2020. RESULTS: We identified three overarching themes and nine sub-themes. The three themes were (1) COVID exacerbated existing problems and created new ones. (2) RESET and other quality improvement efforts were not the priority during the pandemic. (3) Fidelity of RESET implementation regressed. CONCLUSION: COVID had a profound impact on the implementation of a multifaceted intervention to improve quality and teamwork in four hospitals. Notably, COVID led to a diversion of attention and effort away from quality improvement efforts, like RESET, and sites varied in their ability to renew efforts over time. Our findings help explain how COVID adversely affected hospitals' quality improvement efforts throughout the pandemic and support the need for research to identify elements important for fostering hospital resilience.

Effect of an attending nurse on timeliness of discharge, patient satisfaction, and readmission.

AIMS: To improve the timeliness and quality of discharge for patients by creating the role of the attending nurse. BACKGROUND: Discharge time affects hospital throughput and patient satisfaction. Bedside nurses and hospitalists have competing priorities that can hinder performing timely, high-quality discharges. METHODS: This retrospective analysis evaluated the effect of an attending nurse paired with a hospital medicine physician on discharge time and quality. A total of 8329 patient discharges were eligible for the study, and propensity score matching yielded 2715 matched pairs. RESULTS: In the post-intervention matched cohort, the percentage of patients discharged before 2 PM increased from 34.4% to 45.9% (p < .01), and the median discharge time moved 48 min earlier. In the unmatched cohort, patient satisfaction with the discharge process improved on several questions. While length of stay was not affected, the 30-day readmission rate did increase from 8.9% to 10.7% (p = .02). CONCLUSION: With the new attending nurse role, we positively impacted throughput by shifting discharge times earlier in the day while improving patient satisfaction. Length of stay stayed the same but the 30-day readmission rate increased. IMPLICATIONS FOR NURSING MANAGEMENT: Our multidisciplinary approach to the problem of late discharge times led to the creation of a new role. This role made ownership of discharge tasks clear and reduced competing priorities, freeing up nurses and hospitalists to perform other care-related responsibilities without holding up discharges.

Divergent Trends in Emergency Department Presentations Amid the Novel Coronavirus Disease 2019 Pandemic in Chicago, Illinois.

Excess deaths during the coronavirus disease 2019 (COVID-19) pandemic have been largely attributed to cardiovascular disease (CVD); however, patterns in CVD hospitalizations after the first surge of the pandemic have not well-documented. Our brief report, examining trends in health care avoidance documents that CVD hospitalizations decreased in Chicago before significant burden of COVID-19 cases or deaths and normalized during the first COVID-19 surge. These data may help to inform health care systems responses in the coming months while mobilizing vaccinations to the population at large.

Technology acceptance and critical mass: Development of a consolidated model to explain the actual use of mobile health care communication tools.

OBJECTIVE: Secure mobile communication technologies are being implemented at an increasing rate across health care organizations, though providers' use of these tools can remain limited by a perceived lack of other users to communicate with. Enabling acceptance and driving provider utilization of these tools throughout an organization requires attention to the interplay between perceived peer usage (i.e. perceived critical mass) and local user needs within the social context of the care team (e.g. inpatient nursing access to the mobile app). To explain these influences, we developed and tested a consolidated model that shows how mobile health care communication technology acceptance and utilization are influenced by the moderating effects of social context on perceptions about the technology. METHODS: The theoretical model and questionnaire were derived from selected technology acceptance models and frameworks. Survey respondents (n = 1254) completed items measuring perceived critical mass, perceived usefulness, perceived ease of use, personal innovativeness in information technology, behavioral intent, and actual use of a recently implemented secure mobile communication tool. Actual use was additionally measured by logged usage data. Use group was defined as whether a hospital's nurses had access to the tool (expanded use group) or not (limited use group). RESULTS: The model accounted for 61% and 72% of the variance in intent to use the communication tool in the limited and expanded use groups, respectively, which in turn accounted for 53% and 33% of actual use. The total effects coefficient of perceived critical mass on behavioral intent was 0.57 in the limited use group (95% CI 0.51-0.63) and 0.70 in the expanded use group (95% CI 0.61-0.80). CONCLUSION: Our model fit the data well and explained the majority of variance in acceptance of the tool amongst participants. The overall influence of perceived critical mass on intent to use the tool was similarly large in both groups. However, the strength of multiple model pathways varied unexpectedly by use group, suggesting that combining sociotechnical moderators with traditional technology acceptance models may produce greater insights than traditional technology acceptance models alone. Practically, our results suggest that healthcare institutions can drive acceptance by promoting the recruitment of early adopters though liberal access policies and making these users and the technology highly visible to others.

Redesigning systems to improve teamwork and quality for hospitalized patients (RESET): study protocol evaluating the effect of mentored implementation to redesign clinical microsystems.

BACKGROUND: A number of challenges impede our ability to consistently provide high quality care to patients hospitalized with medical conditions. Teams are large, team membership continually evolves, and physicians are often spread across multiple units and floors. Moreover, patients and family members are generally poorly informed and lack opportunities to partner in decision making. Prior studies have tested interventions to redesign aspects of the care delivery system for hospitalized medical patients, but the majority have evaluated the effect of a single intervention. We believe these interventions represent complementary and mutually reinforcing components of a redesigned clinical microsystem. Our specific objective for this study is to implement a set of evidence-based complementary interventions across a range of clinical microsystems, identify factors and strategies associated with successful implementation, and evaluate the impact on quality. METHODS: The RESET project uses the Advanced and Integrated MicroSystems (AIMS) interventions. The AIMS interventions consist of 1) Unit-based Physician Teams, 2) Unit Nurse-Physician Co-leadership, 3) Enhanced Interprofessional Rounds, 4) Unit-level Performance Reports, and 5) Patient Engagement Activities. Four hospital sites were chosen to receive guidance and resources as they implement the AIMS interventions. Each study site has assembled a local leadership team, consisting of a physician and nurse, and receives mentorship from a physician and nurse with experience in leading similar interventions. Primary outcomes include teamwork climate, assessed using the Safety Attitudes Questionnaire, and adverse events using the Medicare Patient Safety Monitoring System (MPSMS). RESET uses a parallel group study design and two group pretest-posttest analyses for primary outcomes. We use a multi-method approach to collect and triangulate qualitative data collected during 3 visits to study sites. We will use cross-case comparisons to consider how site-specific contextual factors interact with the variation in the intensity and fidelity of implementation to affect teamwork and patient outcomes. DISCUSSION: The RESET study provides mentorship and resources to assist hospitals as they implement complementary and mutually reinforcing components to redesign the clinical microsystems caring for medical patients. Our findings will be of interest and directly applicable to all hospitals providing care to patients with medical conditions. TRIAL REGISTRATION: NCT03745677 . Retrospectively registered on November 19, 2018.

Impact of Real-Time Clinical Decision Support on Blood Utilization and Outcomes in Hospitalized Patients with Solid Tumor Cancer.

INTRODUCTION: Patients with cancer are frequently hospitalized, and anemia is a common complication of cancer care. Transfusion is often required and commonly occurs above guideline-supported thresholds. It was hypothesized that an educational intervention, combined with real-time clinical decision support (CDS), would reduce blood utilization among hospitalized solid tumor cancer patients without adversely affecting outcomes. METHODS: A retrospective, historical control analysis was conducted comparing transfusion utilization among hospitalized solid tumor cancer patients before and after implementation of the educational intervention and CDS. The primary outcome was receipt of red blood cell (RBC) transfusion. Secondary outcomes included total RBC transfusions per 100 inpatient-days, readmission, outpatient transfusion within seven days of discharge, inpatient mortality, and odds of transfer to the ICU. RESULTS: The odds of receiving a transfusion were significantly reduced in the postintervention cohort (odds ratio [OR] = 0.52, p = 0.005). Among patients receiving transfusion, there was no significant difference between groups in the number of RBC transfusions per 100 inpatient-days (incidence rate ratio = 0.87, p = 0.26). There were also no significant differences in readmission, outpatient transfusion within seven days of discharge, or inpatient mortality, though patients in the postintervention cohort had lower odds of ICU transfer (OR = 0.29, p = 0.04). CONCLUSION: The combined use of an educational intervention and CDS in a hospitalized solid tumor cancer patient population was associated with lower blood utilization, similar patient outcomes, and unchanged short-term outpatient transfusion requirements. Hospitals should consider similar interventions to work toward appropriate resource allocation and mitigation of transfusion-associated risk in this patient population.

Characteristics of Syncope Admissions Among Hospitals of Varying Teaching Intensity.

OBJECTIVES: Previous work suggests that hospitals' teaching status is correlated with readmission rates, cost of care, and mortality. The degree to which teaching status is associated with the management of syncope has not been studied extensively. We sought to characterize the relation between teaching status and inpatient syncope management. METHODS: We created regression models to characterize the relation between teaching status and cardiac ischemic evaluations (cardiac catheterization and/or stress test) during syncope admissions. Admissions with a primary diagnosis of syncope in Maryland and Kentucky between 2007 and 2014 were included. RESULTS: The dataset included 71,341 syncope admissions at 151 hospitals. Overall, 15% of patients had an ischemic evaluation. There was a significantly lower likelihood of an ischemic evaluation at major teaching hospitals relative to nonteaching hospitals (adjusted odds ratio 0.75, 95% confidence interval 0.71-0.79), but a higher likelihood of an ischemic evaluation at minor teaching hospitals (adjusted odds ratio 1.21, 95% confidence interval 1.16-1.25). CONCLUSIONS: By definition, the syncope admissions included were unexplained or idiopathic cases, and thus likely to be lower-risk syncope cases. Those with a known etiology are coded by the cause of syncope, as dictated by coding guidelines. It is likely that many of these ischemic evaluations represent low-value care. Financial incentives and processes of care at major teaching hospitals may be driving this trend, and efforts should be made to better understand and replicate these at minor teaching and nonteaching hospitals.

Hospitalized Patients' Knowledge of Care: a Systematic Review.

BACKGROUND: Patients' comprehension of their medical conditions is fundamental to patient-centered care. Hospitalizations present opportunities to educate patients but also challenges to patient comprehension given the complexity and rapid pace of clinical care. We conducted a systematic review of the literature to characterize the current state of inpatients' knowledge of their hospitalization, assess the methods used to determine patient comprehension, and appraise the effects of interventions on improving knowledge. METHODS: We searched MEDLINE, EMBASE, and the Cochrane Library for articles published from January 1, 1995 through December 11, 2017. Eligible studies included patients under inpatient or observation status on internal medicine, family medicine, or neurology services. We extracted study characteristics (author, year, country, study design, sample size, patient characteristics, methods, intervention, primary endpoints, results) in a standardized fashion. The quality of observational studies was assessed using the NIH Quality Assessment Tool for Observation Cohort and Cross-Sectional Studies and the quality of interventional studies was assessed using adapted EPOC criteria from the Cochrane Collaboration. RESULTS: Twenty-eight studies met the criteria for inclusion, including 17 observational studies and 11 interventional studies. Patient knowledge of all aspects of their hospitalization was poor and patients often overestimated their knowledge. Older patients and those with lower education levels were more likely to have poorer knowledge. Intervention methods varied, but generally showed improvements in patient knowledge. Few interventional studies assessed the effect on health behaviors or outcomes and those that did were often underpowered. DISCUSSION: Clinicians should be aware that comprehension is often poor among hospitalized patients, especially in those with lower education and advanced age. Our results are limited by overall poor quality of interventional studies. Future research should use objective, standardized measures of patient comprehension and interventions should be multifaceted in approach, focusing on knowledge improvement while also addressing other factors influencing outcomes.

Evaluation of a novel mentor program to improve surgical care for US hospitals.

OBJECTIVE: To evaluate a novel mentor program for 27 US surgeons, charged with improving quality at their respective hospitals, having been paired 1:1 with 27 surgeon mentors through a state-wide quality improvement (QI) initiative. DESIGN: Mixed-methods utilizing quantitative surveys and in-depth semi-structured interviews. SETTING: The Illinois Surgical Quality Improvement Collaborative (ISQIC) utilized a novel Mentor Program to guide surgeons new to QI. PARTICIPANTS: All mentor-mentee pairs received the survey (n = 27). Purposive sampling identified a subset of mentors (n = 8) and mentees (n = 4) for in-depth semi-structured interviews. INTERVENTION: Surgeons with expertise in QI mentored surgeons new to QI. MAIN OUTCOME MEASURES: (i) Quantitative: self-reported satisfaction with the mentor program; (ii) Qualitative: key themes suggesting actions and strategies to facilitate mentorship in QI. RESULTS: Mentees expressed satisfaction with the mentor program (n = 24, 88.9%) and agreed that mentorship is vital to ISQIC (n = 24, 88.9%). Analysis of interview data revealed four key themes: (i) nuances of data management, (ii) culture of quality and safety, (iii) mentor-mentee relationship and (iv) logistics. Strategies from these key themes include: utilize raw data for in-depth QI understanding, facilitate presentations to build QI support, identify opportunities for in-person meetings and establish scheduled conference calls. The mentor's role required sharing experiences and acting as a resource. The mentee's role required actively bringing questions and identifying barriers. CONCLUSIONS: Mentorship plays a vital role in advancing surgeon knowledge and engagement with QI in ISQIC. Key themes in mentorship reflect strategies to best facilitate mentorship, which may serve as a guide to other collaboratives.

Use of Unit-Based Interventions to Improve the Quality of Care for Hospitalized Medical Patients: A National Survey.

BACKGROUND: Recent publications have drawn attention to interventions to redesign aspects of care delivery for hospitalized medical patients, including localization of physicians to specific units, nurse-physician co-leadership, interdisciplinary rounds (IDR), and access to quality performance data. Use of these interventions across hospitals has not been previously described. METHODS: A cross-sectional survey of internal medicine (IM) residency program directors and hospital medicine group (HMG) leaders in the United States was conducted to characterize use of unit-based interventions on inpatient medical services. The survey served as a pilot study to assess the use of localization of physicians to specific units, nurse-physician co-leadership, IDR, and access to quality performance data. RESULTS: Ninety-four IM program directors (response rate, 23.3%) and 62 HMG leaders (response rate, 20.7%) responded. No single intervention was used by the vast majority of sites, and the extent and intensity of use varied. About a quarter of respondents indicated that physicians typically cared for patients on only one to two units, a third or fewer had unit co-leadership on at least half of hospital units, fewer than half had daily IDR, and approximately half had access to unit-level performance data. Most IM programs and hospitalist groups had implemented 0 to 1 interventions to a high degree of fidelity, and few (≤ 5%) had implemented all 4. CONCLUSION: IM program directors and HMG leaders reported variation in use of unit-based interventions to improve quality of care for medical inpatients. Future research should evaluate the association of the degree and intensity of using unit-based interventions on patient outcomes.