Medically ready for discharge: A multisite "point-in-time" assessment of hospitalized patients.

BACKGROUND: Time spent awaiting discharge after the acute need for hospitalization has resolved is an important potential contributor to hospital length of stay (LOS). OBJECTIVE: To measure the prevalence, impact, and context of patients who remain hospitalized for prolonged periods after completion of acute care needs. DESIGN, SETTING, AND PARTICIPANTS: We conducted a cross-sectional "point-in-time" survey at each of 15 academic US hospitals using a structured data collection tool with on-service acute care medicine attending physicians in fall 2022. MAIN OUTCOMES AND MEASURES: Primary outcomes were number and percentage of patients considered "medically ready for discharge" with emphasis on those who had experienced a "major barrier to discharge" (medically ready for discharge for ≥1 week). Estimated LOS attributable to major discharge barriers, contributory discharge needs, and associated hospital characteristics were measured. RESULTS: Of 1928 patients sampled, 35.0% (n = 674) were medically ready for discharge including 9.8% (n = 189) with major discharge barriers. Many patients with major discharge barriers (44.4%; 84/189) had spent a month or longer medically ready for discharge and commonly (84.1%; 159/189) required some form of skilled therapy or daily living support services for discharge. Higher proportions of patients experiencing major discharge barriers were found in public versus private, nonprofit hospitals (12.0% vs. 7.2%; p = .001) and county versus noncounty hospitals (14.5% vs. 8.8%; p = .002). CONCLUSIONS: Patients experience major discharge barriers in many US hospitals and spend prolonged time awaiting discharge, often for support needs that may be outside of clinician control.

Focusing on the Medically Ready for Discharge Patient Using a Reliable Design Strategy: A Quality Improvement Project to Improve Length of Stay on a Medicine Service.

BACKGROUND AND OBJECTIVES: Length of stay is a common measure of efficiency of care. We aimed to reduce length of stay on a general medicine service through a structured quality improvement project. METHODS: A reliable design strategy was implemented in successive stages at a 238-bed academically-affiliated VA hospital. Over a 2-year period, continuous improvement efforts were directed at discrete cohorts of patients deemed medically appropriate for discharge but who remained hospitalized because of discharge barriers. We compared the mean length of stay and medically-ready bed days of care for a hospital in statistical control charts. Pre- and post-intervention comparisons were made using t -tests. RESULTS: In total, 5321 discharges were included in this improvement project, accounting for 35 852 bed days of care. Overall, average length of stay was reduced by 15.7%, from 7.62 to 6.40 days ( P < .05). There was a significant reduction in the mean number of medically-ready bed days of care from 2.3 to 1.72. Statistical process control charts demonstrated special cause variation across patient cohorts. CONCLUSION: A quality improvement project using reliable design principles was associated with shorter length of stay.

Prevalence and Characteristics of House Staff Quality and Safety Councils Within Clinical Learning Environments: Results of a National Survey.

House Staff Quality and Safety Councils (HQSCs) are relatively new multispecialty groups led by residents and fellows that focus on quality and safety activities at their training site. The authors sought to estimate the prevalence of HQSCs, describe their common characteristics and determine any perceived impacts. A national survey was conducted with Designated Institutional Officers (DIO) of graduate medical education programs in 2019. For institutions with an HQSC, a second survey was sent to program leaders to obtain additional details. Responses were obtained from 204 DIOs, 47% of whom currently have an HQSC. Forty-five percent of sites provided details about HQSC membership, leadership, funding, activities/initiatives, facilitators, and barriers. The majority reported positive program outcomes. This study found that HQSCs are common and share key characteristics, yet at the same time have many unique features tailored to their clinical learning environment. Participants report positive outcomes associated with these groups.

Creating a Framework to Integrate Residency Program and Medical Center Approaches to Quality Improvement and Patient Safety Training.

Quality improvement and patient safety (QIPS) are core components of graduate medical education (GME). Training programs and affiliated medical centers must partner to create an environment in which trainees can learn while meaningfully contributing to QIPS efforts, to further the shared goal of improving patient care. Numerous challenges have been identified in the literature, including lack of resources, lack of faculty expertise, and siloed QIPS programs. In this article, the authors describe a framework for integrated QIPS training for residents in the University of Washington Internal Medicine Residency Program, beginning in 2014 with the creation of a dedicated QIPS chief resident position and assistant program director for health systems position, the building of a formal curriculum, and integration with medical center QIPS efforts. The postgraduate year (PGY) 1 curriculum focused on the culture of patient safety and entering traditional patient safety event (PSE) reports. The PGY-2 curriculum highlighted QIPS methodology and how to conduct mentored PSE reviews of cases that were of educational value to trainees and a clinical priority to the medical center. Additional PGY-2/PGY-3 training focused on the active report, presentation, and evaluation of cases during morbidity and mortality conferences while on clinical services, as well as how to lead longitudinal QIPS work. Select residents led mentored QI projects as part of an additional elective. The hallmark feature of this framework was the depth of integration with medical center priorities, which maximized educational and operational value. Evaluation of the program demonstrated improved attitudes, knowledge, and behavior changes in trainees, and significant contributions to medical center QIPS work. This specialty-agnostic framework allowed for training program and medical center integration, as well as horizontal integration across GME specialties, and can be a model for other institutions.

Hospitalized After Medical Readiness for Discharge: A Multidisciplinary Quality Improvement Initiative to Identify Discharge Barriers in General Medicine Patients.

Reducing the length of hospitalization is a shared priority for patients, clinicians, and other health care stakeholders. However, patients can remain hospitalized after being "medically ready" for discharge, accumulating delayed discharge bed days (DDBDs). As part of a quality improvement initiative, the authors developed a method to measure DDBD and define discrete barriers to discharge identified by inpatient clinicians. Patients with delayed discharge had a higher rate of in-hospital complications compared to those who were discharged routinely. To identify modifiable barriers among patients with delayed discharges, 2 patient subgroups were defined: prolonged hospitalization (>19 DDBDs, top quintile accumulated) and extended hospitalization (≤19 DDBDs). Patients with prolonged hospitalization were more likely than those with extended hospitalization to have financial (P < .001) or behavioral (P < .001) barriers, homelessness (P < .05), and impairment of decision-making capacity (P < .01). Understanding the characteristics and discharge barriers of patients who are hospitalized despite medical readiness may increase appropriateness of inpatient resources.

Getting Unstuck: Challenges and Opportunities in Caring for Patients Experiencing Prolonged Hospitalization While Stable for Discharge.

Many physicians care for patients who remain in the hospital for prolonged periods despite being "medically ready" or stable for discharge. However, this phenomenon is not well-defined, and optimal strategies to address the problem are not known. A prolonged hospitalization past the point of medical necessity can harm patients, frustrate care teams, and is costly for the health care system. In this perspective, we describe opportunities to improve value of care for these patients through the lens of the Quadruple Aim, a common framework used to guide health care transformation efforts. We then offer recommendations, including some employed by our hospitals, for clinicians, researchers, and health care systems to improve the care for patients who are "stuck" in the hospital.

Bracing for the Storm: One Health Care System's Planning for the COVID-19 Surge.

PROBLEM: University of Washington Medicine (UW Medicine), an academic health system in Washington State, was at the epicenter of the first outbreak of the COVID-19 pandemic in the United States. The extent of emergency activation needed to adequately respond to this global pandemic was not immediately known, as the evolving situation differed significantly from any past disaster response preparations in that there was potential for exponential growth of infection, unproven mitigation strategies, serious risk to health care workers, and inadequate supply chains for critical equipment. APPROACH: The rapid transition of the UW Medicine system to account for projected COVID-19 and usual patient care, while balancing patient and staff safety and conservation of resources, represents an example of an adaptive disaster response. KEY INSIGHTS: Although our organization's ability to meet the needs of the public was uncertain, we planned and implemented changes to space, supply management, and staffing plans to meet the influx of patients across our clinical entities. The surge management plan called for specific actions to be implemented based on the level of activity. This article describes the approach taken by UW Medicine as we braced for the storm.

Factors influencing liver transplant length of stay at two large-volume transplant centers.

Length of stay (LOS) is considered a reliable surrogate for liver transplant resource utilization. Little information exists about how donor and recipient variables interact to affect transplant LOS. Data for adult, non-status 1 transplants (1998-2005), including the donor risk index (DRI) and Model for End-Stage Liver Disease (MELD) scores, were collected from 2 institutions (n = 745 for center A and n = 710 for center B). Cox proportional hazards models identified variables associated with LOS for the separate and combined cohorts. The cohorts differed significantly in donor, recipient, and transplant factors. DRI (1.46 for center A and 1.40 for center B, P = 0.0013) and MELD (22.4 for center A and 20.4 for center B, P = 0.046) were both higher at center A, but LOS was comparable (13.7 days for center A and 13.3 days for center B, P = 0.052). Three factors at center A (nonlocal donor, recipient age, and MELD) and 7 factors at center B (donor age and weight, recipient female gender, retransplant status, international normalized ratio, MELD, and cold ischemia time) were associated with transplant LOS. For the combined cohort, donor age, weight, nonlocal status, recipient age, female gender, retransplant status, MELD, and transplant center were LOS risk factors. In conclusion, the impact of donor and recipient variables on LOS varies by institution. However, the MELD score exerts a potent and consistent effect across institutions, emphasizing the dominant role of disease severity in liver transplant resource utilization.

Association of Adverse Effects of Medical Treatment With Mortality in the United States: A Secondary Analysis of the Global Burden of Diseases, Injuries, and Risk Factors Study.

Importance: More than 20 years have passed since the first publication of estimates of the extent of medical harm occurring in hospitals in the United States. Since then, considerable resources have been allocated to improve patient safety, yet policymakers lack a clear gauge of the progress made. Objectives: To quantify the cause-specific mortality associated with adverse effects of medical treatment (AEMT) in the United States from 1990 to 2016 by age group, sex, and state of residence and to describe trends in types of harm and associations with other diseases and injuries. Design, Setting, and Participants: Cohort study using 1990-2016 data on mortality due to AEMT from the Global Burden of Diseases, Injuries, and Risk Factors (GBD) 2016 study, which assessed death certificates of US decedents. Exposures: Death with International Classification of Diseases (ICD)-coded registration. Main Outcomes and Measures: Mortality associated with AEMT. Secondary analyses were performed on all ICD codes in the death certificate's causal chain to describe associations between AEMT and other diseases and injuries. Results: From 1990 to 2016, there were an estimated 123 603 deaths (95% uncertainty interval [UI], 100 856-163 814 deaths) with AEMT as the underlying cause. Despite an overall increase in the number of deaths due to AEMT over time, the national age-standardized mortality rate due to AEMT decreased by 21.4% (95% UI, 1.3%-32.2%) from 1.46 (95% UI, 1.09-1.76) deaths per 100 000 population in 1990 to 1.15 (95% UI, 1.00-1.60) deaths per 100 000 population in 2016. Men and women had similar rates of AEMT mortality, and those 70 years or older had mortality rates nearly 20-fold greater compared with those aged 15 to 49 years (mortality rate in 2016 for both sexes, 7.93 [95% UI, 7.23-11.45] per 100 000 population for those aged ≥70 years vs 0.38 [95% UI, 0.34-0.43] per 100 000 population for those aged 15-49 years). Per 100 000 population, California had the lowest age-standardized AEMT mortality rate at 0.84 deaths (95% UI, 0.57-1.47 deaths), whereas Mississippi had the highest mortality rate at 1.67 deaths (95% UI, 1.19-2.03 deaths). Surgical and perioperative events were the most common subtype of AEMT, accounting for 63.6% of all deaths for which an AEMT was identified as the underlying cause. Conclusions and Relevance: This study's findings suggest a modest reduction in the mortality rate associated with AEMT in the United States from 1990 to 2016 while also observing increased mortality associated with advancing age and noted geographic variability. The annual GBD releases may allow for tracking of the burden of AEMT in the United States.

Introducing an electronic tracking tool into daily multidisciplinary discharge rounds on a medicine service: a quality improvement project to reduce length of stay.

BACKGROUND: Inefficient coordination of care around discharge can increase length of stay, lead to ineffective transitions and contribute an unnecessary cost burden to patients and hospital systems. Multidisciplinary discharge rounds can improve situational awareness among team members leading to more efficient and better coordinated care. This project aimed to standardise the daily discharge rounds occurring on a medicine service to reduce length of stay. Participants included physicians, nurses and social workers. METHODS: A key driver diagram was developed to understand drivers of length of stay. Improving multidisciplinary care coordination was targeted as an initial area of focus. Stakeholder interviews were held to understand current participants challenges with the daily discharge rounds process. Baseline assessment included a review of discharges for 6 weeks before the initial intervention. A Plan Do Study Act quality improvement framework was used to implement change. INTERVENTION: An electronic tool was developed which highlighted critical information to be captured during discharge rounds on each current inpatient in a standardised fashion. Information was reviewed and solicited from care teams by a facilitator, then edited and displayed in real time to all team members by a scribe. RESULTS: The average length of stay decreased by 1.4 days (p<0.05), an improvement of 21.1%. There was no measured increase on readmission rate during the intervention period. CONCLUSION: An electronic tool to standardise information gathered among team members in daily discharge rounds led to improvements in length of stay. Multidisciplinary discharge rounds are an important venue for discharge planning across inpatient care teams and efforts to optimise communication between team members can improve care.

Elements of the Veterans Health Administration Patient-Centered Medical Home are Associated with Greater Adherence to Oral Hypoglycemic Agents in Patients with Diabetes.

In 2010, Veterans Health Administration (VHA) primary care clinics adopted a patient-centered medical home (PCMH) model. This study sought to examine the association between the organizational features related to adoption of PCMH and the level of adherence to oral hypoglycemic agents (OHAs) among patients with diabetes. This retrospective cohort study involved 757 VA clinics that provide primary care to 440,971 patients with diabetes who were taking OHAs in fiscal year 2012. One-year refill-based medication possession ratios (MPRs) were calculated at the patient level. Clinic-level adherence was defined as the proportion of clinics with MPR ≥80%. Risk adjustment of adherence was performed using logistic regression to account for differences in patient populations at clinics. Eight domains of the PCMH model (ie, access, continuity, coordination, teamwork, comprehensive care, self-management, communication, shared decision making) were assessed using items from a previously validated index. Multivariate linear regression was applied to identify PCMH components associated with clinic-level adherence. Patients with diabetes per clinic ranged from 100 to 5011. The average level of adherence to OHAs among clinics ranged from 52.8% to 61.9% (interquartile range = 57.9% to 59.4%). In multivariate analysis, organizational features associated with higher clinic-level adherence included access to routine care (standardized beta [Sß] = .21, P = .004), having a respectful office staff (Sß = 0.21, P = .002), and utilization of telephone encounters (Sß = 0.23, P < .001). Among a national cohort of veterans with diabetes, overall PCMH implementation did not significantly increase adherence to oral hypoglycemic agents, although aspects of implementation were associated with increased adherence. Measures of access to care appear the most significant.

Resident perceptions of palliative care training in the emergency department.

OBJECTIVES: To characterize the level of formal training and perceived educational needs in palliative care of emergency medicine (EM) residents. METHODS: This descriptive study used a 16-question survey administered at weekly resident didactic sessions in 2008 to EM residency programs in New York City. Survey items asked residents to: (1) respond to Likert-scaled statements about the role of palliative care in the emergency department (ED); (2) quantify their level of formal training and personal comfort in symptom management, discussion of bad news and prognosis, legal issues, and withdrawing/withholding therapy; and (3) express their interest in future palliative care training. RESULTS: Of 228 total residents, 159 (70%) completed the survey. Of those surveyed, 50% completed some palliative care training before residency; 71.1% agreed or strongly agreed that palliative care was an important competence for an EM physician. However, only 24.3% reported having a "clear idea of the role of palliative care in EM." The highest self-reported level of formal training was in the area of advanced directives or legal issues at the end of life; the lowest levels were in areas of patient management at the end of life. The highest level of self-reported comfort was in giving bad news and the lowest was in withholding/withdrawing therapy. A slight majority of residents (54%) showed positive interest in receiving future training in palliative care. CONCLUSIONS: New York City EM residents reported palliative care as an important competency for emergency medicine physicians, yet also reported low levels of formal training in palliative care. The majority of residents surveyed favored additional training.