Analysing Monday discharges to identify lost opportunities for weekend discharge.

Lower rates of hospital discharge occur on weekends compared with weekdays. The authors performed a retrospective chart review of Monday discharges from the Hospital Medicine service at an academic hospital over a 3-month period to identify reasons for delayed discharge despite medical stability. Of 202 eligible patients, 81 (40%) had documentation indicating stability for earlier discharge. Common causes included bed availability or insurance authorisation at a skilled nursing facility, home care services and patient/family disagreement with discharge.

Severity of illness and the weekend mortality effect: a retrospective cohort study.

BACKGROUND: Weekend admission to the hospital has been found to be associated with higher in-hospital mortality rates, but the cause for this phenomenon remains controversial. US based studies have been limited in their characterization of the weekend patient population, making it difficult to draw conclusions about the implications of this effect. METHODS: A retrospective cohort study, examining de-identified, patient level data from 2015 to 2017 at US academic medical centers submitting data to the Vizient database, comparing demographic and clinical risk profiles, as well as mortality, cost and length of stay, between weekend and weekday patient populations. Between-group differences in mortality were assessed using the chi-square test for categorical measures and Wilcoxon rank-sum test for continuous measures. Logistic regression models were used to test the multivariate association of weekend admission and other patient-level factors with death, LOS, etc. RESULTS: We analyzed 10,365,605 adult inpatient encounters. Within the weekend patient population, 30.6% of patients were categorized as having either a major or extreme risk of mortality on admission, as compared to 23.7% on weekdays (p < 0.001). We found a significantly increased unadjusted mortality rate associated with weekend admission (OR 1.46; 95% CI 1.45-1.47) which was substantially attenuated after adjusting for disease severity and other demographic covariates, though remained significant (OR 1.05; 95% CI 1.04-1.06). In the subgroup of non-elective admissions, the unadjusted OR for death was 1.14 (95% CI 1.13-1.15), and the adjusted OR was 1.04 (95% CI 1.03-1.05). Weekend admission was associated with a longer median LOS (4 vs 3 days in the weekday group; p < 0.01), but a lower median cost ($8224 vs $9999 dollars in the weekday group; p < 0.01). CONCLUSION: The patient population admitted on weekends is proportionally higher risk than the population admitted on weekdays, and the observed weekend mortality effect is largely attributable to this risk imbalance.

Enhanced Communication for Interhospital Transfers Increases Preparedness in an Academic Tertiary Care Center.

OBJECTIVES: This quality improvement project sought to enhance clinical information sharing for interhospital transfers to an inpatient hepatology service comprised of internal medicine resident frontline providers (housestaff) with the specific aims of making housestaff aware of 100% of incoming transfers and providing timely access to clinical summaries. INTERVENTIONS: In February 2020, an email notification system to senior medicine residents responsible for patient triage shared planned arrival time for patients pending transfer. In July 2020, a clinical data repository ("Transfer Log") updated daily by accepting providers (attending physicians and subspecialty fellows) became available to senior medicine residents responsible for triage. METHODS: Likert scale surveys were administered to housestaff before email intervention (pre) and after transfer log intervention (post). The time from patient arrival to team assignment (TTA) in the electronic medical record was used as a proxy for time to patient assessment and was measured pre- and postinterventions; >2 hours to TTA was considered an extreme delay. RESULTS: Housestaff reported frequency of access to clinical information as follows: preinterventions 4/31 (13%) sometimes/very often and 27/31 (87%) never/rarely; postinterventions 11/26 (42%) sometimes/very often and 15/26 (58%) never/rarely (p = 0.02). Preinterventions 12/39 (31%) felt "not at all prepared" versus 27/39 (69%) "somewhat" or "adequately"; postinterventions 2/24 (8%) felt "not at all prepared" versus 22/24 (92%) somewhat/adequately prepared (p = 0.06). There was a significant difference in mean TTA between pre- and posttransfer log groups (62 vs. 40 minutes, p = 0.01) and a significant reduction in patients with extreme delays in TTA post-email (18/180 pre-email vs. 7/174 post-email, p = 0.04). CONCLUSION: Early notification and increased access to clinical information were associated with better sense of preparedness for admitting housestaff, reduction in TTA, and reduced frequency of extreme delays in team assignment.

Point-of-Care Ultrasound and the Rapid Response System.

Over the years, the use of ultrasound has moved solely from the domain of the radiologist to that of the intensivist and emergentologist for use in acute care settings. By virtue of its ease of use and rapid learning curve to proficiency, we are now seeing an increased desire by internists to learn the modality and apply it at the patient's bedside. The rapid response system represents a rational starting point for the introduction of point-of-care ultrasound to the inpatient ward setting.