Cecelia Theobald

Risk Prediction Models for Hospital Readmission: A Systematic Review

CONTEXT Predicting hospital readmission risk is of great interest to identify which patients would benefit most from care transition interventions, as well as to risk-adjust readmission rates for the purposes of hospital comparison. OBJECTIVE To summarize validated readmission risk prediction models, describe their performance, and assess suitability for clinical or administrative use. DATA SOURCES AND STUDY SELECTION The databases of MEDLINE, CINAHL, and the Cochrane Library were searched from inception through March 2011, the EMBASE database was searched through August 2011, and hand searches were performed of the retrieved reference lists. Dual review was conducted to identify studies published in the English language of prediction models tested with medical patients in both derivation and validation cohorts. DATA EXTRACTION Data were extracted on the population, setting, sample size, follow-up interval, readmission rate, model discrimination and calibration, type of data used, and timing of data collection. DATA SYNTHESIS Of 7843 citations reviewed, 30 studies of 26 unique models met the inclusion criteria. The most common outcome used was 30-day readmission; only 1 model specifically addressed preventable readmissions. Fourteen models that relied on retrospective administrative data could be potentially used to risk-adjust readmission rates for hospital comparison; of these, 9 were tested in large US populations and had poor discriminative ability (c statistic range: 0.55-0.65). Seven models could potentially be used to identify high-risk patients for intervention early during a hospitalization (c statistic range: 0.56-0.72), and 5 could be used at hospital discharge (c statistic range: 0.68-0.83). Six studies compared different models in the same population and 2 of these found that functional and social variables improved model discrimination. Although most models incorporated variables for medical comorbidity and use of prior medical services, few examined variables associated with overall health and function, illness severity, or social determinants of health. CONCLUSIONS Most current readmission risk prediction models that were designed for either comparative or clinical purposes perform poorly. Although in certain settings such models may prove useful, efforts to improve their performance are needed as use becomes more widespread.

Effect of a Pharmacist Intervention on Clinically Important Medication Errors After Hospital Discharge: A Randomized Trial

BACKGROUND Clinically important medication errors are common after hospital discharge. They include preventable or ameliorable adverse drug events (ADEs), as well as medication discrepancies or nonadherence with high potential for future harm (potential ADEs). OBJECTIVE To determine the effect of a tailored intervention on the occurrence of clinically important medication errors after hospital discharge. DESIGN Randomized, controlled trial with concealed allocation and blinded outcome assessors. (ClinicalTrials.gov registration number: NCT00632021) SETTING Two tertiary care academic hospitals. PATIENTS Adults hospitalized with acute coronary syndromes or acute decompensated heart failure. INTERVENTION Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge. MEASUREMENTS The primary outcome was the number of clinically important medication errors per patient during the first 30 days after hospital discharge. Secondary outcomes included preventable or ameliorable ADEs, as well as potential ADEs. RESULTS Among 851 participants, 432 (50.8%) had 1 or more clinically important medication errors; 22.9% of such errors were judged to be serious and 1.8% life-threatening. Adverse drug events occurred in 258 patients (30.3%) and potential ADEs in 253 patients (29.7%). The intervention did not significantly alter the per-patient number of clinically important medication errors (unadjusted incidence rate ratio, 0.92 [95% CI, 0.77 to 1.10]) or ADEs (unadjusted incidence rate ratio, 1.09 [CI, 0.86 to 1.39]). Patients in the intervention group tended to have fewer potential ADEs (unadjusted incidence rate ratio, 0.80 [CI, 0.61 to 1.04]). LIMITATION The characteristics of the study hospitals and participants may limit generalizability. CONCLUSION Clinically important medication errors were present among one half of patients after hospital discharge and were not significantly reduced by a health-literacy-sensitive, pharmacist-delivered intervention. PRIMARY FUNDING SOURCE National Heart, Lung, and Blood Institute.

Reducing Hospital Readmission Rates: Current Strategies and Future Directions

New financial penalties for institutions with high readmission rates have intensified efforts to reduce rehospitalization. Several interventions that involve multiple components (e.g., patient needs assessment, medication reconciliation, patient education, arranging timely outpatient appointments, and providing telephone follow-up) have successfully reduced readmission rates for patients discharged to home. The effect of interventions on readmission rates is related to the number of components implemented; single-component interventions are unlikely to reduce readmissions significantly. For patients discharged to postacute care facilities, multicomponent interventions have reduced readmissions through enhanced communication, medication safety, advanced care planning, and enhanced training to manage medical conditions that commonly precipitate readmission. To help hospitals direct resources and services to patients with greater likelihood of readmission, risk-stratification methods are available. Future work should better define the roles of home-based services, information technology, mental health care, caregiver support, community partnerships, and new transitional care personnel.

The effect of reducing maximum shift lengths to 16 hours on internal medicine interns' educational opportunities.

Purpose To evaluate educational experiences of internal medicine interns before and after maximum shift lengths were decreased from 30 hours to 16 hours. Method The authors compared educational experiences of internal medicine interns at Vanderbilt University Medical Center before (2010; 47 interns) and after (2011; 50 interns) duty hours restrictions were implemented in July 2011. The authors compared number of inpatient encounters, breadth of concepts in notes, exposure to five common presenting problems, procedural experience, and attendance at teaching conferences. Results Following the duty hours restrictions, interns cared for more unique patients (mean 118 versus 140 patients per intern, P = .005) and wrote more history and physicals (mean 73 versus 88, P = .005). Documentation included more total concepts after the 16-hour maximum shift implementation, with a 14% increase for history and physicals (338 versus 387, P < .001) and a 10% increase for progress notes (316 versus 349, P < .001). There was no difference in the median number of selected procedures performed (6 versus 6, P = 0.94). Attendance was higher at the weekly chief resident conference (60% versus 68% of expected attendees, P < .001) but unchanged at morning report conferences (79% versus 78%, P = .49). Conclusions Intern clinical exposure did not decrease after implementation of the 16-hour shift length restriction. In fact, interns saw more patients, produced more detailed notes, and attended more conferences following duty hours restrictions.

A multifaceted quality improvement strategy reduces the risk of catheter-associated urinary tract infection

Objective Catheter-associated urinary tract infections (CAUTIs) are common and preventable hospital-acquired infections, yet their rate continues to rise nationwide. We describe the implementation of a multifaceted program to reduce catheter use and CAUTI rates while simultaneously addressing barriers to long-term success. Design/Setting/Participants Pre-post study of medical inpatient veterans between December 2012 and February 2015. Intervention Five component intervention: (i) a bedside catheter reminder; (ii) multidisciplinary educational campaign; (iii) structured catheter order set with clinical decision support; (iv) automated catheter discontinuation orders; and (v) protocol for post-catheter removal care. Main Outcome Measure(s) Catheter utilization rates and CAUTI rates on the study ward were followed during the 14-week baseline period, the 27-week transition/intervention period and the 70-week period of full implementation/sustainability. Rates of patient falls per bed days and catheter reinsertions were collected during the same time periods as balancing measures. Results Catheter use declined by 35% from the baseline period to the full implementation/sustainability period. This improvement was not realized until deployment of the structured electronic orders with automated catheter discontinuation and protocolized post-catheter care. The average number of days between CAUTIs on the study ward increased from 101 days in the baseline period to over 400 days in the full implementation/sustainability period. There was no significant change in the rates of falls or catheter reinsertions during the study period. Conclusions A multicomponent intervention aimed specifically at targeting local barriers was successful in reducing catheter utilization as well as CAUTIs in a veteran population without compensatory increase in patient falls or catheter replacement.

Effect of a Handover Tool on Efficiency of Care and Mortality for Interhospital Transfers.

BACKGROUND: Interhospital transfer is frequent, and transferred patients experience delays in the provision of care and higher mortality rates when compared to patients directly admitted. The interhospital handover is a key opportunity to improve care but has not been evaluated. OBJECTIVE: To determine the effect of a universal handover tool on timeliness of care, length of stay (LOS), and mortality among interhospital transfer patients. DESIGN, SETTING, AND PATIENTS: Retrospective cohort of patients transferred to an academic medical center between July 1, 2009 and December 31, 2010 with interrupted time‐series design. INTERVENTION: One‐page handover tool containing information critical for immediate patient care instituted hospital‐wide on July 1, 2010. The handover tool was completed by the transferring physician and available for review before patient arrival. MEASUREMENTS: Time‐to‐admission order entry, LOS after transfer, in‐hospital mortality RESULTS: There was no significant change in the time‐to‐admission order entry after implementation (47 minutes vs. 45 minutes, adjusted P = 0.94). There was a nonstatistically significant reduction in LOS after implementation (6.5 days vs. 5.8 days, adjusted P = 0.06). In‐hospital mortality for transfer patients declined significantly in the postintervention period from 12.0% to 8.9% (adjusted odds ratio, 0.68; 95% confidence interval, 0.47 ‐ 0.99, P = 0.04). There was no change in mortality for the concurrent control group. CONCLUSION: Implementation of a standardized handover tool for interhospital transfer was feasible and may be associated with significant reductions in length of stay and mortality. Widespread adoption of similar tools may improve outcomes in this high‐risk population.

Urethral Trauma After Foley Catheter Placement: A Teachable Moment

Story From the Front Lines A man in his 60s with a history of hypertension, atrial fibrillation for which he received therapeutic anticoagulation with warfarin, and amyloidosis resulting in stage II diastolic heart failure and nephrotic syndrome presented to the emergency department with nausea, lightheadedness, and hypotension (blood pressure in the 60s/30s mm Hg) within days of starting irbesartan treatment for persistent proteinuria. He was initially admitted to the medical intensive care unit due to the need for vasopressor support with norepinephrine. During his initial care in the emergency department, a Foley catheter was placed for the documented indication of critical illness with a need for accurate urine output assessment. The patient was noted to be a good historian at the time of presentation, with no evidence of delirium on physical examination and no history of obstructive urinary symptoms or urinary retention. His blood pressure normalized within 48 hours following 2.5 L fluid resuscitation and temporarily holding all home antihypertensive medications. No evidence was found for infectious or cardiac contributions to his hypotension. However, at the time of transfer from the intensive care unit to a step-down unit, he developed gross hematuria including passage of blood clots. He was therapeutically anticoagulated with an international normalized ratio of 2.5, and the medical team was not comfortable with cessation of anticoagulation due to his CHADS2-VASc score of 4. Although his symptoms prompting hospitalization had completely resolved following normalization of his blood pressure, the hematuria and ensuing evaluation resulted in an additional 72 hours of hospitalization, as well as 20 days of outpatient catheterization. The urologic surgery team was consulted who believed that his symptoms represented prostatic trauma during Foley placement with bleeding and retained clot. The final recommendations of the urologic surgery team were to perform twice-daily catheter flushes and discharge the patient with an indwelling urinary catheter in place. He continued to experience pain necessitating treatment with rectal opium suppositories. The patient was discharged with the Foley catheter and leg bag in place and was instructed to perform multiple daily flushes until urologic follow-up. He also required home health care assistance given his substantial anxiety regarding Foley care. Long after hospital discharge, the patient underwent a successful voiding trial in urology clinic and the catheter was removed. Teachable Moment Urinary tract infections, restricted mobility, and increased risk of delirium in elderly patients are widely recognized complications of Foley catheter use, but the prevalence and cost of traumatic Foley placement is less well documented. A retrospective medical record review from 1 medical center in 2002 estimated that 67% of anterior urethral injuries were related to urinary catheterization and 25% of these patients ultimately required surgical intervention.1 These injuries are not rare, with an approximate rate of 3.2 Foley catheter– associated injuries per 1000 adult male hospitalizations.2 The economic implications of urinary catheter– associated infections are well known and documented; however, to our knowledge, there are no data to date demonstrating the costs of urinary catheter–associated trauma. The cost of the additional 3 days of hospitalization required for this patient to receive evaluation and management of his Foley catheter–associated injury is estimated at more than

Gastroenterology: Diaphragmatic herniation and pancreatitis

5000.3 And yet this figure is an underestimate, not including the cost of outpatient supplies for Foley care, home health care, subsequent urology follow-up appointments, and missed days from work. Indwelling Foley catheters not only incur additional costs, but they can result in reduced quality of life for patients related to urethral pain, a sense of loss of dignity, urinary leakage, and reduced frequency of sexual intercourse.4 Further quantification of the frequency and both economic and psychosocial costs of catheter-associated trauma warrants investigation and increased attention among clinicians as a preventable harm. These studies highlight the need to recognize the risks of catheter-associated trauma alongside catheterassociated infection as an additional impetus for reducing the frequency of unnecessary urinary catheterization. In 2009, the Centers for Disease Control and Prevention cataloged the appropriate indications for Foley catheterization: acute urinary retention, bladder outlet obstruction, measuring urinary output in a critically ill patient, perioperative use, assist in healing of open sacral or perineal wounds in incontinent patients, prolonged immobilization, and improving comfort in endof-life care.5 One inadequacy of the guidelines for limiting catheter use is the imprecision of the recommended indications for catheter placement. Although technically admitted to an intensive care unit initially, it is unclear that our patient had a degree of critical illness that necessitated Foley catheter placement in lieu of alternatives such as a handheld urinal or condom catheter. Foley catheter placement guidelines for “critically ill” TEACHABLE MOMENT

Effect of Health Literacy on Research Follow-Up.

An 88-year-old veteran with a history of hypertension and dementia presented to the emergency department with acute onset severe epigastric pain and fever. Physical examination showed mild abdominal distension and epigastric tenderness. Initial laboratory studies were notable for mild leukocytosis (12.4 k/uL), modestly elevated amylase (273 U/L, normal 30–110 U/L) and a markedly elevated lipase (1968 U/L, normal 23–300 U/L). Liver function tests, serum triglycerides, and calcium were normal. Contrasted computed tomography (CT) scan of the abdomen revealed a large hiatal hernia containing most of the stomach (S), part of the duodenum (D), as well as the body and a portion of the tail of the pancreas (P), (Fig. 1a, frontal plane; Fig. 1a–d, axial planes). He was managed conservatively with intravenous fluids, analgesia, and a clear liquid diet. Pain, leukocytosis, and fever resolved within 24 h of hospitalization, and the patient was discharged home in good condition. Two months later, he presented with another episode of abdominal pain and dark emesis. Amylase and lipase at this presentation had returned to normal, at 72 U/L and 58 U/L, respectively. Repeat abdominal CT scan showed the hiatal hernia containing only esophagus and stomach; the pancreas had returned to normal position (Fig. 2a–b). There was concern for gastric volvulus or hernia incarceration resulting in ischemia and elective gastropexy was considered. However, due to his progressive severity of illness and stated wishes, the patient and his family ultimately decided to pursue non-operative management and focus on comfort care. Although hiatal hernias are common, transhiatal herniation of the pancreas is exceedingly rare, with only 11 adult cases reported in the past 60 years. Herniation with associated pancreatitis is rarer still, with only eight reported cases, six in the adult population. Only two prior cases have documented transient herniation. When hiatal herniation leads to pancreatitis, the etiology is thought to be ischemia from traction on the vascular pedicle, ductal injury, or direct parenchymal trauma to the pancreas. The clinical presentation of pancreatic herniation varies from mild discomfort to severe pain and shock, with most cases ultimately receiving surgical intervention. Of the published cases, only one group elected for non-surgical intervention with reported patient stability at 6 months follow-up. Given our patient’s advanced age and rapid improvement, surgical intervention was not initially recommended, but was reconsidered when he presented with recurrent symptomatic herniation. This case highlights hiatal herniation as an uncommon cause of pancreatitis and suggests that transient herniation may explain some cases of idiopathic pancreatitis.