Christine Soong

Do Post Discharge Phone Calls Improve Care Transitions? A Cluster-Randomized Trial

Importance The transition from hospital to home can expose patients to adverse events during the post discharge period. Post discharge care including phone calls may provide support for patients returning home but the impact on care transitions is unknown. Objective To examine the effect of a 72-hour post discharge phone call on the patients transition of care experience. Design Cluster-randomized control trial. Setting Urban, academic medical center. Participants General medical patients age 18 and older discharged home after hospitalization. Main Outcomes and Measures Primary outcome measure was the Care Transition Measure (CTM-3) score, a validated measure of the quality of care transitions. Secondary measures included self-reported adherence to medication and follow up plans, and 30-day composite of emergency department (ED) visits and hospital readmission. Results 328 patients were included in the study over an 6-month period. 114 (69%) received a post discharge phone call, and 214 of all patients in the study completed the follow outcome survey (65% response rate). A small difference in CTM-3 scores was observed between the intervention and control groups (1.87 points, 95% CI 0.47–3.27, p = 0.01). Self-reported adherence to treatment plans, ED visits, and emergency readmission rates were similar between the two groups (odds ratio 0.57, 95% CI 0.13–2.45, 1.20, 95% CI 0.61–2.37, and 1.18, 95% CI 0.53–2.61, respectively). Conclusions and Relevance A single post discharge phone call had a small impact on the quality of care transitions and no effect on hospital utilization. Higher intensity post discharge support may be required to improve the patient experience upon returning home. Trial Registration ClinicalTrials.gov NCT01580774

Evidence-Based Guidelines to Eliminate Repetitive Laboratory Testing

Routine daily laboratory testing of hospitalized patients reflects a wasteful clinical practice that threatens the value of health care. Choosing Wisely initiatives from numerous professional societies have identified repetitive laboratory testing in the face of clinical stability as low value care. Although laboratory expenditure often represents less than 5% of most hospital budgets, the impact is far-reaching given that laboratory tests influence nearly 60% to 70% of all medical decisions. Excessive phlebotomy can lead to hospital-acquired anemia, increased costs, and unnecessary downstream testing and procedures. Efforts to reduce the frequency of laboratory orders can improve patient satisfaction and reduce cost without negatively affecting patient outcomes. To date, numerous interventions have been deployed across multiple institutions without a standardized approach. Health care professionals and administrative leaders should carefully strategize and optimize efforts to reduce daily laboratory testing. This review presents an evidence-based implementation blueprint to guide teams aimed at improving appropriate routine laboratory testing among hospitalized patients.

High prevalence of inappropriate benzodiazepine and sedative hypnotic prescriptions among hospitalized older adults

BACKGROUND: Benzodiazepines and sedative hypnotics are commonly used to treat insomnia and agitation in older adults despite significant risk. A clear understanding of the extent of the problem and its contributors is required to implement effective interventions. OBJECTIVE: To determine the proportion of hospitalized older adults who are inappropriately prescribed benzodiazepines or sedative hypnotics, and to identify patient and prescriber factors associated with increased prescriptions. DESIGN: Single‐center retrospective observational study. SETTING: Urban academic medical center. PARTICIPANTS: Medical‐surgical inpatients aged 65 or older who were newly prescribed a benzodiazepine or zopiclone. MEASUREMENTS: Our primary outcome was the proportion of patients who were prescribed a potentially inappropriate benzodiazepine or sedative hypnotic. Potentially inappropriate indications included new prescriptions for insomnia or agitation/anxiety. We used a multivariable random‐intercept logistic regression model to identify patient‐ and prescriber‐level variables that were associated with potentially inappropriate prescriptions. RESULTS: Of 1308 patients, 208 (15.9%) received a potentially inappropriate prescription. The majority of prescriptions, 254 (77.4%), were potentially inappropriate. Of these, most were prescribed for insomnia (222; 87.4%) and during overnight hours (159; 62.3%). Admission to a surgical or specialty service was associated with significantly increased odds of potentially inappropriate prescription compared to the general internal medicine service (odds ratio [OR], 6.61; 95% confidence interval [CI], 2.70–16.17). Prescription by an attending physician or fellow was associated with significantly fewer prescriptions compared to first‐year trainees (OR, 0.28; 95% CI, 0.08–0.93). Nighttime prescriptions did not reach significance in initial bivariate analyses but were associated with increased odds of potentially inappropriate prescription in our regression model (OR, 4.48; 95% CI, 2.21–9.06). CONCLUSIONS: The majority of newly prescribed benzodiazepines and sedative hypnotics were potentially inappropriate and were primarily prescribed as sleep aids. Future interventions should focus on the development of safe sleep protocols and education targeted at first‐year trainees.

A novel approach to improving emergency department consultant response times

Background Emergency department (ED) overcrowding is a threat to patient safety and public health. Availability of specialty consultation to the ED may contribute to overcrowding. We implemented a novel intervention using education, goal setting and real-time performance feedback to improve time to admission for patients referred to general internal medicine (GIM). Methods Using a time-series design, we examined the effects of a quality improvement intervention on ED wait-times in an academic medical centre. The multifaceted approach included a didactic session for GIM housestaff on medicine triage principles and methods; setting a goal to have disposition decisions and, where appropriate, admission order within 4 h of consultation request; and providing personal data feedback on their performance on this metric to GIM housestaff during their rotation on the inpatient teaching service over a 1-year period. We compared time from consultation request to disposition decision and overall ED length of stay (LOS) for all patients referred to GIM during the intervention period (February 2011–February 2012) with data from the control period (January 2010–January 2011). Results Mean time from GIM consultation request to admission order entry decreased by 92 min (SD, 5, p<0.05) from 321min in the control period to 229 min in the intervention period. Overall ED LOS for GIM patients decreased by 59 min (SD, 14, p<0.05) for admitted patients from 1022 min in the control period to 963 min in the intervention period, and by 40 min (SD, 13, p<0.05) for all patients referred to GIM. GIM staffing and patient characteristics remained stable across the two periods. Discussion ED throughput for admitted medical patients improved with a quality improvement initiative involving education, goal setting and performance feedback.

Identifying preventable readmissions: an achievable goal or waiting for Godot?

Hospital readmission rates have captured the attention of policymakers, administrators, researchers and healthcare providers over the last decade. This has been spurred in no small part by the Hospital Readmissions Reduction Program, which began in the USA in 2012 and requires the Centres for Medicare and Medicaid Services to reduce payments to acute care facilities with high rates of readmission within 30 days of discharge for selected conditions. After years of intense research to find an objective measure of preventable readmissions, it seems as imminent as the arrival of Godot. Whether preventable readmissions can be objectively defined or represent a valid patient-centred measure of quality are unclear. While the search continues for validated and objective measures of readmission, emerging commercial software programs using administrative data to flag potentially preventable readmissions (PPRs) are marketed as a solution to labour-intensive chart review. One example is the 3M Potentially Preventable Readmissions Grouping Software, a widely used proprietary program.1 Using hospital administrative data, the program identifies readmissions with diagnoses that are ‘clinically related’ to the index admission and flags them as potentially preventable. Readmissions are risk-adjusted for case mix and severity of illness. Although the program has yet to be validated, its ease of use and promise of producing an objective measure of PPR have resulted in quick uptake by many organisations. In their BMJ Quality and Safety publication, Borzecki et al 2 aim to determine whether the 3M PPR software can accurately identify …

Impact of an Integrated Hip Fracture Inpatient Program on Length of Stay and Costs

Background: Hip fractures are associated with significant morbidity and mortality. Co-management models pairing orthopaedic surgeons with hospitalists or geriatricians may be effective at improving processes of care and outcomes such as length of stay (LOS) and cost. We set out to determine the effect of an integrated hip fracture co-management model on LOS, cost, and process measures. Methods: We conducted a single-center pre–post study of 571 patients admitted to an academic medical center with hip fractures between January 2009 and December 2013. The group receiving an integrated medical-surgical co-management incorporating continuous improvement methodology was compared with a control population. Primary outcome was LOS. Secondary outcomes included cost per case, time to surgery, osteoporosis (OP) treatment, preoperative echocardiogram utilization, mortality, and readmission. Results: LOS decreased from 18.2 (1.1) to 11.9 (1.5) days, a reduction of 6.3 days (P < 0.001). Mean cost decreased by

An Implementation Guide to Reducing Overtreatment of Asymptomatic Bacteriuria

4953 (P < 0.001) per case. Mean time to surgery decreased from 45.8 (66.8) to 29.7 (17.9) hours (P < 0.001). Initiation of OP treatment increased from 55.8% to 96.4% (P < 0.001). Preoperative echocardiogram use decreased from 15.8% to 9.1% (P < 0.05). There was a nonsignificant difference in mortality rate (5.0% vs. 2.1%, P = 0.06). Readmission rate remained unchanged (4.6% vs. 6.0%, P = 0.56). Conclusions: An integrated medical-surgical co-management model incorporating continuous improvement methodology was associated with reduced LOS, costs, time to surgery, and increased initiation of appropriate OP treatment. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A point prevalence study of urinary catheter use among teaching hospitals with and without reduction programs

Treatment of asymptomatic bacteriuria (ASB) frequently lacks appropriate indication, yet remains prevalent across settings. Numerous guidelines, professional societies, and campaigns such as Choosing Wisely advocate against this low-value practice. Efforts aimed at reducing unnecessary treatment of ASB demonstrate improved costs, and avoidable harm without increased risk of adverse events. We propose an evidence-based implementation guide to aid practitioners in reducing inappropriate treatment of ASB.

The Role of Hospitalists in Managing Patient Flow: Lessons from Four Hospitals

Division of General Internal Medicine, Mount Sinai Hospital, Toronto, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Division of Infectious Diseases and General Internal Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada; Division of General Internal Medicine, University Health Network, Toronto, Canada; Division of General Internal Medicine, McGill University Health Centre, Montreal, Canada; Clinical Practice Assessment Unit, McGill University Health Centre, Montreal, Canada.

Sepsis now a priority: a quality improvement initiative for early sepsis recognition and care

Purpose of ReviewHospitalists are leaders in healthcare transformation. They develop innovative models of care that simultaneously meet clinical needs of patients and operational needs of hospitals. One example of a hospitalist-led intervention is active bed management (ABM), which has been shown to improve efficiency and patient flow from the emergency department (ED) to the inpatient setting. Models of ABM are emerging in many institutions, adapting to suit local needs.Recent FindingsIn this report we describe five models of ABM from a variety of hospitals, including academic and community-based, and those of varied sizes from medium (250 beds) to large (856 bed) hospitals. At every hospital, ABM has had a positive effect and influenced myriad outcomes including time to admission, emergency department length of stay, and ambulance diversion.SummaryIn the current climate of pay-for-results and quality-based funding reforms, hospitalist contributions to improving flow and efficiency will be particularly valued by all stakeholders. This report will serve to aid hospitalist groups looking to implement ABM, while navigating challenges and pitfalls.