Eric E. Howell

Project BOOST: effectiveness of a multihospital effort to reduce rehospitalization.

BACKGROUND Rehospitalization is a prominent target for healthcare quality improvement and performance-based reimbursement. The generalizability of existing evidence on best practices is unknown. OBJECTIVE To determine the effect of Project BOOST (Better Outcomes for Older adults through Safe Transitions) on rehospitalization rates and length of stay. DESIGN Semicontrolled pre-post study. SETTING/PARTICIPANTS Volunteer sample of 11 hospitals varying in geography, size, and academic affiliation. INTERVENTION Hospitals implemented Project BOOST-recommended tools supported by an external quality improvement physician mentor. METHODS Pre-post changes in readmission rates and length of stay within BOOST units, and between BOOST units and site-designated control units. RESULTS The average rate of 30-day rehospitalization in BOOST units was 14.7% prior to implementation and 12.7% 12 months later (P = 0.010), reflecting an absolute reduction of 2% and a relative reduction of 13.6%. Rehospitalization rates for matched control units were 14.0% in the preintervention period and 14.1% in the postintervention period (P = 0.831). The mean absolute reduction in readmission rates in BOOST units compared to control units was 2.0% (P = 0.054 for signed rank test comparing differences in readmission rate reduction in BOOST units compared to site-matched control units). CONCLUSIONS Participation in Project BOOST appeared to be associated with a decrease in readmission rates.

Active bed management by hospitalists and emergency department throughput.

Context Can hospitalists help decrease crowding in emergency departments? Contribution This prepost case study describes a quality-improvement partnership between hospitalists and a university-affiliated emergency department. A hospitalist regularly visited the emergency department, assessed inpatient bed availability, and helped triage admitted patients to particular units. After implementing the program, the average time that admitted patients spent in the emergency department decreased from 458 to 360 minutes. The percentage of hours that the emergency department had to divert ambulances because of crowding and lack of intensive care unit beds decreased by 6% and 27%, respectively. Implication A hospitalist-led bed management program improved emergency department throughput and ambulance-diversion status. The Editors The Institute of Medicines 2006 report, Hospital-Based Emergency Care: At the Breaking Point, is explicitthere is a crisis in U.S. emergency departments (1). Ninety-one percent of emergency departments are crowded beyond capacity (1). Emergency department crowding often results in ambulance diversion: the practice of redirecting ambulances destined for a crowded emergency department to another facility. Diverting ambulances prolongs the lead time until therapy can be initiated and has been associated with increased mortality rates (2). In 2003, ambulance diversion occurred nationwide at the rate of 1 ambulance every minute (3). The primary cause of emergency department crowding is inpatient boarding, that is, holding admitted patients until a hospital bed becomes available. This procedure not only reduces patient satisfaction but also may negatively affect patient outcomes and quality measures (48). Most of the 12 recommendations in the Institute of Medicines report concentrated on factors within emergency departments and ways in which emergency departments interface with the larger health care system. However, 1 strategy focused on hospital processes and efficiency as a way to ameliorate crowding (1). Hospitalist physician groups, internists specializing in the care of hospitalized patients, are now ubiquitous (9). By the nature of their work in coordinating patient care from admission through discharge, hospitalists are uniquely positioned to effectuate efficiency. Our group of hospitalists partnered with the emergency department to address the problem of crowding in our emergency department. We describe the effect of our hospitalist-run service called active bed management. The primary objective of this service was to facilitate the safe transfer of patients from the emergency department to the appropriate inpatient clinical setting. Methods Setting and Design This study took place at Johns Hopkins Bayview Medical Center, a 335-bed university-affiliated medical center in Baltimore, Maryland. The emergency department is a designated level-II center for adult trauma, adult burn, and primary stroke. With capacity for 30 primary treatment rooms, the emergency department registered 54607 visits in the fiscal year ending June 2007. Historically, approximately 25% of the patients registered in the emergency department are admitted, which forms 61% of the hospitals total admissions. Roughly 75% of department of medicine admissions come from the emergency department, totaling approximately 9700 patients annually. The hospitalist division had 14.7 full-timeequivalent physician faculty, 3.0 nurse practitioners, and 4.6 physician assistants at the time of the study. In Maryland, the controlling authority for emergency medical services is the Maryland Institute for Emergency Medical Services Systems. It has defined 2 levels of ambulance diversion. First, an emergency department is put on yellow alert when experiencing a temporary overwhelming overload such that priority II or III patients may not be managed safely. During this period, the Emergency Department requests that absolutely no priority II or priority III patients be transported to their facility. Second, red alert is the designation used when a hospital does not have any electrocardiography-monitored or critical care beds available. During red alert, patients who are likely to require this type of care are not to be transported to the emergency department; instead they are taken to the next closest appropriate hospital (10). These distinct alerts can be invoked separately in coordination with Maryland Institute for Emergency Medical Services Systems, which keeps a record of all alerts for all institutions in Maryland. Using a prepost design, we compared the relevant institution-level clinical data from the intervention period (November 2006 to February 2007) with data from the control period (November 2005 to February 2006) (Figure 1). This study was exempt by the institutional review board. Figure 1. Study flow diagram. JHBMC = Johns Hopkins Bayview Medical Center. Active Bed Management Intervention Before active bed management, the emergency department assigned patients who were admitted to 1 of 5 department of medicine admission services (cardiac intensive care unit [ICU]; medical ICU; and cardiology, pulmonary, and general medicine units). For all units except the general medicine unit, once the department of medicine house officer or a physician assistant was informed of the proposed admission by emergency department personnel, they were expected to evaluate the patient in the emergency department and initiate the transfer to the assigned hospital unit. For the general medicine unit, patient assignments were communicated from the emergency department through a page to a triage physician (hospitalists from 8 a.m. to 8 p.m. and house officers overnight), and once accepted, transfers from the emergency department to the medical floor occurred without in-person evaluation by the department of medicine. Active bed management, done in 12-hour shifts, is coordinated and staffed solely by the hospitalist service 24 hours a day, 7 days a week. All hospitalists in the division rotate through the active bed management role, and the active bed management physician is freed from all other clinical care duties so that his or her only clinical responsibility is facilitation of the active bed management processes. Active bed management was strategically designed around 3 fundamental elements: proactive management of department of medicine resources, evaluation and assignment of all departmental admissions, and mobilization of additional resources by the bed director. Proactive Management of Department of Medicine Resources The active bed management hospitalist assesses bed availability in real time for 2 ICUs (12 beds each), the intermediate care unit (3 beds), 2 subspecialty units (cardiac and pulmonary), and the 4 large general medicine units. These continuous assessments are designed to identify potential resource shortages, such as limited ICU beds, before they occur. Assessments are done through collaboration with unit-specific attending physicians, nursing supervisors, and charge nurses in real time, as well as through twice-daily prediversion rounds in the ICUs. Prediversion rounds provide the ICU teams with information on hospital bed status and identify patients who can be downgraded from critical care status and transferred to nonintensive care settings. Prediversion rounds also serve to collect accurate bed information to allow collaboration between the active bed management hospitalist and emergency department physician on patient flow. Evaluation and Assignment of New Admissions to Department of Medicine Inpatient Clinical Settings The active bed management hospitalist makes collaborative triage decisions about the optimal clinical setting for each patient who requires admission through consultation with all admitting physicians (predominantly emergency department physicians) initially by telephone. Pertinent clinical data are documented on a triage template, and the hospitalist then decides about the need to evaluate selected emergency department patients directly. Authority to make determinations on the assignment of patients to beds in the various services in the department of medicine has been granted to the active bed management hospitalist by the department chairman. Once the hospitalist accepts the admission, the emergency department attending writes brief admitting orders from preexisting order sets. Non-ICU admissions are transferred to the inpatient floor as soon as a bed is available. The receiving medical teams are notified about patients on initial triage and on their arrival to the inpatient unit. Intensive care unit admissions are transferred to the unit no longer than 90 minutes after the disposition decision has been made. This brief period allows ICU teams time to ready themselves and stabilize other patients (if necessary) while facilitating the timely transfer of critically ill patients out of the emergency department. Role of the Bed Director The bed director position was created as part of this intervention to support the active bed management hospitalists. The bed director is the hospitalist leader on call (either division chief or associate division chief). The active bed management hospitalist notifies the bed director if the hospital is put on red or yellow alert, if an alert seems to be looming, or if emergency department throughput for admitted patients is long and resultant crowding is occurring. The bed director has the authority to activate additional resources, both internal and external, to the department of medicine to address such issues in real time. Some resources available to the bed director to shorten delays in throughput and prevent ambulance diversion include calling in additional hospitalists, redirecting admissions to departments outside of medicine, and assigning medical admissions to nondepartment of medicine inpatient beds (where they will be cared for by the hospitalists). The Johns Hopkins

Morbidity and mortality conference, grand rounds, and the ACGME's core competencies.

Morbidity and Mortality (M&M) Conferences are an Accreditation Council for Graduate Medical Education (ACGME) mandated educational series that occur regularly at all institutions that have residency training programs. The potential for learning from medical errors, complications, and unanticipated outcomes is immense—provided that the focus is on education, as opposed to culpability. The education innovation described in this manuscript is the manner in which we have used the ACGME Outcome Project’s 6 core competencies as the structure upon which the cases discussed at our M&M conference are framed. When presented at grand rounds in a novel format, M&M conference has not only maintained support for the quality improvement efforts in the Department, but has served to improve the educational impact of the conference.

Residents' perceptions of professionalism in training and practice: barriers, promoters, and duty hour requirements.

BACKGROUND: The Accreditation Council for Graduate Medical Education duty hour requirements may affect residents’ understanding and practice of professionalism.OBJECTIVE: We explored residents’ perceptions about the current teaching and practice of professionalism in residency and the impact of duty hour requirements.DESIGN: Anonymous cross-sectional survey.PARTICIPANTS: Internal medicine, neurology, and family practice residents at 3 teaching hospitals (n=312).MEASUREMENTS: Using Likert scales and open-ended questions, the questionnaire explored the following: residents’ attitudes about the principles of professionalism, the current and their preferred methods for teaching professionalism, barriers or promoters of professionalism, and how implementation of duty hours has affected professionalism.RESULTS: One hundred and sixty-nine residents (54%) responded. Residents rated most principles of professionalism as highly important to daily practice (91.4%, 95% confidence interval [CI] 90.0 to 92.7) and training (84.7%, 95% CI 83.0 to 86.4), but fewer rated them as highly easy to incorporate into daily practice (62.1%, 95% CI 59.9 to 64.3), particularly conflicts of interest (35.3%, 95% CI 28.0 to 42.7) and self-awareness (32.0%, 95% CI 24.9 to 39.1). Role-modeling was the teaching method most residents preferred. Barriers to practicing profession-alism included time constraints, workload, and difficulties interacting with challenging patients. Promoters included role-modeling by faculty and colleagues and a culture of professionalism. Regarding duty hour limits, residents perceived less time to communicate with patients, continuity of care, and accountability toward their colleagues, but felt that limits improved professionalism by promoting resident well-being and teamwork.CONCLUSIONS: Residents perceive challenges to incorporating professionalism into their daily practice. The duty hour implementation offers new challenges and opportunities for negotiating the principles of professionalism.

Improving Interunit Transitions of Care Between Emergency Physicians and Hospital Medicine Physicians: A Conceptual Approach

Patient care transitions across specialties involve more complexity than those within the same specialty, yet the unique social and technical features remain underexplored. Further, little consensus exists among researchers and practitioners about strategies to improve interspecialty communication. This concept article addresses these gaps by focusing on the hand-off process between emergency and hospital medicine physicians. Sensitivity to cultural and operational differences and a common set of expectations pertaining to hand-off content will more effectively prepare the next provider to act safely and efficiently when caring for the patient. Through a consensus decision-making process of experienced and published authorities in health care transitions, including physicians in both specialties as well as in communication studies, the authors propose content and style principles clinicians may use to improve transition communication. With representation from both community and academic settings, similarities and differences between emergency medicine and internal medicine are highlighted to heighten appreciation of the values, attitudes, and goals of each specialty, particularly pertaining to communication. The authors also examine different communication media, social and cultural behaviors, and tools that practitioners use to share patient care information. Quality measures are proposed within the structure, process, and outcome framework for institutions seeking to evaluate and monitor improvement strategies in hand-off performance. Validation studies to determine if these suggested improvements in transition communication will result in improved patient outcomes will be necessary. By exploring the dynamics of transition communication between specialties and suggesting best practices, the authors hope to strengthen hand-off skills and contribute to improved continuity of care.

Clinical Communities at Johns Hopkins Medicine: An Emerging Approach to Quality Improvement

BACKGROUND Clinical communities are an emerging approach to quality improvement (QI) to which several large-scale projects have attributed some success. In 2011 the Armstrong Institute for Patient Safety and Quality established clinical communities as a core strategy to connect frontline providers from six different hospitals to improve quality of care, patient safety, and value across the health system. CLINICAL COMMUNITIES: Fourteen clinical communities that presented great opportunity for improvement were established. A community could focus on a clinical area, a patient population, a group, a process, a safety-related issue, or nearly any health care issue. The collaborative spirit of the communities embraced interdisciplinary membership and representation from each hospital in each community. Communities engaged in team-building activities and facilitated discussions, met monthly, and were encouraged to meet in person to develop relationships and build trust. After a community was established, patients and families were invited to join and share their perspectives and experiences. ENABLING STRUCTURES: The clinical community structure provided clinicians access to resources, such as technical experts and safety and QI researchers, that were not easily otherwise accessible or available. Communities convened clinicians from each hospital to consider safety problems and their resolution and share learning with workplace peers and local unit safety teams. CONCLUSION The clinical communities engaged 195 clinicians from across the health system in QI projects and peer learning. Challenges included limited financial support and time for clinicians, timely access to data, limited resources from the health system, and not enough time with improvement experts.

What motivates physicians throughout their careers in medicine

Review ArticleMotivation provides direction and purpose in physicians’ work, and motivating factors vary during different career stages. Motivation theories divide sources of motivation into those intrinsic to the work, such as the opportunity for self-expression and intellectual challenge, and those extrinsic to the work, such as salary and time. Although much attention has focused on minimizing negative extrinsic factors, the authors argue that career resilience requires that physicians reflect on and define the sources of their own intrinsic motivation. Opportunities to maximize self-awareness may allow physicians to structure their work in ways that maximize meaning and fulfillment over the long-term.

Project BOOST implementation: Lessons learned

Objectives Enhancing care coordination and reducing hospital readmissions have been a focus of multiple quality improvement (QI) initiatives. Project BOOST (Better Outcomes by Optimizing Safe Transitions) aims to enhance the discharge transition from hospital to home. Previous research indicates that QI initiatives originating externally often face difficulties gaining momentum or effecting lasting change in a hospital. We performed a qualitative evaluation of Project BOOST implementation by examining the successes and failures experienced by six pilot sites. We also evaluated the unique physician mentoring component of this program. Finally, we examined the impact of intensification of the physician mentoring model on adoption of BOOST interventions in two later Illinois cohorts (27 hospitals). Methods Qualitative analysis of six pilot hospitals used a process of methodological triangulation and analysis of the BOOST enrollment applications, the listserv, and content from telephone interviews. Evaluation of BOOST implementation at Illinois hospitals occurred via mid-year and year-end surveys. Results The identified common barriers included inadequate understanding of the current discharge process, insufficient administrative support, lack of protected time or dedicated resources, and lack of frontline staff buy-in. Facilitators of implementation included the mentor, a small beginning, teamwork, and proactive engagement of the patient. Notably, hospitals viewed their mentors as essential facilitators of change. Sites consistently commented that the individualized mentoring was extremely helpful and provided significant accountability and stimulated creativity. In the Illinois cohorts, the improved mentoring model showed more complete implementation of BOOST interventions. Conclusions The implementation of Project BOOST was well received by hospitals, although sites faced substantial barriers consistent with other QI research reports. The unique mentorship element of Project BOOST proved extremely valuable in helping sites overcome their distinctive challenges and identify facilitators for success. The findings from this qualitative study should contribute to future BOOST implementation success and others’ efforts to optimize hospital discharge transitions.

An innovative approach to supporting hospitalist physicians towards academic success

BACKGROUND Academic hospitalist physicians face significant challenges that may threaten their chances for successful and timely promotions, such as heavy clinical workloads, limited training in research, and relatively few experienced mentors in their field. The appreciable growth of hospital medicine groups in recent years, as has occurred at our institution, compounds the predicament by diluting the limited resources that are available to support these physicians. METHODS A needs assessment was followed by the development of specific objectives for the division and for individual members of the division related to academic success. The resulting 3-pronged strategy to support the academic success of our group was based on securing strong mentorship, investing requisite resources, and committing to recruit fellowship-trained new faculty. RESULTS To date, the initiative has resulted in an increased number of peer-reviewed publication and grants, as well as national leadership roles for division members.

Hospitalists' ability to use hand-carried ultrasound for central venous pressure estimation after a brief training intervention: A pilot study

BACKGROUND Access to hand-carried ultrasound technology for noncardiologists has increased significantly, yet development and evaluation of training programs are limited. OBJECTIVE We studied a focused program to teach hospitalists image acquisition of inferior vena cava (IVC) diameter and IVC collapsibility index with interpretation of estimated central venous pressure (CVP). METHODS Ten hospitalists completed an online educational module prior to attending a 1-day in-person training session that included directly supervised IVC imaging on volunteer subjects. In addition to making quantitative assessments, hospitalists were also asked to visually assess whether the IVC collapsed more than 50% during rapid inspiration or a sniff maneuver. Skills in image acquisition and interpretation were assessed immediately after training on volunteer patients and prerecorded images, and again on volunteer patients at least 6 weeks later. RESULTS Eight of 10 hospitalists acquired adequate IVC images and interpreted them correctly on 5 of the 5 volunteer subjects and interpreted all 10 prerecorded images correctly at the end of the 1-day training session. At 7.4 ± 0.7 weeks (range, 6.9-8.6 weeks) follow-up, 9 of 10 hospitalists accurately acquired and interpreted all IVC images in 5 of 5 volunteers. Hospitalists were also able to accurately determine whether the IVC collapsibility index was more than 50% by visual assessment in 180 of 198 attempts (91% of the time). CONCLUSIONS After a brief training program, hospitalists acquired adequate skills to perform and interpret hand-carried ultrasound IVC images and retained these skills in the near term. Though calculation of the IVC collapsibility index is more accurate, coupling a qualitative assessment with the IVC maximum diameter measurement may be acceptable in aiding bedside estimation of CVP.