Grace Y. Jenq

Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators

Objective The objective of this study was to qualitatively describe the impact of a Rapid Response Team (RRT) at a 944-bed, university-affiliated hospital. Methods We analysed 49 open-ended interviews with administrators, primary team attending physicians, trainees, RRT attending hospitalists, staff nurses, nurses and respiratory technicians. Results Themes elicited were categorised into the domains of (1) morale and teamwork, (2) education, (3) workload, (4) patient care, and (5) hospital administration. Positive implications beyond improved care for acutely ill patients were: increased morale and empowerment among nurses, real-time redistribution of workload for nurses (reducing neglect of non-acutely ill patients during emergencies), and immediate access to expert help. Negative implications were: increased tensions between nurses and physician teams, a burden on hospitalist RRT members, and reduced autonomy for trainees. Conclusions The RRT provides advantages that extend well beyond a reduction in rates of transfers to intensive care units or codes but are balanced by certain disadvantages. The potential impact from these multiple sources should be evaluated to understand the utility of any RRT programme.

Evaluation of an Asynchronous Physician Voicemail Sign-out for Emergency Department Admissions

STUDY OBJECTIVE Communication failures contribute to errors in the transfer of patients from the emergency department (ED) to inpatient medicine units. Oral (synchronous) communication has numerous benefits but is costly and time consuming. Taped (asynchronous) communication may be more reliable and efficient but lacks interaction. We evaluate a new asynchronous physician-physician sign-out compared with the traditional synchronous sign-out. METHODS A voicemail-based, semistructured sign-out for routine ED admissions to internal medicine was implemented in October 2007 at an urban, academic medical center. Outcomes were obtained by pre- and postintervention surveys of ED and internal medicine house staff, physician assistants, and hospitalist attending physicians and by examination of access logs and administrative data. Outcome measures included utilization; physician perceptions of ease, accuracy, content, interaction, and errors; and rate of transfers to the ICU from the floor within 24 hours of ED admission. Results were analyzed both quantitatively and qualitatively with standard qualitative analytic techniques. RESULTS During September to October 2008 (1 year postintervention), voicemails were recorded about 90.3% of medicine admissions; 69.7% of these were accessed at least once by admitting physicians. The median length of each sign-out was 2.6 minutes (interquartile range 1.9 to 3.5). We received 117 of 197 responses (59%) to the preintervention survey and 113 of 206 responses (55%) to the postintervention survey. A total of 73 of 101 (72%) respondents reported dictated sign-out was easier than oral sign-out and 43 of 101 (43%) reported it was more accurate. However, 70 of 101 (69%) reported that interaction among participants was worse. There was no change in the rate of ICU transfer within 24 hours of admission from the ED in April to June 2007 (65/6,147; 1.1%) versus April to June 2008 (70/6,263; 1.1%); difference of 0%, 95% confidence interval -0.4% to 0.3%. The proportion of internists reporting at least 1 perceived adverse event relating to transfer from the ED decreased a nonsignificant 10% after the intervention (95% confidence interval -27% to 6%), from 44% preintervention (32/72) to 34% postintervention (23/67). CONCLUSION Voicemail sign-out for ED-internal medicine communication was easier than oral sign-out without any change in early ICU transfers or the perception of major adverse events. However, interaction among participants was reduced. Voicemail sign-out may be an efficient means of improving sign-out communication for stable ED admissions.

Comprehensive quality of discharge summaries at an academic medical center

BACKGROUND Discharge summaries are essential for safe transitions from hospital to home. OBJECTIVE To conduct a comprehensive quality assessment of discharge summaries. DESIGN Prospective cohort study. SUBJECTS Three hundred seventy-seven patients discharged home after hospitalization for acute coronary syndrome, heart failure, or pneumonia. MEASURES Discharge summaries were assessed for timeliness of dictation, transmission of the summary to appropriate outpatient clinicians, and presence of key content including elements required by The Joint Commission and elements endorsed by 6 medical societies in the Transitions of Care Consensus Conference (TOCCC). RESULTS A total of 376 of 377 patients had completed discharge summaries. A total of 174 (46.3%) summaries were dictated on the day of discharge; 93 (24.7%) were completed more than a week after discharge. A total of 144 (38.3%) discharge summaries were not sent to any outpatient physician. On average, summaries included 5.6 of 6 The Joint Commission elements and 4.0 of 7 TOCCC elements. Summaries dictated by hospitalists were more likely to be timely and to include key content than summaries dictated by housestaff or advanced practice nurses. Summaries dictated on the day of discharge were more likely to be sent to outside physicians and to include key content. No summary met all 3 quality criteria of timeliness, transmission, and content. CONCLUSIONS Discharge summary quality is inadequate in many domains. This may explain why individual aspects of summary quality such as timeliness or content have not been associated with improved patient outcomes. However, improving discharge summary timeliness may also improve content and transmission.

The revolving hospital door: hospital readmissions among patients who are homeless.

Background:National attention is increasingly focused on hospital readmissions. Little prior research has examined readmissions among patients who are homeless. Objective:The aim of the study was to determine 30-day hospital readmission rates among patients who are homeless and examine factors associated with hospital readmissions in this population. Methods:We conducted a retrospective chart review of patients who were homeless and hospitalized at a single urban hospital from May–August 2012. Homelessness was identified by an electronic medical record flag and confirmed by manual chart review. The primary outcome was all-cause hospital readmission to the study hospital within 30 days of hospital discharge. Patient-level and hospitalization-level factors associated with risk for readmission were examined using generalized estimating equations. Results:There were 113 unique patients who were homeless and admitted to the hospital a total of 266 times during the study period. The mean age was 49 years, 27.4% of patients were women, and 75.2% had Medicaid. Half (50.8%) of all hospitalizations resulted in a 30-day hospital inpatient readmission and 70.3% resulted in either an inpatient readmission, observation status stay, or emergency department visit within 30 days of hospital discharge. Most readmissions occurred early after hospital discharge (53.9% within 1 week, 74.8% within 2 weeks). Discharge to the streets or shelter versus other living situations was associated with increased risk for readmission in multivariable analyses. Conclusions:Patients who were homeless had strikingly high 30-day hospital readmission rates. These findings suggest the urgent need for further research and interventions to improve postdischarge care for patients who are homeless.

Changes in End-of-Life Care Over the Past Decade: More Not Better

IN THIS ISSUE OF JAMA, THE REPORT BY TENO AND COLleagues compared sites of death and health care received in the months prior to death among a total of nearly 850 000 US Medicare beneficiaries who died in 2000, 2005, and 2009. More people died at home or hospice as the decade progressed. Simultaneously, the proportion of people who died in acute care hospitals decreased from 32.6% in 2000 to 24.6% in 2009. The percentage of patients receiving hospice services at the time of death doubled over the decade, from 21.6% in 2000 to 42.2% in 2009. During the same time period, however, the frequency of hospitalizations and intensive care unit (ICU) stays during the last months of life increased. The increased availability of palliative and hospice care services does not appear to have changed the focus on aggressive, curative care. Hospice services appeared to be tagged on to the last days of life. The multiple hospitalizations and transitions in sites of care during the final days of life mirror similar increases reported for patients with nonterminal illness. Hospitals are now penalized by the Centers for Medicare & Medicaid Services (CMS) for high readmission rates. Equating readmissions with inadequate discharge planning and poor care transitions, hospitals are making efforts to improve communication between inpatient and outpatient clinicians, provide better patient education, and enhance posthospitalization support and follow-up. The frequent hospitalizations and transitions in sites of care observed at the end of life, however, suggest that issues other than inadequate discharge planning may be driving many readmissions. The administrative and billing data available in the study by Teno et al do not allow investigation of the reasons for these frequent rehospitalizations, but in-depth local data are available. As part of the CMS’s Community-based Care Transitions Program, funded by section 3026 of the Affordable Care Act, our local community has enhanced its transition care services. Despite these additional posthospitalization supports and services, however, some patients experience frequent hospitalizations toward the end of their lives, similar to the trajectory reported by Teno et al. For instance, an 80-year-old resident of a skilled nursing facility (SNF) who had dementia, chronic kidney disease, and several other chronic conditions exemplifies this phenomenon. She was hospitalized after developing acute kidney injury and hyperkalemia following a few days of decreased food and fluid intake. After receiving intravenous fluids and other interventions, the patient returned to the SNF but was rehospitalized several times until her death a few months later. These subsequent readmissions were for dyspnea, dehydration, and other acute problems that were reversed temporarily with acute care. Were these hospitalizations appropriate? To answer this question, it is necessary to consider whether these hospitalizations were congruent with this patient’s health goals and whether the hospital was the best place to provide the care she received. Fried et al have shown that health outcome goals and preferences of many patients change as their condition worsens; many patients do want to receive acute care even when the effect is short-lived or there is little chance of success. Reasonable people may disagree about whether it is appropriate to provide acute care in these situations. Most people can agree, however, that the preferences and goals of care of patients—and their caregivers, when appropriate—should be elicited. These preferences and goals should determine what services are offered. The focus appears to be on providing curative care in the acute hospital regardless of likelihood of benefit or preferences of patients. If programs aimed at reducing unnecessary care are to be successful, patients’ goals of care must be elicited and treatment options such as palliative and hospice care offered earlier in the process than is the current norm. Studies involving patients with advanced cancer and severe obstructive lung disease show continued communication gaps between patients and clinicians concerning end-of-life care preferences and goals.

The journey across the health care (Dis)continuum for vulnerable patients: Policies, pitfalls, and possibilities

The journey through the health care system for most patients with serious injuries or illnesses begins in the emergency department(ED).EDsarestructured torapidlymanageandtreat largenumbersofpatients.Thenecessary focusonspeed,however,acceleratedwhentheJointCommissioncreatedstandards toaddressovercrowding, and is inconflictwith thecarefuldeliberations needed to care for complex patients with multiple acute and chronic conditions. The chaotic and unfamiliar environmentcanexacerbateproblemssuchaspainanddelirium. In response to these adverse consequences of the ED experience, geriatric ED units have been developed. Less noise, more natural lighting, friendly volunteers, and fewer machines characterize geriatric EDs. Although early evidence suggests fewer return ED visits, opponents cite lack of evidence of better patient outcomes, distraction from giving optimal treatment to all patients, and a focus on amenities rather than medical care. Inclusion of patient satisfaction items in upcoming value-based purchasing initiatives coming from the Centers for Medicare & Medicaid Services (CMS) suggests that amenities are important considerations inhealthcare. Whether geriatric EDs improve outcomes remains to be determined.

Novel Integration of Systems-Based Practice Into Internal Medicine Residency Programs: The Interactive Cost-Awareness Resident Exercise (I-CARE)

Background: The Accreditation Council for Graduate Medical Education and American Board of Internal Medicine have identified cost-awareness as an important component to residency training. Cost-awareness is generally not emphasized in current, traditional residency curricula despite the recognized importance of this topic. Description: Using a traditional Morning Report structure and actual charge data from our institution, the charges associated with trainee-directed workup of clinical cases are compared in a friendly competition among medical students, interns, residents, and faculty. Evaluation: Anonymous, voluntary survey of all participants and comparison of expenditures by training level were used to assess this pilot program. The educational quality of the I-CARE was rated higher than the prior format of Morning Report by participants (10-point Likert scale; 8.57, 6.81 respectively; p < .001). Open-ended comments were overwhelmingly supportive from faculty and trainees. Cost was lower for attending physicians than for trainees (

Republished: Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators.

1,027.45 vs.

Electronic handoff instruments: a truly multidisciplinary tool?

4,264.00, p = .02) and diagnostic accuracy was also highest for attending physicians. Conclusions: The I-CARE is easy and quick to implement, and the preliminary results show a popular cost-awareness educational experience for internal medicine trainees. Further study is needed to determine change in practice habits.

Quasi-Experimental Evaluation of the Effectiveness of a Large-Scale Readmission Reduction Program

Objective The objective of this study was to qualitatively describe the impact of a Rapid Response Team (RRT) at a 944-bed, university-affiliated hospital. Methods We analysed 49 open-ended interviews with administrators, primary team attending physicians, trainees, RRT attending hospitalists, staff nurses, nurses and respiratory technicians. Results Themes elicited were categorised into the domains of (1) morale and teamwork, (2) education, (3) workload, (4) patient care, and (5) hospital administration. Positive implications beyond improved care for acutely ill patients were: increased morale and empowerment among nurses, real-time redistribution of workload for nurses (reducing neglect of non-acutely ill patients during emergencies), and immediate access to expert help. Negative implications were: increased tensions between nurses and physician teams, a burden on hospitalist RRT members, and reduced autonomy for trainees. Conclusions The RRT provides advantages that extend well beyond a reduction in rates of transfers to intensive care units or codes but are balanced by certain disadvantages. The potential impact from these multiple sources should be evaluated to understand the utility of any RRT programme.