Gregory B. Seymann

The Many Faces of Error Disclosure: A Common Set of Elements and a Definition

BackgroundPatients want to know when errors happen in their care. Professional associations, ethicists, and patient safety experts endorse disclosure of medical error to patients. Surveys of physicians show that they believe harmful errors should be disclosed to patients, yet errors are often not disclosed.ObjectiveTo understand the discrepancy between patients’ expectations and physicians’ behavior concerning error disclosure.Design, Setting, and ParticipantsWe conducted focus groups to determine what constitutes disclosure of medical error. Twenty focus groups, 4 at each of 5 academic centers, included 204 hospital administrators, physicians, residents, and nurses.ApproachQualitative analysis of the focus group transcripts with attention to examples of error disclosure by clinicians and hospital administrators.ResultsClinicians and administrators considered various forms of communication about errors to be error disclosure. Six elements of disclosure identified from focus group transcripts characterized disclosures ranging from Full disclosure (including admission of a mistake, discussion of the error, and a link from the error to harm) to Partial disclosures, which included deferral, misleading statements, and inadequate information to “connect the dots.” Descriptions involving nondisclosure of harmful errors were uncommon.ConclusionsError disclosure may mean different things to clinicians than it does to patients. The various forms of communication deemed error disclosure by clinicians may explain the discrepancy between error disclosure beliefs and behaviors. We suggest a definition of error disclosure to inform practical policies and interventions.

The HCAP Gap: Differences between Self-Reported Practice Patterns and Published Guidelines for Health Care-Associated Pneumonia

BACKGROUND Health care-associated pneumonia (HCAP) is prevalent among hospitalized patients. In contrast to community-acquired pneumonia (CAP), patients with HCAP are at increased risk for multidrug-resistant organisms, and appropriate initial antibiotic therapy is associated with reduced mortality. METHODS An online survey was distributed to faculty and housestaff at 4 academic medical centers. The survey required respondents to choose initial antibiotic therapy for 9 hypothetical pneumonia cases (7 cases of HCAP and 2 cases of CAP). Answers were considered correct if the antibiotic regimen chosen was consistent with published guidelines. In addition, physicians rated their knowledge of current guidelines, as well as their level of agreement with guideline recommendations. RESULTS Surveys were sent to 1313 physicians with a response rate of 65% (n = 855). Respondents included physicians in the following categories: hospital medicine/internal medicine, 60%; emergency medicine, 25%; and critical care, 13%. Respondents selected guideline-concordant antibiotic regimens 78% of the time for CAP, but only 9% of the time for HCAP. Because mean scores for HCAP questions were extremely low (mean, 0.63 correct answers out of 7), differences in performance between groups were too small to be meaningful. Despite their poor performance, 71% of the respondents stated that they are aware of published guidelines for HCAP, and 79% stated that they agree with and practice according to the guidelines. CONCLUSIONS In this survey, physicians reported they were aware of, agreed with, and practiced according to published pneumonia guidelines; however, the overwhelming majority did not choose guideline-concordant therapy when tested.

Nicotine patches and quitline counseling to help hospitalized smokers stay quit: study protocol for a randomized controlled trial

BackgroundHospitalized smokers often quit smoking, voluntarily or involuntarily; most relapse soon after discharge. Extended follow-up counseling can help prevent relapse. However, it is difficult for hospitals to provide follow-up and smokers rarely leave the hospital with quitting aids (for example, nicotine patches). This study aims to test a practical model in which hospitals work with a state cessation quitline. Hospital staff briefly intervene with smokers at bedside and refer them to the quitline. Depending on assigned condition, smokers may receive nicotine patches at discharge or extended quitline telephone counseling post-discharge. This project establishes a practical model that lends itself to broader dissemination, while testing the effectiveness of the interventions in a rigorous randomized trial.Methods/designThis randomized clinical trial (N = 1,640) tests the effect of two interventions on long-term quit rates of hospitalized smokers in a 2 x 2 factorial design. The interventions are (1) nicotine patches (eight-week, step down program) dispensed at discharge and (2) proactive telephone counseling provided by the state quitline after discharge. Subjects are randomly assigned into: usual care, nicotine patches, telephone counseling, or both patches and counseling. It is hypothesized that patches and counseling have independent effects and their combined effect is greater than either alone. The primary outcome measure is thirty-day abstinence at six months; a secondary outcome is biochemically validated smoking status. Cost-effectiveness analysis is conducted to compare each intervention condition (patch alone, counseling alone, and combined interventions) against the usual care condition. Further, this study examines whether smokers’ medical diagnosis is a moderator of treatment effect. Generalized linear (binomial) mixed models will be used to study the effect of treatment on abstinence rates. Clustering is accounted for with hospital-specific random effects.DiscussionIf this model is effective, quitlines across the U.S. could work with interested hospitals to set up similar systems. Hospital accreditation standards related to tobacco cessation performance measures require follow-up after discharge and provide additional incentive for hospitals to work with quitlines. The ubiquity of quitlines, combined with the consistency of quitline counseling delivery as centralized state operations, make this partnership attractive.Trial registrationSmoking cessation in hospitalized smokers NCT01289275. Date of registration February 1, 2011; date of first patient August 3, 2011.

Clinical judgment versus the Pneumonia Severity Index in making the admission decision.

The Pneumonia Severity Index (PSI) is a validated risk assessment tool for patients with community-acquired pneumonia (CAP). Guidelines endorse outpatient treatment for patients deemed low risk, but experience shows that such patients are frequently hospitalized. We investigated the limitations of the PSI as a triage tool by examining outcomes in patients whose disposition from the Emergency Department differed from that predicted by the PSI. PSI scores were calculated by retrospective chart review for all adults with CAP presenting to the Emergency Department of a university medical center. Disposition was classified as consistent with the PSI when low-risk patients were discharged and high-risk patients were admitted. Charts of low-risk patients whose disposition was inconsistent with the PSI were abstracted for documentation of comorbidities contributing to the admission decision, as well as length of stay and level of care. There were 174 patients with CAP who met inclusion criteria, and 32% had a disposition inconsistent with the PSI. Eighty-six percent of the inconsistencies involved low-risk patients admitted to the hospital, and 41% of all low-risk patients with CAP were hospitalized. Hypoxia contributed to the decision to admit in 48% of these patients. Average length of stay was 5.2 days, and 78% of patients remained in the hospital > 48 h. Hypoxia was the most frequent factor contributing to admission of low-risk patients with CAP. Low-risk inpatients had a significant length of stay, suggesting that clinical judgment appropriately superseded the PSI in these cases.

Helping Hospitalized Smokers: A Factorial RCT of Nicotine Patches and Counseling.

INTRODUCTION Most smokers abstain from smoking during hospitalization but relapse upon discharge. This study tests the effectiveness of two proven treatments (i.e., nicotine patches and telephone counseling) in helping these patients stay quit after discharge from the hospital, and assesses a model of hospital-quitline partnership. STUDY DESIGN This study had a 2×2 factorial design in which participants were stratified by recruitment site and smoking rate and randomly assigned to usual care, nicotine patches only, counseling only, or patches plus counseling. They were evaluated at 2 and 6 months post-randomization. SETTING/PARTICIPANTS A total of 1,270 hospitalized adult smokers were recruited from August 2011 to November 2013 from five hospitals within three healthcare systems. INTERVENTION Participants in the patch condition were provided 8 weeks of nicotine patches at discharge (or were mailed them post-discharge). Quitline staff started proactively calling participants in the counseling condition 3 days post-discharge to provide standard quitline counseling. MAIN OUTCOME MEASURES The primary outcome measure was self-reported 30-day abstinence at 6 months using an intention-to-treat analysis. Data were analyzed from September 2015 to May 2016. RESULTS The 30-day abstinence rate at 6 months was 22.8% for the nicotine patch condition and 18.3% for the no-patch condition (p=0.051). Nearly all participants (99%) in the patch condition were provided nicotine patches, although 36% were sent post-discharge. The abstinence rates were 20.0% and 21.1% for counseling and no counseling conditions, respectively (p=0.651). Fewer than half of the participants in the counseling condition (47%) received counseling (mean follow-up sessions, 3.6). CONCLUSIONS Provision of nicotine patches proved feasible, although their effectiveness in helping discharged patients stay quit was not significant. Telephone counseling was not effective, in large part because of low rates of engagement. Future interventions will need to be more immediate to be effective. TRIAL REGISTRATION This study is registered at www.clinicaltrials.gov NCT01289275.

Features of successful academic hospitalist programs: Insights from the SCHOLAR (SuCcessful HOspitaLists in academics and research) project

BACKGROUND As clinical demands increase, understanding the features that allow academic hospital medicine programs (AHPs) to thrive has become increasingly important. OBJECTIVE To develop and validate a quantifiable definition of academic success for AHPs. METHODS A working group of academic hospitalists was formed. The group identified grant funding, academic promotion, and scholarship as key domains reflective of success, and specific metrics and approaches to assess these domains were developed. Self-reported data on funding and promotion were available from a preexisting survey of AHP leaders, including total funding/group, funding/full-time equivalent (FTE), and number of faculty at each academic rank. Scholarship was defined in terms of research abstracts presented over a 2-year period. Lists of top performers in each of the 3 domains were constructed. Programs appearing on at least 1 list (the SCHOLAR cohort [SuCcessful HOspitaLists in Academics and Research]) were examined. We compared grant funding and proportion of promoted faculty within the SCHOLAR cohort to a sample of other AHPs identified in the preexisting survey. RESULTS Seventeen SCHOLAR programs were identified, with a mean age of 13.2 years (range, 6-18 years) and mean size of 36 faculty (range, 18-95). The mean total grant funding/program was

Evaluation of the Yale New Haven Readmission Risk Score for Pneumonia in a General Hospital Population

4 million (range,

Hospitalist Management of Community-Acquired Pneumonia: Consensus Statement

0-

Management of community-acquired pneumonia: A hospitalist perspective

15 million), with mean funding/FTE of

A Conceptual Model for Disclosure of Medical Errors

364,000 (range,