Robert Chang

Overutilization of proton-pump inhibitors: what the clinician needs to know.

Proton-pump inhibitors (PPIs) remain the leading evidence-based therapy for upper gastrointestinal disorders, including gastroesophageal reflux disease, dyspepsia, and peptic ulcer disease. The effectiveness of PPIs has led to overutilization in multiple treatment arenas, exposing patients to an increasing number of potential risks. The overutilization of PPIs in ambulatory care settings is often a result of failure to re-evaluate the need for continuation of therapy, or insufficient use of on-demand and step-down therapy. PPI overutilization in the inpatient setting is often a result of inappropriate stress ulcer prophylaxis (SUP) in nonintensive care unit patients, and failure to discontinue SUP prior to hospital discharge. Potential consequences of prolonged PPI therapy include hypergastrinemia, enterochromaffin-like cell hyperplasia, and parietal cell hypertrophy, leading to rebound acid hypersecretion. PPIs have been linked via retrospective studies to increased risk of enteric infections including Clostridium difficile-associated diarrhea, community-acquired pneumonia, bone fracture, nutritional deficiencies, and interference with metabolism of antiplatelet agents. Reducing inappropriate prescribing of PPIs in the inpatient and outpatient settings can minimize potential for adverse events, and foster controllable cost expenditure.

Work sampling: Analyzing nursing staff productivity

Most managers have only a vague idea of how their employees spend their time. Work sampling is a technique that can identify the types of activities that staff perform and the amount of time that they spend on each activity. With this information, managers can make decisions regarding allocation of staff and activities, thereby increasing efficiency and effectiveness of personnel. This paper describes the use of work sampling as a technique to study employee time allocation and productivity. It offers suggestions for planning, implementation, and utilization of the results of a work sampling study. A work sampling study conducted at the University of Michigan Medical Centers Psychiatric Nursing Department is used as an example.

A mobility program for an inpatient acute care medical unit.

OverviewFor many patients, hospitalization brings prolonged periods of bed rest, which are associated with such adverse health outcomes as increased length of stay, increased risk of falls, functional decline, and extended-care facility placement. Most studies of progressive or early mobility protocols designed to minimize these adverse effects have been geared toward specific patient populations and conducted by multidisciplinary teams in either ICUs or surgical units. Very few mobility programs have been developed for and implemented on acute care medical units. This evidence-based quality improvement project describes how a mobility program, devised for and put to use on a general medical unit in a large Midwestern academic health care system, improved patient outcomes.

Leadership at the front line: a clinical partnership model on general care inpatient units.

Hospitals strive to provide all their patients with quality care that is safe, timely, efficient, equitable, effective, and patient centered. Although hospitals have developed technology- and industry-based quality improvement models, there remains a need to better engage the frontline health care workers at the site of care to enhance communication and coordination of care. To foster the work environment and relationships in the general acute care units, the authors describe a leadership model that partners a nurse manager with a physician director to build a local clinical care environment that seeks to enhance the whole patient care experience.

Re-Engineering the Post-Discharge Appointment Process for General Medicine Patients

AbstractBackground: Patients are vulnerable to issues that emerge after discharge from the hospital, and this susceptibility is compounded as patients attempt to navigate complex healthcare organizations. Post-discharge clinic appointments may provide the opportunity to mitigate risks posed to patients during this vulnerable time. Objective: Our aim was to determine whether actively engaging patients in scheduling post-discharge appointments before leaving the hospital affects the rate of patients seeing an ambulatory care physician. Methods: This was a prospective cohort pilot study from May to July 2007 with a historical convenience control from 2003. The setting was an inpatient academic tertiary care referral center in the US. Study participants had been discharged from a general medicine hospitalist service during the study time period. Patients, or their designated caregivers, were contacted in hospital rooms to schedule a post-discharge appointment before discharge. The primary outcome was rate of attendance at post-discharge appointments, determined a priori. Results: Eighty-three patients with 115 scheduled appointments in the intervention group were compared with 306 patients with 398 appointments in the historical control group. The attendance rate was 59.5% in the control group versus 78.3% in the study group (p<0.0001). Patients received 1.3 discharge appointments per discharge in both the historical and study group. In a limited evaluation, the study group had a trend towards a lower return rate to the emergency department within 3 days of discharge (1.2% vs 3.8%, nonsignificant), and a lower readmission rate within 14 days of discharge (10.8% vs 11.8%, nonsignificant). Conclusion: Our patient-centered process for helping patients arrange their post-discharge appointments before discharge improved the attendance rate at those appointments.

Pod nursing on a medical/surgical unit: Implementation and outcomes evaluation

A medical/surgical unit at the University of Michigan Health System implemented a pod nursing model of care to improve efficiency and patient and staff satisfaction. One centralized station was replaced with 4 satellites and supplies were relocated next to patient rooms. Patients were assigned to 2 nurses who worked as partners. Three patient (satisfaction, call lights, and falls) and nurse (satisfaction and overtime) outcomes improved after implementation. Efforts should be focused on addressing patient acuity imbalances across assignments and strengthening communication among the healthcare team. Studies are needed to test the model in larger and more diverse settings.

Interprofessional Rounds Improve Timing of Appropriate Palliative Care Consultation on a Hospitalist Service

Despite known benefits, palliative care (PC) consultation for hospitalized patients remains underutilized. The objective was to improve frequency and timeliness of appropriate inpatient PC consultation. On 2 of 11 hospitalist teams, a PC representative attended discharge rounds twice a week. Control teams’ discharge rounds were unenhanced. Subjects were all patients admitted to a hospitalist service in a quaternary academic medical center. The primary outcome was change in provision of PC consultation over time; the secondary outcome was change in time-to-consult (days). Hospitalists were surveyed regarding the intervention. The unadjusted proportion of patients receiving PC consultation increased from 2.7% to 5.2% on the intervention teams. Compared to control teams over time and adjusting for multiple covariates, the intervention increased PC consultation (difference-in-difference [DID] = 1.0 percentage-point increase [95% CI = 0.3%-1.8%]) and decreased time to consult (DID = −5 days [95% CI = −11 to −1]) in patients admitted for noncancer diagnoses. Hospitalists thought the intervention facilitated effective patient care without increased burden.

Interprofessional Intervention to Improve Geriatric Consultation Timing on an Acute Medical Service: Timing of Inpatient Geriatric Consultation

To determine whether an interprofessional intervention would improve the use and timing of a geriatric consultation on a hospitalist service.