Faculty Bibliography

Student-run clinics increasingly serve as primary care providers for patients of lower socioeconomic status, but studies show that quality of care at student-run clinics has room for improvement. PURPOSE: To examine change in provision of preventive services in a student-run free clinic after implementation of a student-led QI intervention involving prompting. METHOD: Review of patient charts pre- and post-intervention, examining adherence to screening guidelines for diabetes, dyslipidemia, HIV, and cervical cancer. RESULTS: Adherence to guidelines among eligible patients increased after intervention in 3 of 4 services examined. Receipt of HIV testing increased from 33% (80/240) to 48% (74/154; p = 0.004), fasting lipid panel increased from 53% (46/86) to 72% (38/53; p = 0.033), and fasting blood glucose increased from 59% (27/46) to 82% (18/22; p = 0.059). CONCLUSIONS: This student-run free clinic implemented a student-led QI intervention that increased provision of prevention. Such a model for QI could extend to other student-run clinics nationally.

BACKGROUND: Hospital-level, 30-day risk-standardized mortality and readmission rates are publicly reported for Medicare patients admitted with acute myocardial infarction (AMI), heart failure (HF), and pneumonia, but the correlations among mortality rates and among readmission rates within US hospitals for these conditions are unknown. Correlation among measures within the same hospital would suggest that there are common hospital-wide quality factors. METHODS: We designed a cross-sectional study of US hospital 30-day risk-standardized mortality and readmission rates for Medicare fee-for-service beneficiaries from July 2007 to June 2009. We assessed the correlation between pairs of risk-standardized mortality rates and pairs of risk-standardized readmission rates for AMI, HF, and pneumonia. RESULTS: The mortality cohort included 4559 hospitals, and the readmission cohort included 4468 hospitals. Every mortality measure was significantly correlated with every other mortality measure (range of correlation coefficients, 0.27-0.41, P < 0.0001 for all correlations). Every readmission measure was significantly correlated with every other readmission measure (range of correlation coefficients, 0.32-0.47, P < 0.0001 for all correlations). For each condition pair and outcome, one-third or more of hospitals were in the same quartile of performance. Correlations were highest within large, nonprofit, urban, and/or Council of Teaching Hospitals members. For any given condition pair, the correlation between readmission rates was significantly higher than the correlation between mortality rates (P < 0.01 for all pairs). CONCLUSION: Risk-standardized readmission rates are moderately correlated with each other within hospitals, as are risk-standardized mortality rates. This suggests that there may be common hospital-wide factors affecting hospital outcomes.

BACKGROUND: Adverse drug events after hospital discharge are common and often serious. These events may result from provider errors or patient misunderstanding. OBJECTIVE: To determine the prevalence of medication reconciliation errors and patient misunderstanding of discharge medications. DESIGN: Prospective cohort study SUBJECTS: Patients over 64 years of age admitted with heart failure, acute coronary syndrome or pneumonia and discharged to home. MAIN MEASURES: We assessed medication reconciliation accuracy by comparing admission to discharge medication lists and reviewing charts to resolve discrepancies. Medication reconciliation changes that did not appear intentional were classified as suspected provider errors. We assessed patient understanding of intended medication changes through post-discharge interviews. Understanding was scored as full, partial or absent. We tested the association of relevance of the medication to the primary diagnosis with medication accuracy and with patient understanding, accounting for patient demographics, medical team and primary diagnosis. KEY RESULTS: A total of 377 patients were enrolled in the study. A total of 565/2534 (22.3 %) of admission medications were redosed or stopped at discharge. Of these, 137 (24.2 %) were classified as suspected provider errors. Excluding suspected errors, patients had no understanding of 142/205 (69.3 %) of redosed medications, 182/223 (81.6 %) of stopped medications, and 493 (62.0 %) of new medications. Altogether, 307 patients (81.4 %) either experienced a provider error, or had no understanding of at least one intended medication change. Providers were significantly more likely to make an error on a medication unrelated to the primary diagnosis than on a medication related to the primary diagnosis (odds ratio (OR) 4.56, 95 % confidence interval (CI) 2.65, 7.85, p<0.001). Patients were also significantly more likely to misunderstand medication changes unrelated to the primary diagnosis (OR 2.45, 95 % CI 1.68, 3.55), p<0.001). CONCLUSIONS: Medication reconciliation and patient understanding are inadequate in older patients post-discharge. Errors and misunderstandings are particularly common in medications unrelated to the primary diagnosis. Efforts to improve medication reconciliation and patient understanding should not be disease-specific, but should be focused on the whole patient.

BACKGROUND: Transfers of care have become increasingly frequent and complex with shorter inpatient stays and changes in work hour regulations. Potential hazards exist with transfers. There are few reports of institution-wide efforts to improve handoffs. METHODS: An institution-wide physician handoff task force was developed to proactively address issues surrounding handoffs and to ensure a consistent approach to handoffs across the institution. RESULTS: This report discusses the authors' experiences with handoff standardisation, provider utilisation of a new electronic medical record-based handoff tool, and implementation of an educational curriculum; future work in developing hospital-wide policies and procedures for transfers; and the authors' consensus on the best methods for monitoring and evaluation of trainee handoffs. CONCLUSION: The handoff task force infrastructure has enabled the authors to take an institution-wide approach to improving handoffs. The task force has improved patient care by addressing handoffs systematically and consistently and has helped create new strategies for minimising risk in handoffs.

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.

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.

BACKGROUND: Reducing readmissions and post-discharge adverse events by improving the quality of discharge care has become a national priority, yet we have limited understanding about how physicians learn to provide high-quality discharge care. METHODS: We conducted in-depth, in-person interviews with housestaff physicians with qualitative analysis by a multi-disciplinary team using the constant comparative method to explore learning about high-quality discharge care as a systems-based practice and to identify opportunities to improve training around these concepts. RESULTS: We analyzed interview transcripts from 29 internal medicine residents: 17 (59 %) were interns (PGY-2 or PGY-3), 12 (41 %) seniors, and 17 (59 %) were female. We identified a recurrent theme of lack of formal training about the discharge process, substantial peer-to-peer instruction, and "learning by doing" on the wards. Within this theme, we identified five specific concepts related to systems-based practice and high-quality discharge care which residents learned during residency: (1) teamwork and the interdisciplinary nature of discharge planning; (2) advanced planning strategies to anticipate challenges in the discharge process; (3) patient safety and the concept of a "safe discharge;" (4) patient continuity of care and learning from post-discharge outcomes and; (5) documentation of discharge plans as a valuable skill. CONCLUSIONS: Discharge care is an overlooked opportunity to teach concepts of systems-based practice explicitly as learning about discharge care is unstructured and individual experiences may vary considerably. Educational interventions to standardize learning about discharge care may improve the development of systems-based practice during residency and help improve the overall quality of discharge care at teaching hospitals.

BACKGROUND: A national Medicare database indicated that one in eight older patients with diabetes was discharged off all antihyperglycemic therapy (AHT) following acute myocardial infarction (AMI). This practice was associated with increased one-year mortality, but the reasons for stopping AHT were not known. A study was conducted to determine whether such practice might be due to medical necessity (that is, a new contraindication) or oversight--in which case a quality improvement opportunity might exist. METHODS: Some 327 diabetic patients were identified who were hospitalized with AMI during a one-year period at an academic medical center and an affiliated community hospital. Detailed chart reviews were conducted on the 217 patients with AMI as a principal diagnosis who were admitted on AHT (insulin, 81). Twenty-five patients (11.5%) were discharged off AHT, 24 (96%) of whom received some AHT in the hospital, mostly as insulin sliding scale. One patient's (4%) AHT was stopped because of a change in care goals, a second developed recurrent hypoglycemia, and a third had entirely normal in-hospital blood glucose after AHT discontinuation. The remaining 22 patients (88%) were categorized as being discharged off AHT without justification. The demographic/clinical characteristics of those discharged on versus off AHT were similar, except for better left ventricular ejection fraction (LVEF) in the latter. CONCLUSIONS: The percentage of diabetic patients discharged off AHT following AMI was nearly identical to that in a national database (approximately one out of eight). No clear reason for this practice could be found in nearly 90% of the cases, suggesting that it may often constitute a medical error for a growing population of diabetic patients with ischemic heart disease.