Faculty Bibliography

OBJECTIVES: This study sought to determine the range and prevalence of practices being implemented by hospitals to reduce 30-day readmissions of patients with heart failure or acute myocardial infarction (AMI). BACKGROUND: Readmissions of patients with heart failure or AMI are both common and costly; however, evidence on strategies adopted by hospitals to reduce readmission rates is limited. METHODS: We used a Web-based survey to conduct a cross-sectional study of hospitals' reported use of specific practices to reduce readmissions for patients with heart failure or AMI. We contacted all hospitals enrolled in the Hospital to Home (H2H) quality improvement initiative as of July 2010. Of 594 hospitals, 537 completed the survey (response rate of 90.4%). We used standard frequency analysis to describe the prevalence of key hospital practices in the areas of: 1) quality improvement resources and performance monitoring; 2) medication management efforts; and 3) discharge and follow-up processes. RESULTS: Nearly 90% of hospitals agreed or strongly agreed that they had a written objective of reducing preventable readmission for patients with heart failure or AMI. More hospitals reported having quality improvement teams to reduce preventable readmissions for patients with heart failure (87%) than for patients with AMI (54%). Less than one-half (49.3%) of hospitals had partnered with community physicians and only 23.5% had partnered with local hospitals to manage patients at high risk for readmissions. Inpatient and outpatient prescription records were electronically linked usually or always in 28.9% of hospitals, and the discharge summary was always sent directly to the patient's primary medical doctor in only 25.5% of hospitals. On average, hospitals used 4.8 of 10 key practices; <3% of hospitals utilized all 10 practices. CONCLUSIONS: Although most hospitals have a written objective of reducing preventable readmissions of patients with heart failure or AMI, the implementation of recommended practices varied widely. More evidence establishing the effectiveness of various practices is needed.

BACKGROUND: Improving hospital discharge has become a national priority for teaching hospitals, yet little is known about physician perspectives on factors limiting the quality of discharge care. OBJECTIVES: To describe the discharge process from the perspective of housestaff physicians, and to generate hypotheses about quality-limiting factors and key strategies for improvement. METHODS: Qualitative study with in-depth, in-person interviews with a diverse sample of 29 internal medicine housestaff, in 2010-2011, at 2 separate internal medicine training programs, including 7 different hospitals. We used the constant comparative method of qualitative analysis to explore the experiences and perceptions of factors affecting the quality of discharge care. RESULTS: We identified 5 unifying themes describing factors perceived to limit the quality of discharge care: (1) competing priorities in the discharge process; (2) inadequate coordination within multidisciplinary discharge teams; (3) lack of standardization in discharge procedures; (4) poor patient and family communication; and (5) lack of postdischarge feedback and clinical responsibility. CONCLUSIONS: Quality-limiting factors described by housestaff identified key processes for intervention. Establishment of clear standards for discharge procedures, including interdisciplinary teamwork, patient communication, and postdischarge continuity of care, may improve the quality of discharge care by housestaff at teaching hospitals. Journal of Hospital Medicine 2012; (c) 2012 Society of Hospital Medicine.

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.

In 2010, the Accreditation Council for Graduate Medical Education released its resident duty hours restrictions, requiring that faculty monitor their residents' patient handoffs to ensure that residents are competent in handoff communications. Although studies have reported the need to improve the effectiveness of the handoff and a variety of curricula have been suggested and implemented, a common method for teaching and evaluating handoff skills has not been developed. Also in 2010, engineers, informaticians, and physicians interested in patient handoffs attended a symposium in Savannah, Georgia, hosted by the Association for Computing Machinery, entitled Handovers and Handoffs: Collaborating in Turns. As a result of this symposium, a workgroup formed to develop practical and readily implementable educational materials for medical educators involved in teaching patient handoffs to residents. In this article, the result of that yearlong collaboration, the authors aim to provide clarity on the definition of the patient handoff, to review the barriers to performing effective handoffs in academic health centers, to identify available solutions to improve handoffs, and to provide a structured approach to educating residents on handoffs via a curricular blueprint. The authors' blueprint was developed to guide educators in customizing handoff education programs to fit their specific, local needs. Hopefully, it also will provide a starting point for future research into improving the patient handoff. Increasingly complex patient care environments require both innovations in handoff education and improvements in patient care systems to improve continuity of care.

PURPOSE: To investigate use of a new guideline-based, computerized clinical decision support (CCDS) system for asthma in a pediatric pulmonology clinic of a large academic medical center. METHODS: We conducted a qualitative evaluation including review of electronic data, direct observation, and interviews with all nine pediatric pulmonologists in the clinic. Outcome measures included patterns of computer use in relation to patient care, and themes surrounding the relationship between asthma care and computer use. RESULTS: The pediatric pulmonologists entered enough data to trigger the decision support system in 397/445 (89.2%) of all asthma visits from January 2009 to May 2009. However, interviews and direct observations revealed use of the decision support system was limited to documentation activities after clinic sessions ended. Reasons for delayed use reflected barriers common to general medical care and barriers specific to subspecialty care. Subspecialist-specific barriers included the perceived high complexity of patients, the impact of subject matter expertise on the types of decision support needed, and unique workflow concerns such as the need to create letters to referring physicians. CONCLUSIONS: Pediatric pulmonologists demonstrated low use of a computerized decision support system for asthma care because of a combination of general and subspecialist-specific factors. Subspecialist-specific factors should not be underestimated when designing guideline-based, computerized decision support systems for the subspecialty setting.

BACKGROUND: The quality of preventive care provided in student-run free clinics has not been well documented, although an increasing number of vulnerable populations seek care in these settings. OBJECTIVE: To examine the rate of preventive care services provided in one student-run free clinic compared with national data. Design. Cross-sectional chart review. PARTICIPANTS: Randomly selected patients seen between October 2008 and 2009. MAIN MEASURES: Preventive screening guidelines by the U.S. Preventive Services Task Force (USPSTF) and the American Diabetes Association (ADA). KEY RESULTS: Among 114 patient charts examined, 48 (42.1%) received an HIV test, which did not differ from national rates (40.8%, p=.78). Similarly, 63.3% of patients received a fasting blood glucose test (64.2%, p=.92). Among eligible patients, 59.6% received a fasting lipid panel and 54.6% a Pap smear; lower than national rates (86.6%, p<.001, and 70.5%, p=.001 respectively), but not different compared with uninsured nationally (61.5%, p=.79, and 54.7%, p=.98). CONCLUSIONS: This student-run free clinic provided preventive services at comparable rates to national levels, but short of goals specified in Healthy People 2020.