Faculty Bibliography

BACKGROUND: The CDC reports that 5% of hospitalized patients develop hospital acquired infections, which are responsible for 100,000 deaths annually. Poor hand hygiene compliance on the Medicine service placed patients at higher risk for infection and was the impetus for our Clean Hands Save Lives Initiative. METHODS: The Clean Hands Save Lives initiative was a triple-prong systems based strategy that required the leadership of the medical director and nurse manager and the engagement of the entire floor. First, unit leadership dedicated a portion of the the morning unit-based safety huddle to identify daily hand washing champions. Each day a new group of champions was identified, including 2 nurses, one one floor patient unit technician, and two physicians. Champions were responsible for reinforcing correct hand hygiene procedures in real time, promoting a culture of "if you see something, say something."Each week, 35 different health care providers were hand-hygiene champions, hardwiring best practice. Second, proper hand hygiene procedures were reinforced at the safety huddle several times a week and Purell dispensers were installed outside every patient room. Third, an email was sent to each team member regarding the hand hygiene initiative at the start of each rotation. Real time feedback on hand hygiene technique was provided by unit leadership. RESULTS: At the start of the initiative in quarter 1 of 2015, hand hygiene compliance for the 17 East Medical Unit was at 64%. By quarter 1 of 2016, hand hygiene compliance was at 93 and has remained above 90% for the past 4 quarters (Figure 1). CONCLUSIONS: Successful implementation of our Clean Hands Save Lives Initiative on a hospitalist led medicine unit was due in large part to making this a daily focus of all members of the team, leading to unit culture change. The interdisciplinary approach to the problem, daily reinforcement of the initiative, regular education of unit staff and ease of practicing proper hand hygiene all were contributing factors to its success and sustainability. The initiative is now practiced in all units on the Medicine service

BACKGROUND: Patients admitted to the Medicine Service from the Emergency Department (ED) at times when no beds are available pose a particular challenge to workflow, staffing and patient care. Due to the expansion of our clinically integrated network and recruitment of high-volume surgical teams, the hospital daily census surged, causing an increase in the average number of patients admitted to the hospital but physically located in the ED. The Hospitalist program was charged with developing a coordinated strategy to manage these patients METHODS: In 2015, we created an ED Hospitalist Team composed of a hospitalist and a nurse practitioner to care for patients admitted to the Medicine Service but awaiting beds on the floor. We purposely created this model so that the medicine teams could focus on caring for patients on their own units and not disrupt their workflow by traveling to the ED. We created a Checklist (Figure 1) for this ED Hospitalist Team to ensure that protocols and pathways were followed, just as they would be on the medical floor. We partnered with ED leadership to identify workspace and standardize handoffs, as well as with leadership from Social Work to proactively identify complex situations starting on hospital day 0. Patients requiring ICU level care were excluded (as intensivists were involved immediately). All patients admitted to the medicine service (i.e. patients who would ultimately be cared for on the general medicine, cardiac, oncologic or hepatobiliary teams), were cared for by the ED Hospitalist team until a bed became available on the appropriate unit. RESULTS: The average number of patients admitted to the hospital, but physically located in the ED increased from 2.1/day in April 2015 to 14.5/ day in October 2016. At least 70% of these patients were admitted to the Medicine Service. Even with this increase, the observed to expected length of stay (O:E LOS) for Medicine patients remained at 0.92. The discharge before noon rate increased from 39 to 43% during this same period. CONCLUSIONS: We have demonstrated a strategic and sustainable approach for managing a growing number of patients who are admitted to the Medicine Service but physically located in the ED. By consolidating our resources in creating an ED Hospitalist team, we are able to maintain our workflow efficiencies on the floor, as demonstrated by the O:E LOS and our improved discharge before noon rate. (Figure Presented)

PURPOSE: To decrease overutilization of laboratory testing by eliminating a feature of the electronic ordering system that allowed providers to order laboratory tests to occur daily without review. METHODS: We collected rates of utilization of a group of commonly ordered laboratory tests (number of tests per patient per day) throughout the entire hospital from June 10th, 2013 through June 10th, 2015. Our intervention which eliminated the ability to order daily recurring tests was implemented on June 11th, 2014. We compared pre and post-intervention rates in order to assess the impact and surveyed providers about their experience with the intervention. RESULTS: We examined 1,296,742 laboratory tests performed on 92,799 unique patients over 434,059 patient days. Prior to the intervention, the target tests were ordered using this daily recurring mechanism 33% of the time. After the intervention we observed between an 8.5% (p <0.001) to 20.9% (p <0.001) reduction in tests per patient per day. The reduction in rate for some of the target tests persisted during the study period but not for the two most commonly ordered tests. We estimated an approximate reduction in hospital costs of $300,000 due to the intervention. CONCLUSION: A simple modification to the order entry system significantly and immediately altered provider practices throughout a large tertiary care academic center. This strategy is replicable by the many hospitals that use the same electronic health record system and possibly by users of other systems. Future areas of study include evaluating the additive effects of education and real-time decision support.

We report a case of a 29-year-old man who presented with intermittent haemoptysis for about 18 months. Previously, his symptoms had been diagnosed as musculoskeletal pain and later as pneumonia. CT found a venous infarct in the right lung in addition to extensive lymphadenopathy in the mediastinum and pulmonary hila, with associated calcifications almost completely occluding the superior vena cava and azygos vein. Further questioning revealed that the patient had once worked on an organic farm in Colorado. Subsequent work up was positive for histoplasmosis yeast antibodies. The patient was diagnosed with fibrosing mediastinitis (FM) and started on itraconazole for 3 months. We note that FM is a rare complication of histoplasmosis and can present as chronic haemoptysis. Travel history is an important aspect of the clinical evaluation. Antifungal agents have shown some efficacy in treating histoplasmosis-related FM.

BACKGROUND: Late afternoon hospital discharges are thought to contribute to admission bottlenecks. We previously described an intervention that resulted in a statistically significant increase in the discharge before noon (DBN) rate on 2 inpatient medicine units. OBJECTIVE: To evaluate (1) the effect of an increased DBN rate on the admission arrival time and the number of admissions per hour and (2) the sustainability of our DBN initiative. DESIGN: Pre-/postintervention retrospective analysis. SETTING: Two acute-care inpatient medicine units in a tertiary care, urban, academic medical center. PATIENTS: For the admission arrival time and admissions per hour analysis, all inpatients admitted to the medical units from June 1, 2011 to June 31, 2013. For the sustainability analysis, all patients discharged from July 1, 2013 to December 31, 2014. INTERVENTION: A multidisciplinary intervention to increase the DBN rate. MEASUREMENTS: Date and time of arrival to all inpatient sites, and discharge date and time of all patients from 2 inpatient medicine units. RESULTS: Concurrent with our increase in DBN rate, we found a statistically significant change in the median arrival time of emergency department (ED) admissions and transfers from 5 pm to 4 pm. High-frequency admission peaks were statistically significantly reduced for ED admissions. The statistically significant increase in DBN rate is sustained at 35%. CONCLUSIONS: Increasing the DBN rate correlates with admissions arriving earlier in the day and reductions in high-frequency peaks of ED admissions. Statistically significant improvements in DBN rates are sustainable. Journal of Hospital Medicine 2015. (c) 2015 Society of Hospital Medicine.

BACKGROUND: Hospital care on weekends has been associated with delays in care, reduced quality, and poor clinical outcomes. OBJECTIVE: The purpose of this study was to evaluate the impact of a weekend hospital intervention on processes of care and clinical outcomes. The multifaceted intervention included expanded weekend diagnostic services, improved weekend discharge processes, and increased physician and care management services on weekends. DESIGN AND PATIENTS: This was an interrupted time series observational study of adult non-obstetric patients hospitalized at a single academic medical center between January 2011 and January 2014. The study included 18 months prior to and 19 months following the implementation of the intervention. Data were analyzed using segmented regression analysis with adjustment for confounders. MAIN MEASURES: The primary outcome was average length of stay. Secondary outcomes included percent of patients discharged on weekends, 30-day readmission rate, and in-hospital mortality rate. KEY RESULTS: The study included 57,163 hospitalizations. Following implementation of the intervention, average length of stay decreased by 13 % (95 % CI 10-15 %) and continued to decrease by 1 % (95 % CI 1-2 %) per month as compared to the underlying time trend. The proportion of weekend discharges increased by 12 % (95 % CI 2-22 %) at the time of the intervention and continued to increase by 2 % (95 % CI 1-3 %) per month thereafter. The intervention had no impact on readmissions or mortality. During the post-implementation period, the hospital was evacuated and closed for 2 months due to damage from Hurricane Sandy, and a new hospital-wide electronic health record was introduced. The contributions of these events to our findings are not known. We observed a lower inpatient census and found differences in patient characteristics, including higher rates of Medicaid insurance and comorbidities, in the post-Hurricane Sandy period as compared to the pre-Sandy period. CONCLUSIONS: The intervention was associated with a reduction in length of stay and an increase in weekend discharges. Our longitudinal study also illuminated the challenges of evaluating the effectiveness of a large-scale intervention in a real-world hospital setting.

A 49-year-old woman with cholangiocarcinoma metastatic to the lungs presented with new-onset unrelenting headaches. A lumbar puncture revealed malignant cells consistent with leptomeningeal metastasis from her cholangiocarcinoma. Magnetic resonance imaging (MRI) of the brain revealed leptomeningeal enhancement. An intrathecal (IT) catheter was placed and IT chemotherapy was initiated with methotrexate. Her case is notable for the rarity of cholangiocarcinoma spread to the leptomeninges, the use of IT chemotherapy with cytologic and potentially symptomatic response, and a possible survival benefit in comparison to previously reported cases of leptomeningeal carcinomatosis secondary to cholangiocarcinoma.

BACKGROUND: Late afternoon hospital discharges are thought to contribute to admission bottlenecks, overcrowding, and increased length of stay (LOS). In January 2012, the discharge before noon (DBN) percentage on 2 medical units was 7%, below the organizational goal of 30%. OBJECTIVE: To sustainably achieve a DBN rate of 30% and to evaluate the effect of this intervention on observed-to-expected (O/E) LOS and 30-day readmission rate. DESIGN: Pre-/post-intervention retrospective analysis. SETTING: Two acute care inpatient medical units in an urban, academic medical center. PATIENTS: All inpatients discharged from the units. INTERVENTION: All staff helped create a checklist of daily responsibilities at a DBN kickoff event. We initiated afternoon interdisciplinary rounds to identify next-day DBNs and created a website for enhanced communication. We provided daily feedback on the DBN percentage, rewards for success, and real-time opportunities for case review. MEASUREMENTS: Calendar month DBN percentage, O/E LOS, and 30-day readmission rate. RESULTS: The DBN percentage increased from 11% in the 8-month baseline period to an average of 38% over the 13-month intervention (P = 0.0002). The average discharge time moved 1 hour and 31 minutes earlier in the day. The O/E LOS declined from 1.06 to 0.96 (P = 0.0001), and the 30-day readmission rate declined from 14.3% to 13.1% (P = 0.1902). CONCLUSIONS: Our study demonstrates that increased DBN is an achievable and sustainable goal for hospitals. Future work will allow for better understanding of the full effects of such an intervention on patient outcomes and hospital metrics. Journal of Hospital Medicine 2014;9:210-214. (c) 2014 Society of Hospital Medicine.