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Background In response to the Institute of Medicine (IOM) report, Dying in America, we undertook an institution wide effort to improve the experience of patients and families facing serious illness by engaging leadership and developing a program to promote the practice of generalist palliative care. Intervention We developed a three-part generalist palliative care program that focuses on ( 1 ) instructional design, ( 2 ) advance care planning, and ( 3 ) engagement. Measures The impact of the program was measured with process measures related to its’ three parts. Outcomes Over four years, the program trained 51 interprofessional clinicians in a two-week intensive palliative care course and 1,541 interprofessional clinicians in a 90-150 min skills-based training. Clinicians documented 15,791 serious illness conversations. Zoom community engagement sessions were attended by 411 live viewers, and subsequently, 1918 YouTube views. Additionally, we report on the impact of the COIVD-19 crisis on our efforts. Early in the pandemic, over 2 months, 464 interprofessional clinicians documented 5,168 conversations with patients. Conclusion/Lessons Learned A broad based strategy resulted wide institutional engagement with serious illness care.

To understand current and idealized primary care-based care transition workflow processes for hospitalized patients, we conducted 133 interviews with staff at 9 primary care sites; community agency staff (n = 18); recently discharged patients (n = 33); and primary care thought leaders (n = 9). Current postdischarge workflows in primary care vary widely across settings, are often implemented inconsistently, and rarely involve communications with the patient or inpatient team during hospitalization. Based on these findings, we propose 5 principles for primary care practices to facilitate active involvement in postdischarge care, beginning during the hospital admission and extending until after the initial postdischarge primary care visit.

Objective: An effective hospital response to mass casualty incidents (MCIs) requires rapid mobilization of personnel capable of caring for critically ill trauma patients and availability of resuscitation resources. Methods: Hospitals facing an MCI wrestle with the challenge of immediately adjusting their overextended clinical operations to resuscitate a large number of rapidly arriving patients without compromising the care of existing patients. Results: Hospitalists are well positioned to add significant value by off-loading the emergency department (ED) given their broad clinical expertise. We describe our institution’s protocol to generate immediate and sustained surge capacity by integrating our hospitalist service into MCI response. Conclusions: Our protocol details the safe and rapid transfer of care of existing ED patients to hospitalist teams to make ED staff and space available to care for incoming MCI patients.

ObjectiveAlthough important treatment decisions are made in the Emergency Department (ED), conversations about patients’ goals and values and priorities often do not occur. There is a critical need to improve the frequency of these conversations, so that ED providers can align treatment plans with these goals, values, and priorities. The Serious Illness Conversation Guide has been used in other care settings and has been demonstrated to improve the frequency, quality, and timing of conversations, but it has not been used in the ED setting. Additionally, ED social workers, although integrated into hospital and home-based palliative care, have not been engaged in programs to advance serious illness conversations in the ED. We set out to adapt the Serious Illness Conversation Guide for use in the ED by social workers.MethodsWe undertook a four-phase process for the adaptation of the Serious Illness Conversation Guide for use in the ED by social workers. This included simulated testing exercises, pilot testing, and deployment with patients in the ED.ResultsDuring each phase of the Guide's adaptation, changes were made to reflect both the environment of care (ED) and the clinicians (social workers) that would be using the Guide. A final guide is presented.Significance of resultsThis report presents an adapted Serious Illness Conversation Guide for use in the ED by social workers. This Guide may provide a tool that can be used to increase the frequency and quality of serious illness conversations in the ED.

Background: Given the national shortage of palliative care specialists relative to the need for their services, engaging nonspecialists is important to ensure patients with serious illness have an opportunity to share their goals and values with their providers. Hospital medicine clinicians are well positioned to conduct these conversations given they care for many medically complex patients. Yet, little is known about the patient experience of inpatient goals and values conversations led by hospitalist teams. Objective: To assess patients' experience and perception of the quality of goals and values conversations. Design/Setting/Participation: Single center, tertiary care, nonrandomized, two group cohort trial of patients hospitalized on general medical inpatient units staffed by hospital medicine clinicians previously trained to conduct serious illness conversations. Intervention: An automated screening tool was used to identify patients at increased risk for unmet palliative needs. The multidisciplinary team was informed of the screen's results on the intervention units but not on the control units. Intervention unit clinicians were asked to consider talking with patients about their goals and values. Results: One hundred thirty patients participated in the study. The intervention patients reported improved quality of communication and fewer anxiety and depression symptoms compared with the control patients. Hospice utilization in addition to emergency department visits and hospital readmissions did not differ between the two groups. Conclusion: This study suggests that informing the care team regarding their patients' potential unmet palliative care needs is associated with patients reporting improved experience of their care without adverse effects on their mood.

Background: Understanding patients' goals and values is important to ensure goal-concordant care; however, such discussions can be challenging. Little is known about the impact of having these discussions on hospitalists. Objective: To assess the impact on hospitalists of a system that reminds them to have serious illness conversations with their patients identified with potential unmet palliative needs. Design: Two group cohort trial. Setting/Subjects: Single academic center. Internal medicine hospitalist physicians, nurse practitioners, and physician's assistants. Measurements: Before the trial, all participants received serious illness conversation training. During the trial, hospitalists on intervention units received verbal notification when their recently admitted patients were identified using a computer algorithm as having possible unmet palliative needs. Hospitalists on the control unit received no notifications. At baseline and three months, hospitalists completed questionnaires regarding communication skill acquisition, perception of the importance of these conversations, and sense of the meaning gained from having them. Results: Both groups had similar improvements in their self-reported communication skills and experienced a small decline in how important they felt the conversations were. Neither group perceived having the discussions as being affectively harmful to patients. The intervention hospitalists, over time, reported a slight reduction in the sense of meaning they achieved from the conversations. Conclusion: Routinely informing hospitalists when their patients were identified as being at increased risk for unmet palliative needs did not increase the sense of meaning these providers achieved. It is likely the pretrial training accounted for many of the positive outcomes in communication skills observed in both arms of the trial.

Objective: To assess awareness of existing pain management guidelines and compare physicians’ confidence versus competence in selected pain management skills. Design: Prospective survey study. Setting: A large urban tertiary medical center. Patients, participants: All Department of Medicine interns, senior residents, and attending physicians were sent a questionnaire; the overall response rate was 30 percent (91/304). Interventions: The questionnaire assessed physicians’ awareness of the institution’s pain management guidelines, their self-reported comfort level (confidence) with, and a knowledge assessment (competence) of three pain management skills (managing chronic-continuous pain, equianalgesic dose conversion, and managing breakthrough pain) using validated, standardized case vignettes. Main outcome measures: A comparison of physicians’ confidence with their competence in these pain management skills. Results: A total of 23 percent (21/91) of the respondents reported an awareness of the institution’s pain management guidelines. Interns were significantly less confident than senior residents in all three pain management skills (p < 0.001, 0.006, 0.02) but nonsignificantly more competent in two of three skills (chronic-continuous pain, dose conversion). Attendings were generally more confident and nonsignificantly more competent than senior residents in all three pain management skills. Conclusions: The underutilization of the pain management guidelines illustrates that the mere existence of these resources as a means of ensuring optimal pain management is insufficient. Creative pain management educational initiatives are needed to address the disparity between physician confidence and competence.

To describe the concerns, confidence, and barriers of practicing hospitalists around serious illness communication.Hospitalist physicians are optimally positioned to provide primary palliative care, yet their experiences in serious illness communication are not well described.Web-based survey, conducted in May 2016. The survey link was distributed via email to 4000 members of the Society of Hospital Medicine. The 39-item survey assessed frequency of concerns about serious illness communication, confidence for common tasks, and barriers using Likert-type scales. It was developed by the authors based on prior work, a focus group, and feedback from pilot respondents.We received 332 completed surveys. On most or every shift, many participants reported having concerns about a patient's or family's understanding of prognosis (53%) or the patient's code status (63%). Most participants were either confident or very confident in discussing goals of care (93%) and prognosis (87%). Fewer were confident or very confident in responding to patients or families who had not accepted the seriousness of an illness (59%) or in managing conflict (50%). Other frequently cited barriers were lack of time, lack of prior discussions in the outpatient setting, unrealistic prognostic expectations from other physicians, limited institutional support, and difficulty finding records of previous discussions.Our results suggest opportunities to improve hospitalists' ability to lead serious illness communication by increasing the time hospitalists have for discussions, improving documentation systems and communication between inpatient and outpatient clinicians, and targeted training on challenging communication scenarios.

A 73-year-old man with a history of heart failure, pulmonary hypertension, and a hepatic venovenous malformation presented with confusion. CT of the abdomen revealed pneumatosis of the ascending colon to the level of the hepatic flexure. Diagnostic tests were performed.

Background:With the increasing focus on reducing hospital readmissions in the United States, numerous readmissions risk prediction models have been proposed, mostly developed through analyses of structured data fields in electronic medical records and administrative databases. Three areas that may h

Context Palliative care improves the quality of care and may reduce utilization, but delays or the absences of such services are common and costly in inpatient and emergency department settings. Triggered palliative care consults (PCCs) offer one way to identify patients who would benefit from palliative care and to connect them with services early in their course. Consensus reports recommend use of triggers to identify patients for PCC, but no standards exist to guide trigger design or implementation. Objectives To conduct a systematic review of published trigger tools for PCC. Methods Studies included quality improvement and prospective analyses of triggers for PCC for adults in the emergency department and inpatient settings since 2008. Paired reviewers evaluated the studies for inclusion criteria and extracted data related to study demographics, trigger processes, trigger criteria, and study bias. Results The search yielded 5773 citations. Twenty studies were included for final analysis with more than 17,000 patients represented. Trigger processes and composition were heterogeneous, although frequently used categories, such as cancer, dementia, and chronic comorbidities, were identified. Three-quarters of the studies were deemed to have moderate or high risk of bias. Conclusion We present a range of trigger tools spanning different hospital settings and patient populations. Common themes in implementation and content arose, but the limitations of these studies are notable, and further rigorous randomized comparisons are needed to generate standards of care. In addition, future studies should focus on developing triggers that identify patients requiring primary-level vs. specialty-level palliative care.

Introduction The physical appearance of a physician may influence patientsr perceptions of that physicianrs quality of care. There is a lack of studies investigating whether physician appearance is indeed associated with patient satisfaction and mortality. Methods This observational study included adult medical inpatients treated at a Swiss tertiary care hospital between 2013 and 2016. We investigated associations of gender and physician appearance (hair colour, wearing of glasses) with in-hospital mortality and perceived quality of care, assessed by a telephone interview 30 days after admission. Regression models were adjusted for patient age, patient gender, and the Charlson Comorbidity Index. Results We included 18,259 inpatients treated by 494 different physicians during their hospital stay. We had full information regarding patient-perceived quality of care for 9917 patients. Overall, 860 patients (4.7%) died in the hospital and 1479 (14.9%) reported low satisfaction with their care. After multivariable adjustment, there was no difference in mortality or patient-perceived quality of care whether physicians did or did not wear glasses and whether they were male or female. The hair colour of residents was also not associated with outcomes. However, patients treated by grey-haired attending physicians, compared to those with dark or blond hair, had significantly lower in-hospital mortality (adjusted odds ratio 0.70, 95% confidence interval 0.53n0.92, p = 0.011). Conclusions This analysis suggests that physician gender or appearance has little influence on the quality of care provided to hospitalised medical patients. Whether the small but significant mortality benefit observed for grey-haired attending physicians is possibly confounded by age and physician experience clearly needs further investigation. Nevertheless, our analysis provides empirical evidence that having at least some grey-haired attending physicians in the medical physician team seems to be beneficial for patients, even if patients do not recognise the clear superiority of their care.

This systematic review and meta-analysis assesses whether nutritional support is associated with better clinical outcomes in medical inpatients who are malnourished or at nutritional risk., Key Points Question What is the association of nutritional support with clinical outcomes in medical inpatients who are malnourished or at nutritional risk? Findings In this updated systematic review and meta-analysis of 27 trials including 6803 patients, nutritional support provided during hospitalization was associated with significantly lower rates of mortality and nonelective hospital readmissions, as well as higher energy and protein intake and weight increase. Meaning This study’s findings suggest that nutritional support in hospitalized patients who are malnourished or at nutritional risk is associated with improved nutritional and clinical outcomes and should be considered when treating this population., Importance Malnutrition affects a considerable proportion of the medical inpatient population. There is uncertainty regarding whether use of nutritional support during hospitalization in these patients positively alters their clinical outcomes. Objective To assess the association of nutritional support with clinical outcomes in medical inpatients who are malnourished or at nutritional risk. Data Sources For this updated systematic review and meta-analysis, a search of the Cochrane Library, MEDLINE, and Embase was conducted from January 1, 2015, to April 30, 2019; the included studies were published between 1982 and 2019. Study Selection A prespecified Cochrane protocol was followed to identify trials comparing oral and enteral nutritional support interventions with usual care and the association of these treatments with clinical outcomes in non–critically ill medical inpatients who were malnourished. Data Extraction and Synthesis Two reviewers independently extracted data and assessed risk of bias; data were pooled using a random-effects model. Main Outcomes and Measures The primary outcome was mortality. The secondary outcomes included nonelective hospital readmissions, length of hospital stay, infections, functional outcome, daily caloric and protein intake, and weight change. Results A total of 27 trials (n = 6803 patients) were included, of which 5 (n = 3067 patients) were published between 2015 and 2019. Patients receiving nutritional support compared with patients in the control group had significantly lower rates of mortality (230 of 2758 [8.3%] vs 307 of 2787 [11.0%]; odds ratio [OR], 0.73; 95% CI, 0.56-0.97). A sensitivity analysis suggested a more pronounced reduction in the risk of mortality in recent trials (2015 or later) (OR, 0.47; 95% CI, 0.28-0.79) compared with that in older studies (OR, 0.94; 95% CI, 0.72-1.22), in patients with established malnutrition (OR, 0.52; 95% CI, 0.34-0.80) compared with that in patients at nutritional risk (OR, 0.85; 95% CI, 0.62-1.18), and in trials with high protocol adherence (OR, 0.67; 95% CI, 0.54-0.84) compared with that in trials with low protocol adherence (OR, 0.88; 95% CI, 0.44-1.76). Nutritional support was also associated with a reduction in nonelective hospital readmissions (14.7% vs 18.0%; risk ratio, 0.76; 95% CI, 0.60-0.96), higher energy intake (mean difference, 365 kcal; 95% CI, 272-458 kcal) and protein intake (mean difference, 17.7 g; 95% CI, 12.1-23.3 g), and weight increase (0.73 kg; 95% CI, 0.32-1.13 kg). No significant differences were observed in rates of infections (OR, 0.86; 95% CI, 0.64-1.16), functional outcome (mean difference, 0.32; 95% CI, −0.51 to 1.15), and length of hospital stay (mean difference, −0.24; 95% CI, −0.58 to 0.09). Conclusions and Relevance This study’s findings suggest that despite heterogeneity and varying methodological quality among trials, nutritional support was associated with improved survival and nonelective hospital readmission rates among medical inpatients who were malnourished and should therefore be considered when treating this population.

To evaluate the efficiency and safety of emergency department (ED) coronary computed tomography angiography (CTA) during a 3-year clinical experience. Single-center registry of coronary CTA in consecutive ED patients with suspicion of acute coronary syndrome (ACS). The primary outcome was efficiency of coronary CTA defined as the length of hospitalization. Secondary endpoints of safety were defined as the rate of downstream testing, normalcy rates of invasive coronary angiography (ICA), absence of missed ACS, and major adverse cardiac events (MACE) during follow-up, and index radiation exposure. One thousand twenty two consecutive patients were referred for clinical coronary CTA with suspicion of ACS. Overall, median time to discharge home was 10.5 (5.7-24.1) hours. Patient disposition was 42.7 % direct discharge from the ED, 43.2 % discharge from emergency unit, and 14.1 % hospital admission. ACS rate during index hospitalization was 9.1 %. One hundred ninety two patients underwent additional diagnostic imaging and 77 underwent ICA. The positive predictive value of CTA compared to ICA was 78.9 % (95 %-CI 68.1-87.5 %). Median CT radiation exposure was 4.0 (2.5-5.8) mSv. No ACS was missed; MACE at follow-up after negative CTA was 0.2 %. Coronary CTA in an experienced tertiary care setting allows for efficient and safe management of patients with suspicion for ACS. • ED Coronary CTA using advanced systems is associated with low radiation exposure. • Negative coronary CTA is associated with low rates of MACE. • CTA in ED patients enables short median time to discharge home. • CTA strategy is characterized by few downstream tests including unnecessary ICA.

Identifying and addressing the nutritional needs of medically complex inpatients can lead to better patient outcomes. Hospitalists are well positioned to lead the multidisciplinary efforts that wil...

Objective To conduct a systematic review of published cardiac risk indices relevant to patients undergoing noncardiac surgery and to provide clinically meaningful recommendations to physicians regarding the use of these indices. Methods A literature search of articles published from January 1, 1999, through December 28, 2018, was conducted in Ovid (MEDLINE), PubMed, Embase, CINAHL, and Web of Science. Publications describing models predicting risk of cardiac complications after noncardiac surgery were included and citation chaining was used to identify additional studies for inclusion. Results Eleven risk indices involving 2,910,297 adult patients were included in this analysis. Studies varied in size, population, quality, risk of bias, outcome event definitions, risk factors identified, index outputs, accuracy, and clinical usefulness. Studies considered 6 to 83 variables to develop their models. Among the identified models, the factors with the highest predictiveness for adverse cardiac outcomes included congestive heart failure, type of surgery, creatinine, diabetes, history of stroke or transient ischemic attack, and emergency surgery. Substantial data from the large studies also supports advancing age, American Society of Anesthesiology physical status classification, functional status, and hypertension as additional risks. Conclusion The risk indices identified generally fell into two groups — those with higher accuracy for predicting a narrow range of cardiac outcomes and those with lower accuracy for predicting a broader range of cardiac outcomes. Using one index from each group may be the most clinically useful approach. Risk factors identified varied widely among studies. In addition to judicious use of predictive indices, reasoned clinical judgment remains indispensable in assessing perioperative cardiac risk.

Background The practice of hospital medicine is complex, and the number of clinical publications each year continues to grow. To maintain best practice it is necessary for hospitalists to stay abreast of the literature, but difficult to accomplish due to time. The annual Society of Hospital Medicine meeting offers a plenary session on Updates in Hospital Medicine. This article is a summary of those papers presented at the meeting. Methods We reviewed articles published between January 2014 and January 2015 in the leading medical journals, searching for papers with good methodological quality, the potential to change practice, and papers that are thought provoking. The authors collectively agreed on 14 articles. The findings, cautions, and implications are discussed for each paper. Results Key findings include: a novel neprilysin inhibitor and angiotensin receptor blocker combination drug reduces mortality in patients with heart failure; the concern for acute kidney injury after venous contrast may be overstated; the Confusion Assessment Method Severity score is an important tool for prognostication in delirious patients; ramelteon shows promise for lowering incident delirium among elderly medical patients; polyethylene glycol appears effective in rapidly resolving hepatic encephalopathy; cirrhotic patients on a nonselective β-blocker have increased mortality after they develop spontaneous bacterial peritonitis; current guidelines regarding prophylaxis against venous thromboembolism (VTE) in medical inpatients likely result in non-beneficial use of medications; from a safety and efficacy perspective, direct oral anticoagulants perform quite well against conventional therapies in patients with VTE and atrial fibrillation, including in elderly populations; 2 new once-weekly antibiotics, dalbavancin and oritivancin, approved for skin and soft tissue infections, appear noninferior to vancomycin; offering family members of a patient undergoing cardiopulmonary resuscitation the opportunity to observe has durable impact on long-term psychological outcomes. Conclusions This update reviews key clinical articles published in 2014, selected by the authors for their methodological quality and potential for changing the practice of inpatient physicians. All of these articles add to the body of inpatient medical knowledge and contribute to the debate on best practices.

Understanding how best to manage the complex healthcare needs of hospitalised, mostly multimorbid medical patients is an international priority. Healthcare should be effective, safe and provide high quality at a reasonable cost. However, basic logistic and organisational issues of medical ward-based care have received less attention than the medical treatment of specific pathologies. Consequently, we still use old-fashioned care and transition procedures for medical inpatients. This contrasts with dynamic developments in other, non-healthcare industries, where process optimisation is a major part of innovation. Promising new approaches to better align healthcare needs of hospitalised medical patients from clinical trials will help to advance the field significantly. Healthcare costs attributable to the aging, multimorbid population are rising worldwide. One cost driver is the high resource use of in-hospital treatment. In view of the expected demographic evolution of an aging population, better resource allocation is important. As in other countries, the Swiss healthcare system is in the midst of transformation aiming to improve health outcomes of patients at an affordable cost. One important area of redesign is identifying the best setting for diagnosis, treatment and management of acute medical conditions with a shift of in-hospital to outpatient care. Also, safely reducing in-hospital length of stay of inpatient treatment is important, because inpatient care accounts for the largest share of total Swiss healthcare costs. Integration of new technology into these processes holds promises for optimisation. Use of electronic health record-based tools has resulted in improved patient care and patient transitions. But evidence from clinical studies regarding the effect of inter-professional team care interventions on patient relevant outcomes, including activity of daily living, mortality and length of hospital stay, are inconsistent. Thus, there is room for improvement and a need for high quality trials providing evidence on how best to combine technology with innovative transition models for an ameliorated care of medical inpatients. We review in narrative form different transition interventions that have been evaluated for improved medical inpatient care and highlight important patient-centred outcome measures that were investigated. Further, we discuss a novel patient-management tool (In-HospiTOOL), which is currently being evaluated in an ongoing large Swiss multicentre study.

The guidance of a mentor can have a tremendous influence on the careers of academic physicians. The lack of mentorship in the relatively young field of hospital medicine has been documented, but the efficacy of formalized mentorship programs has not been well studied. We implemented and evaluated a structured mentorship program for junior faculty at a large academic medical center. Of the 16 mentees who participated in the mentorship program, 14 (88%) completed preintervention surveys and 10 (63%) completed postintervention surveys. After completing the program, there was a statistically significant improvement in overall satisfaction within 5 specific domains: career planning, professional connectedness, self-reflection, research skills, and mentoring skills. All mentees reported that they would recommend that all hospital medicine faculty participate in similar mentorship programs. In this small, single-center pilot study, we found that the addition of a structured mentorship program based on training sessions that focus on best practices in mentoring was feasible and led to increased satisfaction in certain career domains among early-career hospitalists. Larger prospective studies with a longer follow-up are needed to assess the generalizability and durability of our findings.

BACKGROUND Rehospitalization is a prominent target for healthcare quality improvement and performance-based reimbursement. The generalizability of existing evidence on best practices is unknown. OBJECTIVE To determine the effect of Project BOOST (Better Outcomes for Older adults through Safe Transitions) on rehospitalization rates and length of stay. DESIGN Semicontrolled pre–post study. SETTING/PARTICIPANTS Volunteer sample of 11 hospitals varying in geography, size, and academic affiliation. INTERVENTION Hospitals implemented Project BOOST-recommended tools supported by an external quality improvement physician mentor. METHODS Pre–post changes in readmission rates and length of stay within BOOST units, and between BOOST units and site-designated control units. RESULTS The average rate of 30-day rehospitalization in BOOST units was 14.7% prior to implementation and 12.7% 12 months later (P = 0.010), reflecting an absolute reduction of 2% and a relative reduction of 13.6%. Rehospitalization rates for matched control units were 14.0% in the preintervention period and 14.1% in the postintervention period (P = 0.831). The mean absolute reduction in readmission rates in BOOST units compared to control units was 2.0% (P = 0.054 for signed rank test comparing differences in readmission rate reduction in BOOST units compared to site-matched control units). CONCLUSIONS Participation in Project BOOST appeared to be associated with a decrease in readmission rates. Journal of Hospital Medicine 2013;8:421–427. © 2013 Society of Hospital Medicine

A 69-year-old man with a history of renal transplantation was admitted to the hospital because of increasing weakness, malaise, bradycardia, and hypotension. Diagnostic tests were performed.

Respiratory infections remain the most common reason why patients seek medical care in ambulatory and hospital settings, and they are the most frequent precursor of sepsis. In light of the limitations of clinical signs and symptoms and traditional microbiologic diagnostics for respiratory infections, blood biomarkers that correlate with the presence and extent of bacterial infections may provide additional useful information to improve diagnostic and prognostic efforts and help with therapeutic decisions in individual patients. A growing body of evidence supports the use of procalcitonin (PCT) to differentiate bacterial from viral respiratory diagnoses, to help risk stratify patients, and to guide antibiotic therapy decisions about initial need for, and optimal duration of, therapy. Although still relatively new on the clinical frontier, a series of randomized controlled trials have evaluated PCT protocols for antibiotic-related decision making and have included patients from different clinical settings and with different severities of respiratory infection. In these trials, initial PCT levels were effective in guiding decisions about the initiation of antibiotic therapy in lower-acuity patients, and subsequent measurements were effective for guiding duration of therapy in higher-acuity patients, without apparent harmful effects. Recent European respiratory infection guidelines now also recognize this concept. As with any other laboratory test, PCT should not be used on a stand-alone basis. Rather, it must be integrated into clinical protocols, together with clinical, microbiologic data and with results from clinical risk scores. The aim of this review is to summarize recent evidence about the usefulness of PCT in patients with lower respiratory tract infections and to discuss the potential benefits and limitations of this marker when used for clinical decision making.

While numerous authors acknowledge the challenge of teaching simultaneously to medical students, interns, and residents, few offer specific advice on how to meet that challenge, and none have studied which techniques are most effective.The purpose of this study was to determine whether multilevel teaching is challenging for attendings, whether trainees feel that teaching on rounds is appropriate to their level, and to define multilevel teaching techniques.We surveyed attendings and trainees on the internal medicine services at two academic medical centers.Attendings were divided about whether teaching to multiple levels posed a challenge. Trainees reported that the teaching they received was usually appropriate to their level of training. The most effective techniques for multilevel teaching were Broadening (asking "what if" questions), Targeting (directing questions at specific team members), and Novelty (teaching newly published information), while the least effective were techniques that taught advanced material unfamiliar to most or all of the team. A systematic literature review yielded no studies that focused on multilevel teaching techniques.This article is the first to define and evaluate specific techniques for multilevel instruction in a medical setting and identifies certain techniques as more effective at engaging multiple levels of learners simultaneously.

Medication errors and adverse events caused by them are common during and after a hospitalization. The impact of these events on patient welfare and the financial burden, both to the patient and the healthcare system, are significant. In 2005, The Joint Commission put forth medication reconciliation as National Patient Safety Goal (NPSG) No. 8 in an effort to minimize adverse events caused during these types of care transitions. However, the meaningful and systematic implementation of medication reconciliation, as expressed through NPSG No. 8, proved to be extraordinarily difficult for healthcare institutions around the country. Given the importance of accurate and complete medication reconciliation for patient safety occurring across the continuum of care, the Society of Hospital Medicine convened a stakeholder conference in 2009 to begin to identify and address: (1) barriers to implementation; (2) opportunities to identify best practices surrounding medication reconciliation; (3) the role of partnerships among traditional healthcare sites and nonclinical and other community-based organizations; and (4) metrics for measuring the processes involved in medication reconciliation and their impact on preventing harm to patients. The focus of the conference was oriented toward medication reconciliation for a hospitalized patient population; however, many of the themes and concepts derived would also apply to other care settings. This paper highlights the key domains needing to be addressed and suggests first steps toward doing so. An overarching principle derived at the conference is that medication reconciliation should not be viewed as an accreditation function. It must, first and foremost, be recognized as an important element of patient safety. From this principle, the participants identified ten key areas requiring further attention in order to move medication reconciliation toward this focus. 1 There is need for a uniformly acceptable and accepted definition of what constitutes a medication and what processes are encompassed by reconciliation. Clarifying these terms is critical to ensuring more uniform impact of medication reconciliation. 2 The varying roles of the multidisciplinary participants in the reconciliation process must be clearly defined. These role definitions should include those of the patient and family/caregiver and must occur locally, taking into account the need for flexibility in design given the varying structures and resources at healthcare sites. 3 Measures of the reconciliation processes must be clinically meaningful (i.e., of defined benefit to the patient) and derived through consultation with stakeholder groups. Those measures to be reported for national benchmarking and accreditation should be limited in number and clinically meaningful. 4 While a comprehensive reconciliation system is needed across the continuum of care, a phased approach to implementation, allowing it to start slowly and be tailored to local organizational structures and work flows, will increase the chances of successful organizational uptake. 5 Developing mechanisms for prospectively and proactively identifying patients at risk for medication-related adverse events and failed reconciliation is needed. Such an alert system would help maintain vigilance toward these patient safety issues and help focus additional resources on high risk patients. 6 Given the diversity in medication reconciliation practices, research aimed at identifying effective processes is important and should be funded with national resources. Funding should include varying sites of care (e.g., urban and rural, academic and nonacademic, etc.). 7 Strategies for medication reconciliation-both successes and key lessons learned from unsuccessful efforts-should be widely disseminated. 8 A personal health record that is integrated and easily transferable between sites of care is needed to facilitate successful medication reconciliation. 9 Partnerships between healthcare organizations and community-based organizations create opportunities to reinforce medication safety principles outside the traditional clinician-patient relationship. Leveraging the influence of these organizations and other social networking platforms may augment population-based understanding of their importance and role in medication safety. 10 Aligning healthcare payment structures with medication safety goals is critical to ensure allocation of adequate resources to design and implement effective medication reconciliation processes. Medication reconciliation is complex and made more complicated by the disjointed nature of the American healthcare system. Addressing these ten points with an overarching goal of focusing on patient safety rather than accreditation should result in improvements in medication reconciliation and the health of patients.

BACKGROUND: Little evidence exists to determine whether depression predicts hospital utilization following discharge among adult inpatients on a general medical service. OBJECTIVE: We aimed to determine whether a positive depression screen during hospitalization is significantly associated with an increased rate of returning for hospital services. DESIGN: A secondary analysis was performed using data from 738 English-speaking, hospitalized adults from the Project RED randomized controlled trial (clinicaltrials.gov Identifier: NCT00252057) conducted at an urban academic safety-net hospital. MEASUREMENTS: We used the nine-item Patient Health Questionnaire (PHQ-9) depression screening tool to identify patients with depressive symptoms. The primary endpoint was hospital utilization, defined as the number of emergency department (ED) visits plus readmissions within 30 days of discharge. Poisson regression was used to control for confounding variables. RESULTS: Of the 738 subjects included in the analysis, 238 (32%) screened positive for depressive symptoms. The unadjusted hospital utilization within 30 days of discharge was 56 utilizations per 100 depressed patients compared with 30 utilizations per 100 non-depressed patients, incident rate ratio (IRR) (confidence interval [CI]), 1.90 (1.51–2.40). After controlling for potential confounders, a higher rate of post-discharge hospital utilization was observed in patients with depressive symptoms compared to patients without depressive symptoms (IRR [CI], 1.73 [1.27–2.36]). CONCLUSIONS: A positive screen for depressive symptoms during an inpatient hospital stay is associated with an increased rate of readmission within 30 days of discharge in an urban, academic, safety-net hospital population. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine.

The ability to predict which patients are at high risk for rehospitalizations is an inexact science. The scientific literature has begun to introduce methods of modeling this prediction (Bowles & Cater, 2003; Coleman, Min, Chomiak, & Kramer, 2004; Lagoe, Noetscher, & Murphy, 2001). These models, however, are cumbersome and limited when applied to a general inpatient population. Several, largely retrospective, studies have examined clinical, demographic, and logistical risk factors for rehospitalization and posthospitalization adverse events, some of which may lead to rehospitalization. Caution should be exercised in applying the demographic risks because the studies were often done in small and specific populations. Some of the major clinical parameters identified include high-risk medication use (antibiotics, gluco-corticoids, anticoagulants, narcotics, antiepileptic medications, antipsychotics, antidepressants, and hypoglycemic agents; Budnitz et al., 2006; Budnitz, Shehab, Kegler, & Richards, 2007; Forster et al., 2004; Forster, Murff, Peterson, Gandhi, & Bates, 2005; van Walraven & Forster, 2007), polypharmacy (five or more medications; Campbell, Seymour, Primrose, & ACMEPLUS Project, 2004), and specific clinical conditions (e.g., advanced chronic obstructive pulmonary disease, diabetes, heart failure, stroke, and depression; Bula, Wietlisbach, Burnand, & Yersin, 2001; Coleman et al., 1998; Gwadry-Sridhar, Flintoft, Lee, Lee, & Guyatt, 2004; Kartha et al., 2007; Ng et al., 2007; Phillips et al., 2004; Strunin, Stone, & Jack, 2007). The demographic and logistical factors identified include prior hospitalization (Billings, Dixon, Mijanovich, & Wennberg, 2006; Coleman et al., 1998; Comette et al., 2005; Rodriguez-Artalejo, Guallar-Castillon, & Herrera, 2006; Smith et al., 2000; Soeken, Prescott, Herron, & Creasia, 1991), postdischarge follow-up appointment time provided prior to discharge, low income, low-educational level (Forsythe et al., 2006), low literacy (Baker et al., 2002), reduced social network indicators (Rodriguez-Artalejo et al., 2006), and unmarried/widowed individuals (Forsythe et al., 2006). Adding to the importance of understanding and improving discharge transitions, the Centers for Medicare & Medicaid Services (CMS, 2008) has indicated that it will incorporate reporting rehospitalization rates as a part of its hospital quality measure reporting program starting in 2009. Of note, the literature does question whether rehospitalization is a valid marker of poor healthcare delivery, given the multifaceted etiologies for its occurrence (Ashton & Wray, 1996). Nonetheless, it is clear that some rehospitalizations are preventable. Estimates of how many are preventable vary widely depending on patient population and definitions used for preventability (Oddone et al., 1996). In addition, it is important to recognize that hospitalizations can be upsetting, disruptive (Heiskell & Pasneu, 1991), and costly to patients and are quite costly to healthcare systems (HCUPnet, n.d.). Understanding the root causes of unplanned hospitalizations is critical for strategizing about reducing these adverse events.

BACKGROUND: The status of implementation of medication reconciliation across hospitals is variable to date; the degree to which hospitalists are involved is not known. METHODS: To better describe the current state of medication reconciliation implementation, we conducted a survey of attendees of the 2006 Society of Hospital Medicine national meeting. RESULTS: We identified a lack of uniformity across hospitals with respect to the degree of process implementation. Hospitalists were involved in design and implementation in a majority of cases, and felt that medication reconciliation would likely have a positive impact on patient safety. Tertiary care academic centers were more likely to use physicians to perform medication reconciliation, whereas community hospitals were more likely to involve nurses as well. Pharmacist participation in the medication reconciliation process was found to be quite low. Process and outcome measures were used infrequently. Patients' lack of medication knowledge and absence of preadmission medication information were cited most frequently as barriers to implementation of medication reconciliation. CONCLUSIONS: Implementation of medication reconciliation is complex and challenging. Medication information is often incomplete, and elements of the medication reconciliation process result in increased time demands on providers. Current implementation efforts often have physicians and nurses “share” responsibility for compliance, and pharmacists are underutilized in medication reconciliation processes. Hospitalists have thus far played a substantial role in process design and implementation, and should continue to lead the way in advancing efforts to successfully implement medication reconciliation. © 2008 Society of Hospital Medicine. Journal of Hospital Medicine 2008;3(6):465–472. © 2008 Societyof Hospital Medicine.

Objectives. The Centers for Disease Control and Prevention (CDC) recommends offering human immunodeficiency virus (HIV) testing to all patients in all high HIV-prevalence clinical settings. We evaluated programmatic aspects of HIV testing across multiple clinical settings within a single medical center. Methods. We analyzed programmatic data of HIV testing in the Urgent Care Center (UCC), inpatient floors, outpatient primary care, a non-clinical Drop-In Center, and Emergency Department (ED). HIV testing was by oral mucosal transudate, venous blood samples, or rapid testing fingersticks, with Western blot confirmation. We compared the sociodemographics and behavioral risks of individuals undergoing HIV testing across the five sites and estimated costs per person tested and per HIV-positive test result. Results. From 2002 to 2004, 16,750 HIV tests were conducted, with 229 (1.4%) previously unreported HIV infections diagnosed among 16,696 valid test results. HIV-positive prevalence was 1.5% for the UCC, 1.5% at the Drop-In Center, 1.4% for primary care, 1.2% for inpatient, and 0.6% in the ED. Behavioral risks were most prevalent in the UCC and the Drop-In Center. The cost per test was lowest in the UCC and highest in the Drop-In Center. The cost per previously unreported HIV infection was lowest in the UCC ($1,980) and highest in the ED ($9,724). Conclusions. Although a significant number of HIV infections were identified, the number of tests performed represents

The hospital discharge is a handoff, ripe embedded structural risks and hazards that can result in passive or active failures among "sharp end" providers. These failures can result in medical errors and an array of postdischarge adverse events. There are now emerging data to suggest that postdischarge-related adverse events and rehospitalizations can be reduced through interventions at the time of hospital discharge. This article reviews the modifiable components of the hospital discharge process related to adverse events and rehospitalizations, including those relating to the characteristics of the hospital, patient, and clinician. Using multi- method analysis, our group described the principles thought to be important to the discharge process and delineated what we now call the reengineered discharge, a set of 11 discrete and mutually reinforcing components that we believe should be consistently part of every hospital discharge. Finally, we discuss the work or the National Quality Forum Consensus Standards Maintenance com- mittee who, in 2006, added the hospital discharge as one of its "safe practices for better healthcare."

Hospitals are under great pressure to reduce readmissions of patients. Being able to reliably predict patients at increased risk for rehospitalization would allow for tailored interventions to be offered to them. This requires the creation of a functional predictive model specifically designed to support real-time clinical operations. A predictive model for readmissions within 30 days of discharge was developed using retrospective data from 45,924 MGH admissions between 2/1/2012 and 1/31/2013 only including factors that would be available by the day after admission. It was then validated prospectively in a real-time implementation for 3,074 MGH admissions between 10/1/2013 and 10/31/2013. The model developed retrospectively had an AUC of 0.705 with good calibration. The real-time implementation had an AUC of 0.671 although the model was overestimating readmission risk. A moderately discriminative real-time 30-day readmission predictive model can be developed and implemented in a large academic hospital.

Rapid HIV antibody tests recently approved by the Food and Drug Administration can help reduce unrecognized infections by improving access to testing in both clinical and nonclinical settings and increase the proportion of those tested who learn their results. Four rapid HIV antibody tests are now available in the United States; two are approved for use at point-of-care sites outside a traditional laboratory. All four tests are interpreted visually. Sites offering rapid HIV testing must periodically run external controls (known HIV-positive and HIV-negative specimens) and provide persons who undergo rapid testing a subject information sheet. This paper reviews the operating and performance characteristics, quality assurance and laboratory requirements, and HIV counseling implications of the currently available rapid HIV tests.

Oral case presentations are important for patient care and clinical education. Previously published attempts to improve oral presentation skills have been labor intensive and have focused primarily on medical students.We created a multifaceted intervention to improve oral case presentations of medical students and internal medicine residents. Our intervention included a written handout with detailed instructions, pocket cards, model presentations, and multiple teaching sessions. The intervention was developed by consensus, supported by the department of medicine and endorsed by key faculty within the department. In addition to soliciting feedback from students and residents, we evaluated our intervention with prospectively acquired ratings of student oral case presentation skills recorded on a standardized evaluation for the internal medicine clerkship.Students, residents, and faculty gave positive feedback, although they noted some practical obstacles to effective oral case presentations. After dissemination of the guidelines, 44% of students (42/96) were rated as "excellent" in oral presentation skills on standardized evaluations of the internal medicine clerkship, compared to 30% in the previous academic year (33/111; odds ratio [OR]=1.8, 95% confidence interval=1.04-3.3; p=.036).A multifaceted intervention improved medical student oral case presentation skills. Although participants noted barriers that need further attention, we demonstrated modest improvement in student performance.

Background Unresolved medication discrepancies during hospitalization can contribute to adverse drug events, resulting in patient harm. Discrepancies can be reduced by performing medication reconciliation; however, effective implementation of medication reconciliation has proven to be challenging. The goals of the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) are to operationalize best practices for inpatient medication reconciliation, test their effect on potentially harmful unintentional medication discrepancies, and understand barriers and facilitators of successful implementation. Methods Six U.S. hospitals are participating in this quality improvement mentored implementation study. Each hospital has collected baseline data on the primary outcome: the number of potentially harmful unintentional medication discrepancies per patient, as determined by a trained on-site pharmacist taking a “gold standard” medication history. With the guidance of their mentors, each site has also begun to implement one or more of 11 best practices to improve medication reconciliation. To understand the effect of the implemented interventions on hospital staff and culture, we are performing mixed methods program evaluation including surveys, interviews, and focus groups of front line staff and hospital leaders. Discussion At baseline the number of unintentional medication discrepancies in admission and discharge orders per patient varies by site from 2.35 to 4.67 (mean=3.35). Most discrepancies are due to history errors (mean 2.12 per patient) as opposed to reconciliation errors (mean 1.23 per patient). Potentially harmful medication discrepancies averages 0.45 per patient and varies by site from 0.13 to 0.82 per patient. We discuss several barriers to implementation encountered thus far. In the end, we anticipate that MARQUIS tools and lessons learned have the potential to decrease medication discrepancies and improve patient outcomes. Trial registration Clinicaltrials.gov identifier NCT01337063

Objective: Identify factors associated with false-positive rapid HIV antibody tests. Design: This retrospective cohort study with nested case–controls involved patients tested for HIV by Boston Medical Center (BMC) affiliates. Methods: Cases had a reactive fingerstick OraQuick ADVANCE rapid HIV 1/2 antibody test and a negative Western blot. Controls had nonreactive rapid tests. We compared the prevalence of HIV risk factors between cases and the total nonreactive population and the prevalence of other clinical factors between cases and controls. Results: Of the 15 094 tests, 14 937 (98.9%) were negative and 11 (0.07%) were false positives (specificity of 99.9%). Cases were more likely to have had an HIV-infected sex partner and to be tested at certain sites compared to true negatives. More cases than controls had O-negative blood type. Conclusion: O-negative blood type and sex with an HIV-infected person may increase false-positive HIV fingerstick results. More targeted studies should examine these risk factors.

The Society of Hospital Medicine (SHM) created "Mentored Implementation" (MI) programs with the dual aims of educating and mentoring hospitalists and their quality improvement (QI) teams and accelerating improvement in the inpatient setting in three signature programs: Venous Thromboembolism (VTE) Prevention, Glycemic Control, and Project BOOST (Better Outcomes for Older adults through Safe Transitions).More than 300 hospital improvement teams were enrolled in SHM MI programs in a series of cohorts. Hospitalist mentors worked with individual hospitals/health systems to guide local teams through the life cycle of a QI project. Implementation Guides and comprehensive Web-based "Resource Rooms," as well as the mentor's own experience, provided best-practice definitions, practical implementation tips, measurement strategies, and other tools. E-mail interactions and mentoring were augmented by regularly scheduled teleconferences; group webinars; and, in some instances, a site visit. Performance was tracked in a centralized data tracking center.Preliminary data on all three MI programs show significant improvement in patient outcomes, as well as enhancements of communication and leadership skills of the hospitalists and their QI teams.Although objective data on outcomes and process measures for the MI program's efficacy remain preliminary at this time, the maturing data tracking system, multiple awards, and early results indicate that the MI programs are successful in providing QI training and accelerating improvement efforts.

Objective In the 30 days after hospital discharge, hospital utilisation is common and costly. This study evaluated the association between gender and hospital utilisation within 30 days of discharge. Design Secondary data analysis using Poisson regression stratified by gender. Participants 737 English-speaking hospitalised adults from general medical service in urban, academic safety-net medical centre who participated in the Project Re-Engineered clinical trial (clinicaltrials.gov identifier: NCT00252057). Main outcome measure The primary end point was hospital utilisation, defined as total emergency department visits and hospital readmissions within 30 days after index discharge. Results Female subjects had a rate of 29 events for every 100 people and male subjects had a rate of 47 events for every 100 people (incident rate ratio (IRR) 1.62, 95% CI 1.28 to 2.06). Among men, risk factors included hospital utilisation in the 6 months prior to the index hospitalisation (IRR 3.55, 95% CI 2.38 to 5.29), being unmarried (IRR 1.72, 95% CI 1.12 to 2.64), having a positive depression screen (IRR 1.53, 95% CI 1.09 to 2.13) and no primary care physician (PCP) visit within 30 days (IRR 1.64, 95% CI 1.08 to 2.50). Among women, the only risk factor was hospital utilisation in the 6 months prior to the index hospitalisation (IRR 3.08, 95% CI 1.86 to 5.10). Conclusions In our data, male subjects had a higher rate of hospital utilisation within 30 days of discharge than female subjects. For men—but not for women—risk factors were being retired, unmarried, having depressive symptoms and having no PCP visit within 30 days. Interventions addressing these factors might lower hospital utilisation rates observed among men., Article summary Article focus Early hospital readmission is a common and costly occurrence in the USA. Men often use hospital emergency departments for usual source of medical care. We aimed to study whether men are therefore more likely to be readmitted to the hospital within 30 days of an index discharge. Key messages Men have higher rates of 30-day readmission to hospital than women in this study group. Men also were less likely to complete a follow-up appointment with their primary care physician after discharge. Interventions that promote connecting men to primary care, address social isolation and screen for depressive symptoms may reduce the risk for early readmission among men. Strengths and limitations of this study This analysis was conducted with the Project RED data set, which included, and allowed controlling for certain clinical and social confounders in our analysis such as subjects' comorbidity burden, depression symptoms, homelessness, substance abuse and other similar risk factors, in our analysis. This study is limited in that it was conducted at an urban safety-net hospital and may not be generalisable to other types of hospital systems. We also relied on subject self-report of any rehospitalisation events outside of the study site, however, were able to confirm 91% of all events using our hospital electronic medical record system.

Objective Postdischarge telephone follow-up plays an integral part in transitional care efforts in many regions. We systematically reviewed the literature to evaluate the evidence regarding the impact of primary care–based telephone follow-up on postdischarge emergency department visits and hospital readmissions. Methods We performed an electronic database search for relevant telephone follow-up studies originating in adult primary care settings. Results Only 3 studies (N=1765) met entry criteria for this review. None of the studies demonstrated evidence of reduced admissions or emergency department visits from primary care–based telephone follow-ups. All 3 studies reported improved primary care office contact as a result of telephone follow-up intervention. Conclusions Despite the growing use of primary care-based telephone follow-up in the postdischarge period, there are no high-quality studies demonstrating its benefit. However, its positive impact on patient engagement holds potentially meaningful implications. In light of recent national health care legislation, the primary care field is ripe for high-quality studies to evaluate the effectiveness of telephone follow-up for patients in the postdischarge period. Particular areas of research focus are discussed.