Prevalence and Causes of Diagnostic Errors in Hospitalized Patients Under Investigation for COVID-19.

BACKGROUND: The COVID-19 pandemic required clinicians to care for a disease with evolving characteristics while also adhering to care changes (e.g., physical distancing practices) that might lead to diagnostic errors (DEs). OBJECTIVE: To determine the frequency of DEs and their causes among patients hospitalized under investigation (PUI) for COVID-19. DESIGN: Retrospective cohort. SETTING: Eight medical centers affiliated with the Hospital Medicine ReEngineering Network (HOMERuN). TARGET POPULATION: Adults hospitalized under investigation (PUI) for COVID-19 infection between February and July 2020. MEASUREMENTS: We randomly selected up to 8 cases per site per month for review, with each case reviewed by two clinicians to determine whether a DE (defined as a missed or delayed diagnosis) occurred, and whether any diagnostic process faults took place. We used bivariable statistics to compare patients with and without DE and multivariable models to determine which process faults or patient factors were associated with DEs. RESULTS: Two hundred and fifty-seven patient charts underwent review, of which 36 (14%) had a diagnostic error. Patients with and without DE were statistically similar in terms of socioeconomic factors, comorbidities, risk factors for COVID-19, and COVID-19 test turnaround time and eventual positivity. Most common diagnostic process faults contributing to DE were problems with clinical assessment, testing choices, history taking, and physical examination (all p < 0.01). Diagnostic process faults associated with policies and procedures related to COVID-19 were not associated with DE risk. Fourteen patients (35.9% of patients with errors and 5.4% overall) suffered harm or death due to diagnostic error. LIMITATIONS: Results are limited by available documentation and do not capture communication between providers and patients. CONCLUSION: Among PUI patients, DEs were common and not associated with pandemic-related care changes, suggesting the importance of more general diagnostic process gaps in error propagation.

An accelerated hospital observation pathway to reduce length of stay for patients with COVID-19.

OBJECTIVES: Strategies to maintain hospital capacity during the COVID-19 pandemic included reducing hospital length of stay (LOS) for infected patients. We sought to evaluate the association between LOS and enrollment in the COVID Accelerated Care Pathway, which consisted of a hospital observation protocol and postdischarge automated text message-based monitoring. STUDY DESIGN: Retrospective matched cohort study of patients hospitalized from December 14, 2020, to January 31, 2021. METHODS: Participants were patients who presented to the emergency department with acute infection due to COVID-19, required hospitalization, and met pathway inclusion criteria. Participants were compared with a propensity score-matched cohort of patients with COVID-19 admitted to the same hospital during the 7 weeks preceding and following pathway implementation. RESULTS: There were 44 patients in the intervention group and 83 patients in the propensity score-matched cohort. The mean (SD) hospital LOS for patients in the intervention group was 1.7 (2.6) days compared with 3.9 (2.3) days for patients in the matched cohort (difference, -2.2 days; 95% CI, -3.3 to -1.1). In the intervention group, 2 patients (5%; 95% CI, 0%-15%) were rehospitalized within 14 days compared with 8 (10%; 95% CI, 4%-17%) in the matched cohort. CONCLUSIONS: Patients with COVID-19 who were managed through an accelerated hospital observation protocol and postdischarge monitoring service had reduced hospital LOS compared with patients receiving standard care. Hospital preparedness for future public health emergencies may involve the design of pathways that reduce the time that patients spend in the hospital, lower cost, and ensure continued recovery upon discharge.

An Accelerated Hospital Observation Pathway to Reduce Length of Stay for Patients With COVID-19

Objectives: Strategies to maintain hospital capacity during the COVID-19 pandemic included reducing hospital length of stay (LOS) for infected patients. We sought to evaluate the association between LOS and enrollment in the COVID Accelerated Care Pathway, which consisted of a hospital observation protocol and postdischarge automated text message–based monitoring. Study Design: Retrospective matched cohort study of patients hospitalized from December 14, 2020, to January 31, 2021. Methods: Participants were patients who presented to the emergency department with acute infection due to COVID-19, required hospitalization, and met pathway inclusion criteria. Participants were compared with a propensity score–matched cohort of patients with COVID-19 admitted to the same hospital during the 7 weeks preceding and following pathway implementation. Results: There were 44 patients in the intervention group and 83 patients in the propensity score–matched cohort. The mean (SD) hospital LOS for patients in the intervention group was 1.7 (2.6) days compared with 3.9 (2.3) days for patients in the matched cohort (difference, –2.2 days;95% CI, –3.3 to –1.1). In the intervention group, 2 patients (5%;95% CI, 0%-15%) were rehospitalized within 14 days compared with 8 (10%;95% CI, 4%-17%) in the matched cohort. Conclusions: Patients with COVID-19 who were managed through an accelerated hospital observation protocol and postdischarge monitoring service had reduced hospital LOS compared with patients receiving standard care. Hospital preparedness for future public health emergencies may involve the design of pathways that reduce the time that patients spend in the hospital, lower cost, and ensure continued recovery upon discharge.

Low hospital mobility-resurgence of an old epidemic within a new pandemic and future solutions.

Low mobility during hospitalisation poses risks of functional decline and other poor outcomes for older adults. Given the pervasiveness of this problem, low mobility during hospitalisation was first described as 'dangerous' in 1947 and later described as an epidemic. Hospitals have made considerable progress over the last half-century and the last two decades in particular, however, the COVID-19 pandemic presents serious new challenges that threaten to undermine recent efforts and progress towards a culture of mobility. In this special article, we address the question of how to confront an epidemic of immobility within a pandemic. We identify four specific problems for creating and advancing a culture of mobility posed by COVID-19: social distancing and policies restricting patient movement, personnel constraints, personal protective equipment shortages and increased patient hesitancy to ambulate. We also propose four specific solutions to address these problems. These approaches will help support a culture of healthy mobility during and after hospitalisation and help patients to keep moving during the pandemic and beyond.

Discharge Practices for COVID-19 Patients: Rapid Review of Published Guidance and Synthesis of Documents and Practices at 22 US Academic Medical Centers.

BACKGROUND: There are currently no evidence-based guidelines that provide standardized criteria for the discharge of COVID-19 patients from the hospital. OBJECTIVE: To address this gap in practice guidance, we reviewed published guidance and collected discharge protocols and procedures to identify and synthesize common practices. DESIGN: Rapid review of existing guidance from US and non-US public health organizations and professional societies and qualitative review using content analysis of discharge documents collected from a national sample of US academic medical centers with follow-up survey of hospital leaders SETTING AND PARTICIPANTS: We reviewed 65 websites for major professional societies and public health organizations and collected documents from 22 Academic Medical Centers (AMCs) in the US participating in the HOspital MEdicine Reengineering Network (HOMERuN). RESULTS: We synthesized data regarding common practices around 5 major domains: (1) isolation and transmission mitigation; (2) criteria for discharge to non-home settings including skilled nursing, assisted living, or homeless; (3) clinical criteria for discharge including oxygenation levels, fever, and symptom improvement; (4) social support and ability to perform activities of daily living; (5) post-discharge instructions, monitoring, and follow-up. LIMITATIONS: We used streamlined methods for rapid review of published guidance and collected discharge documents only in a focused sample of US academic medical centers. CONCLUSION: AMCs studied showed strong consensus on discharge practices for COVID-19 patients related to post-discharge isolation and transmission mitigation for home and non-home settings. There was high concordance among AMCs that discharge practices should address COVID-19-specific factors in clinical, functional, and post-discharge monitoring domains although definitions and details varied.

Hospital Ward Adaptation During the COVID-19 Pandemic: A National Survey of Academic Medical Centers.

IMPORTANCE: Although intensive care unit (ICU) adaptations to the coronavirus disease of 2019 (COVID-19) pandemic have received substantial attention , most patients hospitalized with COVID-19 have been in general medical units. OBJECTIVE: To characterize inpatient adaptations to care for non-ICU COVID-19 patients. DESIGN: Cross-sectional survey. SETTING: A network of 72 hospital medicine groups at US academic centers. MAIN OUTCOME MEASURES: COVID-19 testing, approaches to personal protective equipment (PPE), and features of respiratory isolation units (RIUs). RESULTS: Fifty-one of 72 sites responded (71%) between April 3 and April 5, 2020. At the time of our survey, only 15 (30%) reported COVID-19 test results being available in less than 6 hours. Half of sites with PPE data available reported PPE stockpiles of 2 weeks or less. Nearly all sites (90%) reported implementation of RIUs. RIUs primarily utilized attending physicians, with few incorporating residents and none incorporating students. Isolation and room-entry policies focused on grouping care activities and utilizing technology (such as video visits) to communicate with and evaluate patients. The vast majority of sites reported decreases in frequency of in-room encounters across provider or team types. Forty-six percent of respondents reported initially unrecognized non-COVID-19 diagnoses in patients admitted for COVID-19 evaluation; a similar number reported delayed identification of COVID-19 in patients admitted for other reasons. CONCLUSION: The COVID-19 pandemic has required medical wards to rapidly adapt with expanding use of RIUs and use of technology emerging as critical approaches. Reports of unrecognized or delayed diagnoses highlight how such adaptations may produce potential adverse effects on care.