Poverty, Comorbidity, and Ethnicity: COVID-19 Outcomes in a Safety Net Health System.

Objective: To determine if race-ethnicity is correlated with case-fatality rates among low-income patients hospitalized for COVID-19. Research Design: Observational cohort study using electronic health record data. Patients: All patients assessed for COVID-19 from March 2020 to January 2021 at one safety net health system. Measures: Patient demographic and clinical characteristics, and hospital care processes and outcomes. Results: Among 25,253 patients assessed for COVID-19, 6,357 (25.2%) were COVID-19 positive: 1,480 (23.3%) hospitalized; 334 (22.6%) required intensive care; and 106 (7.3%) died. More Hispanic patients tested positive (51.8%) than non-Hispanic Black (31.4%) and White patients (16.7%, P<.001]. Hospitalized Hispanic patients were younger, more often uninsured, and less likely to have comorbid conditions. Non-Hispanic Black patients had significantly more diabetes, hypertension, obesity, chronic kidney disease, and asthma (P<.05). Non-Hispanic White patients were older and had more cigarette smoking history, COPD, and cancer. Non-Hispanic White patients were more likely to receive intensive care (29.6% vs 21.1% vs 20.8%, P=.007) and more likely to die (12% vs 7.3% vs 3.5%, P<.001) compared with non-Hispanic Black and Hispanic patients, respectively. Length of stay was similar for all groups. In logistic regression models, Medicaid insurance status independently correlated with hospitalization (OR 3.67, P<.001) while only age (OR 1.076, P<.001) and cerebrovascular disease independently correlated with in-hospital mortality (OR 2.887, P=.002). Conclusions: Observed COVID-19 in-hospital mortality rate was lower than most published rates. Age, but not race-ethnicity, was independently correlated with in-hospital mortality. Safety net health systems are foundational in the care of vulnerable patients suffering from COVID-19, including patients from under-represented and low-income groups.

Twelve tips for conducting successful interprofessional teaching rounds.

Inpatient bedside teaching rounds provide an opportunity to foster effective interprofessional collaboration between members of the healthcare team. Although effective interprofessional practice has been shown to improve patient satisfaction, patient outcomes, and job satisfaction, there is limited literature for successful implementation of interprofessional teaching rounds. To address this gap, we have compiled 12 tips for conducting effective interprofessional bedside teaching rounds. These tips offer strategies for creating a structured rounding system, with clear delineation of expectations, defined opportunities for learning across disciplines, and active engagement of and respect for all team members. By adopting and promoting this model of interprofessional collaborative practice, the quality and effectiveness of bedside teaching rounds can be improved for the benefit of patients, trainees, and the team as a whole.

Teaching at the Bedside. Maximal Impact in Minimal Time.

Academic physicians encounter many demands on their time including patient care, quality and performance requirements, research, and education. In an era when patient volume is prioritized and competition for research funding is intense, there is a risk that medical education will become marginalized. Bedside teaching, a responsibility of academic physicians regardless of professional track, is challenged in particular out of concern that it generates inefficiency, and distractions from direct patient care, and can distort physician-patient relationships. At the same time, the bedside is a powerful location for teaching as learners more easily engage with educational content when they can directly see its practical relevance for patient care. Also, bedside teaching enables patients and family members to engage directly in the educational process. Successful bedside teaching can be aided by consideration of four factors: climate, attention, reasoning, and evaluation. Creating a safe environment for learning and patient care is essential. We recommend that educators set expectations about use of medical jargon and engagement of the patient and family before they enter the patient room with trainees. Keep learners focused by asking relevant questions of all members of the team and by maintaining a collective leadership style. Assess and model clinical reasoning through a hypothesis-driven approach that explores the rationale for clinical decisions. Focused, specific, real-time feedback is essential for the learner to modify behaviors for future patient encounters. Together, these strategies may alleviate challenges associated with bedside teaching and ensure it remains a part of physician practice in academic medicine.

Smoking-Related Home Oxygen Burn Injuries: Continued Cause for Alarm.

BACKGROUND: Home oxygen therapy is a mainstay of treatment for patients with various cardiopulmonary diseases. In spite of warnings against smoking while using home oxygen, many patients sustain burn injuries. OBJECTIVES: We aimed to quantify the morbidity and mortality of such patients admitted to our regional burn unit over a 6-year period. METHODS: A retrospective chart review of all patients admitted to a regional burn center from 2008 through 2013 was completed. Admitted patients sustaining burns secondary to smoking while using home oxygen therapy were selected as the study population to determine morbidity. RESULTS: Fifty-five subjects were admitted to the burn unit for smoking-related home oxygen injuries. The age range was 40-84 years. Almost all subjects were on home oxygen for chronic obstructive pulmonary disease (96%). Seventy-two percent of burns involved <5% of the total body surface area, 51% of patients were intubated, and of those 33% had evidence of inhalation injury. The hospital mortality rate was 14.5%. The mean length of hospital stay was 8.6 days, and 54.5% were discharged to a nursing home or another advanced facility. Finally, concomitant substance abuse was found in 27%, and a previous history of injury from smoking while on home oxygen was discovered in 14.5%. CONCLUSIONS: This single-center analysis is one of the largest describing burn injuries stemming from smoking while using home oxygen therapy. We identified the morbidity and mortality associated with these injuries. Ongoing education and careful consideration of prescribing home oxygen therapy for known smokers is highly encouraged.

Intensive care unit rounding checklist implementation. Effect of accountability measures on physician compliance.

RATIONALE/OBJECTIVES: Checklist utilization has been shown to improve multiple processes of care in the intensive care unit (ICU). The ICU setting makes checklist implementation challenging, particularly when prompters are unavailable to ensure checklist compliance. We performed a prospective analysis on physician compliance reporting as a means to improve attending physician compliance with checklist use during ICU rounds. METHODS: We performed a prospective analysis of 14 attending physicians' compliance with checklist use before and after accountability measures employed at two urban academic hospitals in the United States. The accountability measures were bimonthly publication of physician checklist compliance via division e-mail and during a multidisciplinary division conference. MEASUREMENTS AND MAIN RESULTS: A total of 5,812 patient days of ICU care were assessed from April 2013 through March 2014. Compliance with checklist use during ICU rounds improved at both academic hospitals during the intervention phase. Initial compliance rates were 67% at both institutions and subsequently improved to 90 and 81%, respectively, after accountability measures were employed. During a 3-month washout phase in which no public accountability measures were employed, compliance was maintained at 89 and 78% at the two hospitals. Foley catheter, central venous catheter, and ventilator utilization rates decreased after initiation of public accountability at both hospitals. CONCLUSIONS: Physician compliance reporting can be used to improve ICU physician compliance with rounding checklists when prompters are unavailable. Improved physician compliance translated into decreased rates of Foley catheter, central venous catheter, and ventilator use. These results highlight the impact physician accountability can have on patient care in the ICU.