Within-team Patterns of Communication and Referral in Multimodal Treatment of Chronic Low Back Pain Patients by an Integrative Care Team.

BACKGROUND: Nonspecific chronic low back pain (CLBP) is a highly prevalent and costly public health problem with few treatment options that provide consistent and greater than modest benefits. Treatment of CLBP is shifting from unimodal to multimodal and multidisciplinary approaches, including biopsychosocially-based complementary and integrative care. Multidisciplinary approaches require unique levels of communication and coordination amongst clinicians; however, to date few studies have evaluated patterns of communication and decision making amongst clinicians collaborating in the care of challenging patients with CLBP. METHODS: As part of an observational study evaluating the effectiveness and cost-effectiveness of an integrative, team-based care model for the treatment of CLBP, we used multiple qualitative research methods to characterize within-team cross-referral and communication amongst jointly-trained practitioners representing diverse biomedical and complementary disciplines. Patterns of communication and coordinated care are summarized for 3 cases of CLBP treated by multiple members (≥3) of an integrative medical team embedded within an academic hospital. RESULTS: Patients were aged from 36 to 88 years with varied comorbidities. Qualitative content analysis revealed 5 emergent themes regarding integrative patient care and treatment decision in this clinic: (1) the fundamental importance of the clinic's formal teamwork training; (2) the critical communicative and collaborative function of regular team meetings; (3) the importance to patient care goals of having the varied disciplines practicing "under one roof"; (4) a universal commitment to understanding and treating patients as whole persons; and (5) a shared philosophy of helping patients to help themselves. These key themes are all interconnected and form the foundation of the clinic's culture. CONCLUSIONS: Our qualitative findings provide context for current trends in enhancing patient-centered, coordinated, and team-based care; efforts towards better understanding interprofessional communication; overcoming barriers to successful collaboration; and identifying best practices for fostering clinical teamwork and a strong team identity. Our findings also support the need for further qualitative research, in combination with quantitative research, for evaluating the effectiveness and cost-effectiveness of resource-intensive integrative models for the treatment of chronic conditions.

Design and implementation of an automated email notification system for results of tests pending at discharge.

Physicians are often unaware of the results of tests pending at discharge (TPADs). The authors designed and implemented an automated system to notify the responsible inpatient physician of the finalized results of TPADs using secure, network email. The system coordinates a series of electronic events triggered by the discharge time stamp and sends an email to the identified discharging attending physician once finalized results are available. A carbon copy is sent to the primary care physicians in order to facilitate communication and the subsequent transfer of responsibility. Logic was incorporated to suppress selected tests and to limit notification volume. The system was activated for patients with TPADs discharged by randomly selected inpatient-attending physicians during a 6-month pilot. They received approximately 1.6 email notifications per discharged patient with TPADs. Eighty-four per cent of inpatient-attending physicians receiving automated email notifications stated that they were satisfied with the system in a brief survey (59% survey response rate). Automated email notification is a useful strategy for managing results of TPADs.

Development of a tool within the electronic medical record to facilitate medication reconciliation after hospital discharge.

Serious medication errors occur commonly in the period after hospital discharge. Medication reconciliation in the postdischarge ambulatory setting may be one way to reduce the frequency of these errors. The authors describe the design and implementation of a novel tool built into an ambulatory electronic medical record (EMR) to facilitate postdischarge medication reconciliation. The tool compares the preadmission medication list within the ambulatory EMR to the hospital discharge medication list, highlights all changes, and allows the EMR medication list to be easily updated. As might be expected for a novel tool intended for use in a minority of visits, use of the tool was low at first: 20% of applicable patient visits within 30 days of discharge. Clinician outreach, education, and a pop-up reminder succeeded in increasing use to 41% of applicable visits. Review of feedback identified several usability issues that will inform subsequent versions of the tool and provide generalizable lessons for how best to design medication reconciliation tools for this setting.

Racial and gender disparities in implantable cardioverter-defibrillator placement: are they due to overuse or underuse?

Previous studies documented racial and gender disparities in implantable cardioverter-defibrillator (ICD) placement. The authors examined whether racial and gender disparities in ICD placement are due to underutilization or overutilization. Among 1,054 adults hospitalized from 2001 to 2004 with ventricular arrhythmias in a large academic hospital, the study found that 17% of patients had clinical indicators concordant with ICD placement criteria. Among those, Blacks were less likely than Whites to receive an ICD (adjusted odds ratio [OR] = 0.24; 95% CI = 0.08-0.71). Among the 83% who were discordant with ICD placement criteria, Blacks (adjusted OR = 0.30; 95% CI = 0.18-0.52) and Hispanics (adjusted OR = 0.24, 95% CI = 0.10-0.57) were less likely than Whites, and women less likely than men, to receive an ICD (adjusted OR = 0.48; 95% CI = 0.34-0.67). In this cohort, these differences appear related to overutilization among men and Whites who are discordant with ICD placement criteria in addition to underutilization among Blacks concordant with placement criteria.

Effects of a computerized order set on the inpatient management of hyperglycemia: a cluster-randomized controlled trial.

OBJECTIVE: To determine the effects of a computerized order set on the inpatient management of diabetes and hyperglycemia. METHODS: We conducted a cluster-randomized controlled trial on the general medical service of an academic medical center staffed by residents and hospitalists. Consecutively enrolled patients with diabetes mellitus or inpatient hyperglycemia were randomized on the basis of their medical team to usual care (control group) or an admission order set built into the hospital's computer provider order entry (CPOE) system (intervention group). All teams received a detailed subcutaneous insulin protocol and case-based education. The primary outcome was the mean percent of glucose readings per patient between 60 and 180 mg/dL. RESULTS: Between April 5 and June 22, 2006, we identified 179 eligible study subjects. The mean percent of glucose readings per patient between 60 and 180 mg/dL was 75% in the intervention group and 71% in the usual care group (adjusted relative risk, 1.36; 95% confidence interval, 1.03 to 1.80). In comparison with usual care, the intervention group also had a lower patient-day weighted mean glucose (148 mg/dL versus 158 mg/dL, P = .04), less use of sliding-scale insulin by itself (25% versus 58%, P = .01), and no significant difference in the rate of severe hypoglycemia (glucose <40 mg/dL; 0.5% versus 0.3% of patient-days, P = .58). CONCLUSION: The use of an order set built into a hospital's CPOE system led to improvements in glycemic control and insulin ordering without causing a significant increase in hypoglycemia. Other institutions with CPOE should consider adopting similar order sets as part of a comprehensive inpatient glycemic management program.

Effect of an electronic medication reconciliation application and process redesign on potential adverse drug events: a cluster-randomized trial.

BACKGROUND: Medication reconciliation at transitions in care is a national patient safety goal, but its effects on important patient outcomes require further evaluation. We sought to measure the impact of an information technology-based medication reconciliation intervention on medication discrepancies with potential for harm (potential adverse drug events [PADEs]). METHODS: We performed a controlled trial, randomized by medical team, on general medical inpatient units at 2 academic hospitals from May to June 2006. We enrolled 322 patients admitted to 14 medical teams, for whom a medication history could be obtained before discharge. The intervention was a computerized medication reconciliation tool and process redesign involving physicians, nurses, and pharmacists. The main outcome was unintentional discrepancies between preadmission medications and admission or discharge medications that had potential for harm (PADEs). RESULTS: Among 160 control patients, there were 230 PADEs (1.44 per patient), while among 162 intervention patients there were 170 PADEs (1.05 per patient) (adjusted relative risk [ARR], 0.72; 95% confidence interval [CI], 0.52-0.99). A significant benefit was found at hospital 1 (ARR, 0.60; 95% CI, 0.38-0.97) but not at hospital 2 (ARR, 0.87; 95% CI, 0.57-1.32) (P = .32 for test of effect modification). Hospitals differed in the extent of integration of the medication reconciliation tool into computerized provider order entry applications at discharge. CONCLUSIONS: A computerized medication reconciliation tool and process redesign were associated with a decrease in unintentional medication discrepancies with potential for patient harm. Software integration issues are likely important for successful implementation of computerized medication reconciliation tools.

Effects of a subcutaneous insulin protocol, clinical education, and computerized order set on the quality of inpatient management of hyperglycemia: results of a clinical trial.

BACKGROUND: Inpatient hyperglycemia is associated with poor patient outcomes. It is unknown how best to implement glycemic management strategies in the non-intensive care unit (ICU) setting. OBJECTIVE: To determine the effects of a multifaceted quality improvement intervention on the management of medical inpatients with diabetes mellitus or hyperglycemia. DESIGN: Before-after trial. SETTING: Geographically localized general medical service staffed by physician's assistants (PAs) and hospitalists. PATIENTS: Consecutively enrolled patients with type 2 diabetes or inpatient hyperglycemia. INTERVENTION: A detailed subcutaneous insulin protocol, an admission order set built into the hospital's computerized order entry system, and case-based educational workshops and lectures to nurses, physicians, and PAs. MEASUREMENTS: Mean percent of glucose readings per patient between 60 and 180 mg/dL; percent patient-days with hypoglycemia; insulin use patterns; and hospital length of stay. RESULTS: The mean percent of readings per patient between 60 and 180 mg/dL was 59% prior to the intervention and 65% afterward (adjusted effect size 9.7%; 95% confidence interval [CI], 0.6%-18.8%). The percent of patient days with any hypoglycemia was 5.5% preintervention and 6.1% afterward (adjusted odds ratio 1.1; 95% CI, 0.6-2.1). Use of scheduled nutritional insulin increased from 40% to 75% (odds ratio 4.5; 95% CI, 2.0-9.9) and adjusted length of stay decreased by 25% (95% CI, 9%-44%). Daily insulin adjustment did not improve, nor did glucose control beyond hospital day 3. CONCLUSIONS: This multifaceted intervention, which was easy to implement and required minimal resources, was associated with improvements in both insulin ordering practices and glycemic control among non-ICU medical patients.

Implementation of a physician assistant/hospitalist service in an academic medical center: impact on efficiency and patient outcomes.

BACKGROUND: Accreditation Council on Graduate Medical Education (ACGME) duty hour restrictions have led to the widespread implementation of non-house staff services in academic medical centers, yet little is known about the quality and efficiency of patient care on such services. OBJECTIVE: To evaluate the quality and efficiency of patient care on a physician assistant/hospitalist service compared with that of traditional house staff services. DESIGN: Retrospective cohort study. SETTING: Inpatient general medicine service of a 747-bed academic medical center. PATIENTS: A total of 5194 consecutive patients admitted to the general medical service from July 2005 to June 2006, including 992 patients on the physician assistant/hospitalist service and 4202 patients on a traditional house staff service. INTERVENTION: A geographically localized service staffed with physician assistants and supervised by hospitalists. MEASUREMENTS: Length of stay (LOS), cost of care, inpatient mortality, intensive care unit (ICU) transfers, readmissions, and patient satisfaction. RESULTS: Patients admitted to the study service were younger, had lower comorbidity scores, and were more likely to be admitted at night. After adjustment for these and other factors, and for clustering by attending physician, total cost of care was marginally lower on the study service (adjusted costs 3.9% lower; 95% confidence interval [CI] -7.5% to -0.3%), but LOS was not significantly different (adjusted LOS 5.0% higher; 95% CI, -0.4% to +10%) as compared with house staff services. No difference was seen in inpatient mortality, ICU transfers, readmissions, or patient satisfaction. CONCLUSIONS: For general medicine inpatients admitted to an academic medical center, a service staffed by hospitalists and physician assistants can provide a safe alternative to house staff services, with comparable efficiency.

Classifying and predicting errors of inpatient medication reconciliation.

BACKGROUND: Failure to reconcile medications across transitions in care is an important source of potential harm to patients. Little is known about the predictors of unintentional medication discrepancies and how, when, and where they occur. OBJECTIVE: To determine the reasons, timing, and predictors of potentially harmful medication discrepancies. DESIGN: Prospective observational study. PATIENTS: Admitted general medical patients. MEASUREMENTS: Study pharmacists took gold-standard medication histories and compared them with medical teams' medication histories, admission and discharge orders. Blinded teams of physicians adjudicated all unexplained discrepancies using a modification of an existing typology. The main outcome was the number of potentially harmful unintentional medication discrepancies per patient (potential adverse drug events or PADEs). RESULTS: Among 180 patients, 2066 medication discrepancies were identified, and 257 (12%) were unintentional and had potential for harm (1.4 per patient). Of these, 186 (72%) were due to errors taking the preadmission medication history, while 68 (26%) were due to errors reconciling the medication history with discharge orders. Most PADEs occurred at discharge (75%). In multivariable analyses, low patient understanding of preadmission medications, number of medication changes from preadmission to discharge, and medication history taken by an intern were associated with PADEs. CONCLUSIONS: Unintentional medication discrepancies are common and more often due to errors taking an accurate medication history than errors reconciling this history with patient orders. Focusing on accurate medication histories, on potential medication errors at discharge, and on identifying high-risk patients for more intensive interventions may improve medication safety during and after hospitalization.