Implementation of a fracture liaison service for patients with hip fracture cared for on a hospital medicine service.

OBJECTIVE: Hip fracture is a common and morbid condition. Prior studies have shown that the majority of patients with fragility fracture are not treated for underlying osteoporosis. Our hospitalist-led co-management service for patients with acute hip fracture had no system for evaluating and treating osteoporosis in this cohort. Our objective was to implement a fracture liaison service (FLS) to assist patients with acute hip fracture and assess subsequent impact on diagnosis and treatment of osteoporosis. METHODS: We conducted a pre-post study design at our tertiary academic center, including patients >50 years old hospitalized with acute hip fracture. We implemented a FLS, whereby all patients received endocrinology consultation. Outcome measures included the proportion of patients evaluated for osteoporosis by time of hospital discharge, comparing pre-implementation (12 months) and post-implementation (9 months) cohorts. We also measured the proportions of patients evaluated for and offered treatment for osteoporosis within 3 months of discharge for patients with post-discharge encounters visible in the medical record. RESULTS: We identified 167 patients before and 124 after FLS implementation. In univariate analysis, the proportion of patients evaluated for osteoporosis before discharge increased from 0.6% to 72.6% (p < 0.001) pre- vs. post-implementation. The proportion of patients offered osteoporosis treatment within 3 months after discharge increased from 25.3% to 46.3% (p = 0.01). In multivariate analysis, post-implementation patients had higher odds of osteoporosis evaluation while hospitalized (OR = 470.4, p < 0.001) and higher odds of being offered osteoporosis treatment within 3 months (OR = 2.8, p = 0.008). CONCLUSIONS: Establishment of an FLS partnered with a hospitalist-led co-management service for patients with hip fracture was associated with significant improvements in the proportions of patients evaluated and offered treatment for osteoporosis. Wider adoption of this model has the potential to improve care for patients with hip fracture by narrowing the osteoporosis treatment gap.

[5 years of hospital medicine in the Netherlands]. / 5 jaar ziekenhuisgeneeskunde.

Hospital medicine ('ziekenhuisgeneeskunde') was introduced in the Dutch health care system 5 years ago. This new specialism, inspired by the American model, seeks to solve the challenge of guaranteeing continuous and high-quality care for hospitalized patients, using an interdisciplinary approach. Although the specialism has received a positive first impact assessment, hospitalists and trainees are also facing difficulties, as the rooting of the new specialism in the healthcare system takes time. Examples of these difficulties include a lack of structural governmental funding and positioning challenges within hospitals.

SPEAKers at the National Society of Hospital Medicine Meeting: A Follow-UP Study of Gender Equity for Conference Speakers from 2015 to 2019. The SPEAK UP Study.

Women continue to be underrepresented as speakers at national conferences, and research has shown similar trends in hospital medicine. The Society of Hospital Medicine (SHM) Annual Meeting has historically had an open call peer review process for workshop speakers and, in 2019, expanded the process for didactic speakers. We aimed to assess the overall conference trends for women speakers and whether the systematic processes in recruitment procedures (ie, open call) resulted in improved representation of women speakers. We also sought to understand how the proportion of women speakers might affect overall scores of the conference. From 2015 to 2019, the overall representation of women speakers increased, as did evaluation scores during the same time period. When selection processes included the open call peer review process, there were higher proportions of women speakers. An open call process with peer review for speakers may be a systematic process that national meetings could replicate to reduce gender inequities.

El problema de la fragmentación de la medicina hospitalaria / The problem of the fragmentation of hospital medicine

No disponible

Evidence-based out-of-hours hospital medicine.

Out-of-hours (OOH) hospital ward cover is generally provided by junior doctors and is typified by heavy workloads, reduced staff numbers and various non-urgent nurse-initiated requests. The present inefficiencies and management problems with the OOH service are reflected by the high number of quality improvement projects recently published. In this narrative review, five common situations peculiar to the OOH general ward setting are discussed with reference to potential areas of inefficiency and unnecessary management steps: (1) prescription of hypnotics and sedatives; (2) overnight fluid therapy; (3) fever; (4) overnight hypotension and (5) chasing outstanding routine diagnostic tests. It is evident that research and consensus guidelines for many clinical situations in the OOH setting are a neglected arena. Many recommendations made herein are based on expert opinion or first principles. In contrast, the management of significant abnormalities in outstanding blood results is based on well-established guidelines using high-quality systematic reviews.

Training Residents in Hospital Medicine: The Hospitalist Elective National Survey.

As the field of hospital medicine expands, internal medicine residency programs can play a role in preparing future hospitalists. To date, little is known of the prevalence and characteristics of hospitalist-focused resident rotations. We surveyed the largest 100 Internal Medicine Residency Programs to better understand the prevalence, objectives, and structure of hospitalist-focused rotations in the United States. Residency leaders from 82 programs responded (82%). The prevalence of hospitalist-focused rotations was 50% (41/82) with an additional 9 programs (11%) planning to start one. Of these 41 rotations, 85% were elective rotations and 15% were mandatory rotations. Rotations involved clinical responsibilities, and most programs incorporated nonclinical curricular activities such as teaching, research, and work on quality improvement and patient safety. Respondents noted that their programs promoted autonomy, mentorship, and "real-world" hospitalist experience. Hospitalist-focused rotations may supplement traditional inpatient rotations and teach skills that facilitate the transition from residency to a career in hospital medicine.

Recommendations on the Use of Ultrasound Guidance for Adult Thoracentesis: A Position Statement of the Society of Hospital Medicine.

Executive Summary: 1) We recommend that ultrasound should be used to guide thoracentesis to reduce the risk of complications, the most common being pneumothorax. 2) We recommend that ultrasound guidance should be used to increase the success rate of thoracentesis. 3) We recommend that ultrasound-guided thoracentesis should be performed or closely supervised by experienced operators. 4) We suggest that ultrasound guidance be used to reduce the risk of complications from thoracentesis in mechanically ventilated patients. 5) We recommend that ultrasound should be used to identify the chest wall, pleura, diaphragm, lung, and subdiaphragmatic organs throughout the respiratory cycle before selecting a needle insertion site. 6) We recommend that ultrasound should be used to detect the presence or absence of an effusion and approximate the volume of pleural fluid to guide clinical decision-making. 7) We recommend that ultrasound should be used to detect complex sonographic features, such as septations, to guide clinical decision-making regarding the timing and method of pleural drainage. 8) We suggest that ultrasound be used to measure the depth from the skin surface to the parietal pleura to help select an appropriate length needle and determine the maximum needle insertion depth. 9) We suggest that ultrasound be used to evaluate normal lung sliding pre- and postprocedure to rule out pneumothorax. 10) We suggest avoiding delay or interval change in patient position from the time of marking the needle insertion site to performing the thoracentesis. 11) We recommend against performing routine postprocedure chest radiographs in patients who have undergone thoracentesis successfully with ultrasound guidance and are asymptomatic with normal lung sliding postprocedure. 12) We recommend that novices who use ultrasound guidance for thoracentesis should receive focused training in lung and pleural ultrasonography and hands-on practice in procedural technique. 13) We suggest that novices undergo simulation-based training prior to performing ultrasound-guided thoracentesis on patients. 14) Learning curves for novices to become competent in lung ultrasound and ultrasound-guided thoracentesis are not completely understood, and we recommend that training should be tailored to the skill acquisition of the learner and the resources of the institution.

Hospital Dermatology, Introduction.

Inpatient dermatology is emerging as a distinct dermatology subspecialty where dermatologists specialize in caring for patients hospitalized with skin disease. While the main focus of inpatient dermatology is the delivery of top-quality and timely dermatologic care to patients in the hospital setting, the practice of hospital-based dermatology has many additional components that are critical to its success.

The logistics of an inpatient dermatology service.

Inpatient dermatology represents a unique challenge as caring for hospitalized patients with skin conditions is different from most dermatologists' daily outpatient practice. Declining rates of inpatient dermatology participation are often attributed to a number of factors, including challenges navigating the administrative burdens of hospital credentialing, acclimating to different hospital systems involving potential alternate electronic medical records systems, medical-legal concerns, and reimbursement concerns. This article aims to provide basic guidelines to help dermatologists establish a presence as a consulting physician in the inpatient hospital-based setting. The emphasis is on identifying potential pitfalls, problematic areas, and laying out strategies for tackling some of the challenges of inpatient dermatology including balancing financial concerns and optimizing reimbursements, tracking data and developing a plan for academic productivity, optimizing workflow, and identifying metrics to document the impact of an inpatient dermatology consult service.

The efficient, effective community hospital inpatient dermatology consult.

Hospital dermatology is often thought to be too cumbersome for the private practicing dermatologist to handle, leaving patients in our communities without needed care and our medical colleagues in the dark when it comes to diagnosing and/or managing skin disease in the hospitalized patient. This notion that "someone else will figure it out" undervalues our expertise as a specialty and threatens the appropriate health outcomes we knowingly understand patients deserve. In this manuscript, we intend to break down the hospital consult conceptually so as to make clear how simple it can be to help our physician colleagues and make an important impact upon patients at their most vulnerable time.

Teledermatology in the inpatient setting.

Teledermatology (TD) is a health care delivery modality that uses telecommunication technology to provide dermatologic care. It has grown to be a reliable and diagnostically accurate means of producing quality care while increasing access and reducing wait times in the outpatient setting. In the inpatient setting, TD may be an effective method to improve access to dermatologic care by remotely triaging, assisting, or providing dermatologic consultative services. For inpatient dermatology, there is the potential for TD to increase access to care in the community setting where dermatologists have full outpatient schedules. Using inpatient TD to triage conditions may be especially helpful in determining if a patient needs to be emergently/urgently seen, or if outpatient care could be appropriate. To best establish TD in the inpatient setting, certain practice guidelines should be considered to ensure the highest quality patient care. These features include Health Insurance Portability and Accountability Act (HIPAA)-consistent protocols to ensure high-quality video sessions and clinical photographs are acquired, stored, and transmitted using secure software and networks, establishing relationships with primary care teams to ensure trust in consulting advice and ensuring consistent communication regarding recommendations, and appropriate patient follow-up.

Hospital Medicine and Fellowship Program in Rural North Dakota - A Multifaceted Success Story.

INTRODUCTION: Recruitment of hospitalists and primary care physicians for Critical Access Hospitals and tertiary care hospitals in North Dakota is difficult. To address this challenge, 2 programs were implemented in Bismarck, North Dakota. METHODS: St. Alexius Medical Center created a hospitalist fellowship training program in collaboration with the University of North Dakota School of Medicine and Health Sciences and physicians willing to work in Critical Access Hospitals were offered a joint appointment to teach hospitalist fellows and obtain a clinical academic appointment at the university. RESULTS: Since it was created in 2012, 84 physicians have applied for 13 fellowships. Of the 11 fellows who have completed the program, 64% (7/11) remained in North Dakota to practice. CONCLUSIONS: Physicians are more likely to work in a rural Critical Access Hospital if they spend time working at a tertiary care center and have clinical academic appointments. Where recruitment is challenging, hospitalist fellowship programs are helpful in meeting the health care workforce demand.

Striving for optimal care: Updates in quality, value, and patient experience.

BACKGROUND: Hospitalists are playing a growing role in quality improvement efforts, and they are increasingly spearheading programs to improve patient experience and healthcare value. We aimed to summarize and critique recent research related to quality, value, and patient experience in the clinical practice of hospital medicine. METHODS: We reviewed articles published between January 2014 and February 2015, identified through a hand search of leading journals, continuing medical education collaborative journal reviews, Agency for Healthcare Research and Quality's Patient Safety network, and PubMed. The authors collectively selected 9 articles based on their relevance to hospital practice. We review their findings, strengths, and limitations and make recommendations for practice. This is a summary of an update we presented at the 2015 Hospital Medicine national meeting. RESULTS: Key findings include: a comprehensive hand-off program was associated with improved patient safety; successful readmissions interventions were resource-intensive, multifaceted and increased patient capacity to handle illness; patient activation was correlated with lower resource use post-hospitalization; positive associations exist between patient experience and understanding of their hospitalization; hospitals and practitioners can adopt simple low-cost strategies to reduce the trauma of hospitalization; hospitalists frequently order low-value tests, most often to reassure themselves or their patients; broad-spectrum antibiotics are grossly overused in hospitalized patients leading to preventable harms including clostridium difficile colitis, and programs that support "self-stewardship" may help moderate this risk. CONCLUSIONS: Recent research provides important insights into readmissions prevention, patient experience and low-value test ordering, as well as introduces interventions that may mitigate the risks of handoffs and the overuse of broad-spectrum antibiotics.

Promoting high value inpatient care via a coaching model of structured, interdisciplinary team rounds.

The professional development of early career hospital physicians may be improved by embedding an experienced physician in a coaching role during structured, interdisciplinary team rounds. This article gives a descriptive report of such a model and discusses how it may promote delivery of high-value care to adult inpatients.

The Pediatric Inpatient Family Care Conference: a proposed structure toward shared decision-making.

Over the past decade, there has been a steady increase in the medical complexity of patients on the pediatric inpatient service while at the same time, there are few data to show that families are satisfied with communication of complex issues. Family care conferences are defined as an opportunity outside of rounds to meet and discuss treatment decisions and options. They offer a potential pathway for psychosocial support and facilitated communication. The lack of consensus about the structure of these conferences impedes our ability to research patient, family, and provider outcomes related to communication. The goal of the present article was to describe a structure for family care conferences in the pediatric inpatient setting with a literature-based description of each phase of the conference. The theoretical framework for the structure is that patient and family engagement can improve communication and ultimately health care quality. This proposed model offers guidance to providers and researchers whose goal is to improve communication on the inpatient service.

The evolving role of the pediatric nurse practitioner in hospital medicine.

BACKGROUND: This program evaluation sought to compare cost and pediatric patient outcomes among a pediatric nurse practitioner (PNP) hospitalist team, a combined PNP/doctor of medicine (MD) team, and 2 resident teams without PNPs. METHODS: Administrative and electronic medical record data from July 1, 2009 to June 30, 2010 was retrospectively reviewed from Children's Hospital Colorado inpatient medical unit and inpatient satellite sites in the Children's Hospital network of care (NOC). The top 3 All Patient Refined Diagnosis Related Groups (APR-DRG) admission codes bronchiolitis and respiratory syncytial virus (RSV) pneumonia, pneumonia not elsewhere classified (NEC), and asthma were selected for this analysis. Inpatient records representing these APR-DRG admission codes were reviewed (N = 1664). Measures included adherence with relevant clinical care guidelines (CCGs), length of stay (LOS), and cost of care. Chi square, t tests, and analysis of variance were used to analyze between-group differences. RESULTS: Approximately 20% of these admissions were on the PNP team, 45% were on the resident teams, and 35% were on the PNP/MD team in the NOC. PNP adherence to CCGs was comparable to resident teams for selected measures. There was no significant difference in LOS among the PNP team, the PNP/MD team, and the resident teams. The direct cost of patient care per encounter provided by the PNP team was significantly less than the PNP/MD team and the resident teams. CONCLUSIONS: There is evidence to suggest that PNP hospitalists provide inpatient care comparable to resident teams at a lower cost for patients with uncomplicated bronchiolitis, pneumonia, and asthma.

Road map to a patient-centered research agenda at the intersection of hospital medicine and geriatric medicine.

As the United States ages, the patient population in acute care hospitals is increasingly older and more medically complex. Despite evidence of a high burden of disease, high costs, and often poor outcomes of care, there is limited understanding of the presentation, diagnostic strategies, and management of acute illness in older adults. In this paper, we present a strategy for the development of a research agenda at the intersection of hospital and geriatric medicine. This approach is informed by the Patient-Centered Outcomes Research Institute (PCORI) framework for identification and prioritization of research areas, emphasizing input from patients and caregivers. The framework's four components are: 1) Topic generation, 2) Gap Analysis in Systematic Review, 3) Value of information (VOI) analysis, and 4) Peer Review. An inclusive process for topic generation requiring the systematic engagement of multiple stakeholders, especially patients, is emphasized. In subsequent steps, researchers and stakeholders prioritize research topics in order to identify areas that optimize patient-centeredness, population impact, impact on clinical decision making, ease of implementation, and durability. Finally, next steps for dissemination of the research agenda and evaluation of the impact of the patient-centered research prioritization process are described.