A Leadership Pathway in Patient Safety and Quality Improvement for Trainees.

Training house staff in patient safety and quality improvement (PSQI) requires multidisciplinary collaboration between program directors, graduate medical education, and hospital safety and quality leadership. A heavy clinical workload and limited protected time hinder trainees from engaging in a meaningful PSQI experience during their years of post-graduate training. This is further exacerbated by the lack of subject experts who are available to mentor young physicians. For pulmonary and critical care trainees who are actively involved in the management and care coordination of high-acuity patients, this lack of experience adds undue burden. The role of house officer for patient safety and quality improvement was implemented to engage those currently in training who have an interest in PSQI. Under the supervision of the hospital PSQI leaders, they are given optimal, purposeful immersion without impacting their primary training specialty. This skill set can then be incorporated into their future careers. In this review, we provide perspective on how this can be accomplished and provide a framework that can be expanded.

Continuation of Opioid Therapy at Transitions of Care in Critically Ill Patients.

PURPOSE: Opioids are one of the high-risk medication classes that are administered to critically ill patients during their intensive care unit (ICU) stay. However, little attention has been given to inpatient opioid prescribing practices, especially in critically ill patients. The purpose of our study was to characterize opioid prescribing practices across 2 transitions of care during an inpatient hospital stay: medical ICU (MICU)/intermediate care unit (IMC) to floor and floor to hospital discharge and identify potential patient-specific factors that impact opioid continuation. METHODS: This is a retrospective cohort study evaluating opioid-naive adult patients with new opioid therapy initiated in MICU/IMC at a tertiary care academic medical center from December 1, 2016, to November 30, 2017. Opioid continuation rate was assessed twice: transition 1 (MICU/IMC to floor) and transition 2 (floor to hospital discharge). RESULTS: In total, 112 opioid-naive patients with initial opioid administration in the MICU/IMC were included. Opioid therapy was continued in 56.1% (37/66) at transition 1 and 56.8% of patients (21/37) at transition 2. Patients with opioids continued at transition 1 had a longer hospital length of stay compared to those not continued on opioids, 22 (interquartile range [IQR] 11-36) vs 8 (IQR 6-14; P = .0004). Among the patients continued on opioids at hospital discharge, intubation during hospital stay and cumulative opioid dosage were greater than those not continued on opioids (17 [80.9%] vs 7 [43.8%], P = .019; and 3482 mcg [IQR 1690-9530] vs 732.5 mcg [IQR 187.5-1360.9], P = .0018, respectively). CONCLUSIONS: Opioid-naive patients receiving opioid therapy in the MICU/IMC had a continuation rate of >56% during transitions of care, including hospital discharge. Factors that contributed to the continuation of opioids at transitions of care included longer hospital length of stay, intubation, and cumulative hospital opioid dosage. These findings may help to provide health systems with guidance on targeted opioid stewardship programs.

Multi-Level Predictors of Discharges Against Medical Advice: Identifying Contributors to Variation Using an All-Payer Database.

ABSTRACT: There is increasing evidence of the role of non-patient-level factors on discharge against medical advice (DAMA), but limited quantitative information regarding the extent of their impact. This study quantifies the contribution of discharge-level and hospital-level factors to the variation in DAMA. We grouped variables from the 2014 National Inpatient Sample data and ran incremental mixed-effects logit models with grouping at the level of the discharge, the hospital, and the census region. We obtained the intraclass correlation coefficients (ICCs), and evaluated the incremental change in ICC. The final sample included 2,687,430 discharges. 12.8% of the identified variation in the probability of DAMA was associated with the hospital, and 1.2% of the variation was associated with the census division in which the hospital was located. The final, fully-adjusted model had 7.3% of variation in DAMA associated with the hospital-level, with the greatest percentage reductions because of the addition of patient demographics. Even after adjusting for measured patient-level characteristics, there was a contribution of non-patient-level factors to DAMA outcomes. The findings identify a role for a multi-level approach to addressing DAMA.

Impact of an Antipsychotic Discontinuation Bundle During Transitions of Care in Critically Ill Patients.

INTRODUCTION:: Delirium affects a large proportion of patients admitted to the intensive care unit (ICU) and is associated with increased morbidity and mortality. Antipsychotics have become frequently used agents for the treatment of delirium; however, they are often continued at transitions of care. This has potential negative short- and long-term health consequences that are preventable. We investigated the antipsychotic tapering bundle's impact on the rate of antipsychotic continuation at transitions from the medical intensive care unit (MICU). METHODS:: This was a preretrospective and postretrospective chart review that included adult patients in the MICU initiated on antipsychotic therapy for ICU delirium. A bundled multidisciplinary education program and antipsychotic discontinuation algorithm were implemented in the MICU to provide recommendations for safe and effective use of antipsychotics for ICU delirium and minimize continuation of therapy at transitions of care. Rates of antipsychotic continuation at transition from the MICU were compared between the preintervention and postintervention groups with the χ2 test. RESULTS:: A total of 140 patients in the prebundle group and 141 patients in the postbundle group were enrolled. Overall, baseline characteristics were similar. After implementation of the discontinuation bundle, antipsychotic continuation at MICU discharge decreased (27.9% in the prebundle group vs 17.7% in the postbundle group; P < .05). In the multivariate analysis, patients were less likely to be continued on antipsychotic therapy at MICU discharge after implementation of the bundle (odds ratio [OR]: 0.47; 95% confidence interval [CI]: 0.26-0.86). There were also lower rates of overall antipsychotic continuation at hospital discharge (OR: 0.4; 95% CI: 0.18-0.89). CONCLUSION:: This is the first study to demonstrate a reduction in antipsychotic continuation at transition from the MICU after implementation of an antipsychotic discontinuation bundle in ICU patients. We believe this bundle allows for safer transitions of care from the MICU and decreases unnecessary antipsychotic therapy.

Results and Implications of Routine HIV Testing in the Inpatient Setting: A Descriptive Analysis.

Policy changes and scientific advances have guided new methods of diagnosing and managing HIV that reduce mortality, morbidity, and transmission. In a high HIV prevalence urban setting, a hospital initiative was implemented to routinely perform HIV testing and provide linkage to care for those with positive results and for individuals with a prior diagnosis of HIV. Maryland's unique all-payer model presents an opportunity to implement population health initiatives in health systems. The rationale, methodology, results and lessons learned from this approach will be discussed. Providers and nurses offered routine HIV screening and activated a Linkage to Care Navigator (LCN) for all HIV positive patients. The LCN provided referrals to HIV care and supportive services. In 22 months, 28 persons were newly diagnosed with HIV. Eighty-two percent (n = 23) were linked to outpatient care; 28.6% (8) were readmitted within 30 days for an inpatient stay. Of 517 patients previously diagnosed with HIV, 27.7% (n = 143) were not engaged in outpatient HIV care. Nearly 50% of those (n = 71) were relinked to care. Of 143 patients with a previous diagnosis who were considered out of care at the time of inpatient admission, 16 (11.2%) were readmitted as an inpatient within 30 days. Routinizing HIV testing and linkage to care in an inpatient setting identifies new and previously diagnosed HIV infected individuals who are not in care. This process has potential to identify HIV earlier, lower community viral load, and decrease transmission of HIV.

Routinization of HIV Testing in an Inpatient Setting: A Systematic Process for Organizational Change.

In 2006, the U.S. Centers for Disease Control and Prevention released revised recommendations for routinization of HIV testing in healthcare settings. Health professionals have been challenged to incorporate these guidelines. In March 2013, a routine HIV testing initiative was launched at a large urban academic medical center in a high prevalence region. The goal was to routinize HIV testing by achieving a 75% offer and 75% acceptance rate and promoting linkage to care in the inpatient setting. A systematic six-step organizational change process included stakeholder buy-in, identification of an interdisciplinary leadership team, infrastructure development, staff education, implementation, and continuous quality improvement. Success was measured by monitoring the percentage of offered and accepted HIV tests from March to December 2013. The targeted offer rate was exceeded consistently once nurses became part of the consent process (September 2013). Fifteen persons were newly diagnosed with HIV. Seventy-eight persons were identified as previously diagnosed with HIV, but not engaged in care. Through this process, patients who may have remained undiagnosed or out-of-care were identified and linked to care. The authors propose that this process can be replicated in other settings. Increasing identification and treatment will improve the individual patient's health and reduce community disease burden.

Hospital delirium treatment: Continuation of antipsychotic therapy from the intensive care unit to discharge.

PURPOSE: The rate of continuation of antipsychotics for the management of delirium during hospital transitions of care in a tertiary care medical center was investigated. METHODS: A retrospective chart review was conducted for adult patients admitted to the medical intensive care unit (MICU) between June 1, 2011, and May 31, 2012, who were initiated on antipsychotic therapy at least 24 hours before transfer out of the MICU. The primary outcome evaluated was the percentage of patients initiated on an antipsychotic in the MICU who were continued on therapy after transfer to a medical ward. Secondary outcomes included the appropriateness of continuing antipsychotic therapy during transitions of care and the percentage of patients continued on an antipsychotic after hospital discharge. RESULTS: Of the 87 patients who met the study inclusion criteria, 23 (26%) were continued on antipsychotic therapy after their transfer from the MICU to the medical ward. Of the 23 patients continued on antipsychotic therapy, 9 (39%) were discharged from the hospital with an antipsychotic. Fourteen of the 23 patients were eligible for assessment of inappropriate antipsychotic continuation upon transfer from the MICU. Of these 14 patients, 9 (64%) were inappropriately continued on an antipsychotic. Patients continued on antipsychotic therapy at hospital discharge were more likely to be discharged to a facility (rehabilitation, skilled nursing facility, or healthcare institution) (p = 0.049).Future areas for study should include (1) prospective analysis to understand the clinical decision-making of providers when treating delirium, (2) evaluation of the long-term impact of continuing antipsychotic therapy for delirium, and (3) ways to improve communication of medication regimens during transitions of care. Plans to reduce antipsychotic continuation could involve reassessing patients on the medical wards, improving documentation of the indication for use in the medical record, or developing protocols to taper off antipsychotics before patients are discharged from the hospital. CONCLUSION: The continuation of antipsychotics for the management of delirium during transitions of care was a common practice at a tertiary care medical center. Patients receiving antipsychotics for treatment of delirium in the MICU were inappropriately continued on these agents when transferred from the MICU to the medical floor or discharged from the hospital.

Choosing wisely in adult hospital medicine: five opportunities for improved healthcare value.

BACKGROUND: In an effort to lead physicians in addressing the problem of overuse of medical tests and treatments, the American Board of Internal Medicine Foundation developed the Choosing Wisely campaign. The Society of Hospital Medicine (SHM) joined the initiative to highlight the need to critically appraise resource utilization in hospitals. METHODS: The SHM employed a staged methodology to develop the adult Choosing Wisely list. This included surveys of the organization's leaders and general membership, a review of the literature, and Delphi panel voting. RESULTS: The 5 recommendations that were subsequently approved by the SHM Board are: (1) Do not place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non-critically ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for <2 days for urologic procedures; use weights instead to monitor diuresis). (2) Do not prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for gastrointestinal complications. (3) Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms or active coronary disease, heart failure, or stroke. (4) Do not order continuous telemetry monitoring outside of the intensive care unit without using a protocol that governs continuation. (5) Do not perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability. CONCLUSIONS: Hospitalists have many opportunities to impact overutilization of care. The adult hospital medicine Choosing Wisely recommendations offer an explicit starting point for eliminating waste in the hospital.

An analysis of deep vein thrombosis in 1277 consecutive neurosurgical patients undergoing routine weekly ultrasonography.

OBJECT: Patients requiring neurosurgical intervention are known to be at increased risk for deep vein thrombosis (DVT) and attendant morbidity and mortality. Pulmonary embolism (PE) is the most catastrophic sequela of DVT and is the direct cause of death in 16% of all in-hospital mortalities. Protocols for DVT screening and early detection, as well as treatment paradigms to prevent PE in the acute postoperative period, are needed in neurosurgery. The authors analyzed the effectiveness of weekly lower-extremity venous duplex ultrasonography (LEVDU) in patients requiring surgical intervention for cranial or spinal pathology for detection of DVT and prevention of PE. METHODS: Data obtained in 1277 consecutive patients admitted to a major tertiary care center requiring neurosurgical intervention were retrospectively reviewed. All patients underwent admission (within 1 week of neurosurgical intervention) LEVDU as well as weekly LEVDU surveillance if the initial study was normal. Additional LEVDU was ordered in any patient in whom DVT was suspected on daily clinical physical examination or in patients in whom chest CT angiography confirmed a pulmonary embolus. An electronic database was created and statistical analyses performed. RESULTS: The overall incidence of acute DVT was 2.8% (36 patients). Of these cases of DVT, a statistically significant greater number (86%) were discovered on admission (within 1-7 days after admission) screening LEVDU (p < 0.05), whereas fewer were documented 8-14 days after admission (2.8%) or after 14 days (11.2%) postadmission. Additionally, for acute DVT detection in the present population, there were no underlying statistically significant risk factors regarding baseline physical examination, age, ambulatory status, or type of surgery. The overall incidence of acute symptomatic PE was 0.3% and the mortality rate was 0%. CONCLUSIONS: Performed within 1 week of admission in patients who will undergo neurosurgical intervention, LEVDU is effective in screening for acute DVT and initiating treatment to prevent PE, thereby decreasing the overall mortality rate. Routine LEVDU beyond this time point may not be needed to detect DVT and prevent PE unless a change in the patient's physical examination status is detected.

Evaluating transitions of care of hospitalized medical patients to long-term care facilities: a retrospective review of venous thromboembolism prophylaxis.

Venous thromboembolism (VTE) is a significant but preventable cause of hospital-related morbidity and mortality. Prevention of in-hospital VTE, thus, has become a major quality improvement initiative within hospitals. However, addressing VTE prophylaxis rates and appropriateness on transition to other facilities has not been fully characterized to date. The authors of this study retrospectively evaluated VTE prophylaxis on transfer from medical inpatient settings to long-term care facilities. Analysis indicated that on transfer to other facilities, VTE prophylaxis recommendations were not routinely documented. Interfacility communication is crucial to ensure that appropriate prophylaxis recommendations are addressed during transitions of care. New processes evaluating VTE prophylaxis recommendations at the time of care transfer warrant further study.