"Where You Feel Like a Family Instead of Co-workers": a Mixed Methods Study on Care Teams and Burnout.

BACKGROUND: Physicians and nurses face high levels of burnout. The role of care teams may be protective against burnout and provide a potential target for future interventions. OBJECTIVE: To explore levels of burnout among physicians and nurses and differences in burnout between physicians and nurses, to understand physician and nurse perspectives of their healthcare teams, and to explore the association of the role of care teams and burnout. DESIGN: A mixed methods study in two school of medicine affiliated teaching hospitals in an urban medical center in Baltimore, Maryland. PARTICIPANTS: Participants included 724 physicians and 971 nurses providing direct clinical care to patients. MAIN MEASURES AND APPROACH: Measures included survey participant characteristics, a single-item burnout measure, and survey questions on care teams and provision of clinical care. Thematic analysis was used to analyze qualitative survey responses from physicians and nurses. KEY RESULTS: Forty-three percent of physicians and nurses screened positive for burnout. Physicians reported more isolation at work than nurses (p<0.001), and nurses reported their care teams worked efficiently together more than physicians did (p<0.001). Team efficiency was associated with decreased likelihood of burnout (p<0.01), and isolation at work was associated with increased likelihood of burnout (p<0.001). Free-text responses revealed themes related to care teams, including emphasis on team functioning, team membership, and care coordination and follow-up. Respondents provided recommendations about optimizing care teams including creating consistent care teams, expanding interdisciplinary team members, and increasing clinical support staffing. CONCLUSIONS: More team efficiency and less isolation at work were associated with decreased likelihood of burnout. Free-text responses emphasized viewpoints on care teams, suggesting that better understanding care teams may provide insight into physician and nurse burnout.

Lessons Learned From Rapid Deployment of 100% Mortality Review for Patients With COVID-19 Across a Health System.

Mortality review is one approach to systematically examine delivery of care and identify areas for improvement. Health system leaders sought to ensure hospitals were adapting to the rapidly changing medical guidance for COVID-19 and delivering high-quality care. Thus, all patients with a COVID-19 diagnosis within the 6-hospital system who died between March and July 2020 were reviewed within 72 hours. Concerns for preventability advanced review to level 2 (content experts) or 3 (hospital leadership). Reviews included available autopsy and cardiac arrest data. Overall health system mortality for COVID-19 patient admissions was 12.5% and mortality for mechanically ventilated patients was 34.4%. Significant differences in mortality rates were observed among hospitals due to demographic variations in patient populations at hospitals. Mortality reviews resulted in the dissemination of evolving knowledge among sites using an electronic medical record order set, implementation of proning teams, and development of checklists for converting COVID-19 floors and units.

Models of Intermediate Care Organization and Staffing at an Academic Medical Center: Considerations of an Inpatient Planning Committee.

Rationale: Geographic co-localization of patients and provider teams (geography) may improve care efficiency and quality. Patients requiring intermediate care present a unique challenge to the geographic model. Objective: Identify the best organizational and staffing model for intermediate care at our academic medical center. Methods: A modified nominal group technique was employed to assess the benefits and limitations of an existing model of intermediate care, identify and review potential alternative models, and choose a new model. Results: In addition to the institution's current model, the benefits and limitations of six alternative organizational and staffing models were characterized. The anticipated impact of each model on nurse: provider communication, maintenance of nursing competencies, nurse satisfaction, efficient utilization of technical and human resources, triage of patients to the unit, care continuity, and the impact on trainee education are described. After considering these features, stakeholders ranked a closed provider staffing model on a unit dedicated to intermediate care highest of the six alternative models. Important outcomes to monitor following transition to a closed staffing model included patient outcomes, nursing job satisfaction and retention, provider and trainee experience, unexpected patient transfers to higher or lower levels of care, and administrative costs. Conclusions: After considering six alternative staffing models for intermediate care, stakeholders ranked a closed provider staffing model highest. Further qualitative and quantitative comparisons to determine optimal models of intermediate care are needed.

Bed downtime: the novel use of a quality metric allows inpatient providers to improve patient flow from the emergency department.

BACKGROUND: Emergency department (ED) boarding time is associated with increased length of stay (LOS) and inpatient mortality. Despite the documented impact of ED boarding on inpatient outcomes, a disparity continues to exist between the attention paid to the issue by inpatient and ED providers. A perceived lack of high yield strategies to address ED boarding from the perspective of the inpatient provider may discourage involvement in improvement initiatives on the subject. As such, further work is needed to identify inpatient metrics and strategies to address patient flow problems, and which may improve ED boarding time. METHODS: After initial system analysis, our multidisciplinary quality improvement (QI) group defined the process time metric 'bed downtime'-the time from which a bed is vacated by a discharged patient to the time an ED patient is assigned to that bed. Using the Lean Sigma QI approach, this metric was targeted for improvement on the internal medicine hospitalist service at a tertiary care academic medical centre. INTERVENTIONS: Interventions included improving inpatient provider awareness of the problem, real-time provider notification of empty beds, a weekly retrospective emailed performance dashboard and the creation of a guideline document for admission procedures. RESULTS: This package of interventions was associated with a 125 min reduction in mean bed downtime for incoming ED patients (254 min to 129 min) admitted to the intervention unit. CONCLUSION: Use of the bed downtime metric as a QI target was associated with marked improvements in process time during our project. The use of this metric may enhance the ability of inpatient providers to participate in QI efforts to improve patient flow from the ED. Further study is needed to determine if use of the metric may be effective at reducing boarding time without requiring alterations to LOS or discharge patterns.

Comparative Effectiveness of Antibiotic Treatment Duration in Children With Pyelonephritis.

Importance: National guidelines recommend treating children with pyelonephritis for 7 to 14 days of antibiotic therapy, yet data are lacking to suggest a more precise treatment duration. Objective: To compare the clinical outcomes of children receiving a short-course vs a prolonged-course of antibiotic treatment for pyelonephritis. Design, Setting, and Participants: Retrospective observational study using inverse probability of treatment weighted propensity score analysis of data from 5 hospitals in Maryland between July 1, 2016, and October 1, 2018. Participants were children aged 6 months to 18 years with a urine culture growing Escherichia coli, Klebsiella species, or Proteus mirabilis with laboratory and clinical criteria for pyelonephritis. Exposures: Treatment of pyelonephritis with a short-course (6 to 9 days) vs a prolonged-course (10 or more days) of antibiotics. Main Outcomes and Measures: Composite outcome of treatment failure within 30 days of completing antibiotic therapy: (a) unanticipated emergency department or outpatient visits related to urinary tract infection symptoms, (b) hospital readmission related to UTI symptoms, (c) prolongation of the planned, initial antibiotic treatment course, or (d) death. A subsequent urinary tract infection caused by a drug-resistant bacteria within 30 days was a secondary outcome. Results: Of 791 children who met study eligibility criteria (mean [SD] age 9.2 [6.3] years; 672 [85.0%]) were girls, 297 patients (37.5%) were prescribed a short-course and 494 patients (62.5%) were prescribed a prolonged-course of antibiotics. The median duration of short-course therapy was 8 days (interquartile range, 7-8 days), and the median duration of prolonged-course therapy was 11 days (interquartile range, 11-12 days). Baseline characteristics were similar between the groups in the inverse probability of treatment weighted cohort. There were 79 children (10.1%) who experienced treatment failure. The odds of treatment failure were similar for patients prescribed a short-course vs a prolonged-course of antibiotics (11.2% vs 9.4%; odds ratio, 1.22; 95% CI, 0.75-1.98). There was no significant difference in the odds of a drug-resistant uropathogen for patients with a subsequent urinary tract infection within 30 days when prescribed a short-courses vs prolonged-course of antibiotics (40% vs 64%; odds ratio, 0.36; 95% CI, 0.09-1.43). Conclusions and Relevance: The study findings suggest that short-course antibiotic therapy may be as effective as prolonged-courses for children with pyelonephritis, and may mitigate the risk of future drug-resistant urinary tract infections. Additional studies are needed to confirm these findings.

Gender Issues in Academic Hospital Medicine: a National Survey of Hospitalist Leaders.

BACKGROUND: Gender inequities are documented in academic medicine. Within General Internal Medicine (GIM), there are fewer female division directors and first and last authors on publications. With gender parity in US medical school graduates and with Academic Hospital (AH) medicine being a relatively newer discipline, one might postulate that AH would have less gender inequity. DESIGN: A national survey of AH programs was developed via literature review and expert recommendations. Domains included program and faculty information. Gender of the leader was determined via website or telephone call. PARTICIPANTS: Leaders of AH programs associated with the American Association of Medical Colleges (AAMC). Programs without a primary teaching hospital or hospitalist program and those not staffed by university-affiliated physicians were excluded. MAIN MEASURES: Description and characteristics of leaders and programs including a multivariable analysis of gender of hospitalist leaders and the portion of female faculty. KEY RESULTS: 59% response rate (80 of 135); there were no differences between responders/non-responders in NIH funding (p = 0.12), type of institution (p = 0.09), geographic region (p = 0.15), or year established (p = 0.86). Reported number of female and male faculty were approximately equal. 80% of hospitalist leaders were male; 37% of male hospitalist leaders were professors, no female leaders were professors. In univariate and multivariate analysis only the number of hospitals staffed was a significant predictor of having a female hospitalist leader. There were no significant predictors of having fewer female faculty. CONCLUSION: This study demonstrated gender inequality in academic hospital medicine regarding leadership and rank. Though there was equal gender distribution of faculty, among leaders most were men and all "full professors" were men. As diversity benefits the tripartite mission research on methods, initiatives and programs that achieve gender equity in leadership are needed.

Things We Do for No Reason™ : Lumbar Punctures in Low-Risk Febrile Infants with Bronchiolitis.

Inspired by the ABIM Foundation's Choosing Wisely® campaign, the "Things We Do for No Reason™ " (TWDFNR) series reviews practices that have become common parts of hospital care but may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent "black and white" conclusions or clinical practice standards but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion.

Hospital Medicine Update: High-Impact Literature from March 2018 to April 2019.

To assist busy hospital medicine clinicians, we summarized 10 impactful articles from last year. The authors reviewed articles published between March 2018-April 2019 for the Hospital Medicine Updates at the Society of Hospital Medicine and the Society of General Internal Medicine Annual Meetings. The authors voted to select 10 of 30 presented articles based on quality and clinical impact for this summary. The key findings include: (1) Vancomycin or fidaxomicin are the first-line treatment for initial Clostridioides difficile infection; (2) Unnecessary supplemental oxygen is linked to increased mortality; aim for a target oxygen saturation of 90%-94% in most hospitalized patients; (3) Stigmatizing language in medical records impacts physician trainees' attitudes and pain management practices; (4) Consider ablation for atrial fibrillation in patients with heart failure; (5) Patients with opioid use disorder should be offered buprenorphine or methadone therapy; (6) Apixaban is safe and may be preferable over warfarin in patients with atrial fibrillation and end-stage kidney disease; (7) It is probably safe to discontinue antimethicillin-resistant Staphylococcus aureus (MRSA) coverage in patients with hospital-acquired pneumonia who are improving and have negative cultures; (8) Selected patients with left-sided endocarditis (excluding MRSA) may switch from intravenous (IV) to oral antibiotics if they are clinically stable after 10 days; (9) Oral antibiotics may be equivalent to IV antibiotics in patients with joint and soft tissue infections; (10) A history-electrocardiogram-age-risk factors-troponin (HEART) score ≥4 is a reliable threshold for determining the patients who are at risk for short-term major adverse cardiac events and may warrant further evaluation.

Geographically Localized Medicine House-Staff Teams and Patient Satisfaction.

BACKGROUND: Geographically localized care teams may demonstrate improved communication between team members and patients, potentially enhancing coordination of care. However, the impact of geographically localized team on patient experience scores is not well understood. OBJECTIVE: To compare experience scores of patients on resident teams home clinical units with patients assigned to them off of their home units over a 10-year period. PARTICIPANTS: Patients admitted to any of the 4 chief resident staffed internal medicine inpatient service were included. Patients admitted to the house-staff teams' home clinical unit comprised the exposure group and their patients off of their home units comprised the control patients. MEASUREMENT: Top-box experience scores calculated from the physician Hospital Consumer Assessment of Healthcare and Provider Systems (HCAHPS) and Press Ganey patient satisfaction surveys. RESULTS: There were 3012 patients included in the study. There were no significant differences in experience scores with physician communication, nursing communication, pain, or discharge planning between the 2 groups. Patients did not report satisfaction more often with the time physicians spent with them on localized teams (48.6% vs 47.5%; P = .54) or that staff were better at working together (63.2% vs 61.3%; P = .29). This did not change during a 45-month period when the proportion of patients on home units exceeded 75% and multidisciplinary rounds were started. CONCLUSION: Patients cared for by geographically localized teams did not have better patient experience. Other factors such as physician communication skills or limited time spent in direct care may overshadow the impact of having localized teams. Further research is needed to better understand organizational, team, and individual factors impacting patient experience.

What Is Career Success for Academic Hospitalists? A Qualitative Analysis of Early-Career Faculty Perspectives.

BACKGROUND: Understanding the concept of career success is critical for hospital medicine groups seeking to create sustainably rewarding faculty positions. Conceptual models of career success describe both extrinsic (compensation and advancement) and intrinsic (career satisfaction and job satisfaction) domains. How hospitalists define career success for themselves is not well understood. In this study, we qualitatively explore perspectives on how early-career clinician-educators define career success. METHODS: We developed a semistructured interview tool of open-ended questions validated by using cognitive interviewing. Transcribed interviews were conducted with 17 early-career academic hospitalists from 3 medical centers to thematic saturation. A mixed deductiveinductive, qualitative, analytic approach was used to code and map themes to the theoretical framework. RESULTS: The single most dominant theme participants described was "excitement about daily work," which mapped to the job satisfaction organizing theme. Participants frequently expressed the importance of "being respected and recognized" and "dissemination of work," which were within the career satisfaction organizing theme. The extrinsic organizing themes of advancement and compensation were described as less important contributors to an individual's sense of career success. Ambivalence toward the "academic value of clinical work," "scholarship," and especially "promotion" represented unexpected themes. CONCLUSIONS: The future of academic hospital medicine is predicated upon faculty finding career success. Clinician-educator hospitalists view some traditional markers of career advancement as relevant to success. However, early-career faculty question the importance of some traditional external markers to their personal definitions of success. This work suggests that the selfconcept of career success is complex and may not be captured by traditional academic metrics and milestones.

A Method for Attributing Patient-Level Metrics to Rotating Providers in an Inpatient Setting.

BACKGROUND: Individual provider performance drives group metrics, and increasingly, individual providers are held accountable for these metrics. However, appropriate attribution can be challenging, particularly when multiple providers care for a single patient. OBJECTIVE: We sought to develop and operationalize individual provider scorecards that fairly attribute patient-level metrics, such as length of stay and patient satisfaction, to individual hospitalists involved in each patient's care. DESIGN: Using patients cared for by hospitalists from July 2010 through June 2014, we linked billing data across each hospitalization to assign "ownership" of patient care based on the type, timing, and number of charges associated with each hospitalization (referred to as "provider day weighted "). These metrics were presented to providers via a dashboard that was updated quarterly with their performance (relative to their peers). For the purposes of this article, we compared the method we used to the traditional method of attribution, in which an entire hospitalization is attributed to 1 provider, based on the attending of record as labeled in the administrative data. RESULTS: Provider performance in the 2 methods was concordant 56% to 75% of the time for top half versus bottom half performance (which would be expected to occur by chance 50% of the time). While provider percentile differences between the 2 methods were modest for most providers, there were some providers for whom the methods yielded dramatically different results for 1 or more metrics. CONCLUSION: We found potentially meaningful discrepancies in how well providers scored (relative to their peers) based on the method used for attribution. We demonstrate that it is possible to generate meaningful provider-level metrics from administrative data by using billing data even when multiple providers care for 1 patient over the course of a hospitalization.

A Department of Medicine Infrastructure for Patient Safety and Clinical Quality Improvement.

Payers, providers, and patients increasingly recognize the importance of quality and safety in health care. Academic Departments of Medicine can advance quality and safety given the large populations they serve and the broad spectrum of diseases they treat. However, there are only few detailed examples of how quality and safety can be organized. This article describes a practical model at The Johns Hopkins Hospital Department of Medicine and details its structure and operation within a large academic health system. It is based on a fractal model that integrates multiple smaller units similar in structure (composition of faculty/staff), process (use of similar tools), and approach (using a common framework to address issues). This organization stresses local, multidisciplinary leadership, facilitates horizontal connections for peer learning, and maintains vertical connections for broader accountability.

Visiting professorship in hospital medicine: An innovative twist for a growing specialty.

INTRODUCTION: As an emerging and rapidly growing specialty, academic hospitalists face unique challenges in career advancement. Key mentoring needs, especially developing reputation and relationships outside of their institution are often challenging. METHODS: We describe the structure of a novel Visiting Professorship in Hospital Medicine Program. It utilizes reciprocal exchanges of hospitalist faculty at the rank of late assistant to early associate professor. The program is designed explicitly to facilitate spread of innovation between institutions through a presentation by the visiting professor and exposure to an innovation at the host hospital medicine group. It provides a platform to advance the career success of both early- and midcareer hospitalist faculty through 1-on-1 coaching sessions between the visiting professor and early-career faculty at the host institution and commitment by visiting professors to engage in mentoring after the visit. RESULTS: Five academic hospitalist groups participated. Seven visiting professors met with 29 early-career faculty. Experience following faculty exchange visits demonstrates program effectiveness, as perceived by both early-career faculty and the visiting professors, in advancing the goals of mentorship and career advancement. One-year follow-up suggests that 62% of early-career faculty will engage in subsequent interactions with the visiting professor, and half report spread of innovation between academic hospital medicine groups. CONCLUSIONS: The Visiting Professorship in Hospital Medicine offers a low-cost framework to promote collaboration between academic hospital medicine groups and facilitate interinstitutional hospitalist mentoring. It is reported to be effective for the goal of professional development for midcareer hospitalists. Journal of Hospital Medicine 2016;11:714-718. © 2016 Society of Hospital Medicine.

Associations between safety culture and employee engagement over time: a retrospective analysis.

With the growth of the patient safety movement and development of methods to measure workforce health and success have come multiple modes of assessing healthcare worker opinions and attitudes about work and the workplace. Safety culture, a group-level measure of patient safety-related norms and behaviours, has been proposed to influence a variety of patient safety outcomes. Employee engagement, conceptualised as a positive, work-related mindset including feelings of vigour, dedication and absorption in one's work, has also demonstrated an association with a number of important worker outcomes in healthcare. To date, the relationship between responses to these two commonly used measures has been poorly characterised. Our study used secondary data analysis to assess the relationship between safety culture and employee engagement over time in a sample of >50 inpatient hospital units in a large US academic health system. With >2000 respondents in each of three time periods assessed, we found moderate to strong positive correlations (r=0.43-0.69) between employee engagement and four Safety Attitudes Questionnaire domains. Independent collection of these two assessments may have limited our analysis in that minimally different inclusion criteria resulted in some differences in the total respondents to the two instruments. Our findings, nevertheless, suggest a key area in which healthcare quality improvement efforts might be streamlined.