Journal of hospital medicine最新文献

{"title":"Clinical features of suspected and unsuspected fatal pulmonary emboli in hospitalized patients.","authors":"Scott L Hagan, Tyler J Albert, Helene Starks, Paul B Cornia","doi":"10.1002/jhm.13533","DOIUrl":"https://doi.org/10.1002/jhm.13533","url":null,"abstract":"<p><strong>Background: </strong>Pulmonary embolism (PE) is often unsuspected by treating clinicians. Since the adoption of clinical prediction scores for PE and the widespread availability of computed tomography (CT)-pulmonary angiogram, there are few reports of clinical presentations of hospitalized patients who died of PE.</p><p><strong>Objectives: </strong>To compare the clinical signs, symptoms, and comorbidities of hospitalized patients who died of PE for whom PE was suspected versus not suspected antemortem.</p><p><strong>Study design and methods: </strong>Case-control study from January 1999 to December 2018 in one Veterans Affairs (VA) hospital. We compared groups to examine differences in clinical presentations of fatal PE over the two decades.</p><p><strong>Results: </strong>Among 1345 autopsies performed during the study period, 52 patients (4%) with fatal PE were included in the final analyses. PE was unsuspected before death in 29/52 patients (56%). Comparing groups, there were significant differences for: dyspnea (suspected 91%; unsuspected: 59%, p = 0.01); active malignancy (suspected 74%; unsuspected: 28%, p = 0.002); and atrioventricular (AV) nodal blocking treatment (suspected: 62%; unsuspected 30%,p= 0.03). A greater proportion of patients with unsuspected PE lacked symptoms of PE (suspected 0%; unsuspected: 31%, p = 0.003).</p><p><strong>Conclusions: </strong>Fatal PE remains a common, unsuspected cause of inpatient death in the modern era. Symptoms of PE, active malignancy, and potentially confounding AV nodal blocking treatment were less frequent in patients with unsuspected PE. These data highlight the variation in presentation and the challenge of making the diagnosis in many hospitalized patients, particularly those without typical symptoms.</p>","PeriodicalId":94084,"journal":{"name":"Journal of hospital medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-10-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142484214","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Understanding characteristics and trajectories of patients experiencing early death after interhospital transfer.","authors":"Rachel A Hadler, Catherine Yoon, Stephanie K Mueller","doi":"10.1002/jhm.13535","DOIUrl":"https://doi.org/10.1002/jhm.13535","url":null,"abstract":"<p><p>Twenty- to fifty-thousand patients die annually within 72 h of interhospital transfer (early death after transfer; EDAT). The characteristics and trajectories of these patients are ill-defined. In this retrospective cohort study, we characterized EDAT at three representative major referral centers. Primary outcomes included the presence and timing of goals of care (GOC) and/or prognostic discussions. Among 190 medical patients experiencing EDAT, 95 (50.0%) were >65 years, 115 (60.5%) male, and 137 (72.6%) White; 140 (73.7%) patients traveled >50 miles from home, and 174 (91.6%) were referred for specialty care. Whereas GOC were documented pretransfer for 40 patients (21.1%) and unknown for 97 patients (51%); 152 (80.0%) had posttransfer discussions, often within 24 h of death (125; 82.2%). Transfer >50 miles was associated with death ≤24 h after transfer and with posttransfer changes in code status. Further research is needed to evaluate disparities and describe the potential burdens of transfer at end-of-life. Infrequent pretransfer discussions of GOC suggest potential targets for improvement.</p>","PeriodicalId":94084,"journal":{"name":"Journal of hospital medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-10-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142484221","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"High burnout and low work well-being create a burning platform for safer hospitalist clinical workloads.","authors":"Michelle Knees, Marisha Burden","doi":"10.1002/jhm.13534","DOIUrl":"https://doi.org/10.1002/jhm.13534","url":null,"abstract":"","PeriodicalId":94084,"journal":{"name":"Journal of hospital medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-10-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142484218","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association between hospital type and length of stay and readmissions for young adults with complex chronic diseases.","authors":"Jeffrey Lutmer, Emily Bucholz, Katherine A Auger, Matt Hall, J Mitchell Harris, Ashley Jenkins, Rustin Morse, Mark I Neuman, Alon Peltz, Harold K Simon, Ronald J Teufel","doi":"10.1002/jhm.13524","DOIUrl":"https://doi.org/10.1002/jhm.13524","url":null,"abstract":"<p><strong>Background: </strong>There is a paucity of information around whether hospital length of stay and readmission rates differ based upon hospital type for adolescents and young adults (AYA) with complex chronic diseases (CCDs).</p><p><strong>Objective: </strong>To measure the association between hospital type and readmission rates and index admission LOS among AYA with CCDs.</p><p><strong>Methods: </strong>We performed a retrospective cross-sectional study of 2017 Healthcare Cost and Utilization Project State Inpatient Databases, including patients 12-25 years old with cystic fibrosis (CF), sickle cell disease (SCD), spina bifida (SB), inflammatory bowel disease (IBD), and diabetes mellitus (DM). Index hospitalizations were categorized by hospital type (pediatric hospitals [PHs], adult hospitals with pediatric services [AHPSs], and adult hospitals without pediatric services [AHs]), CCD, and age group. We compared case-mix adjusted 30-day readmission rates and differences in index admission LOS between hospital types.</p><p><strong>Results: </strong>Adult hospitals without pediatric services exhibited higher readmission rates (25.4%) than AHPS (22.9%) and PH (15.1%). Compared to patients with CF admitted to AH, lower readmission rates were associated with longer LOS at both AHPS (relative ratio [RR]: 1.25, 95% confidence interval [CI]: 1.02-1.55) and PH (RR: 1.59, 95% CI: 1.28-1.97). Patients with DM admitted to AHPS (odds ratio [OR]: 0.75, 95% CI: 0.62-0.91) and PH (OR: 0.47, 95% CI: 0.31-0.71) also demonstrated lower readmission rates than those admitted to AH.</p><p><strong>Conclusions: </strong>For AYA with CCD, hospital type is associated with differences in readmission rates and LOS. Lower readmission rates at hospitals with pediatric services compared to adult hospitals without pediatric services suggest hospital type has a significant impact on outcomes.</p>","PeriodicalId":94084,"journal":{"name":"Journal of hospital medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-10-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142484213","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Things We Do for No Reason™: Routine use of \"denies\" and other stigmatizing language in medical documentation.","authors":"Julia B Caton, Anita Vanka, Rebecca Dougherty","doi":"10.1002/jhm.13527","DOIUrl":"https://doi.org/10.1002/jhm.13527","url":null,"abstract":"","PeriodicalId":94084,"journal":{"name":"Journal of hospital medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-10-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142484220","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Digital supervision in the clinical learning environment: Characterizing teamwork in the electronic health record.","authors":"Dori A Cross, Josh Weiner, Andrew P J Olson","doi":"10.1002/jhm.13529","DOIUrl":"10.1002/jhm.13529","url":null,"abstract":"<p><strong>Background: </strong>Attending physicians in academic hospitals work in supervisory team structures with medical residents to provide patient care. How attendings utilize the electronic health record (EHR) to support learning through supervision is not well understood.</p><p><strong>Objective: </strong>To compare EHR behavior on teaching versus direct care, including evidence of supervisory calibration to learners.</p><p><strong>Methods: </strong>Cross-sectional study analysis of EHR metadata from 1721 shifts of hospital medicine faculty at a large, urban academic medical center, January to June 2022. Measures included total EHR time per shift, EHR time outside shift, and time spent on: note-writing, note review/attestation, order entry, and other clinical review. We assessed within physician differences across these service types and used multilevel modeling to determine whether these behaviors varied with resident physicians' experience, accounting for physician-specific signature behavior patterns.</p><p><strong>Results: </strong>Attendings spent substantially less time in the EHR while on teaching service than on direct service (129 vs. 240 min; p < .001) and apportioned their work differently throughout the day. Physicians were less behaviorally consistent and varied more than their peers when on teaching service. Attendings calibrated their supervision to learners. Attendings logged 12.7% less EHR time when paired with more senior residents than postgraduate year 2 (PGY2) residents (137 vs. 120 min, p = .002). PGY1 presence was also associated with reduced EHR time, suggesting some delegation of supervision to senior trainees.</p><p><strong>Conclusion: </strong>EHR behaviors on teaching service are highly variable and differ substantially from direct care; a lack of consistency suggests important opportunities to establish best practices for EHR-based supervision and create an effective clinical learning environment.</p>","PeriodicalId":94084,"journal":{"name":"Journal of hospital medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-10-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142484216","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"When is enough, enough?","authors":"Derek R Soled","doi":"10.1002/jhm.13530","DOIUrl":"https://doi.org/10.1002/jhm.13530","url":null,"abstract":"","PeriodicalId":94084,"journal":{"name":"Journal of hospital medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-10-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142396348","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association between initial antibiotic route and outcomes for children hospitalized with pneumonia.","authors":"Jillian M Cotter, Isabella Zaniletti, Derek J Williams, Sriram Ramgopal, Cristin Q Fritz, Maia Taft, Matt Hall, Elizabeth Temte, Justine Stassun, Krishna Trivedi, Jack Kapes, Jack Lavey, Allison Kempe, Lilliam Ambroggio","doi":"10.1002/jhm.13516","DOIUrl":"https://doi.org/10.1002/jhm.13516","url":null,"abstract":"<p><strong>Background: </strong>Initial oral antibiotics may be as effective as intravenous (IV) antibiotics for children hospitalized with community-acquired pneumonia (CAP), but further data are needed.</p><p><strong>Objective: </strong>We evaluated for associations of initial antibiotic route (IV vs. oral) with length of stay (LOS) and secondary outcomes for children hospitalized with CAP.</p><p><strong>Methods: </strong>This multicenter, retrospective cohort study included children with CAP who were hospitalized for >48 h, had chest radiographs, and received antibiotics at four children's hospitals between 2014 and 2020. Data were obtained from the Pediatric Health Information System and manual chart review. The exposure was initial antibiotic route (i.e., first antibiotic given intravenously or orally). We performed multivariable regression modeling using inverse probability treatment weights from propensity scores. Outcomes included LOS, oxygen duration, cost, care escalation, and readmission or emergency department revisit.</p><p><strong>Results: </strong>Of 1147 included children, 37% received initial oral antibiotics. Within the propensity balanced sample, LOS was 73.5 h (IQR 61.0, 99.5) and 78.7 (61.0, 118.0) for patients with initial oral and IV antibiotics, respectively. Children receiving initial oral antibiotics had an 8% reduction in LOS (OR 0.92 [95% CI: 0.87, 0.94]) and 14% reduction in cost (OR 0.86 [95% CI 0.79, 0.94]) versus those receiving initial IV antibiotics. There were no differences in other outcomes.</p><p><strong>Conclusions: </strong>Children with CAP receiving initial oral antibiotics had reduced LOS and hospital cost without differences in escalated care or return visits. Starting hospitalized children on oral antibiotics is likely a safe and effective alternative to IV treatment.</p>","PeriodicalId":94084,"journal":{"name":"Journal of hospital medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-10-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142396347","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A time-series analysis examining implementation strategies to increase use of an early-supported discharge hospital at home model.","authors":"Padageshwar Sunkara, Raghava Nagaraj, Hieu Nguyen, Stephanie Murphy, Kevin Goslen, Harsh Barot, Timothy Hetherington, Casey Stephens, McKenzie Isreal, Marc Kowalkowski","doi":"10.1002/jhm.13525","DOIUrl":"https://doi.org/10.1002/jhm.13525","url":null,"abstract":"<p><strong>Background: </strong>Early-supported discharge (ESD) hospital-at-home (HaH) programs facilitate hospitalized patients to receive ongoing acute-level care at home, thereby promoting patient-centeredness while improving hospital throughput.</p><p><strong>Objectives: </strong>The current study aimed to test multiple implementation strategies to increase and sustain HaH ESD utilization.</p><p><strong>Methods: </strong>We conducted interrupted time series analyses to evaluate the effectiveness of implementation strategies on weekly HaH ESD referrals and capacity utilization at five hospitals. Intervention 1 included provider-focused education and HaH nurse navigator support (July 2021 to May 2022). Intervention 2 added provider-level referral performance feedback and daily electronic health record-based eligibility reports (May 2022 to December 2022). During postintervention (January 2023 to June 2023), implementation strategies were no longer supported by the study team. Clinical outcomes were assessed over time and between patient subgroups.</p><p><strong>Results: </strong>There were 5951 HaH ESD patients overall. After Intervention 2, we observed immediate increases in weekly HaH ESD referrals (level change mean difference [MD, 95% confidence interval]: 14.8, 5.9-23.6) and capacity utilization (level change MD: 13.9%, 6.2%-21.5%) and additional week-to-week increases in capacity utilization (slope change MD: 0.6%, 0.2%-0.9%), compared to Intervention 1 trends. HaH ESD referrals and capacity utilization were sustained postintervention. The proportion of provider-initiated referrals increased over time (Intervention 1: 79.4%, Intervention 2: 90.9%, postintervention: 95.2%). As HaH ESD utilization increased, we observed shorter inpatient length of stay and fewer HaH ESD encounters per visit (p < 0.01). There were small, statistically significant differences in 30-day mortality and readmission for residents of rural and socioeconomically disadvantaged areas.</p><p><strong>Conclusion: </strong>Applying referral-focused provider feedback and daily eligibility reports were effective within a multicomponent approach to increase and sustain HaH ESD utilization.</p>","PeriodicalId":94084,"journal":{"name":"Journal of hospital medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-10-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142396346","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Breaking hospital discharge gridlock through policy reforms.","authors":"Robert E Burke, Paula Chatterjee","doi":"10.1002/jhm.13519","DOIUrl":"https://doi.org/10.1002/jhm.13519","url":null,"abstract":"","PeriodicalId":94084,"journal":{"name":"Journal of hospital medicine","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2024-10-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142368051","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}