Healthcare workers face a disproportionately high risk of workplace violence compared to other industries, and disruptive patient behavior causes significant distress for care teams. To address this, we developed a structured, multidisciplinary response to unsafe inpatient behavior, that allows care teams to focus on patient care and maintain therapeutic relationships, while nonclinical administrators enforce hospital rules. In the event of recurrent violence, our framework also provides guidance for administrative discharge—the discharge of an adult inpatient from the hospital before medical readiness—which is available as a last resort to maintain a safe working and healing environment.
A 72-year-old man with multiple myeloma presented with an acute, progressive, exquisitely painful vesicular rash on his left face (Figure 1). Intravenous acyclovir was started to treat herpes zoster ophthalmicus. The following day, new periorbital edema was noted around his right eye (Figure 2). No other vesicles or rash were observed to suggest disseminated herpes zoster. After serial ophthalmologic evaluations, the right-sided periorbital edema was determined to be dependent edema from the patient positioning himself exclusively on his right side due to the allodynia he felt on the left side of his face. The edema resolved spontaneously by changing sleeping position (Figure 3).
Herpes zoster ophthalmicus (HZO) results from reactivation of the varicella zoster virus in the ophthalmic (V1) branch of cranial nerve V. As cranial nerve V innervates the cornea, HZO can lead to sight-threatening keratitis, uveitis, or retinal necrosis. Vesicular lesions on the tip or side of the nose, known as “Hutchinson's sign,” indicate nasociliary branch involvement and predict a higher risk of ocular complications.1 HZO constitutes an ophthalmologic emergency that requires close evaluation by ophthalmology. Although the vesicular lesions of herpes zoster remain confined to a dermatomal distribution, the inflammation-associated edema can freely cross fascial planes. Acute periorbital edema in the contralateral eye should raise concern for disseminated disease, preseptal cellulitis due to bacterial superinfection, or acute angioedema. These diagnoses were considered however the clinical picture combined with the rapid onset and resolution in this case supported a benign, positional cause.
The author declares no conflicts of interest.
The images featured in this manuscript were obtained and published with written informed consent of the patient.
Medicine's clinical understanding of reactive infectious mucocutaneous eruption (RIME) has evolved over time. It was previously described as Mycoplasma pneumoniae-induced rash and mucositis (MIRM), and before that as a variant of Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis. Here, we summarize the current understanding of best practices for RIME diagnosis and management.
In medicine, professional experiences and work environment can impact physician satisfaction and well-being. Little is known about these experiences in pediatric hospital medicine.
The objective of this study was to examine self-reported factors associated with professional experience, career development, and career satisfaction, and to compare aspects of these domains between men and women.
This was a cross-sectional survey study of 1096 pediatric hospitalists performed in 2021. Our survey tool included novel and previously published questions. Responses were collected via an online survey platform and summarized using descriptive statistics, including frequency distributions and measures of central tendency. A multivariable logistic regression was used to examine associations between variables and career satisfaction.
Five hundred and sixty-five respondents (52.3% response rate) completed the survey with 70.6% women. Over three-quarters (77.4%) reported career satisfaction, and 71.9% would choose Pediatric Hospital Medicine (PHM) again. Work-life balance was positively associated with career satisfaction, while perception of gender-specific bias decreased career satisfaction. Satisfaction with mentoring was reported by 88% of respondents with a mentor. Positive aspects of professional experience included peer relationships and support. However, 29.7% experienced gender discrimination, 26.5% were treated with disrespect by colleagues, and 40% perceived gender biases in the professional environment—women more than men on most measures.
Satisfaction with career, peer relationships, and mentoring was high; however, opportunities to improve the professional experience exist, including addressing potential mentorship gaps and discrimination. This study adds insights into career satisfaction in PHM.
Behavioral escalation events have become commonplace in the acute care setting. Disruptive patient behaviors contribute to workplace injuries and can compromise patient care and safety. Despite frequently encountering behavioral escalation, limited research exists on hospitalists' practices and perspectives when addressing disruptive behaviors.
To explore hospitalists' experiences and perspectives when navigating behavioral escalation events in adult acute care settings.
We conducted a rapid qualitative study on February 10, 2023, with four semi-structured virtual focus groups involving 27 hospital medicine participants across 19 US hospitals via the Hospital Medicine Reengineering Network (HOMERuN). Discussions examined hospitalist experiences with behavioral escalation and perspectives on response strategies.
Our rapid qualitative study identified four key themes. (1) Many hospitals lack strategies to identify patients or situations at risk of behavioral escalation. (2) Interdisciplinary collaboration is considered essential, yet dedicated response teams are often unavailable. (3) Lack of standardized approaches to disruptive behaviors and inadequate hospitalist training in de-escalation may lead to varied responses. (4) Limited proactive measures to anticipate escalation and inconsistent use of EHR behavioral alerts may unintentionally stigmatize patients.
Behavioral escalation events in the acute care setting pose significant risks to patient and staff safety while disrupting healthcare delivery. Participants highlighted limited strategies to anticipate behavioral escalation, inconsistent interdisciplinary team response structures, and minimal opportunity for debriefing or event review. Focus groups emphasized the need for systems that support team-based de-escalation training and incorporate bias and equity considerations into behavioral response practices.
Continuous pulse oximetry monitoring in stable children with bronchiolitis not requiring supplemental oxygen has been identified as a low-value practice. However, little is known about how parents and other caregivers experience efforts to deimplement this practice.
This study investigated caregivers' experiences during their child's recent hospitalization for bronchiolitis on units involved in a deimplementation trial.
We conducted semi-structured qualitative interviews with 15 caregivers of children hospitalized with bronchiolitis at 11 hospitals participating in deimplementation strategies to reduce unnecessary continuous pulse oximetry monitoring as part of the Eliminating Monitoring Overuse (EMO) trial. Interviews were recorded, transcribed, and coded using an integrative analytic approach.
Caregivers were a mean (SD) 31.1 (5.7) years old, predominantly female (93.3%), white (73.3%), and Non-Hispanic (86.7%). Previous hospitalization experiences and prior knowledge and training influenced caregiver perceptions of the value of monitoring. Participants did not discuss noticing changes in monitoring practices in interviews.
Findings suggest that tailored education about monitoring may lessen caregiver concerns.
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