Journal of hospital medicine最新文献

In medicine, difficulty integrating work and home can lead to decreased job satisfaction, diminished well-being, and increased turnover. Understanding the experience of pediatric hospitalists can provide insights into building a stable, long-term workforce. We aim to examine gender differences in work–life balance and parental leave for physicians practicing Pediatric Hospital Medicine.

Methods

This was a cross-sectional survey study of 1096 pediatric hospitalists. 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 associated variables and work–life balance satisfaction. We analyzed free responses on parental leave to provide nuance to quantitative survey data.

Results

Five hundred and sixty-five respondents (52% response rate) completed the survey with 71% women. 343 (62%) prioritize work–life balance in career decision-making. Women report taking on more household responsibilities than their partners (41.4% vs. 8.4%; p < .001) including a larger percentage of caregiving and domestic tasks. Female gender and performing <50% caregiving were associated with decreased work–life balance satisfaction; performing <50% domestic tasks increased satisfaction. Median parental leaves were 4 weeks, with men taking significantly shorter leaves (3.5 vs. 6 weeks; p < .001) and more “paid back” time off.

Conclusion

Work–life balance is an important factor in career decisions for men and women. Women perceive carrying a larger load at home. Qualitative results suggest that parental leave may be inadequate in length and salary support for men and women. This study adds insights into work–life integration in PHM.

Background

Central venous access devices (CVADs) allow intravenous therapy, haemodynamic monitoring and blood sampling but many fail before therapy completion.

Objective

To quantify CVAD failure and complications; and identify risk factors.

Designs, Settings, and Participants

Secondary analysis of multicentre randomised controlled trial including patients aged ≥16 years with a non-tunnelled CVAD (NTCVAD), peripherally-inserted central catheter (PICC) or tunnelled CVAD (TCVAD). Primary outcome was incidence of all-cause CVAD failure (central line-associated bloodstream infection [CLABSI], occlusion, accidental dislodgement, catheter fracture, thrombosis, pain). Secondary outcomes were CLABSI, occlusion and dislodgement. Cox regression was used to report time-to-event associations.

Results

In 1892 CVADs, all-cause failure occurred in 10.2% of devices: 49 NTCVADs (6.1%); 100 PICCs (13.2%); 44 TCVADs (13.4%). Failure rates for CLABSI, occlusion and dislodgement were 5.3%, 1.8%, and 1.7%, respectively. Independent CLABSI predictors were blood product administration through PICCs (hazard ratio (HR) 2.62, 95% confidence interval (CI) 1.24–5.55); and in TCVADs, one or two lumens, compared with three to four (HR 3.36, 95%CI 1.68–6.71), intravenous chemotherapy (HR 2.96, 95%CI 1.31–6.68), and diabetes (HR 3.25, 95%CI 1.40–7.57). Independent factors protective for CLABSI include antimicrobial NTCVADs (HR 0.23, 95%CI 0.08–0.63) and lipids in TCVADs (HR 0.32, 95%CI 0.14–0.72). NTCVADs inserted at another hospital (HR 7.06, 95%CI 1.48–33.7) and baseline infection in patients with PICCs (HR 2.72, 95%CI 1.08–6.83) were predictors for dislodgement. No independent occlusion predictors were found. Modifiable risk factors were identified for CVAD failure, which occurred for 1-in-10 catheters. Strict infection prevention measures and improved CVAD securement could reduce CLABSI and dislodgement risk.

Background

Hospitalization rates for childhood pneumonia vary widely. Risk-based clinical decision support (CDS) interventions may reduce unwarranted variation.

Methods

We conducted a pragmatic randomized trial in two US pediatric emergency departments (EDs) comparing electronic health record (EHR)-integrated prognostic CDS versus usual care for promoting appropriate ED disposition in children (<18 years) with pneumonia. Encounters were randomized 1:1 to usual care versus custom CDS featuring a validated pneumonia severity score predicting risk for severe in-hospital outcomes. Clinicians retained full decision-making authority. The primary outcome was inappropriate ED disposition, defined as early transition to lower- or higher-level care. Safety and implementation outcomes were also evaluated.

Results

The study enrolled 536 encounters (269 usual care and 267 CDS). Baseline characteristics were similar across arms. Inappropriate disposition occurred in 3% of usual care encounters and 2% of CDS encounters (adjusted odds ratio: 0.99, 95% confidence interval: [0.32, 2.95]). Length of stay was also similar and adverse safety outcomes were uncommon in both arms. The tool's custom user interface and content were viewed as strengths by surveyed clinicians (>70% satisfied). Implementation barriers include intrinsic (e.g., reaching the right person at the right time) and extrinsic factors (i.e., global pandemic).

Conclusions

EHR-based prognostic CDS did not improve ED disposition decisions for children with pneumonia. Although the intervention's content was favorably received, low subject accrual and workflow integration problems likely limited effectiveness. Clinical Trials Registration: NCT06033079.

Background

Hospital-at-home has become a more recognized way to care for patients requiring inpatient hospitalization. At times, these patients may require escalation of care (transfer from home back to the brick-and-mortar (BAM) hospital for ongoing hospitalization care needs), a process that has not been extensively studied.

Objective

To evaluate what patient factors contribute to escalations of care in the hospital-at-home delivery model.

Designs, Settings, and Participants

We conducted a retrospective review of all patients admitted to Mayo Clinic's Advanced Care at Home (ACH) program from January 1, 2022 to December 31, 2022.

Intervention

None.

Main Outcomes and Measures

Patient information was collected via electronic health record including demographic, socioeconomic, and clinical status. The primary outcome was the of occurrence of an escalation.

Results

A total of 904 patients were included, of whom 80 (8.8%) required an escalation of care. In multivariable analysis, risk of an escalation was significantly higher for patients who were married or had a life partner (HR: 1.82, 95% CI: 1.05–3.23, p = .033) for patients admitted with procedure-related disorders (HR: 2.61, 95% CI: 1.35–5.05, p = .005) and patients with an increased mortality risk score (HR [per each 1–category increase] = 1.86, 95% CI: 1.39–2.50, p < .001).

Background

Length of stay (LOS) is an important measure of hospital quality and may be impacted by patient participation. However, concepts of patient participation, like health confidence, have received little examination in hospitalized patients' LOS, especially in diverse populations.

Objective

To determine if the Health Confidence Score (HCS) is associated with hospital LOS and readmission in a socioeconomically diverse population.

Designs, Settings, and Participants

We conducted a prospective cohort study in 2022 of adult general medicine patients at an academic hospital in Chicago, Illinois.

Intervention

None.

Main Outcome and Measures

Patient-reported responses to the HCS (scored 0 [lowest health confidence] to ‒12 [highest health confidence]), as well as demographic, socioeconomic, and clinical questions, were collected. Primary outcome was LOS and secondary outcomes were 30- and 90-day readmission.

Results

Among 2797 socioeconomically diverse patients who completed the survey (response rate 28.5%), there was an average HCS of 9.19 (SD 2.68, range 0–12). Using linear regression, patients with high HCS (HCS ≥ 9) had a 1.53-day lower LOS (p < .01, 95% confidence interval [CI] [–2.11, –0.95]) than patients with a low HCS (HCS < 9). This association remained when examining individual HCS questions and controlling for covariates. In logistic regression, HCS was not significantly associated with readmission, but the question “I am involved in decisions about me” (adjusted model: odds ratio 0.83; 95% CI [0.71, 0.96]; p = .01) was associated with 90-day readmission.

Background

Hospital medicine (HM) continues to be primarily composed of junior hospitalists and research has highlighted a paucity of mentors and academic output. Faculty advancement programs have been identified as a means to support junior hospitalists in their career trajectories and to advance the field. The optimal approach to supporting faculty development (FD) efforts is not known.

Objective

To understand hospitalist groups' approaches to FD, including efforts that were perceived to be effective, and to identify barriers as well as potential future directions for FD.

Design

Rapid qualitative methods were utilized including templated summaries and matrix analysis to identify major themes.

Setting and Participants

Virtual focus groups with hospitalists in the Hospital Medicine Reengineering Network (HOMERuN).

Main Outcome and Measures

Qualitative themes.

Results

Nineteen individuals from 17 unique institutions from across the United States in May 2022 participated in seven focus groups. Four key themes emerged from the study and included (1) academic hospitalist programs face multifaceted challenges and barriers to FD in HM, (2) groups have embraced a diversity of structures and frameworks, (3) due to clinical volumes, FD programs have had to adapt and evolve to meet FD needs, and (4) participants identified multiple areas for improvement, including defining tangible outcomes of FD programs and creating a repository of FD material which can be shared widely.