Journal of hospital medicine最新文献

Background: Medical training often omits systematic approaches to prognostication and goals of care (GOC) communication, leading to end-of-life (EOL) hospital care misaligned with patients' values, lower clinician self-efficacy, and greater clinician distress.

Objective: This communication training intervention aimed to improve clinician knowledge and self-efficacy and to reduce distress in conducting GOC discussions.

Methods: We developed and implemented GOComm, a 4-h serious illness communication training program across eight campuses of a large health system. Utilizing a train-the-trainer model, facilitators taught GOComm to inpatient clinicians, primarily hospitalists, intensivists, physician assistants (PAs), and trainees. Topics included prognosticating, conveying serious news, managing emotions, creating values-informed medical recommendations, and discussing hospice. Simulations included a clinician and simulated patient (SP) role play and a family meeting, in which a clinical dyad encountered an SP dyad. Mixed methods evaluation included pre- and postsurveys.

Results: Three hundred and ninety-three clinicians participated: 322 provided demographics, with a mean of 5.57 years in practice; 71.7% were women, 50% were White, and 29.5% were Asian. Of 315 listing roles: 41% were physicians, 41% were PAs. Two hundred and forty-two completed both pre- and postsurveys. Clinicians had statistically significant gains in GOC knowledge, self-efficacy, and distress tolerance. GOComm had high clinician acceptability: 96.2% indicated they would recommend GOComm to a colleague, and 83.2% credited it with changing how they will manage patients.

Conclusions: GOComm is an effective train-the-trainer curriculum for hospital-based clinicians to gain knowledge and confidence in empathic communication skills. Clinician distress tolerance can be mitigated by enhancing skills training and social support through team simulations.

Background: Transitions of care (ToC) programs are important for patient safety, but their implementation and success remain highly variable across US hospitals, particularly for patients with multimorbidity and health-related social needs (HRSNs). Hospitalists, as key decision-makers at discharge, encounter firsthand the factors that hinder the success of ToC programs.

Objective: To explore hospitalists' perspectives on successes, shortcomings, and implementation barriers in ToC programs, particularly during transitions from hospital to community settings.

Methods: Rapid qualitative study featuring virtual focus groups with participants from the Hospital Medicine Reengineering Network (HOMERuN). Data were analyzed using a mixed inductive-deductive framework to identify key themes.

Results: Twenty-two individuals from 19 different organizations participated in focus groups. None of the organizations offered comprehensive ToC programs to all patients. Four major themes emerged: (1) Diagnosis-specific ToC programs are effective but contribute to care fragmentation, particularly for patients with multimorbidity; (2) postdischarge follow-up is hindered by limited appointment availability, insurance barriers, and geographic challenges; (3) ToC programs often fail to address patient preferences, HRSNs, and health literacy, and lack adequate resources and leadership support; (4) successful programs require institutional commitment, dedicated funding, interprofessional collaboration, and community engagement. Participants emphasized the need to prioritize patient-centered care over financial return on investment.

Conclusions: Current ToC programs are fragmented, undermining safe and equitable transitions. Addressing HRSNs, fostering leadership support, and prioritizing patient-centered care over short-term financial metrics are essential for improving ToC outcomes.

Hospitalist-focused training (electives, rotations, pathways, and tracks) evolved to address gaps in residency training pertinent to Hospital Medicine (HM). The Immersion in Hospital Medicine Elective (IHME) at Beth Israel Deaconess Medical Center immerses residents in curricular elements fundamental to HM, particularly clinical operations and healthcare economics. We surveyed IHME participants to evaluate the curriculum and characterize its impact on participants' professional development. Throughout the IHME's 20-year course, 120 residents participated, and 76 (63%) completed our survey. The majority practice HM (45, 63%) and viewed the IHME as valuable to their career preparation (36, 63%). The IHME bridged important gaps in medical knowledge and clinical skills development, such as the business of medicine, clinical operations, and creating a clinical staffing model. Most participants (59, 78%) attained key leadership positions, especially in medical education and clinical operations. Our study bolsters evidence that hospitalist-focused training in residency effectively prepares residents for adult HM practice.

About 15% of hospitalized adults report a penicillin allergy. Of these patients, approximately 90% tolerate penicillin when re-challenged, potentially due to misattribution of nonallergic rash as hypersensitivity or outgrowing the index reaction. Patients with penicillin allergy labels are more likely to receive less effective therapy, develop antibiotic resistance, incur higher healthcare costs, and have poorer outcomes. Although cephalosporins are recommended for most patients with a reported or confirmed penicillin allergy, de-labeling and removing penicillin allergies represent an impactful antimicrobial stewardship activity. A recently developed scoring tool (PEN-FAST) identifies those at low risk for a recurrent reaction and is less cumbersome than traditional testing methods.

Many medical providers in the United States have never seen a case of measles. This situation will likely change if decreases in childhood vaccination rates and increases in multi-state measles outbreaks continue. Measles can lead to hospitalization and severe disease, especially for high-risk groups including young children and people who are pregnant or immunocompromised. In-hospital transmission of measles can occur prior to diagnosis, as patients are infectious for approximately 4 days prior to the onset of rash. Review of the diagnosis and management of measles is essential for the hospitalist to ensure timely responses to this highly contagious virus.

CD4 testing is routinely performed when people with human immunodeficiency virus (HIV) (PWH) are hospitalized; however, it is often unhelpful and can even be harmful. Acute stress from sepsis, surgery, cancer, hemorrhage, and viral infections, as well as the effects of medications can temporarily suppress absolute lymphocyte counts (and thus CD4 counts). Most PWH, including most PWH who are hospitalized, are on antiretroviral therapy (ART), with successful viral suppression and immune reconstitution. In such cases, changes in CD4 counts detected in hospitalized patients are more likely to represent transient lymphocyte suppression than HIV disease progression. Similarly, in caring for PWH whose immune status is uncertain, a holistic assessment of immune status should start with history and physical exam, review of outpatient CD4 testing, and assessment of viral suppression and ART adherence. In cases where after these efforts, the patient's immune status remains unclear, and CD4 testing is likely to affect acute management, it is reasonable to obtain CD4 testing in consultation with a clinician with expertise in caring for PWH. When CD4 testing is sent in the hospitalized context, attention should be paid to both the CD4 count and the CD4% (which is less affected by acute stressors), and the CD4 testing should be interpreted in the clinical context in which it was sent.

Background: Efforts to advance health equity are essential in providing high-quality healthcare. The outpatient setting is where the majority of health equity work has been supported with longitudinal relationships, established metrics, and existing dashboards; similar work in the inpatient setting is lacking.

Objectives: To understand the perspectives of frontline hospitalists regarding how health equity is approached and measured in the inpatient setting.

Methods: We conducted an embedded mixed-methods study using semistructured focus groups and surveys. Participants were members of a national collaborative of hospital medicine groups partnering to improve healthcare delivery. Rapid qualitative methods including templated summaries and matrix analysis were used to identify key themes and subthemes using a mixed inductive and deductive approach.

Results: Twenty-two participants engaged in five focus groups. Three key themes were identified: (1) there is no consensus on how to define and scope health equity in the inpatient setting, (2) organizational support and resources for addressing health equity in inpatient settings are variable, and (3) there is an emotional toll on hospitalists working in the face of health inequities.

Conclusions: Advancing health equity in the inpatient setting is needed and will benefit from embracing clear definitions and scope, broad organizational support, and recognition of its impact on hospitalists.

As rural hospitals experiencing low patient volume and workforce shortages continue to close nationally, we present an innovative telemedicine care delivery model utilized to support the opening of a new 25-bed rural hospital in South Carolina in 2023. Since opening, the tele-hospitalist service has been responsible for 84% of discharged patients with high patient experience scores. From quarter 1 to quarter 6, patients were admitted from a growing market area with a financially more favorable payer mix while demonstrating comparable clinical outcomes. We believe this model has the potential to be replicated in other rural hospitals throughout the United States.

As pediatric and neonatal hospitalists assume increasing care for newborns in the delivery room and during the birth hospitalization, preparing pediatric trainees with foundational skills in neonatal resuscitation is increasingly critical. However, residency programs may face challenges in providing sufficient delivery room exposure and procedural opportunities given newer training requirements and updated care practices that reduce procedural interventions during neonatal resuscitation. In this Perspectives article, we examine factors contributing to these gaps, describe our institution's hospitalist-led strategies to optimize resident delivery room training, and highlight complementary educational approaches and future directions to optimally prepare trainees entering the hospital workforce.