Journal of hospital medicine最新文献

Background: Pediatric hospitalizations represent an evolving component of US healthcare utilization. The coronavirus disease 2019 (COVID-19) pandemic hastened rising mental health visits and shrinking rural hospital capacity. Understanding contemporary patterns in pediatric hospitalizations is critical to inform health system planning and policy decisions.

Objectives: To describe the most common and costly diagnoses among US pediatric hospitalizations in 2022, using 2016-2019 data to contextualize trends in admission volume and cost.

Methods: We conducted a cross-sectional analysis of nonlive birth admissions for children (<18 years) using the 2022 Kids' Inpatient Database, the largest US all-payer pediatric inpatient data set, supplemented by an evaluation of volume trends from 2016 to 2019. We evaluated the most common and costly diagnoses in 2022 and evaluated trends in volumes and costs from the prior study years.

Results: There were 1.78 million pediatric hospitalizations in 2016, 1.69 million in 2019, and 1.59 million in 2022, representing a 10.5% overall decline. In 2022, the most common diagnoses were bronchiolitis (7.0%), major depressive disorder (5.2%), and respiratory failure (5.0%). Mental health conditions (major depressive disorder, mood disorder, and suicide and self-inflicted injury) comprised three of the 20 most frequent diagnoses. Inflation-adjusted costs increased from $32.1 billion in 2016 to $35.9 billion in 2022. The costliest conditions in 2022 included respiratory failure, septicemia, and chemotherapy. Rural hospitals represented only 3.1% of admissions in 2022, down from 4.5% in 2016.

Conclusions: Pediatric inpatient care is increasingly centralized in urban and children's hospitals. Respiratory and mental health conditions are among the common conditions requiring hospitalization. These findings highlight the need for stronger regional coordination to support access to pediatric care for these common conditions.

Background: Hospitalized patients often experience poor sleep, which is associated with worse health outcomes, increased rates of delirium, and readmissions.

Objective: To improve overnight sleep for clinically stable general neurology patients at a single academic center.

Methods: We conducted a quasi-experimental pre-post clinical trial of two sleep-protective interventions: (1) a sleep-friendly order set that reduced overnight interruptions by discontinuing vital sign checks/neurological examinations and retiming medications/blood draws; and (2) a "sleep menu" of comfort items. The primary outcome measure was sleep duration. Secondary outcomes were awakenings and patient responses to the Richards-Campbell Sleep Questionnaire. Safety outcomes were rates of delirium, ICU transfers, and 30-day readmissions. We compared the groups using linear mixed-effects models to account for repeated measures (multiple nights per participant).

Results: We analyzed data from 66 pre-intervention participants (238 nights) and 61 post-intervention participants (244 nights). The interventions did not increase sleep duration (pre-intervention median 5.5 h [interquartile range (IQR) 4.0,6.6], post-intervention median 5.4 h [4.1, 6.7], p = .84). There was marginal improvement in nightly awakenings (pre-intervention 2 [1, 4], post-intervention 2 [1, 3], p = .04). There were no significant differences in subjective sleep measures or safety outcomes. Targeted care team interruptions all significantly decreased post-intervention, though staff intrusions remained a common patient-reported barrier to sleep.

Conclusion: Fragmented and reduced sleep was common in our general neurology population. Although our interventions did not improve sleep outcomes-apart from a modest drop in nocturnal awakenings-there was a significant decrease in care team interruptions. Poor inpatient sleep is multifactorial, and meaningful change likely requires comprehensive interventions.

Healthcare workers face escalating violence despite significant security investments, suggesting current approaches miss fundamental causes. We argue that most healthcare violence stems not from individual pathology but from systemic failures-financial barriers, insurance denials, access delays, and administrative complexity-that create volatile patient-provider interactions. Healthcare workers become targets for anger about institutional dysfunctions they cannot control. Current prevention strategies emphasizing individual risk assessment and physical security fail to address these root causes. We propose a research agenda examining connections between system failures and violence, potentially identifying upstream interventions that complement existing security measures while targeting the healthcare dysfunctions driving this epidemic.

Background: Diagnostic error is a major patient safety concern in hospitals, yet most studies have focused on selected high-risk subgroups, leaving the broader general internal medicine inpatient population understudied.

Objectives: To determine the incidence, contributing factors, resulting harm, and predictors of diagnostic error in medical inpatients.

Methods: This retrospective cohort study included adults admitted to internal medicine between 01/2022 and 12/2022 at one tertiary and 4 secondary care hospitals in Switzerland. Retrieved admissions were randomly ordered, and electronic medical records were reviewed sequentially by two clinicians using standardized instruments, until reaching a pre-specified target threshold of 50 patients with ≥1 diagnostic error, enabling analysis of five predictors. The primary outcome was the occurrence of a diagnostic error. The secondary outcome was the resulting level of harm. Five pre-specified predictors were analyzed using multivariable logistic regression.

Results: Of 347 patients (median age 73 [interquartile range, 61-81] years; 140 [40.3%] female), 52 (15%; 95% confidence interval [CI], 11.6%-19.1%) experienced ≥1 diagnostic error, causing harm in 43/52 patients (82.7%; 95% CI 70.3%-90.6%). The most common contributing factors were failures to consider the correct diagnosis (40/52, 76.9%), order appropriate tests (31/52, 59.6%), and act on critical physical exam findings (30/52, 57.7%). Neurocognitive/psychiatric disorders (odds ratio [OR], 2.20; 95% CI, 1.20-4.10) and active cancer (OR, 2.10; 95% CI, 1.01-4.20) independently predicted diagnostic error.

Conclusions: Diagnostic error is common among adult medical inpatients and causes harm. We identified neurocognitive/psychiatric disorders and active cancer as patient-level predictors of diagnostic error, providing a basis for future studies on targeted interventions.

Given the recent expansion of US immigration and customs enforcement (ICE) detention facilities and the growing number of people in immigration detention, hospitalists are increasingly likely to provide care to immigrant detainees. These patients face distinct ethical, legal, and structural challenges that can affect clinical care. In this perspective piece, we outline practical strategies for hospitalists to support patient-centered, equitable care for this population, emphasizing approaches that align with ethical and legal principles, mitigate bias, and respect patient autonomy.

Background: The American Society of Hematology (ASH) recommends assessing venous thromboembolism (VTE) and major bleeding risk to optimize pharmacological VTE prophylaxis for medical inpatients. However, the clinical utility of model-guided approaches remains unknown.

Methods: Our objective was to estimate differences in VTE and major bleeding rates and efficiency with prophylaxis guided by risk models versus clinician judgment. Patients were adults admitted to one of 10 Cleveland Clinic hospitals between December 2017 and January 2020. We compared real-world practice with hypothetical prophylaxis recommended by model-based strategies, including widely used risk scores (Padua & IMPROVE) and locally derived Cleveland Clinic risk prediction models. For each strategy, we quantified the prophylaxis rate, VTE and major bleeding rates, and the incremental number-needed-to-treat (NNT) to prevent one event (VTE or bleeding).

Results: Clinicians prescribed prophylaxis to 62% of patients whereas model-based strategies recommended prophylaxis for 17%-87%. Model-guided prophylaxis produced more VTEs and fewer major bleeds than real-world practice, but total events varied among strategies. Overall, per 1000 patients, model-based strategies produced 14.0-16.1 events compared with 14.3 for real-world practice. The Padua & IMPROVE strategy minimized prophylaxis but caused the most total events. The most efficient model-based strategy recommended prophylaxis to 28% of patients with an incremental NNT (relative to no prophylaxis) of 80. Compared to real-world practice, it reduced prophylaxis by 55% and total events by 0.14%.

Conclusions: Clinicians often prescribed inappropriate prophylaxis, highlighting the need for decision support. Model-guided prophylaxis maximized efficiency by reducing prophylaxis relative to real-world practice without increasing event rates.

Background: Sleep is essential for recovery in hospitalized patients, yet frequent disruptions from medical care make rest difficult. Most prior efforts have focused on environmental modifications, often overlooking patients' role in advocating for their sleep.

Objectives: This study evaluated the effectiveness of the Inpatient Sleep Loss: Educating and Empowering Patients (I-SLEEP) intervention in improving sleep duration and reducing medical care disruptions among hospitalized patients.

Methods: In this single-center randomized controlled trial (NCT04151251), general medicine patients at the University of Chicago were randomized to either I-SLEEP (sleep education, advocacy questions, and a sleep kit) or standard care (sleep kit alone) between July 2019 and March 2023. The primary outcome was patient-reported sleep duration. Secondary outcomes included actigraphy-measured sleep duration and continuity (efficiency and wake after sleep onset), as well as patient-reported sleep disruptions. Mixed effects models adjusted for covariates were used for analysis.

Results: A total of 194 participants were enrolled. There were no significant differences in demographic characteristics between groups. Sleep duration and continuity did not differ significantly between groups. However, patients receiving I-SLEEP reported fewer disruptions from vital sign monitoring (63% vs. 75%, p = .004), medication administration (49% vs. 61%, p = .003), and laboratory draws (57% vs. 68%, p = .009). These findings remained significant after adjusting for covariates.

Conclusions: I-SLEEP did not increase sleep duration or continuity but reduced medical care disruptions. These findings suggest that patient education and empowerment may be effective strategies for reducing preventable care-related sleep disruptions in hospitals. Further research should examine implementation at scale and potential long-term benefits.

Disparities in risk and access to care can lead to a greater incidence of cancer, higher stage at diagnosis, and more frequent cancer-related deaths in communities with high poverty levels. Risk prediction tools that do not take into consideration social determinants of health may underestimate mortality in these populations. We sought to determine whether an association exists between poverty and the ability of the end-of-life index (EOLI) to predict 6-month mortality in hospitalized patients with cancer. Using a sample of 802 patients admitted to oncology in an urban hospital over a 6-month period, we categorized patients according to the percentage of families living at or below the federal poverty line in their zone improvement plan codes. We applied an EOLI score of ≥40 as an indicator of higher risk of 6-month mortality. We found that the EOLI score remained equally predictive of mortality across area poverty level groups. This finding suggests that the score can be used broadly as a screening tool to predict mortality risk in hospitalized patients with cancer.

Low salt diets are a common practice in the management of acute heart failure (HF), founded in classical pathophysiologic teaching related to neurohormonal alterations and associated sodium and fluid avidity in HF. However, trials comparing dietary salt restriction in patients hospitalized with acute HF showed no improvement in outcomes for those randomized to lower salt targets. Outpatient HF data also fails to show a reduction in HF admissions and mortality with salt restrictions. Routine use of dietary salt restrictions, especially those that are stringent, should be avoided to improve patient outcomes and experience.

The recent Acute Hospital Care at Home (AHCaH) initiative has increased Hospital-at-Home (HaH) access and utilization, but it is unknown how care delivery differs between AHCaH-compliant HaH programs and brick-and-mortar (BaM) inpatient care-specifically for common, costly hospital conditions like chronic obstructive pulmonary disease (COPD). In this retrospective cohort study, we compared management and outcomes for adults hospitalized with COPD treated in HaH and BaM settings in 2022. We analyzed EHR data from 297 adults who were eligible for HaH, including 119 who remained in BaM and 178 in HaH. HaH patients had higher likelihood of orders for supplemental oxygen (risk ratio [RR]: 1.04, 95% confidence interval [CI]: 1.01-1.09) and bronchodilators (RR: 1.12, 95% CI: 1.04-1.20), compared to BaM. HaH patients also had higher mean 30-day acute care-free days alive (mean ratio [MR]: 1.04, 1.01-1.08). Our findings suggest similar or improved guideline-directed therapy and outcomes for COPD patients treated in HaH.