Journal of hospital medicine最新文献

Background and objectives: While children's hospitals (CH) tend to be the locus of specialized hospital care, they also care for common conditions. There is no system to understand the distribution of hospital days within CHs and non-CHs (NCH) based on how ubiquitous conditions are across hospitals. We develop a method to classify conditions based on their commonality and consolidation within hospitals.

Methods: We performed a retrospective study of the 2022 Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database, excluding normal newborns. For the 441 conditions, the volume of hospital days and the distribution of days across hospitals using the Hospital Days Consolidation Index (HDCI) were determined. Conditions were categorized into four groups based on k-means clustering of hospital days and HDCI.

Results: There were 1.5 million hospitalizations from 123 CH and 3366 NCH. There were 54 conditions representing 85.7% of hospital days classified as Very High Days & Very Low Consolidation (i.e., commodity conditions); 47.2% of these hospital days were at a CH. At the other extreme, there were 50 conditions classified as Very Low Days & Very High Consolidation (e.g., chronic lymphocytic leukemia) representing <1% of hospital days; 75.3% at CH. Among all hospital days for commodity conditions, 52.8% were at NCH and 47.2% were at a CH. However, for the remaining condition groups, 27.3% of days were at an NCH and 72.7% at a CH.

Conclusion: We identified commodity conditions but also conditions that are consolidated, typically within CH. Consolidation can be quantified, compared, and tracked using the HDCI.

Introduction: Low-value care refers to health services for which the potential harms or costs outweigh the benefits of use. Bronchiolitis is the most common and among the most costly causes of pediatric hospitalizations. Evidence consistently shows that many common tests and treatments used to manage bronchiolitis do not improve outcomes. Further, differential use of low-value care between patients may perpetuate care inequities. In Canada, rates of low-value care use in children hospitalized with bronchiolitis, and differences in care across hospitals, clinicians, and patient subgroups, remain poorly characterized.

Objective: To understand practice patterns for six low-value health services in the care of children aged 1-12 months hospitalized for bronchiolitis: respiratory virus testing; chest X-rays; continuous pulse oximetry; short-acting beta-agonists; systemic corticosteroids; and antibiotics.

Methods: We are conducting a multi-center prospective cohort study of children admitted with bronchiolitis in 15 Canadian hospitals. We will use chart reviews to compare low-value care use between hospitals and clinicians, and caregiver surveys to compare between sociodemographic groups. Questionnaires will also collect caregiver perspectives on their child's bronchiolitis care, including role in medical decision-making and understanding of treatment decisions.

Discussion: Our study will provide critical information on the usage and variation in delivery of low-value care for bronchiolitis in Canada, elucidating potential care inequities. Findings will inform the development of interventions to address such inequities, and improve opportunity costs for health systems. Enrollment began in October 2024 and is projected to be completed in May 2026, with analyses and reporting shortly following.

There is limited data on which hospitalist switch day is optimal for hospital operations and throughput. A quality improvement intervention was implemented, changing the hospitalist switch day from Monday to Tuesday. Retrospective observational analysis revealed an increase in Monday discharges (1.3%, p = .01), a decrease in Tuesday discharges (-1.6%, p < .005), and a significant reduction in 30-day unplanned readmission rates (-1.5%, p = .003), with no significant changes in the average length of stay. Additional studies are needed to further verify these findings in different hospital settings and to consider other switch day patterns.

Background: Achieving racial equity in sepsis care is a complex challenge that requires organizational readiness across multiple domains, such as culture and capacity.

Objectives: This study provides a validated tool to empirically measure health system readiness to address structural racism in sepsis care, essential for improving health equity and patient outcomes.

Methods: This study employed a mixed methods approach involving three key steps: adaptation, cognitive interviews, and psychometric analysis. The novel survey was first adapted based on a literature review and expert input. Cognitive interviews were conducted with healthcare professionals to refine the survey items. Finally, reliability testing was performed for psychometric analysis in measuring health system readiness to address structural racism in sepsis care. The survey was developed in the context of Champions Advancing Racial Equity in Sepsis (CARES), a coalition-based leadership intervention to equip health systems and their surrounding communities to identify and address racial inequities in sepsis care and outcomes. Senior and mid-level and front-line champions from across disciplines and departments that influence sepsis care (N = 30) participated in the survey.

Results: The survey consisted of five domains: learning and problem solving (10 items, Cronbach's α = 0.815), stress/pressure in the system (4 items, Cronbach's α = .779), psychological safety (7 items, Cronbach's α = .515), senior leadership support (4 items, Cronbach's α = .744), and strategic planning process (5 items, Cronbach's α = .918). Overall, the entire scale (30 items) was found to have excellent reliability (Cronbach's α = .908).

Conclusions: This study adapted and validated a novel survey to measure health system readiness to address structural racism in sepsis care, providing a reliable tool for identifying areas for improvement and guiding targeted interventions to enhance health equity.

Background: "Decision fatigue" (DF) is the deterioration in decision-making ability stemming from repeated decision making.

Objective: Explore DF over the clinical workblock and across hospitalist and work characteristics.

Methods: Patients seen by hospitalists at two hospitals in January and February 2022 were retrospectively evaluated for events that may reflect DF. Events were selected through multistakeholder discussion (prescription of pharmacologically antagonistic medications, occurrence of hypoglycemia, and potential overuse of blood transfusions, imaging, and penicillin alternatives). For each date, schedules determined the number of days each hospitalist had been on service and charges submitted assessed census and physician familiarity with their team. Charges and ordering data guided event attribution. The primary predictor was the number of days on service, and the outcome was event occurrence. Secondary predictors included hospitalist gender, weekend versus weekday, census, site, and degree of familiarity.

Results: During the study, 43 hospitalists worked 1306 days over 204 working blocks, providing care to 2081 patients over 3122 encounters. Median daily census was 13, median number of consecutive days worked was seven. DF events were not associated with the primary or secondary predictors except census. In the multivariable model, each one unit increase in the number of patients was associated with event occurrence (odds ratio [OR]: 1.107, 95% confidence interval [CI]: 1.022-1.198, p = .01). The odds of an event were 1.58 times greater at workloads above the median of 13 patients, compared with workloads ≤13. (p = .002).

Conclusion: DF was not detected with an increasing number of days on clinical service. The findings highlight how workloads may threaten care quality.

Invasive meningococcal disease due to Neisseria meningitidis in the United States has decreased since the late 1990s, leading to fewer practicing clinicians with first-hand experience in diagnosing and managing of the disease. However, since 2021, cases have increased, creating an urgency for clinicians to familiarize themselves with the signs and sequelae of severe invasive meningococcal disease and stay up to date with current vaccine recommendations. This review summarizes recent literature and guidance for clinicians on the prevention, early recognition, and management of this vaccine-preventable disease.

Overwhelming inpatient capacity at referral hospitals undermines both regional healthcare networks and patient outcomes. To address increasing capacity constraints, Intermountain Health implemented a Load Balancing Protocol to redirect stable, lower-acuity admissions from our overburdened quaternary hospital to three community hospitals. By aligning patient acuity with optimal care settings, our strategy preserves advanced care capacity and enhances safe, equitable, and efficient care. In 4 years, our protocol diverted 5112 bed-days from the quaternary hospital and has undergone several iterative improvements. In this article, we describe the barriers and keys to innovation that contribute to the success of this Load Balancing Protocol.

Access to infectious diseases physicians has been increasingly difficult, as many infectious diseases fellowship programs have unfilled positions. This has coincided with increasing numbers of internal medicine residents pursuing hospitalist medicine. A small community hospital system merged its infectious diseases practice into a hospitalist group. The group has been able to maintain continuous coverage. Although the majority of physicians enjoyed the work-life balance of being an ID-hospitalist, the majority preferred to do ID without hospital medicine.