Journal of hospital medicine最新文献

Background: Hospital communication is increasingly reliant on asynchronous electronic secure messaging (SM) systems, with the unintended consequence of increased task switching and a greater overall burden of communications. We sought to analyze secure messages sent and received by hospitalists to understand content, urgency, and actionability, which may guide future efforts on best practices around SM.

Methods: A qualitative content analysis was performed on a subset of messages sent and received by hospitalists from 1 weekday and 1 weekend day in 2023, coding them by urgency (i.e., emergent, urgent, nonurgent), context (i.e., clinical, administrative), actionable/non-actionable, content (i.e., social, gratitude, acknowledgment, apology, completion notification), sentiment (i.e., positive, negative, neutral), and other key features (i.e., communication mode change, near miss/miss, presence of emoticon). Thematic analysis was then conducted on conversations that were length outliers, messages with emotion, messages indicating a change in communication mode, and messages with a near miss/miss.

Results: A total of 2706 messages (365 conversations) were coded. These messages were sent and received by physicians (38%), advanced practice providers (22%), nurses (33%), and other team members (8%). The majority of these messages were "nonurgent" (99%), "clinical" (64%), and/or "non-actionable" (66%). Among these messages, nearly one-third were classified as acknowledgment (13%), gratitude (8%), acknowledgment and gratitude (8%), apology (2%), and social interactions (0.6%).

Conclusions: A majority of secure messages were nonurgent and non-actionable, with many containing lower acuity elements (e.g., acknowledgment, gratitude). Hospitals can explore minimizing this type of communication to help decrease task switching and cognitive burden.

We evaluated whether peripheral intravenous catheter (PIV) utilization and complications (i.e., infiltration/extravasation) differed between children hospitalized with pneumonia who received initial oral versus intravenous antibiotics. In a retrospective cohort study of children hospitalized with pneumonia at four affiliated sites within a single hospital system from 2014 to 2020, we evaluated PIV outcomes and compared them using bivariable analyses and multivariable regression models. Among 1035 children, 65% received initial oral antibiotics and 59% had PIVs. PIVs were placed in 38% of children with oral antibiotics and 99% with IV antibiotics. Infiltration/extravasation occurred in 1% of children with oral antibiotics and 9% with IV antibiotics. Among children with PIVs, those with oral antibiotics had lower odds of infiltration/extravasation (odds ratio [OR]: 0.39, 95% confidence interval [CI]: 0.17-0.9). Given the pain and anxiety of PIVs for children and the morbidity associated with infiltrations/extravasations, initial oral antibiotics provide an opportunity to improve patient and family experiences and minimize PIV-related harms.

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.

Introduction: Unplanned hospital readmissions are associated with higher morbidity, mortality, and financial burden. This study evaluated the association between the use of remote biometric sensing devices (RBS) and all-cause readmission and mortality rates among adult patients discharged from the hospital.

Methods: We systematically searched MEDLINE, Embase, Scopus, and Global Health from inception to August 2023. Eligible studies assessed adult patients using RBS devices, defined as tools capable of automatically or manually measuring at least one biometric marker beyond physical activity, after hospital discharge. Studies required a comparison group and reported all-cause readmission rates. Risk ratios (RRs) with 95% confidence intervals (CIs) were summarized using random-effects models to account for variability. Subgroup analysis was conducted based on study design, follow-up period postdischarge, and index discharge diagnosis.

Results: Out of 9363 identified studies, 39 studies (23 randomized control trials, 14 cohort studies, and two nonrandomized trials) comprising 160,857 patients met the inclusion criteria. RBS use was associated with lower risk of all-cause readmission (RR = 0.75; 95% CI: 0.67-0.84, I² = 72.3%); especially within 30-day postdischarge (RR = 0.74; 95% CI: 0.64-0.87; I² = 35%). Among the subgroup of postsurgical patients, RBS use was associated with an 18% lower all-cause readmission risk (RR = 0.82; 95% CI: 0.69-0.98; I² = 0%). RBS use was associated with lower 30-day mortality risk (RR = 0.63; 95% CI: 0.46-0.85), with no significant associations thereafter.

Conclusion: Among patients recently discharged from the hospital, RBS use is associated with improved short-term outcomes. Future studies are needed to validate these findings.

Introduction: Peripheral intravenous catheters (PIVCs) are a vital part of care for hospitalized children. Despite commonality, up to 45% fail before treatment completion, with up to 20% of PIVCs resulting in an infusate-associated injury, such as infiltration or extravasation. Biosensors developed to detect preclinical signs of intravenous catheter dysfunction have the potential to prevent significant injuries.

Methods: This multi-site, type 1 hybrid effectiveness-implementation randomized controlled trial will evaluate an IV biosensor for preventing infiltration/extravasation injuries in hospitalized neonates and infants. Participants up to 1 year of age who require a PIVC with continuous or moderate-high risk infusates will be recruited from three Australian hospitals. Participants (n = 532) will be randomized 1:1 to receive either standard observation plus IV biosensor or standard observation alone. The primary outcome is infiltration/extravasation injury occurrence, measured using the Cincinnati Children's Hospital Medical Centre Extravasation Harm Scale by the masked outcome assessment committee. Secondary outcomes include infiltration/extravasation severity, volume, treatment sequelae, quality of life, and cost-effectiveness. The implementation context exploration will use mixed methods, including ecological momentary assessments and semi-structured interviews, to evaluate barriers and facilitators for future implementation.

Discussion: The PATCH trial addresses a significant gap in evidence regarding the effectiveness and implementation of IV biosensor technology in preventing extravasation injuries in vulnerable infant and neonatal populations. The hybrid effectiveness-implementation study will provide comprehensive data to inform both clinical practice and future implementation strategies.

Trial registration: ACTRN12623000561684.

Background: Against medical advice (AMA) discharges are associated with adverse clinical outcomes and can be stigmatizing to patients. Most prior work has described patient characteristics associated with AMA discharges, with little attention to interpersonal clinician-patient dynamics that culminate in a discharge being designated AMA.

Objective: To describe clinical documentation about patients whose hospitalizations ended in an AMA discharge, attending to both what was written and how it was written.

Methods: We performed a qualitative description using inductive thematic analysis of 185 free-text notes from hospitalizations administratively identified as ending with an AMA discharge from Internal Medicine services at an urban academic medical center in the mid-Atlantic region in 2017.

Results: Common features of notes regarding patients leaving AMA included documentation of: (1) the clinician becoming aware of the patient leaving before planned discharge, (2) the patient's reasons for leaving, (3) the clinical team's response to a patient's decision to leave, (4) the patient's capacity, and (5) insinuation of the patient's character flaws. While some note writers conveyed neutrality, we found extensive evidence of adversarial relationships with patients with unnecessary details and language that could stigmatize patients and bias future readers.

Conclusions: Many notes documenting AMA discharges contain stigmatizing language, with writers frequently taking a defensive or paternalistic stance toward their interactions with patients. Our findings reflect a lack of clarity about what should be documented in the medical record regarding the events surrounding this type of contentious discharge.