Journal of hospital medicine最新文献

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.

Background: Left atrial enlargement (LAE) is predictive of cardiovascular morbidity and mortality. Prior studies of point-of-care ultrasound (POCUS) interpretation methods for identifying LAE utilized older echocardiographic reference ranges.

Objectives: Compare the test characteristics of hospitalist-performed POCUS techniques for identifying LAE as compared to contemporary echocardiographic reference ranges.

Methods: Fully paired, comparative diagnostic accuracy study of two index tests applied to archived echocardiogram images: visual assessment of the left atrium to aorta diameter (LAE sign) and left atrial (LA) anteroposterior diameter >4 cm in the parasternal long axis view. The reference test was moderate to severe LAE by echocardiography-derived left atrial volumetric index.

Results: After exclusion criteria, 239 of 321 (74.5%) exams were included. The LAE sign had a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 67.5%, 71.4%, 32.1%, and 91.6%. LA diameter of >4 cm had a sensitivity, specificity, PPV, and NPV of 87.5%, 75.9%, 42.2%, and 96.8%. The difference in sensitivity (p = .005) and specificity (p = .049) between the index tests was statistically significant. The diameter measurement had better positive and negative likelihood ratios (LR + 3.63, LR-0.16) than the LAE sign (LR + 2.36, LR- 0.46).

Conclusions: Both POCUS techniques for diagnosing LAE performed reasonably well compared to current echocardiographic reference ranges, with LA diameter >4 cm having better sensitivity and specificity than visual estimation of the LAE sign. These tests can help identify patients at risk for cardiovascular disease who may benefit from echocardiogram referral.

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: Glucagon-like peptide-1 (GLP-1) agonists are increasingly prescribed for obesity and type 2 diabetes. GLP-1 agonists influence body composition through effects on both fat mass and fat-free mass. Given that critically ill patients experience severe protein catabolism and commonly develop intensive care unit (ICU)-acquired weakness, questions arise about outcomes when metabolic demands are high during critical illness.

Objective: The objective of this study is to examine the relationship between prior GLP-1 agonist use and critical care outcomes.

Methods: We conducted a retrospective cohort study using Stanford Health Care data from January 2015 to July 2024. Adults aged 18-89 years admitted to intensive care with body mass index (BMI) 20-60 kg/m² were included. Of 15,191 eligible ICU patients, 468 (3.1%) received GLP-1 agonist prescriptions within 12 months before hospitalization. Using high-dimensional propensity score matching with lasso regression, we created 452 matched pairs and compared in-hospital mortality, hospital length of stay, and ICU length of stay between groups.

Results: Baseline characteristics were well-balanced. The matched GLP-1 agonist and comparison groups showed similar in-hospital mortality (5.1% vs. 4.9%, odds ratio [OR]: 1.05, 95% confidence interval [CI]: 0.58 to 1.91, p = .88), mean hospital length of stay (13.7 ± 21.3 vs. 13.4 ± 18.1 days, mean difference [MD]: 0.38, 95% CI: -2.21 to 3.05, p = .77), and ICU length of stay (5.9 ± 9.0 vs. 5.4 ± 6.6 days, MD: 0.51, 95% CI: -0.52 to 1.50, p = .33).

Conclusions: In this first study examining the relationship between prior GLP-1 agonist use and critical care outcomes, we found no significant associations with in-hospital mortality, hospital length of stay, or ICU length of stay.