Journal of hospital medicine最新文献

Background: Initial oral antibiotics may be as effective as intravenous (IV) antibiotics for children hospitalized with community-acquired pneumonia (CAP), but further data are needed.

Objective: We evaluated for associations of initial antibiotic route (IV vs. oral) with length of stay (LOS) and secondary outcomes for children hospitalized with CAP.

Methods: This multicenter, retrospective cohort study included children with CAP who were hospitalized for >48 h, had chest radiographs, and received antibiotics at four children's hospitals between 2014 and 2020. Data were obtained from the Pediatric Health Information System and manual chart review. The exposure was initial antibiotic route (i.e., first antibiotic given intravenously or orally). We performed multivariable regression modeling using inverse probability treatment weights from propensity scores. Outcomes included LOS, oxygen duration, cost, care escalation, and readmission or emergency department revisit.

Results: Of 1147 included children, 37% received initial oral antibiotics. Within the propensity balanced sample, LOS was 73.5 h (IQR 61.0, 99.5) and 78.7 (61.0, 118.0) for patients with initial oral and IV antibiotics, respectively. Children receiving initial oral antibiotics had an 8% reduction in LOS (OR 0.92 [95% CI: 0.87, 0.94]) and 14% reduction in cost (OR 0.86 [95% CI 0.79, 0.94]) versus those receiving initial IV antibiotics. There were no differences in other outcomes.

Conclusions: Children with CAP receiving initial oral antibiotics had reduced LOS and hospital cost without differences in escalated care or return visits. Starting hospitalized children on oral antibiotics is likely a safe and effective alternative to IV treatment.

Background: Early-supported discharge (ESD) hospital-at-home (HaH) programs facilitate hospitalized patients to receive ongoing acute-level care at home, thereby promoting patient-centeredness while improving hospital throughput.

Objectives: The current study aimed to test multiple implementation strategies to increase and sustain HaH ESD utilization.

Methods: We conducted interrupted time series analyses to evaluate the effectiveness of implementation strategies on weekly HaH ESD referrals and capacity utilization at five hospitals. Intervention 1 included provider-focused education and HaH nurse navigator support (July 2021 to May 2022). Intervention 2 added provider-level referral performance feedback and daily electronic health record-based eligibility reports (May 2022 to December 2022). During postintervention (January 2023 to June 2023), implementation strategies were no longer supported by the study team. Clinical outcomes were assessed over time and between patient subgroups.

Results: There were 5951 HaH ESD patients overall. After Intervention 2, we observed immediate increases in weekly HaH ESD referrals (level change mean difference [MD, 95% confidence interval]: 14.8, 5.9-23.6) and capacity utilization (level change MD: 13.9%, 6.2%-21.5%) and additional week-to-week increases in capacity utilization (slope change MD: 0.6%, 0.2%-0.9%), compared to Intervention 1 trends. HaH ESD referrals and capacity utilization were sustained postintervention. The proportion of provider-initiated referrals increased over time (Intervention 1: 79.4%, Intervention 2: 90.9%, postintervention: 95.2%). As HaH ESD utilization increased, we observed shorter inpatient length of stay and fewer HaH ESD encounters per visit (p < 0.01). There were small, statistically significant differences in 30-day mortality and readmission for residents of rural and socioeconomically disadvantaged areas.

Conclusion: Applying referral-focused provider feedback and daily eligibility reports were effective within a multicomponent approach to increase and sustain HaH ESD utilization.

Background: Veterans Health Administration (VHA) enrollees may use community hospitals for inpatient care and sometimes require transfer to larger community or VHA hospitals. Little is known about interhospital transfer patterns among veterans using community and VHA hospitals or how coronavirus disease 2019 (COVID-19) case surges affected transfer.

Methods: Retrospective cohort study among veterans age 65+ admitted to community and VHA hospitals for acute myocardial infarction (AMI) or acute ischemic stroke (AIS) during 2018-2021. We examined associations between COVID-19 case density in regional hospital referral networks and the likelihood of transfer.

Results: A total of 8373 (23.6%) veterans with AMI and 4630 (13.1%) with AIS were transferred in the prepandemic period. Transfer was especially common for rural veterans (36% with AMI, 20% with AIS). Most transfers (88%) were between community hospitals and 6% from community to VHA. Among AMI patients, transfer was less likely among patients age >90 (relative to age 65-69), those with non-White race/ethnicity, and females. Transfer was more common among patients initially seen in rural hospitals (AMI, odds ratio [OR] = 2.73, 95% confidence interval [CI], 2.90-3.74; AIS, OR = 2.43; 95% CI, 2.24-2.65). During 2020-2021, transfer among AMI patients was less likely during COVID-19 case density surges affecting the admitting hospital's referral network (OR = 0.86; 95% CI, 0.78-0.96 for highest compared with lowest quartile of COVID-19 cases).

Conclusion: Interhospital transfer was common for veterans with AMI and AIS, especially among rural veterans. Few transfers were to VHA hospitals. COVID-19 case surges were associated with decreased transfer for veterans with AMI, potentially limiting access to needed care.

Background: Hospitals and patients rely on effective clinician communication. Asynchronous electronic secure messaging (SM) systems are a common way for hospitalists to communicate, but few studies have evaluated how hospitalists are navigating the adoption of SM and the benefits and challenges they are encountering.

Objectives: The objective of this study is to assess academic hospitalist perspectives on SM to guide future research and quality improvement initiatives.

Methods: This was a mixed methods study utilizing an embedded REDCap survey and six virtual semistructured focus groups. It took place during a Hospital Medicine ReEngineering Network Zoom meeting on October 13, 2023. Rapid qualitative methods were used to define major themes.

Results: There were 28 hospitalists and one patient representative across 24 separate academic institutions. There was a 71% survey completion rate (N = 20). SM was felt to be an effective and efficient communication modality but was associated with a large amount of multitasking and interruptions. Perspectives around SM clustered around three main themes: SM has been widely but variably adopted; there is a lack of institutional guidance about how to best engage with SM; and SM is changing the landscape of hospitalist work by increasing ease but decreasing depth of communication, increasing cognitive load, and changing interpersonal relationships. Recommendations for SM improvements included the need for institutions to work with frontline workers to develop and implement clear usage guidelines.

Conclusion: SM is likely contributing to both positive and negative effects for clinicians and patients. Understanding hospitalist perspectives on SM will help guide future research and quality improvement initiatives.

Background: Patient-initiated or "before medically advised" (BMA) hospital discharge is more common among people who use drugs. Transitions of care can be destabilizing and might increase the risk of subsequent illicit drug overdose.

Objectives: This study sought to evaluate whether BMA discharge is associated with an increased risk of subsequent drug overdose (primary objective) and whether physician-advised discharge is associated with an increased risk of subsequent drug overdose (secondary objective).

Methods: We performed a case-crossover analysis of population-based linked administrative health data for individuals experiencing an overdose between 2016 and 2019 in British Columbia, Canada. Using conditional logistic regression, we compared the likelihood of hospital discharge in the 28 days before overdose (the "pre-overdose interval") to the likelihood of hospital discharge in two self-matched 28-day control intervals ending 26 and 52 weeks before overdose.

Results: Over the 3.5-year study interval, 235 of 27,584 (0.9%) pre-overdose intervals and 189 of 55,168 (0.3%) control intervals included a BMA discharge, suggesting that BMA discharge was associated with a twofold increase in the risk of subsequent drug overdose (adjusted odds ratio [aOR], 2.08; 95% confidence interval [95% CI], 1.68-2.58; p < 0.001). Physician-advised hospital discharge was also a risk factor for subsequent overdose, occurring in 1350 of 27,584 (4.9%) pre-overdose intervals and 1625 of 55,168 (2.9%) control intervals (aOR, 1.39; 95% CI, 1.27-1.52; p < .001).

Conclusions: Both BMA and physician-advised hospital discharge are independently associated with transient increases in the risk of subsequent illicit drug overdose. Better in-hospital treatment of substance use disorder and novel means of post-discharge outreach should be deployed to reduce this risk.

Background: Hospital medicine is the largest growing specialty in the United States. It is important to understand factors that are related to burnout and work well-being (WWB), both predictors of workforce retention.

Objective: To examine the relationship between work environment factors and hospitalist burnout and WWB.

Methods: An online cross-sectional survey was completed by hospitalists in July-October 2020. Burnout was assessed using the Mini-Z burnout scale and the Abbreviated Maslach Burnout Inventory. WWB was assessed using the Work Well-Being Scale. Work structure variables included hours worked per week, frustration at work, safety level of clinical workload, lack of control over schedule, lack of control over daily work, continuity of patient care, and ability to optimize license. The current desire to practice medicine was also examined.

Results: Eight-eight hospitalists participated. There were statistically significant differences between levels of safety of workload (F(2,85) = 9.70, p = <.005), frustration at work (F(2,85) = 12.29, p = <.005), control over schedule (F(2,85) = 3.17, p = .04), control over daily work (F(2,85) = 6.17, p = .003), and desire to practice medicine (F(2,85) = 42.34, p = <.005) with WWB. There were statistically significant associations between the presence of burnout and the safety of workload (χ² = 8.167, p = .017), frustration at work (χ² = 15.29, p = .005), control over daily work (χ² = 12.48, p = .002), and desire to practice medicine (χ² = 7.12, p = .03). WWB was positively associated with years as a hospitalist (r = .249, p = .02)).

Conclusion: Work environment factors are associated with WWB and burnout. Modifiable work environment factors may offer a point of intervention for reducing burnout and enhancing WWB among hospitalists.