Journal of hospital medicine最新文献

Background: In-hospital opioid use disorder medication (MOUD) initiation remains low despite its effectiveness to reduce mortality.

Objective: Assess whether a non-interruptive electronic health record (EHR)-embedded intervention with supportive education and outreach increased in-hospital MOUD initiation without disrupting clinical workflow.

Methods: In this mixed-methods study across 12 hospitals, we conducted an interrupted time series analysis of hospitalizations involving OUD and/or opioid poisoning. We condcuted a directed content analysis of interviews from 60 hospital-based clinicians, social workers, nurses, and pharmacists. The intervention involved MOUD initiation orders, discharge naloxone orders, and access to local OUD treatment resources. Strategies for adoption included clinican and nurse OUD education and required nurse trainings for Clinical Opiate Withdrawal Scale (COWS) assessments. Outcome measures included monthly changes of inpatient methadone administration ≥30 mg, discharge buprenorphine and naloxone prescriptions, and COWS assessments. Emergent themes from qualitative data provided context and possible explanations for quantitative results.

Results: From January 2021 to September 2024, there were 450,790 hospitalizations; 3.1% (n = 13,902) involved OUD/opioid poisoning; and, of these, 19.8% (n = 2750) involved MOUD. Between the pre- and post-intervention periods, there was no significant change in monthly methadone administrations or discharge naloxone prescriptions. Monthly buprenorphine discharge prescriptions decreased from 10.5% to 8.2% (slope decrease: -0.35, p < .001) in the post-implementation period. In the immediate post-intervention period, monthly COWS documentation increased from 7.3% to 14.5% (level change: 6.87; p < .001). Qualitative findings reflected a lack of intervention awareness due to limited leadership communication across hospitals.

Conclusion: A non-interruptive EHR-embedded intervention with supportive education and outreach was insufficient to increase MOUD initiation.

Background: Pediatric Hospital Medicine (PHM) has historically underutilized simulation-based medical education (SBME), a proven methodology for improving education and patient care. This study sought to identify and prioritize simulation-appropriate topics to inform a comprehensive PHM SBME curriculum for practicing hospitalists.

Methods: In Phase 1, local and national PHM and simulation experts generated and refined a list of potential topics, categorized into cognitive, psychomotor, and affective domains. In Phase 2, a nationally representative sample of pediatric hospitalists from the Pediatric Research in Inpatient Settings (PRIS) Network ranked their top six topics within each domain. Mean priority scores were calculated for each topic, and high-priority topics (HPTs) were identified utilizing natural breaks analysis, then expanded to balance topics across domains.

Results: Topic generation and expert panel refinement yielded 19 cognitive, 26 psychomotor, and 12 affective topics. These were prioritized by 52 pediatric hospitalists (of 99 [53%] surveyed). Fifteen HPTs were identified: five cognitive (respiratory distress/failure, shock, behavioral escalation, medical technology failure, sepsis), five psychomotor (lumbar puncture, bag-valve-mask ventilation, tracheostomy management, enteral tube management, chest compressions), and five affective (patient/family communication, de-escalation, interprofessional collaboration, handoffs, diagnostic error avoidance strategies) topics. Subgroup analysis revealed small variations across rater demographic characteristics.

Conclusion: Fifteen top-rated PHM SBME topics are suitable for inclusion in a comprehensive curriculum that can be adapted at diverse institutions nationwide. Implementation may augment existing continuing medical education in PHM to help standardize care for hospitalized children.

Introduction: Asthma is one of the most common chronic diseases of childhood with morbidity disproportionately affecting children across different racial and/or ethnic groups and socioeconomic statuses, specifically Black children and those living in poverty. Hospitalization for asthma is a significant risk factor for future readmissions. The Hospital-to-Home (H2H) study seeks to improve asthma care and outcomes by focusing on the transition home after hospitalizations.

Methods: The H2H study is a pragmatic, randomized controlled trial comparing the H2H intervention to usual care. The intervention involves 12 months of care coordination from an asthma navigator. Participants are enrolled during hospitalization from either a freestanding urban children's hospital or an affiliated community hospital. The primary outcome is readmission for asthma within 12 months of index asthma-related hospital admission. Secondary outcomes include caregiver asthma-related quality of life, self-efficacy for asthma management, perceived stress, and resilience.

Discussion: Children admitted with asthma exacerbations represent an at-risk population, thus hospitalization offers a critical opportunity to deliver timely, meaningful interventions that can support sustained improvements in their care and improve long-term outcomes. Despite the majority of asthma hospitalizations occurring in community hospitals, past studies have focused on freestanding children's hospitals. To improve the generalizability of our findings, we also enroll children from a community hospital. Optimizing care with the H2H intervention offers an opportunity to reduce asthma morbidity in an at-risk pediatric cohort by leveraging high-touch, cost-effective asthma navigators for intensive coordination while maintaining low-touch provider oversight to ensure safety and sustainability.

Background: Current guidelines make no recommendations on discharge interventions or scheduling outpatient follow-up after hospitlization for commnity-acquired pneumonia (CAP).

Objectives: To assess the impact of scheduling early primary care follow-up prior to discharge home among survivors of hypoxemic CAP hospitalizations.

Methods: We conducted an observational target trial emulation of 3332 adults (age ≥18 years) with hypoxemic CAP (requiring ≥2 liters oxygen) admitted to a 5-hospital system and discharged home between 2019 and 2024. Treated and control patients were propensity score-matched with replacement on 30 prespecified confounders. Treated patients had early primary care follow-up (to occur within 14 days of discharge) scheduled predischarge. The Average Treatment effect on the Treated (ATT) on a primary composite outcome of postdischarge mortality or readmission was assessed 90 days postdischarge.

Results: After weighting, the matched cohort included 894 patients with equal treated and control groups (median age 66 [interquartile range [IQR]: 54-77]). Treated patients completed 14-day follow-up more frequently compared with controls (85% vs. 36%). The observed reduction in the incidence of the primary outcome in the treated group was not statistically significant (ATT: -1.1% [CI: -7.3, 5.1], p = 0.72). In a post-hoc analysis of 301 treated patients who subsequently completed scheduled follow-up, there was a statistically significant reduction in the incidence of the primary outcome in the treated group (ATT: -7.0% [CI: -13.9, -0.01], p = 0.049).

Conclusion: Scheduling early primary care follow-up after hospitalization for hypoxemic CAP was associated with reduced 90-day readmission and mortality only among patients who completed follow-up. Future work is needed to enhance the completion of scheduled primary care follow-up for hypoxemic CAP survivors.

Background: Manual sepsis screening, which includes bedside clinical assessment, is widely used in emergency departments and hospital wards and may improve early recognition and treatment.

Objectives: To synthesize evidence on the impact of manual sepsis screening on sepsis-related processes of care and mortality.

Methods: We performed a systematic search of MEDLINE, Cochrane, Embase, and CINAHL for original research published between January 1, 2000 and July 31, 2024. Search terms addressed sepsis, screening, and hospital settings (emergency department, ward, intensive care unit). We included full-text studies evaluating the impact of manual screening on sepsis-related processes of care or mortality. Two reviewers screened studies, and risk of bias was assessed using the ROBINS-I tool.

Results: Of 10,469 studies identified, 17 met inclusion criteria. Studies were conducted in nine countries; most were single-center (n = 15), used pre-post designs (n = 15), and were conducted before 2016 (n = 11). Seven of 10 studies reported improvement in at least one process-of-care outcome after implementation. Six of 13 studies reported statistically significant mortality reductions; three additional studies reported ≥5% absolute mortality improvement without statistical testing or significance. Overall conclusions were limited by high risk of bias, primarily due to confounding.

Conclusions: Evidence supporting manual sepsis screening is low quality and may be outdated given evolving sepsis recognition and care. Rigorous contemporary studies are needed to guide adoption and implementation decisions.

Gabapentin and pregabalin are among the most frequently prescribed medications in the United States, with gabapentin in the top 10 and pregabalin in the top 100. Despite FDA approval for only select neuropathic conditions, most use is for off-label pain indications. Randomized trials show minimal or clinically insignificant benefit for most off-label pain syndromes. In contrast, gabapentinoids are associated with sedation, falls, delirium, respiratory depression, misuse, and hospitalization, especially with opioids or renal impairment. Given limited efficacy and harms, they should not routinely substitute for opioids. Clinicians should reassess indications, deprescribe when appropriate, and prioritize nonpharmacologic strategies.

Youth hospitalized for a mental health (MH) condition frequently experience MH-related avoidable hospital days (MH-ADs), or days in which they remain hospitalized for a MH reason despite not requiring services unique to a medical hospital. However, there is currently no reliable method for identifying MH-ADs across healthcare systems, preventing investigation of this systemic problem. A universal and efficient method of determining MH-ADs is needed to guide improvements in access to care for youth with MH needs while reducing unnecessary medical hospital days. Our objectives were to create an administrative algorithm for identifying MH-ADs and to evaluate the algorithm's validity using clinical data from a single hospital site. The resulting algorithm, drawing on coding and billing data from the Pediatric Health Information System Database, identified MH-ADs with good sensitivity (79.9%), specificity (79.2%), and positive predictive value (95.1%), but low negative predictive value (43.5%) when compared to clinically determined MH-ADs.