Journal of hospital medicine最新文献

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.

The Center for Medicare and Medicaid Services Patient Safety Structural Measure is an attestation-based public reporting measure encouraging hospitals to establish comprehensive patient safety programs, measure, and report their outcomes. Hospitalist practice is uniquely situated to benefit from and advance this policy: in particular, the emphasis on transparency and patient and family engagement. A clinical practice of talking openly with patients and families about harm requires clinical teams and leaders to systematically identify, report, analyze, improve, and heal. We describe this new policy, its limitations, and potential influences on hospital care.

Introduction: Community-acquired pneumonia (CAP) is a frequent and costly cause of pediatric emergency department (ED) visits and hospitalizations. Previous prognostic tools for CAP are limited by small samples, single-center or retrospective designs, lack of generalizability to ED settings, lack of biomarkers, or limited objective data. To overcome these limitations, we will derive and externally validate a prediction rule for pediatric CAP severity in a large, multicenter prospective cohort.

Methods: This is a prospective cohort study of children 3 months to 18 years old with CAP who present to EDs within the Pediatric Emergency Care Applied Research Network. Enrollment began 8/2023 and will end 7/2027. We exclude children with recent hospitalizations and chronic conditions (e.g., immunosuppression). A follow-up survey and record review is completed 8-15 days after the visit. Blood and nasal specimens are obtained to evaluate the role of C-reactive protein, procalcitonin, proadrenomedullin, and viral detection in severity prediction. The primary outcome is severity (three-tiered outcome of mild, moderate, or severe CAP) within 7 days of ED presentation. Model derivation will occur in ~4000 children from 7 EDs over 2 years. External validation will occur in a distinct cohort of at least 2000 children from 7 different EDs. Penalized regression, recursive partitioning, and machine learning will be used in model development.

Discussion: At study completion, we will have a validated CAP severity prediction rule well-positioned for implementation and further evaluation. We will also understand the role of specific biomarkers in predicting outcomes in children with CAP.

Background: Routine in-hospital screening of social risk factors linked with poor health outcomes is not done in Singapore, where an aging population pays for 25% healthcare costs out-of-pocket despite universal coverage.

Objective: We developed and implemented a social risk screening tool for hospitalised patients and reported the association between higher social risk and length of stay (LOS) and hospitalisation costs.

Methods: The tool aimed to reveal variation in social risk among patients admitted to medical wards between October and December 2022. Sociodemographic data, medical co-morbidities, and frailty scores were recorded. Multivariable negative binomial regression and Poisson regression assessed the association between higher social risk (risk score above cohort median), and LOS and LOS > 21 days, respectively. A parsimonious multivariable generalised linear model (GLM) modeled the association with direct health costs.

Results: Among 320 patients (median age 75, interquartile range [IQR]: 65-83), 80% were Chinese and 65% female. A total of 33% had higher social risk (>2 social risk factors). They were more likely to be male (50% vs. 27%), frail (66% vs. 50%), and have ≥4 chronic conditions (54% vs. 32%). Higher social risk was associated with a 48% longer LOS (incidence rate ratio: 1.48, confidence interval [CI]: 1.20-1.81), a relative risk of 1.69 (CI: 0.95-3.00) for LOS > 21 days, and $3545 (range: $397-16,718) in added hospitalisation costs per admission. Patients admitted to our unit with higher social risk cost an additional $25 million (range: 2.8-119 million) in 2022.

Conclusions: Prospective screening of social risk for hospitalised patients can help health systems identify patients with higher social needs and prioritise equitable resource allocation.

Background: Digital messaging within electronic health records (EHRs) is central to inpatient communication. While intended to enhance efficiency, these tools may contribute to unequal digital workloads.

Objective: To evaluate gender-based differences in EHR and secure messaging use among hospital-based physicians.

Methods: Retrospective observational study at a single academic tertiary care hospital using EHR metadata from July 2023 to June 2024. Participants included a total of 205 internal medicine and medicine-pediatrics physicians (108 senior residents, 97 faculty) serving as primary clinicians on hospitalist shifts. Measures included daily number of messages sent/received, time spent in EHR and secure chat, and hours worked, stratified by gender and role.

Results: Physicians worked a median of 9.4 h/day, spending 40.7% of their time in the EHR and 6.3% in secure chat. Women and men work similar hours (9.5 vs. 9.3, p = .40) but women spent more time in the EHR (248 vs. 222 min/day; p < .001) and secure chat (38 vs. 34 min, p < .001) and exchanged more daily messages (62 vs. 53 sent; 56 vs. 48 received, both p < .001). Patterns were consistent across residents and faculty. Among faculty, gender differences persisted after a new scheduling model, which reduced overall work hours.

Conclusions: Women physicians engaged more in digital communication than men, despite similar hours worked, and these differences persisted after a workflow change. These findings underscore the need for equity-informed strategies that both mitigate excess burden and recognize the potential value of proactive communication in hospital settings.

Background: Graduate medical education policies surrounding parental leave, lactation support, and childcare resources vary widely. Limited studies focus on the perceptions of residents and fellows regarding childbearing and parenting during training.

Objective: To explore physician trainee experiences with pregnancy and parenthood to inform policies and strengthen support for physicians-in-training.

Methods: We interviewed trainee parents between May and June 2022 at a large institution using structured interviews conducted virtually, transcribed, and deidentified. We independently coded interview transcripts and used inductive and deductive analysis to identify key themes and representative quotations.

Results: We interviewed 28 participants (mean age 32.6 (2.8) years, 23 [82%] women, 5 [29%] surgical specialty) and identified five major themes: (1) The timeline of training creates unique challenges for family planning, related to parental age, infertility/miscarriage, and geographic limitations for partner/family support; (2) Trainee parents rely on support from their partner, extended family, and friends/co-trainees; (3) Trainee parents report misinformation and lack of transparency with parental leave policies; (4) The work environment poses significant challenges to meeting breastfeeding goals; and (5) Trainee parents report inadequate and unreliable childcare, related to limited availability, cost, and lack of back-up childcare options.

Conclusions: Trainee parents face unique challenges related to pregnancy and raising a family during their graduate medical education. Trainees would benefit from improved communication related to parental leave policies, breastfeeding education for faculty, on-site childcare, and stipends for childcare/breast pumps. These results have important implications for institutional policies and reveal additional opportunities to promote trainee parents' wellness.