Journal of hospital medicine最新文献

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.

New policies require hospitals to identify and address patients' health-related social needs (HRSN) yet provide minimal guidance on how screening should be conducted. This observational study occurred at a large academic hospital serving a diverse population. Hospital and research staff independently screened newly admitted medical patients for six HRSNs using an instrument designed by a quality improvement team. We calculated κ statistics to assess HRSN agreement between hospital and research staff. Analysis of 413 patients revealed fair to moderate agreement between hospital and research staff screenings (κ = 0.25-0.54). Hospital staff identified fewer patients with needs related to medication affordability, housing, food, transportation, and mental health, but identified a higher proportion with needs related to the usual source of care. Hospital staff underestimate the proportion of patients with HRSN, potentially excluding patients from referral to social services.

Background: Diabetes is one of the most common diagnoses associated with hospital admissions in the United States, costing billions to healthcare payors. An indicator of readmission risk is the Area Deprivation Index (ADI)-a measure of social determinants of health that utilizes patient residence. In this study, we assess whether ADI is associated with 30-day readmissions in patients admitted with diabetes.

Methods: This retrospective cohort study included adult patients hospitalized between October 2018 and October 2023 with a diagnosis related to diabetes. The main variables included were patient demographics (including zip code as a proxy for neighborhood), comorbidities, and diabetes-related complications. A multivariable logistic regression model was constructed to analyze differences between ADI quartiles and readmission within 30-day postdischarge.

Results: A total of 6095 patients were included, with an average age of 57 (SD = 16.7); 48.4% of participants were Black, and 46.5% were female. There were 848 (14%) readmissions with diabetes. We found no significant association between any ADI groups and 30-day readmissions.

Conclusions: Residence in a socioeconomically disadvantaged neighborhood was not shown to have a significant association with the risk of 30-day readmissions in patients with diabetes mellitus. More research is needed to understand the impact of neighborhood disadvantage on readmissions.

Background: Concerns about contrast-associated acute kidney injury (CA-AKI) may lead to individuals not undergoing necessary contrast-enhanced imaging. Effective risk stratification plays a crucial role in patient management.

Objectives: To develop a prediction model combining the effects of multiple risk factors to predict risk of CA-AKI for individuals undergoing intravenous contrast-enhanced computed tomography (CECT) imaging.

Methods: In this retrospective cohort study, 906 inpatient and outpatient adults who underwent CECT imaging in two tertiary centers, St. Luke's Medical Center-Quezon City and St. Luke's Medical Center-Global City, located in Manila, Philippines, were included. Multivariate logistic regression was used to identify independent predictors for CA-AKI. A p-value ≤ 0.05 was considered significant. Based on the odds ratio, five parameters were identified and included in the model.

Results: The incidence of CA-AKI was 10.38%. A significant association was found between CA-AKI with in-hospital mortality (odds ratio [OR]: 4.23, confidence interval [CI]: 2.59-6.90, p = 0.001) and AKI requiring renal replacement therapy (OR: 3.57, CI: 1.94-6.59, p = 0.001) among admitted patients. Multivariate analysis included reduced estimated glomerular filtration rate (OR = 17.13, p = 0.005), acute heart failure (OR = 9.21, p = 0.006), hypotension (OR = 5.15, p = 0.011), anemia (OR = 4.34, p = 0.004), and use of nephrotoxic antibiotics (OR = 5.82, p = 0.009) in the final prediction model. The prediction model had fair predictive power (area under the curve = 0.737) and good calibration (Hosmer-Lemeshow p-value = 0.418).

Conclusions: This prediction model, incorporating clinical and laboratory parameters, provides a practical tool for estimating CA-AKI risk with fair discrimination and good internal calibration. It may support informed decision-making regarding the risks and benefits of intravenous CECT. External validation is recommended.

Background: Clinicians often repeat blood cultures in hospitalized, bacteremic patients in excess. Unnecessary cultures have negative impacts, including increased length of hospitalization and environmental waste.

Objective: To evaluate the impact of diagnostic stewardship interventions on repeat blood culture ordering in bacteremic patients during the BD Bactec blood culture bottle shortage in 2024.

Methods: We performed a quasi-experimental study including a pre, post, and sustainment phase of adult patients hospitalized with a bloodstream infection at the MaineHealth healthcare system from March to November 2024.

Results: Nine hundred and forty patients met inclusion criteria. Stewardship interventions reduced repeat blood cultures in patients with Gram-negative rod and Streptococcal bacteremia from 52% to 25% (p < .001), which increased to 47% in the sustainment phase. When repeat cultures were warranted (e.g., Staphylococcus aureus), the interval between cultures increased from 1.7 to 2.0 days (p = .002); during the sustainment phase it decreased to 1.9 days. We estimate that 1968 cultures would be averted yearly if the interventions were sustained.

Conclusions: During a culture bottle shortage, diagnostic stewardship interventions significantly decreased the proportion of unnecessary repeat cultures, thereby improving adherence to evidence-based care and reducing cost and environmental impact. After the shortage ended, the gains in stewardship were partially lost. This suggests that beyond improving education, interventions aimed at impressing upon providers the severity of the shortage itself impacted behavior. Future efforts should identify how positive behavior changes can be extended beyond acute crises to promote high-value, environmentally responsible healthcare.