Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care

The impact of obesity on postoperative outcomes following surgery for colorectal cancer: analysis of the National Inpatient Sample 2015-2019

BACKGROUND

The global burden of obesity has reached epidemic proportions, placing great strain on the North American healthcare system. We designed a retrospective cohort database study comparing postoperative morbidity and healthcare resource utilization between patients living with and without obesity undergoing surgery for colorectal cancer.

METHODS

Adult patients undergoing resection for colorectal cancer were identified from the 2015 to 2019 National Inpatient Sample database. Patients were stratified according to obesity status (i.e., body mass index of 30 kg/m2). Propensity score matching (PSM) with 1:1 nearest-neighbour matching was performed according to demographic, operative, and hospital characteristics. The primary outcome was postoperative morbidity. Secondary outcomes included system-specific postoperative complications, postoperative mortality, length of stay, total admission healthcare cost, and post-discharge disposition. McNemar's and Wilcoxon matched pairs signed rank tests were performed.

RESULTS

After PSM, 7565 non-obese and 7565 obese patients were included. Patients with obesity had a 10% increase in relative risk of overall in-hospital postoperative morbidity (23.1% versus 25.6%, P = 0.0015) and a $4564 increase in hospitalization cost ($70 248 USD versus $74 812 USD, P = 0.0004). Patients with obesity were more likely to require post-operative ICU admission (5.0% versus 8.0%, P < 0.0001) and less likely to be discharged home after their index operation (68.3% versus 64.2%, P = 0.0022).

CONCLUSION

Patients with obesity undergoing surgery for colorectal cancer may be at an increased risk of in-hospital postoperative morbidity. They may also be more likely to have increased hospitalization costs, post-operative ICU admissions, and to not be discharged directly home. Preoperative optimization via weight loss strategies should be further explored.

Patients involvement in the discharge process from hospital to home: A patient's journey

AIMS

The aims of the study were to gain insight in the transfer process from hospital to homecare or rehabilitation centre from a patient's perspectives and to describe the experienced involvement, information provision and information needs patients.

DESIGN

A multiple case study with a phenomenological approach.

METHODS

Observations and interviews were employed, between May 2019 and August 2019, to capture the patient's perspectives and experiences on involvement, information provision and needs. Observations were executed during the discharge process from hospital to homecare (n = 6) or revalidation centre (n = 1) and during admission interviews with community nurses (n = 6). Interviews were conducted at the patient's home and the revalidation centre.

RESULTS

Eight themes were identified within three phases of the transfer process. The Sign-up phase contained two themes: 'organizing follow-up care' and 'planning the moment of discharge from the hospital'. The two themes in the Transfer phase were, 'verbal information provision' and 'written information provision'. Four themes were identified in the End phase: 'nursing supplies', 'medication', 'the electronic patient portal' and 'continuation of (para)medical care'.

CONCLUSIONS

Patient participation in the transition process from the hospital to follow-up care can be improved. This study indicates that unsafe situations could be prevented by patient involvement and clear perceptions of the role and responsibilities of patients, family and healthcare professionals.

IMPLICATIONS TO PATIENT CARE

Patient and family involvement has the potential to improve transition of care and techniques for shared decision-making can be applied to a greater extent.

IMPACT

This paper highlights that patients and families should be acknowledged as key figures in the transfer process and gives direction to healthcare professionals on how to increase involvement in the transfer process by actively inviting patients to participate in the transfer process.

REPORTING METHOD

COREQ guidelines for qualitative reporting. No patient or public contribution.

CONTRIBUTION TO GLOBAL CLINICAL COMMUNITY

This paper gives insights in patients' and families' perspectives on transition of nursing care and their involvement during the whole transfer process. This paper gives direction how to improve patient participation during the discharge process from hospital to follow-up care.

Patient medication management, understanding and adherence during the transition from hospital to outpatient care - a qualitative longitudinal study in polymorbid patients with type 2 diabetes

BACKGROUND

Continuity of care is under great pressure during the transition from hospital to outpatient care. Medication changes during hospitalization may be poorly communicated and understood, compromising patient safety during the transition from hospital to home. The main aims of this study were to investigate the perspectives of patients with type 2 diabetes and multimorbidities on their medications from hospital discharge to outpatient care, and their healthcare journey through the outpatient healthcare system. In this article, we present the results focusing on patients' perspectives of their medications from hospital to two months after discharge.

METHODS

Patients with type 2 diabetes, with at least two comorbidities and who returned home after discharge, were recruited during their hospitalization. A descriptive qualitative longitudinal research approach was adopted, with four in-depth semi-structured interviews per participant over a period of two months after discharge. Interviews were based on semi-structured guides, transcribed verbatim, and a thematic analysis was conducted.

RESULTS

Twenty-one participants were included from October 2020 to July 2021. Seventy-five interviews were conducted. Three main themes were identified: (A) Medication management, (B) Medication understanding, and (C) Medication adherence, during three periods: (1) Hospitalization, (2) Care transition, and (3) Outpatient care. Participants had varying levels of need for medication information and involvement in medication management during hospitalization and in outpatient care. The transition from hospital to autonomous medication management was difficult for most participants, who quickly returned to their routines with some participants experiencing difficulties in medication adherence.

CONCLUSIONS

The transition from hospital to outpatient care is a challenging process during which discharged patients are vulnerable and are willing to take steps to better manage, understand, and adhere to their medications. The resulting tension between patients' difficulties with their medications and lack of standardized healthcare support calls for interprofessional guidelines to better address patients' needs, increase their safety, and standardize physicians', pharmacists', and nurses' roles and responsibilities.

Patient experiences of interprofessional collaboration and intersectoral communication in rare disease healthcare in Germany - a mixed-methods study

BACKGROUND

Rare diseases are often complex, chronic and many of them life-shortening. In Germany, healthcare for rare diseases is organized in expert centers for rare diseases. Most patients additionally have regional general practicioners and specialists for basic medical care. Thus, collaboration and information exchange between sectors is highly relevant. Our study focuses on the patient and caregiver perspective on intersectoral and interdisciplinary care between local healthcare professionals (HCPs) and centers for rare diseases in Germany. The aims were (1) to investigate patients' and caregivers' general experience of healthcare, (2) to analyse patients' and caregivers' perception of collaboration and cooperation between local healthcare professionals and expert centers for rare diseases and (3) to investigate patients' and caregivers' satisfaction with healthcare in the expert centers for rare diseases.

RESULTS

In total 299 individuals of whom 176 were patients and 123 were caregivers to pediatric patients participated in a survey using a questionnaire comprising several instruments and constructs. Fifty participants were additionally interviewed using a semistructured guideline. Most patients reported to receive written information about their care, have a contact person for medical issues and experienced interdisciplinary exchange within the centers for rare diseases. Patients and caregivers in our sample were mainly satisfied with the healthcare in the centers for rare diseases. The qualitative interviews showed a rather mixed picture including experiences of uncoordinated care, low engagement and communication difficulties between professionals of different sectors. Patients reported several factors that influenced the organization and quality of healthcare e.g. engagement and health literacy in patients or engagement of HCPs.

CONCLUSIONS

Our findings indicate the high relevance of transferring affected patients to specialized care as fast as possible to provide best medical treatment and increase patient satisfaction. Intersectoral collaboration should exceed written information exchange and should unburden patients of being and feeling responsible for communication between sectors and specialists. Results indicate a lack of inclusion of psychosocial aspects in routine care, which suggests opportunities for necessary improvements.

Health Management Service Models for the Elderly with Visual Impairment: A Scoping Review

Background

The incidence of visual impairment(VI) in older people is gradually increasing. This review aimed to summarise the evidence on existing health management models and strategies for older adults with VI to improve health-related and vision-related quality of life (QoL) in older people.

Methods

Based on the framework of the scoping review methodology of Arksey and O'Malley (2005), a comprehensive literature search of relevant literature published between January 2010 and June 2022 in PubMed, CINAHL, EMBASE, Web of Science, Cochrane Library, CNKI, VIP, Wanfang database, Sinomed and the grey literature.

Results

Finally, 31 articles were included. The health management model had a multidisciplinary team low vision rehabilitation model, medical consortium two-way management model, low vision community comprehensive rehabilitation model, medical consortium-family contract service model, screening-referral-follow-up model, and three-level low vision care model. The health management strategy covers nine aspects, the combination of multi-element strategies is feasible, and network information technology has also shown positive results.

Conclusion

In the future, under the Internet and hierarchical management model, we should provide demand-based personalized support to rationalize and scientifically achieve hierarchical management and improve resource utilization efficiency and eye health outcomes.

A survey on the implementation of clinical medication reviews in community pharmacies within a multidisciplinary setting

BACKGROUND

Polypharmacy is common in chronic medication users, which increases the risk of drug related problems. A suitable intervention is the clinical medication review (CMR) that was introduced in the Netherlands in 2012, but the effectiveness might be hindered by limited implementation in community pharmacies. Therefore our aim was to describe the current implementation of CMRs in Dutch community pharmacies and to identify barriers to the implementation.

METHODS

An online questionnaire was developed based on the Consolidated Framework for Implementation Research (CFIR) and consisted of 58 questions with open ended, multiple choice or Likert-scale answering options. It was sent out to all Dutch community pharmacies (n = 1,953) in January 2021. Descriptive statistics were used.

RESULTS

A total of 289 (14.8%) community pharmacies filled out the questionnaire. Most of the pharmacists agreed that a CMR has a positive effect on the quality of pharmacotherapy (91.3%) and on medication adherence (64.3%). Pharmacists structured CMRs according to available selection criteria or guidelines (92%). Pharmacists (90%) believed that jointly conducting a CMR with a general practitioner (GP) improved their mutual relationship, whereas 21% believed it improved the relationship with a medical specialist. Lack of time was reported by 43% of pharmacists and 80% (fully) agreed conducting CMRs with a medical specialist was complicated. Most pharmacists indicated that pharmacy technicians can assist in performing CMRs, but they rarely do in practice.

CONCLUSIONS

Lack of time and suboptimal collaboration with medical specialists are the most important barriers to the implementation of CMRs.

Improving collaboration between specialists and general practitioners in services for individuals with chronic spinal cord injury living in rural areas of Switzerland: Baseline results from the SCI-Co study

CONTEXT/OBJECTIVE

Strategies to combine primary and specialized care are crucial to meet the needs of individuals with spinal cord injury (SCI) located in rural areas. We explored the collaboration between general practitioners (GPs) and SCI specialists who will participate in an intervention study to improve their collaboration.

DESIGN

A questionnaire survey from August to October 2020.

SETTING

Primary Care, Specialized SCI care.

PARTICIPANTS

Eight GPs and 13 SCI specialists.

INTERVENTIONS

Baseline results from the SCI-Co study.

OUTCOME MEASURES

N/A.

RESULTS

Overall, satisfaction ratings for the collaboration between GPs and SCI specialists were high, and all physicians agreed that they work together well. Especially, SCI specialists were satisfied in collaborating with GPs. Despite Switzerland's fragmented primary and secondary care system, only a few physicians reported about issues with delays and waiting lists. While GPs wanted to improve the quality of their referral, most SCI specialists reported being content with it. GPs were also discontent about discharge organization by specialists.

CONCLUSION

Satisfaction with collaboration was high, both in GPs and specialists. Areas for improvement include discharge and referral processes.

Preoperative Communication Between Anesthesia, Surgery, and Primary Care Providers for Older Surgical Patients

BACKGROUND

Suboptimal communication between clinicians remains a frequent driver of preventable adverse health care-related events, increased costs, and patient and physician dissatisfaction.

METHODS

Cross-sectional surveys on preoperative interspecialty communication, tailored by stakeholder type, were administered to (1) primary care providers in northern New England, (2) anesthesia providers working in the perioperative clinic of a tertiary rural academic medical center, (3) surgeons from the same center, and (4) older surgical patients who underwent preoperative assessment at the same center.

RESULTS

In total, 107/249 (43.0%) providers and 103/265 (39.9%) patients completed the survey. Preoperative communication was perceived as logistically challenging (59.8%), particularly across health systems. More than 77% of anesthesia and surgery providers indicated that they communicate frequently or sometimes, but 92.5% of primary care providers indicated that they rarely or never communicate with anesthesia providers. Some of the most common reasons for preoperative communication were discussion of complex patients, perioperative medication management, and optimization of comorbidities. Although 96.1% of older surgical patients reported that preoperative communication between providers is important, only 40.4% felt that their providers communicate very or extremely well. Many patients emphasized the importance of preoperative communication between providers to ensure transfer of critical clinical information.

CONCLUSION

Surgeons and anesthesiologists infrequently communicate with primary care providers in one rural tertiary center, in contrast to patient expectations and values. These study results will help identify priorities and potentially resolvable barriers to bridging the gap between the inpatient perioperative and outpatient primary care teams. Future studies should focus on strategies to improve communication between hospital and community providers to prevent complications and readmission.

Effective Communication Supported by an App for Pregnant Women: Quantitative Longitudinal Study

BACKGROUND

In the medical field of obstetrics, communication plays a crucial role, and pregnant women, in particular, can benefit from interventions improving their self-reported communication behavior. Effective communication behavior can be understood as the correct transmission of information without misunderstanding, confusion, or losses. Although effective communication can be trained by patient education, there is limited research testing this systematically with an app-based digital intervention. Thus, little is known about the success of such a digital intervention in the form of a web-app, potential behavioral barriers for engagement, as well as the processes by which such a web-app might improve self-reported communication behavior.

OBJECTIVE

This study fills this research gap by applying a web-app aiming at improving pregnant women's communication behavior in clinical care. The goals of this study were to (1) uncover the potential risk factors for early dropout from the web-app and (2) investigate the social-cognitive factors that predict self-reported communication behavior after having used the web-app.

METHODS

In this study, 1187 pregnant women were recruited. They all started to use a theory-based web-app focusing on intention, planning, self-efficacy, and outcome expectancy to improve communication behavior. Mechanisms of behavior change as a result of exposure to the web-app were explored using stepwise regression and path analysis. Moreover, determinants of dropout were tested using logistic regression.

RESULTS

We found that dropout was associated with younger age (P=.014). Mechanisms of behavior change were consistent with the predictions of the health action process approach. The stepwise regression analysis revealed that action planning was the best predictor for successful behavioral change over the course of the app-based digital intervention (β=.331; P<.001). The path analyses proved that self-efficacy beliefs affected the intention to communicate effectively, which in turn, elicited action planning and thereby improved communication behavior (β=.017; comparative fit index=0.994; Tucker-Lewis index=0.971; root mean square error of approximation=0.055).

CONCLUSIONS

Our findings can guide the development and improvement of apps addressing communication behavior in the following ways in obstetric care. First, such tools would enable action planning to improve communication behavior, as action planning is the key predictor of behavior change. Second, younger women need more attention to keep them from dropping out. However, future research should build upon the gained insights by conducting similar internet interventions in related fields of clinical care. The focus should be on processes of behavior change and strategies to minimize dropout rates, as well as replicating the findings with patient safety measures.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03855735; https://classic.clinicaltrials.gov/ct2/show/NCT03855735.

Intersectoral cooperation between university hospitals and physicians in private practice in Germany- where the potential for optimization lies

BACKGROUND

Intersectoral cooperation between physicians in private practice and hospitals is highly relevant for ensuring the quality of medical care. However, the experiences and potential for optimization at this interface from the perspective of physicians in private practice have not yet been systematically investigated. The aim of this questionnaire survey was to record participants' experiences with regard to cooperation with university hospitals and to identify the potential for optimizing intersectoral cooperation.

METHODS

We performed a prospective cross-sectional study using an online survey among practising physicians of all disciplines offering ambulatory care in Germany. The link to a 41-item questionnaire was sent via mail using a commercial mail distributor in which 1095 practising physicians participated. Baseline statistics were performed with SurveyMonkey and Excel.

RESULTS

A total of 70.6%/722 of the responding physicians in private practice rated cooperation with university hospitals as satisfactory. Satisfaction with the quality of treatment was confirmed by 87.2%/956 of the physicians. The subjectively perceived complication rate in patient care was assessed as rare (80.9%/886). However, the median waiting time for patients in the inpatient discharge letter was 4 weeks. The accessibility of medical contact persons was rated as rather difficult by 52.6%/577 of the physicians. A total of 48.6%/629 of the participants considered better communication as an equal partner to be an important potential for optimization. Likewise, 65.2%/714 participants wished for closer cooperation in pre- and/or post inpatient care.

CONCLUSION

The following optimization potentials were identified: timely discharge letters, clear online presentations of clinical contacts, improved accessibility by telephone, introduction or further development of a referral portal, regular intersectoral training and/or "get-togethers", regular surveys of general practitioners and implementation of resulting measures, further development of cross-sectoral communication channels and strengthening of hospital IT.

Navigating outpatient care of patients with type 2 diabetes after hospital discharge - a qualitative longitudinal study

BACKGROUND

The transition from hospital to outpatient care is a particularly vulnerable period for patients as they move from regular health monitoring to self-management. This study aimed to map and investigate the journey of patients with polymorbidities, including type 2 diabetes (T2D), in the 2 months following hospital discharge and examine patients' encounters with healthcare professionals (HCPs).

METHODS

Patients discharged with T2D and at least two other comorbidities were recruited during hospitalization. This qualitative longitudinal study consisted of four semi-structured interviews per participant conducted from discharge up to 2 months after discharge. The interviews were based on a guide, transcribed verbatim, and thematically analyzed. Patient journeys through the healthcare system were represented using the patient journey mapping methodology.

RESULTS

Seventy-five interviews with 21 participants were conducted from October 2020 to July 2021. The participants had a median of 11 encounters (min-max: 6-28) with HCPs. The patient journey was categorized into six key steps: hospitalization, discharge, dispensing prescribed medications by the community pharmacist, follow-up calls, the first medical appointment, and outpatient care.

CONCLUSIONS

The outpatient journey in the 2 months following discharge is a complex and adaptive process. Despite the active role of numerous HCPs, navigation in outpatient care after discharge relies heavily on the involvement and responsibilities of patients. Preparation for discharge, post-hospitalization follow-up, and the first visit to the pharmacy and general practitioner are key moments for carefully considering patient care. Our findings underline the need for clarified roles and a standardized approach to discharge planning and post-discharge care in partnership with patients, family caregivers, and all stakeholders involved.

Qualitative expert evaluation of an educational intervention outline aimed at developing a shared understanding of cross-border healthcare

Objectives

Although cross-border healthcare benefits many patients and healthcare professionals, it also poses challenges. To develop a shared understanding of these opportunities and challenges among healthcare professionals, we designed an educational intervention outline and invited experts in healthcare and education to evaluate it. The proposed intervention was based on theoretical principles of authentic, team, and reflective learning.

Methods

Experts (N=11) received a paper outline of the intervention, which was subsequently discussed in individual, semi-structured interviews.

Results

Based on a thematic analysis of the interviews, we identified 4 themes: 1) using the experience you have, 2) learning with the people you work with, 3) taking the time to reflect on the past and future, and 4) adapting the intervention to its context.

Conclusion

According to the experts, the proposed intervention and its three underlying principles can enhance a shared understanding of cross-border healthcare. To unlock its full potential, however, they suggested adjusting the application of learning principles to its specific context. By situating learning in landscapes of practice, the intervention could contribute to the continuous development of cross-border healthcare.

Medical Measures in Hypertensives Considered Resistant

BACKGROUND

Patients with resistant hypertension are the group of hypertensive patients with the highest cardiovascular risk.

METHODS

All rules and guidelines for treatment of hypertension should be followed strictly to obtain blood pressure (BP) control in resistant hypertension. The mainstay of treatment of hypertension, also for resistant hypertension, is pharmacological treatment, which should be tailored to each patient's specific phenotype. Therefore, it is pivotal to assess nonadherence to pharmacological treatment as this remains the most challenging problem to investigate and manage in the setting of resistant hypertension.

RESULTS

Once adherence has been confirmed, patients must be thoroughly worked-up for secondary causes of hypertension. Until such possible specific causes have been clarified, the diagnosis is apparent treatment-resistant hypertension (TRH). Surprisingly few patients remain with true TRH when the various secondary causes and adherence problems have been detected and resolved. Refractory hypertension is a term used to characterize the treatment resistance in hypertensive patients using ≥5 antihypertensive drugs. All pressor mechanisms may then need blockage before their BPs are reasonably controlled.

CONCLUSIONS

Patients with resistant hypertension need careful and sustained follow-up and review of their medications and dosages at each term since medication adherence is a very dynamic process.

Factors influencing hospitalization or emergency department visits and mortality in type 2 diabetes following the onset of new cardiovascular diagnoses in a population-based study

BACKGROUND

Individuals with type 2 diabetes (T2D) are at increased risk of developing cardiovascular disease (CVD) which necessitates monitoring of risk factors and appropriate pharmacotherapy. This study aimed to identify factors predicting emergency department visits, hospitalizations, and mortality among T2D patients after being newly diagnosed with CVD.

METHODS

In a retrospective observational study conducted in Region Halland, individuals aged > 40 years with T2D diagnosed between 2011 and 2019, and a new diagnosis of CVD between 2016 and 2019, were followed for one year from the date of CVD diagnosis. The first encounter for CVD diagnosis was categorized as inpatient-, outpatient-, primary-, or emergency department care. Follow-up included laboratory tests, blood pressure, pharmacotherapies, and healthcare utilization. Hazard ratios (HR) in two Cox regression analyses determined relative risks for emergency visits/hospitalization and mortality, adjusting for age, sex, glucose regulation, lipid levels, kidney function, blood pressure, pharmacotherapy, and healthcare utilization.

RESULTS

The study included a total of 1759 T2D individuals who received a new CVD diagnosis, with 67% diagnosed during inpatient care. The average hospitalization stay was 6.5 days, and primary care follow-up averaged 10.1 visits. Patients with CVD diagnosed in primary care had a HR 0.52 (confidence interval [CI] 0.35-0.77) for emergency department visits/hospitalization, but age had a HR 1.02 (CI 1.00-1.03). Pharmacotherapy with insulin, DPP4-inhibitors, aldosterone antagonists, and beta-blockers had a raised HR. Highest mortality risk was observed when CVD was diagnosed inpatient care, systolic blood pressure < 100 mm Hg and elevated HbA1c. Age had a HR 1.05 (CI 1.03-1.08), eGFR < 30 ml/min HR 1.46 (CI 1.01-2.11), and LDL-Cholesterol > 2,5 h 1.46 (CI 1.01-2.11) and associated with increased mortality risk. Pharmacotherapy with metformin had a HR 0.41 (CI 0.28-0.62), statins a HR 0.39 (CI 0.27-0.57), and a primary care follow-up < 30 days a HR 0.53 (CI 0.37-0.77) and associated with lower mortality risk.

CONCLUSIONS

T2D individuals who had a new diagnosis of CVD were predominantly diagnosed when hospitalized, while follow-up typically occurred in primary care. Identifying factors that predict risks of mortality and hospitalization should be a focus of follow-up care, underscoring the critical role of primary care in the effective management of T2D and CVD.

Informational continuity of medication management in transitions of care: Qualitative interviews with stakeholders from the HYPERION-TransCare study

BACKGROUND

The transition of patients between inpatient and outpatient care can lead to adverse events and medication-related problems due to medication and communication errors, such as medication discontinuation, the frequency of (re-)hospitalizations, and increased morbidity and mortality. Older patients with multimorbidity and polypharmacy are particularly at high risk during transitions of care. Previous research highlighted the need for interventions to improve transitions of care in order to support information continuity, coordination, and communication. The HYPERION-TransCare project aims to improve the continuity of medication management for older patients during transitions of care.

METHODS AND FINDINGS

Using a qualitative design, 32 expert interviews were conducted to explore the perspectives of key stakeholders, which included healthcare professionals, patients and one informal caregiver, on transitions of care. Interviews were conducted between October 2020 and January 2021, transcribed verbatim and analyzed using content analysis. We narratively summarized four main topics (stakeholders' tasks, challenges, ideas for solutions and best practice examples, and patient-related factors) and mapped them in a patient journey map. Lacking or incomplete information on patients' medication and health conditions, inappropriate communication and collaboration between healthcare providers within and across settings, and insufficient digital support limit the continuity of medication management.

CONCLUSIONS

The study confirms that medication management during transitions of care is a complex process that can be compromised by a variety of factors. Legal requirements and standardized processes are urgently needed to ensure adequate exchange of information and organization of medication management before, during and after hospital admissions. Despite the numerous barriers identified, the findings indicate that involved healthcare professionals from both the inpatient and outpatient care settings have a common understanding.

Drug development for major chronic health conditions-aligning with growing public health needs: Proceedings from a multistakeholder think tank

The global pharmaceutical industry portfolio is skewed towards cancer and rare diseases due to more predictable development pathways and financial incentives. In contrast, drug development for major chronic health conditions that are responsible for a large part of mortality and disability worldwide is stalled. To examine the processes of novel drug development for common chronic health conditions, a multistakeholder Think Tank meeting, including thought leaders from academia, clinical practice, non-profit healthcare organizations, the pharmaceutical industry, the Food and Drug Administration (FDA), payors as well as investors, was convened in July 2022. Herein, we summarize the proceedings of this meeting, including an overview of the current state of drug development for chronic health conditions and key barriers that were identified. Six major action items were formulated to accelerate drug development for chronic diseases, with a focus on improving the efficiency of clinical trials and rapid implementation of evidence into clinical practice.

Direct Admission Program Implementation: A Qualitative Analysis of Variation Across Health Systems

OBJECTIVES

Direct admission (DA) to the hospital has the potential to improve family satisfaction and timeliness of care by bypassing the emergency department. Using the RE-AIM implementation framework, we sought to characterize variation across health systems in the reach, effectiveness, adoption, and implementation of a DA program from the perspectives of parents and multidisciplinary clinicians.

METHODS

As part of a stepped-wedge cluster randomized trial to compare the effectiveness of DA to admission through the emergency department, we evaluated DA rates across 69 clinics and 3 health systems and conducted semi-structured interviews with parents and clinicians. We used thematic analysis to identify themes related to the reach, effectiveness, adoption, and implementation of the DA program and applied axial coding to characterize thematic differences across sites.

RESULTS

Of 2599 hospitalizations, 171 (6.6%) occurred via DA, with DA rates varying 10-fold across health systems from 0.9% to 9.3%. Through the analysis of 137 interviews, including 84 with clinicians and 53 with parents, we identified similarities across health systems in themes related to perceived program effectiveness and patient and family engagement. Thematic differences across sites in the domains of program implementation and clinician adoption included variation in transfer center efficiency, trust between referring and accepting clinicians, and the culture of change within the health system.

CONCLUSIONS

The DA program was adopted variably, highlighting unique challenges and opportunities for implementation in different hospital systems. These findings can inform future quality improvement efforts to improve transitions to the hospital.

Transforming healthcare documentation: harnessing the potential of AI to generate discharge summaries

BACKGROUND

Hospital discharge summaries play an essential role in informing GPs of recent admissions to ensure excellent continuity of care and prevent adverse events; however, they are notoriously poorly written, time-consuming, and can result in delayed discharge.

AIM

To evaluate the potential of artificial intelligence (AI) to produce high-quality discharge summaries equivalent to the level of a doctor who has completed the UK Foundation Programme.

DESIGN & SETTING

Feasibility study using 25 mock patient vignettes.

METHOD

Twenty-five mock patient vignettes were written by the authors. Five junior doctors wrote discharge summaries from the case vignettes (five each). The same case vignettes were input into ChatGPT. In total, 50 discharge summaries were generated; 25 by Al and 25 by junior doctors. Quality and suitability were determined through both independent GP evaluators and adherence to a minimum dataset.

RESULTS

Of the 25 AI-written discharge summaries 100% were deemed by GPs to be of an acceptable quality compared with 92% of the junior doctor summaries. They both showed a mean compliance of 97% with the minimum dataset. In addition, the ability of GPs to determine if the summary was written by ChatGPT was poor, with only a 60% accuracy of detection. Similarly, when run through an AI-detection tool all were recognised as being very unlikely to be written by AI.

CONCLUSION

AI has proven to produce discharge summaries of equivalent quality to a junior doctor who has completed the UK Foundation Programme; however, larger studies with real-world patient data with NHS-approved AI tools will need to be conducted.

Care fragmentation is associated with increased mortality after ileostomy creation

BACKGROUND

Ileostomy is the mainstay treatment option for various gastrointestinal conditions. Given the increased risk of post-discharge complications and high readmission rates that can be further aggravated by receiving care at different facilities (care fragmentation), further examination is necessary. We thus used a national cohort to explore the associations of care fragmentation among ileostomy patients experiencing adverse outcomes and increased hospitalization expenditures.

METHODS

All adult hospitalizations for ileostomy were tabulated from the 2016 to 2020 Nationwide Readmissions Database. Those readmitted within 90 days after discharge were included for analysis. Patients treated at a different facility than the original location where the index ileostomy was performed were categorized into the care-fragmented cohort. Multivariable regressions were developed to characterize the association of the care-fragmented cohort with postoperative outcomes, readmissions, and expenditures.

RESULTS

Of 52,254 patients with ileostomy creation hospitalizations with 90-day nonelective readmission, 9,045 (17.3%) experienced care fragmentation. Following risk adjustment, those experiencing care fragmentation faced increased odds of mortality (adjusted odds ratio 1.81, 95% confidence interval 1.54-2.12), cardiac (adjusted odds ratio 1.63, 95% confidence interval 1.42-1.85), respiratory (adjusted odds ratio 1.71, 95% confidence interval 1.53-1.91), infectious (adjusted odds ratio 1.33, 95% confidence interval 1.23-1.43), and thromboembolic (adjusted odds ratio 1.28, 95% confidence interval 1.13-1.45) complications. Furthermore, patients experiencing care fragmentation were more likely to have increased hospitalization costs ($1,700, 95% confidence interval 0.8-2.5).

CONCLUSION

Care fragmentation in ileostomy patients demonstrated an increased risk for mortality, postoperative complications, and increased hospitalization expenses. To mitigate risks for adverse outcomes, future studies should evaluate the impacts of inter-hospital communication with the goal of improving care continuity and optimizing healthcare delivery for care-fragmented populations.

Designing and Implementation of a Digitalized Intersectoral Discharge Management System and Its Effect on Readmissions: Mixed Methods Approach

BACKGROUND

Digital transformation offers new opportunities to improve the exchange of information between different health care providers, including inpatient, outpatient and care facilities. As information is especially at risk of being lost when a patient is discharged from a hospital, digital transformation offers great opportunities to improve intersectoral discharge management. However, most strategies for improvement have focused on structures within the hospital.

OBJECTIVE

This study aims to evaluate the implementation of a digitalized discharge management system, the project "Optimizing instersectoral discharge management" (SEKMA, derived from the German Sektorübergreifende Optimierung des Entlassmanagements), and its impact on the readmission rate.

METHODS

A mixed methods design was used to evaluate the implementation of a digitalized discharge management system and its impact on the readmission rate. After the implementation, the congruence between the planned (logic model) and the actual intervention was evaluated using a fidelity analysis. Finally, bivariate and multivariate analyses were used to evaluate the effectiveness of the implementation on the readmission rate. For this purpose, a difference-in-difference approach was adopted based on routine data of hospital admissions between April 2019 and August 2019 and between April 2022 and August 2022. The department of vascular surgery served as the intervention group, in which the optimized discharge management was implemented in April 2022. The departments of internal medicine and cardiology formed the control group.

RESULTS

Overall, 26 interviews were conducted, and we explored 21 determinants, which can be categorized into 3 groups: "optimization potential," "barriers," and "enablers." On the basis of these results, 19 strategies were developed to address the determinants, including a lack of networking among health care providers, digital information transmission, and user-unfriendliness. On the basis of these strategies, which were prioritized by 11 hospital physicians, a logic model was formulated. Of the 19 strategies, 7 (37%; eg, electronic discharge letter, providing mobile devices to the hospital's social service, and generating individual medication plans in the format of the national medication plan) have been implemented in SEKMA. A survey on the fidelity of the application of the implemented strategies showed that 3 of these strategies were not yet widely applied. No significant effect of SEKMA on readmissions was observed in the routine data of 14,854 hospital admissions (P=.20).

CONCLUSIONS

This study demonstrates the potential of optimizing intersectoral collaboration for patient care. Although a significant effect of SEKMA on readmissions has not yet been observed, creating a digital ecosystem that connects different health care providers seems to be a promising approach to ensure secure and fast networking of the sectors. The described intersectoral optimization of discharge management provides a structured template for the implementation of a similar local digital care networking infrastructure in other care regions in Germany and other countries with a similarly fragmented health care system.

ChatGPT-4 generates orthopedic discharge documents faster than humans maintaining comparable quality: a pilot study of 6 cases

BACKGROUND AND PURPOSE

Large language models like ChatGPT-4 have emerged. They hold the potential to reduce the administrative burden by generating everyday clinical documents, thus allowing the physician to spend more time with the patient. We aimed to assess both the quality and efficiency of discharge documents generated by ChatGPT-4 in comparison with those produced by physicians.

PATIENTS AND METHODS

To emulate real-world situations, the health records of 6 fictional orthopedic cases were created. Discharge documents for each case were generated by a junior attending orthopedic surgeon and an advanced orthopedic resident. ChatGPT-4 was then prompted to generate the discharge documents using the same health record information. The quality assessment was performed by an expert panel (n = 15) blinded to the source of the documents. As secondary outcome, the time required to generate the documents was compared, logging the duration of the creation of the discharge documents by the physician and by ChatGPT-4.

RESULTS

Overall, both ChatGPT-4 and physician-generated notes were comparable in quality. Notably, ChatGPT-4 generated discharge documents 10 times faster than the traditional method. 4 events of hallucinations were found in the ChatGPT-4-generated content, compared with 6 events in the human/physician produced notes.

CONCLUSION

ChatGPT-4 creates orthopedic discharge notes faster than physicians, with comparable quality. This shows it has great potential for making these documents more efficient in orthopedic care. ChatGPT-4 has the potential to significantly reduce the administrative burden on healthcare professionals.

'I don't know exactly what that means to do check-ups': understanding and experiences of primary care among resettled young adult refugees

Young adult refugees have suboptimal primary care use, including having a regular provider and engaging with a regular source of care for primary and preventive healthcare needs. Our purpose was to understand how young adult refugees (ages 18-29 years) resettled to the United States understand and experience primary care. We conducted 23 semi-structured interviews with young adult refugees and explored their ideas about and experiences of key characteristics of primary care. Emergent themes were synthesized. Young adult refugees reported a lack of an understanding of the idea of primary care. However, they also described the lack of accepted key components of primary care, such as being the first contact and providing continuity, coordination and comprehensiveness. The importance of developing an ability to ask questions, get answers and feel empowered was a facilitator of primary care successes. Young refugees lack access to healthcare that exemplifies quality primary care. Improving understanding of the primary care model and its value as well as increasing access and ease of engagement could improve primary care engagement for young adult refugees.

Deprescribing medications among patients with multiple prescribers: A socioecological model

Deprescribing is the intentional dose reduction or discontinuation of a medication. The development of deprescribing interventions should take into consideration important organizational, interprofessional, and patient-specific barriers that can be further complicated by the presence of multiple prescribers involved in a patient's care. Patients who receive care from an increasing number of prescribers may experience disruptions in the timely transfer of relevant healthcare information, increasing the risk of exposure to drug-drug interactions and other medication-related problems. Furthermore, the fragmentation of healthcare information across health systems can contribute to the refilling of discontinued medications, reducing the effectiveness of deprescribing interventions. Thus, deprescribing interventions must carefully consider the unique characteristics of patients and their prescribers to ensure interventions are successfully implemented. In this special article, an international working group of physicians, pharmacists, nurses, epidemiologists, and researchers from the United States Deprescribing Research Network (USDeN) developed a socioecological model to understand how multiple prescribers may influence the implementation of a deprescribing intervention at the individual, interpersonal, organizational, and societal level. This manuscript also includes a description of the concept of multiple prescribers and outlines a research agenda for future investigations to consider. The information contained in this manuscript should be used as a framework for future deprescribing interventions to carefully consider how multiple prescribers can influence the successful implementation of the service and ensure the intervention is as effective as possible.

Improving the Quality and Completeness of Discharge Summaries at a Tertiary Care Hospital in Pakistan: A Quality Improvement Project

Introduction Discharge summaries (DS) allow continued patient care after being discharged from the hospital. Only a few quality improvement projects (QIPs) focused on assessing and improving the quality and completeness of DS at tertiary care hospitals have been undertaken in Pakistan. This QIP aimed to evaluate and enhance the quality and completeness of DS at a tertiary care hospital in Pakistan to facilitate seamless healthcare transitions. Methods A QIP was conducted in the medical unit of a tertiary care hospital in Rawalpindi, Pakistan. The DS were assessed using the e-discharge summary self-assessment checklist devised by the Royal College of Physicians (RCP). This QIP was done by the plan, do, study, act (PDSA) cycle. The PDSA cycle comprised two audit cycles and an intervention in between them. The first audit cycle (AC) was conducted on 150 DS. Its duration was from March 2023 to June 2023. An educational workshop was conducted before the re-audit cycle (RAC) to address deficiencies and reinforce the implementation of the guidelines provided by the RCP. The RAC was conducted from June 2023 to August 2023. 100 DS were studied and analyzed to assess for improvement in the completeness of DS. Frequencies and percentages were calculated in each audit cycle. The Chi-squared test was applied to compare the statistical difference between the results of both audit cycles. Results A total of 150 DS were analyzed in the first AC and 100 DS in the RAC. The results of the first AC show that the details of any allergies were recorded only in 3% of the DS; this percentage significantly improved to 51% after the RAC (p-value <0.05). Relevant past medical history was included in 52% and 88% of the DS during the first AC and RAC, respectively (p-value <0.05). Secondary diagnoses were written in 54% and 71% of the DS during the first AC and RAC, respectively (p-value <0.05). Details of relevant investigations were included in 60% and 88% of the DS during the first AC and RAC, respectively (p-value <0.05). The post-discharge management plan was written in 90% and 98% of the DS during the first AC and RAC, respectively (p-value <0.05). The follow-up plan was written clearly in 65% and 93% of the DS during the first AC and RAC, respectively (p-value <0.05).  Conclusion The DS was found to be incomplete after analyzing the results of the first AC. The details related to allergies, medications, operations, and procedures were found to be missing in the majority of the cases. No mention of the patient's concerns or expectations was made in the DS. The results of the RAC showed improvement in the level of completeness of DS. The majority of the weak points observed after the first AC seemed to have improved after the RAC, which shows that intervention proved to be quite effective in improving the completeness and quality of DS. The RAC showed significant improvement in the completeness of the details relating to investigations, allergies, past medical history, secondary diagnoses, and the post-discharge follow-up plan. QIP must be routinely carried out to assess and improve the completeness and quality of DS at hospitals.

Assessment of Patient Satisfaction With Inpatient Services Provided at an Acute Care Facility: A Quality Improvement Project

Hospitals across the United States use patient satisfaction surveys to assess the quality of inpatient and outpatient services provided to patients when they interact with the healthcare system. Results from this survey are used as input to identify weaknesses in the system with the intention of providing appropriate intervention. Here, we report the results of the quality improvement project completed in an acute healthcare facility. Patient satisfaction was evaluated based on indices established by the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS). Responses from 400 patients admitted into the hospital between July 2022 and June 2023 were obtained using a pre-designed questionnaire prepared by HCAHPS on behalf of Prime Healthcare Services. Indices of assessment include doctor-patient interaction, nurse-patient interaction, hospital responsiveness to patient needs, hospital environment, communication about medicine, discharge information, transition of care, overall assessment, and willingness to recommend. The best hospital performance was seen in the dissemination of discharge information, while the worst performance was noted in the transition of care and communication about medicine. Appropriate recommendations were made to improve on these weak areas.

The development and evaluation of a medication diary to report problems with medication use

Purpose

The study aimed to develop and evaluate a medication diary for patients to report problems with medication use to enable shared-decision making and improve medication adherence.

Methods

Based on a search for existing diaries, a review of the content, and a list of medication self-management problems compiled from previous research, a paper and pencil version of a medication diary was developed. The diary was reviewed for clarity and overall presentation by five healthcare providers and nine patients. Afterwards, user-friendliness was evaluated by 69 patients with polypharmacy discharged from hospital during a quantitative prospective study.

Results

The medication diary consists of several parts: (1) a medication schedule allowing patients to list their medicines, (2) information sheets allowing patients to write down specific medication-related information, (3) a monthly overview to indicate daily whether medication-related problems were experienced, (4) problem sheets elaborating on the problems encountered, (5) space for specific medication-related questions for healthcare providers to facilitate shared-decision making. The review phase resulted in minor textual adjustments and one extra problem in the problem sheet. Most participants, who tested the medication diary for two months, found the diary user-friendly (80%) and easy to fill in (89%). About 40% of participants reported problems with medication use. Half of the patients indicated that the diary can facilitate discussing problems with healthcare providers.

Conclusion

The medication diary offers patients the opportunity to report problems regarding their medication use in a proven user-friendly manner and to discuss these problems with healthcare providers. Reporting and discussing problems with medication use can serve as a first step towards making shared decisions on how to address the problems encountered.

Medication Safety Events After Acute Myocardial Infarction Among Veterans Treated at VA Versus Non-VA Hospitals

INTRODUCTION

Fragmentation of health care across systems can contribute to mistakes in prescribing and filling medications among patients treated for myocardial infarction (MI). We sought to compare omissions, duplications, and delays in outpatient medications used for secondary prevention among veterans treated for MI at Veterans Affairs (VA) versus non-VA hospitals.

METHODS

We utilized national VA and Centers for Medicare and Medicaid Services data (2012-2018) to identify veterans 65 years or older hospitalized for MI and measured the use of outpatient medications for secondary prevention in the 30 days after MI among those treated at VA versus non-VA hospitals.

RESULTS

A total of 118,456 veterans experiencing MI were included; of which 102,209 were hospitalized at non-VA hospitals. An omission in any medication class occurred more frequently among veterans treated at non-VA versus VA hospitals (82.8% vs 67.8%, P < 0.001). In multivariable modeling, the odds of omissions in any medication class were higher among those treated at non-VA versus VA hospitals (odds ratio: 3.04; 95% CI: 2.88-3.20). Duplications occurred more frequently in veterans treated at non-VA versus VA hospitals: 1.9% versus 1.6% had 1 or more for non-VA versus VA hospitals ( P < 0.001). Veterans treated at non-VA hospitals were more likely to have delays of 3 days or more in prescription fills after hospital discharge (88.4% vs 70.6% across all classes, P < 0.001).

CONCLUSIONS

Omissions, duplications, and delays in outpatient prescribing of secondary prevention medications were more common among 118,456 veterans treated at non-VA versus VA hospitals for MI. Interventions aimed at improving care transitions and optimizing medication use among veterans treated at non-VA hospitals should be implemented.

Implementation of remote home care: assessment guided by the RE-AIM framework

BACKGROUND

Welfare technology interventions have become increasingly important in home-based palliative care for facilitating safe, time-efficient, and cost-effective methods to support patients living independently. However, studies evaluating the implementation of welfare technology innovations are scarce, and the empirical evidence for sustainable models using technology in home-based palliative care remains low. This study aimed to report on the use of the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to assess the implementation of remote home care (RHC) a technology-mediated service for home-living patients in the palliative phase of cancer. Furthermore, it aimed to explore areas of particular importance determining the sustainability of technologies for remote palliative home-based care.

METHODS

A secondary analysis of data collected by semi-structured interviews with patients with cancer in the palliative phase, focus groups, and semi-structured interviews with healthcare professionals (HCPs) experienced with RHC was performed. A deductive reflexive thematic analysis using RE-AIM dimensions was conducted.

RESULTS

Five themes illustrating the five RE-AIM dimensions were identified: (1) Reach: protective actions in recruitment - gatekeeping, (2) Effectiveness: potential to offer person-centered care, (3) Adoption: balancing high touch with high tech, (4) Implementation: moving towards a common understanding, and (5) Maintenance: adjusting to what really matters. The RE-AIM framework highlighted that RHC implementation for patients in the palliative phase of cancer was influenced by HCP gatekeeping behavior, concerns regarding abandoning palliative care as a high-touch specialty, and a lack of competence in palliative care. Although RHC facilitated improved routines in patients' daily lives, it was perceived as a static service unable to keep pace with disease progression.

CONCLUSIONS

A person-centered approach that prioritizes individual needs and preferences is necessary for providing optimal care. Although technologies such as RHC are not a panacea, they can be integrated as support for increasingly strained health services.

Improved patient safety with a simplified operating room to pediatric intensive care unit handover tool (PATHQS)

Introduction

Patient handover is a crucial transition requiring a high level of coordination and communication. In the BC Children's Hospital (BCCH) pediatric intensive care unit (PICU), 10 adverse events stemming from issues that should have been addressed at the operating room (OR) to PICU handover were reported into the patient safety learning system (PSLS) within 1 year. We aimed to undertake a quality improvement project to increase adherence to a standardized OR to PICU handover process to 100% within a 6-month time frame. In doing so, the secondary aim was to reduce adverse events by 50% within the same 6-month period.

Methods

The model for improvement and a Plan, Do, Study, Act method of quality improvement was used in this project. The adverse events were reviewed to identify root causes. The findings were reviewed by a multidisciplinary inter-departmental group comprised of members from surgery, anesthesia, and intensive care. Issues were batched into themes to address the most problematic parts of handover that were contributing to risk.

Intervention

A bedside education campaign was initiated to familiarize the team with an existing handover standard. The project team then formulated a new simplified visual handover tool with the mnemonic "PATHQS" where each letter denoted a step addressing a theme that had been noted in the pre-intervention work as contributing to adverse events.

Results

Adherence to standardized handover at 6 months improved from 69% to 92%. This improvement was sustained at 12 months and 3 years after the introduction of PATHQS. In addition, there were zero PSLS events relating to handover at 6 and 12 months, with only one filed by 36 months. Notably, staff self-reporting of safety concerns during handover reduced from 69% to 13% at 6 months and 0% at 3 years. The PATHQS tool created in this work also spread to six other units within the hospital as well as to one adult teaching hospital.

Conclusion

A simplified handover tool built collaboratively between departments can improve the quality and adherence of OR to PICU handover and improve patient safety. Simplification makes it adaptable and applicable in many different healthcare settings.

Quality in care requires kindness and flexibility - a hermeneutic-phenomenological study of patients' experiences from pathways including transitions across healthcare settings

BACKGROUND

The number of people living with chronic conditions is increasing worldwide, and with that, the need for multiple long-term complex care across care settings. Undergoing transitions across healthcare settings is both challenging and perilous for patients. Nevertheless, knowledge of what facilitates quality during transitions in healthcare settings from the lifeworld perspective of patients is still lacking. Therefore, we aimed to explore the lived experience in healthcare quality for Danish adult patients during healthcare pathways including transitions across settings.

METHODS

Within a hermeneutic-phenomenological approach, interviews were conducted with three women and five men with various diagnoses and care paths between 30 and 75 years of age. Data underwent a three phased thematic analysis leading to three themes.

RESULTS

Patients with various illnesses' experiences of quality of care is described in the themes being powerless in the face of illness; burdensome access and navigation; and being in need of mercy and striving for kindness. This highlights that patients' experiences of quality in healthcare pathways across settings interweaves with an overall understanding of being powerless at the initial encounter. Access and navigation are burdensome, and system inflexibility adds to the burden and enhances powerlessness. However, caring care provided through the kindness of healthcare professionals supports patients in regaining control of their condition.

CONCLUSIONS

This hermeneutical-phenomenological study sheds light on the lived experiences of people who are at various stages in their care paths with transitions across healthcare settings. Although our findings are based on the lived experiences of 8 people in a Danish context, in light of the discussion with nursing theory and other research, the results can be reflected in two main aspects: I) kind and merciful professional relationships and II) system flexibility including access and navigation, were essential for their experiences of care quality during healthcare transitions. This is important knowledge when striving to provide patients with a clear voice regarding quality in care pathways stretching across settings.

Utilization of a multidisciplinary hospital-based approach to reduce readmission rates

Background

Hospital readmissions remain a significant and pressing issue in our healthcare system. In 2010, the Affordable Care Act helped establish the Hospital Readmissions Reduction Program, which incentivized reducing readmission rates by instituting penalties. Hospital readmission, specifically unplanned, refers to a patient returning to the hospital shortly after discharge due to the same or a related medical condition, signaling potential issues in initial care, discharge processes, or post-hospitalization management. For this study, we defined readmission as a return to the hospital within 30 days. In 2018, Staten Island University Hospital started a multidisciplinary and coordinated initiative to reduce patient readmissions. The approach involved the departments of emergency medicine, medicine, cardiology, case management, nursing, pharmacy, and transitional care management. This study aimed to determine if this approach reduced 30-day readmissions.

Methods

This case-control retrospective study reviewed electronic health records between January 2018 and November 2019. Readmission rates within 30 days of index discharge were compared between patients who received transitional care management before and after establishing a multidisciplinary communication of transitional care. Readmission rates were unadjusted and adjusted for patient demographics and predisposed risk for readmission and compared across demographics and select clinical characteristics.

Results

A total of 772 patients were included in the analyses; 323 were in the control group (41.8%), and 449 were in the intervention group (58.2%). After the hospital adopted the workflow for multidisciplinary communication of transitional care, there was 45.2% less adjusted incidence of readmission, or approximately seven fewer overall readmissions per 100 patients (16.4% readmission vs 9.0% readmission; incident rate ratio, 0.55; 95% CI: 0.34-0.88).

Conclusions

Multidisciplinary communication approaches led by emergency medicine can help reduce readmissions significantly. Adopting a structured communication workflow can enhance co-managing patients with a high risk of readmission between the emergency department and hospital medicine teams.

Application of a Human Factors and Systems Engineering Approach to Explore Care Transitions of Sepsis Survivors From Hospital to Home Health Care

STUDY AIM

This study aims to describe the transition-in-care work process for sepsis survivors going from hospitals to home health care (HHC) and identify facilitators and barriers to enable practice change and safe care transitions using a human factors and systems engineering approach.

BACKGROUND

Despite high readmission risk for sepsis survivors, the transition-in-care work process from hospitals to HHC has not been described.

METHODS

We analyzed semi-structured needs assessment interviews with 24 stakeholders involved in transitioning sepsis survivors from two hospitals and one affiliated HHC agency participating in the parent implementation science study, I-TRANSFER. The qualitative data analysis was guided by the Systems Engineering Initiative for Patient Safety (SEIPS) framework to describe the work process and identify work system elements.

RESULTS

We identified 31 tasks characterized as decision making, patient education, communication, information, documentation, and scheduling tasks. Technological and organizational facilitators lacked in HHC compared to the hospitals. Person and organization elements in HHC had the most barriers but few facilitators. Additionally, we identified specific task barriers that could hinder sepsis information transfer from hospitals to HHC.

CONCLUSION

This study explored the complex transition-in-care work processes for sepsis survivors going from hospitals to HHC. We identified barriers, facilitators, and critical areas for improvement to enable implementation and ensure safe care transitions. A key finding was the sepsis information transfer deficit, highlighting a critical issue for future study.

APPLICATION

We recommend using the SEIPS framework to explore complex healthcare work processes before the implementation of evidence-based interventions.

Associations between Hospital Setting and Outcomes after Pediatric Appendectomy

Prior studies of associations between hospital location and outcomes for pediatric appendectomy have not adjusted for significant differences in patient and treatment patterns between settings. This was a cross-sectional analysis of pediatric appendectomies in the 2016 Kids' Inpatient Database (KID). Weighted multiple linear and logistic regression models compared hospital location (urban or rural) and academic status against total admission cost (TAC), length of stay (LOS), and postoperative complications. Patients were stratified by laparoscopic (LA) or open (OA) appendectomy. Among 54,836 patients, 39,454 (73%) were performed at an urban academic center, 11,642 (21%) were performed at an urban non-academic center, and 3740 (7%) were performed at a rural center. LA was utilized for 49,011 (89%) of all 54,386 patients: 36,049 (91%) of 39,454 patients at urban academic hospitals, 10,191 (87%) of 11,642 patients at urban non-academic centers, and 2771 (74%) of 3740 patients at rural centers (p < 0.001). On adjusted analysis, urban academic centers were associated with an 18% decreased TAC (95% CI -0.193--0.165; p < 0.001) despite an 11% increased LOS (95% CI 0.087-0.134; p < 0.001) compared to rural centers. Urban academic centers were associated with a decreased odds of complication among patients who underwent LA (OR 0.787, 95% CI 0.650-0.952) but not after OA. After adjusting for relevant patient and disease-related factors, urban academic centers were associated with lower costs despite longer lengths of stay compared to rural centers. Urban academic centers utilized LA more frequently and were associated with decreased odds of postoperative complications after LA.

The Value of Using a Quality Assurance Follow-Up Team to Address Incidental Findings After Emergency Department or Urgent Care Discharge: A Cost Analysis

BACKGROUND

Incidental finding (IF) follow-up is of critical importance for patient safety and is a source of malpractice risk. Laboratory, imaging, or other types of IFs are often uncovered incidentally and are missed, not addressed, or only result after hospital discharge. Despite a growing IF notification literature, a need remains to study cost-effective non-electronic health record (EHR)-specific solutions that can be used across different types of IFs and EHRs.

OBJECTIVE

The objective of this study was to evaluate the utility and cost-effectiveness of an EHR-independent emergency medicine-based quality assurance (QA) follow-up program in which an experienced nurse reviewed laboratory and imaging studies and ensured appropriate follow-up of results.

METHODS

A QA nurse reviewed preceding-day abnormal studies from a tertiary care hospital, a community hospital, and an urgent care center. Laboratory values outside preset parameters or radiology over-reads resulting in clinically actionable changes triggered contact with an on-call emergency physician to determine an appropriate intervention and its implementation.

RESULTS

Of 104,125 visits with 1,351,212 laboratory studies and 95,000 imaging studies, 6530 visits had IFs, including 2659 laboratory and 4004 imaging results. The most common intervention was contacting a primary care physician (5783 cases [88.6%]). Twenty-one cases resulted in a patient returning to the ED, at an average cost of $28,000 per potential life-/limb-saving intervention.

CONCLUSIONS

Although abnormalities in laboratory results and imaging are often incidental to patient care, a dedicated emergency department QA follow-up program resulted in the identification and communication of numerous laboratory and imaging abnormalities and may result in changes to patients' subsequent clinical course, potentially increasing patient safety.

Feasibility of a brief, in-patient coping and sleep intervention to reduce potentially preventable readmission of cardiac patients to hospital

Background

Psychological distress is prevalent amongst hospital in-patient and may predispose patients to potentially preventable readmissions after discharge. A particularly vulnerable group are patients with cardiac disorders. This study tested the feasibility of a brief cognitive behavioural therapy consisting of an in-hospital coping session and a post-discharge healthy sleep session.

Methods

Standardised questionnaire were used to assess sleep, coping/distress and wellbeing at baseline (pre-intervention) and one-month post-discharge (post-intervention). Treatment fidelity and acceptability were assessed at follow-up. Participants included 72 inpatients admitted with a cardiac disorder or reported to have a cardiac problem whilst in hospital from a single Australian public hospital.

Results

Most (83 %) participants found the intervention helpful/very helpful. At baseline prior to admission, almost half of participants (46 %) reported poor wellbeing, 19 % high levels of distress and poor coping, and 47 % sleeping less than 7 h per night. Following the intervention, 45 % of participants with poor wellbeing at baseline had reliable change in wellbeing at follow-up. Conversely, only 22 % of patients with high levels of coping/distress at baseline demonstrated improved coping/distress at follow-up suggesting smaller gains. On average a large 43 min gain in sleep duration was observed post-treatment in patients with poor sleep at baseline. Fourteen percent of participants were readmitted to hospital within 34-days of discharge.

Conclusions

The coping and sleep intervention was well received with positive outcomes in patients especially those reporting high levels of distress for sleep and to lesser extent coping and wellbeing. Future studies to assess the efficacy of the brief intervention at reducing hospital readmissions are needed.

[Physical Strain after Abdominal Surgery - Results of a Patient Survey]

INTRODUCTION

Incision hernias are common complications after abdominal surgery and affect the recommendations on postoperative physical strain, as it is thought that excessively early strain causes incisional hernias. However, there is no evidence to justify this. This study evaluates the effect of postoperative strain on the risk of incisional hernia.

MATERIALS AND METHODS

Patients with a laparoscopy (LS) or laparotomy (LT) were asked to complete a questionnaire on postoperative strain, complaints and quality of life. Patients with hernia surgery, or open abdomen therapy for complicated courses (Clavien-Dindo > III) were excluded.

RESULTS

393 patients completed the questionnaire (43.6%). 274 were LS and 128 LT. The incidence of incisional hernias was 5.2% (LS) and 18.0% (LT, p = 0.001). Incisional hernia patients were younger and more commonly males. 30.5% of incisional hernia patients did not return to normal physical strain postoperatively. Abdominal binders did not affect the hernia rate. The incisional hernia patients showed decreased quality of life scores in both mental and physical domains.

CONCLUSION

Early postoperative physical strain was not a risk factor for incisional hernia development in this study. However, prospective studies are needed to create necessary evidence to recommend earlier postoperative return to normal physical strain.

Patient Adherence Following Knee Surgery: Evidence-Based Practices to Equip Patients for Success

Patient adherence with postoperative wound care, activity restrictions, rehabilitation, medication, and follow-up protocols is paramount to achieving optimal outcomes following knee surgery. However, the ability to adhere to prescribed postoperative protocols is dependent on multiple factors both in and out of the patient's control. The goals of this review article are (1) to outline key factors contributing to patient nonadherence with treatment protocols following knee surgery and (2) to synthesize current management strategies and tools for optimizing patient adherence in order to facilitate efficient and effective implementation by orthopaedic health care teams. Patient adherence is commonly impacted by both modifiable and nonmodifiable factors, including health literacy, social determinants of health, patient fear/stigma associated with nonadherence, surgical indication (elective vs. traumatic), and distrust of physicians or the health care system. In addition, health care team factors, such as poor communication strategies or failure to follow internal protocols, and health system factors, such as prior authorization delays, staffing shortages, or complex record management systems, impact patient's ability to be adherent. Because the majority of factors found to impact patient adherence are nonmodifiable, it is paramount that health care teams adjust to better equip patients for success. For health care teams to successfully optimize patient adherence, focus should be paid to education strategies, individualized protocols that consider patient enablers and barriers to adherence, and consistent communication methodologies for both team and patient-facing communication.

Medication reconciliation and discharge communication from hospital to general practice: a quantitative analysis

BACKGROUND

The aim of this study was to assess the quality of effective discharge communication to primary practice from a hospital that uses ieMR (integrated electronic Medical Record), a complete electronic prescribing/medical record platform.

METHODS

A retrospective quantitative analysis of 232 discharge encounters from a major tertiary hospital assessed the discharge summary quality; timeliness, completeness and medication information.

RESULTS

Median time to discharge summary was 1day. 22.0% of discharge summaries were incomplete at 30days post discharge and 44.5% of discharge summaries were incomplete at 30days post discharge if discharged on a weekend compared to weekday (P -value=0.001). Rates of medication reconciliation were completed at approximately 35% at each point of the patient stay and 56.9% of patients had a GP discharge summary listing discharge medications. However, if certain progressive steps were completed (i.e. Home Medications recorded in ieMR, Discharge Reconciliation in ieMR, and Patient Discharge Medication Record in eLMs (Enterprise-wide Liaison Medication System)), then, the 'Medications on Discharge' was significantly more likely to be present in the discharge summary, at rates of 70.1%, 85.9%, and 98.6% respectively (P -value=0.007, <0.001, <0.001). Conversely not doing these steps dropped rates of having medications listed in the discharge summary to 50.0%, 40.3% and 34.1% respectively.

CONCLUSIONS

This study assessed current discharge summary quality since the introduction of electronic medical records. It demonstrated the significant value of correct use of electronic programs, including performing all crucial steps of reconciliation. Targeted interventions in future studies that rectify the shortfalls in discharge communication are warranted.

Association of functional and cognitive impairment severity with discharge to long-term care facilities in older patients admitted to a general acute care hospital from home

BACKGROUND

The early recognition of hospitalized patients at risk of being discharged to long-term care facilities (LTCFs) may help to identify those who require transitional care programs and interventions that support discharge to home. We examined the association of functional and cognitive impairment severity with discharge to LTCFs among older hospitalized patients.

METHODS

In this retrospective cohort study, we used an administrative claims database linked with geriatric assessment data from a general acute care hospital in Japan. We analyzed patients aged ≥65 years discharged between July 2016 and December 2018. The severity of functional and cognitive impairments was assessed using the Dementia Assessment Sheet for Community-based Integrated Care System 8-items (DASC-8) scale. Based on their DASC-8 scores, patients were designated as Category I (no impairment), Category Ⅱ (mild impairment), or Category III (moderate/severe impairment). We conducted logistic regression analyses to examine the association between the severity of impairments and discharge to LTCFs after adjusting for patient-level factors.

RESULTS

We analyzed 9,060 patients (mean age: 79.4 years). Among the 112 patients (1.2%) discharged to LTCFs, 62.3%, 18.6%, and 19.2% fell under Category I, Category Ⅱ, and Category III, respectively. Category II was not significantly associated with discharge to LTCFs. However, Category III had a significantly higher odds of discharge to LTCFs than Category I (Adjusted odds ratio: 2.812, 95% confidence interval: 1.452-5.449).

CONCLUSION

Patients identified as Category III by the DASC-8 on admission may benefit from enhanced transitional care and interventions that promote discharge to home.

Trajectories of emotional functioning and experienced care of relatives in the last year of life of patients with advanced cancer: A longitudinal analysis of the eQuiPe study

OBJECTIVE

Advanced cancer has a major impact on both patients and their relatives. To allow for personalized support, it is important to recognize which relatives will experience a decline in emotional functioning during the patient's last year of life, when this decline will occur, and what factors are associated with it. This study aimed to examine the trajectory of emotional functioning of relatives during that time and the characteristics associated with changes in this trajectory.

METHODS

A prospective, longitudinal, multicenter, observational study in patients with advanced cancer and their relatives was conducted (eQuiPe). We analyzed relatives' changes in emotional functioning in the patient's last year using the EORTC QLQ-C30 and assessed associations with sociodemographic and care characteristics using multivariable mixed-effects analysis.

RESULTS

409 relatives completed ≥1 questionnaires during the patient's last year of life. Mean age was 64 years, 61% were female and 75% were the patient's partner. During this year, mean emotional functioning declined significantly over time from 73.9 to 64.6 (p = 0.023, effect size = 0.43). The type of relationship between relatives and patients (p = 0.002), patient' sleep problems (p = 0.033), and continuity of care (p = 0.002) were significantly associated with changes in emotional functioning.

CONCLUSIONS

Relatives' emotional functioning declined during the patient's last year of life. Support for them, especially partners and relatives of patients with sleep problems, is important. Relatives who experienced more continuity of care had a less steep decline in emotional functioning.

What do parents think about the quality and safety of care provided by hospitals to children and young people with an intellectual disability? A qualitative study using thematic analysis

OBJECTIVES

Children with intellectual disability experience patient safety issues resulting in poor care experiences and health outcomes. This study sought to identify patient safety issues that pertain to children aged 0-16 years with intellectual disability admitted to two tertiary state-wide children's hospitals and a children's palliative care centre; to describe and understand these factors to modify the Australian Patient Safety Education Framework to meet the particular needs for children and young people with intellectual disability.

DESIGN, SETTING AND PARTICIPANTS

Parents of children with intellectual disability from two paediatric hospitals and a palliative care unit participated in semi-structured interviews to elicit their experiences of their child's care in the context of patient safety. Thirteen interviews were conducted with parents from various backgrounds with children with intellectual, developmental and medical diagnoses.

RESULTS

Eight themes about safety in hospital care for children and young people with intellectual disability emerged from thematic analyses: Safety is not only being safe but feeling safe; Negative dismissive attitudes compromise safety, quality and care experience; Parental roles as safety advocates involve being heard, included and empowered; Need for purposeful and planned communication and care coordination to build trust and improve care; Systems, processes and environments require adjustments to prevent patient safety events; Inequity in care due to lack of resources and skills, Need for training in disability-specific safety and quality issues and Core staff attributes: Kindness, Patience, Flexibility and Responsiveness. Parents highlighted the dilemma of being dismissed when raising concerns with staff and being required to provide care with little support. Parents also reported a lack of comprehensive care coordination services. They noted limitations within the healthcare system in accommodating reasonable adjustments for a family and child-centred context.

CONCLUSIONS

The development of an adapted Patient Safety Education Framework for children with intellectual disability should consider ways for staff to transform attitudes and reduce bias which leads to adaptations for safer and better care. In addition, issues that apply to quality and safety for these children can be generalised to all children in the hospital.

PATIENT AND PUBLIC CONTRIBUTION

Parent advocates in the project advisory team were shown the questions to determine their appropriateness for the interviews.

Development of a tool for assessing the performance of long-term care systems in relation to care transition: Transitional Care Assessment Tool in Long-Term Care (TCAT-LTC)

BACKGROUND

Improving the quality and safety of care transitions is a priority in many countries. Carrying out performance measurements play a significant role in improving quality of decisions undertaken by different actors involved in reforms. Therefore, the main objective of this paper is to present the development of an evaluation tool for assessing the performance of long-term care systems in relation to care transition, namely the Transitional Care Assessment Tool in Long-Term Care (TCAT-LTC). This study is performed as part of a larger European TRANS-SENIOR project.

METHODS

The development of the TCAT-LTC involved three steps. First, we developed a conceptual model based on Donabedian's quality framework and literature review. Second, we carried out a thorough process of item pool generation using deductive (systematic literature review) and deductive-inductive methods (in-depth interviews) with experts in the field of long-term care. Third, we conducted preliminary validation of the tool by asking experts in research and practice to provide an opinion on a tool and to assess content validity. Future fourth step will involve a tool's pilot with country experts from Germany, the Netherlands and Poland.

RESULTS

By applying methodological triangulation, we developed the TCAT-LTC, which consists of 2 themes, 12 categories and 63 items. Themes include organizational and financial aspects. Organizational aspects include categories such as communication, transfer of information, availability and coordination of resources, training and education of staff, education/support of the patient/informal caregiver, involvement of the patient/informal caregiver, telemedicine and e-Health, and social care. Financial aspects include categories such as primary care, hospital, and long-term care. We also present the instructions on the application of the TCAT-LTC.

CONCLUSIONS

In this paper, we presented the development of the TCAT-LTC evaluation tool for assessing the performance of long-term care systems in relation to care transition. The TCAT-LTC is the first tool to assess the performance of long-term care systems in relation to care transition. Assessments can be carried out at the national and international level and enable to monitor, evaluate, and compare performance of the long-term care systems in relation to care transition within and across countries.

A method to automate the discharge summary hospital course for neurology patients

OBJECTIVE

Generation of automated clinical notes has been posited as a strategy to mitigate physician burnout. In particular, an automated narrative summary of a patient's hospital stay could supplement the hospital course section of the discharge summary that inpatient physicians document in electronic health record (EHR) systems. In the current study, we developed and evaluated an automated method for summarizing the hospital course section using encoder-decoder sequence-to-sequence transformer models.

MATERIALS AND METHODS

We fine-tuned BERT and BART models and optimized for factuality through constraining beam search, which we trained and tested using EHR data from patients admitted to the neurology unit of an academic medical center.

RESULTS

The approach demonstrated good ROUGE scores with an R-2 of 13.76. In a blind evaluation, 2 board-certified physicians rated 62% of the automated summaries as meeting the standard of care, which suggests the method may be useful clinically.

DISCUSSION AND CONCLUSION

To our knowledge, this study is among the first to demonstrate an automated method for generating a discharge summary hospital course that approaches a quality level of what a physician would write.

The complexities of communication at hospital discharge of older patients: a qualitative study of healthcare professionals' views

BACKGROUND

Hospital discharge of older patients is a high-risk situation in terms of patient safety. Due to the fragmentation of the healthcare system, communication and coordination between stakeholders are required at discharge. The aim of this study was to explore communication in general and medication information transfer in particular at hospital discharge of older patients from the perspective of healthcare professionals (HCPs) across different organisations within the healthcare system.

METHODS

We conducted a qualitative study using focus group and individual or group interviews with HCPs (physicians, nurses and pharmacists) across different healthcare organisations in Sweden. Data were collected from September to October 2021. A semi-structured interview guide including questions on current medication communication practices, possible improvements and feedback on suggestions for alternative processes was used. The data were analysed thematically, guided by the systematic text condensation method.

RESULTS

In total, four focus group and three semi-structured interviews were conducted with 23 HCPs. Three main themes were identified: 1) Support systems that help and hinder describes the use of support systems in the discharge process to compensate for the fragmentation of the healthcare system and the impact of these systems on HCPs' communication; 2) Communication between two separate worlds depicts the difficulties in communication experienced by HCPs in different healthcare organisations and how they cope with them; and 3) The large number of medically complex patients disrupts the communication reveals how the highly pressurised healthcare system impacts on HCPs' communication at hospital discharge.

CONCLUSIONS

Communication at hospital discharge is hindered by the fragmented, highly pressurised healthcare system. HCPs are at risk of moral distress when coping with communication difficulties. Improved communication methods at hospital discharge are needed for the benefit of both patients and HCPs.

The future landscape of large language models in medicine

Large language models (LLMs) are artificial intelligence (AI) tools specifically trained to process and generate text. LLMs attracted substantial public attention after OpenAI's ChatGPT was made publicly available in November 2022. LLMs can often answer questions, summarize, paraphrase and translate text on a level that is nearly indistinguishable from human capabilities. The possibility to actively interact with models like ChatGPT makes LLMs attractive tools in various fields, including medicine. While these models have the potential to democratize medical knowledge and facilitate access to healthcare, they could equally distribute misinformation and exacerbate scientific misconduct due to a lack of accountability and transparency. In this article, we provide a systematic and comprehensive overview of the potentials and limitations of LLMs in clinical practice, medical research and medical education.

How Safe are Outpatient Electronic Health Records? An Evaluation of Medication-Related Decision Support using the Ambulatory Electronic Health Record Evaluation Tool

BACKGROUND

The purpose of the Ambulatory Electronic Health Record (EHR) Evaluation Tool is to provide outpatient clinics with an assessment that they can use to measure the ability of the EHR system to detect and prevent common prescriber errors. The tool consists of a medication safety test and a medication reconciliation module.

OBJECTIVES

The goal of this study was to perform a broad evaluation of outpatient medication-related decision support using the Ambulatory EHR Evaluation Tool.

METHODS

We performed a cross-sectional study with 10 outpatient clinics using the Ambulatory EHR Evaluation Tool. For the medication safety test, clinics were provided test patients and associated medication test orders to enter in their EHR, where they recorded any advice or information they received. Once finished, clinics received an overall percentage score of unsafe orders detected and individual order category scores. For the medication reconciliation module, clinics were asked to electronically reconcile two medication lists, where modifications were made by adding and removing medications and changing the dosage of select medications.

RESULTS

For the medication safety test, the mean overall score was 57%, with the highest score being 70%, and the lowest score being 40%. Clinics performed well in the drug allergy (100%), drug dose daily (85%), and inappropriate medication combinations (74%) order categories. Order categories with the lowest performance were drug laboratory (10%) and drug monitoring (3%). Most clinics (90%) scored a 0% in at least one order category. For the medication reconciliation module, only one clinic (10%) could reconcile medication lists electronically; however, there was no clinical decision support available that checked for drug interactions.

CONCLUSION

We evaluated a sample of ambulatory practices around their medication-related decision support and found that advanced capabilities within these systems have yet to be widely implemented. The tool was practical to use and identified substantial opportunities for improvement in outpatient medication safety.

The Use of Telehealth to Improve Handoffs Between Neonatologists and Primary Care Providers for Medically Complex Infants

As part of the Supporting Pediatric Research Outcomes Utilizing Telehealth (SPROUT) collaboration, three institutions (University of California, Davis, Children's Hospital Colorado, and Children's Hospital of Philadelphia) sought to improve communication with primary care providers (PCPs) using telehealth. This project connected families of neonatal intensive care unit (NICU) patients, their PCPs, and their NICU team through telehealth to provide an enhanced hospital handoff. This case series reports four cases that exemplify the benefits of these enhanced hospital handoffs: Case 1: assisting with changing care plans after NICU discharge, Case 2: demonstrating physical findings, Case 3: incorporation of additional subspecialties through telehealth, Case 4: arranging care for remote patients. Although these cases demonstrate some of the potential benefits of these handoffs, further study is needed to determine acceptability of these handoffs and to see whether they impact patient outcomes.

Quality indicators of hospitalized children influenced by clinical pharmacist services: A systematic review

BACKGROUND

Care for children who are hospitalized can be optimized if the pharmacist, in conjunction with the multidisciplinary team, promotes the rational use of medicines. In this sense, the evaluation of the quality of these clinical services through indicators is important in the planning, decision making of pharmacists and managers of these services.

OBJECTIVE

To characterize which health indicators were influenced by the pharmaceutical clinical services for the care of children in hospitals.

METHODS

A systematic review was performed. The search for data was made on the bases: Cochrane, Embase, Lilacs, Pubmed and Web of Science. Then, the search included studies in which evaluated the impact of pharmaceutical clinical services on clinical, economic and humanistic outcomes.

RESULTS

The search resulted in 11 included studies. In this review, four pharmaceutical clinical services were found: pharmacotherapy review, multiprofessional team interventions, antimicrobial stewardship program and pharmaceutical services at discharge hospital. The most influenced outcome indicators were length of hospital stay, with average time in the group that received the pharmacotherapy review service, and interventions multiprofessional team with a 6.45-day vs. 10.83 days in the control group; hospital readmissions with a significant reduction of non-scheduled readmission of 30 days in the ntimicrobial stewardship program; reduction of hospital costs and caregiver satisfaction.

CONCLUSION

In this study, we can highlight that pharmacotherapy review, multiprofessional team interventions and Antimicrobial Stewardship Program that significantly reduced the clinical results of length of hospital stay and hospital readmission, as well as a significant reduction of hospital costs.