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Nelson A, Stuckey H, Snyder B, Van Scoy LJ, Daymont C, Irvin C, Wasserman E, Beck M. Provider Perspectives of Transitions of Care at a Tertiary Care Children's Hospital With a Hospitalist-Run Discharge Clinic. Clin Pediatr (Phila) 2023; 62:926-934. [PMID: 36726290 PMCID: PMC10986183 DOI: 10.1177/00099228221149279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Children's hospitals are discharging patients to home with increasingly complex outpatient needs, making safe transitions of care (ToCs) of vital importance. Our study involved a survey of both outpatient providers and pediatric hospitalists associated with our medical center to better describe providers' views on the ToC process. The survey included questions assessing views on patient care responsibilities, resource availability, our hospitalist-run postdischarge clinic (PDC), and comfort with telemedicine. Our hospitalists generally believed that primary care providers (PCPs) did not have adequate access to important ToC elements, whereas PCPs felt their access was adequate. Both provider types felt it was the inpatient team's responsibility to manage patient events between discharge and PCP follow-up and that a hospitalist-run PDC may reduce interim emergency room visits. This study challenges perceptions about the ToC process in children and describes a generalizable approach to assessing provider perceptions surrounding the ToC within individual health systems.
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Affiliation(s)
- Abigail Nelson
- Penn State Children’s Hospital, Department of Pediatrics
| | - Heather Stuckey
- Penn State Hershey College of Medicine; Department of Medicine
| | - Bethany Snyder
- Penn State Hershey College of Medicine; Department of Medicine
| | | | - Carrie Daymont
- Penn State Children’s Hospital, Department of Pediatrics
- Penn State Hershey College of Medicine, Department of Public Health Sciences
| | | | - Emily Wasserman
- Penn State Hershey College of Medicine, Department of Public Health Sciences
| | - Michael Beck
- Penn State Children’s Hospital, Department of Pediatrics
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Amin AN, Cornelison S, Woods JA, Hanania NA. Managing hospitalized patients with a COPD exacerbation: the role of hospitalists and the multidisciplinary team. Postgrad Med 2021; 134:152-159. [PMID: 34913814 DOI: 10.1080/00325481.2021.2018257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Exacerbations of chronic obstructive pulmonary disease (COPD) are associated with high rates of hospitalizations, costs, and morbidity. Therefore, hospitalists and the multidisciplinary team (hospital team) need to take a proactive approach to ensure patients are effectively managed from hospital admission to postdischarge. Comprehensive screening and diagnostic testing of patients at admission will enable an accurate diagnosis of COPD exacerbations, and severity, as well as other factors that may impact the length of hospital stay. Depending on the exacerbation severity and cause, pharmacotherapies may include short-acting bronchodilators, systemic corticosteroids, and antibiotics. Oxygen and/or ventilatory support may benefit patients with demonstrable hypoxemia. In preparation for discharge, the hospital team should ensure that patients receive the appropriate maintenance therapy, are counseled on their medications including inhalation devices, and proactively discuss smoking cessation and vaccinations. For follow-up, effective communication can be achieved by transferring discharge summaries to the primary care physician via an inpatient case manager. An inpatient case manager can support both the hospitalist and the patient in scheduling follow-up appointments, sending patient reminders, and confirming that a first outpatient visit has occurred. A PubMed search (prior to 26 January 2021) was conducted using terms such as: COPD, exacerbation, hospitalization. This narrative review focuses on the challenges the hospital team encounters in achieving optimal outcomes in the management of patients with COPD exacerbations. Additionally, we propose a novel simplified algorithm that may help the hospital team to be more proactive in the diagnosis and management of patients with COPD exacerbations.
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Affiliation(s)
- Alpesh N Amin
- Department of Medicine, University of California, Irvine, Irvine, CA, USA
| | - Sharon Cornelison
- Department of Pulmonary and Cardiac Rehabilitation, J. Paul Sticht Center on Aging and Rehabilitation, Wake Forest Baptist Health, Medical Center Boulevard, Winston Salem, NC, USA
| | - J Andrew Woods
- Wingate University School of Pharmacy, and Atrium Health, Carolinas Medical Center Main, Charlotte, NC, USA
| | - Nicola A Hanania
- Section of Pulmonary and Critical Care Medicine, Baylor College of Medicine, Houston, TX, USA
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Trivedi SP, Kopp Z, Tang AJ, Mammen A, Pandya D, Horwitz LI, Schwartz MD. Discharge Communication: A Multi-Institutional Survey of Internal Medicine Residents' Education and Practices. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2021; 96:1043-1049. [PMID: 33332907 DOI: 10.1097/acm.0000000000003896] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
PURPOSE To characterize residents' practices around hospital discharge communication and their exposure to transitions-of-care instruction in graduate medical education (GME). METHOD In 2019, internal medicine residents at 7 academic medical centers completed a cross-sectional survey reporting the types of transitions-of-care instruction they experienced during GME training and the frequency with which they performed 6 key discharge communication practices. The authors calculated a mean discharge communication score for each resident, and, using multiple logistic regression, they analyzed the relationship between exposure to types of educational experiences and discharge communication practices residents reported they performed frequently (> 60% of time). The authors used content analysis to explore factors that motivated residents to change their discharge practices. RESULTS The response rate was 63.5% (613/966). Resident discharge communication practices varied. Notably, only 17.0% (n = 104) reported routinely asking patients to "teach-back" or explain their understanding of the discharge plans. The odds of frequently performing key discharge communication practices were greater if residents received instruction based on observation of and feedback regarding their communication (adjusted odds ratio 1.73; 95% confidence interval [CI], 1.07-2.81) or if they received explicit on-rounds teaching (adjusted OR 1.46; 95% CI, 1.04-2.23). In open-ended comments, residents reported that experiencing adverse patient events at some point in the postdischarge continuum was a major impetus for practice change. CONCLUSIONS This study exposes gaps in hospital discharge communication with patients, highlights the benefits of workplace-based instruction on discharge communication skills, and reveals the influence of adverse events as a source of hidden curricula. The results suggest that developing faculty to incorporate transitions-of-care instruction in their rounds teaching and integrating experiences across the postdischarge continuum into residents' education may foster physicians-in-training who are champions of effective transitions of care within the fragmented health care system.
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Affiliation(s)
- Shreya P Trivedi
- S.P. Trivedi is co-director, Innovations in Media and Education Delivery and clinical instructor, Beth Israel Deaconess Medical Center, Department of Medicine, Boston, Massachusetts. The author was, when the study occurred, a population health fellow, New York University Grossman School of Medicine, New York, New York
| | - Zoe Kopp
- Z. Kopp is a second-year resident in internal medicine, Department of Medicine, University of California, San Francisco, School of Medicine, San Francisco, California
| | - Alice J Tang
- A.J. Tang is assistant professor, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Albin Mammen
- A. Mammen is a third-year resident in internal medicine, Department of Medicine, Baylor College of Medicine, Baylor, Texas
| | - Dharmini Pandya
- D. Pandya is assistant professor, Department of Medicine, Temple University School of Medicine, Philadelphia, Pennsylvania
| | - Leora I Horwitz
- L.I. Horwitz is associate professor, Department of Population Health and Medicine, and director, Center for Healthcare Innovation and Delivery Science, New York University Grossman School of Medicine, New York, New York; ORCID: https://orcid.org/0000-0003-1800-6040
| | - Mark D Schwartz
- M.D. Schwartz is professor, Department of Population Health, New York University Grossman School of Medicine, New York, New York; ORCID: https://orcid.org/0000-0002-7123-0060
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Lee JH, Kim AJ, Kyong TY, Jang JH, Park J, Lee JH, Lee MJ, Kim JS, Suh YJ, Kwon SR, Kim CW. Evaluating the Outcome of Multi-Morbid Patients Cared for by Hospitalists: a Report of Integrated Medical Model in Korea. J Korean Med Sci 2019; 34:e179. [PMID: 31243937 PMCID: PMC6597483 DOI: 10.3346/jkms.2019.34.e179] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 06/06/2019] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The lack of medical personnel has led to the employment of hospitalists in Korean hospitals to provide high-quality medical care. However, whether hospitalists' care can improve patients' outcomes remains unclear. We aimed to analyze the outcome in patients cared for by hospitalists. METHODS A retrospective review was conducted in 1,015 patients diagnosed with pneumonia or urinary tract infection from March 2017 to July 2018. After excluding 306 patients, 709 in the general ward who were admitted via the emergency department were enrolled, including 169 and 540 who were cared for by hospitalists (HGs) and non-hospitalists (NHGs), respectively. We compared the length of hospital stay (LOS), in-hospital mortality, readmission rate, comorbidity, and disease severity between the two groups. Comorbidities were analyzed using Charlson comorbidity index (CCI). RESULTS HG LOS (median, interquartile range [IQR], 8 [5-12] days) was lower than NHG LOS (median [IQR], 10 [7-15] days), (P < 0.001). Of the 30 (4.2%) patients who died during their hospital stay, a lower percentage of HG patients (2.4%) than that of NHG patients (4.8%) died, but the difference between the two groups was not significant (P = 0.170). In a subgroup analysis, HG LOS was shorter than NHG LOS (median [IQR], 8 [5-12] vs. 10 [7-16] days, respectively, P < 0.001) with CCI of ≥ 5 points. CONCLUSION Hospitalist care can improve the LOS of patients, especially those with multiple comorbidities. Further studies are warranted to evaluate the impact of hospitalist care in Korea.
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Affiliation(s)
- Jung Hwan Lee
- Department of Hospital Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Ah Jin Kim
- Department of Hospital Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea.
| | - Tae Young Kyong
- Department of Hospital Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hun Jang
- Department of Hospital Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jeongmi Park
- Department of Hospital Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jeong Hoon Lee
- Department of Hospital Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Man Jong Lee
- Department of Hospital Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Jung Soo Kim
- Department of Hospital Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Young Ju Suh
- Department of Biomedical Sciences, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Seong Ryul Kwon
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
| | - Cheol Woo Kim
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon, Korea
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Affiliation(s)
- Carol K Bates
- Harvard Medical School, Boston, MA, USA.
- Beth Israel Deaconess Medical Center, Boston, MA, USA.
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Abstract
Over the past 10 years, postdischarge clinics have been introduced in response to various health system pressures, including the focus on rehospitalizations and the challenges of primary care access. Often ignored in the discussion are questions of the effect of postdischarge physician visits on readmissions. In addition, little attention has been given to other clinical outcomes, such as reducing preventable harm and mortality. A review of dedicated, hospitalist-led postdischarge clinics, of the data supporting postdischarge physician visits, and of the role of hospitalists in these clinics may be instructive for hospitalists and health systems considering the postdischarge clinic environment. Journal of Hospital Medicine 2017;12:467-471.
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Affiliation(s)
- Lauren Doctoroff
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Young E, Stickrath C, McNulty M, Calderon AJ, Chapman E, Gonzalo JD, Kuperman EF, Lopez M, Smith CJ, Sweigart JR, Theobald CN, Burke RE. Residents' Exposure to Educational Experiences in Facilitating Hospital Discharges. J Grad Med Educ 2017; 9:184-189. [PMID: 28439351 PMCID: PMC5398134 DOI: 10.4300/jgme-d-16-00503.1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Revised: 11/01/2016] [Accepted: 11/25/2016] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND There is an incomplete understanding of the most effective approaches for motivating residents to adopt guideline-recommended practices for hospital discharges. OBJECTIVE We evaluated internal medicine (IM) residents' exposure to educational experiences focused on facilitating hospital discharges and compared those experiences based on correlations with residents' perceived responsibility for safely transitioning patients from the hospital. METHODS A cross-sectional, multi-center survey of IM residents at 9 US university- and community-based training programs in 2014-2015 measured exposure to 8 transitional care experiences, their perceived impact on care transitions attitudes, and the correlation between experiences and residents' perceptions of postdischarge responsibility. RESULTS Of 817 residents surveyed, 469 (57%) responded. Teaching about care transitions on rounds was the most common educational experience reported by residents (74%, 327 of 439). Learning opportunities with postdischarge patient contact were less common (clinic visits: 32%, 142 of 439; telephone calls: 12%, 53 of 439; and home visits: 4%, 18 of 439). On a 1-10 scale (10 = highest impact), residents rated postdischarge clinic as having the highest impact on their motivation to ensure safe transitions of care (mean = 7.61). Prior experiences with a postdischarge clinic visit, home visit, or telephone call were each correlated with increased perceived responsibility for transitional care tasks (correlation coefficients 0.12 [P = .004], 0.1 [P = .012], and 0.13 [P = 001], respectively). CONCLUSIONS IM residents learn to facilitate hospital discharges most often through direct patient care. Opportunities to interact with patients across the postdischarge continuum are uncommon, despite correlating with increased perceived responsibility for ensuring safe transitions of care.
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Stack SW. Capsule Commentary on Young et al., Internal Medicine Residents' Perceived Responsibility for Patients at Hospital Discharge: A National Survey. J Gen Intern Med 2016; 31:1508. [PMID: 27612484 PMCID: PMC5130962 DOI: 10.1007/s11606-016-3859-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Shobha W Stack
- Division of General Internal Medicine, University of Washington Medical Center, Seattle, WA, USA.
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Internal Medicine Residents' Perceived Responsibility for Patients at Hospital Discharge: A National Survey. J Gen Intern Med 2016; 31:1490-1495. [PMID: 27629784 PMCID: PMC5130960 DOI: 10.1007/s11606-016-3855-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Medical residents are routinely entrusted with transitions of care, yet little is known about the duration or content of their perceived responsibility for patients they discharge from the hospital. OBJECTIVE To examine the duration and content of internal medicine residents' perceived responsibility for patients they discharge from the hospital. The secondary objective was to determine whether specific individual experiences and characteristics correlate with perceived responsibility. DESIGN Multi-site, cross-sectional 24-question survey delivered via email or paper-based form. PARTICIPANTS Internal medicine residents (post-graduate years 1-3) at nine university and community-based internal medicine training programs in the United States. MAIN MEASURES Perceived responsibility for patients after discharge as measured by a previously developed single-item tool for duration of responsibility and novel domain-specific questions assessing attitudes towards specific transition of care behaviors. KEY RESULTS Of 817 residents surveyed, 469 responded (57.4 %). One quarter of residents (26.1 %) indicated that their responsibility for patients ended at discharge, while 19.3 % reported perceived responsibility extending beyond 2 weeks. Perceived duration of responsibility did not correlate with level of training (P = 0.57), program type (P = 0.28), career path (P = 0.12), or presence of burnout (P = 0.59). The majority of residents indicated they were responsible for six of eight transitional care tasks (85.1-99.3 % strongly agree or agree). Approximately half of residents (57 %) indicated that it was their responsibility to directly contact patients' primary care providers at discharge. and 21.6 % indicated that it was their responsibility to ensure that patients attended their follow-up appointments. CONCLUSIONS Internal medicine residents demonstrate variability in perceived duration of responsibility for recently discharged patients. Neither the duration nor the content of residents' perceived responsibility was consistently associated with level of training, program type, career path, or burnout, suggesting there may be unmeasured factors such as professional role modeling that shape these perceptions.
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Abstract
Transitions of care have emerged as an important point of vulnerability in the health care system where medical errors and clinical deterioration can occur. Most research in the area has focused on non-neurologically ill patients in the postdischarge transition from the inpatient to outpatient clinical environment in part due to the emergence of hospital readmissions reduction programs. A multidisciplinary strategy that addresses several common opportunities for improvement can mitigate the risk to patients during these periods and can serve as an opportunity for neurologists to take the lead in developing systems-based solutions that can ultimately enhance the quality of care for our patients.
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