Implementation of a continuous admission model reduces the length of stay of patients on an internal medicine clinical teaching unit

Residents and staff perceptions of a pediatric clinical teaching unit in a large tertiary care center in Saudi Arabia

BACKGROUND

The clinical teaching unit (CTU) is a commonly used model of patient care and teaching. Despite being a common model of care, very few studies have looked at its impact on the education of trainees. In addition, it is a relatively new structure for pediatric inpatient care in Saudi Arabia. The purpose of this study was to compare postgraduate trainees (residents) and staff perceptions of the old and the new (the CTU) inpatient team structures, and to evaluate the impact of the CTU on residents' education.

METHODS

An online survey was sent to nurses, pediatric residents, and attending physicians who worked under both structures. Questions for residents were adopted from the National training survey of the General Medical Council, United Kingdom.

RESULTS

A total of 147 pediatric healthcare workers completed the survey (97 nurses, 39 residents, and 11 attending physicians), most of whom worked in both the old and new inpatient team structures. More than 97% of residents reported being supervised by their attending on a daily basis in the CTU structure as compared with 15% in the old structure. A higher proportion of residents favored the old structure in terms of the opportunity it provided to develop their leadership skills. Eighty-seven percent of nurses believed the CTU had improved patient safety of pediatric inpatients. Overall, 82% of residents, 91% of nurses, and 100% of attending physicians favoured the CTU structure over the old inpatient model.

CONCLUSIONS

Our study shows that pediatric residents and staff perceived the CTU structure as superior to the old inpatient team structure, especially in terms of patient safety. Although the CTU seemed to have a positive impact on residents' education, this must be further examined especially with respect to its impact on residents' leadership skills.

Trends in Medical and Surgical Admission Length of Stay by Race/Ethnicity and Socioeconomic Status: A Time Series Analysis

BACKGROUND

Length of stay (LOS), a metric of hospital efficiency, differs by race/ethnicity and socioeconomic status (SES) and longer LOS is associated with adverse health outcomes. Historically, projects to improve LOS efficiency have yielded LOS reductions by 0.3 to 0.7 days per admission.

OBJECTIVE

To assess differences in average adjusted length of stay (aALOS) over time by race/ethnicity, and SES stratified by discharge destination (home or non-home).

METHOD

Data were obtained from 2009-2014 Healthcare Cost and Utilization Project State Inpatient Datasets for New York, New Jersey, and Florida. Multivariate generalized linear models were used to examine trends in aALOS differences by race/ethnicity, and by high vs low SES patients (defined first vs fourth quartile of median income by zip code) controlling for patient, disease and hospital characteristics.

RESULTS

For those discharged home, racial/ethnic and SES aALOS differences remained stable from 2009 to 2014. However, among those discharged to non-home destinations, Black vs White aALOS differences increased from 0.21 days in Q1 2009, (95% confidence interval (CI): 0.13 to 0.30) to 0.32 days in Q3 2013, (95% CI: 0.23 to 0.40), and for low vs high SES patients from 0.03 days in Q1 2009 (95% CI: -0.04 to 0.1) to 0.26 days, (95% CI: 0.19 to 0.34). Notably, for patients not discharged home, racial/ethnic and SES aALOS differences increased and persisted after Q3 2011, coinciding with the introduction of the Affordable Care Act (ACA).

CONCLUSION

Further research to understand the ACA's policy impact on hospital efficiencies, and relationship to racial/ethnic and SES differences in LOS is warranted.

Drip System for Admissions to Resident Teams: Impact on Workload and Education

OBJECTIVES

Assigning patients to a call team every fourth day (bolus system) caused the maldistribution of patients among resident teams and required additional faculty effort for overflow patient care. We changed to a continuous daily rotation (drip system) and examined the effect on clinical workload among resident teams, resident education, and faculty utilization.

METHODS

This is a retrospective study based on the daily records of 7 am team census, the attending physician schedules for a pediatric hospital medicine service with 5 teams, and the measures of resident education, including noon conference attendance, scores on in-service examinations, and duty hour violations. Data from the bolus system (May 2014-June 2015) were compared with the drip system (May 2016-June 2017).

RESULTS

Data from 348 bolus days and 338 drip days were analyzed. There was a decrease in interteam variation from 6.2 to 3.9 patients (P < 0.001). There were fewer days with the following: large interteam variation (143 to 25, P < 0.001), days with resident teams at or above capacity (26 to 11, P = 0.01), resident teams below a minimum 7 am census (133 to 18, P < 0.001), and days when additional faculty were pulled for clinical care (61 to 9, P < 0.001). Resident noon conference attendance was unchanged and there was no adverse effect on examination scores or duty hour violations.

CONCLUSIONS

Changing from a bolus to a drip model for admissions to inpatient teams resulted in a more even distribution of the workload and a more efficient use of physician resources without negatively affecting resident education.

Inpatient flow management: a systematic review

Purpose

In hospitals, several patient flows compete for access to shared resources. Failure to manage these flows result in one or more disruptions within a hospital system. To ensure continuous care delivery, solving flow problems must not be limited to one unit, but should be extended to other departments – a prerequisite for solving flow problems in the entire hospital. Since most current studies focus solely on overcrowding in emergency units, additional insights are needed on system-wide patient flow management. The purpose of this paper is to look at the information available in system-wide patient flow management studies, which were also systematically evaluated to demonstrate which interventions improve inpatient flow.

Design/methodology/approach

The authors searched PubMed and Web of Science (Core Collection) literature databases and collected full-text articles using two selection and classification stages. Stage 1 was used to screen articles relating to patient flow management for inpatient settings with typical characteristics. Stage 2 was used to classify the articles selected in Stage 1 according to the interventions and their impact on patient flow within a hospital system.

Findings

In Stage 1, 107 studies were selected. Although a growing trend was observed, there were fewer studies on patient flow management in inpatient than studies in emergency settings. In Stage 2, 61 intervention studies were classified. The authors found that most interventions were about creating and adding supply resources. Since many hospital managers these days cannot easily add capacity owing to cost and resource constraints, using existing capacity efficiently is important – unfortunately not addressed in many studies. Furthermore, arrival variability was the factor most frequently mentioned as affecting flow. Of all interventions addressed in this review, the most prominent for advancing patient access to inpatient units was employing a specialized individual or team to maintain patient flow and bed placement across hospital units.

Originality/value

This study provides the first patient flow management systematic overview within an inpatient setting context.

Bedside nurses' roles in discharge collaboration in general internal medicine: Disconnected, disempowered and devalued?

Collaboration among nurses and other healthcare professionals is needed for effective hospital discharge planning. However, interprofessional interactions and practices related to discharge vary within and across hospitals. These interactions are influenced by the ways in which healthcare professionals' roles are being shaped by hospital discharge priorities. This study explored the experience of bedside nurses' interprofessional collaboration in relation to discharge in a general medicine unit. An ethnographic approach was employed to obtain an in-depth insight into the perceptions and practices of nurses and other healthcare professionals regarding collaborative practices around discharge. Sixty-five hours of observations was undertaken, and 23 interviews were conducted with nurses and other healthcare professionals. According to our results, bedside nurses had limited engagement in interprofessional collaboration and discharge planning. This was apparent by bedside nurses' absence from morning rounds, one-way flow of information from rounds to the bedside nurses following rounds, and limited opportunities for interaction with other healthcare professionals and decision-making during the day. The disconnection, disempowerment and devaluing of bedside nurses in patient discharge planning has implications for quality of care and nursing work. Study findings are positioned within previous work on nurse-physician interactions and the current context of nursing care.

Use of a 90-Minute Admission Window and Front-Fill System to Reduce Work Compression on a General Medicine Inpatient Teaching Service

BACKGROUND

Duty hour limits have shortened intern shifts without concurrent reductions in workload, creating work compression. Multiple admissions during shortened shifts can result in poor training experience and patient care.

OBJECTIVE

To relieve work compression, improve resident satisfaction, and improve duty hour compliance in an academic internal medicine program.

METHODS

In 2014, interns on general ward services were allotted 90 minutes per admission from 3 pm to 7 pm, when the rate of admissions was high. Additional admissions arriving during the protected period were directed to hospitalists. Resident teams received 2 patients admitted by the night float team to start the call day (front-fill).

RESULTS

Of the 51 residents surveyed before and after the implementation of the intervention, 39 (77%) completed both surveys. Respondents reporting an unmanageable workload fell from 14 to 1 (P < .001), and the number of residents reporting that they felt unable to admit patients in a timely manner decreased from 14 to 2 (P < .001). Reports of adequate time with patients increased from 16 to 36 (P < .001), and residents indicating that they had time to learn from patients increased from 19 to 35 (P < .001). Reports of leaving on time after call days rose from 12 to 33 (P < .01), and overall satisfaction increased from 26 to 35 (P = .002). Results were similar when residents were resurveyed 6 months after the intervention.

CONCLUSIONS

Call day modifications improved resident perceptions of their workload and time for resident learning and patient care.

Hospital Readmissions Following Physician Call System Change: A Comparison of Concentrated and Distributed Schedules

BACKGROUND

Physician call schedules are a critical element for medical practice and hospital efficiency. We compared readmission rates prior to and after a change in physician call system at Sunnybrook Health Sciences Centre.

METHODS

We studied patients discharged over a decade (2004 through 2013) and identified whether or not each patient was readmitted within the subsequent 28 days. We excluded patients discharged for a surgical, obstetrical, or psychiatric diagnosis. We used time-to-event analysis and time-series analysis to compare rates of readmission prior to and after the physician call system change (January 1, 2009).

RESULTS

A total of 89,697 patients were discharged, of whom 10,001 (11%) were subsequently readmitted and 4280 died. The risk of readmission was increased by about 26% following physician call system change (9.7% vs 12.2%, P <.001). Time-series analysis confirmed a 26% increase in the readmission rate after call system change (95% confidence interval, 22%-31%; P <.001). The increase in readmission rate after call system change persisted across patients with diverse ages, estimated readmission risks, and medical diagnoses. The net effect was equal to 7240 additional patient days in the hospital following call system change. A modest increase was observed at a nearby acute care hospital that did not change physician call system, and no increase in risk of death was observed with increased hospital readmissions.

CONCLUSION

We suggest that changes in physician call systems sometimes increase subsequent hospital readmission rates. Further reductions in readmissions may instead require additional resources or ingenuity.

A sociological exploration of the tensions related to interprofessional collaboration in acute-care discharge planning

Patient discharge is a key concern in hospitals, particularly in acute care, given the multifaceted and challenging nature of patients' healthcare needs. Policies on discharge have identified the importance of interprofessional collaboration, yet research has described its limitations in this clinical context. This study aimed to extend our understanding of interprofessional interactions related to discharge in a general internal medicine setting by using sociological theories to illuminate the existence of, and interplay between, structural factors and microlevel practices. An ethnographic approach was employed to obtain an in-depth insight into healthcare providers' perspectives, behaviours, and interactions regarding discharge. Data collection involved observations, interviews, and document analysis. Approximately 65 hours of observations were undertaken, 23 interviews were conducted with healthcare providers, and government and hospital discharge documents were collected. Data were analysed using a directed content approach. The findings indicate the existence of a medically dominated division of healthcare labour in patient discharge with opportunities for some interprofessional negotiations; the role of organizational routines in facilitating and challenging interprofessional negotiations in patient discharge; and tensions in organizational priorities that impact an interprofessional approach to discharge. The findings provide insight into the various levels at which interventions can be targeted to improve interprofessional collaboration in discharge while recognizing the organizational tensions that challenge an interprofessional approach.

Medical Residents and Interprofessional Interactions in Discharge: An Ethnographic Exploration of Factors That Affect Negotiation

BACKGROUND

Interprofessional collaboration is an important aspect of patient discharge from a general internal medicine (GIM) unit. However, there has been minimal empirical or theoretical research that has examined interactions that occur between medical residents and other healthcare professionals in the discharge process. This study provides insight into the social processes that shape and characterize such interactions.

OBJECTIVE

To explore factors that shape interactions between medical residents and other healthcare professionals in relation to patient discharge, and to examine the opportunities for negotiations about discharge between these professional groups.

DESIGN

A qualitative ethnographic approach using observations, interviews and documentary analysis.

PARTICIPANTS AND SETTING

Healthcare professionals working in a GIM unit in Canada.

APPROACH

Sixty-five hours of observations were undertaken in a range of settings (e.g. interprofessional rounds, medical and nursing rounds, nursing station) in the unit over a 17-month period. A maximum variation sampling approach was used to identify healthcare professionals working in the unit. Twenty-three interviews were completed, recorded and transcribed verbatim. A directed content approach using theories of medical dominance and negotiated order was used to analyze the data.

KEY RESULTS

The organization of clinical work in combination with clinical teaching influenced interprofessional interactions and the quality of discharge in this GIM unit. While organizational activities (orientation and rounds) and individual activities (e.g. role modeling, teaching) supported negotiations between medical residents and other healthcare professionals around discharge, participants had varied perspectives about their effectiveness.

CONCLUSIONS

This study illuminates social factors and processes that require attention in order to address challenges with interprofessional collaboration and discharge in GIM. These findings have implications for medical education, workplace learning, patient safety and quality improvement.

Point-of-prescription interventions to improve antimicrobial stewardship

Antimicrobial stewardship is pivotal to improving patient outcomes, reducing adverse events, decreasing healthcare costs, and preventing further emergence of antimicrobial resistance. In an era in which antimicrobial resistance is increasing, judicious antimicrobial use is the responsibility of every healthcare provider. Antimicrobial stewardship programs (ASPs) have made headway in improving antimicrobial prescribing using such "top-down" methods as formulary restriction and prospective audit with feedback; however, engagement of prescribers has not been fully explored. Strategies that include frontline prescribers and other unit-based healthcare providers have the potential to expand stewardship, both to augment existing centralized ASPs and to provide alternative approaches to perform stewardship at healthcare facilities with limited resources. This review discusses interventions focusing on antimicrobial prescribing at the point of prescription as well as a pilot project to engage unit-based healthcare providers in antimicrobial stewardship.

Internal medicine residents' perspectives on effects of 2011 ACGME work hour regulations on patient care

BACKGROUND

The Accreditation Council for Graduate Medical Education (ACGME) introduced new work hour limitations in July 2011.

PURPOSES

The aim is to assess internal medicine residents' perspectives on the impact of these limitations on their ability to discharge patient care duties.

METHODS

An anonymous survey was administered to 158 medicine residents in an urban university-affiliated internal medicine residency program. Residents' perspectives on various aspects of patient care were recorded on a 5-point Likert-type scale.

RESULTS

The response rate was 62%. The majority of residents (80%) agreed that patients had adequate continuity of care. Most residents agreed that they had enough time to follow up on consult notes (64% agreed) and investigations (80% agreed) daily. Most PGY-1 residents (59%) reported having enough time to prepare sign-outs. Most (60%) residents felt that reducing handoffs would improve patient care.

CONCLUSIONS

Most residents believe that the new work hour limitations would continue to uphold patient safety, but handoffs in care must be restricted.