Emergency medicine and hospital medicine: a call for collaboration

Hospitalist Perceptions of Fall Prevention: A Comparison of Two Health Care Systems

Inpatient falls are common, but little is known about hospitalist perceptions regarding their exact role in fall prevention. The authors conducted a cross-sectional analysis of hospitalists' attitudes and perceived barriers to fall prevention practices in 2 different hospital systems in Portland, Oregon. A total of 42 responses were collected. Although hospitalists in both groups agreed that all patients admitted should undergo fall risk assessments (FRAs), both groups disagreed that hospitalists should be responsible for performing them. Neither group felt that they had the time to complete FRAs and were either neutral or felt the lack of expertise to conduct them. These findings suggest that the hospitalist role in inpatient fall prevention multidisciplinary teams may be unclear to physician providers and that health care systems may benefit from examining this further.

Facilitators of interdepartmental quality improvement: a mixed-methods analysis of a collaborative to improve pediatric community-acquired pneumonia management

BACKGROUND

Emergency medicine and paediatric hospital medicine physicians each provide a portion of the initial clinical care for the majority of hospitalised children in the USA. While these disciplines share goals to increase quality of care, there are scant data describing their collaboration. Our national, multihospital learning collaborative, which aimed to increase narrow-spectrum antibiotic prescribing for paediatric community-acquired pneumonia, provided an opportunity to examine factors influencing the success of quality improvement efforts across these two clinical departments.

OBJECTIVE

To identify barriers to and facilitators of interdepartmental quality improvement implementation, with a particular focus on increasing narrow-spectrum antibiotic use in the emergency department and inpatient settings for children hospitalised with pneumonia.

METHODS

We used a mixed-methods design, analysing interviews, written reports and quality measures. To describe hospital characteristics and quality measures, we calculated medians/IQRs for continuous variables, frequencies for categorical variables and Pearson correlation coefficients. We conducted in-depth, semistructured interviews by phone with collaborative site leaders; interviews were transcribed verbatim and, with progress reports, analysed using a general inductive approach.

RESULTS

47 US-based hospitals were included in this analysis. Qualitative analysis of 35 interview transcripts and 142 written reports yielded eight inter-related domains that facilitated successful interdepartmental quality improvement: (1) hospital leadership and support, (2) quality improvement champions, (3) evidence supporting the intervention, (4) national health system influences, (5) collaborative culture, (6) departments' structure and resources, (7) quality improvement implementation strategies and (8) interdepartmental relationships.

CONCLUSIONS

The conceptual framework presented here may be used to identify hospitals' strengths and potential barriers to successful implementation of quality improvement efforts across clinical departments.

Interunit handoffs from emergency department to inpatient care: A cross-sectional survey of physicians at a university medical center

BACKGROUND

Emergency department (ED) to inpatient physician handoffs are subject to complex challenges. We assessed physicians' perceptions of the ED admission handoff process and identified potential barriers to safe patient care.

METHODS

We conducted a cross-sectional survey at a 627-bed tertiary care academic medical center. Eligible participants included all resident, fellow, and faculty physicians directly involved in admission handoffs from emergency medicine (EM) and 5 medical admitting services. The survey addressed communication quality, clinical information, interpersonal perceptions, assignment of responsibilities, organizational factors, and patient safety. Participants reported their responses via a 5-point Likert scale and an open-ended description of handoff-related adverse events.

RESULTS

Response rates were 63% for admitting (94/150) and 86% for EM physicians (32/37). Compared to EM respondents, admitting physicians reported that vital clinical information was communicated less frequently for all 8 content areas (P < 0.001). Ninety-four percent of EM physicians felt defensive at least "sometimes." Twenty-nine percent of all respondents reported handoff-related adverse events, most frequently related to ineffective communication. Sequential handoffs were common for both EM and admitting services, with 78% of physicians reporting they negatively impacted patient care.

CONCLUSION

Physicians reported that patient safety was often at risk during the ED admission handoff process. Admitting and EM physicians had divergent perceptions regarding handoff communication, and sequential handoffs were common. Further research is needed to better understand this complex process and to investigate strategies for improvement.

Hospital collaboration with emergency medical services in the care of patients with acute myocardial infarction: perspectives from key hospital staff

STUDY OBJECTIVE

Evidence suggests that active collaboration between hospitals and emergency medical services (EMS) is significantly associated with lower acute myocardial infarction mortality rates; however, the nature of such collaborations is not well understood. We seek to characterize views of key hospital staff about collaboration with EMS in the care of patients hospitalized with acute myocardial infarction.

METHODS

We performed an exploratory analysis of qualitative data previously collected from site visits and detailed interviews with 11 US hospitals that ranked in the top or bottom 5% of performance on 30-day risk-standardized acute myocardial infarction mortality rates, using Centers for Medicare & Medicaid Services data from 2005 to 2007. We selected all codes from the previous analysis in which EMS was most likely to have been discussed. A multidisciplinary team analyzed the data with the constant comparative method to generate recurrent themes.

RESULTS

Both higher- and lower-performing hospitals reported that EMS is critical to the provision of timely care for patients with acute myocardial infarction. However, close collaborative relationships with EMS were more apparent in the higher-performing hospitals, which demonstrated specific investment in and attention to EMS through respect for EMS as valued professionals and colleagues, strong communication and coordination with EMS and active engagement of EMS in hospital acute myocardial infarction quality improvement efforts.

CONCLUSION

Hospital staff from higher-performing hospitals described broad, multifaceted strategies to support collaboration with EMS in providing acute myocardial infarction care. The association of these strategies with hospital performance should be tested quantitatively in a larger representative study.