2011 November 02

Inpatient insulin orders: Are patients getting what is prescribed?

Nov 022011

Inpatient insulin orders: Are patients getting what is prescribed?

J Hosp Med. 2011 Oct 31;

Authors: Deal EN, Liu A, Wise LL, Honick KA, Tobin GS

Abstract
BACKGROUND: In-hospital insulin administration is associated with many medication errors, but the frequency and reasons for insulin administration errors are poorly described. To document types and frequency of errors related to insulin administration, an examination of 4 units was conducted. METHODS: Using snapshot methodology, 4 non-intensive care unit (ICU) areas (medicine, cardiology, transplant, and surgery) were examined in an observational, prospective manner for 4 weeks. Each patient on insulin on the first day was followed for 7 days. Definitions and error categories were defined prior to data collection. Error types and numbers were collected and quantified on per-day or per-patient basis. RESULTS: A total of 116 patient audit periods covering a total of 378 inpatient hospital days were examined. Inpatient insulin regimens on day 1 included correctional insulin only (51.7% of cases), neutral protamine Hagedorn ([NPH] 12%), and glargine (28.4%). A total of 199 administration errors occurred at a rate of 1.72 errors/patient-period and 0.53 errors/patient day. Missing documentation of doses (15.5% of all patients) and insulin being held without an order (25% of patients) were the most frequently occurring events. Other errors include transcription (7.5%), timing errors (22.7%), and lack of documentation of physician notification of hypoglycemia (12.6%). CONCLUSIONS: Errors associated with insulin in the hospital are common and reveal a number of system errors that should be addressed. These data provide a foundation for future performance improvement. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

PMID: 22042479 [PubMed - as supplied by publisher]

Link to Article at PubMed

Interdisciplinary teamwork in hospitals: A review and practical recommendations for improvement.

J Hosp Med Start a Discussion »

Nov 022011

Interdisciplinary teamwork in hospitals: A review and practical recommendations for improvement.

J Hosp Med. 2011 Oct 31;

Authors: O'Leary KJ, Sehgal NL, Terrell G, Williams MV,

Abstract
Recognizing the importance of teamwork in hospitals, senior leadership from the American College of Physician Executives (ACPE), the American Hospital Association (AHA), the American Organization of Nurse Executives (AONE), and the Society of Hospital Medicine (SHM) established the High Performance Teams and the Hospital of the Future project. This collaborative learning effort aims to redesign care delivery to provide optimal value to hospitalized patients. With input from members of this initiative, we prepared this report which reviews the literature related to teamwork in hospitals. Teamwork is critically important to provide safe and effective hospital care. Hospitals with high teamwork ratings experience higher patient satisfaction, higher nurse retention, and lower hospital costs. Elements of effective teamwork have been defined and provide a framework for assessment and improvement efforts in hospitals. Measurement of teamwork is essential to understand baseline performance, and to demonstrate the utility of resources invested to enhance it and the subsequent impact on patient care. Interventions designed to improve teamwork in hospitals include localization of physicians, daily goals of care forms and checklists, teamwork training, and interdisciplinary rounds. Though additional research is needed to evaluate the impact on patient outcomes, these interventions consistently result in improved teamwork knowledge, ratings of teamwork climate, and better understanding of patients' plans of care. The optimal approach is implementation of a combination of interventions, with adaptations to fit unique clinical settings and local culture. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

PMID: 22042511 [PubMed - as supplied by publisher]

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Comparing the pulmonary embolism severity index and the prognosis in pulmonary embolism scores as risk stratification tools.

J Hosp Med Start a Discussion »

Nov 022011

Comparing the pulmonary embolism severity index and the prognosis in pulmonary embolism scores as risk stratification tools.

J Hosp Med. 2011 Oct 31;

Authors: Chan CM, Woods CJ, Shorr AF

Abstract
BACKGROUND: Multiple risk stratification scoring systems exist to forecast outcomes in patients with acute pulmonary embolism (PE). OBJECTIVE: We evaluated the comparative validity of the PE severity index (PESI) and the prognosis in pulmonary embolism (PREP) scores to predict mortality in acute PE. DESIGN: Retrospective observational cohort study. SETTING: Washington Hospital Center, Washington, DC. PATIENTS: Consecutive adults (aged >18 years) diagnosed with acute PE. INTERVENTION: The PESI and PREP scores were calculated. MEASUREMENTS: Raw PESI scores were segregated into risk class (I-V) and then dichotomized into low (I-II) versus high (III-V) risk groups; the raw PREP scores were divided into low (0-7) versus high (>7) risk groups. The primary endpoint was 30-day and 90-day mortality. We determined the negative predictive value and computed the area under the receiver operating characteristics (AUROC) curves to compare the ability of these scoring tools. RESULTS: The cohort consisted of 302 subjects. Thirty-day mortality was 3.0%, and 4.0% died within 90 days. The PESI and the PREP performed similarly (PESI AUROC: 0.858 [95% confidence interval (CI), 0.773-0.943] vs 0.719 [95% CI, 0.563-0.875] for PREP). Segregating these scores into risk categories did not affect their discriminatory power (AUROC: 0.684 [95% CI, 0.559-0.810] for PESI and 0.790 [95% CI, 0.679-0.903] for PREP). The negative predictive value for death of being classified as low risk by the PESI or PREP was 100% and 99%, respectively. CONCLUSIONS: The PREP score performed comparably to the PESI score for identifying PE patients at low risk for short-term and intermediate-term mortality. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

PMID: 22042764 [PubMed - as supplied by publisher]

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Impact of heart failure on hip fracture outcomes: A population-based study.

J Hosp Med Start a Discussion »

Nov 022011

Impact of heart failure on hip fracture outcomes: A population-based study.

J Hosp Med. 2011 Oct 31;

Authors: Cullen MW, Gullerud RE, Larson DR, Melton LJ, Huddleston JM

Abstract
BACKGROUND: Hip fracture and heart failure are becoming more prevalent conditions in hospitalized patients. Despite differences in postoperative outcomes from other intermediate risk procedures, guidelines classify hip fracture repair as an intermediate risk operation. OBJECTIVE: This population-based study sought to examine the prevalence and incidence of heart failure in hip fracture patients. DESIGN, SETTING, AND PATIENTS: We conducted a population-based historical cohort study of 1116 Olmsted County, MN residents undergoing 1212 hip surgeries from 1988 through 2002. Data were obtained through medical record review. Heart failure was defined by Framingham criteria. RESULTS: The prevalence of preoperative heart failure in our study population was 27% (327 of 1212 cases). Those with preoperative heart failure demonstrated longer lengths of stay, were more often discharged to a skilled facility, and had higher inpatient mortality rates. Rates of postoperative heart failure were 6.7% at seven days and 21.3% at one year. Postoperative heart failure was more common among those with preoperative heart failure (HR 3.0), and those with preoperative heart failure demonstrated higher postoperative mortality rates. Men had a higher risk of postoperative mortality compared to women. Overall survival was lowest among those with both preoperative and postoperative heart failure. CONCLUSIONS: Heart failure represents a common and serious perioperative condition in hip fracture patients. Hip fracture patients with and without heart failure carry higher postoperative risk than guidelines may suggest. Future work must focus on the perioperative management of hip fracture patients with and without heart failure to mitigate postoperative morbidity. Journal of Hospital Medicine 2011; © 2011 Society of Hospital Medicine.

PMID: 22042721 [PubMed - as supplied by publisher]

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Improving the discharge process by embedding a discharge facilitator in a resident team.

J Hosp Med Start a Discussion »

Nov 022011

Improving the discharge process by embedding a discharge facilitator in a resident team.

J Hosp Med. 2011 Oct 31;

Authors: Finn KM, Heffner R, Chang Y, Bazari H, Hunt D, Pickell K, Berube R, Raju S, Farrell E, Iyasere C, Thompson R, O'Malley T, O'Donnell W, Karson A

Abstract
BACKGROUND: Hospital discharges are vulnerable periods for patient safety, especially in teaching hospitals where discharges are done by residents with competing demands. We sought to assess whether embedding a nurse practitioner on a medical team to help physicians with the discharge process would improve communication, patient follow-up, and hospital reutilization. METHODS: A 5-month randomized controlled trial was conducted on the medical service at an academic tertiary-care hospital. A nurse practitioner was randomly assigned to 1 resident team to complete discharge paperwork, arrange follow-up appointments and prescriptions, communicate discharge plans with nursing and primary care physicians, and answer questions from discharged patients. RESULTS: Intervention patients had more discharge summaries completed within 24 hours (67% vs 47%, P < 0.001). Similarly, they had more follow-up appointments scheduled by the time of discharge (62% vs 36%, P < 0.0001) and attended those appointments more often within 2 weeks (36% vs 23%, P < 0.0002). Intervention patients knew whom to call with questions (95% vs 85%, P = 0.003) and were more satisfied with the discharge process (97% vs 76%, P < 0.0001). Attending rounds on the intervention team finished on time (45% vs 31%, P = 0.058), and residents signed out on average 46 minutes earlier each day. There was no significant difference between the groups in 30-day emergency department visits or readmissions. CONCLUSIONS: Helping resident physicians with the discharge process improves many aspects of discharge communication and patient follow-up, and saves residents' time, but had no effect on hospital reutilization for a general medicine population. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

PMID: 22042739 [PubMed - as supplied by publisher]

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Behaviors of successful interdisciplinary hospital quality improvement teams.

J Hosp Med Start a Discussion »

Nov 022011

Behaviors of successful interdisciplinary hospital quality improvement teams.

J Hosp Med. 2011 Oct 31;

Authors: Santana C, Curry LA, Nembhard IM, Berg DN, Bradley EH

Abstract
BACKGROUND: Although interdisciplinary hospital quality improvement (QI) teams are both prevalent and associated with success of (QI) efforts, little is known about the behaviors of successful interdisciplinary QI teams. OBJECTIVE: We examined the specific behaviors of interdisciplinary QI teams in hospitals that successfully redesigned care for patients with ST-elevation myocardial infarction (STEMI) and reduced door-to-balloon times. DESIGN: Qualitative study. PARTICIPANTS: Researchers interviewed 122 administrators, providers, and staff in 11 hospitals with substantial improvements in door-to-balloon times. MEASUREMENTS: Using data from the in-depth qualitative interviews, the authors identified themes that described the behaviors of interdisciplinary QI teams in successful hospitals. RESULTS: Teams focused on 5 behaviors: (1) motivating involved hospital staff toward a shared goal, (2) creating opportunities for learning and problem-solving, (3) addressing the impact of changes to care processes on staff, (4) protecting the integrity of the new care processes, and (5) representing each involved clinical discipline effectively. CONCLUSIONS: The behaviors observed may enhance a QI team's ability to motivate the various disciplines involved, understand the care process they must change, be responsive to front-line concerns while maintaining control over the improvement process, and share information across all levels of the hospital hierarchy. Teams in successful hospitals did not avoid interdisciplinary conflict, but rather allowed each discipline to contribute to the team from its own perspective. Successful QI teams addressed the concerns of each involved discipline, modified protocols guided by clinical outcomes, and became conduits of information on changes to care processes to both executive managers and front-line staff. Journal of Hospital Medicine 2011;. © 2011 Society of Hospital Medicine.

PMID: 22042750 [PubMed - as supplied by publisher]

Link to Article at PubMed

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