Do timely outpatient follow-up visits decrease hospital readmission rates?

Am J Med Qual. 2012 Jan-Feb;27(1):11-5

Authors: Kashiwagi DT, Burton MC, Kirkland LL, Cha S, Varkey P

Abstract
It is widely believed that timely follow-up decreases hospital readmissions; however, the literature evaluating time to follow-up is limited. The authors conducted a retrospective analysis of patients discharged from a tertiary care academic medical center and evaluated the relationship between outpatient follow-up appointments made and 30-day unplanned readmissions. Of 1044 patients discharged home, 518 (49.6%) patients had scheduled follow-up ?14 days after discharge, 52 (4.9%) patients were scheduled ?15 days after discharge, and 474 (45.4%) had no scheduled follow-up. There was no statistical difference in 30-day readmissions between patients with follow-up within 14 days and those with follow-up 15 days or longer from discharge (P = .36) or between patients with follow-up within 14 days and those without scheduled follow-up (P = .75). The timing of postdischarge follow-up did not affect readmissions. Further research is needed to determine such factors and to prospectively study time to outpatient follow-up after discharge and the decrease in readmission rates.

PMID: 21835809 [PubMed - indexed for MEDLINE]

An assessment of patient sign-outs conducted by University at Buffalo internal medicine residents.

Am J Med Qual. 2012 Jan-Feb;27(1):39-47

Authors: Wheat D, Co C, Manochakian R, Rich E

Abstract
Internal medicine residents were surveyed regarding patient sign-outs at shift change. Data were used to design and implement interventions aimed at improving sign-out quality. This quasi-experimental project incorporated the Plan, Do, Study, Act methodology. Residents completed an anonymous electronic survey regarding experiences during sign-outs. Survey questions assessed structure, process, and outcome of sign-outs. Analysis of qualitative and quantitative data was performed; interventions were implemented based on survey findings. A total of 120 surveys (89% response) and 115 surveys (83% response) were completed by residents of 4 postgraduate years in response to the first (2008) and second (2009) survey requests, respectively. Approximately 79% of the respondents to the second survey indicated that postintervention sign-out systems were superior to preintervention systems. Results indicated improvement in specific areas of structure, process, and outcome. Survey-based modifications to existing sign-out systems effected measurable quality improvement in structure, process, and outcome.

PMID: 21926279 [PubMed - indexed for MEDLINE]

Inappropriate use of D-dimer assay and pulmonary CT angiography in the evaluation of suspected acute pulmonary embolism.

Am J Med Qual. 2012 Jan-Feb;27(1):74-9

Authors: Yin F, Wilson T, Della Fave A, Larsen M, Yoon J, Nugusie B, Freeland H, Chow RD

Abstract
The authors question whether the d-dimer assay and pulmonary computed tomography angiography (CTA) are being used appropriately to evaluate suspected acute pulmonary embolism (PE) at their hospital. To answer this question, a retrospective review was performed on all emergency department (ED) patients who underwent d-dimer assay and/or CTA from August 15, 2008, to August 14, 2009. The authors' algorithm for diagnosing PE requires that patients with low or intermediate probability of acute PE undergo a d-dimer assay, followed by CTA if the d-dimer is positive. Patients with high probability of PE should have CTA performed without a d-dimer assay. This result suggests that d-dimer assay and CTA are used inappropriately to evaluate patients with suspected acute PE in our ED. The low threshold for initiating an evaluation for PE decreases the prevalence of PE in this population.

PMID: 21666066 [PubMed - indexed for MEDLINE]

The role of housestaff in implementing medication reconciliation on admission at an academic medical center.

Am J Med Qual. 2011 Jan-Feb;26(1):39-42

Authors: Evans AS, Lazar EJ, Tiase VL, Fleischut P, Bostwick SB, Hripcsak G, Liebowitz R, Forese LL, Kerr G

Abstract
Since 2006, the Joint Commission has required all hospitals to have a process in place for medication reconciliation (MR). Although it has been shown that MR decreases medical errors, achieving compliance has proven difficult for many health care institutions. This article describes a housestaff-championed intervention of a "hard stop" for on-admission MR orders that led to a statistically significant increase in compliance that was sustained at 6 months after intervention. Academic medical centers, which comprise large numbers of housestaff, can improve compliance with on-admission MR by engaging housestaff in the development of solutions and in communication to their peers, leading to sustained results.

PMID: 20501865 [PubMed - indexed for MEDLINE]

A Hospital's Adoption of Information Technology Is Associated With Altered Risks of Hospital-Acquired Venous Thromboembolism.

Am J Med Qual. 2012 Jan 4;

Authors: Hu HM, Tzeng HM

Abstract
The objective was to examine the relationship between hospital adoption of information technology (IT) and hospital-acquired venous thromboembolism (VTE). Inpatients aged 65 years and older who were discharged from hospitals in California, Florida, and New York were analyzed. A cross-sectional study design was used to perform secondary data analyses. The association between implementing IT applications (ie, electronic clinical documentation, electronic lab orders, medication orders written electronically) in the patients' hospitals (independent variables) and hospital-acquired VTE (the dependent variable) were studied using a hierarchical logistic model. Electronic clinical documentation was associated with lower odds of hospital-acquired VTE (odds ratio [OR] = 0.835, P < .001). An even larger reduction in the odds was found among patients of hospitals that implemented electronic lab orders (OR = 0.627, P < .001). However, the implementation of electronic medication orders did not show such an association.

PMID: 22223815 [PubMed - as supplied by publisher]

It's the writing on the wall: Whiteboards improve inpatient satisfaction with provider communication.

Am J Med Qual. 2011 Mar-Apr;26(2):127-31

Authors: Singh S, Fletcher KE, Pandl GJ, Schapira MM, Nattinger AB, Biblo LA, Whittle J

Although keeping patients informed is a part of quality hospital care, inpatients often report they are not well informed. The authors placed whiteboards in each patient room on medicine wards in their hospital and asked nurses and physicians to use them to improve communication with inpatients. The authors then examined the effect of these whiteboards by comparing satisfaction with communication of patients discharged from medical wards before and after whiteboards were placed to satisfaction with communication of patients from surgical wards that did not have whiteboards. Patient satisfaction scores (0-100 scale) with communication improved significantly on medicine wards: nurse communication (+6.4, P < .001), physician communication (+4.0, P = .04), and involvement in decision making (+6.3, P = .002). Patient satisfaction scores did not change significantly on surgical wards. There was no secular trend, and the authors excluded a trend in overall patient satisfaction. Whiteboards could be a simple and effective tool to increase inpatient satisfaction with communication.

PMID: 20870743 [PubMed - indexed for MEDLINE]

Adherence to Guideline-Directed Venous Thromboembolism Prophylaxis Among Medical and Surgical Inpatients at 33 Academic Medical Centers in the United States.

Am J Med Qual. 2011 Apr 13;

Authors: Schleyer AM, Schreuder AB, Jarman KM, Logerfo JP, Goss JR

This study's purpose was to describe compliance with established venous thromboembolism (VTE) prophylaxis guidelines in medical and surgical inpatients at US academic medical centers (AMCs). Data were collected for a 2007 University HealthSystem Consortium Deep Vein Thrombosis/Pulmonary Embolism (DVT/PE) Benchmarking Project that explored VTE in AMCs. Prophylaxis was considered appropriate based on 2004 American College of Chest Physicians guidelines. A total of 33 AMCs from 30 states participated. In all, 48% of patients received guideline-directed prophylaxis-59% were medical and 41% were surgical patients. VTE history was more common among medical patients with guideline-directed prophylaxis. Surgical patients admitted from the emergency department and with higher illness severity were more likely to receive appropriate prophylaxis. Despite guidelines, VTE prophylaxis remains underutilized in these US AMCs, particularly among surgical patients. Because AMCs provide the majority of physician training and should reflect and set care standards, this appears to be an opportunity for practice and quality improvement and for education.

PMID: 21490270 [PubMed - as supplied by publisher]

Patient Satisfaction With Hospitalists: Facility-Level Analyses.

Am J Med Qual. 2011 Mar 1;

Authors: Fulton BR, Drevs KE, Ayala LJ, Malott DL

Despite concerns and disagreements about the impact of hospitalist models on health care, hospitalists are becoming the dominant means of providing inpatient care, and models continue to diversify. Understanding their impact and the factors that influence their adoption is essential. This study examined hospitalists' impact on patient satisfaction, considering a host of characteristics. Cross-sectional data received in calendar year 2008, aggregated to the facility level, represent 1777 hospitals (41% of which employed hospitalists) and 2 648 275 patients. Press Ganey's psychometrically sound inpatient satisfaction survey consists of 38 items (10 sections) rated on a 5-point Likert-type scale. Findings suggest that facilities with hospitalists may have an advantage regarding satisfaction with nursing and personal issues (eg, privacy, emotional needs, response to complaints), both of which may be related to broader communication issues. Moreover, teaching (overall satisfaction) and large facilities (satisfaction with admissions, nursing, and tests/treatments) might especially benefit from the presence of hospitalists. Exploring how specific hospitalist functions influence patient satisfaction may reap rewards.

PMID: 21364030 [PubMed - as supplied by publisher]

Management of difficult airways using a hospital-wide "Alpha Team" approach.

Am J Med Qual. 2010 Jul-Aug;25(4):297-304

Authors: Long L, Vanderhoff B, Smyke N, Shaffer LE, Solomon J, Steuer JD

Airway management is germane to safe patient care. Keys to management of difficult airways (DAs) are the "Right People, Right Parts, and Right Place" (R3P3). Successful management of DA requires clinicians who have adequate training, experience, and equipment. Policies were implemented to optimize the management of DAs. One identified inpatients with potential DAs, whereas the other addressed creation and deployment of "Alpha Teams" (ATs). In the event of impending respiratory compromise, an AT was called in the same manner as a code blue. Health care providers were educated about these process changes, and ATs were tested using computerized patient simulators and self-paced observations. Testing assessed performance before, immediately after, and 30 days after the seminar. Changes in, and retention of, knowledge about DAs was analyzed. The goal of the R3P3 was to identify DAs and then to bring a well-trained hospital-wide AT to the bedside to decrease response time, rapidly establish a definitive airway, and improve survivability in an airway emergency.

PMID: 20606209 [PubMed - indexed for MEDLINE]

Preprinted Standardized Orders Promote Venous Thromboembolism Prophylaxis Compared With Traditional Handwritten Orders: An Endorsement of Standardized Evidence-Based Practice.

Am J Med Qual. 2010 Aug 30;

Authors: Gaylis FD, Van SJ, Daneshvar MA, Gaylis GM, Gaylis JB, Sheela RB, Stern EJ, Hanson PB, Sur RL

The objective was to determine if a standardized process of care-namely, standardized evidence-based medical orders (SEBMOs)-improves physician compliance with venous thromboembolism (VTE) prophylaxis. A total of 61 physicians received information about VTE prophylaxis after introduction of an admission SEBMO. Hospitalists received enhanced presentations about SEBMOs and their value in VTE prevention; specialists did not. Data were analyzed for 2 cohorts of 249 at-risk patients: one cohort was admitted with SEBMOs and the other with handwritten orders. VTE prophylaxis was ordered for 70% (173 of 249) of the SEBMO cohort compared with 22% (55 of 249) of patients whose physicians handwrote orders (relative risk ratio = 2.97; 95% confidence interval = 2.33-3.79; P < .0001). Specialists, who did not receive the enhanced education, were more likely to use handwritten orders and less likely to comply with prophylaxis standards. Standardized orders promote VTE prophylaxis more than handwritten orders. More rigorous education is required to promote compliance with evidence-based standards of medical practice.

PMID: 20805424 [PubMed - as supplied by publisher]

Replacing an academic internal medicine residency program with a physician assistant--hospitalist model: a comparative analysis study.

Am J Med Qual. 2009 Mar-Apr;24(2):132-9

Authors: Dhuper S, Choksi S

This study describes a comparative analysis of replacing medical residents with physician assistants and hospitalists on patient outcomes in a community hospital. Prospective data during the physician assistants-hospitalists service for 2 years was compared with 2 years of retrospective data of the medical residents model. Outcome measures included mortality, adverse events, readmissions, and patient satisfaction. For physician assistants- hospitalists versus medical residents models, all-cause and case mix index-adjusted mortality was 107/5508 (1.94%) and 0.019 versus 156/5458 (2.85%) and 0.029, respectively (P < or = .001). The adverse event cases were 9 versus 5 ( P = .29), and the readmission rate within 30 days was 64 versus 69 (P = .34). Patient satisfaction was 95% versus 96% (P = .33). Quality of care provided by the physician assistants-hospitalists model was equivalent. All-cause and case mix index- adjusted mortality was significantly lower during the physician assistants-hospitalists period.Although the application of these findings to other institutions requires further study, the authors found no intrinsic barriers that would impede implementation elsewhere.

PMID: 19204122 [PubMed - indexed for MEDLINE]

Spirometry utilization after hospitalization for patients with chronic obstructive pulmonary disease exacerbations.

Am J Med Qual. 2009 Jan-Feb;24(1):61-6

Authors: Volkova NB, Kodani A, Hilario D, Munyaradzi SM, Peterson MW

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the US population. An area of improvement hinges on early detection and proper monitoring. Spirometry is an important interventional tool; its underuse among hospitalized patients with COPD could affect quality of care. This study evaluates spirometry use at the Community Medical Center-Sierra in hospitalized patients with COPD. A retrospective medical record review from January 1, 2000, to March 15, 2002, assesses 1507 inpatients with COPD. The effects are analyzed of age, sex, race/ethnicity, diagnosis, insurance status, disposition, and admitting service on spirometry use by physicians are analyzed. A questionnaire is used to evaluate the knowledge, attitudes, and behaviors of residents toward spirometry ordering. Baseline characteristics are similar between study groups. Only 3% of 1476 study patients have spirometry performed within the recommended time frame, and only 12.2% have at least 1 spirometry performed. Patients having a primary diagnosis of COPD have a greater likelihood of having spirometry performed (20.3% vs 11.1%, P < .001), as do patients who are discharged to home (13.4% vs 5.9%, P = .001). No significant effects are noted for sex, race/ethnicity, insurance status, or admitting service. The house staff surveys reveal that most do not know the indications for (72.0%) or how to order (46.0%) spirometry. Spirometry is underused among physicians who treat hospitalized patients with COPD. Future educational efforts aimed at improving physicians' ordering and use of spirometry are needed to address this disparity.

PMID: 19139465 [PubMed - indexed for MEDLINE]

The tipping point: the relationship between volume and patient harm.

Am J Med Qual. 2008 Sep-Oct;23(5):336-41

Authors: Pedroja AT

This study purports to show the relationship between volume and patient harm due to health care error. Using 5 measures of volume and incident reports weighted for patient harm over the course of 515 days, it is shown that increased volume is related to increased harm to patients. As the number of areas in the hospital experiencing high volume increased, the likelihood of patients sustaining serious harm because of health care error also increased. This is attributed to reaching system capacity causing support services (ie, lab, pharmacy, radiology, housekeeping and engineering) to be overwhelmed and unable to keep up with requests from caregivers.

PMID: 18820138 [PubMed - indexed for MEDLINE]