A 56-year-old with diarrhea and weakness

A 56-YEAR-OLD MAN presents to the emergency department with nausea, weakness, and exertional dyspnea, which have been going on for 1 week. He is sent by his primary care physician after being noted to be hypotensive with a weak, thready pulse. He has had diarrhea with intermittent abdominal pain over the past year, with 10 stools daily, including 3 or 4 at night. The stools are described as large, nonbloody, sticky, greasy, and occasionally watery. Stools are fewer when he curtails his food intake. The diarrhea is associated with occasional diffuse abdominal pain he describes as a burning sensation. He has no incontinence or tenesmus. He reports that he has unintentionally lost 137 lb (62 kg) over the past year. He has not taken over-the-counter antidiarrheal agents

Bedside Interprofessional Rounding: The View From the Patient's Side of the Bed

BACKGROUND: Bedside interprofessional rounding is gaining ground as a means to improve collaboration and patient outcomes, yet little is known regarding patients' perceptions of the practice. METHODS: This descriptive study used individual patient interviews to elicit views on interprofessional rounding from 35 patients at a large, urban hospital. RESULTS: The findings identified three major categories: 1) about the rounding process; 2) clinical information; and 3) the impact/value of bedside inter-professional rounding. DISCUSSION: Intentionally eliciting and responding to our patients' views of interprofessional rounding may help us design methods that are patient centered and effective

Simvastatin: A Risk Factor for Angioedema?

Objective. To report a case of simvastatin-induced angioedema in a patient with near nightly episodes of orofacial angioedema. Case Summary. A 75-year-old African American female presented to the emergency department with recurrent face, lip, and tongue swelling. The patient described frequent episodes of orofacial edema, with 4 emergency department visits over the previous 6 months. Her home medications were reviewed and simvastatin was identified as a possible contributing medication. Simvastatin was discontinued with resolution of the symptoms during hospitalization and a significant reduction in episodes. Discussion. Drug-induced angioedema has been documented with several agents, most commonly angiotensin-converting enzyme inhibitors. The association with different drug classes has led to several postulated pathways for the development of angioedema. Notable mechanisms include mediation by bradykinin, inhibition of arachidonic acid metabolism, and complement activation. Each pathway culminates in increasing vascular permeability causing fluid accumulation in subcutaneous tissues. While statin use has been associated with drug-induced angioedema in postmarketing reports, there are no published cases involving simvastatin. Use of the Naranjo probability scale demonstrated a probable relationship between simvastatin use and the patient’s recurrent angioedema. Conclusions. While statin use is not commonly associated with angioedema, clinicians must be aware of this possible adverse reaction. Consideration must also be given to potential drug interactions, increasing the risk of this adverse event

Prescriptions for Bedtime Sedatives After the Introduction of a General Admission Order Set at an Academic Health Center: The Potential and Pitfalls of Order Sets.

OBJECTIVE: This study describes the impact of modifications to a general admission order set on physician prescribing of 2 as-needed or pro re nata (PRN) bedtime sedatives. METHODS: The hospitalists at our institution have used a general medical admission order set since 2005. Zolpidem was the only as-needed (PRN) bedtime sedative option on the order set until trazodone was added in December 2008. Trazodone is preferred over zolpidem in the geriatric population. We identified patients admitted by the hospitalists between January 2007 and August 2013 who were prescribed with either zolpidem or trazodone as a PRN sedative. Patient demographics, date and time of the order, and number of sedative doses administered during the hospitalization were recorded. Orders placed within 12 hours of admission were attributed to admission orders. RESULTS: Between 2007 and 2013, the number of patients admitted by the hospitalists with an order for PRN trazodone on admission increased by 18-fold. During the same period, the number of admissions by the hospitalists increased by 2.3 times. Zolpidem orders exceeded those for trazodone in all age groups until 2008. After the addition of trazodone, its use exceeded that of zolpidem. Almost half (48%) of all patients did not have a dose of the PRN trazodone administered. CONCLUSIONS: Although order sets can be leveraged to align practitioners with established guidelines, the expediency of using medications on an order set may overcome physicians\u27 clinical judgment. The content of an order set therefore deserves careful scrutiny before implementation

Redesigning inpatient care: testing the effectiveness of an Accountable Care Team model

BACKGROUND US healthcare underperforms on quality and safety metrics. Inpatient care constitutes an immense opportunity to intervene to improve care. OBJECTIVE Describe a model of inpatient care and measure its impact. DESIGN A quantitative assessment of the implementation of a new model of care. The graded implementation of the model allowed us to follow outcomes and measure their association with the dose of the implementation. SETTING AND PATIENTS Inpatient medical and surgical units in a large academic health center. INTERVENTION Eight interventions rooted in improving interprofessional collaboration (IPC), enabling data-driven decisions, and providing leadership were implemented. MEASUREMENTS Outcome data from August 2012 to December 2013 were analyzed using generalized linear mixed models for associations with the implementation of the model. Length of stay (LOS) index, case-mix index–adjusted variable direct costs (CMI-adjusted VDC), 30-day readmission rates, overall patient satisfaction scores, and provider satisfaction with the model were measured. RESULTS The implementation of the model was associated with decreases in LOS index (P < 0.0001) and CMI-adjusted VDC (P = 0.0006). We did not detect improvements in readmission rates or patient satisfaction scores. Most providers (95.8%, n = 92) agreed that the model had improved the quality and safety of the care delivered. CONCLUSIONS Creating an environment and framework in which IPC is fostered, performance data are transparently available, and leadership is provided may improve value on both medical and surgical units. These interventions appear to be well accepted by front-line staff. Readmission rates and patient satisfaction remain challenging

Balancing patient-centered and safe pain care for non-surgical inpatients: clinical and managerial perspectives

Background: Hospitals and clinicians aim to deliver care that is safe. Simultaneously, they are ensuring that care is patient-centered, meaning that it is respectful of patients’ values, preferences, and experiences. However, little is known about delivering care in cases where these goals may not align. For example, hospitals and clinicians are facing the daunting challenge of balancing safe and patient-centered pain care for nonsurgical patients, due to lack of comprehensive care guidelines and complexity of this patient population. Methods: To gather clinical and managerial perspectives on the importance, feasibility, and strategies used to balance patient-centered care (PCC) and safe pain care for nonsurgical inpatients, we conducted in-depth, semi-structured interviews with hospitalists (n=10), registered nurses (n=10), and health care managers (n=10) from one healthcare system in the Midwestern United States. We systematically examined transcribed interviews and identified major themes using a thematic analysis approach. Results: Participants acknowledged the importance of balancing PCC and safe pain care. They envisioned this balance as a continuum, with certain patients for whom it is easier (e.g., opioid-naïve patient with a fracture), versus more difficult (e.g., patient with opioid use disorder). Participants also reported several strategies they use to balance PCC and safe pain care, including offering alternatives to opioids, setting realistic pain goals and expectations, and using a team approach. Conclusions: Clinicians and health care managers use various strategies to balance PCC and safe pain care for nonsurgical patients. Future studies should examine the effectiveness of these strategies on patient outcomes

Clinical perspectives on hospitals’ role in the opioid epidemic

Policymakers, legislators, and clinicians have raised concerns that hospital-based clinicians may be incentivized to inappropriately prescribe and administer opioids when addressing pain care needs of their patients, thus potentially contributing to the ongoing opioid epidemic in the United States. Given the need to involve all healthcare settings, including hospitals, in joint efforts to curb the opioid epidemic, it is essential to understand if clinicians perceive hospitals as contributors to the problem. Therefore, we examined clinical perspectives on the role of hospitals in the opioid epidemic

Clinician Perspectives on Unmet Needs for Mobile Technology Among Hospitalists:Workflow Analysis Based on Semistructured Interviews

Background: The hospitalist workday is cognitively demanding and dominated by activities away from patients’ bedsides. Although mobile technologies are offered as solutions, clinicians report lower expectations of mobile technology after actual use. Objective: The purpose of this study is to better understand opportunities for integrating mobile technology and apps into hospitalists’ workflows. We aim to identify difficult tasks and contextual factors that introduce inefficiencies and characterize hospitalists’ perspectives on mobile technology and apps. Methods: We conducted a workflow analysis based on semistructured interviews. At a Midwestern US medical center, we recruited physicians and nurse practitioners from hospitalist and inpatient teaching teams and internal medicine residents. Interviews focused on tasks perceived as frequent, redundant, and difficult. Additionally, participants were asked to describe opportunities for mobile technology interventions. We analyzed contributing factors, impacted workflows, and mobile app ideas. Results: Over 3 months, we interviewed 12 hospitalists. Participants collectively identified chart reviews, orders, and documentation as the most frequent, redundant, and difficult tasks. Based on those tasks, the intake, discharge, and rounding workflows were characterized as difficult and inefficient. The difficulty was associated with a lack of access to electronic health records at the bedside. Contributing factors for inefficiencies were poor usability and inconsistent availability of health information technology combined with organizational policies. Participants thought mobile apps designed to improve team communications would be most beneficial. Based on our analysis, mobile apps focused on data entry and presentation supporting specific tasks should also be prioritized. Conclusions: Based on our results, there are prioritized opportunities for mobile technology to decrease difficulty and increase the efficiency of hospitalists’workflows. Mobile technology and task-specific mobile apps with enhanced usability could decrease overreliance on hospitalists’ memory and fragmentation of clinical tasks across locations. This study informs the design and implementation processes of future health information technologies to improve continuity in hospital-based medicine.This work was supported by a pilot grant (PPO 15-401; AS) and a Center of Innovation grant (CIN 13-416, M Weiner), both from the United States Department of Veterans Affairs Health Services Research and Development. AS is supported in part by the following grants: KL2TR002530 (A Carroll, PI), and UL1TR002529 (A Shekhar, PI) from the National Institutes of Health, National Center for Advancing Translational Sciences, Clinical and Translational Sciences Award

“Clinical Characteristics, Outcomes and Prognosticators in Adult Patients Hospitalized with COVID-19”

Background: COVID-19 is a novel disease caused by SARS-CoV-2. Methods: We conducted a retrospective evaluation of patients admitted with COVID-19 to one site in March 2020. Patients were stratified into three groups: survivors who did not receive mechanical ventilation (MV), survivors who received MV and those who received MV and died during hospitalization. Results: There were 140 hospitalizations; 22 deaths (mortality rate 15.7%), 83 (59%) survived and did not receive MV, 35 (25%) received MV and survived; 18 (12.9%) received MV and died. Thee mean age of each group was 57.8 , 55.8 and 72.7 years respectively (p=.0001). Of those who received MV and died, 61% were male (p=.01). More than half the patients ( n=90, 64%) were African American. First measured d-dimer >575.5 ng/mL, procalcitonin > 0.24 ng/mL, LDH > 445.6 units/L and BNP > 104.75 pg/mL had odds ratios of 10.5, 5 , 4.5 and 2.9 respectively forMV (p 167.5 pg/mL had an odds ratio of 6.7 for inpatient mortalitywhen mechanically ventilated (p= .02).Conclusions: Age and gender may impact outcomes in COVID-19. D-dimer, procalcitonin, LDH and BNP may serve as early indicators of disease trajectory

Reframing Academic Productivity, Promotion and Tenure As a Result of the COVID-19 Pandemic

Faculty members have been impacted in a multitude of ways by the COVID-19 pandemic. In particular, faculty seeking promotion and tenure have been impacted by the disruption and inconsistent levels of productivity. In this article, we consider academic productivity in the context of clinical, research, education and service missions within higher education and the academic medicine professoriate. We offer a series of recommendations to faculty members, to institutions, and to professional societies in hopes we can challenge pre-existing deficits in promotion and tenure processes, and academic worth