General Internal Medicine Units Research Articles

Prevalence, clinical characteristics, and health outcomes of dysmagnesemia measured by ionized and total body concentrations among medically hospitalized patients

Ionized Mg (iMg) may offer a more reliable indicator of Mg status during acute illness than total Mg (tMg) concentrations. This study aimed to determine the prevalence of dysmagnesemia and their relationship using iMg and tMg. The clinical and biochemical characteristics as well as health outcomes and their association with iMg and tMg were also assessed. A prospective study including all eligible adult patients (≥18 years) who were hospitalized in the General Internal Medicine unit at Sultan Qaboos University Hospital (SQUH) for 3.5 months in 2023. The iMg and tMg concentrations were collected on all at the admission. In total 500 patients were included (females 49.2%) with a median age of 64.5 years (IQR: 48-77). The prevalence of hypomagnesemia and hypermagnesemia by iMg concentrations was 3.4% and 26.6%, respectively, while by tMg concentrations 13.2% and 11.0%, respectively. The agreement between both measurements was strong (r=0.665, p<0.01). An increased tMg concentration was independently associated with high dependency units’ admission (adjusted odds ratio (aOR): 4.34, 95%CI: 1.24-15.06, p=0.02) and cardiac arrest (aOR: 14.64, 95%CI: 3.04-70.57, p<0.01), and 6-month all-cause mortality (aOR: 11.44, 95%CI: 2.46-53.17, p<0.01). During follow-up hypermagnesemia using tMg had a higher mortality compared to other groups (hazard ratio (HR): 1.82, 95%CI: 1.11-3.01, p=0.02) while no significant findings were demonstrated using iMg concentrations. iMg and tMg concentrations had a strong correlation that might be supporting the potential use of point-of-care devices. Multivariant regression analysis showed that hypermagnesemia by tMg was associated with adverse outcomes. However, the generalizability of the study findings should be taken with caution and the difference in the associations with outcomes highlight the importance of further research to examine the complex associations and impacts of dysmagnesemia in various clinical settings.

Impact of Constipation on Health Outcomes in Medically Hospitalized Patients: A Prospective Study on Laxative Use and Health Care Outcomes

Background and Objectives: Constipation affects health-related quality of life and increases hospital visits. We conducted this prospective cohort study to assess laxative use, health outcomes of constipation in medically hospitalized patients, and related health outcomes. Materials and Methods: A prospective single-center study included all adult patients admitted under the General Internal Medicine Unit from 1 February 2022, to 31 August 2022. Constipation was defined using the Constipation Assessment Scale (CAS). Patients were assessed for 28 days during their hospital stay and up to 90 days post-discharge. Result: Among the included patients, 62.45% experienced constipation, which was associated with poor health outcomes including delirium (p = 0.048), intensive care admission (p &lt; 0.01), cardiopulmonary arrest (p &lt; 0.01), inpatient mortality (p &lt; 0.01), longer hospital stay (p &lt; 0.01), 90-day mortality (p &lt; 0.01), and 90-day hospital readmission (p &lt; 0.01). Laxative treatment was administered to only 33.93% of patients with constipation and was more commonly used among older patients (p &lt; 0.01), those with high CAS scores (p &lt; 0.01), longer hospital stays (p &lt; 0.01), and critically ill patients (intensive care admission) (p = 0.01), as well as those who had cardiopulmonary arrest (p &lt; 0.01) and high inpatient mortality (p &lt; 0.01). Conclusions: This study identified several associations between constipation and poor health outcomes and highlighted the underutilization of laxatives in treating constipation. It is vital to interpret our results with caution. Therefore, we believe that a randomized controlled trial will help enhance our understanding of the interaction between constipation, laxative use, and poor health outcomes.

Clinical evaluation of a machine learning-based early warning system for patient deterioration.

The implementation and clinical impact of machine learning-based early warning systems for patient deterioration in hospitals have not been well described. We sought to describe the implementation and evaluation of a multifaceted, real-time, machine learning-based early warning system for patient deterioration used in the general internal medicine (GIM) unit of an academic medical centre. In this nonrandomized, controlled study, we evaluated the association between the implementation of a machine learning-based early warning system and clinical outcomes. We used propensity score-based overlap weighting to compare patients in the GIM unit during the intervention period (Nov. 1, 2020, to June 1, 2022) to those admitted during the pre-intervention period (Nov. 1, 2016, to June 1, 2020). In a difference-indifferences analysis, we compared patients in the GIM unit with those in the cardiology, respirology, and nephrology units who did not receive the intervention. We retrospectively calculated system predictions for each patient in the control cohorts, although alerts were sent to clinicians only during the intervention period for patients in GIM. The primary outcome was non-palliative in-hospital death. The study included 13 649 patient admissions in GIM and 8470 patient admissions in subspecialty units. Non-palliative deaths were significantly lower in the intervention period than the pre-intervention period among patients in GIM (1.6% v. 2.1%; adjusted relative risk [RR] 0.74, 95% confidence interval [CI] 0.55-1.00) but not in the subspecialty cohorts (1.9% v. 2.1%; adjusted RR 0.89, 95% CI 0.63-1.28). Among high-risk patients in GIM for whom the system triggered at least 1 alert, the proportion of non-palliative deaths was 7.1% in the intervention period, compared with 10.3% in the pre-intervention period (adjusted RR 0.69, 95% CI 0.46-1.02), with no meaningful difference in subspecialty cohorts (10.4% v. 10.6%; adjusted RR 0.98, 95% CI 0.60-1.59). In the difference-indifferences analysis, the adjusted relative risk reduction for non-palliative death in GIM was 0.79 (95% CI 0.50-1.24). Implementing a machine learning-based early warning system in the GIM unit was associated with lower risk of non-palliative death than in the pre-intervention period. Machine learning-based early warning systems are promising technologies for improving clinical outcomes.

Effectiveness of an Artificial Intelligence–Enabled Intervention for Detecting Clinical Deterioration

Inpatient clinical deterioration is associated with substantial morbidity and mortality but may be easily missed by clinicians. Early warning scores have been developed to alert clinicians to patients at high risk of clinical deterioration, but there is limited evidence for their effectiveness. To evaluate the effectiveness of an artificial intelligence deterioration model-enabled intervention to reduce the risk of escalations in care among hospitalized patients using a study design that facilitates stronger causal inference. This cohort study used a regression discontinuity design that controlled for confounding and was based on Epic Deterioration Index (EDI; Epic Systems Corporation) prediction model scores. Compared with other observational research, the regression discontinuity design facilitates causal analysis. Hospitalized adults were included from 4 general internal medicine units in 1 academic hospital from January 17, 2021, through November 16, 2022. An artificial intelligence deterioration model-enabled intervention, consisting of alerts based on an EDI score threshold with an associated collaborative workflow among nurses and physicians. The primary outcome was escalations in care, including rapid response team activation, transfer to the intensive care unit, or cardiopulmonary arrest during hospitalization. During the study, 9938 patients were admitted to 1 of the 4 units, with 963 patients (median [IQR] age, 76.1 [64.2-86.2] years; 498 males [52.3%]) included within the primary regression discontinuity analysis. The median (IQR) Elixhauser Comorbidity Index score in the primary analysis cohort was 10 (0-24). The intervention was associated with a -10.4-percentage point (95% CI, -20.1 to -0.8 percentage points; P = .03) absolute risk reduction in the primary outcome for patients at the EDI score threshold. There was no evidence of a discontinuity in measured confounders at the EDI score threshold. Using a regression discontinuity design, this cohort study found that the implementation of an artificial intelligence deterioration model-enabled intervention was associated with a significantly decreased risk of escalations in care among inpatients. These results provide evidence for the effectiveness of this intervention and support its further expansion and testing in other care settings.

Melatonin does not reduce delirium severity in hospitalized older adults: Results of a randomized placebo-controlled trial.

Delirium is common in older inpatients, causing distress, cognitive decline, and death. Current therapies are unsatisfactory, limited by lack of efficacy and adverse effects. There is an urgent need for effective delirium treatment. Sleep wake cycle is disturbed in delirium; endogenous Melatonin is perturbed, and exogenous Melatonin is a safe and effective medication for sleep disorders. This study aims to determine the effect of oral Melatonin 5 mg immediate release (IR) nightly for five nights on the severity of delirium in older (≥65 years) medical inpatients. This was a double-blinded, randomized controlled trial in general internal medicine units of a tertiary teaching hospital. Older inpatients with Confusion Assessment Method positive, hyperactive or mixed delirium within 48 h of admission or onset of in-hospital delirium were included. The primary outcome was change in delirium severity measured with the Memorial Delirium Assessment Scale (MDAS). A previous pilot trial showed 120 participants randomized 1:1 to Melatonin or Placebo would provide 90% power to demonstrate a 3-point reduction in the MDAS. One hundred and twenty participants were randomized, 61 to Melatonin 5 mg and 59 to Placebo. The medication was well tolerated. The mean MDAS improvement was 4.9 (SD 7.6) in the Melatonin group and 5.4 (SD 7.2) in the Placebo group, p-value 0.42, a non-significant difference. A post-hoc analysis showed length of stay (LOS) was shorter in the intervention group (median 9 days [Interquartile Range (IQR) 4, 12] vs. Placebo group 10 [IQR 6, 16] p-value = 0.033, Wilcoxon Rank Sum test). This trial does not support the hypothesis that Melatonin reduces the severity of delirium. This may be due to no effect of Melatonin, a smaller effect than anticipated, an effect not captured on a multidimensional delirium assessment scale, or a type II statistical error. Melatonin may improve LOS; this hypothesis should be studied.

Incidence of Dysmagnesemia among Medically Hospitalized Patients and Associated Clinical Characteristics: A Prospective Cohort Study.

Magnesium (Mg) disorders are common among hospitalized patients and are linked to poor health outcomes. We aimed to determine the incidence of dysmagnesemia among medically hospitalized patients and to identify factors that are associated with dysmagnesemia. A prospective cohort study was conducted at Sultan Qaboos University Hospital (SQUH) from April 1st, 2022, to October 31st, 2022, and involved hospitalized adult patients (≥18 years) under the care of the general internal medicine unit. The patients' serum total magnesium (Mg) concentrations were categorized as hypomagnesemia (≤0.69 mmol/L), hypermagnesemia (≥1.01 mmol/L), or dysmagnesemia, which encompassed either hypomagnesemia or hypermagnesemia. Of the 304 patients evaluated, dysmagnesemia was observed in 22.0%, which comprised of 17.4% with hypomagnesemia and 4.6% with hypermagnesemia. Statistically significant associations were identified between hypermagnesemia and chronic kidney disease (CKD) (p = 0.05) and elevated creatinine levels (p < 0.01) and lower estimated glomerular filtration rate (eGFR) (p < 0.01). Hypomagnesemia was linked to lower ionized calcium (p = 0.03) and admission due to infectious diseases (p = 0.02). However, ordered regression analysis did not find any significant associations with the different magnesium groups. Dysmagnesemia was prevalent among hospitalized patients and was associated with different factors; however, ordered regression analysis did not find any association with the different magnesium group, probably due to the limited number of included individuals.

The Burden of Sickle Cell Disease in Saudi Arabia: A Single-Institution Large Retrospective Study.

Sickle cell disease (SCD) is a significant burden for patients and healthcare systems due to multiple factors, including high readmission rates. This study aimed to determine the general characteristics, etiology of admissions, annual admission rate, length of stay, and readmission rate of patients with SCD. This retrospective observational study included all adult patients with SCD admitted to the General Internal Medicine (GIM) unit between 2016 and 2021. There were 160 patients (mean age, 31.08 ± 9.06 years; 51.25% female) with SCD included in this study. Most originated from southern Saudi Arabia (45.62%). The average annual number of emergency department (ED) visits was 4, and approximately 19% of patients had ≥3 annual admissions. The mean length of stay was 6 days. The readmission rates at 7, 30, 60, and 90 days were 8%, 24.5%, 13.6%, and 10.8%, respectively. SCD generates a significant economic burden on the Saudi society and the effects on the healthcare system and patients' quality of life are evident in the high ED visits, readmission rates and prolonged hospitalization. Thereupon we advocate the implementation of sickle cell disease-specialized multidisciplinary clinics.

Incidence and Risk Factors for 28 Days Hospital Readmission: A Retrospective Study from Oman.

ObjectivesWe sought to evaluate the incidence of 28-day hospital readmission in a tertiary hospital in Oman and identify potential factors associated with increased risk of hospital readmission.MethodsWe conducted a retrospective study of all adult patients (≥ 18 years) admitted under the care of the General Internal Medicine unit from 1 June to 31 December 2020 at Sultan Qaboos University Hospital. Elective admissions and COVID-19 infection-related admission were excluded from the study.ResultsThere were 200 patients admitted during the study period. The mean age was 58.6±19.3 years, and 106 (53.0%) patients were males. Forty-eight (24.0%) patients had unplanned readmission within 28-days after discharge from the hospital. Patients with 28 days unplanned readmission were older (66.6 vs. 56.0 years, p < 0.001) and had a longer length of hospital stay (6.0 vs. 4.0 days, p < 0.001). Also, hypertension (77.1% vs. 55.3%, p =0.007), diabetes mellitus (64.6% vs. 48.0%, p =0.045), and comorbidity (≥ 3 comorbidities, [43.8% vs. 23.8%, p =0.005]) were more prevalent in the unplanned readmission group. Patients with poor functional status (43.7% vs. 26.3%, p < 0.001), requiring feeding tube (25.0% vs. 5.3%, p < 0.001), and with polypharmacy (75.0% vs. 50.0%, p =0.003) were at increased risk of readmission.Conclusions28-day hospital readmission is prevalent in our health care setting. Old age, polypharmacy, comorbidities, and poor functional status were associated with an increased risk of hospital readmission. Therefore, evidence-based interventions must be implemented in our health care system to minimize the risk of hospital readmission.

Impact of low health literacy on patients’ health outcomes: a multicenter cohort study

BackgroundThis study aims to assess the health literacy of medical patients admitted to hospitals and examine its correlation with patients’ emergency department visits, hospital readmissions, and durations of hospital stay.MethodsThis prospective cohort study recruited patients admitted to the general internal medicine units at the two urban tertiary care hospitals. Health literacy was measured using the full-length Test of Functional Health Literacy in Adults. Logistic regression analyses were performed to examine the correlation between health literacy and the desired outcomes. The primary outcome of interest of this study was to determine the correlation between health literacy and emergency department revisit within 90 days of discharge. The secondary outcomes of interest were to assess the correlation between health literacy and length of stay and hospital readmission within 90 days of discharge.ResultsWe found that 50% had adequate health literacy, 32% had inadequate, and 18% of patients had marginal health literacy. Patients with inadequate health literacy were more likely to revisit the emergency department as compared to patients with adequate health literacy (odds ratio: 3.0; 95% Confidence Interval: 1.3–6.9, p = 0.01). In patients with inadequate health literacy, the mean predicted probability of emergency department revisits was 0.22 ± 0.11 if their education level was some high school or less and 0.57 ± 0.18 if they had completed college. No significant correlation was noted between health literacy and duration of hospital stay or readmission.ConclusionsOnly half of the patients admitted to the general internal medicine unit had adequate health literacy. Patients with low health literacy, but high education, had a higher probability of emergency department revisits.

Knowledge, perspectives and health outcome expectations of antibiotic therapy in hospitalized patients

SummaryBackgroundThe World Health Organization (WHO) has recognized antimicrobial resistance (AMR) as a top threat to global health. However, the public has an incomplete understanding of AMR and its consequences.AimThe aim of this study was to explore patients’ understanding, perspective and health outcome expectations for antibiotic therapy within an inpatient internal medicine population.MethodsA mixed methods study, combining a cross-sectional survey with qualitative methods. Fourteen questions (10 paper survey and four open ended interview questions) were used, and were completed by the participant in one sitting. Participants were recruited from General Internal Medicine units at two academic hospitals in Canada (convenience sample).FindingsThirty participants were included. Out of a scale of 1–100%, participants indicated moderate concern (mean of 40%) about getting an infection that could not be cured by antibiotics. The majority agreed that they trusted their healthcare team to decide on appropriate antibiotic therapy (mean of 81%). The participants strongly agreed (mean of 90%) that it was important to understand the rationale for their antibiotic therapy. Three themes emerged from the qualitative analysis: 1) varying levels of knowledge; 2) viewing antibiotics as beneficial while emphasizing effectiveness; and 3) trusting the healthcare team with expectations for inclusion in decision making.ConclusionThe study results showed varying levels of patients’ antibiotic knowledge and large gaps in awareness related to AMR. Exploring the role and workflow of interdisciplinary healthcare professionals may be a potential strategy to minimize patients’ knowledge gap related to antimicrobial therapy and AMR.

Inappropriate Hospital Stay of Patients Admitted Under Care of General Medicine Units: A retrospective study.

This study aimed to assess the incidence of inappropriate hospital stay and to identify the reasons behind inappropriate hospitalisation. This retrospective cohort study included patients admitted in the General Internal Medicine Unit, Sultan Qaboos University Hospital, Muscat, Oman, from January to June 2020. The average length of hospital stay for all included patients was calculated. The appropriateness evaluation protocol technique was used to examine admissions that exceeded the average length of hospital stay; subsequently, the reasons for the inappropriate hospital stay were identified. There were 855 admissions during the study period. In this cohort, 53.1% were male and the median age was 64 years (interquartile range [IQR]: 44-75 years). There was a total of 6,785.4 hospitalisation days and the average length of hospital stay was five days (IQR: 3-9 days). A total of 31.8% of admissions (n = 272) and 9.9% of hospitalisation days (n = 674 days) were classified as inappropriate. Delay in complementary tests (29.0%) and unavailability of extra hospital resources (21.7%) were identified as the most common reasons associated with inappropriate hospital stays. Old age was associated with increase in inappropriate hospital stay. A significant proportion of hospitalisation days were inappropriate due to hospital-related factors. Therefore, auditing hospital services and investing in home-based care are among the top strategies that are likely to improve early discharge and minimise inappropriate hospital bed occupancy.

Risk Factors of Venous Thromboembolism in Noncritically Ill Patients Hospitalized for Acute COVID-19 Pneumonia Receiving Prophylactic-Dose Anticoagulation.

Background: Therapeutic/intermediate-dose heparin reduces the risk of thromboembolic events but increases the risk of major bleeding in patients hospitalized for acute COVID-19 pneumonia. Objectives: To prospectively assess the incidence of objectively proven venous thromboembolism (VTE) and identify predisposing risk factors in a cohort of hospitalized patients with acute COVID-19 pneumonia undergoing prophylactic-dose heparin. Patients and methods: All consecutive patients admitted for acute COVID-19 pneumonia to the General Internal Medicine Unit of Padova University Hospital, Italy between November 2020 and April 2021, and undergoing prophylactic-dose heparin, were enrolled. Demographic and clinical characteristics and laboratory and radiological findings were recorded on admission. Cases were patients who developed VTE during their hospital stay. Univariable and multivariable logistic regression analyses were used to ascertain the risk factors associated with developing in-hospital VTE. Results: 208 patients (median age: 77 years; M/F 98/110) were included; 37 (18%) developed in-hospital VTE during a median follow-up of 10 days (IQR, 4–18). VTE patients were significantly younger (p = 0.004), more obese (p = 0.002), and had a lower Padua prediction score (p < 0.03) and reduced PaO2/FIO2 ratio (p < 0.03) vs. controls. Radiological findings of bilateral pulmonary infiltrates were significantly more frequent in VTE patients than controls (p = 0.003). Multivariable regression showed that obesity (1.75, 95% CI 1.02–3.36; p = 0.04) and bilateral pulmonary infiltrates on X-rays (2.39, 95% CI 1.22–5.69; p = 0.04) were correlated with increased risk of in-hospital VTE. Conclusions: Obesity and bilateral pulmonary infiltrates on imaging may help clinicians to identify patients admitted to medical wards for acute COVID-19 pneumonia at risk of developing VTE despite prophylactic-dose heparin. Further studies are needed to evaluate whether the administration of therapeutic/intermediate-dose heparin may help prevent VTE episodes without further increasing the bleeding risk.

Australian public hospital inpatient satisfaction related to early patient involvement and shared decision-making in discharge planning.

BackgroundSurveys of hospital inpatient satisfaction may help develop actionable plans for quality improvement, and patients have preferred to give feedback during admission at the point of service compared to after discharge. However, patient satisfaction measurement has often been done by questionnaires post‐discharge, and without focussing on an Australian general internal medicine setting.AimsTo understand patients' perceptions of their admission experiences in an Australian public teaching hospital's general internal medicine unit, and to understand the opportunities for quality improvement.MethodsA prospective study of 50 inpatients of a general internal medicine unit at an Australian public teaching hospital was carried out using a patient satisfaction questionnaire given to patients on the day of discharge.ResultsPatients perceived deficits in early communication about discharge destination planning, and provision of written discharge instructions. Responses highlighted the importance of checking with patients to elicit further information that was not previously captured during initial history‐taking, patient‐centred communication to enable informed consent and decision making, use of language readily understandable to laypersons, and checking for patients' understanding of messages as communicated by the treating clinician.ConclusionsIn an Australian general internal medicine service, early involvement and shared decision‐making in discharge planning are valued by patients. Incorporating checking of patients' understanding of diagnoses, management, discharge instructions, and follow‐up plans into ward round routines may benefit patient satisfaction. This study stimulates further research into the use of a proforma to capture and check patients' understanding of discharge diagnoses and plans.

Factors Associated with Readmission Among General Internal Medicine Patients Experiencing Homelessness.

People who are homeless have a higher burden of illness and higher rates of hospital admission and readmission compared to the general population. Identifying the factors associated with hospital readmission could help healthcare providers and policymakers improve post-discharge care for homeless patients. To identify factors associated with hospital readmission within 90 days of discharge from a general internal medicine unit among patients experiencing homelessness. This prospective observational study was conducted at an urban academic teaching hospital in Toronto, Canada. Interviewer-administered questionnaires and chart reviews were completed to assess medical, social, processes of care, and hospitalization data. Multivariable logistic regression with backward selection was used to identify factors associated with a subsequent readmission and estimate odds ratios and 95% confidence intervals. Adults (N = 129) who were admitted to the general internal medicine service between November 2017 and November 2018 and who were homeless at the time of admission. Unplanned all-cause readmission to the study hospital within 90 days of discharge. Thirty-five of 129 participants (27.1%) were readmitted within 90 days of discharge. Factors associated with lower odds of readmission included having an active case manager (adjusted odds ratios [aOR]: 0.31, 95% CI, 0.13-0.76), having informal support such as friends and family (aOR: 0.25, 95% CI, 0.08-0.78), and sending a copy of the patient's discharge plan to a primary care physician who had cared for the patient within the last year (aOR: 0.44, 95% CI, 0.17-1.16). A higher number of medications prescribed at discharge was associated with higher odds of readmission (aOR: 1.12, 95% CI, 1.02-1.23). Interventions to reduce hospital readmission for people who are homeless should evaluate tailored discharge planning and dedicated resources to support implementation of these plans in the community.

Results from a double blinded, randomised, placebo-controlled, feasibility trial of melatonin for the treatment of delirium in older medical inpatients.

Delirium is common in elderly inpatients, causing distress, cognitive decline and death. No known intervention improves the course of delirium; current treatments are symptomatic, and limited by lack of efficacy and adverse effects. There is an urgent need to find an effective treatment for delirium. To determine the feasibility of a trial of oral melatonin 5 mg nightly for five nights for the treatment of delirium in older medical inpatients, and determine the participants required to demonstrate a clinically and statistically significant decrease in severity of delirium in older medical inpatients treated with melatonin. This was a double blinded, randomised controlled trial in general internal medicine units of a tertiary teaching hospital. Older (≥70 years) inpatients with confusion assessment method positive hyperactive or mixed delirium were suitable for inclusion. Subjects received melatonin 5 mg oral nightly for five nights or matching placebo. The primary outcome was the Memorial Delirium Assessment Scale (MDAS) administered daily. No adverse effects occurred due to melatonin. In the treatment group, the mean change in MDAS from baseline during treatment period was 2.5 ± 5.0 points, in the placebo group, 2.1 ± 4.1 points, a non-significant difference. A power calculation accounting for drop-out (31.0%), suggests 120 participants would be required to demonstrate with 90% power that melatonin 5 mg reduces the severity of delirium by 3 points or more on MDAS. A trial of the hypothesis that 5 mg melatonin nightly for five nights reduces delirium severity in older medical inpatients would require 120 patients, and is feasible.

Empowering nurses and residents to improve telemetry stewardship in the academic care setting.

Inappropriate use of telemetry frequently occurs in the inpatient, non-intensive care unit setting. Telemetry practice standards have attempted to guide appropriate use and limit the overuse of this important resource with limited success. Clinical-effectiveness studies have thus far not included care settings in which resident-physicians are the primary caregivers. We implemented two interventions on general internal medicine units of an academic hospital. The first intervention, or nurse-discontinuation protocol, allowed nurses to trigger the discontinuation of telemetry once the appropriate duration had passed according to practice standards. The second intervention, or physician-discontinuation protocol, instituted a best-practice advisory that notified the resident-physician via the electronic medical record when the appropriate telemetry duration for each patient had elapsed and suggested termination of telemetry. Data collection spanned 8 months following the implementation of the nurse-discontinuation protocol and 12 months following the physician-discontinuation protocol. During the control period, the average time spent on telemetry was 86.29 hours/patient/month. During the nurse-discontinuation protocol, patients spent, on average, 70.86 hours/patient/month on telemetry. During the physician-discontinuation protocol, patients spent, on average, 81.6 hours/patient/month on telemetry. During the nurse-discontinuation protocol, there was no significant change in the likelihood that a patient was placed on telemetry throughout their admission when compared with the control period. During the physician-discontinuation protocol, there was a significant decrease of 56.1% in the likelihood that a patient would be put on telemetry when compared with the control time period. These findings expand our understanding of telemetry use in the academic care setting in which trainees serve as the primary caregivers. Furthermore, these findings represent an important addition to the telemetry and patient monitoring literature by demonstrating the impact that nurse-managed protocols can have on telemetry use and by highlighting effective strategies to improve telemetry use by physicians in training.

Implementing the patient care collaborative model in three general internal medicine units: a mixed-methods healthcare improvement initiative

BackgroundAs part of the scale-up of the Patient Care Collaborative (PCC) at our institution, we explored staff perceptions and patient outcomes at different levels of model implementation in three general...

Preventing Catheter-Associated Urinary Tract Infection: A Multipronged Collaborative Approach.

Research has shown that catheter-associated urinary tract infections (CAUTIs) are highly preventable and have significant impact on patient morbidity and mortality as well as financial consequences for the health care system. CAUTI rates were documented to be higher in the general internal medicine units when compared with the overall hospital rates. A comparative analysis was undertaken. An interprofessional working group developed and implemented a quality improvement initiative bundled approach to reducing CAUTIs. There was a 79% reduction in average CAUTI rates following the bundle implementation along with reduced variability in rates. Implementation of a standardized bundle of practices aimed at reducing CAUTIs resulted in decreased CAUTI rates. Organizations can use the design and implementation approach to reduce and minimize CAUTI rates, which can positively impact cost, care experience, and outcomes.

1057. The Impact of Temporary Suspensions of an Antimicrobial Stewardship Audit and Feedback Program on Antimicrobial Utilization of General Internal Medicine Inpatients

BackgroundA goal of Antimicrobial Stewardship Programs (ASP) is to optimize antimicrobial use; many using audit and feedback (AAF). Although AAF decreases unnecessary target antimicrobial use, it is resource-intensive. As a result, temporary suspensions in AAF activity may occur from human resource limitations or other factors. We describe the impact of these temporary suspensions and intensity of care on antimicrobial utilization trends.MethodsThis retrospective study describes the initiation and temporary suspensions of AAF in the General Internal Medicine (GIM) unit at an urban teaching hospital. Data were collected over 65 months. During active-AAF, a dedicated ID trained clinical pharmacist and ID physician-reviewed antimicrobial use for all GIM patients and provided patient-specific advice to physicians. Antimicrobial use was measured by Defined Daily Doses (DDD) normalized per 1,000 patient-days. To assess the impact of temporary suspensions, data were compared in two ways: 1. All nonactive-AAF time-frames were compared with active AAF 2. Pre-ASP was compared with Post-ASP Initiation which includes suspension periods. To determine whether differences in trends were seen based on acuity level of the patients (identified at admission as benefiting from frequent monitoring), analyses were repeated after stratification of patients admitted to the Step-Up unit (GIM-SU) and the regular ward (GIM-W).ResultsComparing nonactive AAF vs. active-AAF, significant changes (P < 0.05) in mean normalized DDD were observed for total antimicrobials (-19%), antipseudomonals (-21%) fluoroquinolones (−41%) and first-generation β lactams (−30%). Pre ASP vs. Post ASP comparisons showed similar but less pronounced trends. Following stratification to GIM-SU and GIM-W, greater variation in significant changes to targeted antimicrobials between comparisons was observed. Different significant antimicrobial changes were seen in SU vs. W.ConclusionOur results show that the temporary suspension of ASP AAF impacts antimicrobial utilization trends. Greater sustained decreases in targeted antimicrobials utilization were associated with active AAF. Stratification by patient acuity lead to increased variation in the impact on target antimicrobials and increased the impact of suspension. Disclosures All authors: No reported disclosures.

Enhanced communication between inpatient and community pharmacists to optimize medication management during transitions of care

ObjectivesTo describe the Pharmacy Communication Partnership (PROMPT) program’s approach to improving medication management for patients during transitions from hospital to the community. SettingTwo general internal medicine units within a multisite academic hospital in Canada. Practice innovationDesigned by an interprofessional working group, PROMPT uses evidence-informed approaches to facilitate communication between pharmacists in different settings: faxing of the discharge prescription and medical discharge summary to a patient’s community pharmacy, followed by a telephone call to the community pharmacist. EvaluationA multimethod cross-sectional study used telephone surveys and retrospective chart reviews to describe: 1) the characteristics of patients that hospital pharmacists thought would benefit from PROMPT and the community pharmacies that served them; 2) the number and nature of communication attempts made by community and hospital pharmacists; and 3) community pharmacists’ views about PROMPT’s potential impact on continuity of care and potential program enhancements. ResultsA convenience sample of 100 patients (median age 77 years, interquartile range 66 to 83) who received care from 86 pharmacies were used to evaluate the program. The majority of community pharmacists participating in the surveys considered the intervention to be helpful. Of the 53.7% (n = 44/82) community pharmacists who received discharge summaries, 93.2% (n = 41/44) found the summaries to be useful. Themes arising from community pharmacists’ comments were categorized into 3 topics: 1) the benefits of PROMPT; 2) topics of discussion and clarification during telephone calls with hospital pharmacists; and 3) future program improvements. ConclusionCommunity pharmacists described PROMPT as a time-efficient and helpful bridge linking community pharmacy to hospital inpatient care. Opportunities for future research include determining the characteristics of patients who may benefit most from PROMPT, determining the optimal components of discharge information needed by community pharmacists to enhance medication management, and evaluating whether follow-up telephone calls from the hospital to community pharmacists are necessary for all patients.