Inpatient Consult Service Research Articles

The effects of inpatient music therapy on self-reported symptoms at an academic cancer center: a preliminary report.

Music therapy has shown benefits for reducing distress in individuals with cancer. We explore the effects of music therapy on self-reported symptoms of patients receiving inpatient care at a comprehensive cancer center. Music therapy was available as part of an inpatient integrative oncology consultation service; we examined interventions and symptoms for consecutive patients treated by a board-certified music therapist from September 2016 to May 2017. Patients completed the Edmonton Symptom Assessment Scale (ESAS, 10 symptoms, scale 0-10, 10 most severe) before and after the intervention. Data was summarized by descriptive statistics. Changes in ESAS symptom and subscale scores (physical distress (PHS), psychological distress (PSS), and global distress (GDS)) were evaluated by Wilcoxon signed rank test. Data were evaluable for 96 of 100 consecutive initial, unique patient encounters; 55% were women, average age 50, and majority with hematologic malignancies (47%). Reasons for music therapy referral included anxiety/stress (67%), adjustment disorder/coping (28%), and mood elevation/depression (17%). The highest (worst) symptoms at baseline were sleep disturbance (5.7) and well-being (5.5). We observed statistically and clinically significant improvement (means) for anxiety (- 2.3 ± 1.5), drowsiness (- 2.1 ± 2.2), depression (- 2.1 ± 1.9), nausea (- 2.0 ± 2.4), fatigue (- 1.9 ± 1.5), pain (- 1.8 ± 1.4), shortness of breath (- 1.4 ± 2.2), appetite (- 1.1 ± 1.7), and for all ESAS subscales (all ps < 0.02). The highest clinical response rates were observed for anxiety (92%), depression (91%), and pain (89%). A single, in-person, tailored music therapy intervention as part of an integrative oncology inpatient consultation service contributed to the significant improvement in global, physical, and psychosocial distress. A randomized controlled trial is justified.

1909. Do Infectious Disease Services Save Money? Accounting Analysis Before and After Introduction of a New Clinical Infectious Disease Service at a Tertiary Hospital in New Zealand

BackgroundInfectious disease and antimicrobial stewardship services are generally held to be cost-saving in large healthcare facilities. Actual comparisons comparing costs before and after implementation of a clinical infectious disease (CID) service are lacking.MethodsOur 600+ bed tertiary hospital funded a CID service in 2015. Prior to this, CID expertise was largely provided by telephone consultation to a microbiologist and/or a part-time CID specialist with no nursing, pharmacy or resident medical officer (RMO) support. Out-patient IV antibiotics (OPIVA) were provided at the discretion of individual clinicians. The new CID team introduced an in-patient consult and OPIVA service. A management accounting analysis was undertaken to compare the total costs of care for patients admitted to OPIVA in financial years (FY) 2011 and 2012 (FY11/12) and 2016 (FY16). Short courses of out-patient therapy for cellulitis were excluded during both periods.ResultsIn FY11/12 and FY16, 144 and 145 patients were discharged to OPIVA. 51 of 191 patients (27%) with CID consults for suspected or proven bacterial infection were admitted to OPIVA in 2016. Age, sex, and diagnosis were similar in both groups. Ceftriaxone and glycopeptide use increased in the 2016 cohort. Drug-related adverse events were more common in 2016 whilst line complications did not change. There were two unexpected OPIVA deaths in FY11/12 and none in FY16. Reduced in-patient bed-days in 2016 saved NZD 1.45 million, with an additional NZD 157,000 saving in total drug costs. This represented a 276% return on investment against wage costs for the CID team.ConclusionIn our hospital, a CID team significantly reduced bed-days and drug costs for common infectious diseases.Disclosures All authors: No reported disclosures.

1308. Predictors of Career Interest in Infectious Diseases Among US Pharmacy Students

BackgroundPharmacists have a central role in infectious diseases (ID) and antibiotic stewardship efforts across multiple healthcare settings. The demand for pharmacist to fill ID and stewardship-related careers will likely increase as institutions create antibiotic stewardship programs in response to the 2016 Joint Commission standard. The objective of this study was to compare students’ perceptions of their school’s ID curriculum between students interested in an ID career and those who are not.MethodsA cross-sectional survey study of students graduating from US pharmacy schools was conducted in September 2017. Students received the survey link from the ID faculty at participating schools.ResultsFive hundred thirty-seven students from 28 pharmacy schools completed surveys. Quality of ID didactic education was rated as Very Good by 220 (41%), Good by 219 (40%), Acceptable by 76 (14%), and Poor by 22 (4%) respondents. The most common career interests were ambulatory care (44%), community practice (38%), and infectious diseases (29%). The most common preferred practice settings for students with an interest in ID (n = 157) were inpatient/hospital (86%), inpatient stewardship (70%), and inpatient ID consult service (66%). Differences in responses about didactic ID education between students interested in an ID career and those not interested included: perception of education as Very Good (52% vs. 37%, P = 0.005), faculty providing handouts and/or worksheets (89% vs. 82%, P = 0.009), and the desire for more time allocated to antibiotic stewardship (47% vs. 31%, P < 0.001). Multivariate logistic regression found variables to be predictive of pharmacy student interest in an ID career including: pharmacy school curriculum (OR 2.5, 95% CI 1.5–4.0), perception of a Very Good didactic ID education (OR 1.5, 95% CI 1.0–2.3), and faculty mentor(s) (OR 1.8, 95% CI 1.2–2.7).ConclusionPharmacy students expressing interest in ID as a career had positive views of their didactic ID education, were more likely to report faculty mentorship, and desired more time for antibiotic stewardship in the curriculum. These results can inform efforts to encourage pharmacy students to pursue careers in ID.Disclosures All authors: No reported disclosures.

Patients With Substance Use Disorders Leaving Against Medical Advice: Strategies for Improvement.

: In this issue of the Journal of Addiction Medicine, 2 studies fill an important gap in knowledge by examining predictors of leaving against medical advice from inpatient withdrawal management settings. The studies identify important risk factors for leaving against medical advice and highlight important areas for inpatient withdrawal management. These include the use of substance specific standardized protocols and initiation of opioid agonist treatment instead of opioid detoxification given harms associated with opioid withdrawal. Further need for increased training in addiction medicine for primary care physicians, and use of inpatient addiction medicine consult services as part of early intervention for substance withdrawal are also discussed.

Common Consumer Health-Related Needs in the Pediatric Hospital Setting: Lessons from an Engagement Consultation Service.

Informed and engaged parents may influence outcomes for childhood illness. Understanding the needs of the caregivers of pediatric patients is a critical first step in promoting engagement in their child's care. In 2014, we developed an Engagement Consultation Service at the Monroe Carell Jr. Children's Hospital at Vanderbilt. This service determines the health-related needs of the caregivers of hospitalized children and makes educational or technology recommendations to meet those needs and support engagement. This report describes the most common health-related needs identified in the caregivers of hospitalized pediatric patients and details the recommended interventions to meet those needs. The most commonly reported consumer health-related needs from our 3-year experience with the Engagement Consultation Service were extracted from consultations notes. Each need was classified by semantic type using a taxonomy of consumer health needs. Typical recommendations for each need and their administration were detailed. The most frequently recognized needs involved communicating with health care providers after discharge, using medical devices, distinguishing between benign and concerning symptoms, knowing what questions to ask providers and remembering them, finding trustworthy sources of information online, understanding disease prognosis, and getting emotional support. A variety of apps, Web sites, printed materials, and online groups were recommended. The parents of hospitalized patients share several common health-related needs that can be addressed with educational and technology interventions. An inpatient Engagement Consultation Service provides a generalizable framework for identifying health-related needs and delivers tools to meet those needs and promote engagement during and after hospitalizations.

Inpatient Palliative Care Consultations From a Canadian Clinical Teaching Unit: Who is Referred and When?

Inpatient palliative care consultation has been demonstrated to improve quality of life as well as decrease hospital readmissions, intensive care unit transfers, and hospital costs for people with a life limiting illness. The clinical teaching units (CTUs) at London Health Sciences Centre (LHSC) routinely admit patients with noncurable cancer as well as end-stage heart, lung, liver, or kidney disease. However, the use of inpatient palliative care consultations for CTU patients remains unexamined. We conducted a descriptive study of all patients referred from LHSC CTU from both University and Victoria hospital to inpatient palliative care over a 1-year period from August 2013 to July 2014. The purpose of this study was to characterize the population and identify possible areas for quality improvement. In a 1-year period, 638 patients were referred from CTU to the inpatient palliative care consultation service. Of referrals, 55% died during their admission. Based on data collected, we conclude that many patients are referred early in their admission to CTU and patients are referred for a variety of noncancer diseases, suggesting knowledge and appreciation of the benefit of early palliative care consultation for malignant and nonmalignant disease. However, when further analyzed, there is indication that patients with noncancer diagnoses are referred statistically significantly later than those with a cancer diagnosis. The CTUs are sites of core medical training, and therefore, it is imperative that we model early integration of palliative care in order to continue to improve care of patients at end of life.

Experience and Views of Oncology and Palliative Care Professionals on a Corounding Model of Care for Inpatients With Advanced Cancer.

Palliative care is associated with better outcomes in advanced cancer, but there is limited research comparing different models of palliative care delivery alongside oncology care. For inpatients with cancer, palliative care is mostly delivered through a consult service, primarily relying on oncologist-initiated referrals to a separate specialist palliative care team. In our hospital setting, we piloted a palliative care and oncology corounding model of care. To explore the views and experience of oncology and palliative care professionals on the corounding model compared to an inpatient consult service. A qualitative study nested within a pre-post study of the corounding model of care, with semistructured interviews using thematic analysis. Eleven doctors and nurses involved in the pilot corounding model were interviewed. Two main themes emerged: (1) the efficiency of care delivery and (2) quality of patient care. The theme on the efficiency of care delivery was related to access to palliative care input, team communications, and parallel workflow. The quality of patient care was described in terms of holistic approach to cancer care and rapport building with patients and their families. Most participants acknowledged positive aspects of the corounding model, yet some minor concerns were reported, such as disagreements between oncology and palliative care professionals. This study provides insights into the benefits and drawbacks of a corounding model of care for inpatients. The views of health-care professionals can be incorporated into the development of integrated oncology and palliative care models to improve care for patients with advanced cancer.

Neurological Symptoms in Palliative Care Patients.

Neurological expertise in palliative care may be required not only for patients with primary neurological disorders but also for patients with non-neurological diseases suffering from burdensome neurological symptoms. The aim of this study was to determine the prevalence of neurological diagnoses and symptoms in palliative care patients, as well as the related burden and impact on everyday life. We analyzed retrospectively the medical records of 255 consecutive patients from a tertiary medical center, at the time point of referral to an inpatient palliative care consultation service. In addition, 100 patients prospectively answered a questionnaire which included the assessment of neurological symptoms, as well as numeric rating scales for quality of life, symptom-specific burden, and restrictions in everyday life. Forty-one patients (16%) suffered from a primary neurological disease. Most decisions regarding the termination of life-sustaining measures concerned this group (20/22, 91%). Neurological symptoms (excluding pain) were documented in 122 patients (48%) with an underlying non-neurological disease. In the questionnaire study, 98/100 patients reported at least one neurological or neuropsychiatric symptom, most frequently sleeping problems (N = 63), difficulty concentrating (N = 55), and sensory symptoms (N = 50). Vertigo/dizziness (N = 19) had the greatest impact on everyday life (7.57/10 ± 2.17) and the highest symptom-specific burden (7.14 ± 2.51). Difficulty concentrating (restrictions in everyday life/burden) and pain intensity were the only symptoms significantly correlated with quality of life (r = -0.36, p = 0.009/r = -0.32; p = 0.04; r = -0.327, p = 0.003). Neurological diseases and symptoms are frequent among palliative care patients and are often associated with a high symptom burden, which may severely affect the patients' lives. It is thus of paramount importance to implement neurological expertise in palliative care.

Rural Readmissions in the Palliative Care Vacuum.

Palliative care consultation is associated with reduced health care costs and improved quality of life while reducing length of stay. Small rural hospitals lack the depth of multidisciplinary resources to provide inpatient palliative care consult services. The purpose of this research was to assess the need for palliative care service in rural hospitals, while examining for a difference in hospital readmission rates in hospitals lacking palliative consult services. Data were obtained from the Pennsylvania Health Cost Containment Counsel including 3 hospitals with palliative programs and 3 without. Inclusion criteria were admissions for a patient carrying a diagnosis appropriate for palliative consultation between the last quarter of 2014 and 2015. There were 1394 index patients admitted to 3 rural hospitals lacking a palliative consult program. There was a higher rate of readmissions at the nonpalliative hospitals, 71.6% versus 55.1% (P < .001). Data suggest there is a need for palliative telemedicine services to meet needs in rural hospitals.

Development and Implementation of an Inpatient Otolaryngology Consultation Service at an Academic Medical Center.

To design and implement a formal otolaryngology inpatient consultation service that improves satisfaction of consulting services, increases educational opportunities, improves the quality of patient care, and ensures sustainability after implementation. This was a retrospective cohort study in a large academic medical center encompassing all inpatient otolaryngology service consultations from July 2005 to June 2014. Staged interventions included adding fellow coverage (July 2007 onward), intermittent hospitalist coverage (July 2010 onward), and a physician assistant (October 2011 onward). Billing data were collected for incidences of new patient and subsequent consultation charges. The 2-year preimplementation period (July 2005-June 2007) was compared with the postimplementation periods, divided into 2-year blocks (July 2007-June 2013). Outcome measures of patient encounters and work relative value units were compared between pre- and postimplementation blocks. Total encounters increased from 321 preimplementation to 1211, 1347, and 1073 in postimplementation groups (P < 0.001). Total work relative value units increased from 515 preimplementation to 2090, 1934, and 1273 in postimplementation groups (P < 0.001). A formal inpatient consultation service was designed with supervisory oversight by non-Accreditation Council for Graduate Medical Education fellows and then expanded to include intermittent hospitalist management, followed by the addition of a dedicated physician assistant. These additions have led to the formation of a sustainable consultation service that supports the mission of high-quality care and service to consulting teams.

Social Worker as Leader on the Inpatient Consult Service: An Innovative Model for Palliative Care Delivery (QI823)

Social Worker as Leader on the Inpatient Consult Service: An Innovative Model for Palliative Care Delivery (QI823)

Lifestyle Medicine Inpatient Consultation Services at Loma Linda University Health: A Novel Approach in a Tertiary Care Center.

As a nation facing primary care provider shortages, an expanding chronic disease burden, and rising health care costs, lifestyle medicine interventions have become critical for patient care and management. The current fee-for-service health care system in the United States is designed for delivering acute care but has made it challenging to deliver and be reimbursed sufficiently for lifestyle interventions that can help prevent and treat chronic disease. Loma Linda University Health began to address these concerns through the creation of an inpatient consultation service for the neurology rehabilitation stroke team. Initiation of the consultation service took 2 years of planning, testing, and resource development. Currently, the consultation service operates one half-day per week in the rehabilitation hospital utilizing 1 attending physician and 2 residents. Visiting residents and medical students are also permitted to rotate with the new service. In coordination with billing experts, a standard number of 21.2 to 25.4 RVUs (relative value units) has been established for the half-day service. As the service continues to expand, future considerations include adding consultation availability to other departments and increasing the consultation workforce.

The Pediatric Heart Failure Workforce: An International, Multicenter Survey.

Our objective was to understand the scope of pediatric heart failure (HF) and the current staffing environment of HF programs. An online survey was distributed to members of the Pediatric Heart Transplant Study and the Pediatric Council of the International Society for Heart and Lung Transplantation. All participants received the primary 23-question survey. Additionally, HF program directors received a 32-question supplemental survey. Of 235 invitations sent, there were 69 (29%) primary surveys and 34 program director surveys completed (24 U.S. programs, 9 outside non-U.S., and one non-specified location). A formal HF program was reported by 88% of directors. There were 150 [IQR 50-200] outpatients/institution and 40% [25-50] of patients had congenital heart disease. Inpatient HF census was 3 [2-4] patients. Most programs (70%) used a consulting service model to provide HF specialty care, while only 10 (30%) utilized an inpatient HF service. Inpatient HF service programs had a higher daily inpatient census versus consult service model programs (4 [3-7] vs. 2 [1-4], respectively; p=0.022) and had a higher number of full-time equivalents dedicated to HF (5.5 [2-7] vs. 2.5 [1-4], respectively; p=0.024). Only 47% of programs report a general fellowship rotation devoted to HF. Advanced practice providers (APP) were utilized in 15 programs, nurse coordinators in 2, and both in 3. Most HF programs are formalized, utilize APP, and have inadequate HF staffing to utilize a separate inpatient HF service. Exposure of general pediatric cardiology fellows to HF care is variable between institutions.

Impact of palliative care rotation on gynecologic oncology fellows' knowledge, rates of explicit teaching, and perceived competence in palliative care.

95 Background: Impact of a PC rotation on fellows in the primarily surgical specialty of Gynecologic Oncology (GO) has not been described. We aimed to evaluate the impact of a month-long PC rotation on GO fellows’ knowledge, exposure to explicit teaching and perceived competence in PC. Methods: Four years of GO fellows (n = 8) were surveyed before and immediately after a month-long PC rotation about knowledge, explicit teaching and perceived competence across four domains - pain management, non-pain symptom management, out of hospital care and communication/ethics. Knowledge was assessed via 30 multiple choice questions (MCQ). Perceived competence to address 25 PC topics was assessed on a Likert scale (1 to 5). Participants were asked about explicit teaching of 21 PC topics before and during the rotation. The rotation included 5 clinical settings and 7 dedicated didactic strategies beyond routine participation in clinical care. We used medians tests to compare total correct items pre vs post rotation, paired differences pre to post of perceived competence and paired differences pre to during rotation rates of explicit teaching of PC topics. Results: Post-rotation, participants demonstrated significant improvement in knowledge (median MCQ percent correct pre 62% v post 67%; p = 0.01), explicit teaching (median percent items explicitly taught pre 19% v post 91%; p = 0.02) and perceived competence (median percent items competent or better pre 34% v post 100%; p = 0.01). The most highly rated clinical settings were inpatient hospice and inpatient PC consult service. The most highly rated didactic strategies were direct observation of communication skills practice and 10 minute didactics. The educational value of the overall rotation was rated as superior by 100% of participants. Conclusions: After a month-long PC rotation, GO fellows demonstrated significant improvement in knowledge, rates of explicit teaching and perceived competence in PC across all domains examined. Routine incorporation of a dedicated PC rotation should be considered for all gynecologic oncology fellows.

Early integration of supportive oncology consultation for hospitalized cancer patients.

136 Background: Integration of Palliative Care (PC) for patients with cancer is associated with improved symptom control, clearer understanding of prognosis, lower utilization of health care resources, and increased hospice use. Yet few studies identify which elements of a PC consultation are most associated with improved outcomes, particularly in the inpatient setting. This study describes the processes of a specialized, interdisciplinary, inpatient PC consultation service that utilized standardized referral criteria and demonstrated improved 30-day readmission, oncology service mortality, and hospice utilization. Methods: We implemented a 3-month intervention on the solid tumor oncology service requiring an automatic PC consultation for patients with one or more of the following criteria: stage IV disease, Stage III lung or pancreatic cancer, hospitalization within 30 days, &gt; 7 day hospitalization, or uncontrolled symptoms. Descriptive statistics were used to identify specific processes associated with the consultation. Results: A total of 52 patients were evaluated. The median time of initial consult was on hospital day 2 and patients were followed for an average of 9 days (±11). The majority of patient encounters were by a physician (47%) or advanced practice nurse (42%), with 48% of encounters lasting 35-60 minutes. Integrative services (massage, yoga etc.) were offered in 72% of consults. The most common issues addressed throughout the consultation were pain (85%), non-pain symptoms (85%), transition planning (85%), and plan of care (82%). Overall, consulting teams addressed more PC needs than were initially identified by chart review. Conclusions: Implementing standardized PC consultations in patients with solid malignancies requires the full support of an interdisciplinary team. PC consultations are time-consuming undertakings, often addressing needs broader in scope than initially identified and requiring the use of specialty level PC in the majority of cases. Future efforts to implement similar interventions can use these data to identify specific staffing needs and to ensure cancer patients receive quality care.

Implementation of a Centralized Infectious Diseases Telehealth (IDt) Service for 16 Small Community Hospitals

Abstract Background The majority of U.S. small community hospitals (SCHs) lack access to infectious diseases (ID) subspecialists. Telehealth can extend ID expertise to such facilities. We describe lessons learned from implementing a new IDt program for 16 SCHs in the Intermountain Healthcare system in Utah and Idaho. Methods From October 1, 2016 to April 30, 2017, we implemented an IDt service comprised of: a 24-hour ID physician advice line; an inpatient ID consult service that provided chart review and documentation (e-consults) and daytime telemedicine consultation (TC) using encrypted, HIPAA-compliant, synchronous, 2-way audio-video connection; and an ID pharmacist-led antibiotic stewardship program. The IDt service included a medical director, operations officer, ID pharmacist, analyst, and rotating ID physicians, and was implemented in a step-wise manner at 16 SCHs. IDt requests were received through a dedicated phone line with duplicate transcription to a monitored email inbox or generated from daily antibiotic stewardship rounds. Results The physician advice line was operational for all 16 SCHs on October 1, 2016. 312 advice-only calls were fielded (92 per 1000 hospital-days covered) through April 30, 2017. Common infections requiring phone advice included: bloodstream (16%), genitourinary (13%), and musculoskeletal (12%). E-consult and TC services were operational at 11 SCHs by April 30, 2017 (hospital-days covered: 1074). The IDt service completed 104 eConsults, 163 TCs, and 1198 stewardship reviews. Mean time [minutes (range)] spent per case was 16 (5–30) for eConsults and 55 (30–120) for TCs [on-camera time: 25 (12–46)]. Common infections requiring e-consult or TC were: bloodstream (45%), musculoskeletal (16%), and skin/soft tissue (11%). 22 patients (14%) seen by TC were surveyed: 100% felt the service improved their care and was necessary at their SCH. 97% of surveyed SCH staff felt the IDt service improved patient care and 90% felt it was a necessary service (32% response from 98 providers, nurses, pharmacists). Conclusion A new IDt service was well utilized and received by SCH staff and patients, with bloodstream infections being the most common reason for consultation. Future steps include evaluation of the IDt effect on clinical outcomes, financial metrics, and staff education on common ID conditions. Disclosures All authors: No reported disclosures.

Strategies to embed palliative care into a culture of cancer care.

e21678 Background: In 2012, the 3 hospital Lifespan Health System launched a palliative care initiative. The hospitals and medical oncologists knew this was critical for patient centered and value-based cancer care, but recognized many barriers: physician practice patterns, lack of dedicated resources and systems, patient and family education gaps, and limited return on investment in the current environment. A multi-level inpatient and outpatient strategy was implemented and tracked over four years. Methods: External benchmarking data from a Medicare claims analysis of Vizient (academic health system consortium) member organizations and from ASCO QOPI data were used in the analysis. Internal data analysis included a study on symptom management for lung cancer patients, hospital reports on palliative care service utilization, ED visits and hospital admission trends for cancer patients. Multi-level interventions were employed: hospital investment in staff and systems, partnership with a community-based hospice and palliative care provider, a medical oncology physician champion with Board certification in palliative care, a palliative care inpatient consult service and daily ICU rounds, an oncology medical home, medical oncologist Saturday hours, electronic prompts for consults, and a cancer call triage center. Results: A Medicare claims analysis for 2012 to 2014 on cancer decedents with ICU stays in the last 30 days in the Vizient national study of health systems showed that Lifespan was at the 11th percentile, making them the 4th lowest (days in ICU) in performance (pre/post data requested). QOPI data on appropriate referrals to hospice or palliative care prior to death improved from 58% in 2010, which was below the QOPI benchmark of 61%, to 94% in 2016 which is above the QOPI benchmark of 74%. Other QOPI and hospital data will be included in the presentation. Conclusions: Palliative care, a crucial tool for the delivery of future cancer care, is challenging to implement effectively. This study shows that a hospital/medical oncology partnership can drive change to embed palliative care into the culture of cancer care and these strategies offer a roadmap for others to follow as they strive to offer patient centered and value-based cancer care.

Addiction consultation services – Linking hospitalized patients to outpatient addiction treatment

BackgroundApproximately 15% of hospitalized patients have an active substance use disorder (SUD). Starting treatment for SUD, including medications, during acute hospitalizations can engage patients in addiction care. In July 2015, the Boston Medical Center Addiction Consult Service (ACS), began providing inpatient diagnostic, management, and discharge linkage consultations. We describe this implementation. MethodsThe ACS staff recorded SUDs diagnoses and medication recommendations and tracked follow-up data for affiliated outpatient office-based addiction clinics and methadone maintenance programs. We assessed the number of consults, SUDs diagnoses, medications recommended and initiated, and outpatient addiction clinic follow-up. ResultsOver 26weeks, the BMC ACS completed 337 consults: 78% had an opioid use disorder (UD), 37% an alcohol UD, 28% a cocaine UD, 9% a benzodiazepine UD, 3% a cannabinoid (including K2) UD, and <1% a methamphetamine UD. Methadone was initiated in 70 inpatients and buprenorphine in 40 inpatients. Naltrexone was recommended 45 times (for opioid UD, alcohol UD, or both). Of the patients initiated on methadone, 76% linked to methadone clinic, with 54%, 39%, and 29% still retained at 30, 90, and 180days, respectively. For buprenorphine, 49% linked to clinic, with 39%, 27%, and 18% retained at 30, 90, and 180days, respectively. For naltrexone, 26% linked to clinic, all with alcohol UD alone. ConclusionsA new inpatient addiction consultation service diagnosed and treated hospitalized patients with substance use disorders and linked them to outpatient addiction treatment care. Initiating addiction medications, particularly opioid agonists, was feasible in the inpatient setting. Optimal linkage and retention of hospitalized patients to post-discharge addiction care warrants further innovation and program development.

Planning and Designing the Improving Addiction Care Team (IMPACT) for Hospitalized Adults with Substance Use Disorder.

People with substance use disorders (SUD) have high rates of hospitalization and readmission, long lengths of stay, and skyrocketing healthcare costs. Yet, models for improving care are extremely limited. We performed a needs assessment and then convened academic and community partners, including a hospital, community SUD organizations, and Medicaid accountable care organizations, to design a care model for medically complex hospitalized patients with SUD. Needs assessment showed that 58% to 67% of participants who reported active substance use said they were interested in cutting back or quitting. Many reported interest in medication for addiction treatment (MAT). Participants had high rates of costly readmissions and longer than expected length of stay. Community stakeholders identified long wait times and lack of resources for medically complex patients as key barriers. We developed the Improving Addiction Care Team (IMPACT), which includes an inpatient addiction medicine consultation service, rapid-access pathways to posthospital SUD treatment, and a medically enhanced residential care model that integrates antibiotic infusion and residential addiction care. We developed a business case and secured funding from Medicaid and hospital payers. IMPACT provides one pathway for hospitals, payers, and communities to collaboratively address the SUD epidemic. Journal of Hospital Medicine 2017;12:339-342.

Role of anesthesiology in pain medicine and palliative care treatment in German hospitals : Survey of department heads of anesthesiology on treatment structures

The aim of this analysis was to describe the role of anesthesiology departments in pain medicine and palliative care services in German hospitals. In the year 2012, all heads of departments of anesthesiology registered with the German Society of Anesthesiology and Intensive Care Medicine were surveyed about structures of pain medicine and palliative care services in their hospitals using astandardized postal questionnaire. Out of 408 returned questionnaires (response rate 47%) 403 could be evaluated. Of the hospitals 58% had adesignated pain medicine service, in 36 (9%) of the hospitals this was organized as an independent department and in 195 (57%) as part of another department, mostly the department of anesthesiology. The "pain clinic" as an outpatient service was the most common form of structure for pain medicine services (41%). Inpatient pain medicine units were available in 77(19%) of the hospitals and apartial inpatient unit in the form of aday hospital in 26(7%) of the hospitals. For the care of inpatients from other departments, there was an intrahospital pain consultation service in 166 of the hospitals, which was the only structure for pain medicine in 32of the 231 hospitals that reported having adesignated pain medicine service. In 160 pain medicine services anesthesiologists were the only medical practitioners and in a further 18both anesthesiologists and other specialists were available (orthopedist/orthopedic surgeons n= 6, internal medicine n= 4, psychiatrist n= 2, general practitioner= 1 and neurologist n= 1). Only two hospitals had no anesthesiologist in the pain medicine team and for the remaining 51hospitals no information was provided. In 189 of the 231 hospitals with pain medicine services, there was at least 1 physician with special qualifications in pain management. In 97(44%) of the hospitals psychologists were part of the team with 53having at least 1 psychologist with aspecial qualification in chronic pain management. Of the hospitals, 16% had aspecialized department for palliative care, in 32% aspecialized palliative care service was part of another department, which was the department of anesthesiology in 30%. Of the hospitals 56% had apalliative care consultation service, 41% had a specialized inpatient palliative care unit, 6% an outpatient clinic, 4% aday hospital and in 16% aspecialized outpatient palliative care (SOPC) serving the community was incorporated. Inpatient consultation services and the SOPC were more common when the department of anesthesiology was involved in the palliative care services. In German hospitals, the departments of anesthesiology make a significant contribution to the provision of both pain medicine and palliative care services. Nevertheless, the respective structures of care are often incomplete or even lacking. There were shortcomings in terms of organization and qualification of the team in pain medicine services (e.g. no doctor with special qualifications in pain management or no psychologist). Palliative care services are more often organized as independent departments than as pain medicine services. Engagement of the anesthesiology department in palliative care is linked to abroader scope of the services provided, which might reflect the capacity of many anesthesiologists to work in an interdisciplinary manner and across interfaces.