Medicine For Patients Research Articles

Acid-Base Balance and Electrolyte Management

Perhaps the most ubiquitous set of interlinked clinical issues to be addressed in inpatient medicine is fluids, electrolytes, and acid-base balance. Decision making for the first two directly and measurably impacts the latter. Unlike most other critical therapies whose management is tied to a specific skill set and competency, every practitioner is empowered to prescribe and direct fluid and electrolyte management and, secondarily, pH. Downstream consequences in terms of compensation, both pulmonary and renal, may be singularly important for those with preexisting conditions that impact organ function and drive the need for unanticipated monitoring and therapy, including organ support. Therefore, the basics of fluid and electrolyte management are essential to be mastered, as is specific knowledge of the consequences of that prescription to enhance recovery and avoid preventable errors with important sequelae. Accordingly, current different but complementary methods of assessing acid-base balance are presented so that the reader may have a systematic approach to determining pH before intervention as well as after the initiation of fluid and electrolyte therapy. This review contains 12 figures, 2 tables, and 34 references. Key words: acid, base, electrolyte disturbances, Henderson-Hasselbach, maintenance, proton, resuscitation, Stewart methodology

Acid-Base Balance and Electrolyte Management

Perhaps the most ubiquitous set of interlinked clinical issues to be addressed in inpatient medicine is fluids, electrolytes, and acid-base balance. Decision making for the first two directly and measurably impacts the latter. Unlike most other critical therapies whose management is tied to a specific skill set and competency, every practitioner is empowered to prescribe and direct fluid and electrolyte management and, secondarily, pH. Downstream consequences in terms of compensation, both pulmonary and renal, may be singularly important for those with preexisting conditions that impact organ function and drive the need for unanticipated monitoring and therapy, including organ support. Therefore, the basics of fluid and electrolyte management are essential to be mastered, as is specific knowledge of the consequences of that prescription to enhance recovery and avoid preventable errors with important sequelae. Accordingly, current different but complementary methods of assessing acid-base balance are presented so that the reader may have a systematic approach to determining pH before intervention as well as after the initiation of fluid and electrolyte therapy. This review contains 12 figures, 7 tables, and 38 references Keywords: acid, base, electrolyte disturbances, Henderson-Hasselbach, maintenance, proton, resuscitation, Stewart methodology

Wie wählen internistische Patienten ihr Krankenhaus? Eine Querschnittstudie

ZusammenfassungEinleitung Die freie Krankenhauswahl durch Patienten wird gesundheitspolitisch gefördert und soll durch die Qualitätsberichte der Krankenhäuser unterstützt werden. Doch wie entscheiden sich Patienten für ein Krankenhaus? Wie viele können selber entscheiden, wo informieren sie sich und was sind in der konkreten Situation ihre Entscheidungskriterien? Dies soll für stationäre Patienten der Inneren Medizin im Vergleich zu denen anderer Fachgebiete beantwortet werden. Methoden Die Daten entstammen einer Beobachtungsstudie. Die nach Fachgebieten und Krankenhausversorgungsstufen geschichtete Zufallsstichprobe wurde in 46 Fachabteilungen von 17 Krankenhäusern aus 15 Städten und Gemeinden Nordrhein-Westfalens erhoben. Die gewichtete Stichprobe wertet 758 Patienten der Inneren Medizin und 1168 Patienten anderer Fachgebiete deskriptiv und inferenzstatistisch aus. Ergebnisse Internistische Patienten sind älter, häufiger Männer, ohne Migrationshintergrund und chronisch krank, zudem öfter stationär vorbehandelt. Etwa die Hälfte entscheidet selbst über das Krankenhaus, wobei die eigene Kenntnis des Krankenhauses durch einen Voraufenthalt die wichtigste Informationsquelle darstellt und wichtige Entscheidungskriterien die eigene Vorerfahrung, der Ruf des Krankenhauses und die Empfehlung der ambulanten Behandler sind. Der kleine Anteil Patienten mit mehr Zeit vor der Aufnahme wählt das Krankenhaus aktiver. Diskussion In der Inneren Medizin können weniger Patienten selbst über das Krankenhaus bestimmen. Diese entscheiden dann überwiegend aufgrund ihrer Vorerfahrung mit dem Krankenhaus und setzen die erneute Behandlung im ihnen bekannten Krankenhaus, in dem auch sie bekannt sind, fort. Ein kleiner Anteil jüngerer, gebildeterer und weniger krankenhauserfahrener Patienten informiert sich aktiver vor elektiven Eingriffen. Die Behandlungserfahrungen der Patienten sind zentral bei der eigenen Krankenhauswahl und über den sozialen Austausch auch bei der ihrer Angehörigen.

Admitted Cases of Dengue Fever among Dengue Positive Cases in a Tertiary Care Hospital: A Descriptive Cross-sectional Study.

Dengue fever, a mosquito-borne disease, is one of the emerging tropical diseases that appear primarily in rainy seasons. The number of dengue cases was increased in recent years in Nepal. Chitwan is one of the risky areas of dengue. This aim of the study is to find out the prevalence of hospital admission among the dengue positive cases. The descriptive cross-sectional study was carried out among 323 serologically confirmed dengue fever positive patient admitted in Medicine Inpatients Department of Chitwan Medical College Teaching Hospital. Ethical approval was taken from the Institutional Review Committee (Reference number. 076/077-121 dated August 30, 2019). Data were collected from 1st September 2019 to 31st December 2019 using a structured interview schedule and record review. Convenience sampling was done. Data was analysed using Statistical Package for Social Sciences version 11. Point estimate at 95% Confidence Interval was calculated, with frequency and percentage. Among 1206 patient with dengue fever, 323 (26.78%) (24.29-29.27 at 95% confidence Interval) were admitted in the tertiary care hospital. Study findings revealed that out of 323 admitted patients with dengue fever, 182 (56.3%) patients were between 20-40 years of age and 179 (55.4%) were males. The highest number of patients were admitted in the months of September 192 (59.4%) and October 101 (31.2%). Admission rate among dengue positive cases are comparable to other studies of the similar settings. Dengue fever is common among community people especially in young adult and males. Hence, screening of dengue fever in febrile illness is necessary for the early diagnosis and prompt treatment.

Virtual Team Rounding: A Cross-Specialty Inpatient Care Staffing Program to Manage COVID-19 Surges.

ProblemThe SARS-CoV-2 (COVID-19) pandemic presented numerous challenges to inpatient care, including overtaxed inpatient medicine services, surges in patient censuses, disrupted patient care and educational activities for trainees, underused providers in certain specialties, and personal protective equipment shortages and new requirements for physical distancing. In March 2020, as the COVID-19 surge began, an interdisciplinary group of administrators, providers, and trainees at Brigham and Women’s Hospital created an inpatient virtual staffing model called the Virtual Team Rounding Program (VTRP).ApproachThe conceptual framework guiding VTRP development was rapid-cycle innovation. The VTRP was designed iteratively using feedback from residents, physician assistants, attendings, and administrators from March to June 2020. The VTRP trained and deployed a diverse set of providers across specialties as “virtual rounders” to support inpatient teams by joining and participating in rounds via videoconference and completing documentation tasks during and after rounds. The program was rapidly scaled up from March to June 2020.OutcomesIn a survey of inpatient providers at the end of the pilot phase, 10/10 (100%) respondents reported they were getting either “a lot” or “a little” benefit from the VTRP and did not find the addition of the virtual rounder burdensome. During the scaling phase, the program grew to support 24 teams. In a survey at the end of the contraction phase, 117/187 (62.6%) inpatient providers who worked with a virtual rounder felt the rounder saved them time. VTRP leadership collaboratively and iteratively developed best practices for challenges encountered during implementation.Next StepsVirtual rounding provides a valuable extension of inpatient teams to manage COVID-19 surges. Future work will quantitatively and qualitatively assess the impact of the VTRP on inpatient provider satisfaction and well-being, virtual rounders’ experiences, and patient care outcomes.

Developing and validating natural language processing algorithms for radiology reports compared to ICD-10 codes for identifying venous thromboembolism in hospitalized medical patients

BackgroundIdentifying venous thromboembolism (VTE) from large clinical and administrative databases is important for research and quality improvement. ObjectiveTo develop and validate natural language processing (NLP) algorithms to identify VTE from radiology reports among general internal medicine (GIM) inpatients. MethodsThis cross-sectional study included GIM hospitalizations between April 1, 2010 and March 31, 2017 at 5 hospitals in Toronto, Ontario, Canada. We developed NLP algorithms to identify pulmonary embolism (PE) and deep venous thrombosis (DVT) from radiologist reports of thoracic computed tomography (CT), extremity compression ultrasound (US), and nuclear ventilation-perfusion (VQ) scans in a training dataset of 1551 hospitalizations. We compared the accuracy of our NLP algorithms, the previously-published “simpleNLP” tool, and administrative discharge diagnosis codes (ICD-10-CA) for PE and DVT to the “gold standard” manual review in a separate random sample of 4000 GIM hospitalizations. ResultsOur NLP algorithms were highly accurate for identifying DVT from US, with sensitivity 0.94, positive predictive value (PPV) 0.90, and Area Under the Receiver-Operating-Characteristic Curve (AUC) 0.96; and in identifying PE from CT, with sensitivity 0.91, PPV 0.89, and AUC 0.96. Administrative diagnosis codes and the simple NLP tool were less accurate for DVT (ICD-10-CA sensitivity 0.63, PPV 0.43, AUC 0.81; simpleNLP sensitivity 0.41, PPV 0.36, AUC 0.66) and PE (ICD-10-CA sensitivity 0.83, PPV 0.70, AUC 0.91; simpleNLP sensitivity 0.89, PPV 0.62, AUC 0.92). ConclusionsAdministrative diagnosis codes are unreliable in identifying VTE in hospitalized patients. We developed highly accurate NLP algorithms to identify VTE from radiology reports in a multicentre sample and have made the algorithms freely available to the academic community with a user-friendly tool (https://lks-chart.github.io/CHARTextract-docs/08-downloads/rulesets.html#venous-thromboembolism-vte-rulesets)

Prospective determination of the incidence and severity of hyponatraemia in older hospitalised patients with acute urinary tract obstruction.

acute urinary tract obstruction (aUTO) is a common finding in older hospitalised patients. Anecdotal reports described hyponatraemia in patients with aUTO, which subsides rapidly with relief of the obstruction.The aim of this study was to determine the incidence, severity and subsequent correction of hyponatraemia in patients with aUTO. this is a prospective, single-centre, observational study including inpatients in the internal medicine and geriatric wards. A total of 204 patients were investigated, 104 with aUTO and 100 controls. The prevalence, severity and associations of hyponatraemia between aUTO and control patients were compared. the incidence of hyponatraemia was similar in aUTO and control groups 28% versus 22%, respectively (P = 0.42). However, the incidence of severe hyponatraemia was significantly higher in the study group 7% versus 1% (P = 0.04). Mean sodium level was lower in hyponatremic patients with aUTO 127.7 ± 5.9mEq/l versus 130.8 ± 3mEq/l (P = 0.013). Serum sodium remained largely unchanged in the control group (∆Na 1.5 ± 2.3mEq/l) but increased significantly within 48hours following catheter insertion in patients with urinary retention (∆Na 5.3 ± 4.2mEq/l overall in the aUTO group and 9.6 ± 3mEq/l in those with urinary retention and severe hyponatraemia (P = 0.002)).

Sex Differences in Anemia and Red Blood Cell Transfusions Among General Internal Medicine Inpatients

Background: Epidemiological data from the general population have shown that women have lower hemoglobin values compared to men. Previous research on surgical patients showed that women were significantly more likely to receive red blood cell (RBC) transfusions compared to men in the peri-operative period due to multiple factors including the application of absolute transfusion thresholds. Sex differences in RBC transfusion frequencies have not been well studied in non-surgical settings. Here we investigated sex differences in anemia and in RBC transfusion frequencies in patients admitted to General Internal Medicine (GIM) wards.Study design and methods: This was a retrospective cohort study using de-identified electronic patient data from all patients admitted to the GIM wards from the emergency department across 4 different hospitals between 2010 and 2017, who had at least 1 CBC test during their admission. Patients with multiple hospital admissions during the study period, those who were pregnant, those who underwent surgery during the admission, and those transferred to or from another service besides GIM during their admission were excluded. Severity of anemia was stratified using the WHO sex-specific quantitative thresholds for hemoglobin: mild anemia (110 to 119 g/L in women and 110 to 129 g/L in men), moderate anemia (80 to 109 g/L in both men and women) and severe anemia (lower than 80 g/L in both men and women).Results: The study cohort consisted of 51,073 inpatients (24,666 men and 26,407 women). The median hemoglobin at the time of admission was significantly higher (p < 0.001) in men (median 135 g/L, IQR 31) compared to women (median 127 g/L, IQR 25). The prevalence of moderate and severe anemia was significantly higher (p < 0.001) in female inpatients (56%) compared to males (44%). The proportion of patients who received RBC transfusions during their admission was not significantly different (p = 0.36) between men (49%) and women (51%). There was no significant sex difference (p = 0.28) observed in the median hemoglobin prior to RBC transfusions between men (median 68 g/L, IQR 10.5) and women (median 68 g/L, IQR 11). The number of patients with pre-transfusion hemoglobin less than 70 g/L, the commonly used threshold for transfusion in the in-patient setting, was not significantly different (p = 0.91) between men and women. However, among the patients with hemoglobin < 70 g/L, a significantly lower proportion (p < 0.001) of women (82%) received RBC transfusions compared to men (91%).Conclusions: In a large cohort of GIM inpatients, we observed significantly higher prevalence of moderate and severe anemia in women compared to men. While there was no sex difference in overall RBC transfusion frequencies in this inpatient population, there was a lower proportion of women receiving RBC transfusions compared to men in the subgroup of patients with hemoglobin less than 70 g/L. DisclosuresNo relevant conflicts of interest to declare.

Accuracy of Cell-Free DNA (cfDNA) in Colorectal Cancer Diagnosis

Background: The requirement for malaria elimination to be recognized is to prove Background. Colorectal cancer is the third most common type of cancer following lung and breast cancer with the second most common cause of cancer-related death globally. Delayed diagnosis due to limited source and modality to perform early diagnosis lead to advanced-stage condition which contributes to higher morbidities and mortalities. Recent diagnosis of colorectal cancer depends on biopsy of suspected tissues, either obtained surgically or per colonoscopy. Colorectal cancer detection through cell-free DNA measurement allowing small-size cancer being detected even in early stage. cfDNA originated from derivates of increased and abnormality apoptosis-necrosis pathway from cancer lesion, therefore can be managed as specific tumor marker.&#x0D; Methods: Diagnostic test was performed at the Gastroentero Hepatology Outpatient Unit and Internal Medicine Inpatient Unit of Dr. Mohammad Hoesin General Hospital Palembang from March to June 2021. Data processing and analysis using SPSS version 26.0 for Windows. &#x0D; Results: Among 50 subjects included, 39 subjects (78%) are diagnosed with colorectal cancer, whereas 11 subjects (22%) as control. The median of cfDNA result is 59,71 ng/mL with 92,3% sensitivity, 90,9% specificity, 95,2% positive predictive value, 82,3% negative predictive value, and 92,4% accuracy rate. Combination the measurement of cfDNA, CEA, and CA19-9 appears to have better AUC instead of single measurement.&#x0D; Conclusion: The study reveals that cell-free DNA (cfDNA) demonstrated a very promising accuracy rate in diagnosing colorectal cancer.

102 Virtual family-centered rounds: A collaborative necessity during COVID-19 and beyond

Primary Subject areaHospital PaediatricsBackgroundFamily-centered rounds (FCR) are the cornerstone of pediatric hospital care and have many proven benefits including improved patient outcomes, satisfaction, communication and safety. Traditionally, FCR take place in the patient’s room; however, due the COVID-19 pandemic, entering patient rooms was no longer advisable in order to maintain physical distancing and preserve personal protective equipment (PPE). Therefore, it became clear early in our pandemic response that a new process was required to ensure the benefits of FCR were maintained given their paramount importance to safe and quality patient care.ObjectivesThe objective of this study was to virtualize the in-person FCR process used by our pediatric inpatient medicine teams to improve safety and reduce PPE costs during the COVID-19 pandemic.Design/MethodsWe quickly identified available hardware (laptops, tablets) and video conferencing software, assembled a multidisciplinary project team and secured administrative and quality improvement support. Quality improvement methodology and participatory design were used to develop and refine our virtual family-centered rounds (vFCR) standard work, and on April 6, 2020 we launched our first vFCR. Over the next 3 months we engaged in a series of plan-do-study-act (PDSA) cycles to iteratively improve our process: nurse auditors attended vFCR daily then met with our project team to review data and observations, and real-time feedback was sought from patients and caregivers.ResultsData collected on 1792 vFCR between April 6 and July 31, 2020 revealed 74% of nurses, physicians and trainees were satisfied or very satisfied with vFCR and 88% felt they had a good understanding of the patient care plan after vFCR. 79% of patients and caregivers were satisfied or very satisfied with vFCR and 88% of caregivers felt like a valued member of their child’s care team. We met our target of 10 minutes per patient in 74% of vFCR with an average transition time of <3 minutes between patients. Patients and caregivers felt vFCR were collaborative, more private and less intimidating than in-person FCR, and some even preferred the virtual approach.ConclusionDuring this pilot, we achieved a standardized vFCR workflow that is safe, feasible, efficient and confidential, with high levels of stakeholder satisfaction and support. vFCR was highly valued by families and yielded unanticipated benefits. Based on current usage, vFCR are saving ~$36,000 monthly in PPE. The importance of this work during the COVID-19 pandemic is clear, but also has benefits in non-pandemic times, including allowing caregivers to participate in FCR when they cannot be at the bedside, enhancing FCR confidentiality, and improving communication and care for isolated patients. Furthermore, the vFCR process is easily adaptable to other inpatient workflows such as consults and multi-disciplinary meetings. We believe this virtual care model is both highly relevant and transferable to a variety of health care settings across Canada and beyond.

Antimicrobial Stewardship: A Modified Team-Based Learning Curriculum With Timeouts for the Inpatient Medicine Clerkship.

Purpose: Medical students are typically introduced to the principle of antimicrobial stewardship in their preclinical years. However, they are often inadequately prepared to participate in the clinical application of stewardship principles when they begin clinical clerkships. 1 While stewardship is an evolving practice, students should be reintroduced and exposed to stewardship principles frequently and identify practical skills to optimize stewardship. In addition, students should be familiar with resources, such as practice guidelines and local antibiograms, as optimal therapies and resistance patterns often change. 2 A timeout is a stepwise approach to evaluating the need for antibiotics and the optimal use of antibiotics. Timeouts are a common tool implemented by hospitals to monitor and manage the use of antibiotics. We propose that teaching clinical medical students to perform timeouts can lead to increased comfort with clinical decision making as it relates to antimicrobial stewardship. Approach: We implemented a modified team-based learning (TBL) curriculum to teach medical students to perform timeouts focusing on common inpatient infections. This curriculum was integrated into the inpatient medicine clerkship orientation for third-year medical students. Students received the following presession materials: (1) a prereading assignment covering basic antimicrobial stewardship principles and a summary of guideline-directed management for common inpatient infections, and (2) a readiness test consisting of multiple-choice questions. The in-person session was 1.5 hours, led by 1 instructor and 1 facilitator, given to 25 to 30 third-year medical students during the required inpatient medicine clerkship orientation occurring 6 times per academic year. The instructor begins the session reviewing the readiness test with the group, then students divide into small groups of 4–5 to work through 2 clinical cases using the timeout framework throughout the case. The instructor and facilitator were available to assist the small groups with problem-solving and clarification. Each timeout case and learning points were discussed with the large group at the end of each case, highlighting different approaches to problem-solving and providing real-time feedback. Outcomes: Surveys completed during the pilot academic year 2017–2018 revealed that over 90% of students agreed or strongly agreed that the learning activity would help their performance on the inpatient medicine clerkship (n = 121). Over 75% of students reported an improved understanding of the purpose of a timeout, and 85% reported an improved ability to participate in completing an antibiotic timeout. Qualitative survey data indicated that students valued both the presession reading materials and interactive nature of the learning activity, which provided a useful review of common inpatient infections and helpful tools for applying the principles of antimicrobial stewardship to clinical cases. Discussion: The modified TBL session, focused on teaching antimicrobial stewardship through the structured framework of a timeout, was an effective teaching strategy in introducing and applying basic stewardship principles. Survey data from this study indicate that medical students find value in learning how to perform a timeout during this interactive session. This skill may translate to the early adoption of stewardship principles, self-guided learning, improved patient outcomes, and the lifelong practice of antimicrobial stewardship. However, further study is needed to determine the long-term effects of antimicrobial use and the most optimal modality to teach this skill set. Significance: A modified TBL curriculum shows promise as an effective teaching modality for antimicrobial stewardship. Formal instruction in how to perform timeouts should be an essential component of the curriculum for clinical medical students as they begin their medicine clerkships to promote and reinforce the practice of these skills early in their careers. Acknowledgments: The authors would like to thank Dr. Clarence Braddock for his support and mentorship in the medical education fellowship program at the University of California, Los Angeles.

When it\u2019s needed most: a blueprint for resident creative writing workshops during inpatient rotations

BackgroundNarrative Medicine may mitigate physician burnout by increasing empathy and self-compassion, and by encouraging physicians to deeply connect with patient stories/experiences. However, Narrative Medicine has been difficult to implement on hectic inpatient teaching services that are often the most emotionally taxing for residents.ObjectiveTo evaluate programmatic and learner outcomes of a novel narrative medicine curriculum implementation during inpatient medicine rotations for medical residents. Programmatic outcomes included implementation lessons. Learner outcomes included preliminary understanding of impact on feelings of burnout. Additionally, we developed a generalizable narrative medicine framework for program implementation across institutions.MethodsWe developed and implemented a monthly 45-min Narrative Medicine workshop on Stanford’s busiest and emotionally-demanding inpatient rotation (medical oncology). Using the Physician Wellbeing Inventory (PWBI, range 1–7; 3–4 = high burnout risk; ≥4, high burnout), we anonymously assessed resident burnout during pre-implementation control year (2017–2018, weeks 1 and 4), and implementation year (2018–2019, weeks 1 and 4). We interviewed program directors and facilitators regarding curriculum implementation challenges/facilitators.ResultsResidents highly rated the narrative medicine curriculum, and the residency program renewed the course for 3 additional years. We identified success factors for programmatic success including time neutrality, control of session, learning climate, building trust, staff partnership, and facilitators training. During control year, resident burnout was initially high (n = 16; mean PBWI = 3.0, SD: 1.1) and increased by the final week (n = 15; PBWI = 3.4, SD: 1.6). During implementation year, resident burnout was initially similar (n = 13; PBWI = 3.1, SD: 1.9) but did not rise as much by rotation end (n = 24; PBWI = 3.3, SD: 1.6). Implementation was underpowered to detect small effect sizes. Based on our our experience and literature review, we propose an educational competency framework potentially helpful to facilitate inpatient narrative medicine workshops, as a blueprint for other institutions.ConclusionsInpatient Narrative Medicine is feasible to implement during a challenging inpatient rotation and may have important short-term effects in mitigating burnout rise, with more study needed. We share teaching tools and propose a competency framework which may be useful to support development of inpatient narrative medicine curricula across institutions.

The Virtual Team Member: Remote Engagement of Medical Students in COVID-19 Care.

BackgroundMedical education abruptly changed in the setting of the COVID-19 pandemic, impacting experiential learning in clinical clerkship as medical students were removed from direct patient interactions and care team participation. Re-configuring a hospital clinical rotation using virtual care platforms allowed students to re-engage in the clinical environment and actively participate in patient care.MethodsDuring the height of the pandemic, we implemented a 4-week “virtual team member” (VTM) inpatient medicine elective for medical students in their second year and above to participate in acute patient care during the height of the COVID-19 pandemic. Tasks included providing daily updates to patients and family members along and care coordination. Faculty experts in infectious disease, mental health, ethics, and patient safety incorporated weekly didactic video talks throughout the elective. Student feedback was obtained anonymously through pre-, mid-, and post-elective questionnaires.ResultsA total of 26 students enrolled in the two 4-week blocks, with 85% in the 2nd year. Survey response rates for the pre, mid, and post-rotation questionnaires were 96%, 77%, 58% respectively. Of the 15 students who completed the post-survey, the majority strongly and somewhat agreed that the elective met expectations (12/15, 80%), was worthwhile (14/15, 93%) and met goals (12/15, 80%). Best parts of the elective most frequently cited by students were patient care and teamwork. Working remotely was the greatest challenge.ConclusionsDesigning a virtual role for students successfully allowed students to re-engage in the acute care setting and connect with patients and participate in COVID-19 care.Supplementary InformationThe online version contains supplementary material available at 10.1007/s40670-021-01422-8.

Improving Efficiency of Primary Care Provider Communication for Uncomplicated Admissions.

Communication between inpatient pediatric hospital medicine (HM) and primary care providers (PCPs) is important for quality care. As provider workload increases, it is important to focus on a means to improve communication efficiency. Our goal was to increase the percentage of HM admissions using 1-way communication from 0% to 35% over a 16-month period. HM providers and PCPs collaborated to identify 12 admission diagnoses for which 1-way communication could be used. Using quality improvement methods, we studied the implementation of "Leave a Message" (LAM) calls for 1-way communication and providing PCPs with the option to place a return call. Control charts were used to track LAM call use and balancing measures of PCP return phone calls, additional PCP communications, and 7-day readmissions over time. A total of 778 LAM calls were placed by HM providers over 16 months. The percentage of LAM calls out of all PCP calls placed ranged from 0% to 35% during this time, increasing significantly during winter months and before the coronavirus disease 2019 pandemic. Only 0.4% (n = 3) of LAM calls were returned by PCPs. Estimated PCP return phone calls were reduced by 11.1 calls per week. We created a system for 1-way telephone communication between HM providers and PCPs for common, simple admissions and reduced the need for PCP return phone calls. The low percentage of LAM calls returned by PCPs may suggest that 1-way communication is adequate for most simple admissions.

Safety of induction at standard doses of buprenorphine for inpatients with opioid use disorder

Introduction: Patients with opioid use disorder (OUD) are commonly admitted to various inpatient services where treatment can be started. The typical initiation of buprenorphine involves delay of treatment until withdrawal symptoms occur, however, those symptoms may interfere with other medical therapy. The purpose of this study was to evaluate the safety and efficacy of initiation of buprenorphine for inpatients with OUD. Methods: We reviewed the charts of 99 patients for whom the inpatient addiction medicine consult service was contacted over a 15-month period from January 2020 to identify those patients started on buprenorphine. We abstracted data on toxicology results, prior use of buprenorphine, and Clinical Opioid Withdrawal Scale (COWS) and pain scores before and after the administration of buprenorphine. Results: There was no significant difference in COWS classification post treatment based on ancillary or non use of full agonist therapy. There was no significant change in COWS scores based on prior buprenorphine or methadone use. 5% of patients developed moderate withdrawal (COWS score 12–24) after the initiation of buprenorphine. Twenty of the study patients (20%) developed a 2-point increase in pain scores after the initiation of buprenorphine. Summary: The initiation of buprenorphine for inpatients rarely results in a significant increase in withdrawal symptoms. A larger percent of patients may have an increase in pain scores which would need to be managed. Further prospective work on this subject is warranted.

Developing a machine learning model to identify delirium risk in geriatric internal medicine inpatients.

To develop a machine learning model that predicts delirium risk in geriatric internal medicine inpatients. A prospective cohort study of internal medicine wards in a tertiary care hospital in China. Blinded observers assessed delirium using the Confusion Assessment Method (CAM). The data set was randomly divided into a training set (70%) and a test set (30%). The model was trained on the training set using the decision tree and the five-fold cross-validation, and then the model performance was evaluated on the test set. Under-sampling was used to address the class imbalance. The discriminatory power of the model was measured by the area under the receiver operating characteristic curve (AUC) and F1 score. The data set comprised 740 patients from March 2016 to January 2017. The training set included 518 patients; the median (IQR) age was 84 (79-87) years; 364 (70.3%) were men; 71 (13.7%) with delirium. The test set included 222 patients; the median (IQR) age was 84.5 (79-87) years; 163 (73.4%) were men; 30 (13.5%) with delirium. In total, the data set included 740 hospital admissions with a median (IQR) age of 84 (79-87) years, 527 (71.2%) were men, and 101 (13.6%) with delirium. From 32 potential predictors, we included five variables in the predictive model: depression, cognitive impairment, types of drugs, nutritional status, and activity of daily life (ADL). The mean AUC on the training set was 0.967, the AUC and F1 score on the test set was 0.950 and 0.810, respectively. The model achieved 93.3% sensitivity, 94.3% specificity, 71.8% positive predictive value, 98.9% negative predictive value, and 94.1% accuracy on the test set. This machine learning model may allow more precise targeting of delirium prevention and could support clinical decision making in geriatric internal medicine wards.

Drug Utilization Evaluation of Anti-diabetics in Type 2 Diabetes Mellitus Patients with or without Comorbidities in a Tertiary Care Teaching Hospital

<p style="text-align: justify;"><strong>Background: </strong>Evaluation of utilization pattern and prescribing trend of anti-diabetics is of paramount importance to promote rational drug use. <strong>Objectives:</strong> The primary objective of this research is to assess drug utilization evaluation of anti-diabetics in type 2 diabetes mellitus patients with or without comorbidities. <strong>Methods:</strong> A prospective observational study was carried out for six months in the inpatient medicine department of Chigateri District, Hospital Davanagere. <strong>Results: </strong>A total of 151 patients were enrolled, out of which 93 (62%) patients were males and 58 (38%) patients were females. Most of the patients belong to the age group of 51-60 (29%) years, followed by 61-70(28%) years. The pattern of drug prescription in diabetes shows that insulin (52%) was the most utilized monotherapy followed by metformin (47%). Among dual therapy, 34(60%) patients were treated with the combination of metformin+ glimepiride. A total of 8 patients were treated with triple therapy, out of which 4 (50%) patients were prescribed a combination of metformin+glimepride+human actrapid. <strong>Conclusion: </strong>The prescribing trend was found to be monotherapy with insulin followed by dual therapy and triple therapy. The combination of biguanides and sulfonylureas was the most commonly prescribed antidiabetic regimen among dual therapy. <p style="text-align: justify;"><strong> Key words:</strong> Utilization Pattern, Comorbid, Anti-diabetics, Prescribing Trend.

Discharging the complex patient - changing our focus to patients\u2019 networks of care providers

BackgroundA disconnect exists between the idealized model of every patient having a family physician (FP) who acts as the central hub for care, and the reality of health care where patients must navigate a network of different providers. This disconnect is particularly evident when hospitalized multimorbid patients transition back into the community. These discharges are identified as high-risk due to lapses in care continuity. The aim of this study was to identify and explore the networks of care providers in a sample of hospitalized, complex patients, and better understand the nature of their attachments to these providers as a means of discovering novel approaches for improving discharge planning.MethodsThis was a constructivist grounded theory study. Data included interviews from 30 patients admitted to an inpatient internal medicine service of a midsized academic hospital in Ontario, Canada. Analysis and data collection proceeded iteratively with sampling progressing from purposive to theoretical.ResultsWe identified network of care configurations commonly found in patients with multiple medical comorbidities receiving care from multiple different providers admitted to an internal medicine service. FPs and specialists form the network’s scaffold. The involvement of physicians in the network dictated not only how patients experienced transitions in care but the degree of reliance on social supports and personal capacities. The ideal for the multimorbid patient is an optimally involved FP that remains at the centre, even when patients require more subspecialized care. However, in cases where a rostered FP is non-existent or inadequate, increased involvement and advocacy from specialists is crucial.ConclusionsOur results have implications for transition planning in hospitalized complex patients. Recognizing salient network features can help identify patients who would benefit from enhanced discharge support.

Reliability of Patient-Report, Physician-Report, and Medical Record Review to Identify Hospital-Acquired Complications: A Prospective Cohort Study.

This prospective study of internal medicine inpatients treated at 2 hospitals in Toronto, Canada, between September 1, 2016, and September 1, 2017, compared patient-report, physician-report, and detailed medical record review to identify specific hospital-acquired complications. Six complications were assessed: delirium, catheter-associated urinary tract infection, acute kidney injury, deep vein thrombosis/pulmonary embolism, hospital-acquired pneumonia, or fall. The study included 207 patients and physician responses were obtained for 156 (75%). Complications were identified in 28 (14%) patients by medical record review, 30 (14%) patients by patient-report, and 11 (7%) patients by physician-report. Fifty-four (26%) patients experienced a complication as identified through at least one of the 3 methods. There was little agreement between the 3 methods (Fleiss' ĸ 0.15, P < 0.001). All 3 sources agreed on the occurrence of a specific complication in only 1 patient (1%). Multiple approaches likely are needed to adequately measure hospital-acquired complications.

How is mobile health technology transforming physician-nurse collaboration?

The integration of mobile health technologies in medical practice has the potential to promote in‐person, high‐quality care. We examine the impact of Voalte, a healthcare‐specific mobile application, on bedside rounding and care coordination. A cross‐sectional survey was conducted on 71 medical ward‐based nurses from a quaternary‐care academic centre, capturing 183 rounding events. The frequency of physician–nurse overlap at the bedside was 50.3%, representing a >20% increase when compared with the 2018 baseline before Voalte's introduction. Our results show that mobile health technologies can strengthen inpatient medicine workflows and interdisciplinary collaboration when implemented successfully.