Inpatient Team Research Articles

Optimal staffing for a good quality inpatient diabetes service.

Increasing numbers of people admitted to hospital have diabetes and need specialist support. To date, there is no mechanism which can help teams estimate the number of health care professionals they need to provide optimal care for people with diabetes in hospitals. The Joint British Diabetes Societies (JBDS) for Inpatient Care Group organised a survey of specialist inpatient diabetes teams in the UK for current staffing and the perception of optimal staffing using mailing lists available through their representative organisations. The results were verified and confirmed by one-to-one conversations with individual respondents and discussed in multiple expert-group meetings to agree on the results. Responses were received from 17 Trusts covering 30 hospital sites. Current diabetes specialist staffing level per 100 people with diabetes in hospital (Median, IQR) for consultants was 0.24 (0.22-0.37), diabetes inpatient specialist nurses was 1.94 (1.22-2.6), dieticians was 0.00 (0.00-0.00), podiatrists was 0.19 (0.00-0.62), pharmacists was 0.00 (0.00-0.37), psychologists was 0.00 (0.00-0.00). The teams also reported that for optimal care the total staff needed for each group (Median, IQR) was much higher; consultants 0.65 (0.50-0.88), specialist nurses 3.38 (2.78-4.59), dieticians 0.48 (0.33-0.72), podiatrists, 0.93 (0.65-1.24), pharmacists, 0.65 (0.40-0.79) and psychologists 0.33 (0.27-0.58). Based on the results of the survey, the JBDS expert group produced an Excel calculator to estimate staffing needs of any hospital site in question just by populating a few of the cells. Current inpatient diabetes staffing is much lower than needed in most Trusts who responded to the survey. The JBDS calculator can provide an estimate of the staffing needs of any hospital.

The quality of advance care planning at a comprehensive cancer center.

e18700 Background: Advanced care planning (ACP) is the comprehensive process of clarifying, communicating, and implementing patient preferences, personal values, and goals as they pertain to medical care and quality of life, and is especially important for patients with cancer. Early communication regarding ACP can improve patient satisfaction and limit unwanted hospital visits and treatments. One study of 200 cancer patients showed that only 24% reported having conversations with any provider regarding end-of-life care despite 82.5% wanting to do so. The lack of ACP documentation is particularly concerning in patients with malignancies due to their high risk of sudden deterioration, especially during hospitalization. Therefore, there is an unmet need to complete ACP documentation which can be addressed during hospital admissions. Methods: We created a comprehensive process map for the current ACP note documentation process to determine areas for improvement in our inpatient hospital medicine resident team, where we take care of patients with GI, lung, endocrine, breast, and head/neck malignancies. We analyzed hospital admissions 4 weeks before and 4 weeks after our intervention to determine the rates of ACP note documentation, as well as ACP note documenter provider specialty. Our intervention consisted of (1) providing education during team orientation with individualized slides emphasizing on the importance of ACP documentation and how to write such note, (2) displaying instructional flyers in the communal workroom, and (3) implementing a new electronic medical record admission template with a forcing function. We established the percent of ACP note documentation as our primary outcome measure which was modeled via run chart. Results: Of the sixty-four patients admitted to our hospital team during the 1 month prior to our intervention, 24 (38%) had an ACP note documented within the first 72 hours of admission and 5 of the 24 patients had two ACP notes written by different providers. In total there were 13 notes completed by hospitalists, 7 by oncologists, 5 by ER physicians, 2 by supportive care providers and 1 by a medicine resident. One month after our intervention, 38 of the 44 (86%) patients admitted had an ACP note documented within 72 hours of admission and only one patient had 2 notes from different providers. In this cohort, there were 28 notes completed by residents, 3 by hospitalists, 3 by oncologists, 3 by supportive care providers and 2 by ER physicians. At 3 months post-intervention, 22 patients (34%) of the pre-intervention cohort were deceased, 14 (64%) of whom had ACP documentation. Conclusions: Cancer patients are at an increased risk of deterioration during their clinical course. Quality improvement interventions to promote ACP documentation during hospital admissions leads to care better aligned with patients' wishes and fulfills an unmet need in addressing goals of care.

End-of-life outcomes after implementation of an embedded, criteria-based palliative care consultation service in inpatient oncology.

12121 Background: Specialty palliative care (PC) improves outcomes for patients with advanced cancer, including quality of life and end-of-life (EOL) care utilization. In 2017, the American Society of Clinical Oncology recommended that patients with advanced cancer see specialty PC within 8 weeks of diagnosis. Despite this, inpatient PC referrals exceed outpatient referrals nationwide. Recognizing the importance of earlier PC access, our cancer center implemented a criteria-based PC consultation service in the inpatient oncology setting. We now report pre/post EOL outcomes from this novel care model. Care model: Our center embedded a “Palliative Oncology” consult team on the oncology floor consisting of 1 physician, 1 nurse practitioner (NP), 2 social workers, and 2 spiritual care providers, all with PC specialization. Admitted patients were screened by a floor nurse or PC NP for 2 referral criteria: 1) advanced/metastatic solid cancer, or 2) moderate/severe symptoms. The inpatient oncology team was informed of patients meeting criteria through daily prompting supported by ongoing education. Referrals remained at discretion of the oncology team rather than triggering automatically. Methods: We identified all cancer center decedents with advanced solid cancers who experienced an admission to the oncology floor before (10/1/19-6/30/20) or after (7/1/20-9/30/21) the new model. Six trained abstractors performed chart review. We compared outcomes between patients who died pre- and post-implementation using a t-test (continuous variables) and χ2 test (categorical variables). Results: Of 820 decedents, 186 died pre-intervention and 634 died post-intervention. During the post-intervention period, more decedents saw inpatient PC (72% vs. 59%, p < .001) and outpatient PC (34% vs. 23%, p < .01). Post-intervention decedents had more inpatient PC visits (mean: 11.1 vs. 8.9, p < .05) and had their first PC visit sooner before death (mean: 159 vs. 76 days, p < .001). During the post-intervention period, fewer decedents had ED (41% vs. 52%, p < 0.05), hospital (57% vs. 71%, p < .001), or ICU encounters (17% vs. 25%, p < .01) in the last 30 days of life. For post-intervention decedents, the proportion referred to hospice remained stable (67% vs. 60%, p = .09), but mean hospice length-of-stay increased (36 vs. 22 days, p < .05), as did the proportion who died at home (50% vs. 41%, p < .05). Fewer post-intervention decedents received systemic cancer therapy in the last 14 days of life (5% vs. 9%, p < .05). There were no between-group differences in age at cancer diagnosis, age at death, gender, race/ethnicity, insurance, or primary cancer. Conclusions: A criteria-based “Palliative Oncology” inpatient consult service was associated with earlier, more intense PC and improved EOL quality outcomes, representing a successful effort to enhance PC integration in the inpatient oncology setting.

CHRONIC OSTEOMYELITIS: BEWARE OF PRE-REFERRAL CULTURES

Materials & MethodsChronic osteomyelitis is a complex and challenging condition the successful treatment of which requires a specialist multidisciplinary approach. Prior to tertiary referral to a specialist Orthoplastic Unit, patients often receive multiple courses of antibiotics, in usually unsuccessful attempts, to eradicate infection. This often results in the development of chronic polymicrobial infection. We reviewed the intra-operative cultures of patients treated in our Orthoplastic unit over a 9-year period from 2012–2021 to determine the spectrum of polymicrobial cultures and the relationship to pre-operative cultures.ResultsWe reviewed the electronic care records and laboratory results of all patients referred to or directly admitted to our unit with a diagnosis of chronic osteomyelitis between 2012–2021. We checked all culture results, antibiotic sensitivities and prescription for treatment. We also checked for any recurrence of infection within 1 year.60 patients were treated over the 9-year period. 9 upper and 51 lower limbs. The most common referral sources were from the surgical specialties of Trauma & Orthopaedics and Plastic Surgery (62%) while an equal amount came from the Emergency Department and other inpatient medical teams, each making up 15%. A small cohort (8%) developed the infection while still being followed up post fixation.Aetiology of Infection were post fracture fixation 41 (68%), spontaneous osteomyelitis 10 (17%), soft tissue infection 4 (7%). The remaining 5 patients (8%) had a combination failed arthroplasty, arthrodesis and chronic infection from ring sequestrum. 58 patients (97%) had positive cultures with 26 being polymicrobial. 12 cultures were gram negative (G-ve), 11 G+ve 12, 4 anaerobic and 1 Fungal. In 24 patients (40%) the pre-operative cultures and antibiotic sensitivities did not correspond to the intra-operative cultures and sensitivities. 55 patients (92%) required dual or triple therapy with 8% requiring further debridement and extended therapy. 2 (3%) patients had failed treatment requiring amputation.ConclusionsChronic osteomyelitis is a complex and challenging condition the successful treatment of which requires early referral to a specialist Orthoplastic unit. Less than half of organisms cultured pre-operatively reflect the causative organisms cultured intra-operatively with 52% of these infections being polymicrobial.After initial treatment, 8% of patients will require a further combination of extended antibiotic therapy and surgery to eradicate infection.

Trends, sociodemographic and hospital-level factors associated with inpatient palliative care utilization among malignant melanoma patients: A 5-year National Inpatient Sample (NIS) study.

e21526 Background: Palliative care improves the quality of life in cancer patients; however, there is no literature on specific factors that predict its use in patients with malignant melanoma. We explored the prevalence trends, and predictors of palliative care utilization among hospitalized patients with malignant melanoma. Methods: Retrospective analyses were conducted using the National Inpatient Sample (NIS) data collected between 2016 and 2020. Descriptive analyses and multivariable regression models were used to investigate the prevalence trends, and sociodemographic and hospital-level factors associated with palliative care utilization in hospitalized malignant melanoma patients. Results: Of the 9,760 hospitalizations with a diagnosis of malignant melanoma over the study duration, 14% utilized palliative care during their hospital stay. Overall, 9.2% of malignant melanoma patients used palliative care and were discharged alive. There was a stable trend of palliative care use over the 5-year period (14%). Compared to patients on Medicare, those on Medicaid were twice (adjusted odds ratio (AOR): 2.12; 95% confidence interval (CI): 1.26–3.64) more likely to utilize palliative care. Relative to other regions in the US, patients hospitalized in the West were 40% less likely to receive the service of the palliative team (AOR: 0.61; 95% CI: 0.38-0.96). Those admitted to teaching hospitals (AOR: 0.55; 95% CI: 0.40-0.77) had lower odds of having palliative care consultations when compared to non-teaching hospitals. Patients admitted to urban hospitals had 50% (AOR: 0.51; 95% CI: 0.27–0.98) lesser odds of getting palliative care when compared to their counterparts in rural hospitals. Individuals who were either discharged to a facility/with home health (AOR: 8.81; 95% CI: 5.88–13.23) or died during hospitalization (AOR: 128.42; 95% CI: 72.10–228.77) had higher odds of utilizing palliative care when compared to those with a routine discharge. Conclusions: The prevalence of palliative care utilization was low, and factors associated with utilization in our population were identified. Our findings emphasize the necessity to improve awareness among medical oncologists and primary inpatient teams on the importance of involving the palliative care service early in the management of hospitalized patients with malignant melanoma.

Abstract #1401801: A Late Diagnosis of Cushing's Disease

Cushing’s disease is a well-known entity that is frequently described in the literature; however, amongst all pituitary lesions, ACTH-secreting tumors are among the least prevalent and are frequently diagnosed later in the disease course when compared to other functional adenomas. Here we describe a case of Cushing’s disease in a patient who had gone without a diagnosis for many years despite her vast symptomatology. A 60-year-old woman presented for a transsphenoidal resection of a pituitary tumor. Endocrinology was consulted for post-operative monitoring. Initially thought to be the usual case of watching for diabetes insipidus and secondary adrenal insufficiency, this patient provided an extensive and unusual history. About 15 years prior, the patient abruptly began to gain weight notwithstanding a healthy diet and a busy lifestyle. After a year of dedicated lifestyle modifications failing to allow for weight loss, the patient underwent bariatric surgery alongside her sister (who had also gained a tremendous amount of weight attributed to overeating). The patient’s sister succeeded in losing a great deal of weight, however the patient plateaued after losing approximately 35 pounds. During the next few years, the patient started breaking bones, first her hip, then her sternum. Her inpatient medical team checked her ACTH, which was found to be 747 pg/mL (reference range 7.2-63.3 pg/mL). They then checked her AM cortisol, which was not surprisingly elevated to 56.5 mcg/dL (reference range 6.0-18.4 mcg/dL). The patient endorsed numerous symptoms of Cushing’s disease and was referred to an endocrinologist who ordered an MRI of her brain, revealing a macroadenoma. The patient underwent tumor resection and was able to lose over 100 pounds over the course of the next year. Over the following 10 years, the patient remained asymptomatic, until she suddenly, and familiarly, began to gain a copious amount of weight and again experienced fatigability, easy bruising, and hair growth. The patient knew to re-present to her endocrinologist, at which time both her ACTH and cortisol were both elevated (1082 pg/mL and 39.0 mcg/dL, respectively). An MRI of the brain performed at that time revealed recurrence of her pituitary tumor. The patient went for a second resection of her pituitary lesion, after which time our endocrinology team was consulted. Patient did require treatment for diabetes insipidus, secondary AI, and central hypothyroidism, however her symptoms of Cushing’s quickly resolved, and her AM cortisol two days post-operatively was found to be 0.7 mcg/dL, indicating a successful tumor removal. This particular case of Cushing’s disease recurrence highlights the importance of continued post-operative monitoring. Although frequent monitoring may not be indicated, and blood work and imaging may be spaced out, it may be good practice to watch these patients closely to prevent further disease sequalae. Furthermore, we are reminded that a secondary workup of obesity is of paramount importance, as this patient likely would not have required bariatric surgery has she been properly workup up for endocrinological causes of weight gain.

Inpatient Neurology Huddle Quality Improvement Project (P3-7.006)

<h3>Objective:</h3> To implement a standardized huddle checklist that includes the important patient related issues that need to be addressed daily during inpatient neurology huddle and to assess the level of satisfaction of neurology health care providers about daily huddle flow both before and after implementing the checklist. <h3>Background:</h3> Inpatient interdisciplinary medical team members’ daily huddle is a meeting at which key issues related to patient care and management are discussed among medical team members. Clear communication is important for good patient outcome as well as health care providers satisfaction. Daily huddle improves patient care, safety, and outcomes by facilitating direct communication among all key members involved in patient care. <h3>Design/Methods:</h3> Using Survey monkey, a pre-implementation data was collected to assess the level of satisfaction of the healthcare providers with huddle flow and patient safety. Post-implementation data collected after 9 months of standard checklist implementation. Descriptive analysis was performed for survey results. <h3>Results:</h3> 33 health care providers participated in the pre-implementation survey: 10 (30.3%) nurses, 20 (60.6%) physicians, 2 (6.06 %) case managers, 1 (3.03%) social worker. 32 health care providers participated in the post-implementation survey: 11 (34.38%) nurses, 17 (53.13%) physicians, 2 (6.25%) case managers, 2 (6.25%) social workers. Prior to checklist implementation, 13 (39.39%) of the participants were satisfied with overall huddle flow. After checklist implementation 25 (78.13%) were satisfied with overall huddle flow. Regarding overall patient’s safety as a result of daily huddle, 14 (42.4%) of the participants were satisfied, 5 (15.15%) were dissatisfied and 14 (42.4%) were neither satisfied nor dissatisfied prior to checklist implementation. After checklist implementation, 24 (75 %) were satisfied, 2 (6.25%) were dissatisfied and 6 (18.75%) were neither satisfied nor dissatisfied with the overall patient’s safety because of daily huddle. <h3>Conclusions:</h3> Our data suggest that standardized huddle checklist improves provider’s satisfaction with huddle workflow and patient safety. <b>Disclosure:</b> Dr. Matloub has nothing to disclose. Dr. Carter has nothing to disclose. Dr. Wang has nothing to disclose.

Cobalamin C Deficiency, an Inborn Error of Metabolism presenting with Subacute Neuropsychiatric Symptoms (P9-4.001)

<h3>Objective:</h3> Inpatient Neurology teams are often consulted to rule out neurological causes for new-onset neuropsychiatric symptoms. This case highlights the importance of considering possible Inborn Errors of Metabolism (IEM) that require specific treatments, and avoiding premature closure on a primary psychiatric disorder. <h3>Background:</h3> A 15-year-old presented to a pediatric hospital with a 4–8 week onset of neuropsychiatric (psychosis, psychomotor slowing, catatonia, sleep cycle irregularities, and tremors) and systemic (acute on chronic kidney injury and hypertension) symptoms. Neurology was consulted for further evaluation. In addition to the abnormal higher mental function exam, the neurological exam was significant for hyperreflexia in both the upper and lower extremities. <h3>Design/Methods:</h3> N/A <h3>Results:</h3> Neuroimaging (an initial non-contrast CT Head and MRI brain with and without contrast) did not reveal an intracranial abnormality. Analysis of cerebrospinal fluid, including an autoimmune encephalitis panel, was unremarkable. Metabolic testing was significant for elevated homocysteine and methylmalonic aciduria with normal Vitamin B12 levels. Genetics and metabolic consult recommended testing for Cobalamin C deficiency that returned positive with pathogenic mutations in MMACHC gene. Neuropsychiatric symptoms began to improve after the initiation of treatment with hydroxocobalamin, carnitine, betaine, and leucovorin. <h3>Conclusions:</h3> Cobalamin C deficiency (CblC) most commonly presents in infants less than 1 year, but is also known to present rarely in adolescence or adulthood, most commonly with subacute onset psychiatric symptoms, myelopathy, and cardiovascular disease. CblC is an autosomal recessive disorder caused most commonly by pathogenic variants within the MMACHC gene. Late-onset forms of IEM can present with isolated neuropsychiatric symptoms years after birth and thus are prone to be missed. Treatable metabolic disorders should be considered in the workup for new-onset neuropsychiatric symptoms. <b>Disclosure:</b> Dr. Engel has nothing to disclose. Dr. Rashid has nothing to disclose. Dr. Al-Beshri has nothing to disclose. Dr. Ananth has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Reata Therapeutics. The institution of Dr. Ananth has received research support from Acadia Pharmaceuticals.

“To Call or Not to Call” Communication Preferences Among Pediatric Hospital Medicine Team Leaders

Pediatric Hospital Medicine fellowship programs need to abide by Accreditation Council for Graduate Medical Education requirements regarding communication and supervision. Effective communication is critical for safe patient care, yet no prior research has explored optimal communication practices between residents, fellows, and attending hospitalists. Our objective is to explore communication preferences among pediatric senior residents (SRs), Pediatric Hospital Medicine fellows, and hospitalists on an inpatient team during clinical decision-making. We conducted a cross-sectional survey study at 6 institutions nationwide. We developed 3 complementary surveys adapted from prior research, 1 for each population: 200 hospitalists, 20 fellows, and 380 SRs. The instruments included questions about communication preferences between the SR, fellow, and hospitalist during clinical scenarios. We calculated univariate descriptive statistics and examined paired differences in percent agreement using χ2 tests, accounting for clustering by institution. Response rates were: 53% hospitalists; 100% fellows; 39% SRs. Communication preferences varied based on role, scenario, and time of day. For most situations, hospitalists preferred more communication with the fellow overnight and when a patient or family is upset than expressed by fellows (P < .01). Hospitalists also desired more communication between the SR and fellow for an upset patient or family than SRs (P < .01), but all respondents agreed the SR should call the fellow for adverse events. More fellows and hospitalists felt that the SR should contact the fellow before placing a consult compared with SRs (95%, 86% vs 64%). Hospitalists, fellows, and SRs may have differing preferences regarding communication, impacting supervision, autonomy, and patient safety. Training programs should consider such perspectives when creating expectations and communication guidelines.

Hispanic/Latinx and Spanish Language Concordance Among Palliative Care Clinicians and Patients in Hospital Settings in California

Background: Members of racial or ethnic minority groups utilize palliative care (PC) services less than non-Hispanic White patients and multiple factors contribute to this disparity. The impact of racial, ethnic, and language (REL) concordance between patients and clinicians has been demonstrated in general medical populations, but not in PC populations. We characterized the racial and ethnic composition and languages spoken of California PC clinicians and patients to examine clinical impacts of REL concordance. Methods: Using Palliative Care Quality Network data, 15 inpatient teams were identified in California that had collected data on patient race/ethnicity and language. Patient and clinician data were analyzed using means and medians for continuous variables, and chi-squared tests to explore similarities and differences between clinician and patient data. Results: 51 clinicians from nine teams completed the survey. The largest non-White and non-English speaking groups among patients and clinicians identified as Hispanic/Latinx (31.5% of patients, 16.3% of clinicians) and as Spanish speakers (22.6% of patients, 7.5% of clinicians). There was a significantly higher proportion of Hispanic/Latinx patients compared to clinicians (p-value 0.01), with Southern California demonstrating the largest difference (30.4% of patients vs. 10.7 % of clinicians, p-value 0.01). Similar proportions of patients and clinicians reported Spanish fluency (22.6% vs 27.5%, p-value 0.31). Discussion: We found significant differences in the racial/ethnic distributions of Hispanic/Latinx patients and clinicians in California, prompting consideration of whether a lack of representation of Hispanic/Latinx clinicians relative to the patient population may contribute to lower palliative care utilization among Hispanic/Latinx patients.

Supporting post-stroke access to services and resources for individuals with low income: understanding usual care practices in acute care and rehabilitation settings

Purpose Following stroke, individuals who live in a low-income or are at risk of living in a low-income situation face challenges with timely access to social services and community resources. Understanding the usual care practices of stroke teams, specifically, how they support this access to services and resources, is an important first step in promoting the implementation of practice change. Method A qualitative multiple-case study of acute care, inpatient, and outpatient rehabilitation stroke teams in an urban area of Canada. Semi-structured interviews and questionnaires about the workplace context were conducted with 19 professionals (social workers, occupational therapists, physiotherapists, speech-language pathologists) at four sites. Results In their usual practice, stroke teams prioritized immediate care needs. The stroke team professionals did not address income or resources unless it directly affected discharge. Usual care was influenced by factors such as time constraints, lack of knowledge about services and resources, and social service system limitations. Conclusion To better support post-stroke access to social services and resource for low-income individuals, a multidisciplinary approach, with actions beginning earlier on and extending throughout the continuum of care, is recommended, in addition to system-level advocacy.

Implementation of fully closed-loop insulin delivery for inpatients with diabetes: real-world outcomes.

Fully closed-loop insulin delivery has been shown in clinical trials to be safe and improve glucose control compared with standard insulin therapy in the inpatient setting. We investigated the feasibility of implementing the approved CamAPS HX fully closed-loop system in a hospital setting. This implementation project was conducted in a large teaching hospital in Cambridge, UK. Healthcare professional training was multimodal including face-to-face workshops, online learning modules and supported by standard operating procedures. Set-up and maintenance of closed-loop devices was undertaken by the inpatient diabetes team. Selection of suitable patients was multidisciplinary and prioritised those with more challenging diabetes management. Demographic and clinical data were collected from electronic health records and diabetes data management platforms. In the 12 months since the closed-loop system was implemented, 32 inpatients (mean±SD age 61±16 years, 8 females, 24 males) used closed-loop insulin delivery during their admission, across medical and surgical wards in the hospital with a total of 555 days of closed-loop glucose control (median[IQR]: 14[6, 22] days per inpatient). The time spent in target glucose range 3.9-10.0mmol/L was 53.3±18.3%. Mean glucose was 10.7±1.9mmol/L with 46.0±18.2% of time spent with glucose >10.0mmol/L. Time spent with sensor glucose below 3.9mmol/L was low (median[IQR]: 0.38[0.00, 0.85]). There were no episodes of severe hypoglycaemia or diabetic ketoacidosis during closed-loop use. We have demonstrated that the fully closed-loop system can be safely and effectively implemented by a diabetes outreach team in complex medical and surgical inpatients with challenging glycaemic control.

How Is Functional Neurological Disorder Managed in Australian Hospitals? A Multi-Site Study Conducted on Acute Inpatient and Inpatient Rehabilitation Wards.

Successful management for functional neurological disorder (FND) requires multidisciplinary involvement starting with providing a definitive diagnosis. To observe clinical management of patients with FND during hospital admission. A prospective observational study was conducted over six Australian hospitals over a 4-month period. Data collected included patient demographics, communication of the diagnosis of FND, access to the multidisciplinary team, hospital length of stay (LOS), and emergency department (ED) presentations. A total of 113 patients were included. Median LOS was 6 (interquartile range, 3-14) days. Thirty-five (31%) presented to ED with 9 (8%) re-presenting two or more times after hospital discharge. Total hospital utilization cost was AUD$3.5million. A new diagnosis was made in 82 (73%) patients. Inpatient referrals were made to neurology (81, 72%), psychology (29, 26%), psychiatry (27, 24%), and physiotherapy (100, 88%). Forty-four (54%) were not told of the diagnosis. Twenty (24%) did not have their diagnosis documented in their medical record. Of the 19 (23%) not reviewed by neurology on non-neurosciences wards, 17 (89%) did not have their diagnosis communicated and 11 (58%) did not have it documented. Twenty-five (42%) referred to neurology were not provided with a diagnosis. Current gaps in service provision during inpatient hospital admissions in Australia include low rates of communication of a diagnosis, particularly when patients are not located on a neurosciences ward, and limited and variable access to inpatient multidisciplinary teams. Specialized services are needed to improve education, clinical pathways, communication, and health outcomes while reducing healthcare system costs.

Factors Associated With Inpatient Subspecialty Consultation Patterns Among Pediatric Hospitalists

Subspecialty consultation is a frequent, consequential practice in the pediatric inpatient setting. Little is known about factors affecting consultation practices. To identify patient, physician, admission, and systems characteristics that are independently associated with subspecialty consultation among pediatric hospitalists at the patient-day level and to describe variation in consultation utilization among pediatric hospitalist physicians. This retrospective cohort study of hospitalized children used electronic health record data from October 1, 2015, through December 31, 2020, combined with a cross-sectional physician survey completed between March 3 and April 11, 2021. The study was conducted at a freestanding quaternary children's hospital. Physician survey participants were active pediatric hospitalists. The patient cohort included children hospitalized with 1 of 15 common conditions, excluding patients with complex chronic conditions, intensive care unit stay, or 30-day readmission for the same condition. Data were analyzed from June 2021 to January 2023. Patient (sex, age, race and ethnicity), admission (condition, insurance, year), physician (experience, anxiety due to uncertainty, gender), and systems (hospitalization day, day of week, inpatient team, and prior consultation) characteristics. The primary outcome was receipt of inpatient consultation on each patient-day. Risk-adjusted consultation rates, expressed as number of patient-days consulting per 100, were compared between physicians. We evaluated 15 922 patient-days attributed to 92 surveyed physicians (68 [74%] women; 74 [80%] with ≥3 years' attending experience) caring for 7283 unique patients (3955 [54%] male patients; 3450 [47%] non-Hispanic Black and 2174 [30%] non-Hispanic White patients; median [IQR] age, 2.5 ([0.9-6.5] years). Odds of consultation were higher among patients with private insurance compared with those with Medicaid (adjusted odds ratio [aOR], 1.19 [95% CI, 1.01-1.42]; P = .04) and physicians with 0 to 2 years of experience vs those with 3 to 10 years of experience (aOR, 1.42 [95% CI, 1.08-1.88]; P = .01). Hospitalist anxiety due to uncertainty was not associated with consultation. Among patient-days with at least 1 consultation, non-Hispanic White race and ethnicity was associated with higher odds of multiple consultations vs non-Hispanic Black race and ethnicity (aOR, 2.23 [95% CI, 1.20-4.13]; P = .01). Risk-adjusted physician consultation rates were 2.1 times higher in the top quartile of consultation use (mean [SD], 9.8 [2.0] patient-days consulting per 100) compared with the bottom quartile (mean [SD], 4.7 [0.8] patient-days consulting per 100; P < .001). In this cohort study, consultation use varied widely and was associated with patient, physician, and systems factors. These findings offer specific targets for improving value and equity in pediatric inpatient consultation.

Disparities in advance care planning rates persist among emergency general surgery patients: Current state and recommendations for improvement.

Unanticipated changes in health status and worsening of chronic conditions often prompt the need to consider emergency general surgery (EGS). Although discussions about goals of care may promote goal-concordant care and reduce patient and caregiver depression and anxiety, these conversations, as well as standardized documentation, remain infrequent for EGS patients. We conducted a retrospective cohort study using electronic health record data from patients admitted to an EGS service at a tertiary academic center to determine the prevalence of clinically meaningful advance care planning (ACP) documentation (conversations and legal ACP forms) during the EGS hospitalization. Multivariable regression was performed to identify patient, clinician, and procedural factors associated with the lack of ACP. Among 681 patients admitted to the EGS service in 2019, only 20.1% had ACP documentation in the electronic health record at any time point during their hospitalization (of those, 75.5% completed before and 24.5% completed during admission). Two thirds (65.8%) of the total cohort had surgery during their admission, but none of them had a documented ACP conversation with the surgical team preoperatively. Patients with ACP documentation tended to have Medicare insurance (adjusted odds ratio, 5.06; 95% confidence interval, 2.09-12.23; p < 0.001) and had greater burden of comorbid conditions (adjusted odds ratio, 4.19; 95% confidence interval, 2.55-6.88; p < 0.001). Adults experiencing a significant, often abrupt change in health status leading to an EGS admission are infrequently engaged in ACP conducted by the surgical team. This is a critical missed opportunity to promote patient-centered care and to communicate patients' care preferences to the surgical and other inpatient medical teams. Therapeutic/Care Management; Level IV.

Embedding the rehabilitation treatment specification system (RTSS) into clinical practice: an evaluation of a pilot teaching programme

BackgroundDeficiency in the provision and quality of treatment specification by rehabilitation clinicians impairs the ability to differentiate effective from ineffective elements of treatment. The standardised language of the rehabilitation treatment specification system (RTSS) has been proposed as a countermeasure. To date, there is no evidence of its use in clinical practice and what effect it may have. This study aimed to assess the ability of a pilot teaching programme to embed the RTSS into the clinical practice of an inpatient oncology physiotherapy team. The objectives were to evaluate the teaching programme’s effect on; participants’ familiarity and perceived benefit of the RTSS, its uptake, participants’ clinical reasoning, and their feelings and attitudes towards adopting the RTSS. This study provides an evaluation of the pilot teaching programme which will subsequently inform a larger iteration in an ongoing Health Education England (HEE) project aiming to disseminate and embed the RTSS into physiotherapy practice to improve physiotherapists’ treatment specification.MethodsA 6-week, multi-modal RTSS pilot teaching programme based upon socio-constructivist theory was delivered to 10 inpatient oncology physiotherapists at a large urban UK trust in 2021. Self-reported measures and clinical case note audits were assessed before and after the RTSS teaching programme to evaluate its effect on RTSS familiarity and perceived benefit, uptake, and clinical reasoning. A post-teaching focus group was undertaken. It was qualitatively analysed using an inductive, independent thematic approach to evaluate clinicians’ reflection and adoption.ResultsTen participants (8F, 29.4(±3.5) years) with variable clinical experience completed the RTSS teaching programme (six 1-hour lecture/case-based-learning sessions weekly) with 85% mean attendance. Nine yielded complete data for analyses, and 7 participated in the focus group. There was significant improvements in self-reported familiarity and confidence using the RTSS. Furthermore, there was a significant effect of the teaching on self-reported clinical reasoning overall and specifically in knowledge and theory application. But this was not reflected in clinicians’ uptake of RTSS language, nor in the quality of clinical reasoning emergent in their case notes. Qualitative analyses revealed that while clinicians’ conceptual understanding and the relative advantage of using the RTSS in practice was pervasive, they articulated that translating its perceived academic disposition into their clinical practice a challenge.ConclusionsThe RTSS teaching programme was shown to be effective in improving self-reported measures of clinical reasoning, despite clinical uptake of the RTSS remaining low. Future iterations should be tested across physiotherapy specialisms and in a larger sample with consideration of pedagogical and cultural measures to support the clinical diffusion of the RTSS.

Provider Perspectives of Transitions of Care at a Tertiary Care Children's Hospital With a Hospitalist-Run Discharge Clinic.

Children's hospitals are discharging patients to home with increasingly complex outpatient needs, making safe transitions of care (ToCs) of vital importance. Our study involved a survey of both outpatient providers and pediatric hospitalists associated with our medical center to better describe providers' views on the ToC process. The survey included questions assessing views on patient care responsibilities, resource availability, our hospitalist-run postdischarge clinic (PDC), and comfort with telemedicine. Our hospitalists generally believed that primary care providers (PCPs) did not have adequate access to important ToC elements, whereas PCPs felt their access was adequate. Both provider types felt it was the inpatient team's responsibility to manage patient events between discharge and PCP follow-up and that a hospitalist-run PDC may reduce interim emergency room visits. This study challenges perceptions about the ToC process in children and describes a generalizable approach to assessing provider perceptions surrounding the ToC within individual health systems.

Decision-making and best practice when nasogastric tube feeding under restraint: multi-informant qualitative study.

Clinicians working in mental health in-patient settings may have to use nasogastric tube feeding under physical restraint to reverse the life-threatening consequences of malnutrition when this is driven by a psychiatric condition such as a restrictive eating disorder. To understand the decision-making process when nasogastric tube feeding under restraint is initiated in mental health in-patient settings. People with lived experience of nasogastric tube feeding under restraint and parents/carers were recruited via the website of the UK's eating disorder charity BEAT. Eating disorder clinicians were recruited via an online post by the British Eating Disorders Society. Semi-structured interviews were administered to all participants. Themes overlapped between the participant groups and were integrated in the final analysis. Two main themes were generated: first, 'quick decisions', with the subthemes of 'medical risk', 'impact of not eating' and 'limited discussions'; second, 'slow decisions', with subthemes of 'threats', 'discussions with patient', 'not giving up' and 'advanced directives'. Benefits and harms of both quick and slow decisions were identified. This research offers a new perspective regarding how clinical teams can make best practice decisions regarding initiating nasogastric feeding under restraint. In-patient mental health teams facilitating this clinical intervention should consider discussing it with the patient at the beginning of their admission in anticipation of the need for emergency intervention and in full collaboration with the multidisciplinary team.

Delivering Palliative Care to Hospitalized Oncology Patients: A Scoping Review.

Early, longitudinal integration of palliative care (PC) is recommended for patients with advanced cancer, in both inpatient and outpatient settings. Despite the growth of specialty PC teams in the last decade, the majority of PC is still delivered in the inpatient setting using a traditional referral-based consult delivery model. However, traditional consultation can lead to significant variation or delay in inpatient PC utilization. New care delivery models and strategies are emerging to deliver PC to hospitalized oncology patients who would most benefit from their services and to better align with professional society recommendations. To identify different care models to deliver PC to ho`spitalized oncology patients and summarize their impact on patient and health system-related outcomes. We conducted a scoping review of peer-reviewed articles from 2006 to 2021 evaluating delivery of PC to oncology patients in acute inpatient care. We abstracted study characteristics, the study's intervention and comparison arms, and outcomes related to specialty PC intervention. We identified four delivery models that have been reported to deliver PC: 1) traditional referral-based consultation, 2) criterion-based or "triggered" consultation, 3) co-rounding with primary inpatient team, and 4) PC clinicians serving as the primary team. We summarize the known outcomes data from each model, and compare the benefits and limitations of each model. Our findings provide guidance to health systems about care delivery models to deploy and implement inpatient PC resources to best serve their unique populations.

Adaptations within Palliative Care Delivery Models Due to the COVID-19 Pandemic at a Tertiary Care Hospital.

Background: Since the onset of the COVID-19 pandemic, all facets of palliative care provision for patients with serious illness have faced unparalleled challenges. Methods: We describe our palliative care program's response to the increased clinical volume associated with the pandemic by adapting workflows for inpatient and outpatient palliative care teams caring for oncology and nononcology populations. Results: During the initial surge, the demand for palliative care consultation for patients affected by SARS-CoV-2 was high, accounting for 75% of all inpatient palliative care referral requests for oncology and nononcology patients. Furthermore, our ambulatory clinic experienced a 40% increase in visits for complex oncology patients between February and December of 2020. Discussion: This article highlights transformations in palliative care delivery implemented in response to the pandemic and reflects on how these transformations have shaped our current care delivery models. We further delineate our intentional reliance on key population health principles to drive ongoing innovation in palliative care provision across our clinical teams.