Hospitalists Research Articles

Depression, a Hidden Co-Morbidity in Patients of Chronic Ailments; An Outpatient-Based Study

Objective: To identify the rate of depression among patients with chronic diseases attending outpatient clinics. Methodology: This cross-sectional study was conducted at the Department of Medicine in a Tertiary care Hospital, Rawalpindi, from December 2023 to May 2024. A total of two hundred and forty-six patients visiting the outpatient department (OPD) were chosen through consecutive sampling, adhering to specific exclusion and inclusion criteria. All participants provided informed written consent. Demographic data, information on comorbidities, and clinical and laboratory details were collected. The (CESD-10) scale “Center for Epidemiologic Studies Depression” was utilized to evaluate depression. Results: Among the 246 patients with chronic ailments in the medical OPD, 115 were male, and 131 were female. Depression was prevalent in 57 (86.4%) cases of diabetes mellitus (p-value 0.014), 37 (61.7%) cases of hypertension (p-value 0.005), 40 (64.5%) cases of chronic kidney disease (p-value 0.024), and 51 (87.9%) cases of asthma (p-value 0.010). Conclusion: Patients with chronic ailments are more susceptible to depression, highlighting the importance of considering this comorbidity in their treatment plans. Keywords: Diabetes mellitus, hypertension, chronic kidney disease, asthma, depression.

Assessing the impact of workload and clinician experience on patient throughput: A multicenter study.

Various strategies have attempted to address increased patient lengths of stay (LOS), but effectiveness varies. Factors related to work design and workforce experience may also play significant roles. Utilizing data from the Discharge in the A.M. trial, we aimed to validate an electronic measure of workload (i.e., note count) and assess the relationship of workload, patient complexity, and physician years of experience to LOS. Retrospective observational study at three large academic hospitals with hospital medicine physicians and patients they care for during the study. Workload as measured by electronic note count and physician years of experience; patient LOS. From February 9, 2021 to July 31, 2021, 59 physicians completed daily surveys for 93% of 2318 scheduled shifts. We observed a moderate correlation (r: .56) between starting morning census and note counts but no association with LOS. We observed an effect modification between note count and the Charlson Comorbidity Index (CCI), with LOS increasing by 2.3% (95% CI: 0.3%, 4.3%; p = .02) and 3.9% (95% CI: 2.0%, 5.9%; p < .0001) per patient for every 1 unit increase in note count for patients with a moderate CCI or severe CCI, respectively. Years since training was associated with a 0.7% decrease in LOS (95% CI: -1.3%, -0.1%, p = .03). Physician workload, as measured by note count, was associated with longer LOS with higher CCI, while more years of experience was associated with shorter LOS. Original Clinical Trial Registration: ClinicalTrials.gov number, NCT05370638.

Planning hospital-focused training in internal medicine at the CHUV

Switzerland already suffers from the long-predicted shortage of physicians. Moreover, the latter often face long and meandering postgraduate training. At the beginning of their career, most doctors work on internal medicine hospital wards, even though their future may just as well lie in an outpatient or inpatient setting, in general internal medicine or in other disciplines. To help these physicians identify and clarify their hospital trajectory at an early stage, thus optimizing training pathways, the Medicine Department of the CHUV set up its Housestaff. Using a mentorship system and clearly defining a training track (outpatient practice, hospital, academic, or transition), it supports candidates, in close partnership with other departments, regional hospitals and networks, in particular ambulatory ones.

Adaptation, Validation, and Feasibility Evaluation of Mindful Standing Yoga Combined with Baduanjin for Older Patients with Primary Osteoporosis.

This study aimed to adapt, validate, and evaluate the feasibility of a mindful exercise program (Mindful Standing Yoga combined with Baduanjin) for older patients with primary osteoporosis. The study was conducted in 3 stages. Stage 1 involved a qualitative focus group discussion with 6 experts to gather perspectives on modifying the exercise program. Stage 2 used a Delphi approach with another 6 experts to validate the program. In Stage 3, a feasibility study was conducted with 20 eligible patients (out of 23 initially enrolled) at a traditional Chinese medicine hospital, using a single-group pre- and posttest design. The strenuousness of the adapted exercise was assessed through heart rate (HR) and rating of perceived exertion (RPE). Its effects were measured using the Global Pain Scale (GPS), the Five Facets Mindfulness Questionnaire-Short Form (FFMQ-SF), the Tampa Kinesiophobia-11 Scale, and the Timed Up and Go test. Patient satisfaction and feedback were also collected. The modified program, consisting of 9 movements and taking 30 min to complete, was validated by experts as suitable, safe, and effective for practice. HR and RPE measurements confirmed it as a low-intensity exercise and not strenuous for the study population. The program significantly improved back pain and mindfulness in the feasibility study, with most participants expressing satisfaction with the protocol. Experts and participants affirmed that the program was appropriate and satisfactory for older patients with primary osteoporosis, particularly those with back pain. Further high-quality randomized controlled trials are needed to validate its effectiveness.

Individual on Death Row Receiving Electroconvulsive Therapy (ECT) for Catatonia

Abstract Electroconvulsive therapy (ECT) is underused, logistically challenging for those who are justice-involved, and laced with ethical problems for those on death row. Herein we describe a case of a man without history of long-standing psychiatric illness who, after more than 15 years on death row, was hospitalized for altered mental status. After medical stabilization, the altered mental status persisted. On exam, he displayed signs of catatonic stupor with repetitive non–goal-directed motor activity, repetition of words, rigidity, and negativism, among others. The Bush-Francis Catatonia Rating Scale was found to be 23. Lorazepam was nontherapeutic. Hospital psychiatry considered ECT. Hospital medicine, medical prison staff, and the hospital ethics committee were consulted. Consent to treat catatonia with ECT was obtained from next of kin. Before treatment, the ECT psychiatrist spoke with prison staff regarding the presence of plastic restraints. To balance the competing demands of carceral policies and musculoskeletal protection, we implemented the practice of removing plastic restraints after the patient was sedated by anesthetic, with restraints being reapplied after the motor convulsion ended. Five days after 7 ECT treatments given thrice weekly, the catatonic symptoms remitted. Ethically, psychiatrists are not to restore competency for the purpose of execution. In this case, ECT was used by psychiatrists unaffiliated with the criminal legal system to reduce suffering and improve quality of life given the potentially fatal consequences of catatonia.

Analysis of Emergency Internal Medicine Hospitalization after the Earthquake in Türkiye: Demographic and Clinical Results of Victims

Analysis of Emergency Internal Medicine Hospitalization after the Earthquake in Türkiye: Demographic and Clinical Results of Victims

Effect of goal-directed mobilisation versus standard care on physical functioning among medical inpatients: the GoMob-in randomised, controlled trial

ObjectiveTo assess the effect of goal-directed mobilisation (GDM) on physical functioning in medical inpatients.DesignRandomised, controlled, single-centre, parallel, superiority trial with a 3-month follow-up and blinded outcome assessment.SettingGeneral internal medicine wards...

Assessment of Transcription Errors and their Effects on Medical Approach, Hospitalization Duration, and Financial Costs of Traumatic Patients: How Can We Prevent Them?

Background and aims: Transcription errors pose significant risks to patient well-being, potentially leading to morbidity, mortality, and financial burdens on healthcare systems and society. This study assessed the prevalence of transcription errors and their impacts on medical treatment approaches, hospitalization duration, and associated costs. Methods: Direct observation was used to evaluate and compare all patients’ medical records, identifying errors, costs, and hospitalization duration. Physician orders and patient applications were checked, with intervention and control groups categorized based on the presence or absence of errors, respectively. Data were analyzed using descriptive and quantitative methods such as the chi-square, student’s t-test, Mann-Whitney test, and ANCOVA, to assess statistical significance. Results: No significant differences were observed in gender (P=0.73) and age (P=0.89) between patients. Omission errors and incorrect dosage forms were the most common. Errors were more frequent in patients with underlying diseases (P&lt;0.001), with nurses frequently involved (P&lt;0.001). Errors were more prevalent in intensive care units (ICUs) (P=0.002) and during morning and night shifts (P&lt;0.001). A significant association was found between trauma severity and medication error occurrence (P&lt;0.001). Moreover, patients with transcription errors had higher medical expenses and extended hospital stays (P&lt;0.001). Conclusion: Effective preventive measures are crucial to avoid transcription errors and their adverse consequences. Recommendations include minimizing abbreviations, ensuring complete and explicit orders, rigorous training, double-checking, using technology such as Electronic Prescription and Physician Orders, maintaining a distraction-free, ergonomic work environment, and fostering open communication among healthcare providers and patients to enhance medication safety.

Cognizance of patients’ rights towards health in a teaching hospital in Sindh, Pakistan: A comparative study

Objectives The objective of this study is to compare cognizance of patients’ rights among patients and doctors. Material and Methods The comparative cross-sectional study was undertaken in various wards of a teaching hospital in Sindh, Pakistan to explore cognizance of patients’ rights among patients and doctors. A total of 390 patients and 417 doctors were selected from the general medicine and general surgery wards of a teaching hospital in Sindh, Pakistan, from December 01, 2021 to February 28, 2022, through convenience sampling. A validated, pre-guided questionnaire was used for data collection. SPSS version 26.0 was used for analysis. The cumulative and segregated analysis of mean ± standard scores of patients’ and doctors’ cognizance regarding patients’ rights were assessed using an independent t-test. Result The segregated analysis of the mean scores of cognizance of patients’ rights among patients and doctors revealed that the majority of associations were statistically significant (p &lt; 0.05), with a few exceptions. These included the right to receive the best available care and respect (p = 0.29), the right to know about their treatment in an understandable language (p = 0.23), and the right to receive healthcare in a hygienic, clean, and safe environment (p = 0.79). Conclusion There is a significant difference in the levels of cognizance regarding patients’ rights between patients and doctors.

The Journal of Hospital Medicine turns 20.

The Journal of Hospital Medicine turns 20.

Comparison of characteristics of urine specimens at physiological state versus post-artificial heating at the National Traditional Medicine Hospital, Bhutan

Introduction: Urine reflects the body’s functional status playing a central role in the diagnosis of disease conditions. This study aimed to compare six of the nine features of urine at physiological and lukewarm states after artificial heating – colour, odour, steam, bubbles, sediment, and frothiness. Method: This comparative study utilized the Bhutan Analysis System for Urine Properties (BASUP) chart. The study was conducted from July 2021 to January 2022 at the Eastern Regional Referral Hospital, Wangdicholing District Hospital, and the National Traditional Medicine Hospital. The properties of urine were evaluated soon after collection at physiological state. After the urine specimen had cooled down to room temperature, it was heated to body temperature following a standard procedure for reassessment of its properties. Results: A total of 91 specimens from 35 men and 56 women were analysed. There were no significant differences observed in the colour, odour, steam, bubbles, sediment, or frothiness between physiological and artificially heated specimens. However, there were differences in the colours of དམར་ཤས་ ཆེ་བ། (Marshechewa) with p = 0.023 and སེར་ཤས་ ཆེ་བ། (Sershechewa) with p = 0.015. Conclusion: The study found no significant differences in the majority of the properties of urine in specimens at physiological state and after artificial heating. However, further studies are required to evaluate the physicochemical properties and the differences in the Marshechewa and Sershechewa colours noted.

Clinical characteristics and associated factors of pediatric acute necrotizing encephalopathy: a retrospective study.

In the clinic, pediatric acute necrotizing encephalopathy (ANE) primarily affects children under five years of age and is characterized by severe brain damage and high mortality. However, some challenges remain regarding the diagnosis and treatment of ANE. In the present study, we analyzed the clinical characteristics and related factors of ANE with the aim of providing improved diagnostic and treatment strategies. Thirty-four pediatric ANE patients admitted to Zhejiang University School of Medicine Hospital between February 2019 and December 2023 were included in this study. To identify the factors associated with mortality, clinical, laboratory and imaging data were analyzed with independent-sample t tests, Mann‒Whitney U tests, Fisher's exact probability tests and receiver operating characteristic (ROC) curve analyses. In this cohort of 34 patients, the most common symptoms were fever, seizures, altered consciousness, vomiting, diarrhea and shock. The mortality rate was 55.9%. Laboratory tests revealed that patients who died had higher creatinine, lactate, activated partial thromboplastin time (APTT), thrombin time (TT), interleukin-6 (IL-6), interleukin-10 (IL-10), creatine kinase (CK), and D-dimer than survivors. Imaging examinations predominantly revealed symmetrical lesions in the thalamus. The fatal group displayed lower Glasgow Coma Scale (GCS) scores and severe complications. Other factors related to mortality included the arterial pH, GCS score and hospitalization duration. The most common symptoms of ANE are fever, seizures, altered consciousness, vomiting, diarrhea and shock, and ANE has a high mortality rate. The GCS score and arterial pH are critical biomarkers for assessing the severity of ANE.

Challenges in delivery of Bhutanese Traditional Medicine (Sowa Rigpa) services at Primary Healthcare Centres in Bhutan

Bhutanese Traditional Medicine (Sowa Rigpa) and allopathic medicine are integrated and state-funded in the three-tier healthcare system of Bhutan. Bhutanese Traditional Medicine services are available in all three levels of the healthcare system offering a range of services, from consultations to therapies and drug dispensations. Except for the National Traditional Medicine Hospital in Thimphu, all the centres across the country offer only outpatient services. Out of 81 traditional medicine centres, 55 centres are located at the primary level, serving people in different geographical areas of the country. Despite an increasing number of patients availing the traditional medicine services, the facilities at the primary level continue to face several challenges. The challenges include delayed and disruptive medicine supply chain, lack of an effective and systematic patient referral system, misconceptions and lack of awareness of traditional medicine services and inadequate infrastructure. All of these impede the provision of traditional medicine services in the communities. We recommend a technology-based drug delivery system in addition to resilient production centres, an effective patient referral system in traditional medicine practice by leveraging on the guideline and electronic patient information system, advocacies in the communities to dispel the myths and misconceptions regarding the Bhutanese Traditional Medicine, and adequate and architecturally smart infrastructure. Implementing these solutions could enhance access and utilization of traditional medicine services, leveraging the best use of this important component of the healthcare system.

Cognitive load in hospital medicine: Implications for teachers, learners, and programs.

Cognitive load in hospital medicine: Implications for teachers, learners, and programs.

Feasibility and acceptability of the brief patient-reported experience measure consideRATE within the hospital setting for patients with palliative care needs, their families/carers and clinicians.

Supporting clinical teams to improve care for inpatients with palliative care needs and their carers is a known priority. Patient reported experience measures (PREMs) may assist in improvement work. Evidence about how to collect and feedback PREM data for this population and context is required. To determine the feasibility of implementing a brief, validated PREM, consideRATE and appraise its acceptability as perceived by inpatients with palliative care needs, their carers and clinicians. A prospective study using: 1) PREM administration, screening log and field note completion; and; 2) a focus group with clinicians. Eligible participants recruited from three wards (cancer care and internal medicine) of an Australian tertiary metropolitan hospital. Participants included patients screened to have palliative care needs (using the SPICTTM criteria), their carers and multidisciplinary clinicians (including clinical managers). Feasibility: A 71% response rate was achieved (n = 80 from 112 eligible patients approached). Mean screening time to inform eligible patients for PREM completion was 7.5 min. More than half of eligible participants (n = 47, 59%) opted for electronic completion of consideRATE and mean completion time was 6.12 min. A third of participants required assistance for PREM completion (n = 27, 34%). Score distribution varied across response options, albeit with a positive skew towards 'very good' and 'good'. Two thirds of respondents (n = 50, 62.5%) provided ⩾1 free-text response. Acceptability: Clinicians valued consideRATE data noting feedback needed to be: accessible, supported by free-text and responsive to local contexts. It is feasible to implement consideRATE for inpatients with palliative care needs. Clinicians note consideRATE data is acceptable in informing improvement foci.

Economic Evaluations of Health Care Interventions in Pediatric Hospital Care.

The hospital medicine movement thrives in a health care environment committed to providing high-quality, safe, and value-based care. Hospitalists and hospitals continually grapple with many decisions regarding adopting new interventions and deadopting established ones. These decisions span the gamut from tests, treatments, and supportive care, to care models. Traditionally, the choice to adopt one intervention over another is commonly thought of in terms of its direct impact on patient outcomes, benefits, and harms. However, the evolving landscape of health care, characterized by increasing constraints on resources necessitates a broader perspective, one that includes a thorough consideration of the economic implications. The goal is not to minimize costs but rather to maximize value, outcomes achieved for money spent. Economic evaluations of health care interventions can provide this information by quantifying value and assisting health care providers, hospitals, and health systems in deciding which intervention to adopt. Economic evaluations deal with both inputs (ie, costs) and outputs (ie, consequences). Few economic evaluations in pediatric hospital medicine have been published, and many clinicians are unfamiliar with them. This paper discusses the economic evaluation of health care interventions with special attention to the pediatric hospitalist and hospital care. The paper aims to give readers an understanding of the key concepts underlying economic evaluations.

Role of Serum Ferritin and Prediction of Neurological Outcome in Acute Ischemic Stroke Patients

Background: Stroke, also known as cerebrovascular accident (CVA), is an abrupt onset of neurological deficiency caused by a specific vascular aetiology. Aim: This study aimed to assess the role of serum ferritin in acute ischaemic stroke patients to correlate serum ferritin and neurological scales on the day of admission and during follow-up and to predict neurological outcomes. Methods: This prospective observational study included 100 patients who presented with acute ischaemic stroke clinically and with radiological imaging in the General Medicine and Neurology departments of Saveetha Medical College and Hospital for 18 months. Functional disability was assessed for all patients after 3 months based on the correlation of serum ferritin levels with the neurological scales, and the outcome was estimated. Results: The mean age of the patients was 59.45 ± 14.39. The serum ferritin level and Canadian Stroke Scale score during admission on day 7th and day 30th, were significantly different (p &lt; 0.01). Serum ferritin levels were positively associated with the Glasgow Coma Scale score at admission and on the 7th and 30th days after admission. Ferritin levels were significantly higher in the moderate category under all circumstances (p &lt; 0.01). Patients with mRS scores of 2, 3, and 4 were compared with serum ferritin levels and found to be significantly associated with serum ferritin levels. Conclusion: This study found that patients with higher serum ferritin levels experienced increased stroke severity and lower GCS and mRS scores, which correlated with increased morbidity.

Musculoskeletal Sepsis in the Pediatric Intensive Care Unit

Background: Childhood bone and joint infection (BJI) ranges in severity, with the most unwell children requiring pediatric intensive care unit (PICU) support. We describe demographic and prehospital features of BJI cases associated with PICU admission and report treatment outcomes and costs for these cases. Methods: This study includes a retrospective cohort of children ≤15 years of age hospitalized with acute hematogenous osteomyelitis or septic arthritis in Auckland between 2018 and 2023. Cases admitted to PICU were compared to non-PICU hospitalized BJI cases. Direct medical hospitalization costs, treatment type and outcomes were described up to 1 year following discharge. Results: Of 563 BJI cases, 43 (8%) were admitted to PICU. PICU cases had shorter prehospital symptom duration (3.78 vs. 5.73 days, P = 0.0002). Sensitive Staphylococcus aureus was equally likely to cause disease in PICU and non-PICU cases (P = 0.86). Average hospitalization was longer (35.78 vs. 8.71 days, P ≤ 0.0001) for those admitted to PICU. Readmission and complication rates were both higher within the first year. Average cost per admission was $378,120 NZ dollars (±$796,891.64) for PICU cases versus $32,219 (±$201,797.33), P = 0.01 for cases not requiring PICU admission. In regression analysis, Māori ethnicity, previous history of infections and congenital conditions were statistically associated with PICU admission. Conclusion: In this study, children admitted to PICU with severe BJIs were more likely to have a history of congenital conditions or previous infections. Those of Māori ethnicity are overrepresented. Children treated in PICU have longer hospitalizations and experience more adverse outcomes at 1 year following discharge.

Antibiotic Prescribing Practices in a Tertiary Care Teaching Hospital: A Retrospective Cross-Sectional Analysis.

Background Antibiotics are among the most frequently prescribed medications in hospitals, yet a significant portion of their use is inappropriate, contributing to the growing global threat of antimicrobial resistance (AMR). In Pakistan, AMR has reached alarming levels with the rise of multi- and extensively drug-resistant bacteria. This study evaluates antibiotic prescribing practices and the use of culture sensitivity (CS) testing to assess the appropriateness of antibiotic therapy. Methods This cross-sectional retrospective study was conducted in a 500-bed tertiary care teaching hospital in Islamabad, Pakistan, analyzing inpatient records from 2020 to 2022. From over 5000 patient files, 1012 met the inclusion criteria and were reviewed. The study assessed the rationality of antibiotic prescriptions based on the evidence of infection (EoI), clinical parameters, and the presence or absence of CS testing. Statistical analyses, including Chi-square tests, logistic regression, and Cox proportional hazards regression, were applied to determine the association between antibiotic use and patient outcomes. Results Among the 1,012 patients analyzed, 91.8% (n = 929) received one or more antibiotics. However, 30% (n = 274) of these prescriptions were issued without any documented EoI.Only 17.5% of patients underwent CS testing. Patients exposed to five or more antibiotics had a 2.5-fold increased risk of ICU mortality (HR = 2.50, p < 0.001). A positive correlation (r = 0.42, p < 0.001) was found between the number of antibiotics prescribed and the length of hospitalization. Conclusion The findings of this study reveal a high rate of inappropriate antibiotics prescribed without EoI and CS testing. The results emphasize the urgent need for comprehensive Antibiotic Stewardship Programs (ASPs) in hospital settings, particularly focusing on mandatory CStesting protocols. By reducing irrational antibiotic use, these initiatives can significantly mitigate the rise of AMRglobally, especially in resource-limited settings. Implementing ASPs not only optimizes antibiotic use but also aligns with the WHO recommendations, demonstrating the effectiveness of multifaceted interventions in minimizing resistance and improving patient outcomes.

Categorizing Care Delays and Their Impact on Hospital Length of Stay.

Unnecessary care delays of hospitalized patients increase the risk of hospital-related complications and drive up health care costs. While health systems focus on reducing the length of stay of hospitalized patients, not many studies looked at specific causes of the care delays that prolong length of stay. In this study, we sought to systematically identify and categorize the various care delays that contribute to prolonged length of stay on a hospital medicine service. We conducted a retrospective observational study looking at all inpatient encounters to the hospitalist service (N=6633) for the fiscal year 2021. Observation status, COVID-19 positive, and other services' discharged patients were excluded (N=2849) leaving 3784 eligible encounters. The resulting 5% stratified random sample accounted for 190 encounters accounting for a total of 1152 patient-days. Using a standardized data extraction tool, a day-by-day review of the sample encounters was performed for all care delays. These care delays were categorized into specific groups (System, Discharge, Provider, Patient/Family, or Consultant related) and subgroups based on predetermined criteria. The stratified sample was found to be comparable to the total patient population, with no statistically significant differences in key demographic and clinical metrics. About 30% of all patient-days had a care delay; 33% of these delays were attributable to system delays internal to the hospital such as waiting for imaging/procedures; 28% of delays were due to discharge barriers, driven overwhelmingly by a lack of available post-acute care beds, and about 20% of delays were attributable to the provider. Our study systematically looked at care delays that led to prolonged hospital length of stay. Most of these care delays were caused by either wait times for procedures and imaging studies or by a lack of post-acute care bed availability. Hospitals and health systems can use this approach to better determine which systemic changes are likely to be the most effective at reducing length of stay.