BACKGROUND

Care by hospitalists has been associated with improved/similar clinical outcomes and efficiency. However, less is known about their effect on conditions dependent upon specialists for procedures/treatment plans. Our objective was to compare care for upper gastrointestinal hemorrhage (UGIH) patients attended by academic hospitalists and non-hospitalists.

METHODS

The study included 450 UGIH patients admitted to general medical services of 6 teaching hospitals. Outcomes included in-hospital mortality and complications (i.e., recurrent bleeding, ICU-transfer, decompensation, transfusion, re-endoscopy, 30-day readmission). Efficiency was measured by hospital costs and length of stay (LOS).

RESULTS

Of 450 patients, 40% (177) were cared for by hospitalists with no differences between groups by endoscopic diagnosis, performance of early esophagogastroduodenoscopy (EGD), Rockall risk score, or Charlson index. Unadjusted clinical outcomes between hospitalists and non-hospitalists were similar except for 2 outcomes: patients cared for by hospitalists were more likely to receive a transfusion (74% vs. 63%; p=.02) or be re-admitted within 30-days (7.3% vs. 3.3%; p=.05). However, differences in adverse outcomes between providers were not seen after multivariable adjustments. Median LOS was similar for hospitalists and non-hospitalists (4 days; p=.69), but patients cared for by hospitalists had higher median costs ($7,359 vs. $6,181; p<.01). In multivariable analyses, LOS was similar (5.2 vs. 4.7 days; p=.15) and costs remained higher for the hospitalist-led teams (p<0.03).

CONCLUSIONS

Despite having similar overall outcomes and LOS, costs were higher in UGIH patients attended by hospitalists. These results suggest that the academic hospitalist model may be tempered in patients requiring specialists for procedures or management.

Background

Interventions designed to improve the delivery of primary care, including Patient-Centered Medical Homes and electronic health records, require an understanding of clinical workflow to be successfully implemented. However, there is a lack of tools to describe and study primary care physician workflow. We developed a comprehensive list of primary care physician tasks that occur during a face-to-face patient visit.

Methods

A validated list of tasks performed by primary care physicians during patient clinic visits was developed from a secondary data analysis of observation data from two studies evaluating primary care workflow. Thirty primary care physicians participated from a convenience sample of 17 internal medicine and family medicine clinics in Wisconsin and Iowa across rural and urban settings and community and academic settings.

Results

The final task list has 12 major tasks, 189 subtasks, and 191 total tasks. The major tasks are: Enter Room, Gather Information from Patient, Review Patient Information, Document Patient Information, Perform, Recommend / Discuss Treatment Options, Look Up, Order, Communicate, Print / Give Patient (advice, instructions), Appointment Wrap-up, and Leave Room. Additional subcodes note use of paper or EHR and the presence of a caregiver or medical student.

Conclusions

The task list presented here is a tool that will help clinics study their workflows so they can plan for changes that will take place because of EHR implementation and/or transformation to a patient centered medical home.

ABSTRACT

BACKGROUND

The number of hospitalists in the US is growing rapidly, yet little is known about their worklife to inform whether hospital medicine is a viable long-term career for physicians.

OBJECTIVE

Determine current satisfaction levels among hospitalists.

DESIGN

Survey study.

METHODS

A national random stratified sample of 3,105 potential hospitalists plus 662 hospitalist employees of three multi-state hospitalist companies were administered the Hospital Medicine Physician Worklife Survey. Using 5-point Likert scales, the survey assessed demographic information, global job and specialty satisfaction, and 11 satisfaction domains: workload, compensation, care quality, organizational fairness, autonomy, personal time, organizational climate, and relationships with colleagues, staff, patients, and leader. Relationships between global satisfaction and satisfaction domains, and burnout symptoms and career longevity were explored.

RESULTS

There were 816 hospitalist responses (adjusted response rate, 25.6%). Correcting for oversampling of pediatricians, 33.5% of respondents were women, and 7.4% were pediatricians. Overall, 62.6% of respondents reported high satisfaction (≥4 on a 5-point scale) with their job, and 69.0% with their specialty. Hospitalists were most satisfied with the quality of care they provided and relationships with staff and colleagues. They were least satisfied with organizational climate, autonomy, compensation, and availability of personal time. In adjusted analysis, satisfaction with organizational climate, quality of care provided, organizational fairness, personal time, relationship with leader, compensation, and relationship with patients predicted job satisfaction. Satisfaction with personal time, care quality, patient relationships, staff relationships, and compensation predicted specialty satisfaction. Job burnout symptoms were reported by 29.9% of respondents who were more likely to leave and reduce work effort.

CONCLUSIONS

Hospitalists rate their job and specialty satisfaction highly, but burnout symptoms are common. Hospitalist programs should focus on organizational climate, organizational fairness, personal time, and compensation to improve satisfaction and minimize attrition.

Objective

To assess intensive care unit (ICU) nurses' acceptance of electronic health records (EHR) technology and examine the relationship between EHR design, implementation factors, and nurse acceptance.

Design

The authors analyzed data from two cross-sectional survey questionnaires distributed to nurses working in four ICUs at a northeastern US regional medical center, 3 months and 12 months after EHR implementation.

Measurements

Survey items were drawn from established instruments used to measure EHR acceptance and usability, and the usefulness of three EHR functionalities, specifically computerized provider order entry (CPOE), the electronic medication administration record (eMAR), and a nursing documentation flowsheet.

Results

On average, ICU nurses were more accepting of the EHR at 12 months as compared to 3 months. They also perceived the EHR as being more usable and both CPOE and eMAR as being more useful. Multivariate hierarchical modeling indicated that EHR usability and CPOE usefulness predicted EHR acceptance at both 3 and 12 months. At 3 months postimplementation, eMAR usefulness predicted EHR acceptance, but its effect disappeared at 12 months. Nursing flowsheet usefulness predicted EHR acceptance but only at 12 months.

Conclusion

As the push toward implementation of EHR technology continues, more hospitals will face issues related to acceptance of EHR technology by staff caring for critically ill patients. This research suggests that factors related to technology design have strong effects on acceptance, even 1 year following the EHR implementation.

Objective

To evaluate the incidence of duplicate medication orders before and after computerized provider order entry (CPOE) with clinical decision support (CDS) implementation and identify contributing factors.

Design

CPOE with duplicate medication order alerts was implemented in a 400-bed Northeastern US community tertiary care teaching hospital. In a pre-implementation post-implementation design, trained nurses used chart review, computer-generated reports of medication orders, provider alerts, and staff reports to identify medication errors in two intensive care units (ICUs).

Measurement

Medication error data were adjudicated by a physician and a human factors engineer for error stage and type. A qualitative analysis of duplicate medication ordering errors was performed to identify contributing factors.

Results

Data were collected for 4147 patient-days pre-implementation and 4013 patient-days post-implementation. Duplicate medication ordering errors increased after CPOE implementation (pre: 48 errors, 2.6% total; post: 167 errors, 8.1% total; p<0.0001). Most post-implementation duplicate orders were either for the identical order or the same medication. Contributing factors included: (1) provider ordering practices and computer availability, for example, two orders placed within minutes by different providers on rounds; (2) communication and hand-offs, for example, duplicate orders around shift change; (3) CDS and medication database design, for example confusing alert content, high false-positive alert rate, and CDS algorithms missing true duplicates; (4) CPOE data display, for example, difficulty reviewing existing orders; and (5) local CDS design, for example, medications in order sets defaulted as ordered.

Conclusions

Duplicate medication order errors increased with CPOE and CDS implementation. Many work system factors, including the CPOE, CDS, and medication database design, contributed to their occurrence.

Purpose

The purpose of this paper is to explore the concept of information chaos as it applies to the issues of patient safety and physician workload in primary care and to propose a research agenda.

Methods

We use a human factors engineering perspective to discuss the concept of information chaos in primary care and explore implications for its impact on physician performance and patient safety.

Results

Information chaos is comprised of various combinations of information overload, information underload, information scatter, information conflict, and erroneous information. We provide a framework for understanding information chaos, its impact on physician mental workload and situation awareness, its consequences, discuss possible solutions and suggest a research agenda which may lead to methods to reduce the problem.

Conclusions

Information chaos is experienced routinely by primary care physicians. This is not just inconvenient, annoying and frustrating; it has implications for physician performance and patient safety. Additional research is needed to define methods to measure and eventually reduce information chaos.

Background

“Smart” intravenous infusion pumps (Smart IV pumps) are increasingly being implemented in hospitals to reduce medication administration errors.

Objectives

This study examines nurses’ experience with the implementation and use of a Smart IV pump in an academic hospital.

Method

Data were collected in three longitudinal surveys: (a) a pre-implementation survey, (b) a 6-week-post-implementation survey, and (c) a 1-year-post-implementation survey. We examined: (a) the technology implementation process, (b) technical performance of the pump, (c) usability of the pump, and (d) user acceptance of the pump.

Results

Initially, nurses had a somewhat positive acceptance of the Smart IV pump technology that significantly increased one year after implementation. User experiences associated with the pump in general improved over time, especially perceptions of pump efficiency. However, user experience with the pump implementation process and pump technical performance did not consistently improve from the pre-implementation survey to the post-implementation survey. Several characteristics of pump technical performance and usability influenced user acceptance at the one-year post-implementation survey.

Discussion

These data may be useful for other institutions to guide implementation and post-implementation follow-up of IV pump use; other institutions could use the survey instrument from this study to evaluate nurses’ perceptions of the technology. Our study identified several characteristics of the implementation process that other institutions may need to pay attention to (e.g., sharing information about the implementation process with nurses).

Background

Previous studies of hospital readmission have focused on specific conditions or populations and generated complex prediction models.

Objective

To identify predictors of early hospital readmission in a diverse patient population and derive and validate a simple model for identifying patients at high readmission risk.

Design

Prospective observational cohort study.

Patients

Participants encompassed 10,946 patients discharged home from general medicine services at six academic medical centers and were randomly divided into derivation (n = 7,287) and validation (n = 3,659) cohorts.

Measurements

We identified readmissions from administrative data and 30-day post-discharge telephone follow-up. Patient-level factors were grouped into four categories: sociodemographic factors, social support, health condition, and healthcare utilization. We performed logistic regression analysis to identify significant predictors of unplanned readmission within 30 days of discharge and developed a scoring system for estimating readmission risk.

Results

Approximately 17.5% of patients were readmitted in each cohort. Among patients in the derivation cohort, seven factors emerged as significant predictors of early readmission: insurance status, marital status, having a regular physician, Charlson comorbidity index, SF12 physical component score, ≥1 admission(s) within the last year, and current length of stay >2 days. A cumulative risk score of ≥25 points identified 5% of patients with a readmission risk of approximately 30% in each cohort. Model discrimination was fair with a c-statistic of 0.65 and 0.61 for the derivation and validation cohorts, respectively.

Conclusions

Select patient characteristics easily available shortly after admission can be used to identify a subset of patients at elevated risk of early readmission. This information may guide the efficient use of interventions to prevent readmission.

ABSTRACT

BACKGROUND

Patients admitted to general medicine inpatient services are increasingly cared for by hospital-based physicians rather than their primary care providers (PCPs). This separation of hospital and ambulatory care may result in important care discontinuities after discharge. We sought to determine whether communication between hospital-based physicians and PCPs influences patient outcomes.

METHODS

We approached consecutive patients admitted to general medicine services at six US academic centers from July 2001 to June 2003. A random sample of the PCPs for consented patients was contacted 2 weeks after patient discharge and surveyed about communication with the hospital medical team. Responses were linked with the 30-day composite patient outcomes of mortality, hospital readmission, and emergency department (ED) visits obtained through follow-up telephone survey and National Death Index search. We used hierarchical multi-variable logistic regression to model whether communication with the patient’s PCP was associated with the 30-day composite outcome.

RESULTS

A total of 1,772 PCPs for 2,336 patients were surveyed with 908 PCPs responses and complete patient follow-up available for 1,078 patients. The PCPs for 834 patients (77%) were aware that their patient had been admitted to the hospital. Of these, direct communication between PCPs and inpatient physicians took place for 194 patients (23%), and a discharge summary was available within 2 weeks of discharge for 347 patients (42%). Within 30 days of discharge, 233 (22%) patients died, were readmitted to the hospital, or visited an ED. In adjusted analyses, no relationship was seen between the composite outcome and direct physician communication (adjusted odds ratio 0.87, 95% confidence interval 0.56 – 1.34), the presence of a discharge summary (0.84, 95% CI 0.57–1.22), or PCP awareness of the index hospitalization (1.08, 95% CI 0.73–1.59).

CONCLUSION

Analysis of communication between PCPs and inpatient medical teams revealed much room for improvement. Although communication during handoffs of care is important, we were not able to find a relationship between several aspects of communication and associated adverse clinical outcomes in this multi-center patient sample.

BACKGROUND

Entry into general internal medicine (GIM) has declined. The effect of the inpatient general medicine rotation on medical student career choices is uncertain.

OBJECTIVE

To assess the effect of student satisfaction with the inpatient general medicine rotation on pursuit of a career in GIM.

DESIGN

Multicenter cohort study.

PARTICIPANTS

Third-year medical students between July 2001 and June 2003.

MEASUREMENTS

End-of-internal medicine clerkship survey assessed satisfaction with the rotation using a 5-point Likert scale. Pursuit of a career in GIM defined as: (1) response of “Very Likely” or “Certain” to the question “How likely are you to pursue a career in GIM?”; and (2) entry into an internal medicine residency using institutional match data.

RESULTS

Four hundred and two of 751 (54%) students responded. Of the student respondents, 307 (75%) matched in the 2 years following their rotations. Twenty-eight percent (87) of those that matched chose an internal medicine residency. Of these, 8% (25/307) were pursuing a career in GIM. Adjusting for site and preclerkship interest, overall satisfaction with the rotation predicted pursuit of a career in GIM (odds ratio [OR] 3.91, P<.001). Although satisfaction with individual items did not predict pursuit of a generalist career, factor analysis revealed 3 components of satisfaction (attending, resident, and teaching). Adjusting for preclerkship interest, 2 factors (attending and teaching) were associated with student pursuit of a career in GIM (P<.01).

CONCLUSIONS

Increased satisfaction with the inpatient general medicine rotation promotes pursuit of a career in GIM.