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Background: It is commonly believed that the quality of health care decreases during trainee changeovers at the end of the academic year.Purpose: To systematically review studies describing the effects of trainee changeover on patient outcomes.Data Sources: Electronic literature search of PubMed, Educational Research Information Center (ERIC), EMBASE, and the Cochrane Library for English-language studies published between 1989 and July 2010.Study Selection: Title and abstract review followed by full-text review to identify studies that assessed the effect of the changeover on patient outcomes and that used a control group or period as a comparator.Data Extraction: Using a standardized form, 2 authors independently abstracted data on outcomes, study setting and design, and statistical methods. Differences between reviewers were reconciled by consensus. Studies were then categorized according to methodological quality, sample size, and outcomes reported.Data Synthesis: Of the 39 included studies, 27 (69%) reported mortality, 19 (49%) reported efficiency (length of stay, duration of procedure, hospital charges), 23 (59%) reported morbidity, and 6 (15%) reported medical error outcomes; all studies focused on inpatient settings. Most studies were conducted in the United States. Thirteen (33%) were of higher quality. Studies with higher-quality designs and larger sample sizes more often showed increased mortality and decreased efficiency at time of changeover. Studies examining morbidity and medical error outcomes were of lower quality and produced inconsistent results.Limitations: The review was limited to English-language reports. No study focused on the effect of changeovers in ambulatory care settings. The definition of changeover, resident role in patient care, and supervision structure varied considerably among studies. Most studies did not control for time trends or level of supervision or use methods appropriate for hierarchical data.Conclusion: Mortality increases and efficiency decreases in hospitals because of year-end changeovers, although heterogeneity in the existing literature does not permit firm conclusions about the degree of risk posed, how changeover affects morbidity and rates of medical errors, or whether particular models are more or less problematic.Primary Funding Source: National Heart, Lung, and Blood Institute. [ABSTRACT FROM AUTHOR]

Context: There have been numerous reports of interventions designed to improve the care of patients with diabetes, but the effectiveness of such interventions is unclear.Objective: To assess the impact on glycemic control of 11 distinct strategies for quality improvement (QI) in adults with type 2 diabetes.Data Sources and Study Selection: MEDLINE (1966-April 2006) and the Cochrane Collaboration's Effective Practice and Organisation of Care Group database, which covers multiple bibliographic databases. Eligible studies included randomized or quasi-randomized controlled trials and controlled before-after studies that evaluated a QI intervention targeting some aspect of clinician behavior or organizational change and reported changes in glycosylated hemoglobin (HbA1c) values.Data Extraction: Postintervention difference in HbA1c values were estimated using a meta-regression model that included baseline glycemic control and other key intervention and study features as predictors.Data Synthesis: Fifty randomized controlled trials, 3 quasi-randomized trials, and 13 controlled before-after trials met all inclusion criteria. Across these 66 trials, interventions reduced HbA(1c) values by a mean of 0.42% (95% confidence interval [CI], 0.29%-0.54%) over a median of 13 months of follow-up. Trials with fewer patients than the median for all included trials reported significantly greater effects than did larger trials (0.61% vs 0.27%, P = .004), strongly suggesting publication bias. Trials with mean baseline HbA1c values of 8.0% or greater also reported significantly larger effects (0.54% vs 0.20%, P = .005). Adjusting for these effects, 2 of the 11 categories of QI strategies were associated with reductions in HbA(1c) values of at least 0.50%: team changes (0.67%; 95% CI, 0.43%-0.91%; n = 26 trials) and case management (0.52%; 95% CI, 0.31%-0.73%; n = 26 trials); these also represented the only 2 strategies conferring significant incremental reductions in HbA1c values. Interventions involving team changes reduced values by 0.33% more (95% CI, 0.12%-0.54%; P = .004) than those without this strategy, and those involving case management reduced values by 0.22% more (95% CI, 0.00%-0.44%; P = .04) than those without case management. Interventions in which nurse or pharmacist case managers could make medication adjustments without awaiting physician authorization reduced values by 0.80% (95% CI, 0.51%-1.10%), vs only 0.32% (95% CI, 0.14%-0.49%) for all other interventions (P = .002).Conclusions: Most QI strategies produced small to modest improvements in glycemic control. Team changes and case management showed more robust improvements, especially for interventions in which case managers could adjust medications without awaiting physician approval. Estimates of the effectiveness of other specific QI strategies may have been limited by difficulty in classifying complex interventions, insufficient numbers of studies, and publication bias. [ABSTRACT FROM AUTHOR]

Importance: Diagnostic errors contribute to patient harm, though few data exist to describe their prevalence or underlying causes among medical inpatients., Objective: To determine the prevalence, underlying cause, and harms of diagnostic errors among hospitalized adults transferred to an intensive care unit (ICU) or who died., Design, Setting, and Participants: Retrospective cohort study conducted at 29 academic medical centers in the US in a random sample of adults hospitalized with general medical conditions and who were transferred to an ICU, died, or both from January 1 to December 31, 2019. Each record was reviewed by 2 trained clinicians to determine whether a diagnostic error occurred (ie, missed or delayed diagnosis), identify diagnostic process faults, and classify harms. Multivariable models estimated association between process faults and diagnostic error. Opportunity for diagnostic error reduction associated with each fault was estimated using the adjusted proportion attributable fraction (aPAF). Data analysis was performed from April through September 2023., Main Outcomes and Measures: Whether or not a diagnostic error took place, the frequency of underlying causes of errors, and harms associated with those errors., Results: Of 2428 patient records at 29 hospitals that underwent review (mean [SD] patient age, 63.9 [17.0] years; 1107 [45.6%] female and 1321 male individuals [54.4%]), 550 patients (23.0%; 95% CI, 20.9%-25.3%) had experienced a diagnostic error. Errors were judged to have contributed to temporary harm, permanent harm, or death in 436 patients (17.8%; 95% CI, 15.9%-19.8%); among the 1863 patients who died, diagnostic error was judged to have contributed to death in 121 (6.6%; 95% CI, 5.3%-8.2%). In multivariable models examining process faults associated with any diagnostic error, patient assessment problems (aPAF, 21.4%; 95% CI, 16.4%-26.4%) and problems with test ordering and interpretation (aPAF, 19.9%; 95% CI, 14.7%-25.1%) had the highest opportunity to reduce diagnostic errors; similar ranking was seen in multivariable models examining harmful diagnostic errors., Conclusions and Relevance: In this cohort study, diagnostic errors in hospitalized adults who died or were transferred to the ICU were common and associated with patient harm. Problems with choosing and interpreting tests and the processes involved with clinician assessment are high-priority areas for improvement efforts.

Background: The COVID-19 pandemic required clinicians to care for a disease with evolving characteristics while also adhering to care changes (e.g., physical distancing practices) that might lead to diagnostic errors (DEs)., Objective: To determine the frequency of DEs and their causes among patients hospitalized under investigation (PUI) for COVID-19., Design: Retrospective cohort., Setting: Eight medical centers affiliated with the Hospital Medicine ReEngineering Network (HOMERuN)., Target Population: Adults hospitalized under investigation (PUI) for COVID-19 infection between February and July 2020., Measurements: We randomly selected up to 8 cases per site per month for review, with each case reviewed by two clinicians to determine whether a DE (defined as a missed or delayed diagnosis) occurred, and whether any diagnostic process faults took place. We used bivariable statistics to compare patients with and without DE and multivariable models to determine which process faults or patient factors were associated with DEs., Results: Two hundred and fifty-seven patient charts underwent review, of which 36 (14%) had a diagnostic error. Patients with and without DE were statistically similar in terms of socioeconomic factors, comorbidities, risk factors for COVID-19, and COVID-19 test turnaround time and eventual positivity. Most common diagnostic process faults contributing to DE were problems with clinical assessment, testing choices, history taking, and physical examination (all p < 0.01). Diagnostic process faults associated with policies and procedures related to COVID-19 were not associated with DE risk. Fourteen patients (35.9% of patients with errors and 5.4% overall) suffered harm or death due to diagnostic error., Limitations: Results are limited by available documentation and do not capture communication between providers and patients., Conclusion: Among PUI patients, DEs were common and not associated with pandemic-related care changes, suggesting the importance of more general diagnostic process gaps in error propagation., (© 2023. The Author(s).)

Background: Hospitalizations by patients who do not meet acute inpatient criteria are common and overburden healthcare systems. Studies have characterized these alternate levels of care (ALC) but have not delineated prolonged (pALC) versus short ALC (sALC) stays., Objective: To descriptively compare pALC and sALC hospitalizations-groups we hypothesize have unique needs., Designs, Settings, and Participants: A retrospective study of hospitalizations from March-April 2018 at an academic safety-net hospital., Main Outcome and Measures: Levels of care for pALC (>3 days) and sALC (1-3 days) were determined using InterQual©, an industry standard utilization review tool for determining the clinical appropriateness of hospitalization. We examined sociodemographic and clinical characteristics., Results: Of 2365 hospitalizations, 215 (9.1%) were pALC, 277 (11.7%) were sALC, and 1873 (79.2%) had no ALC days. There were 17,683 hospital days included, and 28.3% (n = 5006) were considered ALC. Compared to patients with sALC, those with pALC were older and more likely to be publicly insured, experience homelessness, and have substance use or psychiatric comorbidities. Patients with pALC were more likely to be admitted for care meeting inpatient criteria (89.3% vs. 66.8%, p < .001), had significantly more ALC days (median 8 vs. 1 day, p < .001), and were less likely to be discharged to the community (p < .001)., Conclusions: Patients with prolonged ALC stays were more likely to be admitted for acute care, had greater psychosocial complexity, significantly longer lengths of stay, and unique discharge needs. Given the complexity and needs for hospitalizations with pALC days, intensive interdisciplinary coordination and resource mobilization are necessary., (© 2023 Society of Hospital Medicine.)

Across the USA, morbidity and mortality from substance use are rising as reflected by increases in acute care hospitalisations for substance use complications and substance-related deaths. Patients with substance use disorders (SUD) have long and costly hospitalisations and higher readmission rates compared to those without SUD. Hospitalisation presents an opportunity to diagnose and treat individuals with SUD and connect them to ongoing care. However, SUD care often remains unaddressed by hospital providers due to lack of a systems approach and addiction medicine knowledge, and is compounded by stigma. We present a blueprint to launching an interprofessional inpatient addiction care team embedded in the hospital medicine division of an urban, safety-net integrated health system. We describe key factors for successful implementation including: (1) demonstrating the scope and impact of SUD in our health system via a needs assessment; (2) aligning improvement areas with health system leadership priorities; (3) involving executive leadership to create goal and initiative alignment; and (4) obtaining seed funding for a pilot programme from our Medicaid health plan partner. We also present challenges and lessons learnt., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The prevalence and aetiology of diagnostic error among hospitalised adults is unknown, though likely contributes to patient morbidity and mortality. We aim to identify and characterise the prevalence and types of diagnostic error among patients readmitted within 7 days of hospital discharge., Methods: Retrospective cohort study at a single urban academic hospital examining adult patients discharged from the medical service and readmitted to the same hospital within 7 days between January and December 2018. The primary outcome was diagnostic error presence, identified through two-physician adjudication using validated tools. Secondary outcomes included severity of error impact and characterisation of diagnostic process failures contributing to error., Results: There were 391 cases of unplanned 7-day readmission (5.2% of 7507 discharges), of which 376 (96.2%) were reviewed. Twenty-one (5.6%) admissions were found to contain at least one diagnostic error during the index admission. The most common problem areas in the diagnostic process included failure to order needed test(s) (n=11, 52.4%), erroneous clinician interpretation of test(s) (n=10, 47.6%) and failure to consider the correct diagnosis (n=8, 38.1%). Nineteen (90.5%) of the diagnostic errors resulted in moderate clinical impact, primarily due to short-term morbidity or contribution to the readmission., Conclusion: The prevalence of diagnostic error among 7-day medical readmissions was 5.6%. The most common drivers of diagnostic error were related to clinician diagnostic reasoning. Efforts to reduce diagnostic error should include strategies to augment diagnostic reasoning and improve clinician decision-making around diagnostic studies., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Importance: The United States has the world's highest rate of incarceration. Clinicians practicing outside of correctional facilities receive little dedicated training in the care of patients who are incarcerated, are unaware of guidelines for the treatment of patients in custody, and practice in health care systems with varying policies toward these patients. This review considers legal precedents for care of individuals who are incarcerated, frequently encountered terminology, characteristics of hospitalized incarcerated patients, considerations for clinical management, and challenges during transitions of care., Observations: The Eighth Amendment of the US Constitution mandates basic health care for incarcerated individuals within or outside of dedicated correctional facilities. Incarcerated patients in the acute hospital setting are predominantly young men who have received trauma-related admitting diagnoses. Hospital practices pertaining to privacy, physical restraint, discharge counseling, and surrogate decision-making are affected by a patient's incarcerated status under state or federal law, institutional policy, and individual health care professional practice. Transitions of care necessitate consideration of the disparate medical resources of correctional facilities as well as awareness of transitions unique to incarcerated individuals, such as compassionate release., Conclusions and Relevance: Patients who are incarcerated have a protected right to health care but may experience exceptions to physical comfort, health privacy, and informed decision-making in the acute care setting. Research on the management of issues associated with hospitalized incarcerated patients is limited and primarily focuses on the care of pregnant women, a small portion of all hospitalized incarcerated individuals. Clinicians and health care facilities should work toward creating evidence-based and legally supported guidelines for the care of incarcerated individuals in the acute care setting that balance the rights of the patient, responsibilities of the clinician, and safety mandates of the institution and law enforcement.

Solid waste management (SWM) is a key function of local government and is critical to protecting human health and the environment. Development of effective SWM strategies should consider comprehensive SWM process choices and policy implications on system-level cost and environmental performance. This analysis evaluated cost and select environmental implications of SWM policies for Wake County, North Carolina using a life-cycle approach. A county-specific data set and scenarios were developed to evaluate alternatives for residential municipal SWM, which included combinations of a mixed waste material recovery facility (MRF), anaerobic digestion, and waste-to-energy combustion in addition to existing SWM infrastructure (composting, landfilling, single stream recycling). Multiple landfill diversion and budget levels were considered for each scenario. At maximum diversion, the greenhouse gas (GHG) mitigation costs ranged from 30 to 900 $/MTCO 2 e; the lower values were when a mixed waste MRF was used, and the higher values when anaerobic digestion was used. Utilization of the mixed waste MRF was sensitive to the efficiency of material separation and operating cost. Maintaining the current separate collection scheme limited the potential for cost and GHG reductions. Municipalities seeking to cost-effectively increase landfill diversion while reducing GHGs should consider waste-to-energy, mixed waste separation, and changes to collection.

Background: Audit and feedback improves clinical care by highlighting the gap between current and ideal practice. We combined best practices of audit and feedback with continuously generated electronic health record data to improve performance on quality metrics in an inpatient setting., Methods: We conducted a cluster randomised control trial comparing intensive audit and feedback with usual audit and feedback from February 2016 to June 2016. The study subjects were internal medicine teams on the teaching service at an urban tertiary care hospital. Teams in the intensive feedback arm received access to a daily-updated team-based data dashboard as well as weekly inperson review of performance data ('STAT rounds'). The usual feedback arm received ongoing twice-monthly emails with graphical depictions of team performance on selected quality metrics. The primary outcome was performance on a composite discharge metric (Discharge Mix Index, 'DMI'). A washout period occurred at the end of the trial (from May through June 2016) during which STAT rounds were removed from the intensive feedback arm., Results: A total of 40 medicine teams participated in the trial. During the intervention period, the primary outcome of completion of the DMI was achieved on 79.3% (426/537) of patients in the intervention group compared with 63.2% (326/516) in the control group (P<0.0001). During the washout period, there was no significant difference in performance between the intensive and usual feedback groups., Conclusion: Intensive audit and feedback using timely data and STAT rounds significantly increased performance on a composite discharge metric compared with usual feedback. With the cessation of STAT rounds, performance between the intensive and usual feedback groups did not differ significantly, highlighting the importance of feedback delivery on effecting change., Clinical Trial: The trial was registered with ClinicalTrials.gov (NCT02593253)., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Importance: Robust laboratory use data are lacking to support the general assumption that teaching hospitals with trainees routinely order more laboratory tests for inpatients than do nonteaching hospitals., Objective: To quantify differences in the use of laboratory tests between teaching and nonteaching hospitals., Design, Setting, and Participants: A cross-sectional study was performed using a statewide database to identify hospitalizations with a primary diagnosis of bacterial pneumonia or cellulitis from January 1, 2014, to June 30, 2015, at teaching and nonteaching hospitals with 100 or more hospitalizations of each condition. Patients included were adult inpatients with a primary diagnosis of bacterial pneumonia (n = 24 118) or cellulitis (n = 19 211); patients excluded were those with an intensive care unit stay, transfer from another hospital, or a length of stay that was 2 SDs or more of the condition's mean length of stay., Main Outcomes and Measures: Mean laboratory tests per day stratified by illness severity, as well as factors associated with laboratory use rates., Results: A total of 43 329 hospitalized patients (20493 women and 22836 men) had a principal diagnosis of bacterial pneumonia or cellulitis across 11 major teaching hospitals, 12 minor teaching hospitals, and 73 nonteaching hospitals in Texas. Mean number of laboratory tests per day varied significantly by hospital type and was highest for major teaching hospitals for both conditions (bacterial pneumonia: major teaching hospitals, 13.21; 95% CI, 12.91-13.51; nonteaching hospitals, 8.92; 95% CI, 8.84-9.00; P < .001; cellulitis: major teaching hospitals, 10.43; 95% CI, 10.16-10.70; nonteaching hospitals, 7.29; 95% CI, 7.22-7.36; P < .001). This association held for all levels of illness severity for both conditions, except for patients with cellulitis with the highest illness severity level. In generalized mixed linear regression models, controlling for additional patient and encounter covariates, there was a significant difference in the marginal effect of hospital teaching status on mean number of laboratory tests per day between major teaching and nonteaching hospitals (difference in marginal mean laboratory tests per day for bacterial pneumonia, 3.58; 95% CI, 2.61-4.55; P < .001; for cellulitis, 2.61; 95% CI, 1.76-3.47; P < .001)., Conclusions and Relevance: Compared with nonteaching hospitals, patients in Texas admitted to major teaching hospitals with bacterial pneumonia or cellulitis received significantly more laboratory tests after controlling for illness severity, length of stay, and patient demographics. These results support the need to examine how the culture of training environments may contribute to increased use of laboratory tests.

Background: Following up on patients' clinical courses after hospital discharge may enhance physicians' learning and care of future patients. Barriers to this practice for residents include time constraints, discontinuous training environments, and difficulty accessing patient information., Objective: We designed an educational intervention facilitating informed self-assessment and reflection through structured postdischarge follow-up of patients' longitudinal clinical courses. We then examined the experience of interns who received this intervention in a mixed methods study., Methods: Internal medicine interns on a 4-week patient safety rotation received lists of hospitalized patients they had cared for earlier in the year. They selected patients for chart review and completed a guided reflection worksheet for each patient reviewed. Interns then discussed lessons learned in a faculty-led group debrief session., Results: Of 62 eligible interns, 62 (100%) participated in this intervention and completed 293 reflection worksheets. We analyzed worksheets and transcripts from 6 debrief sessions. Interns reported that postdischarge patient follow-up was valuable for their professional development, and helped them understand the natural history of disease and patients' illness experiences. After reviewing their patients' clinical courses, interns stated that they would advocate for earlier end-of-life counseling, improve care transitions, and adjust their clinical decision-making for similar patients in the future., Conclusions: Our educational intervention created the time, space, and structure for postdischarge patient follow-up. It was well received by participants, and is an opportunity for experiential learning., Competing Interests: Conflict of interest: Dr Dhaliwal has received speaking honoraria from the Studer Group.

Quality Issue: Implementing quality improvement (QI) education during clinical training is challenging due to time constraints and inadequate faculty development in these areas., Initial Assessment: Quiz-based reinforcement systems show promise in fostering active engagement, collaboration, healthy competition and real-time formative feedback, although further research on their effectiveness is required., Choice of Solution: An online quiz-based reinforcement system to increase resident and faculty knowledge in QI, patient safety and care transitions., Implementation: Experts in QI and educational assessment at the 5 University of California medical campuses developed a course comprised of 3 quizzes on Introduction to QI, Patient Safety and Care Transitions. Each quiz contained 20 questions and utilized an online educational quiz-based reinforcement system that leveraged spaced learning., Evaluation: Approximately 500 learners completed the course (completion rate 66-86%). Knowledge acquisition scores for all quizzes increased after completion: Introduction to QI (35-73%), Patient Safety (58-95%), and Care Transitions (66-90%). Learners reported that the quiz-based system was an effective teaching modality and preferred this type of education to classroom-based lectures. Suggestions for improvement included reducing frequency of presentation of questions and utilizing more questions that test learners on application of knowledge instead of knowledge acquisition., Lessons Learned: A multi-campus online quiz-based reinforcement system to train residents in QI, patient safety and care transitions was feasible, acceptable, and increased knowledge. The course may be best utilized to supplement classroom-based and experiential curricula, along with increased attention to optimizing frequency of presentation of questions and enhancing application skills., (© The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com)

Background: Improving the quality of health care and education has become a mandate at all levels within the medical profession. While several published quality improvement (QI) assessment tools exist, all have limitations in addressing the range of QI projects undertaken by learners in undergraduate medical education, graduate medical education, and continuing medical education., Objective: We developed and validated a tool to assess QI projects with learner engagement across the educational continuum., Methods: After reviewing existing tools, we interviewed local faculty who taught QI to understand how learners were engaged and what these faculty wanted in an ideal assessment tool. We then developed a list of competencies associated with QI, established items linked to these competencies, revised the items using an iterative process, and collected validity evidence for the tool., Results: The resulting Multi-Domain Assessment of Quality Improvement Projects (MAQIP) rating tool contains 9 items, with criteria that may be completely fulfilled, partially fulfilled, or not fulfilled. Interrater reliability was 0.77. Untrained local faculty were able to use the tool with minimal guidance., Conclusions: The MAQIP is a 9-item, user-friendly tool that can be used to assess QI projects at various stages and to provide formative and summative feedback to learners at all levels., Competing Interests: Conflict of interest: The authors declare they have no competing interests. An earlier version of this work was presented as a poster at the Association of American Medical Colleges Annual Meeting, Philadelphia, Pennsylvania, November 1–6, 2013, and on MedEdPORTAL's iCollaborative Web site (https://www.mededportal.org/icollaborative/resource/841). The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the US government.

Background: The term "holdover admissions" refers to patients admitted by an overnight physician and whose care is then transferred to a new primary team the next morning. Descriptions of the holdover process in internal medicine are sparse., Objective: To identify important factors affecting the quality of holdover handoffs at an internal medicine (IM) residency program and to compare them to previously identified factors for other handoffs., Design: We undertook a qualitative study using structured focus groups and interviews. We analyzed data using qualitative content analysis., Participants: IM residents, IM program directors, and hospitalists at a large academic medical center., Main Measures: A nine-question open-ended interview guide., Key Results: We identified 13 factors describing holdover handoffs. Five factors-physical space, standardization, task accountability, closed-loop verification, and resilience-were similar to those described in prior handoff literature in other specialties. Eight factors were new concepts that may uniquely affect the quality of the holdover handoff in IM. These included electronic health record access, redundancy, unwritten thoughts, different clinician needs, diagnostic uncertainty, anchoring, teaching, and feedback. These factors were organized into five overarching themes: physical environment, information transfer, responsibility, clinical reasoning, and education., Conclusions: The holdover handoff in IM is complex and has unique considerations for achieving high quality. Further exploration of safe, efficient, and educational holdover handoff practices is necessary.

Background: At academic medical centers, attending rounds (AR) serve to coordinate patient care and educate trainees, yet variably involve patients., Objective: To determine the impact of standardized bedside AR on patient satisfaction with rounds., Design: Cluster randomized controlled trial., Setting: 500-bed urban, quaternary care hospital., Patients: 1200 patients admitted to the medicine service., Intervention: Teams in the intervention arm received training to adhere to 5 AR practices: 1) pre-rounds huddle; 2) bedside rounds; 3) nurse integration; 4) real-time order entry; 5) whiteboard updates. Control arm teams continued usual rounding practices., Measurements: Trained observers audited rounds to assess adherence to recommended AR practices and surveyed patients following AR. The primary outcome was patient satisfaction with AR. Secondary outcomes were perceived and actual AR duration, and attending and trainee satisfaction., Results: We observed 241 (70.1%) and 264 (76.7%) AR in the intervention and control arms, respectively, which included 1855 and 1903 patient rounding encounters. Using a 5-point Likert scale, patients in the intervention arm reported increased satisfaction with AR (4.49 vs 4.25; P = 0.01) and felt more cared for by their medicine team (4.54 vs 4.36; P = 0.03). Although the intervention shortened the duration of AR by 8 minutes on average (143 vs 151 minutes; P = 0.052), trainees perceived intervention AR as lasting longer and reported lower satisfaction with intervention AR., Conclusions: Medicine teams can adopt a standardized, patient-centered, time-saving rounding model that leads to increased patient satisfaction with AR and the perception that patients are more cared for by their medicine team. Journal of Hospital Medicine 2017;12:143-149., (© 2017 Society of Hospital Medicine)

Background: An important component of internal medicine residency is clinical immersion in core rotations to expose first-year residents to common diagnoses., Objective: Quantify intern experience with common diagnoses through clinical documentation in an electronic health record., Methods: We analyzed all clinical notes written by postgraduate year (PGY) 1, PGY-2, and PGY-3 residents on medicine service at an academic medical center July 1, 2012, through June 30, 2014. We quantified the number of notes written by PGY-1s at 1 of 3 hospitals where they rotate, by the number of notes written about patients with a specific principal billing diagnosis, which we defined as diagnosis-days . We used the International Classification of Diseases 9 (ICD-9) and the Clinical Classification Software (CCS) to group the diagnoses., Results: We analyzed 53 066 clinical notes covering 10 022 hospitalizations with 1436 different ICD-9 diagnoses spanning 217 CCS diagnostic categories. The 10 most common ICD-9 diagnoses accounted for 23% of diagnosis-days, while the 10 most common CCS groupings accounted for more than 40% of the diagnosis-days. Of 122 PGY-1s, 107 (88%) spent at least 2 months on the service, and 3% were exposed to all of the top 10 ICD-9 diagnoses, while 31% had experience with fewer than 5 of the top 10 diagnoses. In addition, 17% of PGY-1s saw all top 10 CCS diagnoses, and 5% had exposure to fewer than 5 CCS diagnoses., Conclusions: Automated detection of clinical experience may help programs review inpatient clinical experiences of PGY-1s., Competing Interests: Conflict of interest: The authors declare they have no competing interests. These results were presented as a poster at the Society of Hospital Medicine Annual Meeting, Las Vegas, Nevada, March 24–27, 2014.

Hospitals are challenged with reevaluating their hospital's transitional care practices, to reduce 30-day readmission rates, prevent adverse events, and ensure a safe transition of patients from hospital to home. Despite the increasing attention to transitional care, there are few published studies that have shown significant reductions in readmission rates, particularly for patients with stroke and other neurologic diagnoses. Successful hospital-initiated transitional care programs include a "bridging" strategy with both predischarge and postdischarge interventions and dedicated transitions provider involved at multiple points in time. Although multicomponent strategies including patient engagement, use of a dedicated transition provider, and facilitation of communication with outpatient providers require time and resources, there is evidence that neurohospitalists can implement a transitional care program with the aim of improving patient safety across the continuum of care.

Background: The impact of rapid response teams (RRTs) on resident physicians' education and clinical autonomy is not well described., Objective: To determine whether resident physicians perceive educational benefit from collaboration with an RRT and whether they believe that the RRT adversely affects their clinical autonomy., Design: Survey study., Methods: Study subjects were asked to participate in a brief online survey. The survey contained 7 demographic items and 20 RRT-related items graded on a 5-point Likert scale ranging from strongly disagree to strongly agree., Setting/subjects: The study was conducted at a tertiary care academic medical center. Subjects included all residents in specialties involving direct patient care and the potential to use the adult RRT., Results: The response rate was 72%; 35% of respondents were interns, and 69% were in medical fields. Residents agreed that working with the RRT is a valuable educational experience (78%) and disagreed that the RRT decreased their clinical autonomy (76%). Surgical residents were less likely than medical residents to perceive educational value from RRT interactions (P = 0.01) or to report collaborative decision making with the RRT (P = 0.04)., Conclusions: The majority of resident physicians perceive educational benefit from interaction with the RRT, though this benefit is greater for less experienced residents and for those residents who routinely provide care for critically ill patients and serve as code team leaders. Few residents, irrespective of years of training or specialty, felt that the RRT reduced their clinical autonomy., (© 2015 Society of Hospital Medicine.)

Background: Adverse drug events (ADEs) are a major cause of morbidity in hospitalised and ambulatory patients. Computerised provider order entry (CPOE) combined with clinical decision support systems (CDSS) are being widely implemented with the goal of preventing ADEs, but the effectiveness of these systems remains unclear., Methods: We searched the specialised database Agency for Healthcare Research and Quality (AHRQ) Patient Safety Net to identify reviews of the effect of CPOE combined with CDSS on ADE rates in inpatient and outpatient settings. We included systematic and narrative reviews published since 2008 and controlled clinical trials published since 2012., Results: We included five systematic reviews, one narrative review and two controlled trials. The existing literature consists mostly of studies of homegrown systems conducted in the inpatient setting. CPOE+CDSS was consistently reported to reduce prescribing errors, but does not appear to prevent clinical ADEs in either the inpatient or outpatient setting. Implementation of CPOE+CDSS profoundly changes staff workflow, and often leads to unintended consequences and new safety issues (such as alert fatigue) which limit the system's safety effects., Conclusions: CPOE+CDSS does not appear to reliably prevent clinical ADEs. Despite more widespread implementation over the past decade, it remains a work in progress., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Solid waste management (SWM) systems must proactively adapt to changing policy requirements, waste composition, and an evolving energy system to sustainably manage future solid waste. This study represents the first application of an optimizable dynamic life-cycle assessment framework capable of considering these future changes. The framework was used to draw insights by analyzing the SWM system of a hypothetical suburban U.S. city of 100 000 people over 30 years while considering changes to population, waste generation, and energy mix and costs. The SWM system included 3 waste generation sectors, 30 types of waste materials, and 9 processes for waste separation, treatment, and disposal. A business-as-usual scenario (BAU) was compared to three optimization scenarios that (1) minimized cost (Min Cost), (2) maximized diversion (Max Diversion), and (3) minimized greenhouse gas (GHG) emissions (Min GHG) from the system. The Min Cost scenario saved $7.2 million (12%) and reduced GHG emissions (3%) relative to the BAU scenario. Compared to the Max Diversion scenario, the Min GHG scenario cost approximately 27% less and more than doubled the net reduction in GHG emissions. The results illustrate how the timed-deployment of technologies in response to changes in waste composition and the energy system results in more efficient SWM system performance compared to what is possible from static analyses.

Background: Assessing growth is a useful tool for defining health and nutritional status of children. The objective of this study was to construct growth reference curves of Iranian infants and children (0-6 years old) and compare them with previous and international references., Methods: Weight, height or length of 2107 Iranian infants and children aged 0-6 years old were measured using a cross-sectional survey in Tehran in 2010. Standard smooth reference curves for Iranian population were constructed and compared to multinational World Health Organization 2006 reference standards as well as a previous study from two decades ago., Results: Growth index references for Iranian girls are increased in compare to data from two decades ago and are approximately close to the international references. In boys; however, the increment was considerably large as it passed the international references. Not only the values for indexes was changed during two decades, but also the age at adiposity rebound came near the age of 3, which is an important risk factor for later obesity., Conclusions: During two decades, growth indexes of Iranian children raised noticeable. Risk factors for later obesity are now apparent and demand immediate policy formulations. In addition, reference curves presented in this paper can be used as a diagnostic tool for monitoring growth of Iranian children.

This article reports on a resident-led quality improvement program to improve communication between inpatient internal medicine residents and their patients' primary care physicians (PCPs). The program included education on care transitions, standardization of documentation, audit and feedback of documented PCP communication rates with public reporting of performance, rapid-cycle data analysis and improvement projects, and a financial incentive. At baseline, PCP communication was documented in 55% of patients; after implementation of the intervention, communication was documented in 89.3% (2477 of 2772) of discharges during the program period. The program was associated with a significant increase in referring PCP satisfaction with communication at hospital admission (baseline, 27.7% "satisfied" or "very satisfied"; postintervention, 58.2%; P < .01) but not at discharge (baseline, 14.9%; postintervention, 21.8%; P = .41). Residents cited the importance of PCP communication for patient care and audit and feedback of their performance as the principal drivers of their engagement in the project.

Background: Quality improvement has become increasingly important in the practice of medicine; however, engaging residents in meaningful projects within the demanding training environment remains challenging., Methods: We conducted a year-long quality improvement project involving internal medicine residents at an academic medical centre. Resident champions designed and implemented a discharge summary improvement bundle, which employed an educational curriculum, an electronic discharge summary template, regular data feedback and a financial incentive. The timeliness and quality of discharge summaries were measured before and after the intervention. Residents and faculty were surveyed about their perceptions of the project; primary care providers were surveyed about their satisfaction with hospital provider communication., Results: With implementation of the bundle, the average time from patient discharge to completion of the discharge summary fell from 3.5 to 0.61 days (p<0.001). The percentage of summaries completed on the day of discharge rose from 38% to 83% (p<0.001) and this improvement was sustained for 6 months following the end of the project. The percentage of summaries that included all recommended elements increased from 5% to 88% (p<0.001). Primary care providers reported a lower likelihood of discharge summaries being unavailable at the time of outpatient follow-up (38% to 4%, p<0.001). Residents reported that the systems changes, more than the financial incentive, accounted for their behaviour change., Conclusions: Our discharge summary improvement project provides an instructive example of how residents can lead clinically meaningful quality improvement projects.

Objectives: There is widespread recognition that physical examination (PE) should be taught in Graduate Medical Education (GME), but little is known regarding how to best teach PE to residents. Deliberate practice fosters expertise in other fields, but its utility in teaching PE is unknown. We systematically reviewed the literature to determine the effectiveness of methods to teach PE in GME, with attention to usage of deliberate practice., Data Sources: We searched PubMed, ERIC, and EMBASE for English language studies regarding PE education in GME published between January 1951 and December 2012., Study Eligibility Criteria: Seven eligibility criteria were applied to studies of PE education: (1) English language; (2) subjects in GME; (3) description of study population; (4) description of intervention; (5) assessment of efficacy; (6) inclusion of control group; and (7) report of data analysis., Study Appraisal and Synthesis Methods: We extracted data regarding study quality, type of PE, study population, curricular features, use of deliberate practice, outcomes and assessment methods. Tabulated summaries of studies were reviewed for narrative synthesis., Results: Fourteen studies met inclusion criteria. The mean Medical Education Research Study Quality Instrument (MERSQI) score was 9.0 out of 18. Most studies (n = 8) included internal medicine residents. Half of the studies used resident interaction with a human examinee as the primary means of teaching PE. Three studies "definitely" and four studies "possibly" used deliberate practice; all but one of these studies demonstrated improved educational outcomes., Limitations: We used a non-validated deliberate practice assessment. Given the heterogeneity of assessment modalities, we did not perform a meta-analysis., Conclusions and Implications of Key Findings: No single strategy for teaching PE in GME is clearly superior to another. Following the principles of deliberate practice and interaction with human examinees may be beneficial in teaching PE; controlled studies including these educational features should be performed to investigate these exploratory findings.

Background: Graduate medical education programs assess trainees' performance to determine readiness for unsupervised practice. Entrustable professional activities (EPAs) are a novel approach for assessing performance of core professional tasks., Aim: To describe a pilot and feasibility evaluation of two EPAs for competency-based assessment in internal medicine (IM) residency., Setting/participants: Post-graduate year-1 interns (PGY-1s) and attendings at a large internal medicine (IM) residency program., Program Description: Two Entrustable professional activities (EPA) assessments (Discharge, Family Meeting) were piloted., Program Feasibility Evaluation: Twenty-eight out of 43 (65.1 %) PGY-1 s and 32/43 (74.4 %) attendings completed surveys about the Discharge EPA experience. Most who completed the EPA assessment (10/12, 83.8 %, PGY-1s; 9/11, 83.3 %, attendings) agreed it facilitated useful feedback discussions. For the Family Meeting EPA, 16/26 (61.5 %) PGY-1s completed surveys, and most who participated (9/12 PGY1s, 75 %) reported it improved attention to family meeting education, although only half recommended continuing the EPA assessment., Discussion: From piloting two EPA assessments in a large IM residency, we recognized our reminder systems and time dedicated for completing EPA requirements as inadequate. Collaboration around patient safety and palliative care with relevant clinical services has enhanced implementation and buy-in. We will evaluate how well EPA-based assessment serves the intended purpose of capturing trainees' trustworthiness to conduct activities unsupervised.

Hospitals now have the responsibility to implement strategies to prevent adverse outcomes after discharge. This systematic review addressed the effectiveness of hospital-initiated care transition strategies aimed at preventing clinical adverse events (AEs), emergency department (ED) visits, and readmissions after discharge in general medical patients. MEDLINE, CINAHL, EMBASE, and Cochrane Database of Clinical Trials (January 1990 to September 2012) were searched, and 47 controlled studies of fair methodological quality were identified. Forty-six studies reported readmission rates, 26 reported ED visit rates, and 9 reported AE rates. A "bridging" strategy (incorporating both predischarge and postdischarge interventions) with a dedicated transition provider reduced readmission or ED visit rates in 10 studies, but the overall strength of evidence for this strategy was low. Because of scant evidence, no conclusions could be reached on methods to prevent postdischarge AEs. Most studies did not report intervention context, implementation, or cost. The strategies hospitals should implement to improve patient safety at hospital discharge remain unclear.

Background: Entrustable professional activities (EPAs) can form the foundation of competency-based assessment in medical training, focused on performance of discipline-specific core clinical activities., Objective: To identify EPAs for the Internal Medicine (IM) Educational Milestones to operationalize competency-based assessment of residents using EPAs., Methods: We used a modified Delphi approach to conduct a 2-step cross-sectional survey of IM educators at a 3-hospital IM residency program; residents also completed a survey. Participants rated the importance and appropriate year of training to reach competence for 30 proposed IM EPAs. Content validity indices identified essential EPAs. We conducted independent sample t tests to determine IM educator-resident agreement and calculated effect sizes. Finally, we determined the effect of different physician roles on ratings., Results: Thirty-six IM educators participated; 22 completed both surveys. Twelve residents participated. Seventeen EPAs had a content validity index of 100%; 10 additional EPAs exceeded 80%. Educators and residents rated the importance of 27 of 30 EPAs similarly. Residents felt that 10 EPAs could be met at least 1 year earlier than educators had specified., Conclusions: Internal medicine educators had a stable opinion of EPAs developed through this study, and residents generally agreed. Using this approach, programs could identify EPAs for resident evaluation, building on the initial list created via our study.

Objectives: To review important patient safety practices for evidence of effectiveness, implementation, and adoption., Data Sources: Searches of multiple computerized databases, gray literature, and the judgments of a 20-member panel of patient safety stakeholders., Review Methods: The judgments of the stakeholders were used to prioritize patient safety practices for review, and to select which practices received in-depth reviews and which received brief reviews. In-depth reviews consisted of a formal literature search, usually of multiple databases, and included gray literature, where applicable. In-depth reviews assessed practices on the following domains: • How important is the problem? • What is the patient safety practice? • Why should this practice work? • What are the beneficial effects of the practice? • What are the harms of the practice? • How has the practice been implemented, and in what contexts? • Are there any data about costs? • Are there data about the effect of context on effectiveness? We assessed individual studies for risk of bias using tools appropriate to specific study designs. We assessed the strength of evidence of effectiveness using a system developed for this project. Brief reviews had focused literature searches for focused questions. All practices were then summarized on the following domains: scope of the problem, strength of evidence for effectiveness, evidence on potential for harmful unintended consequences, estimate of costs, how much is known about implementation and how difficult the practice is to implement. Stakeholder judgment was then used to identify practices that were "strongly encouraged" for adoption, and those practices that were "encouraged" for adoption., Results: From an initial list of over 100 patient safety practices, the stakeholders identified 41 practices as a priority for this review: 18 in-depth reviews and 23 brief reviews. Of these, 20 practices had their strength of evidence of effectiveness rated as at least "moderate," and 25 practices had at least "moderate" evidence of how to implement them. Ten practices were classified by the stakeholders as having sufficient evidence of effectiveness and implementation and should be "strongly encouraged" for adoption, and an additional 12 practices were classified as those that should be "encouraged" for adoption., Conclusions: The evidence supporting the effectiveness of many patient safety practices has improved substantially over the past decade. Evidence about implementation and context has also improved, but continues to lag behind evidence of effectiveness. Twenty-two patient safety practices are sufficiently well understood, and health care providers can consider adopting them now.

Background: New supervisory regulations highlight the challenge of balancing housestaff supervision and autonomy. To better understand the impact of increased supervision on residency training, we investigated housestaff perceptions of education, autonomy, and clinical decision-making before and after implementation of an in-hospital, overnight attending physician (nocturnist)., Methods: We established a nocturnist program in July 2010 at our academic, tertiary care medical center. We administered pre-surveys and post-surveys of internal medicine residents on night float rotation during the 2010-2011 academic year. We surveyed residents before and after experiencing the nocturnist program., Results: Housestaff reported an increase in the clinical value of the night float rotation (3.95 vs 4.27, P = 0.01) and the adequacy of overnight supervision (3.65 vs 4.30, P < 0.0001) without a change in decision-making autonomy (4.35 vs 4.45, P = 0.44). Trainees agreed that nocturnist supervision positively impacted patient outcomes (3.79 vs 4.30, P = 0.002). Housestaff contacted attendings more frequently for transfers from outside facilities (2.00 vs 3.20, P = 0.006), during adverse events (2.51 vs 3.25, P = 0.04), prior to ordering invasive diagnostics (1.75 vs 2.76, P = 0.004), and prior to vasopressor use (1.52 vs 2.40, P = 0.004). Residents' fear of revealing knowledge gaps and desire to make decisions independently did not change., Conclusions: Increased overnight supervision enhanced the clinical value of the night float rotation, increased rates of attending contact during critical clinical decision-making, and improved perception of patient care. These changes occurred without a decrease in housestaff's perceived decision-making autonomy., (Copyright © 2012 Society of Hospital Medicine.)

Purpose: Few data describe how often residents defer indirect patient care tasks to after hours or show whether residents report this time in duty hours logs. Thus, the authors examined how often residents perform one such task, discharge dictation, outside scheduled hours., Method: The authors tracked all discharge summaries dictated by internal medicine residents at a single teaching hospital from January to June 2009. They determined the length and timing of discharge dictations by querying the hospital voice-dictation system. Definite work hours violations occurred when residents completed dictations on the postcall day after reaching mandated duty hours limits or on scheduled days off. Potential work hours violations arose when residents dictated after 6 pm or during the month subsequent to their rotation. The authors compared the number of residents they determined to have incurred duty hours violations with the number self-reporting violations., Results: The authors obtained data on 1,152 dictations performed by 39 residents. Residents spent a mean 6.5 hours dictating per month, averaging 13 minutes per dictation. Using objective criteria, the authors determined that the majority of residents (32; 82%) incurred definite duty hours violations. Far fewer (2; 5%) self-reported violations. Team census, total time spent dictating, and dictation length were associated with dictating during restricted hours., Conclusions: Indirect patient care tasks, such as dictating discharge summaries, may contribute substantially to unrecognized duty hours violations. Accurate and objective ways to assess resident workflow can help create effective solutions for resident efficiency and inform changes to resident schedules., (Copyright © by the Association of American medical Colleges.)

Background: Medicare has selected 10 hospital-acquired conditions for which it will not reimburse hospitals unless the condition was documented as "present on admission." This "no pay for errors" rule may have a profound effect on the clinical practice of physicians., Objective: To determine how physicians might change their behavior after learning about the Medicare rule., Design: We conducted a randomized trial of a brief educational intervention embedded in an online survey, using clinical vignettes to estimate behavioral changes., Participants: At a university-based internal medicine residency program, 168 internal medicine residents were eligible to participate., Intervention: Residents were randomized to receive a one-page description of Medicare's "no pay for errors" rule with pre-vignette reminders (intervention group) or no information (control group). Residents responded to five clinical vignettes in which "no pay for errors" conditions might be present on admission., Main Measures: Primary outcome was selection of the single most clinically appropriate option from three clinical practice choices presented for each clinical vignette., Key Results: Survey administered from December 2008 to March 2009. There were 119 responses (71%). In four of five vignettes, the intervention group was less likely to select the most clinically appropriate response. This was statistically significant in two of the cases. Most residents were aware of the rule but not its impact and specifics. Residents acknowledged responsibility to know Medicare documentation rules but felt poorly trained to do so. Residents educated about the Medicare's "no pay for errors" were less likely to select the most clinically appropriate responses to clinical vignettes. Such choices, if implemented in practice, have the potential for causing patient harm through unnecessary tests, procedures, and other interventions.

Background: Trainees receive much of their inpatient education from hospitalists., Purpose: To characterize the effects of hospitalists on trainee education., Data Sources: MEDLINE, Database of Reviews of Effectiveness (DARE), National Health Service (NHS) Economic Evaluation Database (EED), Health Technology Assessment (HTA), and the Cochrane Collaboration Database (last searched October 2008) databases using the term "hospitalist", and meeting abstracts from the Society of Hospital Medicine (SHM) (2002-2007), Society of General Internal Medicine (SGIM) (2001-2007), and Pediatric Academic Societies (PAS) (2000-2007)., Study Selection: Original English language research studies meeting all of the following: involvement of hospitalists; comparison to nonhospitalist attendings; evaluation of trainee knowledge, skills, or attitudes. 711 articles were reviewed, 32 retrieved, and 6 included; 7,062 meeting abstracts were reviewed, 9 retrieved, and 2 included., Data Extraction: Two authors reviewed articles to determine study eligibility. Three authors independently reviewed included articles to abstract data elements and classify study quality., Data Synthesis: Seven studies were quasirandomized one was a noncontemporaneous comparison. All citations only measured trainee attitudes. In all studies comparing hospitalists to nonhospitalists, trainees were more satisfied with hospitalists overall, and with other aspects of their teaching, but ratings were high for both groups. One of 2 studies that distinguished nonhospitalist general internists from specialists showed that trainees preferred hospitalists, but the other did not demonstrate a hospitalist advantage over general internists., Conclusions: Trainees are more satisfied with inpatient education from hospitalists. Whether the increased satisfaction translates to improved learning is unclear., (Copyright 2009 Society of Hospital Medicine)

A survey suggests that the academic medical centers with successful rapid response system programs defined each call as a chance to save a life, as well as an educational opportunity to increase the knowledge of nurses, interns, and residents throughout the institution.