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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 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.

This survey study aimed to provide a contemporary appraisal of advanced practice provider (APP) practice and to summarize perceptions of the benefits and challenges of integrating APPs into adult academic hospital medicine (HM) groups. We surveyed leaders of academic HM groups. We received responses from 43 of 86 groups (50%) surveyed. Thirty-four (79%) reported that they employed APPs. In most groups (85%), APPs were reported to perform daily tasks of patient care, including rounding and documentation. Less than half of the groups reported that APPs had completed HM-specific postgraduate training. The reported benefits of APPs included improved perceived quality of care and greater volume of patients that could be seen. Reported challenges included training requirements and support for new hires. Further investigation is needed to determine which APP team structures deliver the highest quality care. There may be a role for expanding standardized competency-based postgraduate training for APPs planning to practice HM.

BACKGROUND: Interhospital transfer (IHT) is often performed to provide patients with specialized care. Racial/ethnic disparities in IHT have been suggested but are not well-characterized. OBJECTIVE: To evaluate the association between race/ethnicity and IHT. DESIGN: Cross-sectional analysis of 2016 National Inpatient Sample data. PATIENTS: Patients aged ≥ 18 years old with common medical diagnoses at transfer, including acute myocardial infarction, congestive heart failure, arrhythmia, stroke, sepsis, pneumonia, and gastrointestinal bleed. MAIN MEASURES: We performed a series of logistic regression models to estimate adjusted odds of transfer by race/ethnicity controlling for patient demographics, clinical variables, and hospital characteristics and to identify potential mediators. In secondary analyses, we estimated adjusted odds of transfer among patients at community hospitals (those more likely to transfer patients) and performed subgroup analyses by region and primary medical diagnosis. KEY RESULTS: Of 5,774,175 weighted hospital admissions, 199,015 (4.5%) underwent IHT, including 4.7% of White patients, compared with 3.9% of Black patients and 3.8% of Hispanic patients. Black (OR 0.83, 95% CI 0.78–0.89) and Hispanic (OR 0.81, 95% CI 0.75–0.87) patients had lower crude odds of transfer compared with White patients, but this became non-significant after adjusting for hospital-level characteristics. In secondary analyses among patients hospitalized at community hospitals, Hispanic patients had lower adjusted odds of transfer (aOR 0.89, 95% CI 0.79–0.98). Disparities in IHT by race/ethnicity varied by region and medical diagnosis. CONCLUSIONS: Black and Hispanic patients had lower odds of IHT, largely explained by a higher likelihood of being hospitalized at urban teaching hospitals. Racial/ethnic disparities in transfer were demonstrated at community hospitals, in certain geographic regions and among patients with specific diseases.

BackgroundThe second Multicenter Medication Reconciliation Quality Improvement Study demonstrated a marked reduction in medication discrepancies per patient. The aim of the current analysis was to determine the association of patient exposure to each system-level intervention and receipt of each patient-level intervention on these results.MethodsThis study was conducted at 17 North American Hospitals, the study period was 18 months per site, and sites typically adopted interventions after 2–5 months of preintervention data collection. We conducted an on-treatment analysis (ie, an evaluation of outcomes based on patient exposure) of system-level interventions, both at the category level and at the individual component level, based on monthly surveys of implementation site leads at each site (response rate 65%). We then conducted a similar analysis of patient-level interventions, as determined by study pharmacist review of documented activities in the medical record. We analysed the association of each intervention on the adjusted number of medication discrepancies per patient in admission and discharge orders, based on a random sample of up to 22 patients per month per site, using mixed-effects Poisson regression with hospital site as a random effect. We then used a generalised linear mixed-effects model (GLMM) decision tree to determine which patient-level interventions explained the most variance in discrepancy rates.ResultsAmong 4947 patients, patient exposure to seven of the eight system-level component categories was associated with modest but significant reductions in discrepancy rates (adjusted rate ratios (ARR) 0.75–0.97), as were 15 of the 17 individual system-level intervention components, including hiring, reallocating and training personnel to take a best possible medication history (BPMH) and training personnel to perform discharge medication reconciliation and patient counselling. Receipt of five of seven patient-level interventions was independently associated with large reductions in discrepancy rates, including receipt of a BPMH in the emergency department (ED) by a trained clinician (ARR 0.40, 95% CI 0.37 to 0.43), admission medication reconciliation by a trained clinician (ARR 0.57, 95% CI 0.50 to 0.64) and discharge medication reconciliation by a trained clinician (ARR 0.64, 95% CI 0.57 to 0.73). In GLMM decision tree analyses, patients who received both a BPMH in the ED and discharge medication reconciliation by a trained clinician experienced the lowest discrepancy rates (0.08 per medication per patient).Conclusion and relevancePatient-level interventions most associated with reductions in discrepancies were receipt of a BPMH of admitted patients in the ED and admission and discharge medication reconciliation by a trained clinician. System-level interventions were associated with modest reduction in discrepancies for the average patient but are likely important to support patient-level interventions and may reach more patients. These findings can be used to help hospitals and health systems prioritise interventions to improve medication safety during care transitions.

Objective The transfer of patients between acute care hospitals (interhospital transfer [IHT]) is a common but nonstandardized process leading to variable quality and safety. The goal of this study was to survey accepting physicians regarding problems encountered in the transfer process. Methods A cross-sectional survey of residents and inpatient attendings from internal medicine, neurology, and surgery services at a large tertiary care referral hospital was undertaken to identify problematic aspects of the IHT process as perceived by accepting frontline providers. The frequency that specific scenarios were encountered in caring for transferred patients and whether these processes impacted patient safety were determined using 5- and 3-point Likert scales, respectively. The frequency of responses to each question were measured using proportions. Results Approximately 51% of the 284 physicians surveyed responded. Pertinent findings included the following: physician subject surveys found that transferred patients sometimes, frequently, or always arrived without requiring specialized care in 56% of responses, arrived with unrealistic expectations of care in 77.2% of responses, arrived more than 24 hours after accepted for transfer in 80.1% of responses, and arrived without necessary transfer records in 86.9% of responses. Most respondents felt that lack of availability of transfer records and the time of day of arrival frequently posed a risk to transferred patients (57.2% and 53.1%, respectively). Response variation was noted between resident and attending physician respondents. Conclusions Expectations of care, delays and timing of transfer, and information exchange at time of transfer were identified as all too common problems in IHT, which creates a risk for patient safety. These areas are important targets for investigation and the development of interventions to improve patient safety.

Background The transfer of patients between hospitals (inter-hospital transfer, or IHT) is a common occurrence for patients, but guidelines to ensure safe and effective IHTs are lacking. Poor IHTs result in higher rates of mortality, longer lengths of stay, and higher hospitalization costs compared to admissions from the emergency department. Nurses are often the first point of contact for IHT patients and can provide valuable insights on key challenges to IHT processes. Objective To characterize the experiences of inpatient floor-level bedside nurses caring for IHT patients and identify care coordination challenges and solutions. Design/Participants/Approach Qualitative study using semi-structured focus groups and interviews conducted from October 2019 to July 2020 with 21 inpatient floor-level nurses caring for adult medicine patients at an academic hospital. Nurses were recruited using a purposive convenience sampling approach. A combined inductive and deductive coding approach guided by thematic analysis was used for data analysis. Key Results Results from this study are mapped to the Agency for Healthcare Research and Quality Care Coordination Measurement Framework domains of communication, assessing needs and goals, and negotiating accountability. The following key themes characterize nurses’ experiences with IHT related to these domains: (1) challenges with information exchange and team communication during IHT, (2) environmental and information preparation needed to anticipate transfers, and (3) determining responsibility and care plans after the IHT patient has arrived at the accepting facility. Conclusions Nurses described the absence of standardized processes to coordinate care before or at the time of patient arrival. Challenges to communication and coordination during IHTs negatively impacted patient care and nursing professional satisfaction. To streamline care for IHT patients and reduce nursing stress, future IHT interventions should include standardized handoff reports, timely identification and easy access to admitting clinicians, and timely clinician evaluation and orders. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-021-07276-5.

BackgroundThe first Multicenter Medication Reconciliation Quality Improvement (QI) Study (MARQUIS1) demonstrated that mentored implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals, but results varied by site. The objective of this study was to determine the effects of a refined toolkit on a larger group of hospitals.MethodsWe conducted a pragmatic quality improvement study (MARQUIS2) at 18 North American hospitals or hospital systems from 2016 to 2018. Incorporating lessons learnt from MARQUIS1, we implemented a refined toolkit, offering 17 system-level and 6 patient-level interventions. One of eight physician mentors coached each site via monthly calls and performed one to two site visits. The primary outcome was number of unintentional medication discrepancies in admission or discharge orders per patient. Time series analysis used multivariable Poisson regression.ResultsA total of 4947 patients were sampled, including 1229 patients preimplementation and 3718 patients postimplementation. Both the number of system-level interventions adopted per site and the proportion of patients receiving patient-level interventions increased over time. During the intervention, patients experienced a steady decline in their medication discrepancy rate from 2.85 discrepancies per patient to 0.98 discrepancies per patient. An interrupted time series analysis of the 17 sites with sufficient data for analysis showed the intervention was associated with a 5% relative decrease in discrepancies per month over baseline temporal trends (adjusted incidence rate ratio: 0.95, 95% CI 0.93 to 0.97, pConclusionA multicentre medication reconciliation QI initiative using mentored implementation of a refined best practices toolkit, including patient-level and system-level interventions, was associated with a substantial decrease in unintentional medication discrepancies over time. Future efforts should focus on sustainability and spread.

Objectives Although existing data suggest marked variability in interhospital transfer (IHT), little is known about specific factors that may impact the quality and safety of this care transition. We aimed to explore transferred patients' and involved physicians' experience with IHT to better understand the components of the transfer continuum and identify potential targets for improvement. Methods We performed a qualitative study using individual interviews of adult patients recently transferred to cardiology, general medicine, and oncology services at a tertiary care academic medical center, as well as their transferring physician, accepting attending physician, and accepting/admitting resident physician. We conducted a thematic analysis, using an inductive approach and an a priori framework from pre-established domains. Results Participants included 10 hospitalized adults (6 cardiology, 2 general medicine, and 2 oncology), 9 accepting attending physicians, 12 accepting and/or admitting resident physicians, and 5 transferring physicians (N = 36). Emergent themes demonstrated that participants held a shared understanding of the reason for transfer (most commonly access to more specialized care), and relayed a general dissatisfaction regarding the timing and lack of advanced notification of transfer. We also found distinct differences in IHT experience by stakeholder group: physician participants relayed discontent with intrahospital chains of communication and interhospital information exchange, and patient participants focused more readily on the physical aspects of IHT. Conclusions This study offers insight into IHT from the perspective of those most affected by this process, thereby identifying potential targets in addressing the quality and safety of this transition.

Importance Interhospital transfer (IHT) remains a largely unstudied process of care. Objective To determine the nationwide frequency of, patient and hospital-level predictors of, and hospital variability in IHT. Design Cross-sectional study. Setting Centers for Medicare and Medicaid 2013 100% Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data. Patients Beneficiaries ≥65 years and older enrolled in Medicare A and B, with an acute care hospitalization claim in 2013. Exposures Patient and hospital characteristics of transferred and nontransferred patients. Measurements Frequency of interhospital transfers (IHT); adjusted odds of transfer of each patient and each hospital characteristic; and variability in hospital transfer rates. Results Of 6.6 million eligible beneficiaries with an acute care hospitalization, 101,507 (1.5%) underwent IHT. Selected characteristics associated with greater adjusted odds of transfer included: patient age 74-85 years (odds ratio [OR], 2.38 compared with 65-74 years; 95% confidence intervals [CI], 2.33-2.43); nonblack race (OR, 1.17; 95% CI, 1.13-1.20); higher comorbidity (OR, 1.37; 95% CI, 1.36-1.37); lower diagnosis-related group-weight (OR, 2.02; 95% CI, 1.95-2.09); fewer recent hospitalizations (OR, 1.87; 95% CI, 1.79-1.95); and hospitalization in the Northeast (OR, 1.40; 95% CI, 1.27-1.55). Higher case mix index of the hospital was associated with a lower adjusted odds of transfer (OR, 0.36; 95% CI, 0.30-0.45). Variability in hospital transfer rates remained significant after adjustment for patient and hospital characteristics (variance 0.28, P = 0.01). Conclusions In this nationally representative evaluation, we found that a sizable number of patients undergo IHT. We identified both expected and unexpected patient and hospital-level predictors of IHT, as well as unexplained variability in hospital transfer rates, suggesting lack of standardization of this complex care transition. Our study highlights further investigative avenues to help guide best practices in IHT. Journal of Hospital Medicine 2017;12:435-442.

It is unclear which medication reconciliation interventions are most effective at reducing inpatient medication discrepancies. Five United States hospitals’ interdisciplinary quality improvement (QI) teams were virtually mentored by QI-trained physicians. Sites implemented one to seven evidence-based interventions in 791 patients during the 25-month implementation period. Three interventions were associated with significant decreases in potentially harmful discrepancy rates: (1) defining clinical roles and responsibilities, (2) training, and (3) hiring staff to perform discharge medication reconciliation. Two interventions were associated with significant increases in potentially harmful discrepancy rates: training staff to take medication histories and implementing a new electronic health record (EHR). Hospitals should focus first on hiring and training pharmacy staff to assist with medication reconciliation at discharge and delineating roles and responsibilities of clinical staff. We caution hospitals implementing a large vendor EHR, as medication discrepancies may increase. Finally, the effect of medication history training on discrepancies needs further study.

BackgroundThe first Multi-center Medication Reconciliation Quality Improvement Study (MARQUIS1) demonstrated that implementation of a medication reconciliation best practices toolkit decreased total unintentional medication discrepancies in five hospitals. We sought to implement the MARQUIS toolkit in more diverse hospitals, incorporating lessons learned from MARQUIS1.MethodsMARQUIS2 is a pragmatic, mentored implementation QI study which collected clinical and implementation outcomes. Sites implemented a revised toolkit, which included interventions from these domains: 1) best possible medication history (BPMH)-taking; 2) discharge medication reconciliation and patient/caregiver counseling; 3) identifying and defining clinician roles and responsibilities; 4) risk stratification; 5) health information technology improvements; 6) improved access to medication sources; 7) identification and correction of real-time discrepancies; and, 8) stakeholder engagement. Eight hospitalists mentored the sites via one site visit and monthly phone calls over the 18-month intervention period. Each site’s local QI team assessed opportunities to improve, implemented at least one of the 17 toolkit components, and accessed a variety of resources (e.g. implementation manual, webinars, and workshops). Outcomes to be assessed will include unintentional medication discrepancies per patient.DiscussionA mentored multi-center medication reconciliation QI initiative using a best practices toolkit was successfully implemented across 18 medical centers. The 18 participating sites varied in size, teaching status, location, and electronic health record (EHR) platform.We introduce barriers to implementation and lessons learned from MARQUIS1, such as the importance of utilizing dedicated, trained medication history takers, simple EHR solutions, clarifying roles and responsibilities, and the input of patients and families when improving medication reconciliation.

Though often undertaken to provide patients with specialized care, interhospital transfer (IHT) is associated with worse outcomes for select patients. Certain aspects of the transfer process have been suggested as contributors to these outcomes. We performed a retrospective cohort study including patients ≥ 18 years who underwent IHT to a tertiary care hospital between January 2005 and September 2013. We examined the association between “weekend” transfer, “nighttime” transfer, “time delay” between transfer acceptance and arrival, and admission team “busyness” on the day of transfer, and patient outcomes, including transfer to the intensive care unit (ICU) within 48 hours and 30-day mortality. We utilized multivariable logistic regression models, adjusting for patient characteristics. Secondary analyses examined detailed timing of transfer and evaluated 30-day mortality stratified by service of transfer. Among the 24,352 patients who underwent IHT, the nighttime transfer was associated with increased adjusted odds of ICU transfer (odds ratio [OR] 1.54; 95% CI 1.38, 1.72) and 30-day mortality (OR 1.16; 95% CI 1.01, 1.35). Secondary analyses confirmed the association between nighttime transfer and ICU transfer throughout the week and demonstrated that Sunday (and trend towards Friday) night transfers had increased 30-day mortality, as compared with Monday daytime transfer. Stratified analyses demonstrated a significant association between transfer characteristics and adjusted odds of 30-day mortality among cardiothoracic and gastrointestinal surgical service transfers. Our findings suggest high acuity patients have worse outcomes during off-peak times of transfer and during times of high care team workload. Further study is needed to identify underlying reasons to explain these associations and devise potential solutions.

This cross-sectional study examines disparities by race/ethnicity in interhospital transfer among among Medicare-enrolled patients with conditions previously found to have a potential mortality benefit from transfer., Key Points Question Are there disparities by race/ethnicity in interhospital transfer (IHT) for patients with conditions previously found to have a potential mortality benefit from transfer? Findings In this cross-sectional study of 2013 Medicare data merged with American Hospital Association data that included 899 557 patients, after adjusting for patient characteristics and hospital fixed effects, Black patients had significantly lower adjusted odds and Hispanic patients had significantly higher adjusted odds of IHT compared with White patients. Meaning There may be differential practices in IHT by race/ethnicity., Importance Interhospital transfer (IHT) of patients is a common occurrence in modern health care. Racial/ethnic disparities are prevalent throughout US health care, but their presence in IHT is not well characterized. Objective To determine if there are racial/ethnic disparities in IHT for medical diagnoses for which IHT is associated with a mortality benefit. Design, Setting, and Participants This cross-sectional analysis used 2013 data from the Center for Medicare & Medicaid Services 100% Master Beneficiary Summary and Inpatient Claims merged with 2013 American Hospital Association data. Individuals with Medicare aged 65 years or older continuously enrolled in Medicare Part A and B with an inpatient hospitalization claim in 2013 for primary diagnosis of acute myocardial infarction, stroke, sepsis, or respiratory diseases were included. Data analysis occurred from November 2019 through July 2020. Exposures Race/ethnicity. Main Outcomes and Measures The primary outcome of interest was IHT. For the primary analysis, a series of logistic regression models were created to estimate the adjusted odds of IHT for Black and Hispanic patients compared with White patients, controlling for patient clinical and demographic variables and incorporating hospital fixed effects. In secondary analyses, subgroup analyses were conducted by diagnosis, hospital teaching status, and hospitalization to hospitals in the top decile of Black and Hispanic patient proportion. Results Among 899 557 patients, 734 958 patients were White (81.7%), 84 544 patients were Black (9.4%), and 47 588 patients were Hispanic (5.3%); there were 418 683 men (46.5%), and 306 215 patients (34.0%) were older than 84 years. The mean (SD) age was 76.8 (7.5) years. Among all patients, 20 171 White patients (2.7%), 1913 Black patients (2.3%), and 1062 Hispanic patients (2.2%) underwent IHT. After controlling for patient variables and hospital fixed effects, Black patients had a persistently lower odds of IHT (adjusted odds ratio, 0.87; 95% CI, 0.81-0.92; P

BACKGROUND Dispersion of inpatient care teams across different medical units impedes effective team communication, potentially leading to adverse events (AEs). OBJECTIVE To regionalize 3 inpatient general medical teams to nursing units and examine the association with communication and preventable AEs. DESIGN Pre-post cohort analysis. SETTING A 700-bed academic medical center. PATIENTS General medicine patients on any of the participating nursing units before and after implementation of regionalized care. INTERVENTION Regionalizing 3 general medical physician teams to 3 corresponding nursing units. MEASUREMENTS Concordance of patient care plan between nurse and intern, and adjusted odds of preventable AEs. RESULTS Of the 414 included nurse and intern paired surveys, there were no significant differences pre- versus postregionalization in total mean concordance scores (0.65 vs 0.67, P = 0.26), but there was significant improvement in agreement on expected discharge date (0.56 vs 0.68, P = 0.003), knowledge of the other provider's name (0.56 vs 0.86,P < 0.001), and daily care plan discussions (0.73 vs 0.88, P < 0.001). Of the 392 reviewed patient medical records, there was no significant difference in the adjusted odds of preventable AEs pre- versus postregionalization (adjusted odds ratio: 1.37, 95% confidence interval: 0.69, 2.69). CONCLUSIONS We found that regionalization of care teams improved recognition of care team members, discussion of daily care plan, and agreement on estimated discharge date, but did not significantly improve nurse and physician concordance of the care plan or reduce the odds of preventable AEs. Our findings suggest that regionalization alone may be insufficient to effectively promote communication and lead to patient safety improvements. Journal of Hospital Medicine 2016. © 2016 Society of Hospital Medicine

Poor communication during inter-hospital transfer (IHT, the transfer of patients between acute care hospitals) is common. Clinicians often report feeling unprepared to care for IHT patients due to inadequate advance notification. The aim of this project was to improve advance notification of general medicine service patient transfers to a tertiary care referral hospital. We used quality improvement principles to design and implement two interventions: (1) Use of a checklist; (2) Redesign role/responsibilities within the Access Center and Bed Control Department. Data on frequency of advance notification was collected over 9 months and plotted on a statistical process control chart with evaluation for special cause variation. We also evaluated barriers/facilitators to implementation and surveyed clinicians on information received with the advance notification. 103 patients underwent IHT during the study. Frequency of advance notification increased from a baseline of 63.6%-85.4% post-intervention. Several contributors to successful implementation were identified, including ensuring key stakeholder input and leveraging existing systems structure, among others. Survey results highlighted potential targets for future IHT improvements such as improved clinical information available to admitting clinicians in advance of patient transfer. In conclusion, we successfully improved advance notification of IHT, an essential step to improve communication. Next steps include sustainment and automation of these efforts and ongoing targeted process improvement efforts with an ultimate goal of improving patient outcomes during IHT.

BackgroundInter-hospital transfer (IHT, the transfer of patients between hospitals) occurs regularly and exposes patients to risks of discontinuity of care, though outcomes of transferred patients remains largely understudied.ObjectiveTo evaluate the association between IHT and healthcare utilisation and clinical outcomes.DesignRetrospective cohort.SettingCMS 2013 100 % Master Beneficiary Summary and Inpatient claims files merged with 2013 American Hospital Association data.ParticipantsBeneficiaries≥age 65 enrolled in Medicare A and B, with an acute care hospitalisation claim in 2013 and 1 of 15 top disease categories.Main outcome measuresCost of hospitalisation, length of stay (LOS) (of entire hospitalisation), discharge home, 3 -day and 30- day mortality, in transferred vs non-transferred patients.ResultsThe final cohort consisted of 53 420 transferred patients and 53 420 propensity-score matched non-transferred patients. Across all 15 disease categories, IHT was associated with significantly higher costs, longer LOS and lower odds of discharge home. Additionally, IHT was associated with lower propensity-matched odds of 3-day and/or 30- day mortality for some disease categories (acute myocardial infarction, stroke, sepsis, respiratory disease) and higher propensity-matched odds of mortality for other disease categories (oesophageal/gastrointestinal disease, renal failure, congestive heart failure, pneumonia, renal failure, chronic obstructivepulmonary disease, hip fracture/dislocation, urinary tract infection and metabolic disease).ConclusionsIn this nationally representative study of Medicare beneficiaries, IHT was associated with higher costs, longer LOS and lower odds of discharge home, but was differentially associated with odds of early death and 30 -day mortality depending on patients’ disease category. These findings demonstrate heterogeneity among transferred patients depending on the diagnosis, presenting a nuanced assessment of this complex care transition.

Objective Low health literacy is common, leading to patient vulnerability during hospital discharge, when patients rely on written health instructions. We aimed to examine the impact of the use of electronic, patient-friendly, templated discharge instructions on the readability of discharge instructions provided to patients at discharge. Materials and Methods We performed a retrospective cohort study of 233 patients discharged from a large tertiary care hospital to their homes following the implementation of a web-based “discharge module,” which included the optional use of diagnosis-specific templated discharge instructions. We compared the readability of discharge instructions, as measured by the Flesch Reading Ease Level test (FREL, on a 0–100 scale, with higher scores indicating greater readability) and the Flesch–Kincaid Grade Level test (FKGL, measured in grade levels), between discharges that used templated instructions (with or without modification) versus discharges that used clinician-generated instructions (with or without available templated instructions for the specific discharge diagnosis). Results Templated discharge instructions were provided to patients in 45% of discharges. Of the 55% of patients that received clinician-generated discharge instructions, the majority (78.1%) had no available templated instruction for the specific discharge diagnosis. Templated discharge instructions had higher FREL scores (71 vs. 57, P < .001) and lower FKGL scores (5.6 vs. 7.6, P < .001), compared to clinician-generated discharge instructions. Discussion The use of electronically available templated discharge instructions was associated with better readability (a higher FREL score and a lower FKGL score) than the use of clinician-generated discharge instructions. The main reason for clinicians to create discharge instructions was the lack of available templates for the patient’s specific discharge diagnosis. Conclusions Use of electronically available templated discharge instructions may be a viable option to improve the readability of written material provided to patients at discharge, although the library of available templates requires expansion.

The practice of transferring patients between acute care hospitals is variable and largely nonstandardized. Although often-cited reasons for transfer include providing patients access to specialty services only available at the receiving institution, little is known about whether and when patients receive such specialty care during the transfer continuum. We performed a retrospective analysis using 2013 100% Master Beneficiary Summary and Inpatient claims files from Centers for Medicare and Medicaid Services. Beneficiaries were included if they were aged =65 years, continuously enrolled in Medicare A and B, with an acute care hospitalization claim, and transferred to another acute care hospital with a primary diagnosis of acute myocardial infarction, gastrointestinal bleed, renal failure, or hip fracture/dislocation. Associated specialty procedure codes (International Classification of Diseases, Ninth Revision, Clinical Modification) were identified for each diagnosis. We performed descriptive analyses to compare receipt of specialty procedural services between transferring and receiving hospitals, stratified by diagnosis. Across the 19,613 included beneficiaries, receipt of associated specialty procedures was more common at the receiving than the transferring hospital, with the exception of patients with a diagnosis of gastrointestinal bleed. Depending on primary diagnosis, between 32.4% and 89.1% of patients did not receive any associated specialty procedure at the receiving hospital. Our results demonstrate variable receipt of specialty procedural care across the transfer continuum, implying the likelihood of alternate drivers of interhospital transfer other than solely receipt of specialty procedural care.

BACKGROUND Little is currently known regarding physicians' opinions on the relative appropriateness of inpatient management of medical conditions unrelated to the reason for admission. OBJECTIVE Investigate physician attitudes on the appropriateness of inpatient medication interventions, based on the interventions' relatedness to the reason for admission. DESIGN, SETTING, AND PARTICIPANTS Case-based survey of hospitalists and hospital-based primary care physicians at 3 academic medical centers in Boston, Massachusetts. METHODS Physicians were emailed a survey consisting of 6 pairs of clinical cases. Each pair included 1 case with an inpatient management decision related to the reason for admission, followed by a case involving the same management decision but unrelated to the reason for admission. Respondents rated the appropriateness of the interventions, and results were compared based on the relatedness to the reason for admission and based on the respondents' primary role. RESULTS Overall, 162 out of 295 providers (55%) responded to the survey. Physicians were significantly more likely to rate inpatient interventions as appropriate when they were related, compared to unrelated, to the reason for admission (78.9% vs 38.8%; P

Impact of Resident Workload and Handoff Training on Patient Outcomes Stephanie K. Mueller, MD, Stephanie A. Call, MD, MSPH, Furman S. McDonald, MD, MPH, Andrew J. Halvorsen, MS, Jeffrey L. Schnipper, MD, MPH, LeRoi S. Hicks, MD, MPH Brigham and Women’s-Faulkner Hospital Academic Hospitalist Service, Boston, Mass; Division of General Internal edicine, Brigham and Women’s Hospital, Boston, Mass; Division of General Internal Medicine, Virginia Commonwealth University, Richmond; Divisions of General and Hospital Internal Medicine and Office of Educational Innovations, Internal Medicine Residency, Mayo Clinic, Rochester, Minn; Division of Hospital Medicine, UMass Memorial Healthcare, Worcester; Department of Quantitative Sciences, University of Massachusetts Medical School, Worcester.

A fragment of HIV-tat protein, RKKRRQRRR, has been shown to have membrane penetration and nuclear localization properties, which are critical attributes of gene therapy agents. In this study, we designed a series of arborizing tat peptides, containing 1-8 tat moieties, and evaluated them as transfection enhancers in a variety of cell lines. We found that all compounds complexed with plasmid DNA, but only the molecule containing 8 tat-peptide chains shows significant transfection capabilities. Using rhodamine labeled plasmid and eight tat-peptide complex, we were also able to demonstrate intracellular delivery of the complex by fluorescence microscopy.

Background Unresolved medication discrepancies during hospitalization can contribute to adverse drug events, resulting in patient harm. Discrepancies can be reduced by performing medication reconciliation; however, effective implementation of medication reconciliation has proven to be challenging. The goals of the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) are to operationalize best practices for inpatient medication reconciliation, test their effect on potentially harmful unintentional medication discrepancies, and understand barriers and facilitators of successful implementation. Methods Six U.S. hospitals are participating in this quality improvement mentored implementation study. Each hospital has collected baseline data on the primary outcome: the number of potentially harmful unintentional medication discrepancies per patient, as determined by a trained on-site pharmacist taking a “gold standard” medication history. With the guidance of their mentors, each site has also begun to implement one or more of 11 best practices to improve medication reconciliation. To understand the effect of the implemented interventions on hospital staff and culture, we are performing mixed methods program evaluation including surveys, interviews, and focus groups of front line staff and hospital leaders. Discussion At baseline the number of unintentional medication discrepancies in admission and discharge orders per patient varies by site from 2.35 to 4.67 (mean=3.35). Most discrepancies are due to history errors (mean 2.12 per patient) as opposed to reconciliation errors (mean 1.23 per patient). Potentially harmful medication discrepancies averages 0.45 per patient and varies by site from 0.13 to 0.82 per patient. We discuss several barriers to implementation encountered thus far. In the end, we anticipate that MARQUIS tools and lessons learned have the potential to decrease medication discrepancies and improve patient outcomes. Trial registration Clinicaltrials.gov identifier NCT01337063

Background Medication discrepancies at care transitions are common and lead to patient harm. Medication reconciliation is a strategy to reduce this risk. Objectives To summarize available evidence on medication reconciliation interventions in the hospital setting and to identify the most effective practices. Data Sources MEDLINE (1966 through February 2012) and a manual search of article bibliographies. Study Selection Twenty-six controlled studies. Data Extraction Data were extracted on study design, setting, participants, inclusion/exclusion criteria, intervention components, timing, comparison group, outcome measures, and results. Data Synthesis Studies were grouped by type of medication reconciliation intervention—pharmacist related, information technology (IT), or other—and were assigned quality ratings using US Preventive Services Task Force criteria. Results Fifteen of 26 studies reported pharmacist-related interventions, 6 evaluated IT interventions, and 5 studied other interventions. Six studies were classified as good quality. The comparison group for all the studies was usual care; no studies compared different types of interventions. Studies consistently demonstrated a reduction in medication discrepancies (17 of 17 studies), potential adverse drug events (5 of 6 studies), and adverse drug events (2 of 2 studies) but showed an inconsistent reduction in postdischarge health care utilization (improvement in 2 of 8 studies). Key aspects of successful interventions included intensive pharmacy staff involvement and targeting the intervention to a high-risk patient population. Conclusions Rigorously designed studies comparing different inpatient medication reconciliation practices and their effects on clinical outcomes are scarce. Available evidence supports medication reconciliation interventions that heavily use pharmacy staff and focus on patients at high risk for adverse events. Higher-quality studies are needed to determine the most effective approaches to inpatient medication reconciliation.