Journal of Hospital Medicine
SCOPUS (2006-2023)SCIE-ISI
1553-5606
1553-5592
Mỹ
Cơ quản chủ quản: John Wiley & Sons Inc. , Frontline Medical Communications Inc.
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The period following discharge from the hospital is a vulnerable time for patients. About half of adults experience a medical error after hospital discharge, and 19%–23% suffer an adverse event, most commonly an adverse drug event. This article reviews several important challenges to providing high‐quality care as patients leave the hospital. These include the discontinuity between hospitalists and primary care physicians, changes to the medication regimen, new self‐care responsibilities that may stress available resources, and complex discharge instructions. We also discuss approaches to promoting more effective transitions of care, including improvements in communication between inpatient and outpatient physicians, effective reconciliation of prescribed medication regimens, adequate education of patients about medication use, closer medical follow‐up, engagement with social support systems, and greater clarity in physician–patient communication. By understanding the key challenges and adopting strategies to improve patient care in the transition from hospital to home, hospitalists could significantly reduce medical errors in the postdischarge period. Journal of Hospital Medicine 2007;2:314–323. © 2007 Society of Hospital Medicine.
Early reports showed high mortality from coronavirus disease 2019 (COVID‐19). Mortality rates have recently been lower, raising hope that treatments have improved. However, patients are also now younger, with fewer comorbidities. We explored whether hospital mortality was associated with changing demographics at a 3‐hospital academic health system in New York. We examined in‐hospital mortality or discharge to hospice from March through August 2020, adjusted for demographic and clinical factors, including comorbidities, admission vital signs, and laboratory results. Among 5,121 hospitalizations, adjusted mortality dropped from 25.6% (95% CI, 23.2‐28.1) in March to 7.6% (95% CI, 2.5‐17.8) in August. The standardized mortality ratio dropped from 1.26 (95% CI, 1.15‐1.39) in March to 0.38 (95% CI, 0.12‐0.88) in August, at which time the average probability of death (average marginal effect) was 18.2 percentage points lower than in March. Data from one health system suggest that mortality from COVID‐19 is decreasing even after accounting for patient characteristics.
Alarm fatigue from frequent nonactionable physiologic monitor alarms is frequently named as a threat to patient safety.
To critically examine the available literature relevant to alarm fatigue.
Articles published in English, Spanish, or French between January 1980 and April 2015 indexed in PubMed, Cumulative Index to Nursing and Allied Health Literature, Scopus, Cochrane Library, Google Scholar, and
Articles focused on hospital physiologic monitor alarms addressing any of the following: (1) the proportion of alarms that are actionable, (2) the relationship between alarm exposure and nurse response time, and (3) the effectiveness of interventions in reducing alarm frequency.
We extracted data on setting, collection methods, proportion of alarms determined to be actionable, nurse response time, and associations between interventions and alarm rates.
Our search produced 24 observational studies focused on alarm characteristics and response time and 8 studies evaluating interventions. Actionable alarm proportion ranged from <1% to 36% across a range of hospital settings. Two studies showed relationships between high alarm exposure and longer nurse response time. Most intervention studies included multiple components implemented simultaneously. Although studies varied widely, and many had high risk of bias, promising but still unproven interventions include widening alarm parameters, instituting alarm delays, and using disposable electrocardiographic wires or frequently changed electrocardiographic electrodes.
Physiologic monitor alarms are commonly nonactionable, and evidence supporting the concept of alarm fatigue is emerging. Several interventions have the potential to reduce alarms safely, but more rigorously designed studies with attention to possible unintended consequences are needed.
The efficacy of glucocorticoids in COVID-19 is unclear. This study was designed to determine whether systemic glucocorticoid treatment in COVID-19 patients is associated with reduced mortality or mechanical ventilation. This observational study included 1,806 hospitalized COVID-19 patients; 140 were treated with glucocorticoids within 48 hours of admission. Early use of glucocorticoids was not associated with mortality or mechanical ventilation. However, glucocorticoid treatment of patients with initial C-reactive protein (CRP) ≥20 mg/dL was associated with significantly reduced risk of mortality or mechanical ventilation (odds ratio, 0.23; 95% CI, 0.08- 0.70), while glucocorticoid treatment of patients with CRP <10 mg/dL was associated with significantly increased risk of mortality or mechanical ventilation (OR, 2.64; 95% CI, 1.39-5.03). Whether glucocorticoid treatment is associated with changes in mortality or mechanical ventilation in patients with high or low CRP needs study in prospective, randomized clinical trials. Journal of Hospital Medicine 2020;15:XXX-XXX. © 2020 Society of Hospital Medicine
Hospitalized patients who develop severe sepsis have significant morbidity and mortality. Early goal‐directed therapy has been shown to decrease mortality in severe sepsis and septic shock, though a delay in recognizing impending sepsis often precludes this intervention.
To identify early predictors of septic shock among hospitalized non‐intensive care unit (ICU) medical patients.
Retrospective cohort analysis.
A 1200‐bed academic medical center.
Derivation cohort consisted of 13,785 patients hospitalized during 2005. The validation cohorts consisted of 13,737 patients during 2006 and 13,937 patients from 2007.
Development and prospective validation of a prediction model using Recursive Partitioning And Regression Tree (RPART) analysis.
RPART analysis of routine laboratory and hemodynamic variables from the derivation cohort to identify predictors prior to the occurrence of shock. Two models were generated, 1 including arterial blood gas (ABG) data and 1 without.
When applied to the 2006 cohort, 347 (54.7%) and 121 (19.1%) of the 635 patients developing septic shock were correctly identified by the 2 models, respectively. For the 2007 patients, the 2 models correctly identified 367 (55.0%) and 102 (15.3%) of the 667 patients developing septic shock, respectively.
Readily available data can be employed to predict non‐ICU patients who develop septic shock several hours prior to ICU admission. Journal of Hospital Medicine 2010;5:19–25. © 2010 Society of Hospital Medicine.
Although timely treatment of sepsis improves outcomes, delays in administering evidence‐based therapies are common.
To determine whether automated real‐time electronic sepsis alerts can: (1) accurately identify sepsis and (2) improve process measures and outcomes.
We systematically searched MEDLINE, Embase, The Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature from database inception through June 27, 2014.
Included studies that empirically evaluated 1 or both of the prespecified objectives.
Two independent reviewers extracted data and assessed the risk of bias. Diagnostic accuracy of sepsis identification was measured by sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and likelihood ratio (LR). Effectiveness was assessed by changes in sepsis care process measures and outcomes.
Of 1293 citations, 8 studies met inclusion criteria, 5 for the identification of sepsis (n = 35,423) and 5 for the effectiveness of sepsis alerts (n = 6894). Though definition of sepsis alert thresholds varied, most included systemic inflammatory response syndrome criteria ± evidence of shock. Diagnostic accuracy varied greatly, with PPV ranging from 20.5% to 53.8%, NPV 76.5% to 99.7%, LR+ 1.2 to 145.8, and LR− 0.06 to 0.86. There was modest evidence for improvement in process measures (ie, antibiotic escalation), but only among patients in non–critical care settings; there were no corresponding improvements in mortality or length of stay. Minimal data were reported on potential harms due to false positive alerts.
Automated sepsis alerts derived from electronic health data may improve care processes but tend to have poor PPV and do not improve mortality or length of stay.
Optimizing postdischarge medication adherence is a target for avoiding adverse events. Nevertheless, few studies have focused on predictors of postdischarge medication adherence.
The Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL‐CVD) study used counseling and follow‐up to improve postdischarge medication safety. In this secondary data analysis, we analyzed predictors of self‐reported medication adherence after discharge. Based on an interview at 30‐days postdischarge, an adherence score was calculated as the mean adherence in the previous week of all regularly scheduled medications. Multivariable linear regression was used to determine the independent predictors of postdischarge adherence.
The mean age of the 646 included patients was 61.2 years, and they were prescribed an average of 8 daily medications. The mean postdischarge adherence score was 95% (standard deviation [SD] = 10.2%). For every 10‐year increase in age, there was a 1% absolute increase in postdischarge adherence (95% confidence interval [CI] 0.4% to 2.0%). Compared to patients with private insurance, patients with Medicaid were 4.5% less adherent (95% CI −7.6% to −1.4%). For every 1‐point increase in baseline medication adherence score, as measured by the 4‐item Morisky score, there was a 1.6% absolute increase in postdischarge medication adherence (95% CI 0.8% to 2.4%). Surprisingly, health literacy was not an independent predictor of postdischarge adherence.
In patients hospitalized for cardiovascular disease, predictors of lower medication adherence postdischarge included younger age, Medicaid insurance, and baseline nonadherence. These factors can help predict patients who may benefit from further interventions.
Infection is a leading cause of hospitalization with high morbidity and mortality, but there are limited data to guide the duration of antibiotic therapy.
Systematic review to compare outcomes of shorter versus longer antibiotic courses among hospitalized adults and adolescents.
MEDLINE and Embase databases, 1990‐2017.
Inclusion criteria were human randomized controlled trials (RCTs) in English comparing a prespecified short course of antibiotics to a longer course for treatment of infection in hospitalized adults and adolescents aged 12 years and older.
Two authors independently extracted study characteristics, methods of statistical analysis, outcomes, and risk of bias.
Of 5187 unique citations identified, 19 RCTs comprising 2867 patients met our inclusion criteria, including the following: 9 noninferiority trials, 1 superiority design trial, and 9 pilot studies. Across 13 studies evaluating 1727 patients, no significant difference in clinical efficacy was observed (d = 1.6% [95% confidence interval (CI), ‐1.0%‐4.2%]). No significant difference was detected in microbiologic cure (8 studies, d = 1.2% [95% CI, ‐4.1%‐6.4%]), short‐term mortality (8 studies, d = 0.3% [95% CI, ‐1.2%‐1.8%]), longer‐term mortality (3 studies, d = ‐0.4% [95% CI, ‐6.3%‐5.5%]), or recurrence (10 studies, d = 2.1% [95% CI, ‐1.2%‐5.3%]). Heterogeneity across studies was not significant for any of the primary outcomes.
Based on the available literature, shorter courses of antibiotics can be safely utilized in hospitalized patients with common infections, including pneumonia, urinary tract infection, and intra‐abdominal infection, to achieve clinical and microbiologic resolution without adverse effects on mortality or recurrence.
Severe sepsis is a common, costly, and complex problem, the epidemiology of which has only been well studied in the intensive care unit (
To determine rates of infection and organ system dysfunction in patients with severe sepsis admitted to non‐
Retrospective cohort study.
A large, tertiary, academic medical center in the United States.
Adult patients initially admitted to non‐
All International Classification of Diseases, 9th Revision, Clinical Modification diagnosis codes were screened for severe sepsis. Three hospitalists reviewed a sample of medical records evaluating the characteristics of severe sepsis.
Of 23,288 hospitalizations, 14% screened positive for severe sepsis. A sample of 111 cases was manually reviewed, identifying 64 cases of severe sepsis. The mean age of patients with severe sepsis was 63 years, and 39% were immunosuppressed prior to presentation. The most common site of infection was the urinary tract (41%). The most common organ system dysfunctions were cardiovascular (hypotension) and renal dysfunction occurring in 66% and 64% of patients, respectively. An increase in the number of organ systems affected was associated with an increase in mortality and eventual ICU utilization. Severe sepsis was documented by the treating clinicians in 47% of cases.
Severe sepsis was commonly found and poorly documented on the wards at our medical center. The epidemiology and organ dysfunctions among patients with severe sepsis appear to be different from previously described ICU severe sepsis populations.