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Journal of Hospital Medicine

Continuation of Antibiotics for UTI Often Inappropriate

Posted on Sun, Nov 22, 2015
Continuation of Antibiotics for UTI Often Inappropriate

Antibiotics frequently initiated inappropriately in ER; continuation after admission inappropriate for 68%

For patients with urinary tract infections (UTIs), initiation of antibiotics in the emergency department is frequently inappropriate, as is continuation of antibiotics after admission, according to a study published online Nov. 12 in the Journal of Hospital Medicine.

Dmitry Kiyatkin, M.D., from the Johns Hopkins Bayview Medical Center in Baltimore, and colleagues reviewed the medical records for all patients admitted to the hospital who initiated treatment for a UTI in the emergency department during a four-week period.

The researchers found that antibiotic initiation was inappropriate for 59 percent of 94 patients. Continuation of antibiotics after admission was inappropriate for 68 percent of 80 patients.

"In conclusion, we found a high rate of inappropriate antibiotic administration for UTIs that began in the emergency department and continued after admission," the authors write. "Specific guidelines should be developed and validated to direct diagnosis and treatment of UTIs in the emergency department and hospital."

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Displaying Prices to Providers Seems to Reduce Order Costs

Posted on Sun, Nov 08, 2015
Displaying Prices to Providers Seems to Reduce Order Costs

Review shows price display decreases aggregate order costs more frequently than order volume

Displaying order prices to physicians seems to reduce order costs, according to a review published online Oct. 23 in the Journal of Hospital Medicine.

Mark T. Silvestri, M.D., from the Yale School of Medicine in New Haven, Conn., and colleagues conducted a systematic review to examine the impact of displaying order prices to physicians on patterns of care. Data were included from 19 studies (five randomized trials, 13 pre-post intervention studies, and one time series analysis) that assessed the impact of showing numeric prices of laboratory tests, imaging studies, or medications to providers in real time during the ordering process.

The researchers found that 10 of the 15 studies that reported the quantitative impact of price display on aggregate order costs or volume demonstrated a significant decrease in the intervention group. Price display more often decreased aggregate order costs than order volume (nine of 13 studies versus three of eight studies, respectively). Five studies examined patient safety, which was not affected by price display. Evidence was limited but suggested that provider acceptability tended to be positive.

"Provider price display likely reduces order costs to a modest degree," the authors write. "More high-quality evidence is needed to confirm these findings within a modern context."

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Observation Stays Can Exceed Cost of Inpatient Deductible

Posted on Mon, Sep 07, 2015
Observation Stays Can Exceed Cost of Inpatient Deductible

For 26.6% of Medicare beneficiaries, cumulative financial liability up with observational stays

TUESDAY, Sept. 1, 2015 (HealthDay News) -- More than one-quarter of Medicare beneficiaries with multiple observation stays have a cumulative financial liability that exceeds that of the inpatient deductible, according to a study published online Aug. 20 in the Journal of Hospital Medicine.

Shreya Kangovi, M.D., from the University of Pennsylvania Perelman School of Medicine in Philadelphia, and colleagues examined the costs associated with revisiting observation care versus readmission for Medicare beneficiaries. The total cumulative financial liability for Medicare beneficiaries who revisit observation care multiple times within a 60-day period was determined using a 20 percent sample of the Medicare Outpatient Standard Analytic File.

The researchers found that beneficiaries with multiple observation stays in a 60-day period had a cumulative financial liability of $947.40 on average, which was significantly lower than the $1,100 inpatient deductible (P < 0.01). Of those beneficiaries, 26.6 percent had a cumulative financial liability that surpassed the inpatient deductible.

"More than a quarter of Medicare beneficiaries with multiple observation stays in a 60-day time period have a higher financial liability than they would have had under Part A benefits," the authors write.

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How We’re Improving ED-Inpatient Hand-Offs

Posted on Tue, Aug 18, 2015
How We’re Improving ED-Inpatient Hand-Offs

By Nathan Goldfein, M.D.

A recent study published in the Journal of Hospital Medicine found that challenges still exist in the patient hand-off process from ED to inpatient unit. Researchers concluded that communication needs to improve between EM physicians and hospitalists to ensure quick transfer and optimal patient safety.

It’s true – communication errors do exist, and sometimes the hand-off is sloppy and the baton gets dropped. These issues are precisely the reason I looked for a better way to pass that baton; an electronic, fool-proof way to ensure accountability and accuracy.

We’ve developed Rapid Admission Process and Gap Orders™ (RAP&GO™), a digital integration mechanism between the emergency department and the inpatient units. The software collects and distributes all of the data needed by both specialists. It delivers concise information and timely notifications to all who are involved in arranging and expediting an admission from the ED, truly “hardwiring” Lean principles into the process. The automated notification system effectively manages many of the inefficiencies involved in calling, tracking and following-up. System protocols can help reduce the errors, delays and distractions that naturally occur in a fast-paced, complex environment.

Through agreed-upon protocols, both emergency and hospital medicine physicians have a better understanding of the process and requirements of each specialty. Also, by automating the steps that are unrelated to patient care, physicians can focus on what matters most - physician-to-physician communication, high-quality patient care, patient satisfaction and financial impact. 

The Benefits of Automating Hand-Offs

The benefits of this technology in an integrated emergency medicine-hospital medicine model include:
 

  • Allowing emergency physicians to quickly provide needed information to hospitalists, which expedites decision-making
  • Decreasing administrative tasks for physicians and nurses
  • Providing a shared tool to measure and manage time intervals to identify opportunities for improvement
  • Automating timely notifications to case managers to keep patient flow on track
  • Eliminating the need for time-consuming back-and-forth conversations, arguments and debates about admission criteria
  • Streamlining processes that can bolster patient care and improve the patient experienceHow it Works

The RAP&GO software, now available as a smartphone app, provides relevant patient information in a format that is useful to both the hospitalist and the emergency physician.  If the patient meets the agreed-upon criteria for admission, the emergency physician creates a gap order, and the patient can be sent straight to the inpatient unit. This reduces the time that the patient spends boarding in the ED and decreases the likelihood of a bottleneck.

The system uses telephonic technology to page, text or call each person in the chain of events and delivers an automated message about actions needed (i.e., call the ED, assign a bed, move the patient to the inpatient floor). If someone in that chain fails to respond in the predetermined time, the software will escalate the activity by contacting the next person in the chain of command. Everyone in the communication loop is held accountable to respond quickly and move the patient to the inpatient floor.

Yes, healthcare is inefficient. Yes, there are pieces of the process that are broken. But as physicians and as leaders, we’ve got to keep exploring ways to fix these problems in ways that are easily adaptable and pro-patient. There’s always a better way.

Nathan Goldfein

Nathan Goldfein, M.D., is Vice President of Operations with EmCare Hospital Medicine and the director of the Hospital Medicine program at Gerald Champion Regional Medical Center in Alamogordo, N.M. Dr. Goldfein graduated from the University of Arizona College of Medicine and finished his residency in internal / hospital medicine at the University of New Mexico in 2008. His undergraduate degree is in mechanical engineering and manufacturing. Prior to pursuing medical school, Dr. Goldfein worked in manufacturing. He holds more than eight patents and is the inventor of more than 100 additional products and programs.
 

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