JHM Research Series

The JHM Research Series highlights some of the most recent and impactful research coming out of the Journal of Hospital Medicine, SHM’s peer-reviewed research journal. Read what contributors and primary investigators have to say about the latest hospital medicine research. Visit www.journalofhospitalmedicine.com for more.

Prioritizing Inpatient Geriatric Care Is NOT a Moon Shot.

Most physicians recognize the JNC guideline for blood pressure management, or the ACCP thrombosis guideline for VTE.  Most would agree we use a handful of accepted benchmarks to manage a limited number of conditions.  For the rest, it’s the wild wild west. Try to develop consensus around delirium management or treatment of alcohol withdrawal, and you will likely find yourself on the road to nowhere. If you have never visited The National Guideline Clearinghouse, you should have a peek.  Sometimes I find the site helpful for a management dilemma or patient with a rare presentation. However, for most, the compilation runs endlessly long and you will begin a convoluted journey if you crave a solution.  The same road to nowhere. As of this writing, the database has close to 2400 entries.  Have fun with that: (more…)

Low Hanging Fruit

I just finished reading the soon to be published JHM article called "The highest utilizers of care: individualized care plans to coordinate care, improve health care service utilization, and reduce costs at an academic tertiary care center" by Mercer et al. Using a multidisciplinary team of volunteers including members from hospital medicine, ER, psychiatry, ambulatory care, social work, nursing and risk management,  individualized care plans were developed for high utilizer patients.  These patients had multiple co-morbidities, or concomitant psychiatric illness or substance abuse issues.  This team took the top 24 patient utilizers and developed individualized care plans and loaded them into the EMR. With this change, they saved money.  They saved hospitalizations. They reduced readmissions by about 60%.  But they didn't really reduce ER visits.  But that is actually the most interesting part.  Because it means the patient's behavior didn't change.  The PROVIDER'S did. I had the opportunity so talk…

Frequency and Clinical Relevance of Inconsistent Code Status Documentation

I had the pleasure of interviewing Adina Weinerman, a Hospitalist in the Division of General Internal Medicine at Sunnybrook Health Sciences Centre in Toronto, Canada, about her team’s recent publication in the Journal of Hospital Medicine (JHM) Frequency and Clinical Relevance of Inconsistent Code Status Documentation. This “point prevalence” study from 3 academic medical centers found that 65% of inpatients had at least 1 code status documentation inconsistency, and 20% were clinically relevant. What is your background and how did you become interested in evaluating inconsistencies in code status in the medical record? I did my IM residency at University of Toronto, and during my last year I had the opportunity to do an administrative position as a chief resident, which helped me get a good understanding of the administrative side of medical centers. Also during my residency, I was surrounded by mentors in quality improvement at the University and…

Teaching on Today’s Wards: All You Need Is 1 Minute, So SNAPPS to It?

During my eight-year tenure as Associate Program Director for our Internal Medicine Residency, I read countless letters of recommendation for aspiring residents, and many were signed by familiar hospitalist friends from all over the country.  If you think about how many students and residents come into contact with hospitalists, making sure hospitalists are great teachers is more than just a pride issue, it's also critical to training the next generation of physicians, no matter what specialty they go into. Unfortunately, there are many barriers to teaching on the wards today for hospitalists.  First and foremost, time is of the essence.  Less time worked by residents has increased the clinical workload of teaching attend ings…and what has been squeezed out is time for teaching.  Therefore, methods to teach trainees efficiently on the wards are must-have skills for any academic hospitalist. Fortunately, there are two new articles in the Journal of Hospital…

Analyzing Best Practice Alerts to Understand Blood Transfusions Ordered outside Recommended Guidelines

I had the pleasure of interviewing Lisa Shieh, a Hospitalist at Stanford University, about her team’s recent publication in JHM Why providers transfuse blood products outside recommended guidelines in spite of integrated electronic best practice alerts. The study found that many best practice alerts (BPAs) “overrides” were due to protocolized behaviors, resident/nurse practitioner/physician assistant ordering, or subjective indications, such as “symptomatic anemia”. What is your background and how did you become interested in using BPAs to enhance quality? I am a hospitalist and Medical Director of Quality for the Department of Medicine at Stanford University Medical Center, and have a longstanding interest in how the appropriate use of BPAs can enhance quality efforts. Our medical center has been on Epic EMR for many years, and over time we continually strive to optimize our EMR clinical decision support to try to achieve the right amount of support, without invoking alert fatigue.…