BACKGROUND Interprofessional collaboration improves the quality of care, but integration into workflow is challenging. Although a shared conceptualization regarding bedside interprofessional rounds may enhance implementation, little work has investigated providers' perceptions of this activity. OBJECTIVE To evaluate the perceptions of nurses, attending physicians, and housestaff physicians regarding the benefits/barriers to bedside interprofessional rounds. DESIGN AND PARTICIPANTS Observational, cross‐sectional survey of hospital‐based medicine nurses, attending physicians, and housestaff physicians. Descriptive, nonparametric Wilcoxon rank sum and nonparametric correlation were used. MAIN MEASURES Bedside interprofessional rounds were defined as “encounters including 2 physicians plus a nurse or other care provider discussing the case at the patient's bedside.” Eighteen items related to “benefits” and 21 items related to “barriers” associated with bedside interprofessional rounds. RESULTS Of 171 surveys sent, 149 were completed (87%). Highest‐ranked benefits were related to communication/coordination, including “improves communication between nurses‐physicians;” lowest‐ranked benefits were related to efficiency, process, and outcomes, including “decreases length‐of‐stay” and “improves timeliness of consultations.” Nurses reported most favorable ratings for all items (P < 0.05). Rank order for 3 provider groups showed high correlation (r = 0.92, P < 0.001). Highest‐ranked barriers were related to time, including “nursing staff have limited time;” lowest‐ranked barriers were related to provider‐ and patient‐related factors, including “patient lack of comfort.” Rank order of barriers among all groups showed moderate correlation (r = 0.62–0.82). CONCLUSIONS Although nurses perceived greater benefit for bedside interprofessional rounds than physicians, all providers perceived coordination/teamwork benefits higher than outcomes. To the extent the results are generalizable, these findings lay the foundation for facilitating meaningful patient‐centered interprofessional collaboration. Journal of Hospital Medicine 2014;9:646–651. © 2014 Society of Hospital Medicine
BackgroundTotal knee arthroplasty is an effective treatment when nonsurgical treatments fail, but it is associated with risk of complications which may be increased in advanced age. The purpose of this study was to quantify age-related differences in perioperative morbidity and mortality after total knee arthroplasty through systematic review of existing literature.MethodsPubMed, the Cochrane database of systematic reviews, Scopus, and clinicaltrials.gov, were queried for relevant studies that compared primary total knee arthroplasty outcomes of mortality, myocardial infarction (MI), deep vein thrombosis (DVT), pulmonary embolism (PE) and functional status, of geriatric patients (>75 years old) with a younger control group (<65 years old). Pertinent journals and reference lists were hand searched. Eligibility criteria included all articles except case reports, meta-analyses, and systematic reviews. Two authors independently extracted data from each paper. Article quality was assessed using the Newcastle-Ottawa Scale.ResultsTwenty-two studies were included. Geriatric patients had higher rates of mortality, MI, DVT, and length of stay in older compared to younger patients, however the absolute magnitude of these increases were small. The increase in mortality may have reflected decreased life expectancy in the geriatric populations as opposed to mortality specifically due perioperative risk. There were no differences in PE incidence and improvement in pain and functional status was equal in older and younger patients. Existing studies were limited by non-randomized patient selection, as well as variation in definitions and methodology.ConclusionsExisting data supports offering primary total knee arthroplasty to select geriatric patients, although the risk of complications may be increased. Much of the data was of poor quality. Future prospective studies are needed to better identify risks and benefits of total knee arthroplasty so that patients and surgeons can make informed decisions.Electronic supplementary materialThe online version of this article (doi:10.1186/s12877-016-0215-4) contains supplementary material, which is available to authorized users.
BackgroundRecent sepsis guidelines have focused on the early identification and risk stratification of patients on presentation. Obesity is associated with alterations in multiple inflammatory regulators similar to changes seen in sepsis, suggesting a potential interaction between the presence of obesity and the severity of illness in sepsis.MethodsWe performed a retrospective chart review of patients admitted with a primary billing diagnosis of sepsis at a single United States university hospital from 2007 to 2010. Seven hundred and ninety-two charts were identified meeting inclusion criteria. Obesity was defined as a body mass index (BMI) ≥ 30 kg/m2. The data recorded included age, race, sex, vital signs, laboratory values, length of stay, comorbidities, weight, height, and survival to discharge. A modified APACHE II score was calculated to estimate disease severity. The primary outcome variable was inpatient mortality.ResultsSurvivors had higher average BMI than nonsurvivors (27.6 vs. 26.3 kg/m2, p = 0.03) in unadjusted analysis. Severity of illness and comorbid conditions including cancer were similar across BMI categories. Increased incidence of diabetes mellitus type 2 was associated with increasing BMI (p < 0.01) and was associated with decreased mortality, with an odds ratio of 0.53 compared with nondiabetic patients. After adjusting for age, gender, race, severity of illness, length of stay, and comorbid conditions, the trend of decreased mortality for increased BMI was no longer statistically significant, however diabetes continued to be strongly protective (odds ratio 0.52, p = 0.03).ConclusionsThis retrospective analysis suggests obesity may be protective against mortality in septic inpatients. The protective effect of obesity may be dependent on diabetes, possibly through an unidentified hormonal intermediary. Further prospective studies are necessary to elaborate the specific mechanism of this protective effect.
BACKGROUND On‐site hospitalist care can improve patient care, but it is economically infeasible for small critical access hospitals (CAHs). A telemedicine “virtual hospitalist” may expand CAH capabilities at a fractional cost of an on‐site provider. OBJECTIVE To evaluate the impact of a virtual hospitalist on transfers from a CAH to outside hospitals. DESIGN, SETTING, AND PARTICIPANTS A six‐month pilot program providing “virtual hospitalist” coverage to patients at a CAH in rural Iowa. MEASUREMENTS The primary outcome was the rate of outside transfers from the CAH Emergency Department (ED). The secondary outcomes included transfer from either the ED or the inpatient wards, daily census, length of stay, transfers after admission, virtual hospitalist time commitment, and patient and staff satisfaction. The preceding 24‐week baseline was compared with 24 weeks after implementation, excluding a two‐week transition period. RESULTS At baseline, there were 947 ED visits and 176 combined inpatient and observation encounters, compared to 930 and 176 after implementation, respectively. Outside transfers from the ED decreased from 16.6% to 10.5% (157/947 to 98/930, P < .001), and transfers at any time decreased from 17.3% to 11.9% (164/947 to 111/930, P < .001). Daily census, length of stay, and transfers after admission were unchanged. Time commitment for a virtual hospitalist was 35 minutes per patient per day. The intervention was well received by the CAH staff and patients. CONCLUSIONS The virtual hospitalist model increased the percentage of ED patients who could safely receive their care locally. A single virtual hospitalist may be able to cover multiple CAHs simultaneously.
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