BACKGROUND Despite estimates that waste constitutes up to 20% of healthcare expenditures in the United States, overuse of tests and therapies is significantly under‐recognized in medicine, particularly in pediatrics. The American Board of Internal Medicine Foundation developed the Choosing Wisely campaign, which challenged medical societies to develop a list of 5 things physicians and patients should question. The Society of Hospital Medicine (SHM) joined this effort in the spring of 2012. This report provides the pediatric workgroup's results. METHODS A workgroup of experienced and geographically dispersed pediatric hospitalists was convened by the Quality and Safety Committee of the SHM. This group developed an initial list of 20 recommendations, which was pared down through a modified Delphi process to the final 5 listed below. RESULTS The top 5 recommendations proposed for pediatric hospital medicine are: (1) Do not order chest radiographs in children with asthma or bronchiolitis. (2) Do not use systemic corticosteroids in children under 2 years of age with a lower respiratory tract infection. (3) Do not use bronchodilators in children with bronchiolitis. (4) Do not treat gastroesophageal reflux in infants routinely with acid suppression therapy. (5) Do not use continuous pulse oximetry routinely in children with acute respiratory illness unless they are on supplemental oxygen. CONCLUSION We recommend that pediatric hospitalists use this list to prioritize quality improvement efforts and include issues of waste and overuse in their efforts to improve patient care. Journal of Hospital Medicine 2013;8:479–485. © 2013 Society of Hospital Medicine

BACKGROUND In an effort to lead physicians in addressing the problem of overuse of medical tests and treatments, the American Board of Internal Medicine Foundation developed the Choosing Wisely campaign. The Society of Hospital Medicine (SHM) joined the initiative to highlight the need to critically appraise resource utilization in hospitals. METHODS The SHM employed a staged methodology to develop the adult Choosing Wisely list. This included surveys of the organization's leaders and general membership, a review of the literature, and Delphi panel voting. RESULTS The 5 recommendations that were subsequently approved by the SHM Board are: (1) Do not place, or leave in place, urinary catheters for incontinence or convenience or monitoring of output for non–critically ill patients (acceptable indications: critical illness, obstruction, hospice, perioperatively for <2 days for urologic procedures; use weights instead to monitor diuresis). (2) Do not prescribe medications for stress ulcer prophylaxis to medical inpatients unless at high risk for gastrointestinal complications. (3) Avoid transfusions of red blood cells for arbitrary hemoglobin or hematocrit thresholds and in the absence of symptoms or active coronary disease, heart failure, or stroke. (4) Do not order continuous telemetry monitoring outside of the intensive care unit without using a protocol that governs continuation. (5) Do not perform repetitive complete blood count and chemistry testing in the face of clinical and lab stability. CONCLUSIONS Hospitalists have many opportunities to impact overutilization of care. The adult hospital medicine Choosing Wisely recommendations offer an explicit starting point for eliminating waste in the hospital. Journal of Hospital Medicine 2013;8:486–492. © 2013 Society of Hospital Medicine

NCT01337063.

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, p<0.001). Receipt of patient-level interventions was associated with decreased discrepancy rates, and these associations increased over time as sites adopted more system-level interventions.ConclusionA 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.

Implementation of I-PASS has been associated with substantial improvements in patient safety and can be applied to a variety of disciplines and types of patient handoffs. Widespread implementation of I-PASS has the potential to substantially improve patient safety in the United States and beyond.

BackgroundHandoff miscommunications are a leading source of medical errors. Error rates decreased following implementation of the I-PASS handoff program (a bundled intervention using a structured mnemonic, I-PASS, and other initiatives to sustain implementation) in a pediatric research trial. Whether I-PASS can be implemented in settings outside academic pediatric institutions is unknown.ObjectivesTo implement I-PASS in a variety of hospitals and medical specialties using a mentored process. (2) To measure the association of I-PASS implementation with handoff quality and provider-reported medical error rates.MethodsWe implemented I-PASS in 16 hospitals [community (n=5), academic (n=11)] and multiple specialties [internal medicine (n=7), pediatrics (n=3), other (n=6)]. We paired each site with an external mentorship team of I-PASS experts that conducted a site visit and provided ongoing coaching. Site leads participated in program wide webinars and shared data with participating sites. Validated handoff observation tools and a provider survey assessed handoff quality and rates of adverse events.ResultsImplementation was associated with increased inclusion of all 5 I-PASS mnemonic elements for both verbal (14% vs 70%) and written (0% vs 81%) handoffs. Additionally, increases were noted in the frequency of high quality verbal (44% vs 81%) and written (49% vs 73%) patient summaries, verbal (22% vs 82%) and written (44% vs 72%) contingency plans, and verbal receiver syntheses (4% vs 81%). Adverse events decreased by 27%. All changes statistically significant. Improvements were similar across provider types and settings.ConclusionsThe I-PASS Handoff program is associated with improved handoff communication in a variety of settings and provider types.Figure 1Verbal Handoff Assessments: adherence to all 5 mnemonic elements.Figure 2Written Handoff Assessments: adherence to all 5 mnemonic elements.Figure 3Verbal Handoff Assessments: quality of patient summaries.Figure 4Written Handoff Assessments: quality of patient summaries.Figure 5Verbal Handoff Assessments: quality of contigency plans.Figure 6Written Handoff Assessments: quality of contigency plans.Figure 7Verbal Handoff Assessments: quality of synthesis by receiver.Figure 8Provider-reported adverse event rate.

Background The 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. Methods MARQUIS2 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. Discussion A 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.

Background A number of challenges impede our ability to consistently provide high quality care to patients hospitalized with medical conditions. Teams are large, team membership continually evolves, and physicians are often spread across multiple units and floors. Moreover, patients and family members are generally poorly informed and lack opportunities to partner in decision making. Prior studies have tested interventions to redesign aspects of the care delivery system for hospitalized medical patients, but the majority have evaluated the effect of a single intervention. We believe these interventions represent complementary and mutually reinforcing components of a redesigned clinical microsystem. Our specific objective for this study is to implement a set of evidence-based complementary interventions across a range of clinical microsystems, identify factors and strategies associated with successful implementation, and evaluate the impact on quality. Methods The RESET project uses the Advanced and Integrated MicroSystems (AIMS) interventions. The AIMS interventions consist of 1) Unit-based Physician Teams, 2) Unit Nurse-Physician Co-leadership, 3) Enhanced Interprofessional Rounds, 4) Unit-level Performance Reports, and 5) Patient Engagement Activities. Four hospital sites were chosen to receive guidance and resources as they implement the AIMS interventions. Each study site has assembled a local leadership team, consisting of a physician and nurse, and receives mentorship from a physician and nurse with experience in leading similar interventions. Primary outcomes include teamwork climate, assessed using the Safety Attitudes Questionnaire, and adverse events using the Medicare Patient Safety Monitoring System (MPSMS). RESET uses a parallel group study design and two group pretest-posttest analyses for primary outcomes. We use a multi-method approach to collect and triangulate qualitative data collected during 3 visits to study sites. We will use cross-case comparisons to consider how site-specific contextual factors interact with the variation in the intensity and fidelity of implementation to affect teamwork and patient outcomes. Discussion The RESET study provides mentorship and resources to assist hospitals as they implement complementary and mutually reinforcing components to redesign the clinical microsystems caring for medical patients. Our findings will be of interest and directly applicable to all hospitals providing care to patients with medical conditions. Trial registration NCT03745677 . Retrospectively registered on November 19, 2018. Electronic supplementary material The online version of this article (10.1186/s12913-019-4116-z) contains supplementary material, which is available to authorized users.