Objectives: To characterize the level of formal training and perceived educational needs in palliative care of emergency medicine (EM) residents. Methods: This descriptive study used a 16-question survey administered at weekly resident didactic sessions in 2008 to EM residency programs in New York City. Survey items asked residents to: (1) respond to Likert-scaled statements about the role of palliative care in the emergency department (ED); (2) quantify their level of formal training and personal comfort in symptom management, discussion of bad news and prognosis, legal issues, and withdrawing/withholding therapy; and (3) express their interest in future palliative care training. Results: Of 228 total residents, 159 (70%) completed the survey. Of those surveyed, 50% completed some palliative care training before residency; 71.1% agreed or strongly agreed that palliative care was an important competence for an EM physician. However, only 24.3% reported having a ''clear idea of the role of palliative care in EM.'' The highest self-reported level of formal training was in the area of advanced directives or legal issues at the end of life; the lowest levels were in areas of patient management at the end of life. The highest level of selfreported comfort was in giving bad news and the lowest was in withholding/withdrawing therapy. A slight majority of residents (54%) showed positive interest in receiving future training in palliative care. Conclusions: New York City EM residents reported palliative care as an important competency for emergency medicine physicians, yet also reported low levels of formal training in palliative care. The majority of residents surveyed favored additional training.

Reducing the length of hospitalization is a shared priority for patients, clinicians, and other health care stakeholders. However, patients can remain hospitalized after being “medically ready” for discharge, accumulating delayed discharge bed days (DDBDs). As part of a quality improvement initiative, the authors developed a method to measure DDBD and define discrete barriers to discharge identified by inpatient clinicians. Patients with delayed discharge had a higher rate of in-hospital complications compared to those who were discharged routinely. To identify modifiable barriers among patients with delayed discharges, 2 patient subgroups were defined: prolonged hospitalization (>19 DDBDs, top quintile accumulated) and extended hospitalization (≤19 DDBDs). Patients with prolonged hospitalization were more likely than those with extended hospitalization to have financial ( P < .001) or behavioral ( P < .001) barriers, homelessness ( P < .05), and impairment of decision-making capacity ( P < .01). Understanding the characteristics and discharge barriers of patients who are hospitalized despite medical readiness may increase appropriateness of inpatient resources.

BackgroundInefficient coordination of care around discharge can increase length of stay, lead to ineffective transitions and contribute an unnecessary cost burden to patients and hospital systems. Multidisciplinary discharge rounds can improve situational awareness among team members leading to more efficient and better coordinated care. This project aimed to standardise the daily discharge rounds occurring on a medicine service to reduce length of stay. Participants included physicians, nurses and social workers.MethodsA key driver diagram was developed to understand drivers of length of stay. Improving multidisciplinary care coordination was targeted as an initial area of focus. Stakeholder interviews were held to understand current participants challenges with the daily discharge rounds process. Baseline assessment included a review of discharges for 6 weeks before the initial intervention. A Plan Do Study Act quality improvement framework was used to implement change.InterventionAn electronic tool was developed which highlighted critical information to be captured during discharge rounds on each current inpatient in a standardised fashion. Information was reviewed and solicited from care teams by a facilitator, then edited and displayed in real time to all team members by a scribe.ResultsThe average length of stay decreased by 1.4 days (p<0.05), an improvement of 21.1%. There was no measured increase on readmission rate during the intervention period.ConclusionAn electronic tool to standardise information gathered among team members in daily discharge rounds led to improvements in length of stay. Multidisciplinary discharge rounds are an important venue for discharge planning across inpatient care teams and efforts to optimise communication between team members can improve care.

Key Points Question How has mortality associated with adverse effects of medical treatment in the United States changed over time, by state, age, and sex? Findings In this cohort study, there was a decrease in the national age-standardized mortality rate associated with adverse effects of medical treatment in the United States between 1990 and 2016. Although no differences by sex were observed, increased mortality due to adverse effects of medical treatment was associated with advancing age, and geographic variability was noted. Meaning Global Burden of Disease 2016 results suggest that mortality associated with the adverse effects of medical treatment has decreased modestly over the past 25 years, and although the degree of improvement varies by state, it appears that an increased burden of adverse effects of medical treatment on aging populations continues to affect the US health system.