Limited health literacy is a common but often unrecognized problem associated with poor health outcomes. Well-validated screening tools are available to identify and provide the opportunity to intervene for at-risk patients in a resource-efficient manner. This is a multimethod study describing the implementation of a hospital-wide routine health literacy assessment at an academic medical center initiated by nurses in April 2014 and applied to all adult inpatients. Results were documented in the electronic health record, which then generated care plans and alerts for patients who screened positive. A nursing survey showed good ease of use and adequate patient acceptance of the screening process. Six months after hospital-wide implementation, retrospective chart abstraction of 1,455 patients showed that 84% were screened. We conclude that a routine health literacy assessment can be feasibly and successfully implemented into the nursing workflow and electronic health record of a major academic medical center.

The new rounding system has the potential to reduce waste and improve the quality of patient care while improving caregiver satisfaction and medical student teaching. Adaptive leadership skills will be required to overcome resistance to change. The use of athletic analogies can improve teamwork and facilitate the adoption of a systems approach to the delivery of patient care.

Background: Endogenous endophthalmitis is an infection of the eye secondary to sepsis, occurring in 0.04-0.5% of bacteremia or fungemia. Risk factors include intravenous drug abuse (IVDA), diabetes, indwelling catheters, and immune suppression. Many patients have known or suspected bacteremia or fungemia; however, culture yield is reported to be low (approximately 50%). The purpose of this study is to elucidate the yield of diagnostic evaluation including microbial cultures over a 6.5 year period at an academic center in the United States. Methods: Retrospective chart review of patients with endogenous endophthalmitis at the University of Florida from June 2011 to February 2018. Results: Included are 40 eyes of 35 patients. Endophthalmitis was secondary to an endogenous source in 23.5% of all endophthalmitis cases observed. Intraocular culture positivity was 28.6% overall but was 0% after initiation of systemic antibiotics. Most commonly identified organisms from the eye were coagulase-negative Staphylococcus and Candida. Blood culture positivity was 48.6%, most commonly Staphylococcus. IVDA was noted with increasing frequency as a risk factor. Diagnosis of endophthalmitis upon hospital admission was associated with a higher intraocular culture positivity (P = 0.040) and a shorter hospital stay (P = 0.035). Computed tomography (CT) and magnetic resonance imaging (MRI) were the highest yield imaging modalities; X-ray and non-ocular ultrasound were less diagnostically useful. Echocardiogram was positive by transesophageal route (TEE) in 22% and in 9% by transthoracic (TTE) testing. Following discharge from the hospital, 48.4% of patients failed to follow up with outpatient ophthalmology. Conclusions: Based on the results of this study, the interdisciplinary team should consider directed imaging, eye cultures prior to antimicrobial administration, thorough history for IVDA, and caution with premature discharge from the hospital.

BackgroundThe recommendations of the American Board of Internal Medicine Foundation’s “Choosing Wisely®” initiative recognize the importance of improving the appropriateness of testing behavior and reducing the number of duplicate laboratory tests.ObjectiveTo assess the effectiveness of an electronic medical record Best Practice Alert (BPA or “pop up”) intervention aimed at reducing duplicate laboratory tests and hospital costs.DesignComparison of the number of duplicated laboratory tests performed on inpatients before and after the intervention.SettingUniversity of Florida Health Shands Hospital, Gainesville, FL, USA, during 2014–2017.InterventionThe electronic medical record intervention was a BPA pop-up alert that informed the ordering physician if a recent identical order already existed along with the “ordering time”, “collecting time”, “resulting time”, and the result itself.Main outcome measuresPercentage change in the number of inpatient duplicate orders of selected clinical biochemistry tests and cost savings from reduction of the duplicates. Student’s t-test and beta-binomial models were used to analyze the data.ResultsResults from the beta-binomial model indicated that the intervention reduced the overall duplicates by 18% (OR=0.82, standard error=0.016, P-value<0.000). Percent reductions in 9 of the 17 tests were statistically significant: serum hemoglobin A1C level, vitamin B12, serum erythrocyte sedimentation rate, serum folate, serum iron, lipid panel, respiratory viral panel, serum thyroid stimulating hormone level, and Vitamin D. Additionally, important cost savings were realized from the reduction of duplicates for each lab test (with the exception of CRP) with an estimated overall savings of $72,543 over 17 months in the post-intervention period.ConclusionsThe present study included all hospital inpatients and covered 17 clinical laboratory tests. This rather simple and low-cost intervention resulted in significant reductions in percentage duplicates of several tests and resulted in cost savings. The study also highlights the role of hospitalists in quality improvement.

Introduction Total hip and knee replacement (THR and TKR) are high risk settings for venous thromboembolism (VTE). Objectives (1) Summarize cost-effectiveness of VTE prophylaxis regimens for THR and TKR a Data Sources Medline (from January 1997 to October 2009), EMBASE (January 1997 until June 2009), and the Economic Evaluation Database[12] (1997- October 2009) Methods We identified recent cost-effectiveness studies examining five categories of comparisons: (1) anticoagulants (warfarin, low molecular weight heparin - LMWH, or fondaparinux) vs. aspirin; (2) LMWH vs. warfarin; (3) fondaparinux vs. LMWH; (4) comparisons with new oral anticoagulants; and (5) extended (≥3 weeks) vs. short duration prophylaxis (< 3 weeks). We abstracted information on cost and effectiveness for each prophylaxis regimen in order to calculate an incremental cost-effectiveness ratio. Because of variations in effectiveness units reported and horizon length analyzed, we calculate two cost-effectiveness ratios, one for the number of symptomatic, proximal VTE events avoided at 90 days and the other for quality adjusted life-years (QALYs) at the one year mark or beyond. Results We identified 33 studies with 67 comparisons. After standardization, comparisons between LMWH and warfarin were inconclusive whereas fondaparinux dominated LMWH in nearly every comparison. The latter results were derived from radiographic VTE rates. Extended duration prophylaxis after THR was generally cost-effective. Small numbers prohibit conclusions about aspirin, new oral anticoagulants, or extended duration prophylaxis after TKR. Conclusions Fondaparinux after both THR and TKR and Extended duration LMWH after THR appear to be cost cost-effective prophylaxis regimens. Small numbers for other comparisons and absence of trials reporting symptomatic endpoints prohibit comprehensive conclusions.

PCATS serves as a useful, and valid, predictor of ASA PS classification. Thus, it may also serve as a tool to triage patients to an appropriate venue for preoperative assessment that can be utilized by nonclinical schedulers. Using a simple tool such as PCATS may help streamline the presurgical patient experience and improve clinic staff utilization.

Standardized bedside rounds can improve communication and the quality of care for patients in hospitals. However, it can be challenging to change previously established provider practices to adhere to new procedures. This study evaluated 2 packaged interventions, derived from a modified Performance Diagnostic Checklist interview, to increase adherence to standardized rounding practices in 2 hospital units. Researchers observed physicians at a university hospital on rounds 2-3 times per week, and 2 phases of intervention were implemented to improve adherence. The interventions included task clarification, feedback, and weekly huddles. Compared to baseline, phases 1 and 2 of the intervention improved clinician adherence to the standardized bedside rounding checklist by 24.94% and 30.94% in unit 1 and 26.76% and 44.06% in unit 2, respectively. The standardized rounds did not require additional time following the intervention. These results indicate that physician adherence can be improved through behavioral interventions.

Purpose: Traditionally, the morbidity and mortality conference (M&MC) is a forum where possible medical errors are discussed. Although M&MCs can facilitate identification of opportunities for systemwide improvements, few studies have described their use for this purpose, particularly in residency training programs. This paper describes the use of M&MC case review as a quality improvement activity that teaches system-based practice and can engage residents in improving systems of care. Methods: Internal medicine residents at a tertiary care academic medical center reviewed 347 consecutive mortalities from March 2014 to September 2017. The residents used case review worksheets to categorize and track causes of mortality, and then debriefed with a faculty member. Selected cases were then presented at a larger interdepartmental meeting and action items were implemented. Descriptive statistics and thematic analysis were used to analyze the results. Results: The residents identified a possible diagnostic mismatch at some point from admission to death in 54.5% of cases (n= 189) and a possible need for improved management in 48.0% of cases. Three possible management failure themes were identified, including failure to plan, failure to communicate, and failure to rescue, which accounted for 21.9%, 10.7 %, and 10.1% of cases, respectively. Following these reviews, quality improvement initiatives proposed by residents led to system-based changes. Conclusion: A resident-driven mortality review curriculum can lead to improvements in systems of care. This novel type of curriculum can be used to teach system-based practice. The recruitment of teaching faculty with expertise in quality improvement and mortality case analyses is essential for such a project.