Objectives: Many patients are discharged from the emergency department (ED) with an incomplete understanding of the information needed to safely care for themselves at home. Patients have demonstrated particular difficulty in understanding post-ED care instructions (including medications, home care, and follow-up). The objective of this study was to further characterize these deficits and identify gaps in knowledge that may place the patient at risk for complications or poor outcomes.Methods: This was a prospective cohort, phone interview-based study of 159 adult English-speaking patients within 24 to 36 hours of ED discharge. Patient knowledge was assessed for five diagnoses (ankle sprain, back pain, head injury, kidney stone, and laceration) across the following five domains: diagnosis, medications, home care, follow-up, and return instructions. Knowledge was determined based on the concordance between direct patient recall and diagnosis-specific discharge instructions combined with chart review. Two authors scored each case independently and discussed discrepancies before providing a final score for each domain (no, minimal, partial, or complete comprehension). Descriptive statistics were used for the analyses.Results: The study population was 50% female with a median age of 41 years (interquartile range [IQR] = 29 to 53 years). Knowledge deficits were demonstrated by the majority of patients in the domain of home care instructions (80%) and return instructions (79%). Less frequent deficits were found for the domains of follow-up (39%), medications (22%), and diagnosis (14%). Minimal or no understanding in at least one domain was demonstrated by greater than two-thirds of patients and was found in 40% of cases for home care and 51% for return instructions. These deficits occurred less frequently for domains of follow-up (18%), diagnosis (3%), and medications (3%). Conclusions:Patients demonstrate the most frequent knowledge deficits for home care and return instructions, raising significant concerns for adherence and outcomes.
BACKGROUND: Within the last decade hospitalists have become an integral part of inpatient care in the United States and now care for about half of all Medicare patients requiring hospitalization. However, little data exists describing hospitalist workflow and their activities in daily patient care. OBJECTIVE: To clarify how hospitalists spend their time and how patient volumes affect their workflow. DESIGN: Observers continuously shadowed each of 24 hospitalists for two complete shifts. Observations were recorded using a handheld computer device with customized data collection software. SETTING: Urban, tertiary care, academic medical center. RESULTS: Hospitalists spent 17% of their time on direct patient contact, and 64% on indirect patient care. For 16% of all time recorded, more than one activity was occurring simultaneously (i.e., multitasking). Professional development, personal time, and travel each accounted for about 6% of their time. Communication and electronic medical record (EMR) use, two components of indirect care, occupied 25% and 34% of recorded time respectively. Hospitalists with above average patient loads spent less time per patient communicating with others and working with the EMR than those hospitalists with below average patient loads, but reported delaying documentation until later in the evening or next day. Patient load did not change the amount of time hospitalists spent with each patient. CONCLUSIONS: Hospitalists spend more time reviewing the EMR and documenting in it, than directly with the patient. Multi‐tasking occurred frequently and occupied a significant portion of each shift. Journal of Hospital Medicine 2010;5:323–328. © 2010 Society of Hospital Medicine.
BACKGROUND: Time studies, first developed in the late 19th century, are now being used to evaluate and improve worker efficiency in the hospital setting. This is the first review of hospital time study literature of which we are aware. PURPOSE: We performed a systematic review of the literature to better understand the available time study literature describing the activities of hospital physicians. DATA SOURCES: We searched MEDLINE, EMBASE, EMBASE Classic, PsycINFO, Cochrane Library, CINAHL, and Web of Science. We also manually reviewed the reference lists of retrieved articles and consulted experts in the field to identify additional articles for review. STUDY SELECTION: We selected studies that used time‐motion or work‐sampling performed via direct observation, included physicians, medical residents, or interns in their study population, and were performed on an inpatient hospital ward. DATA EXTRACTION: We abstracted data on subject population, study site, collection tools, and percentage of time spent on key categories of activity. DATA SYNTHESIS: Our search produced 11 time‐motion and 2 work‐sampling studies that met our criteria. These studies focused primarily on academic hospitals (92%) and the activities of physicians in training (69%). Other results varied widely. A lack of methodological standardization and dissimilar activity categorizations inhibited our efforts to summarize detailed findings across studies. However, we consistently found that activities indirectly related to a patient's care took more of hospital physicians' time than direct interaction with hospitalized patients. CONCLUSIONS: Time studies, when properly performed, have a great deal to offer in helping us understand and reengineer hospital care. Journal of Hospital Medicine 2010;5:353–359. © 2010 Society of Hospital Medicine.
The implementation of Project BOOST was well received by hospitals, although sites faced substantial barriers consistent with other QI research reports. The unique mentorship element of Project BOOST proved extremely valuable in helping sites overcome their distinctive challenges and identify facilitators for success. The findings from this qualitative study should contribute to future BOOST implementation success and others' efforts to optimize hospital discharge transitions.
BACKGROUND:Hospitalists care for an increasing percentage of hospitalized patients, yet evaluations of patient perceptions of hospitalists' communication skills are lacking.OBJECTIVE:Assess hospitalist communication skills using the Communication Assessment Tool (CAT).METHODS:A cross‐sectional study of patients, age 18 or older, admitted to the hospital medicine service at an urban, academic medical center with 873 beds. Thirty‐five hospitalists assigned to both direct care and teaching service were assessed.MEASUREMENTS:Hospitalist communication was measured with the CAT. The 14‐item survey, written at a fourth grade level, measures responses along a 5‐point scale (“poor” to “excellent”). Scores are reported as a percentage of “excellent” responses.RESULTS:We analyzed 700 patient surveys (20 for each of 35 hospitalists). The proportion of excellent ratings for each hospitalist ranged from 38.5% to 73.5%, with an average of 59.1% excellent (SD=9.5). Highest ratings on individual CAT items were for treating the patient with respect, letting the patient talk without interruptions, and talking in terms the patient can understand. Lowest ratings were for involving the patient in decisions as much as he or she wanted, encouraging the patient to ask questions, and greeting the patient in a way that made him or her feel comfortable. Overall scale reliability was high (Cronbach's alpha = 0.97).CONCLUSIONS:The CAT can be used to gauge patient perceptions of hospitalist communication skills. Many hospitalists may benefit from targeted training to improve communication skills, particularly in the areas of encouraging questions and involving patients in decision making. Journal of Hospital Medicine 2010. © 2010 Society of Hospital Medicine.
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