Publications

BACKGROUND: Daily multidisciplinary rounds (MDR) in the ICU represent a mechanism by which health care professionals from different disciplines and specialties can meet to synthesize data, think collectively, and form complete patient care plans. It was hypothesized that providing a standardized, structured approach to the daily rounds process would improve communication and collaboration in seven distinct ICUs in a single academic medical center.

METHODS: Lean-inspired methodology and information provided by frontline staff regarding inefficiencies and barriers to optimal team functioning were used in designing a toolkit for standardization of rounds in the ICUs. Staff perceptions about communication were measured, and direct observations of rounds were conducted before and after implementation of the intervention.

RESULTS: After implementation of the intervention, nurse participation during presentation of patient data increased from 17/47 (36.2%) to 56/78 (71.8%) (p < 0.0002) in the surgical ICUs and from 8/23 (34.8%) to 107/107 (100%) (p <0.0001) in the medical ICUs. Nurse participation during generation of the daily plan increased in the surgical ICUs from 24/47 (51.1%) to 63/78 (80.8%) (p = 0.0005) and from 7/23 (30.4%) to 106/107 (99.1%) (p < 0.0001) in the medical ICUs. Miscommunications and errors were corrected in nearly half of the rounding episodes observed.

CONCLUSION: This study demonstrated that the implementation of a simple toolkit that can be incorporated into existing work flow and rounding culture in several different types of ICUs can result in improvements in engagement of nursing staff and in overall communication.

OBJECTIVES: To assess whether Massachusetts legislation directed at ICU nurse staffing was associated with improvements in patient outcomes.

DESIGN: Retrospective cohort study; difference-in-difference design to compare outcomes in Massachusetts with outcomes of other states (before and after the March 31, 2016, compliance deadline).

SETTING: Administrative claims data collected from medical centers across the United States (Vizient).

PATIENTS: Adults between 18 and 99 years old who were admitted to ICUs for greater than or equal to 1 day.

INTERVENTIONS: Massachusetts General Law c. 111, § 231, which established 1) maximum patient-to-nurse assignments of 2:1 in the ICU and 2) that this determination should be based on a patient acuity tool and by the staff nurses in the unit.

MEASUREMENTS AND MAIN RESULTS: Nurse staffing increased similarly in Massachusetts (n = 11 ICUs, Baseline patient-to-nurse ratio 1.38 ± 0.16 to Post-mandate 1.28 ± 0.15; p = 0.006) and other states (n = 88 ICUs, Baseline 1.35 ± 0.19 to Post-mandate 1.31 ± 0.17; p = 0.002; difference-in-difference p = 0.20). Massachusetts ICU nurse staffing regulations were not associated with changes in hospital mortality within Massachusetts (Baseline n = 29,754, standardized mortality ratio 1.20 ± 0.04 to Post-mandate n = 30,058, 1.15 ± 0.04; p = 0.11) or when compared with changes in hospital mortality in other states (Baseline n = 572,952, 1.15 ± 0.01 to Post-mandate n = 567,608, 1.09 ± 0.01; difference-in-difference p = 0.69). Complications (Massachusetts: Baseline 0.68% to Post-mandate 0.67%; other states: Baseline 0.72% to Post-mandate 0.72%; difference-in-difference p = 0.92) and do-not-resuscitate orders (Massachusetts: Baseline 13.5% to Post-mandate 15.4%; other states: Baseline 12.3% to Post-mandate 14.5%; difference-in-difference p = 0.07) also remained unchanged relative to secular trends. Results were similar in interrupted time series analysis, as well as in subgroups of community hospitals and workload intensive patients receiving mechanical ventilation.

CONCLUSIONS: State regulation of patient-to-nurse staffing with the aid of patient complexity scores in intensive care was not associated with either increased nurse staffing or changes in patient outcomes.

BACKGROUND AND AIMS: The full burden of the opioid epidemic on US hospitals has not been described. We aimed to estimate how heroin (HOD) and prescription opioid (POD) overdose-associated admissions, costs, outcomes and patient characteristics have changed from 2001 to 2012.

DESIGN: Retrospective cohort study of hospital admissions from the National Inpatient Sample (NIS).

SETTING: United States of America.

PARTICIPANTS: Hospital admissions in patients aged 18 years or older admitted with a diagnosis of HOD or POD. The NIS sample included 94 492 438 admissions from 2001 to 2012. The final unweighted study sample included 138 610 admissions (POD: 122 147 and HOD: 16 463).

MEASUREMENTS: Primary outcomes were rates of admissions per 100 000 people using US Census Bureau annual estimates. Other outcomes included in-patient mortality, hospital length-of-stay, cumulative and mean hospital costs and patient demographics. All analyses were weighted to provide national estimates.

FINDINGS: Between 2001 and 2012, an estimated 663 715 POD and HOD admissions occurred nation-wide. HOD admissions increased 0.11 per 100 000 people per year [95% confidence interval (CI) = 0.04, 0.17], while POD admissions increased 1.25 per 100 000 people per year (95% CI = 1.15, 1.34). Total in-patient costs increased by $4.1 million dollars per year (95% CI = 2.7, 5.5) for HOD admissions and by $46.0 million dollars per year (95% CI = 43.1, 48.9) for POD admissions, with an associated increase in hospitalization costs to more than $700 million annually. The adjusted odds of death in the POD group declined modestly per year [odds ratio (OR) = 0.98, 95% CI = 0.97, 0.99], with no difference in HOD mortality or length-of-stay. Patients with POD were older, more likely to be female and more likely to be white compared with HOD patients.

CONCLUSIONS: Rates and costs of heroin and prescription opioid overdose related admissions in the United States increased substantially from 2001 to 2012. The rapid and ongoing rise in both numbers of hospitalizations and their costs suggests that the burden of POD may threaten the infrastructure and finances of US hospitals.

RATIONALE: Opioid abuse is increasing, but its impact on critical care resources in the United States is unknown.

OBJECTIVES: We hypothesized that there would be a rising need for critical care among opioid-associated overdoses in the United States.

METHODS: We analyzed all adult admissions, using a retrospective cohort study from 162 hospitals in 44 states, discharged between January 1, 2009, and September 31, 2015 to describe the incidence of intensive care unit (ICU) admissions for opioid overdose during this time. Admissions were identified using the Clinical Database/Resource Manager of Vizient, the successor to the University Health System Consortium.

RESULTS: Our primary outcome was opioid-associated overdose admissions to the ICU. The outcome was defined on the basis of previously validated ICD-9 codes. Our secondary outcomes were in-hospital death and markers of ICU resources. The final cohort included 22,783,628 admissions; 4,145,068 required ICU care. There were 52.4 ICU admissions for overdose per 10,000 ICU admissions over the entire study (95% confidence interval [CI], 51.8-53.0 per 10,000 ICU admissions). During this time period, opioid overdose admissions requiring intensive care increased 34%, from 44 per 10,000 (95% CI, 43-46 per 10,000) to 59 per 10,000 ICU admissions (95% CI, 57-61 per 10,000; P < 0.0001). The mortality rate of patients with ICU admissions with overdoses averaged 7% (95% CI, 7.0-7.6%) but increased to 10% in 2015 (95% CI, 8.8-10.8%).

CONCLUSIONS: The number of deaths of ICU patients with opioid overdoses increased substantially in the 7 years of our study, reflecting increases in both the incidence and mortality of this condition. Our findings raise the need for a national approach to developing safe strategies to care for patients with overdose in the ICU, to providing coordinated resources in the hospital for patients and families, and to helping survivors maintain sobriety on discharge.

IMPORTANCE: A physician's prior experience caring for a patient may be associated with patient outcomes and care patterns during and after hospitalization.

OBJECTIVE: To examine differences in the use of health care resources and outcomes among hospitalized patients cared for by hospitalists, their own primary care physicians (PCPs), or other generalists.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective study analyzed admissions for the 20 most common medical diagnoses among elderly fee-for-service Medicare patients from January 1 through December 31, 2013. Patients had at least 1 previous encounter with an outpatient clinician within the 365 days before admission, and diagnoses were restricted to the 20 most common diagnosis related groups. Data were collected from Medicare Parts A and B claims data, and outcomes were analyzed from January 1, 2013, through January 31, 2014.

EXPOSURES: Physician types included hospitalists, PCPs (ie, the physicians who provided a plurality of ambulatory visits in the year preceding admission), or generalists (not the patients' PCPs).

MAIN OUTCOMES AND MEASURES: Number of in-hospital specialist consultations, length of stay, discharge site, all-cause 7- and 30-day readmission rates, and 30-day mortality.

RESULTS: A total of 560 651 admissions were analyzed (41.9% men and 59.1% women; mean [SD] age, 80 [8] years). Patients' physicians were hospitalists in 59.7% of admissions; PCPs, in 14.2%; and other generalists, in 26.1%. Primary care physicians used consultations 3% more (relative risk, 1.03; 95% CI, 1.02-1.05) and other generalists used consultations 6% more (relative risk, 1.06; 95% CI, 1.05-1.07) than hospitalists. Lengths of stay were 12% longer among patients cared for by PCPs (adjusted incidence rate ratio, 1.12; 95% CI, 1.11-1.13) and 6% longer among those cared for by other generalists (adjusted incidence rate ratio, 1.06; 95% CI, 1.05-1.07) compared with patients cared for by hospitalists. However, PCPs were more likely to discharge patients home (adjusted odds ratio [AOR], 1.14; 95% CI, 1.11-1.17), whereas other generalists were less likely to do so (AOR, 0.94; 95% CI, 0.92-0.96). Relative to hospitalists, patients cared for by PCPs had similar readmission rates at 7 days (AOR, 0.98; 95% CI, 0.96-1.01) and 30 days (AOR, 1.02; 95% CI, 0.99-1.04), whereas other generalists' readmission rates were greater than hospitalists' rates at 7 (AOR, 1.05; 95% CI, 1.02-1.07) and 30 (AOR, 1.04; 95% CI, 1.03-1.06) days. Patients cared for by PCPs had lower 30-day mortality than patients of hospitalists (AOR, 0.94; 95% CI, 0.91-0.97), whereas the mortality rate of patients of other generalists was higher (AOR, 1.09; 95% CI, 1.07-1.12).

CONCLUSIONS AND RELEVANCE: A PCP's prior experience with a patient may be associated with inpatient use of resources and patient outcomes. Patients cared for by their own PCP had slightly longer lengths of stay and were more likely to be discharged home but also were less likely to die within 30 days compared with those cared for by hospitalists or other generalists.

PURPOSE: The objective of this study was to quantify the rate at which newly initiated antipsychotic therapy is continued on discharge from the intensive care unit (ICU) and describe risk factors for continuation post-ICU discharge.

MATERIALS AND METHODS: This is a retrospective cohort study of all patients receiving an antipsychotic in the ICUs of a large academic medical center from January 1, 2005, to October 31, 2011. Medical record review was conducted to ascertain whether a patient was newly started on antipsychotic therapy and whether therapy was continued post-ICU discharge.

RESULTS: A total of 39,248 ICU admissions over the 7-year period were evaluated. Of these, 4468 (11%) were exposed to antipsychotic therapy, of which 3119 (8%) were newly initiated. In the newly initiated cohort, 642 (21%) were continued on therapy on discharge from the hospital. Type of drug (use of quetiapine vs no use of quetiapine: odds ratio, 3.2; 95% confidence interval, 2.5-4.0; P < .0001 and use of olanzapine: odds ratio, 2.4, 95% confidence interval, 2.0-3.1; P ≤ .0001) was a significant risk factor for continuing antipsychotics on discharge despite adjustment for clinical factors.

CONCLUSIONS: Antipsychotic use is common in the ICU setting, and a significant number of newly initiated patients have therapy continued upon discharge from the hospital.

BACKGROUND: Dyspnea (breathing discomfort) can be as powerfully aversive as pain, yet is not routinely assessed and documented in the clinical environment. Routine identification and documentation of dyspnea is the first step to improved symptom management and it may also identify patients at risk of negative clinical outcomes.

OBJECTIVE: To estimate the prevalence of dyspnea and of dyspnea-associated risk among hospitalized patients.

DESIGN: Two pilot prospective cohort studies.

SETTING: Single academic medical center.

PATIENTS: Consecutive patients admitted to four inpatient units: cardiology, hematology/oncology, medicine, and bariatric surgery.

MEASUREMENTS: In Study 1, nurses documented current and recent patient-reported dyspnea at the time of the Initial Patient Assessment in 581 inpatients. In Study 2, nurses documented current dyspnea at least once every nursing shift in 367 patients. We describe the prevalence of burdensome dyspnea, and compare it to pain. We also compared dyspnea ratings with a composite of adverse outcomes: 1) receipt of care from the hospital's rapid response system, 2) transfer to the intensive care unit, or 3) death in hospital. We defined burdensome dyspnea as a rating of 4 or more on a 10-point scale.

RESULTS: Prevalence of burdensome current dyspnea upon admission (Study 1) was 13% (77 of 581, 95% CI 11%-16%). Prevalence of burdensome dyspnea at some time during the hospitalization (Study 2) was 16% (57 of 367, 95% CI 12%-20%). Dyspnea was associated with higher odds of a negative outcome.

CONCLUSIONS: In two pilot studies, we identified a significant symptom burden of dyspnea in hospitalized patients. Patients reporting dyspnea may benefit from a more careful focus on symptom management and may represent a population at greater risk for negative outcomes.

OBJECTIVES: To investigate patterns and predictors of use of antipsychotics in hospitalized adults.

DESIGN: Retrospective cohort study.

SETTING: Academic medical center.

PARTICIPANTS: Individuals aged 18 and older hospitalized from August 2012 to August 2013, excluding those admitted to obstetrics and gynecology or psychiatry or with a psychotic disorder.

MEASUREMENTS: Use was ascertained from pharmacy charges. Potentially excessive dosing was defined using guidelines for long-term care facilities. A review of 100 records was performed to determine reasons for use.

RESULTS: The cohort included 17,775 admissions with a median age 64; individuals could have been admitted more than once during the study period. Antipsychotics were used in 9%, 55% of which were initiations. The most common reasons for initiation were delirium (53%) and probable delirium (12%). Potentially excessive dosing occurred in 16% of admissions exposed to an antipsychotic. Of admissions with antipsychotic initiation, 26% were discharged on these medications. Characteristics associated with initiation included age 75 and older (relative risk (RR) = 1.4, 95% confidence interval (CI) = 1.2-1.7), male sex (RR = 1.2, 95% CI = 1.1-1.4), black race (RR = 0.8, 95% CI = 0.6-0.96), delirium (RR = 4.8, 95% CI = 4.2-5.7), dementia (RR = 2.1, 95% CI = 1.7-2.6), admission to a medical service (RR = 1.2, 95% CI = 1.1-1.4), intensive care unit stay (RR = 2.1, 95% CI = 1.8-2.4), and mechanical ventilation (RR = 2.0, 95% CI = 1.7-2.4). In individuals who were initiated on an antipsychotic, characteristics associated with discharge on antipsychotics were age 75 and older (RR = 0.6, 95% CI = 0.4-0.7), discharge to any location other than home (RR = 2.5, 95% CI = 1.8-3.3), and class of in-hospital antipsychotic exposure (RR = 1.6, 95% CI = 1.1-2.3 for atypical vs typical; RR = 2.7, 95% CI = 1.9-3.8 for both vs typical).

CONCLUSION: Antipsychotic initiation and use were common during hospitalization, most often for delirium, and individuals were frequently discharged on these medications. Several predictors of use on discharge were identified, suggesting potential targets for decision support tools that would be used to prompt consideration of ongoing necessity.