Traditional hospital wards are not specifically designed as effective clinical microsystems. The feasibility and sustainability of doing so are unclear, as are the possible outcomes. To reorganize a traditional hospital ward with the traits of an effective clinical microsystem, we designed it to have 4 specific features: (1) unit-based teams, (2) structured interdisciplinary bedside rounds, (3) unit-level performance reporting, and (4) unit-level nurse and physician coleadership. We called this type of unit an accountable care unit (ACU). In this narrative article, we describe our experience implementing each feature of the ACU. Our aim was to introduce a progressive approach to hospital care and training.

/pdf/reorganizing-a-hospital-ward-as-an-accountable-care-unit-2fldxov2pc.pdf

Reorganizing a hospital ward as an accountable care unit

Background Telemedicine use is increasing in many specialties, but its impact on clinical outcomes in infectious diseases has not been systematically reviewed. We reviewed the current evidence for clinical effectiveness of telemedicine infectious diseases consultations, including outcomes of mortality, hospital readmission, antimicrobial use, cost, length of stay, adherence, and patient satisfaction. Methods We queried Ovid MEDLINE 1946-, Embase.com 1947-, Scopus 1823-, Cochrane Database of Systematic Reviews (CDSR), Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov 1997- through August 5, 2019, for studies looking at clinical outcomes of infectious diseases in the setting of telemedicine use. We did not restrict by language or year of publication. Clinical outcomes searched included 30-day all-cause mortality, 30-day readmissions, patient compliance/adherence, patient satisfaction, cost or cost-effectiveness, length of hospital stay, antimicrobial use, and antimicrobial stewardship. Bias was assessed using standard methodologies. PROSPERO CRD42018105225. Results From a search pool of 1154 studies, only 18 involved telemedicine infectious diseases consultation and our selected clinical outcomes. The outcomes tracked were heterogeneous, precluding meta-analysis, and the majority of studies were of poor quality. Overall, clinical outcomes with telemedicine infectious diseases consultation seem comparable to in-person infectious diseases consultation. Conclusions Although in widespread use, the clinical effectiveness of telemedicine infectious diseases consultations has yet to be sufficiently studied. Further studies, or publication of previously collected and available data, are warranted to verify the cost-effectiveness of this widespread practice. Systematic review registration PROSPERO CRD42018105225.

/pdf/telemedicine-infectious-diseases-consultations-and-clinical-29e6s20133.pdf

Telemedicine Infectious Diseases Consultations and Clinical Outcomes: A Systematic Review

Implementation of a unique in-person pediatric antimicrobial stewardship program was associated with a significant increase in infectious disease consultations at a quaternary care children's hospital. This study demonstrates that antimicrobial stewardship programs support, and do not compete with, infectious disease programs.

/pdf/a-handshake-from-antimicrobial-stewardship-opens-doors-for-134ac8q4ax.pdf

A Handshake From Antimicrobial Stewardship Opens Doors for Infectious Disease Consultations.

In our prior work, we conducted a field trial of the mobile application DocCHIRP (Crowdsourcing Health Information Retrieval Protocol for Doctors), designed to help clinicians problem-solve at the point of care by crowdsourcing their peers. Here, we present the results of our post-trial survey that investigated the impressions of participating clinicians regarding the use of medical crowdsourcing and to identify factors influencing adoption of the technology. In all, 72 valid surveys were received from 85 registered users (85% response rate). The majority of clinicians (>80%) felt crowdsourcing would be useful to diagnose unusual cases, facilitate patient referrals, and problem-solve at the point of care. Perceived barriers to adoption included interruptions in workflow and the reluctance to publicly expose knowledge gaps. While considered a useful alternative to existing methods, future studies are needed to investigate whether the approach and application can be modified to effectively address these bar...

https://journals.sagepub.com/doi/pdf/10.1177/1460458214545896

Provider impressions of the use of a mobile crowdsourcing app in medical practice.

Although the use of electronic consultations (e-consults) in the outpatient setting is commonplace, there is little evidence of their use in the inpatient setting. Often, the only choice hospitalists have is between requesting a time-consuming in-person consultation or requesting an informal, undocumented "curbside" consultation. For a new, remote hospital in our healthcare system, we developed an e-consult protocol that can be used to address simple consultation questions. In the first year of the program, 143 e-consults occurred; the top 5 consultants were infectious disease, hematology, endocrinology, nephrology, and cardiology. Over the first 4 months, no safety issues were identified in chart review audits; to date, no safety issues have been identified through the hospital's incident reporting system. In surveys, hospitalists were universally pleased with the quality of e-consult recommendations, though only 43% of consultantsagreed. With appropriate care for patient selection, e-consults can be used to safely and efficiently provide subspecialty expertise to a remote inpatient site Journal of Hospital Medicine 2017;12:332-334.

/pdf/it-all-just-clicks-development-of-an-inpatient-e-consult-3y0il5td9p.pdf

It All Just Clicks: Development of an Inpatient E-Consult Program.

BACKGROUND:

Curbside consultations are commonly requested during the care of hospitalized patients, but physicians perceive that the recommendations provided may be based on inaccurate or incomplete information.



OBJECTIVE:

To compare the accuracy and completeness of the information received from providers requesting a curbside consultation of hospitalists with that obtained in a formal consultation on the same patients, and to examine whether the recommendations offered in the 2 consultations differed.



DESIGN:

Prospective cohort.



SETTING:

University-affiliated, urban safety net hospital.



MAIN OUTCOME MEASURES:

Proportion of curbside consultations with inaccurate or incomplete information; frequency with which recommendations in the formal consultation differed from those in the curbside consultation.



RESULTS:

Curbside consultations were requested for 50 patients, 47 of which were also evaluated in a formal consultation performed on the same day by a hospitalist other than the one performing the curbside consultation. Based on information collected in the formal consultation, information was either inaccurate or incomplete in 24/47 (51%) of the curbside consultations. Management advice after formal consultation differed from that given in the curbside consultation for 28/47 patients (60%). When inaccurate or incomplete information was received, the advice provided in the formal versus the curbside consultation differed in 22/24 patients (92%, P < 0.0001).



CONCLUSIONS:

Information presented during inpatient curbside consultations of hospitalists is often inaccurate or incomplete, and this often results in inaccurate management advice. Journal of Hospital Medicine 2013. © 2012 Society of Hospital Medicine

/pdf/prospective-comparison-of-curbside-versus-formal-zgibpihyr1.pdf

Prospective comparison of curbside versus formal consultations.

Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency. Hospital leaders have stated they expect hospitalists to comanage surgical patients, participate in observation units, and screen medical admissions, in addition to providing inpatient care for medical patients. We review how the hospitalists' role in acute inpatient care, surgical comanagement, short stay units, chest pain units, and active bed management has improved throughput and patient flow.

/pdf/evolving-practice-of-hospital-medicine-and-its-impact-on-cdehqnfd1p.pdf

Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies

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Prospective comparison of curbside versus formal consultations.

Evolving practice of hospital medicine and its impact on hospital throughput and efficiencies