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Item A decade post-HITECH: Critical access hospitals have electronic health records but struggle to keep up with other advanced functions(Oxford University Press, 2021) Apathy, Nate C.; Holmgren, A. Jay; Adler-Milstein, Julia; Health Policy and Management, Richard M. Fairbanks School of Public HealthObjective: Despite broad electronic health record (EHR) adoption in U.S. hospitals, there is concern that an "advanced use" digital divide exists between critical access hospitals (CAHs) and non-CAHs. We measured EHR adoption and advanced use over time to analyzed changes in the divide. Materials and methods: We used 2008 to 2018 American Hospital Association Information Technology survey data to update national EHR adoption statistics. We stratified EHR adoption by CAH status and measured advanced use for both patient engagement (PE) and clinical data analytics (CDA) domains. We used a linear probability regression for each domain with year-CAH interactions to measure temporal changes in the relationship between CAH status and advanced use. Results: In 2018, 98.3% of hospitals had adopted EHRs; there were no differences by CAH status. A total of 58.7% and 55.6% of hospitals adopted advanced PE and CDA functions, respectively. In both domains, CAHs were less likely to be advanced users: 46.6% demonstrated advanced use for PE and 32.0% for CDA. Since 2015, the advanced use divide has persisted for PE and widened for CDA. Discussion: EHR adoption among hospitals is essentially ubiquitous; however, CAHs still lag behind in advanced use functions critical to improving care quality. This may be rooted in different advanced use needs among CAH patients and lack of access to technical expertise. Conclusions: The advanced use divide prevents CAH patients from benefitting from a fully digitized healthcare system. To close the widening gap in CDA, policymakers should consider partnering with vendors to develop implementation guides and standards for functions like dashboards and high-risk patient identification algorithms to better support CAH adoption.Item A study of error reporting by nurses: the significant impact of nursing team dynamics(Sage, 2023) Thompson Munn, Lindsay; Lynn, Mary R.; Knafl, George J.; Schade Willis, Tina; Jones, Cheryl B.; Pediatrics, School of MedicineBackground: Error reporting is crucial for organisational learning and improving patient safety in hospitals, yet errors are significantly underreported. Aims: The aim of this study was to understand how the nursing team dynamics of leader inclusiveness, safety climate and psychological safety affected the willingness of hospital nurses to report errors. Methods: The study was a cross-sectional design. Self-administered surveys were used to collect data from nurses and nurse managers. Data were analysed using linear mixed models. Bootstrap confidence intervals with bias correction were used for mediation analysis. Results: Leader inclusiveness, safety climate and psychological safety significantly affected willingness to report errors. Psychological safety mediated the relationship between safety climate and error reporting as well as the relationship between leader inclusiveness and error reporting. Conclusion: The findings of the study emphasise the importance of nursing team dynamics to error reporting and suggest that psychological safety is especially important to error reporting.Item African-American Hospitals and Health Care in Early Twentieth Century Indianapolis, Indiana, 1894-1917(2016-05) Erickson, Norma B.; Labode, Modupe Gloria; Schneider, William H.; Barrows, Robert G.At the end of the nineteenth century, the African-American population of Indianapolis increased, triggering a need for health care for the new emigrants from the South. Within the black population, some individuals pursued medical degrees to become physicians. At the same time, advances in medical treatment—especially surgical operations—shifted the most common site of care from patients’ homes to hospitals. Professionally trained nurses, mostly white, began to replace family members or untrained African-American nurses who previously delivered care to Black patients. Barriers of racial segregation kept both the Black doctors and Black nurses from practicing in the municipal City Hospital in Indianapolis. To remedy this problem, the city's African-American leaders undertook establishing healthcare institutions with nurse training schools during the first few years of the twentieth century. This thesis argues that the healthcare institution-building that occurred in the early twentieth century offered opportunities for the practice of self-help in the Black community. The institutions also created a bridge for Black-white relations because the Black hospitals attracted the support of prominent white leaders. Good health and health care for the sick or injured were necessary to achieve racial uplift, and healthcare consumption became an indicator of social status and economic success. Racially segregated institutions afforded doctors and nurses a chance to increase their expertise and prove they were capable of functioning in the public hospital system. After a decade of working in separate institutions, the Black community prepared to push for full access to the city's tax-supported City Hospital as a civil right.Item Association of a Positive Drug Screening for Cannabis With Mortality and Hospital Visits Among Veterans Affairs Enrollees Prescribed Opioids(American Medical Association, 2022-12-01) Keyhani, Salomeh; Leonard, Samuel; Byers, Amy L.; Zaman, Tauheed; Krebs, Erin; Austin, Peter C.; Moss-Vazquez, Tristan; Austin, Charles; Sandbrink, Friedhelm; Bravata, Dawn M.; Medicine, School of MedicineImportance: Cannabis has been proposed as a therapeutic with potential opioid-sparing properties in chronic pain, and its use could theoretically be associated with decreased amounts of opioids used and decreased risk of mortality among individuals prescribed opioids. Objective: To examine the risks associated with cannabis use among adults prescribed opioid analgesic medications. Design, setting, and participants: This cohort study was conducted among individuals aged 18 years and older who had urine drug screening in 2014 to 2019 and received any prescription opioid in the prior 90 days or long-term opioid therapy (LTOT), defined as more than 84 days of the prior 90 days, through the Veterans Affairs health system. Data were analyzed from November 2020 through March 2022. Exposures: Biologically verified cannabis use from a urine drug screen. Main outcomes and measures: The main outcomes were 90-day and 180-day all-cause mortality. A composite outcome of all-cause emergency department (ED) visits, all-cause hospitalization, or all-cause mortality was a secondary outcome. Weights based on the propensity score were used to reduce confounding, and hazard ratios [HRs] were estimated using Cox proportional hazards regression models. Analyses were conducted among the overall sample of patients who received any prescription opioid in the prior 90 days and were repeated among those who received LTOT. Analyses were repeated among adults aged 65 years and older. Results: Among 297 620 adults treated with opioids, 30 514 individuals used cannabis (mean [SE] age, 57.8 [10.5] years; 28 784 [94.3%] men) and 267 106 adults did not (mean [SE] age, 62.3 [12.3] years; P < .001; 247 684 [92.7%] men; P < .001). Among all patients, cannabis use was not associated with increased all-cause mortality at 90 days (HR, 1.07; 95% CI, 0.92-1.22) or 180 days (HR, 1.00; 95% CI, 0.90-1.10) but was associated with an increased hazard of the composite outcome at 90 days (HR, 1.05; 95% CI, 1.01-1.07) and 180 days (HR, 1.04; 95% CI, 1.01-1.06). Among 181 096 adults receiving LTOT, cannabis use was not associated with increased risk of all-cause mortality at 90 or 180 days but was associated with an increased hazard of the composite outcome at 90 days (HR, 1.05; 95% CI, 1.02-1.09) and 180 days (HR, 1.05; 95% CI, 1.02-1.09). Among 77 791 adults aged 65 years and older receiving LTOT, cannabis use was associated with increased 90-day mortality (HR, 1.55; 95% CI, 1.17-2.04). Conclusions and relevance: This study found that cannabis use among adults receiving opioid analgesic medications was not associated with any change in mortality risk but was associated with a small increased risk of adverse outcomes and that short-term risks were higher among older adults receiving LTOT.Item A Case Study of Safe and Cost-Effective Hospital HVAC Strategies(2022-08-02) Caesar, Jeffrey; Ray, Matthew Veto; Koo, Dan; Dalir, HamidThe pressures of healthcare facilities to keep patients safe while also maintaining financial viability have been felt in recent years amongst industry leaders. The impacts COVID has had on patient safety and planning has in any way fast-tracked patient safety progress, but certainly at a financial cost. As hospital leaders and facility leaders attempt to grapple with these realities, a facility's operating strategy that addresses both safety and cost should be employed. The below study aims to solve two issues facing hospital facility leadership in regards to the facilities’ HVAC system. The first issue is how to decrease energy consumption and operating expenses in light of industry pressures to improve the financial outlook and secondly, how to increase patient safety as a direct result of COVID-19 realities. Increasing safety and ultimately flexibility can many times increase costs, so utilizing the most appropriate and tested techniques that follow patient safety protocols will be necessary. The importance of this study cannot be understated. As with any healthcare system, improving patient outcomes are at the heart of the industry and especially in light of our recent pandemic. The fundamental question as to how facilities can keep patients safer while simultaneously reducing energy consumption is a tough question to answer, but manageable due to both recent industry experience and up-to-date research on the topic. The methodology will be to conduct a straightforward cost benefit analysis that takes into account both patient safety and energy consumption. The first step will be to gather baseline data for Lutheran Hospital’s HVAC system to gauge current system performance vs. benchmarked performance. Next, the data will inform us as to what strategies to implement to both curb costs and increase patient safety. The third step will be to implement those strategies where possible and measure their benefits. Lastly, a conclusion will be made as to what long-term solutions will be most useful to both this hospital and the other hospitals within Lutheran Health Network.Item The conference effect: National surgery meetings are associated with increased mortality at trauma centers without American College of Surgeons verification(PLOS, 2019-03-26) Jenkins, Peter C.; Painter, Scott; Bell, Teresa M.; Kline, Jeffrey A.; Zarzaur, Ben L.; Surgery, School of MedicineBACKGROUND: Thousands of physicians attend scientific conferences each year. While recent data indicate that variation in staffing during such meetings impacts survival of non-surgical patients, the association between treatment during conferences and outcomes of a surgical population remain unknown. The purpose of this study was to examine mortality resulting from traumatic injuries and the influence of hospital admission during national surgery meetings. STUDY DESIGN: Retrospective analysis of in-hospital mortality using data from the Trauma Quality Improvement Program (2010-2011). Identified patients admitted during four annual meetings and compared their mortality with that of patients admitted during non-conference periods. Analysis included 155 hospitals with 12,256 patients admitted on 42 conference days and 82,399 patients admitted on 270 non-conference days. Multivariate analysis performed separately for hospitals with different levels of trauma center verification by state and American College of Surgeons (ACS) criteria. RESULTS: Patient characteristics were similar between meeting and non-meeting dates. At ACS level I and level II trauma centers during conference versus non-conference dates, adjusted mortality was not significantly different. However, adjusted mortality increased significantly for patients admitted to trauma centers that lacked ACS trauma verification during conferences versus non-conference days (OR 1.2, p = 0.008), particularly for patients with penetrating injuries, whose mortality rose from 11.6% to 15.9% (p = 0.006). CONCLUSIONS: Trauma mortality increased during surgery conferences compared to non-conference dates for patients admitted to hospitals that lacked ACS trauma level verification. The mortality difference at those hospitals was greatest for patients who presented with penetrating injuries.Item Decision fatigue in hospital medicine: A scoping review(The Society for Hospital Medicine, 2024-04) Jones, Sarah; Perry, Kelsey; Stumpff, Julia C.; Kruer, Rachel; Czosnowski, Lauren; Kara, AreebaBACKGROUND: Decision fatigue describes the erosion of decision-making capacity as a consequence of the repeated acts of decision making. The phenomenon has been detected in ambulatory settings with higher rates of inappropriate antimicrobial and opiate prescribing and lower rates of cancer screening associated with appointments that occur later in the day. As hospital medicine is acknowledged to be a cognitively intense specialty, we decided to explore decision fatigue in hospital medicine. METHODS: As a relatively unexplored concept, we undertook a scoping review to understand what is known about decision fatigue in hospital medicine. All studies including healthcare workers in acute care settings and exploring the concepts of decision fatigue, cognitive burden and/or fatigue were included. Conceptually related studies of sleep deprivation, shift work, Circadian disruption, and excessive workloads with actual or theoretical paths of causality related to patient outcomes were also included. RESULTS: Our preliminary search revealed fifteen studies that met our inclusion criteria. No study specifically included hospitalists. Most studies described the concept among nurses, residents, and/or emergency department physicians. The outcomes studied were diverse and included self reported perceptions (e.g. perceived impact on patient care) and validated scales to measure fatigue and psychomotor performance. Fewer studies investigated clinical decisions such as the use of consultations, imaging and disposition decisions through the emergency department. Mitigating circumstances such as age, experience, responsibilities outside the hospital (e.g. having children) were infrequently described. CONCLUSIONS: While hospital medicine's fast pace, multitasking, fragmentation between clinicians and interruptions make it susceptible to decision fatigue, the concept remains under-explored in hospital medicine. The lack of consistent terminology complicates the evaluation of a phenomenon which ultimately is the culmination of individual, patient, work system and work environment factors. There is a need to detect and defuse the impact of decision fatigue in hospital medicine.Item Defining safety net hospitals in the health services research literature: a systematic review and critical appraisal(BMC, 2021-03-25) Hefner, Jennifer L.; Hogan, Tory Harper; Opoku-Agyeman, William; Menachemi, Nir; Health Policy and Management, School of Public HealthBackground: The aim of this study was to identify the range of ways that safety net hospitals (SNHs) have been empirically operationalized in the literature and determine the extent to which patterns could be identified in the use of empirical definitions of SNHs. Methods: We conducted a PRISMA guided systematic review of studies published between 2009 and 2018 and analyzed 22 articles that met the inclusion criteria of hospital-level analyses with a clear SNH definition. Results: Eleven unique SNH definitions were identified, and there were no obvious patterns in the use of a definition category (Medicaid caseload, DSH payment status, uncompensated care, facility characteristics, patient care mix) by the journal type where the article appeared, dataset used, or the year of publication. Conclusions: Overall, there is broad variability in the conceptualization of, and variables used to define, SNHs. Our work advances the field toward the development of standards in measuring, operationalizing, and conceptualizing SNHs across research and policy questions.Item An educational video improves physician knowledge of a public health care law that affects patient care during hospital clinical practice(Sage, 2021-05-31) Comer, Amber R.; Salven, James; Torke, Alexia; Medicine, School of MedicineWhen public health laws are passed that affect clinical practice within hospitals, it is important to educate physicians about best practices in implementing these laws into routine patient care in hospitals. An educational video was developed to inform physicians about a new state public health care law. This study sought to determine whether an educational video about a new state public health care law improves physicians' knowledge of the law and how to implement the law during clinical practice. A total of n=33 internal medicine physicians participated in this study. This study found that an educational video was successful in increasing physician knowledge about a new public health care law that affects clinical practice. The utilization of validated educational videos may provide a useful resource when attempting to provide education about new public health laws that effect the provision of medical care.Item Effects of Implementation of a Supervised Walking Program in Veterans Affairs Hospitals : A Stepped-Wedge, Cluster Randomized Trial(American College of Physicians, 2023) Hastings, Susan N.; Stechuchak, Karen M.; Choate, Ashley; Van Houtven, Courtney Harold; Allen, Kelli D.; Wang, Virginia; Colón-Emeric, Cathleen; Jackson, George L.; Damush, Teresa M.; Meyer, Cassie; Kappler, Caitlin B.; Hoenig, Helen; Sperber, Nina; Coffman, Cynthia J.; Medicine, School of MedicineBackground: In trials, hospital walking programs have been shown to improve functional ability after discharge, but little evidence exists about their effectiveness under routine practice conditions. Objective: To evaluate the effect of implementation of a supervised walking program known as STRIDE (AssiSTed EaRly MobIlity for HospitalizeD VEterans) on discharge to a skilled-nursing facility (SNF), length of stay (LOS), and inpatient falls. Design: Stepped-wedge, cluster randomized trial. (ClinicalTrials.gov: NCT03300336). Setting: 8 Veterans Affairs hospitals from 20 August 2017 to 19 August 2019. Patients: Analyses included hospitalizations involving patients aged 60 years or older who were community dwelling and admitted for 2 or more days to a participating medicine ward. Intervention: Hospitals were randomly assigned in 2 stratified blocks to a launch date for STRIDE. All hospitals received implementation support according to the Replicating Effective Programs framework. Measurements: The prespecified primary outcomes were discharge to a SNF and hospital LOS, and having 1 or more inpatient falls was exploratory. Generalized linear mixed models were fit to account for clustering of patients within hospitals and included patient-level covariates. Results: Patients in pre-STRIDE time periods (n = 6722) were similar to post-STRIDE time periods (n = 6141). The proportion of patients with any documented walk during a potentially eligible hospitalization ranged from 0.6% to 22.7% per hospital. The estimated rates of discharge to a SNF were 13% pre-STRIDE and 8% post-STRIDE. In adjusted models, odds of discharge to a SNF were lower among eligible patients hospitalized in post-STRIDE time periods (odds ratio [OR], 0.6 [95% CI, 0.5 to 0.8]) compared with pre-STRIDE. Findings were robust to sensitivity analyses. There were no differences in LOS (rate ratio, 1.0 [CI, 0.9 to 1.1]) or having an inpatient fall (OR, 0.8 [CI, 0.5 to 1.1]). Limitation: Direct program reach was low. Conclusion: Although the reach was limited and variable, hospitalizations occurring during the STRIDE hospital walking program implementation period had lower odds of discharge to a SNF, with no change in hospital LOS or inpatient falls.