Natural history of late discharges from a general medical ward

The Hidden Work of Urology Residents - A Cross-Sectional Study

Background: In a tertiary care hospital that caters to all kinds of patients in the clinical and emergency setting, consultation is an important service provided by the urology team. Profiling the spectrum of urologic disease encountered by trainees will assist in the planning of residency curricula and is bound to improve patient outcome for procedural education.

Methods: All urologic consultation requests received over a period of three months (November 22, 2019, to February 22, 2020) were identified and recorded in a prospectively maintained consult log. Information collected for each encounter included the time, date, reason for consult, primary service and diagnosis along with the final urologic diagnosis, any urologic intervention, and basic patient demographics (gender and age).

Results: Over three months, a total of 568 consult requests were reviewed. Of the patients consulted for, 74% were males; the mean age was 58.45 years (SD+/-19.5 years). The most common service seeking urology consult was the Emergency Room (n=240, 42.25%). The most common reason for consultation was hematuria (n=103, 18.13%) followed by obstructive uropathy (n=98, 17.25%). The majority (n=147, 26%) of the calls were placed between mid-day and 4 pm. Of the total, 26% required immediate attention. Urologic intervention was required in 226 (39.8%). The number of consults seen by junior team members was 478 (84.14%).

Conclusion: Hematuria and obstructive uropathy are the most common reasons for urologic consultation requests. Nearly two-thirds of the consults either required immediate attention or intervention. Most of the consults were seen by junior residents, who required elaborate training to address these common issues independently. We believe that our results will be helpful in developing a curriculum for training junior residents.

Characteristics, Burden, and Necessity of Inpatient Consults for Academic and Private Practice Urologists

OBJECTIVE

To compare differences in the characteristics and outcomes of inpatient consults between academic and private practice urologists.

MATERIALS AND METHODS

We performed a retrospective review of urology consults at a large tertiary-care hospital from June 1st, 2017 to June 30th, 2018. Patient demographics, timing of consult, location of consult, reasons for consult, requesting physicians, and procedures performed were analyzed and compared.

RESULTS

A total of 613 consults were identified. The most common consults were for a Foley catheter/suprapubic tube (16%), urinary retention (15%), kidney/bladder stones (11%), and hematuria (11%). Seventy-seven percent of the consults were seen in the day time and 79% were seen on the weekdays. One hundred and ten (18%) consults resulted in an operative intervention during the same admission. The others required a Foley catheter placement or suprapubic exchange (17%), bedside procedure (9%), or interventional radiology procedure (4%). The remaining 319 consults (52%) required no intervention and were considered potentially unnecessary. There were no differences in the timing of the consults and the need for intervention between academic and private practice urologists (P = .20). Only 37% of patients followed up as an outpatient. These potentially unnecessary consults resulted an annual loss of 265.8 hours for the urologists and $44,376.09 in excess health care costs.

CONCLUSION

Over half of inpatient urologic consultations required no urologic intervention and therefore represented potential overuse of urgent inpatient specialty care. This may contribute towards the growing epidemic of burnout in urology. Further work needs to be done to educate other hospital services and nurses to minimize these unnecessary consults.

Understanding predictors of prolonged hospitalizations among general medicine patients: A guide and preliminary analysis

Targeting patients with prolonged hospitalizations may represent an effective strategy for reducing average hospital length of stay (LOS). We sought to characterize predictors of prolonged hospitalizations among general medicine patients to guide future improvement efforts. We conducted a retrospective cohort study using administrative data of general medicine patients discharged from inpatient status from our academic medical center between 2012 and 2014. Multivariable logistic regression was performed to assess the association between sociodemographic and clinical variables with prolonged LOS, defined as >21 days. Of 18,363 discharges, 416 (2.3%) demonstrated prolonged LOS. Prolonged hospitalizations accounted for 18.6% of total inpatient days and contributed 0.8 days to an average LOS of 4.8 days during the study period. Prolonged hospitalizations were associated with younger age (odds ratio [OR]: 0.80 per 10-year increase in age, 95% confidence interval [CI]: 0.73-0.87) and Medicaid insurance (OR: 1.99, 95% CI: 1.29-3.05, REF = Medicare). Compared to patients without prolonged LOS, prolonged LOS patients were more likely to have methicillin-resistant Staphylococcus aureus septicemia (OR: 8.83, 95% CI: 1.72-45.36); require a palliative care consult (OR: 4.63, 95% CI: 2.86-7.49), ICU stay (OR: 6.66, 95% CI: 5.22-8.50), or surgery (OR: 5.04, 95% CI: 3.90-6.52); and be discharged to a post-acute-care facility (OR: 10.37, 95% CI: 6.92-15.56). Prolonged hospitalizations in a small proportion of patients were an important contributor to overall LOS and particularly affected Medicaid enrollees with complex hospital stays who were not discharged home. Further studies are needed to determine the reasons for discharge delays in this population.

Solutions to emergency department 'boarding' and crowding are underused and may need to be legislated

The practice of keeping admitted patients on stretchers in hospital emergency department hallways for hours or days, called "boarding," causes emergency department crowding and can be harmful to patients. Boarding increases patients' morbidity, lengths of hospital stay, and mortality. Strategies that optimize bed management reduce boarding by improving the efficiency of hospital patient flow, but these strategies are grossly underused. Convincing hospital leaders of the value of such solutions, and educating patients to advocate for such changes, may promote improvements. If these strategies do not work, legislation may be required to effect meaningful change.

Nonmedical factors associated with prolonged hospital length of stay in an urban homebound population

BACKGROUND

Prolonged length of stay (LOS) is a major concern for hospitalized populations at risk for adverse events. Homebound patients are at particular risk for long stays and may have unique discharge needs because of their commitment to be cared for at home despite poor functional status.

OBJECTIVE

The goal of this study was to describe factors contributing to long hospitalizations in the homebound population.

DESIGN

This retrospective observational pilot study included all 2007 discharges that occurred for patients at The Mount Sinai Hospital enrolled in the Mount Sinai Visiting Doctors Program.

MEASURES

Long-stay patients were defined as those having an LOS 2 standard deviations above the mean. Hospitalization days were defined as "nonmedical" when patients medically ready for discharge remained in the hospital. Patients discharged immediately after determination of medical readiness were characterized as "medical stay" cases. The University HealthSystems Consortium Database was used to calculate expected LOS and the LOS ratio. Chart reviews were performed to describe long-stay cases as nonmedical or medical.

RESULTS

The average LOS for 479 discharges was 7.84 days, with a mean LOS Ratio of 1.23. Seventeen cases were determined to be long stays. Eight of these cases (47%) were defined as nonmedical stays. These accounted for 136 days of hospitalization and 32% of total long-stay days. The most common reason for a nonmedical stay was nursing facility placement delay.

CONCLUSIONS

Nonmedical factors accounted for nearly one-third of all long-stay days in the hospitalized homebound population. Increased interdisciplinary collaboration may help address homebound patient LOS.