Characteristics of short general internal medicine hospital stays: a multicentre cross-sectional study

Glucagon-like Peptide-1 Receptor Agonist Use in Hospital: A Multicentre Observational Study

BACKGROUND

Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are effective medications for type 2 diabetes mellitus (T2DM) and obesity, yet their uptake among individuals most likely to benefit has been slow.

METHODS

We conducted a cross-sectional analysis of medication exposure in adults hospitalized at 16 hospitals in Ontario, Canada, between 2015 and 2022. We estimated the proportions of those with T2DM, obesity, and cardiovascular disease. We identified the frequency of GLP-1RA use and conducted multivariable logistic regression to identify factors associated with their use.

RESULTS

Across 1,278,863 hospitalizations, 396,084 (31%) patients had T2DM and approximately 327,844 (26%) had obesity. GLP-1RA use (n=1,274) was low among those with a diagnosis of T2DM (0.3%) or obesity (0.7%), despite a high prevalence of cardiovascular disease (36%). In contrast, the use of diabetes medications lacking cardiovascular benefit was high during inpatient hospitalizations related to diabetes: 60% (n=236,612) received insulin and 14% (n=54,885) received a sulfonylurea. Apart from T2DM (odds ratio [OR]=29.6, 95% confidence interval [CI] 23.5 to 37.2), characteristics associated with greater odds of receiving a GLP-1RA were seen in those 50 to 70 years of age (OR=1.71, 95% CI 1.38 to 2.11) compared with those <50 years of age, glycated hemoglobin >9% (OR=1.83, 95% CI 1.36 to 2.47) compared with <6.5%, and highest income quintile (OR=1.73, 95% CI 1.45 to 2.07) compared with lowest income quintile.

CONCLUSION

Knowledge translation interventions are needed to address the low adoption of GLP-1RAs among hospitalized patients with T2DM and obesity, who are the most likely to benefit from this treatment.

A simple electronic medical record-based predictors of illness severity in sepsis (sepsis) score

OBJECTIVE

Current scores for predicting sepsis outcomes are limited by generalizability, complexity, and electronic medical record (EMR) integration. Here, we validate a simple EMR-based score for sepsis outcomes in a large multi-centre cohort.

DESIGN

A simple electronic medical record-based predictor of illness severity in sepsis (SEPSIS) score was developed (4 additive lab-based predictors) using a population-based retrospective cohort study.

SETTING

Internal medicine services across four academic teaching hospitals in Toronto, Canada from April 2010-March 2015 (primary cohort) and 2015-2019 (secondary cohort).

PATIENTS

We identified patients admitted with sepsis based upon receipt of antibiotics and positive cultures.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was in-hospital mortality and secondary outcomes were ICU admission at 72 hours, and hospital length of stay (LOS). We calculated the area under the receiver operating curve (AUROC) for the SEPSIS score, qSOFA, and NEWS2. We then evaluated the SEPSIS score in a secondary cohort (2015-2019) of hospitalized patients receiving antibiotics. Our primary cohort included 1,890 patients with a median age of 72 years (IQR: 56-83). 9% died during hospitalization, 18.6% were admitted to ICU, and mean LOS was 12.7 days (SD: 21.5). In the primary and secondary (2015-2019, 4811 patients) cohorts, the AUROCs of the SEPSIS score for predicting in-hospital mortality were 0.63 and 0.64 respectively, which were similar to NEWS2 (0.62 and 0.67) and qSOFA (0.62 and 0.68). AUROCs for predicting ICU admission at 72 hours, and length of stay > 14 days, were similar between scores, in the primary and secondary cohorts. All scores had comparable calibration for predicting mortality.

CONCLUSIONS

An EMR-based SEPSIS score shows a similar ability to predict important clinical outcomes compared with other validated scores (qSOFA and NEWS2). Because of the SEPSIS score's simplicity, it may prove a useful tool for clinical and research applications.

Potentially avoidable admissions to general internal medicine at an academic teaching hospital: an observational study

BACKGROUND

Identifying potentially avoidable admissions to Canadian hospitals is an important health system goal. With general internal medicine (GIM) accounting for 40% of hospital admissions, we sought to develop a method to identify potentially avoidable admissions and characterize patient, provider and health system factors.

METHODS

We conducted an observational study of GIM admissions at our institution from August 2019 to February 2020. We defined potentially avoidable admissions as admissions that could be managed in an appropriate and safe manner in the emergency department or ambulatory setting and asked staff physicians to screen admissions daily and flag candidates as potentially avoidable admissions. For each candidate, we prepared a case review and debriefed with members of the admitting team. We then reviewed each candidate with our research team, assigned an avoidability score (1 [low] to 4 [high]) and identified contributing factors for those with scores of 3 or more.

RESULTS

We screened 601 total admissions and staff physicians flagged 117 (19.5%) of these as candidate potential avoidable admissions. Consensus review identified 67 candidates as potentially avoidable admissions (11.1%, 95% confidence interval 8.8%-13.9%); these patients were younger (mean age 65 yr v. 72 yr), had fewer comorbidities (Canadian Institute for Health Information Case Mix Group+ 0.42 v. 1.14), had lower resource-intensity weighting scores (0.72 v. 1.50) and shorter hospital lengths of stay (29 h v. 105 h) (p < 0.01). Common factors included diagnostic and therapeutic uncertainty, perceived need for short-term monitoring, government directive of a 4-hour limit for admission decision-making and subspecialist request to admit.

INTERPRETATION

Our prospective method of screening, flagging and case review showed that 1 in 9 GIM admissions were potentially avoidable. Other institutions could consider adapting this methodology to ascertain their rate of potentially avoidable admissions and to understand contributing factors to inform improvement endeavours.

Effects of multimedia-based fall prevention education on the knowledge, attitudes, or behaviors of patients

OBJECTIVES

Patient safety is regarded as a critical quality monitoring indicator for medical institutions. The effects of a multimedia-based patient education intervention on knowledge, attitudes, and behaviors regarding fall prevention were observed.

METHODS

The study had a quasi-experimental research design and enrolled 140 participants. Seventy participants in the experimental group received multimedia-based patient education and a health education leaflet, while those in the control group received only the health education leaflet. A structured questionnaire was used for data collection at baseline, and a posttest was applied after the intervention.

RESULTS

The participants were predominantly treated in the gastroenterology department (45.7%), followed by the pulmonology department (33.6%). A total of 86.4% of patients had not experienced a fall within 3 months. After the intervention, the average scores for all variables in the experimental group were higher than those in the control group. The results indicate that attitudes, knowledge, and behaviors regarding fall prevention among patients in the pulmonology department were higher than those among patients in the gastroenterology department; the differences were statistically significant.

CONCLUSION

The individualized health education content was of substantial significance for patients with different disease backgrounds and facilitated changes in their knowledge, attitudes, and behaviors regarding falls.

RELEVANCE TO CLINICAL PRACTICE

Multimedia-based patient education influenced inpatients' knowledge, attitudes, and behaviors for preventing falls.

Modelling resource requirements and physician staffing to provide virtual urgent medical care for residents of long-term care homes: a cross-sectional study

BACKGROUND

The coronavirus disease 2019 (COVID-19) outbreak increases the importance of strategies to enhance urgent medical care delivery in long-term care (LTC) facilities that could potentially reduce transfers to emergency departments. The study objective was to model resource requirements to deliver virtual urgent medical care in LTC facilities.

METHODS

We used data from all general medicine inpatient admissions at 7 hospitals in the Greater Toronto Area, Ontario, Canada, over a 7.5-year period (Apr. 1, 2010, to Oct. 31, 2017) to estimate historical patterns of hospital resource use by LTC residents. We estimated an upper bound of potentially avoidable transfers by combining data on short admissions (≤ 72 h) with historical data on the proportion of transfers from LTC facilities for which patients were discharged from the emergency department without admission. Regression models were used to extrapolate future resource requirements, and queuing models were used to estimate physician staffing requirements to perform virtual assessments.

RESULTS

There were 235 375 admissions to general medicine wards, and residents of LTC facilities (age 16 yr or older) accounted for 9.3% (n = 21 948) of these admissions. Among the admissions of residents of LTC facilities, short admissions constituted 24.1% (n = 5297), and for 99.8% (n = 5284) of these admissions, the patient received laboratory testing, for 86.9% (n = 4604) the patient received plain radiography, for 41.5% (n = 2197) the patient received computed tomography and for 81.2% (n = 4300) the patient received intravenous medications. If all patients who have short admissions and are transferred from the emergency department were diverted to outpatient care, the average weekly demand for outpatient imaging per hospital would be 2.6 ultrasounds, 11.9 computed tomographic scans and 23.9 radiographs per week. The average daily volume of urgent medical virtual assessments would range from 2.0 to 5.8 per hospital. A single centralized virtual assessment centre staffed by 2 or 3 physicians would provide services similar in efficiency (measured by waiting time for physician assessment) to 7 separate centres staffed by 1 physician each.

INTERPRETATION

The provision of acute medical care to LTC residents at their facility would probably require rapid access to outpatient diagnostic imaging, within-facility access to laboratory services and intravenous medication and virtual consultations with physicians. The results of this study can inform efforts to deliver urgent medical care in LTC facilities in light of a potential surge in COVID-19 cases.

Appropriateness of peripherally inserted central catheter use among general medical inpatients: an observational study using routinely collected data

Background

Peripherally inserted central catheters (PICC) are among the most commonly used medical devices in hospital. This study sought to determine the appropriateness of inpatient PICC use in general medicine at five academic hospitals in Toronto, Ontario, Canada, based on the Michigan Appropriateness Guide for Intravenous Catheters (MAGIC).

Methods

This was a retrospective, cross-sectional study of general internal medicine patients discharged between 1 April 2010 and 31 March 2015 who received a PICC during hospitalisation. The primary outcomes were the proportions of appropriate and inappropriate inpatient PICC use based on MAGIC recommendations. Hospital administrative data and electronic clinical data were used to determine appropriateness of each PICC placement. Multivariable regression models were fit to explore patient predictors of inappropriate use.

Results

Among 3479 PICC placements, 1848 (53%, 95% CI 51% to 55%) were appropriate, 573 (16%, 95% CI 15% to 18%) were inappropriate and 1058 (30%, 95% CI 29% to 32%) were of uncertain appropriateness. The proportion of appropriate and inappropriate PICCs ranged from 44% to 61% (p<0.001) and 13% to 21% (p<0.001) across hospitals, respectively. The most common reasons for inappropriate PICC use were placement in patients with advanced chronic kidney disease (n=500, 14%) and use for fewer than 15 days in patients who are critically ill (n=53), which represented 14% of all PICC placements in the intensive care unit. Patients who were older, female, had a Charlson Comorbidity Index score greater than 0 and more severe illness based on the Laboratory-based Acute Physiology Score were more likely to receive an inappropriate PICC.

Conclusions

Clinical practice recommendations can be operationalised into measurable domains to estimate the appropriateness of PICC insertions using routinely collected hospital data. Inappropriate PICC use was common and varied substantially across hospitals in this study, suggesting that there are important opportunities to improve care.