Background: Post hospital discharge review during the transition from hospital to skilled nursing facility (SNF) is critical to avoid medication errors, improve patient outcomes and reduce hospital readmissions (1-3). Despite increased integration of electronic health records (EHR) across health entities, communication gaps and discharge-related medication errors still persist (2,4). These challenges can be more predominant [...]

Background: Post hospital discharge review during the transition from hospital to skilled nursing facility (SNF) is critical to avoid medication errors, improve patient outcomes and reduce hospital readmissions (1-3). Despite increased integration of electronic health records (EHR) across health entities, communication gaps and discharge-related medication errors still persist (2,4). These challenges can be more predominant [...]

Background: Many patients continue their post-acute care in settings such as skilled nursing facilities (SNFs). One in four hospitalized Medicare patients are discharged to SNFs. These patients are generally the elderly or require more care than patients discharged home, placing them at greater risk of clinical decline and rehospitalization. Moreover, 25% of patients discharged to [...]

Background: At our Level 1 trauma center, geriatric trauma (GT) patients are primarily managed by hospitalists with surgical consultation. This care model offloads the trauma surgical services, improving time to surgery and hospital throughput. As the number of injured GT patients rose, so did the need to address a higher complication risk, longer hospital stays, [...]

Background: Accountable Care Units (ACUs) with Structured Interdisciplinary Bedside Rounds (SIBR® rounds) have shown significant improvements in throughput, clinical outcomes, and satisfaction. Yet, prior studies have noted difficulties achieving such improvements or sustaining them. Interdisciplinary rounds are a predominantly physician-led teamwork process with efficacy vulnerable to inconsistent physician leadership and engagement. Our hospital had previously [...]

Background: Cancer is a risk factor for readmissions. We aimed to describe the potentially preventable 7-day unplanned readmissions in patients admitted to the hospital medicine service at a tertiary comprehensive cancer center. There is currently no defined criteria for potentially preventable readmissions among the cancer population. Methods: This was a retrospective analysis performed by a [...]

Background: Heart Failure (HF) is among the top 10 causes of hospitalization and almost a fifth are readmitted within 30 days. Clinical assessment of lung congestion is subjective and patients may be discharged prior to good resolution. Lung ultrasound (LUS) is helpful in evaluating lung congestion. The presence of B-lines on LUS can reliably indicate [...]

Background: Hospitalized patients with COVID-19 who improve clinically but have ongoing oxygen requirements are often discharged with home oxygen. There are important considerations for home monitoring, follow-up and education at the time of discharge for these patients who must manage new equipment at home. This project aimed to describe discharge planning for COVID-19 patients with [...]

Background: Prolonged length of stay (LOS) is associated with worse quality outcomes, poor patient satisfaction, and negative financial performance for hospitals. Geographic cohorting of provider teams and their patients could improve LOS, readmissions, and other quality metrics. Many prior studies of geographic cohorting have shown no beneficial effect on these metrics. In 2021, we implemented [...]

Background: Case Managers (CM) are now a standard presence in emergency departments (ED) of large hospitals, partnering with ED and Hospital Medicine providers to improve care. They are integral in improving hospital throughput and reducing unnecessary hospital admissions and readmissions. Case Managers generally identify high-risk patients using a manual chart review process or by provider [...]