Society of Hospital Medicine

This article presents an updated framework from the Society of Hospital Medicine for individual learning objectives related to key procedures in hospital medicine. Building upon the 2017 framework, these objectives have been revised to reflect evolving clinical evidence, advancements, and shifts in hospital medicine practice patterns. The methodology included a comprehensive literature review, expert consensus panels, and feedback from practicing hospitalists across diverse clinical settings. The updated learning objectives address procedural competencies for the most common interventions in hospital medicine, including arthrocentesis, emergency procedures, interpretation of chest radiographs and electrocardiograms, lumbar puncture, paracentesis, thoracentesis, and vascular access. These revised learning objectives provide a framework to guide curricular development, continuing medical education, and hospital medicine practitioners in developing and maintaining procedural competence essential for high-quality inpatient care.

Rationale: COPD affects 16 million US adults, with many returning to the Emergency Department (ED) or hospital following a COPD hospitalization. In 2014, Medicare added COPD to their Hospital Readmissions Reduction Program. For successful wide-scale adoption of COPD readmission reduction programs, US hospitals evidence-based strategies. We enrolled diverse US hospitals to develop and implement COPD transition-of-care (TOC) intervention bundles (2-3 evidence-based interventions). Here we present the baseline study data. Methods: In this hybrid type II effectiveness-implementation cluster randomized study, sites were randomized into four groups delivering COPD TOC programs virtually (V) or in-person (IP) with mentoring (M) plus/minus co-design (CD) support: Group 1:V/M+CD, Group 2:IP/M+CD, Group 3:V/M, Group 4:IP/M. The baseline period consisted of a one-year period pre-implementation of patients with at least one COPD admission plus all return ED visits and/or re-hospitalizations for any cause. Analyses included descriptive statistics of patient demographics, COPD-specific and all-cause utilization acute care visits (30, 90 days), and group-based analyses. Analysis of variance and Kruskal-Wallis tests were performed to evaluate mean and median group demographic differences, respectively. GEE models were used to assess acute care group differences while accounting for within-hospital correlations. Results: The 20 sites with 5,271 unique patients hospitalized at least once for COPD were randomized in four groups: 1:V/M+CD (N=6, n=1,543), 2:IP/M+CD (N=5, n=1,522), 3:V/M (N=4, n=1,068), and 4:IP/M (N=5, n=1,138). Overall, patients had a mean age of 67.87 years, with 55% female, 67% white, 92% non-Hispanic, 63% on Medicare, and 71% current/former smokers. Group differences were observed for patients’ age, gender, race, ethnicity, insurance, and smoking status (all p<0.001). No group differences were observed for sites’ hospital type, region, or size (all p<0.001). Group differences were observed for 30-day COPD-related revisits (p=0.02), ED visits (p<0.001), and readmissions (p=0.002) and for 90-day COPD revisits (p=0.001), ED visits (p<0.001), and readmissions (p<0.001); similar results were seen for all-cause utilization at 30 and 90 days except 90-day all-cause revisits. (Table)Conclusions: These findings underscore the heterogeneity of patient populations across the enrolled hospitals. Significant variations in baseline healthcare utilization highlight the need for tailored interventions to reduce acute care revisits and improve health outcomes in this vulnerable patient population. Future analyses will compare within-site and across-cohort acute care utilization post-implementation of COPD TOC intervention-bundles, examining baseline heterogeneity across cohorts. Findings from this multi-site study will provide critical insights into intervention bundles to address diverse patient and hospital needs and reduce acute care utilization.

Rationale: Of the 16 million US adults with COPD, approximately 700,000 will be hospitalized annually with 20% re-hospitalized within 30 days. Due to these potentially preventable re-hospitalizations, Medicare included COPD in its Hospital Readmission Reduction Program. Several non-pharmacologic approaches to reducing readmissions are effective, including early pulmonary rehabilitation, inhaler education, and medication reconciliation. We recruited diverse US hospitals to develop and implement COPD transition of care intervention-bundles. We tested providing the bundle in-person or virtually with mentoring plus/minus co-design implementation support. We hypothesized that sites randomized to deliver interventions virtually receiving co-design support would have lower acute healthcare utilization and broader reach. Methods: This hybrid type II effectiveness-implementation two-factor cluster randomized trial randomized hospitals to: group1) virtual/codesign, group2) in-person/codesign, group3) virtual/mentor, group4) in-person/mentor [Table]. Co-primary outcomes were 30-day COPD-specific revisits and bundle reach; secondary outcomes were additional 30 and 90-day COPD-specific and all-cause revisits, ED visits, and hospitalizations. Under intention-to-treat, we used two-factor generalized estimating equation models to evaluate effects of intervention (virtual [groups1+3] versus in-person [groups2+4]), implementation (codesign [groups1+2] versus mentor-only [groups3+4]), and their interaction (virtual/codesign [group1] versus other groups [groups2-4]). Results: Of 21 US hospitals randomized, 19 were analyzed (one left study; one missing data) with 6,241 unique patients hospitalized for COPD at least one time. Sites randomized to group1 had fewer 30-day COPD-specific revisits (11.5% vs 12.8-15%; p<0.001) and fewer 90-day COPD-specific revisits (19.1% vs. 23.8%, p<0.001) and hospitalizations (12.6% vs. 16.8%, p=0.01) than other groups. Sites randomized to virtual delivery [groups1+3] (versus in-person [groups2+4]) had fewer 30-day COPD-specific revisits (11.5% vs. 15%; p<0.001). Sites randomized to co-design plus mentoring [groups1+2] (vs mentoring alone [ g3+4]) had fewer revisits (12.8% vs. 14.3%; p=0.005). [Table] Greater reach was seen with Group1 (vs other groups; 76.3% vs. 69.5%, p=0.04), virtual [groups1+3] (versus in-person [groups2+4]; 75.4% vs. 68.2%, p=0.01), and co-design [groups1+2] (versus mentoring alone [g3+4]; 76.3% vs. 69.5%, p=0.04). Conclusion: These preliminary unadjusted analyses indicate that hospitals randomized to virtual intervention delivery with co-design support were more effective (lower 30-day COPD-specific revisits) and had greater reach compared to the other three randomization groups. Other acute care metrics results were mixed. Due to site heterogeneity, additional analyses will be conducted to adjust for patient and site-level characteristics. Per protocol and as treated analyses will also be conducted to better understand whether these results are robust and aligned with actual delivery of virtual or in-person interventions with or without co-design support.

OBJECTIVES Clinical pathways can improve care and outcomes for children with respiratory illnesses. The Simultaneously Implementing Pathways for Improving Asthma, Pneumonia, and Bronchiolitis Care for Hospitalized Children (SIP) trial is a multicenter, randomized trial of a high-efficiency pathway intervention in general and community hospitals. Our objective was to describe implementation fidelity, strategy use, time costs, barriers, and facilitators. METHODS We conducted a mixed-methods study. Hospitals received clinical pathways (intervention) and used 5 implementation strategies: quality improvement (QI) mentor meetings, education, iterative changes, audit and feedback, and clinical decision support via electronic order sets. Data were collected through monthly surveys (11 months) of site leaders and recordings of mentor meetings. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed using thematic content analysis. RESULTS Eighteen site leaders (from 18 hospitals) and 8 QI mentors participated. Monthly survey completion rates were 72% to 100%. Pathway implementation fidelity was high (94%). Implementation strategies with the highest use were QI mentor meetings, iterative changes, and electronic order sets. Audit and feedback had the lowest use, driven by information technology challenges and delays in data collection. Implementation time costs were approximately 14 hours per month, and data collection had the highest time cost. Implementation barriers included time limitations and stakeholder resistance to change. Facilitators included SIP study resources, engagement of multidisciplinary staff, and alignment with institutional goals. CONCLUSIONS Our multicenter study provides detailed guidance on implementation fidelity, strategy use, time costs, barriers, and facilitators for general and community hospitals implementing high-efficiency pediatric pathway interventions.