We developed a multidisciplinary initiative,"Lose the Tube," focused on a Choosing Wisely recommendation to decrease catheter-associated urinary tract infection (CAUTI) rates and catheter days. Through an electronic health record catheter identification tool, daily interdisciplinary query, and clinician education, our multifaceted intervention reduced mean per-person catheter days from 3.3 to 2.9, decreased CAUTI rates from 2.85 to 0.32 per 1,000 catheter days, and reduced cost by $ 32,245. (C) 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Abstract Introduction This patient safety curriculum was developed to address two important needs in contemporary graduate medical education: training frontline providers in key patient safety skills and producing tangible products that demonstrate resident achievement in this area. The curriculum is geared towards second- and third-year internal medicine residents. Methods It employs a mixed-methods approach to teaching patient safety concepts by integrating standardized introductory cases with individualized real-time cases under consideration by the department's peer review committee. This resource consists of an instructional slide set and facilitator guide for the patient safety and peer review course, including standardized cases of medical error. Also included are a practical workflow depicting faculty and resident training, as well as guidance on the necessary collaboration with local peer review leadership. Results Following the training of 14 faculty members and curriculum completion by 60 residents, preliminary resident before-after survey results demonstrate a significant increase in the percentage of residents who report being able to complete a mortality review, feeling comfortable with key components of the curriculum (e.g., teaching the difference between active and latent failures, recognizing the difference between levels of standard of care), and having a high level of comfort with the concept of peer review (either performing it on a colleague's case or having a colleague perform it on one of their own cases). Discussion Integrating residents into ongoing departmental patient safety efforts can provide residency programs with a novel way to teach essential patient safety concepts as well as to meet current competency requirements.

Vesiculobullous skin disease is a group of diseases that cause blistering of the skin. The differential is broad and includes multiple causes such as infection, allergic reaction, physical trauma, and autoimmune disease. Autoimmune bullous diseases are those caused by dysregulation of the immune system, leading to autoantibodies against protein components of the skin and mucous membranes. In turn, this causes disruption of the integrity of these crucial areas, leading to bullae formation. The 2 most common autoimmune bullous diseases are pemphigus vulgaris and bullous pemphigoid.

As the cost of care rises and fragmentation of health care increases, care transitions have become critical parts of the health care system. Physicians and other inpatient providers have the responsibility to communicate to subsequent providers, but such communication occurs far less than is optimal. Timely discharge summaries for the next-level provider, postdischarge phone calls to patients, and postdischarge follow-up appointments with primary-care physicians or inpatient providers may improve postdischarge health care utilization. Pharmacists may also reduce medication errors, adverse medication events, and even readmissions. The most promising data, however, come from studies of multidisciplinary approaches, some of which have shown large reductions in postdischarge utilization and costs. More study is needed to pinpoint the most cost-effective and efficient strategies to improve transitions from the inpatient setting to other settings.

Journal of Hospital MedicineVolume 5, Issue 6 p. 360-364 Innovations A model of a hospitalist role in the care of admitted patients in the emergency department† Alan Briones MD, Corresponding Author Alan Briones MD alan.briones@mountsinai.org briones.alan@gmail.com Department of Medicine, Mount Sinai Medical Center, New York, New York Telephone: 212-241-1653; Fax: 212-289-6393Division of General Internal Medicine, One Gustave L. Levy Place Box 1087, New York, NY 10029-6574Search for more papers by this authorBrian Markoff MD, Brian Markoff MD Department of Medicine, Mount Sinai Medical Center, New York, New YorkSearch for more papers by this authorNavneet Kathuria MD, Navneet Kathuria MD Department of Medicine, Mount Sinai Medical Center, New York, New YorkSearch for more papers by this authorAndy Jagoda MD, Andy Jagoda MD Department of Emergency Medicine, Mount Sinai Medical Center, New York, New YorkSearch for more papers by this authorKevin Baumlin MD, Kevin Baumlin MD Department of Emergency Medicine, Mount Sinai Medical Center, New York, New YorkSearch for more papers by this authorScot Hill MD, Scot Hill MD Department of Emergency Medicine, Mount Sinai Medical Center, New York, New YorkSearch for more papers by this authorLawrence Mumm BS, Lawrence Mumm BS Department of Medicine, Mount Sinai Medical Center, New York, New YorkSearch for more papers by this authorRamiro Jervis MD, Ramiro Jervis MD Department of Medicine, Mount Sinai Medical Center, New York, New YorkSearch for more papers by this authorAndrew Dunn MD, Andrew Dunn MD Department of Medicine, Mount Sinai Medical Center, New York, New YorkSearch for more papers by this author Alan Briones MD, Corresponding Author Alan Briones MD alan.briones@mountsinai.org briones.alan@gmail.com Department of Medicine, Mount Sinai Medical Center, New York, New York Telephone: 212-241-1653; Fax: 212-289-6393Division of General Internal Medicine, One Gustave L. Levy Place Box 1087, New York, NY 10029-6574Search for more papers by this authorBrian Markoff MD, Brian Markoff MD Department of Medicine, Mount Sinai Medical Center, New York, New YorkSearch for more papers by this authorNavneet Kathuria MD, Navneet Kathuria MD Department of Medicine, Mount Sinai Medical Center, New York, New YorkSearch for more papers by this authorAndy Jagoda MD, Andy Jagoda MD Department of Emergency Medicine, Mount Sinai Medical Center, New York, New YorkSearch for more papers by this authorKevin Baumlin MD, Kevin Baumlin MD Department of Emergency Medicine, Mount Sinai Medical Center, New York, New YorkSearch for more papers by this authorScot Hill MD, Scot Hill MD Department of Emergency Medicine, Mount Sinai Medical Center, New York, New YorkSearch for more papers by this authorLawrence Mumm BS, Lawrence Mumm BS Department of Medicine, Mount Sinai Medical Center, New York, New YorkSearch for more papers by this authorRamiro Jervis MD, Ramiro Jervis MD Department of Medicine, Mount Sinai Medical Center, New York, New YorkSearch for more papers by this authorAndrew Dunn MD, Andrew Dunn MD Department of Medicine, Mount Sinai Medical Center, New York, New YorkSearch for more papers by this author First published: 20 August 2010 https://doi.org/10.1002/jhm.636Citations: 4 † Disclosure: Nothing to report. Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Citing Literature Volume5, Issue6July/August 2010Pages 360-364 RelatedInformation

Inadequate communication as patients transition across venues of care carries substantial risks. At the time of discharge, changes in medications may be missed, abnormal or pending test results ignored, and evolving aspects of the patient’s condition may not receive appropriate attention. The essential nature of timely communication at discharge has been recognized by the Joint Commission (TJC), which mandates that discharge summaries be completed within 30 days of discharge and specifies the core elements that need to be included. Though the discharge summary is a key component of the transfer of information, inadequate communication at admission carries additional hazards. At the time of admission, inaccurate medication reconciliation may occur, key elements of the history missed, prior studies unnecessarily repeated, and important aspects of the home situation overlooked. Given the importance, it could be assumed that communication with the primary care physician (PCP) is a routine staple of hospitalization and performed in a systematic manner along with other essential items, such as assessment of allergies and documentation of prior laboratory results. On the contrary, the inconsistent nature of physician–physician communication is well-established. A systematic review of the literature found that direct communication between inpatient physicians and PCPs occurred during only 3–20% of hospitalization. Deficiencies noted have included poor quality of referral letters from general practitioners to inpatient physicians in Norway; poor timeliness and quality of discharge summaries in Canada, England, and Australia; and discontinuity in the care plan after discharge at an academic hospital in the U.S.. These studies suggest that inadequate communication between inpatient and outpatient physicians is the norm rather than the exception. Two studies in this issue of JGIM offer further insights into the nature of doctor-doctor communication in the inpatient arena. Bell and colleagues surveyed 1,772 PCPs for 1,078 hospitalized patients at six academic medical centers. Of the 77% of PCPs who were aware that their patient was admitted, only 23% received direct communication from an inpatient physician at any point during hospitalization. Roy and colleagues examined communicationpatterns for readmittedpatients at two academicmedical centers to determine if the admitting team had contacted the prior inpatient team. The results are consistent with other assessments of communication: only 43.7% of admitting teams had communicated with the prior inpatient teams. Though the consequences of inadequate communication have been repeatedly demonstrated, the gains from enhanced communication have not been as clearly proven. The lack of definitive data may be due to inability to control for important confounders, inadequate power, inability to assess the quality of the communication, or intrinsic difficulties with communication preventing meaningful improvement in outcomes. In addition, most studies have examined the transfer of information at the end of hospitalization, and little examination has been done on communication at the time of admission. Benefit was shown in a randomized trial which found that an intervention to facilitate the transition from hospital to home, including a comprehensive discharge form completed by a discharge planning nurse and electronically transmitted to a nurse at the PCP’s office, markedly decreased the number of incomplete workups, though ED visits and readmissions were unchanged. A large retrospective chart review found a trend towards decreased readmission (RR 0.74) for patients for whom a discharge summary was available at the time of their follow-up visit with their PCP. Coleman and colleagues randomized 750 adults to usual care or to an intervention including a “transitions coach” and a patient-centered record designed to facilitate transfer of information across sites. This comprehensive approach to enhancing communication achieved significant reductions in rehospitalization rates at 30 days (8.3 vs. 11.9 days) and was net cost-saving. Additional support comes from a study of the impact of discharge summaries in London, which noted that 24% of patients had management affected by delayed or poor discharge summaries as determined by their PCP. In the study by Bell and colleagues in this issue, there was no significant association between the PCP having communicated with the inpatient team with the composite endpoint of death, readmission, or emergency department visits, though a nonsignificant 5% decrease in the composite outcome was noted. Though this result could have been due to chance, the study was underpowered to find a small benefit. Given the likely scale of any potential gain, future studies will need to have sufficient power to detect modest improvements in outcomes. Also, though the authors adjusted for comorbidities, this study and others may be confounded by communication being more Published online January 27, 2009

Obesity is increasing at an alarming rate worldwide and is a risk factor for cardiac disease, diabetes, and stroke. This provides a challenge for the physicians caring for this patient population in the hospital. Skin integrity, medication dosing, testing, and nutrition are all altered by obesity. We summarize some of the current data on caring for the obese inpatient. Unfortunately, few data on this unique inpatient population exist.

Conclusion: Combined death and MI rates at 30 days in patients evaluated for chest pain and normal troponin ranges from 0.3% to 11%. Only one trial identified a risk <1% for patients with a normal troponin. Although the risk is small, a 30 day event rate of >1% may represent an unacceptable risk for this cohort of patients. Prompt inpatient or outpatient evaluation with provocative testing is still necessary in this patient population.