Analyzing Malpractice Claims Against Hospitalists
The Particulars: Hospitalists often have malpractice claims made against them due to the high rates of high-acuity patients they treat, limited access to patients’ medical histories, and high rates of receiving patients with serious conditions. However, few studies have assessed these claims to determine the most common reasons behind them and how such claims may be avoided.
Data Breakdown: For a study, researchers analyzed malpractice claims made against hospitalists that were closed between 2007 and 2014. More than one-third (36%) were related to diagnoses, including missed, late, or incorrect diagnoses. Of these claims, 35% were the result of an inadequate initial assessment, and 16% involved intestinal disorders. Poor communication was the root cause of 23% of claims. Claims arising from hospitalist care involved a higher rate of very severe injuries (72%) when compared with those arising from care provided by all physicians (34%).
Take Home Pearls: Malpractice lawsuits made against hospitalists appear to most commonly be related to diagnostic errors or poor communication. Increasing timely access to records for hospitalists and optimizing the co-management of hospital patients may help reduce the rate of these claims.
Reducing Physician Burnout Risk
The Particulars: Research suggests that the number of physicians reporting burnout has increased with time in recent years. For hospitalists, the risk of burnout is particularly strong because of the high acuity of patients and their exposure to loss. However, little is known regarding strategies to address burnout among hospitalists.
Data Breakdown: Two physicians have assessed strategies to help avoid and address burnout among hospitalists. They recommend that physicians do the following:
- Take time to reflect on what being a hospitalist means personally.
- Use reflective writing to reconnect.
- Take a moment for meditation to be aware of surroundings.
- Practice spirituality, such as singing or praying, and/or playing with kids.
- Ask colleagues to exchange ideas on what is meaningful about their work.
- Discuss implementing provider stress reduction programs into system-wide goals within the hospital.
Take Home Pearl: Burnout appears to be a constant threat for hospitalists, but several strategies may help reduce this risk.
Diagnosing Infectious Disease Emergencies
The Particulars: Data indicate that bacterial meningitis, spinal epidural abscesses, and necrotizing soft tissue infections are relatively uncommon. However, each is associated with a high rate of mortality, particularly when diagnosis and treatment are delayed. Understanding how to make an early, accurate diagnosis may help reduce mortality rates associated with these infectious diseases.
Data Breakdown: A Cleveland Clinic researcher provided several key points to help hospitalists make the right diagnosis in patients suspected of having bacterial meningitis, spinal epidural abscesses, or necrotizing soft tissue infections. Whereas many patients with bacterial meningitis do not have fever, nuchal rigidity, and altered mental status, nearly all have at least one of these symptoms, and most have headache. A diagnosis of bacterial meningitis should be confirmed by lumbar puncture, and empiric antibiotics should be initiated promptly to cover pneumococcus and meningococcus. Patients presenting with spinal epidural abscesses usually have central back pain, radicular pain, neurologic deficits, and paralysis, and variable fever. Most patients have an elevated erythrocyte sedimentation rate. Imaging of these patients should include MRI, and initial management should include antibiotics to cover Staphylococcus Aureus and gram negative rods as well as surgery consultation. Symptoms of necrotizing soft tissue infections include pain out of proportion, anesthesia, systemic toxicity, rapid progression, bullae/crepitus, and failure to respond to antibiotics. Initial management should include initiating β-lactam/lactamase inhibitor or carbapenem clindamycin as well as MRSA coverage, imaging, and prompt surgical consultation.
Take Home Pearls: Clinical suspicion appears to be paramount to the diagnosis of bacterial meningitis, spinal epidural abscesses, and necrotizing soft tissue infections. Knowing the signs and symptoms of these infectious diseases is crucial because delays in diagnosis and treatment are associated with increased mortality.
Engaging Physicians in Quality Improvement
The Particulars: Previous studies have found that physician engagement in quality improvement initiatives is often limited. Understanding the culture that limits engagement and motivators for engagement may help improve and create a better environment for physician engagement.
Data Breakdown: A hospitalist in Arkansas suggested that one of the key characteristics of a successful hospital medicine group is an engaged hospitalist. Motivators for engagement in quality improvement efforts include establishing a sense of ownership, autonomy, mastery, and rediscovery of purpose for providing care and improving it. Applying behavioral economics concepts (ie, science of human motivation) can help in the development of incentives in several domains, including inertia (by simplifying processes), immediacy (by giving bonuses immediately after achieving goals), and mental accounting (by using paper checks for rewards).
Take Home Pearl: A culture of ownership, mastery, autonomy, and rediscovery of purpose along with the right mix of incentives may help increase physician engagement in quality improvement efforts.
Addressing Health IT Controversies
The Particulars: The use of copy-and-paste functions in electronic charting, alert fatigue, and patient access to electronic charts have been identified as three pressing concerns in health information technology (IT) that warrant more attention.
Data Breakdown: Emory Healthcare’s chief medical information officer addressed these three issues in a presentation. Whereas 90% of residents and attendings commonly reported using copy-and-paste in electronic charts, most physicians agreed that doing so increases inconsistencies. About 90% of physicians said they wished to continue this practice, but the need to do so should decrease as electronic medical records advance and as expectations are communicated more broadly. Alert fatigue is a health IT issue that can be addressed by:
- Making alerts non-interruptive.
- Tier-basing alerts by severity.
- Decreasing the frequency of drug interaction alerts.
Patient access to health information on web portals has been shown to improve patient engagement. Most physician concerns about open access have not been seen in actual practices. Few patients report that access to these notes causes confusion, worry, or offense.
Take Home Pearls: The use of copy-and-paste in electronic charts is an important health IT issue that should be discouraged and appears to cause inconsistencies in patient care. Patients appear to prefer access to health information on web portals, with access leading to improved patient engagement. Physicians are encouraged to read all alerts when electronically charting patients.
For more information on these studies and others that were presented at Hospital Medicine 2016, visit http://www.hospitalmedicine2016.org.