Emergency department returns and early follow-up visits after heart failure hospitalization: Cohort study examining the role of race.

Health disparities in heart failure (HF) show that Black patients face greater ED utilization and worse clinical outcomes. Transitional care post-HF hospitalization, such as 7-day early follow-up visits, may prevent ED returns. We examine whether early follow-up is associated with lower ED returns visits within 30 days and whether Black race is associated with receiving early follow-up after HF hospitalization.

Patient Perspectives on Care Transitions From Hospital to Home.

Importance: Understanding the patient's perspective of their care transition process from hospital or skilled nursing facility (SNF) to home may highlight gaps in care and inform system improvements.

Objective: To gather data about patients' care transition experiences and factors associated with follow-up appointment completion.

Design, Setting, And Participants: A survey tool was developed with input from patient advisors and organizations participating in a collaborative quality initiative.

Development of the Socioeconomic Screening, Active Engagement, Follow-up, Education, Discharge Readiness, and Consistency (SAFEDC) Model for Improving Transitions of Care: Participatory Design.

Background: Transition to home after hospitalization involves the potential risk of adverse patient events, such as knowledge deficits related to self-care, medication errors, and readmissions. Despite broad organizational efforts to provide better care transitions for patients, there are challenges in implementing interventions that effectively improve care transition outcomes, as evidenced by readmission rates. Collaborative efforts that require health care professionals, patients, and caregivers to work together are necessary to identify gaps associated with transitions of care and generate effective transitional care interventions.

Environmental contamination with SARS-CoV-2 in nursing homes.

Background: SARS-CoV-2 outbreaks in nursing homes (NHs) have been devastating and have led to the creation of coronavirus disease 2019 (COVID-19) units within NHs to care for affected patients. Frequency and persistence of SARS-CoV-2 environmental contamination in these units have not been studied.

Methods: A prospective cohort study was conducted between October 2020 and January 2021 in four Michigan NHs.

A New Tool to Assess Clinician Experience With Patient Care Transitions.

Background And Objectives: Clinician experience of intrahospital patient care transfers can drive transfer success and safe patient care. Measuring clinician experience can provide insights into opportunities to improve transfer processes that impact patient care. As part of a quality improvement project, we developed a brief survey to gauge clinician experience with patient care transfers that occur within a hospital.

Partnering with Local Hospitals and Public Health to Manage COVID-19 Outbreaks in Nursing Homes.

Background/objectives: Almost half of deaths related to COVID-19 in the United States are linked to nursing homes (NHs). We describe among short-term and long-term residents at three NHs in Michigan the outbreak identification process, universal testing, point prevalence of COVID-19, and subsequent containment efforts, outcomes, and challenges.

Design: Outbreak investigation.

A taxonomy and cultural analysis of intra-hospital patient transfers.

Existing research on intra-hospital patient transitions focuses chiefly on handoffs, or exchanges of information, between clinicians. Less is known about patient transfers within hospitals, which include but extend beyond the exchange of information. Using participant observations and interviews at a 1,541-bed, academic, tertiary medical center, we explored the ways in which staff define and understand patient transfers between units.

Predictors for patients understanding reason for hospitalization.

Objective: To examine predictors for understanding reason for hospitalization.

Methods: This was a retrospective analysis of a prospective, observational cohort study of patients 65 years or older admitted for acute coronary syndrome, heart failure, or pneumonia and discharged home. Primary outcome was complete understanding of diagnosis, based on post-discharge patient interview.

Quasi-Experimental Evaluation of the Effectiveness of a Large-Scale Readmission Reduction Program.

Importance: Feasibility, effectiveness, and sustainability of large-scale readmission reduction efforts are uncertain. The Greater New Haven Coalition for Safe Transitions and Readmission Reductions was funded by the Center for Medicare & Medicaid Services (CMS) to reduce readmissions among all discharged Medicare fee-for-service (FFS) patients.

Objective: To evaluate whether overall Medicare FFS readmissions were reduced through an intervention applied to high-risk discharge patients.

Using the red/yellow/green discharge tool to improve the timeliness of hospital discharges.

Background: As part of Yale-New Haven Hospital (Connecticut)'s Safe Patient Flow Initiative, the physician leadership developed the Red/Yellow/Green (RYG) Discharge Tool, an electronic medical record-based prompt to identify likelihood of patients' next-day discharge: green (very likely), yellow (possibly), and red (unlikely). The tool's purpose was to enhance communication with nursing/care coordination and trigger earlier discharge steps for patients identified as "green" or "yellow."

Methods: Data on discharge assignments, discharge dates/ times, and team designation were collected for all adult medicine patients discharged in October-December 2009 (Study Period 1) and October-December 2011 (Study Period 2), between which the tool's placement changed from the sign-out note to the daily progress note.

Electronic handoff instruments: a truly multidisciplinary tool?

The objective was to assess use of a physician handoff tool embedded in the electronic medical record by nurses and other non-physicians. We administered a survey to nurses, physical therapists, discharge planners, social workers, and others to assess integration into daily practice, usefulness, and accuracy of the handoff tool. 231 individuals (61% response) participated.

Novel integration of systems-based practice into internal medicine residency programs: the Interactive Cost-Awareness Resident Exercise (I-CARE).

Background: The Accreditation Council for Graduate Medical Education and American Board of Internal Medicine have identified cost-awareness as an important component to residency training. Cost-awareness is generally not emphasized in current, traditional residency curricula despite the recognized importance of this topic.

Description: Using a traditional Morning Report structure and actual charge data from our institution, the charges associated with trainee-directed workup of clinical cases are compared in a friendly competition among medical students, interns, residents, and faculty.

Quality of discharge practices and patient understanding at an academic medical center.

Importance: With growing national focus on reducing readmissions, there is a need to comprehensively assess the quality of transitional care, including discharge practices, patient perspectives, and patient understanding.

Objective: To conduct a multifaceted evaluation of transitional care from a patient-centered perspective.

Design: Prospective observational cohort study, May 2009 through April 2010.

The revolving hospital door: hospital readmissions among patients who are homeless.

Background: National attention is increasingly focused on hospital readmissions. Little prior research has examined readmissions among patients who are homeless.

Objective: The aim of the study was to determine 30-day hospital readmission rates among patients who are homeless and examine factors associated with hospital readmissions in this population.

Comprehensive quality of discharge summaries at an academic medical center.

Background: Discharge summaries are essential for safe transitions from hospital to home.

Objective: To conduct a comprehensive quality assessment of discharge summaries.

Design: Prospective cohort study.

Republished: Defining impact of a rapid response team: qualitative study with nurses, physicians and hospital administrators.

Objective: The objective of this study was to qualitatively describe the impact of a Rapid Response Team (RRT) at a 944-bed, university-affiliated hospital.

Methods: We analysed 49 open-ended interviews with administrators, primary team attending physicians, trainees, RRT attending hospitalists, staff nurses, nurses and respiratory technicians.

Results: Themes elicited were categorised into the domains of (1) morale and teamwork, (2) education, (3) workload, (4) patient care, and (5) hospital administration.

An institution-wide handoff task force to standardise and improve physician handoffs.

Background: Transfers of care have become increasingly frequent and complex with shorter inpatient stays and changes in work hour regulations. Potential hazards exist with transfers. There are few reports of institution-wide efforts to improve handoffs.