Clinical texting systems (CTS) are widely used in hospitals for team communication about patients... more Clinical texting systems (CTS) are widely used in hospitals for team communication about patients. With more institutions adopting such systems, there is a need to understand how texting is being used in clinical practice. We conducted content analysis of 809 randomly selected message threads sent to and from hospitalists in a 9-month window. The process, purpose and content of messages were analysed. We also examined messages for personal content (to identify whether CTS was being used for professional matters) and discussion of near miss errors. The risk levels of these near misses were also assessed. Most messages focused on clinical management of patient needs (62%; n=498) and functioned to provide a notification or update regarding clinical care (64%; n=518) or make a request of the recipient (63%; n=510). Personal content was infrequent in message threads (10%; n=80). Five per cent (n=38) of message threads included discussion of a near miss, and most near misses posed low clinical risk overall (66%; n=25). Further examination of care delivery, error communication, and the consequences of the care discussed in messages would help clinical leaders understand the impact of clinical texting on teamwork and quality of care.
A time motion study evaluating the impact of geographic cohorting of hospitalists
BACKGROUND: Geographic cohorting (GCh) localizes hospitalists to a unit. Our objective was to com... more BACKGROUND: Geographic cohorting (GCh) localizes hospitalists to a unit. Our objective was to compare the GCh and non-GCh workday. METHODS: In an academic, Midwestern hospital we observed hospitalists in GCh and non-GCh teams. Time in patient rooms was considered direct care; other locations were considered ‘indirect’ care. Geotracking identified time spent in each location and was obtained for 17 hospitalists. It was supplemented by in-person observation of four GCh and four non-GCh hospitalists for a workday each. Multilevel modeling was used to analyze associations between direct and indirect care time and team and workday characteristics. RESULTS: Geotracking yielded 10,522 direct care episodes. GCh was associated with longer durations of patient visits while increasing patient loads were associated with shorter visits. GCh, increasing patient loads, and increasing numbers of units visited were associated with increased indirect care time. In-person observations yielded 3,032 minutes of data. GCh hospitalists were observed spending 56% of the day in computer interactions vs non-GCh hospitalists (39%; P < .005). The percentage of time spent multitasking was 18% for GCh and 14% for non-GCh hospitalists (P > .05). Interruptions were pervasive, but the highest interruption rate of once every eight minutes in the afternoon was noted in the GCh group. CONCLUSION: GCh may have the potential to increase patient–hospitalist interactions but these gains may be attenuated if patient loads and the structure of cohorting are suboptimal. The hospitalist workday is cognitively intense. The interruptions noted may increase the time taken for time-intensive tasks like electronic medical record interactions.
Papers by Areeba Kara
Inpatient opioid receipt and care experiences for vaginal delivery
Antisynthetase syndrome is a rare autoimmune disease within the subset of idiopathic infammatory ... more Antisynthetase syndrome is a rare autoimmune disease within the subset of idiopathic infammatory myopathies. Te diagnostic criteria include the presence of an aminoacyl-tRNA synthetase antibody, and typical clinical fndings, including myositis, mechanic's hands, Raynaud phenomenon, unexplained fever, and interstitial lung disease. We describe a case of a 59-year-old male who presented with a 1-month history of progressive purplish discoloration and pain of the fngertips, dyspnea, cough, weight loss, fatigue, and who developed progressive proximal muscle weakness and dysphagia. Investigations revealed pulmonic valve and mitral valve marantic endocarditis, pulmonary embolism, myositis, organizing pneumonia, and elevation of anti-OJ antibodies. He was diagnosed with antisynthetase syndrome and treated with high dose corticosteroids and mycophenolate mofetil with a fair response.
Professional Performance Audit and Feedback for Quality Improvement: Necessary but Insufficient
Joint Commission journal on quality and patient safety, Mar 1, 2022
Two-step algorithm-based Clostridioides difficile testing as a tool for antibiotic stewardship
Clinical Microbiology and Infection, Jun 1, 2023
Mixing It Up: Operational Impact of Hospitalist Caseload and Case-Mix
Management Science, 2023
Hospitalists are medical doctors that specialize in the care of hospitalized patients, a role tha... more Hospitalists are medical doctors that specialize in the care of hospitalized patients, a role that until recently belonged to primary care physicians. We develop an operational model of hospitalist-patient interactions with rounding and responding service modes, optimizing hospitalist caseload and case-mix to achieve the maximal reduction in patient length of stay (LOS). We show that hospitalists are effective at reducing LOS for patients with complex conditions, corroborating intuitive reasoning. However, the optimal hospitalist case-mix also includes “simple” patients with few interventions and short LOS, as they can effectively reduce discharge delays. This actionable insight is particularly salient for small community hospitals with simple, short-stay patients, where hospitalists may be undervalued due to the prevailing belief that they are primarily effective for complex patients. We conduct a comparative case study of a small community hospital and a large academic hospital, drawing a stark contrast between the two in terms of ideal caseload and patient coverage. Despite the fact that the academic hospital treats higher complexity patients, hospitalists at the community hospital should actually have a lower caseload than hospitalists at the academic hospital due to shorter stays in the community hospital. We find that both hospitals are understaffed but for different reasons: the academic hospital needs to staff more hospitalists to reduce the current caseload of its hospitalists, whereas the community hospital needs to staff more hospitalists to expand its hospitalist coverage to more patients. We estimate that these hospitals can save on average $1.5 million annually by implementing the optimal staffing policies. This paper was accepted by Stefan Scholtes, healthcare management. Funding: This work was supported by a PSC-CUNY Award, jointly funded by The Professional Staff Congress and The City University of New York. Supplemental Material: The e-companion and data files are available at https://doi.org/10.1287/mnsc.2022.4342 .
Texting is caring: a content analysis of clinical text messages by hospitalists
BMJ Open Quality
BackgroundClinical texting systems (CTS) are widely used in hospitals for team communication abou... more BackgroundClinical texting systems (CTS) are widely used in hospitals for team communication about patients. With more institutions adopting such systems, there is a need to understand how texting is being used in clinical practice.MethodsWe conducted content analysis of 809 randomly selected message threads sent to and from hospitalists in a 9-month window. The process, purpose and content of messages were analysed. We also examined messages for personal content (to identify whether CTS was being used for professional matters) and discussion of near miss errors. The risk levels of these near misses were also assessed.ResultsMost messages focused on clinical management of patient needs (62%; n=498) and functioned to provide a notification or update regarding clinical care (64%; n=518) or make a request of the recipient (63%; n=510). Personal content was infrequent in message threads (10%; n=80). Five per cent (n=38) of message threads included discussion of a near miss, and most nea...
Musculocutaneous manifestations of scurvy
BMJ Case Reports
An interprofessional patient assessment involving medical and nursing students: a qualitative study
Patient movements following hospitalization are difficult to track. In a large Midwestern academi... more Patient movements following hospitalization are difficult to track. In a large Midwestern academic institution, we analyzed data using network statistics for patients discharged by the hospitalist service between June 2016-June 2018. We retrieved all major patient movements logged in the patient throughput management system following admission. The 4,869 patients discharged by the hospitalist service during the study period experienced 6,832 movements. The mean was 1.4 movements per patient while the maximum was 8. Most patients (72.3%) moved once following hospitalization while 27.7% moved more than once. The predominant movement type was downgrades which comprised 51.8% (n = 3,543) of all movements. Lateral movements were the next most common (25.9%, n = 1,771). Network statistics revealed progressive care units to be central to patient flow across the system. Transfers following hospitalization are common. Visualizing these transfers using network statistics may provide valuable ...
Clostridioides difficile infection (CDI) is the leading cause of hospital-acquired infections (HA... more Clostridioides difficile infection (CDI) is the leading cause of hospital-acquired infections (HAI) in the United States. 1 Although multiple interventions have been shown to reduce CDI, the adoption of these evidence-based practices remains suboptimal, and the burden of CDI remains high. 2 There is a pressing need to develop strategies that bridge the gap between the available evidence and clinical practice to reduce harm from CDI. The 'Agile Implementation' (AI) framework was used to reduce central-line-associated bloodstream infections (CLABSIs) at our institution. 3 In study described here, we used the AI model to achieve reductions in CDI. Methods Setting The study was conducted in 2 large academic hospitals in the
OBJECTIVES/SPECIFIC AIMS: Research overview: Providing patient-centered care is increasingly a to... more OBJECTIVES/SPECIFIC AIMS: Research overview: Providing patient-centered care is increasingly a top priority in the U.S. healthcare system.1,2 Hospitals are required to publicly report patient-centered assessments, including results from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) patient satisfaction surveys.3 Furthermore, clinician and hospital reimbursements are partially determined by performance on patient satisfaction measures.3 Consequently, hospitals and clinicians may be incentivized to improve patient satisfaction scores over other important outcomes.4 Paradoxically then, the pursuit of patient-centered care may lead clinicians to fulfill patient requests for unnecessary and potentially harmful treatments.5 Opioid prescribing during hospitalizations may be particularly affected by clinicians’ seeking to optimize patient satisfaction scores.6,7 Satisfaction with pain care is an important predictor of overall patient satisfaction in the HCAHP...
Balancing Patient-Centered and Safe Pain Care for Nonsurgical Inpatients: Clinical and Managerial Perspectives
The Joint Commission Journal on Quality and Patient Safety
Background Hospitals and clinicians aim to deliver care that is safe. Simultaneously, they are en... more Background Hospitals and clinicians aim to deliver care that is safe. Simultaneously, they are ensuring that care is patient centered, meaning that it is respectful of patients’ values, preferences, and experiences. However, little is known about delivering care in cases in which these goals may not align. For example, hospitals and clinicians are facing the daunting challenge of balancing safe and patient-centered pain care for nonsurgical patients, due to lack of comprehensive care guidelines and complexity of this patient population. Methods To gather clinical and managerial perspectives on the importance, feasibility, and strategies used to balance patient-centered care (PCC) and safe pain care for nonsurgical inpatients, the research team conducted in-depth, semistructured interviews with hospitalists, registered nurses, and health care managers from one health care system in the Midwestern United States. We systematically examined transcribed interviews and identified major themes using a thematic analysis approach. Results Participants acknowledged the importance of balancing PCC and safe pain care. They envisioned this balance as a continuum, with certain patients for whom it is easier (for example, an opioid-naive patient with a fracture), vs. more difficult (for example, a patient with opioid use disorder). Participants reported several strategies they use to balance PCC and safe pain care, including offering alternatives to opioids, setting realistic pain goals and expectations, and using a team approach. Conclusion Clinicians and health care managers use various strategies to balance PCC and safe pain care for nonsurgical patients. Future studies should examine the effectiveness of these strategies on patient outcomes.
American journal of infection control, Jan 7, 2018
Central line-associated bloodstream infections (CLABSIs) are among the most common hospital-acqui... more Central line-associated bloodstream infections (CLABSIs) are among the most common hospital-acquired infections and can lead to increased patient morbidity and mortality rates. Implementation of practice guidelines and recommended prevention bundles has historically been suboptimal, suggesting that improvements in implementation methods could further reductions in CLABSI rates. In this article, we describe the agile implementation methodology and present details of how it was successfully used to reduce CLABSI. We conducted an observational study of patients with central line catheters at 2 adult tertiary care hospitals in Indianapolis from January 2015 to June 2017. The intervention successfully reduced the CLABSI rate from 1.76 infections per 1,000 central line days to 1.24 (rate ratio = 0.70; P = .011). We also observed reductions in the rates of Clostridium difficile and surgical site infections, whereas catheter-associated urinary tract infections remained stable. Using the AI ...
OBJECTIVES/SPECIFIC AIMS: This study seeks to understand the relationship between opioid prescrib... more OBJECTIVES/SPECIFIC AIMS: This study seeks to understand the relationship between opioid prescribing and patient satisfaction among non-surgical, hospitalized patients. As part of this study, we qualitatively examined challenges in delivering safe and patient-centered care through voices of physicians’, and nurses.’ METHODS/STUDY POPULATION: We collected data through in-person interviews using semi-structured guides tailored to the informant roles. Study participants came from 1 healthcare system located in a mid-Western state. Each interview lasted 30–45 minutes, was audio-recorded with consent, and transcribed for analysis. Two researchers each coded 17 transcripts for discussions around patient-centeredness (including patient satisfaction, patient experiences), and patient safety for hospitalized patients experiencing pain. Analysis followed a general inductive approach, where researchers identified themes related to the research questions using an open coding technique. They dis...
Hospital-Based Clinicians' Perceptions of Geographic Cohorting: Identifying Opportunities for Improvement
American journal of medical quality : the official journal of the American College of Medical Quality
Members of the Society of Hospital Medicine were surveyed about geographic cohorting (GCh); 369 r... more Members of the Society of Hospital Medicine were surveyed about geographic cohorting (GCh); 369 responses were analyzed, two thirds of which were from GCh participants. Improved collaboration with the bedside nurse, increased nonclinical interactions, decreased paging interruptions, and improved efficiency were perceived by >50%. Narrowed clinical expertise, increased fragmentation, increased face-to-face interruptions, and an adverse impact on camaraderie within the hospitalist group were reported by 25% to 50%. Academic practices were associated with positive perceptions while higher patient loads were associated with negative perceptions. Comments on GCh benefits invoked improvements in (1) interprofessional collaboration, (2) efficiency, (3) patient-centeredness, (4) nursing satisfaction, and (5) GCh mediated facilitation of other interventions. GCh downsides included (1) professional and personal dissatisfaction, (2) concerns about providing suboptimal care, and (3) implemen...
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articles by Areeba Kara
METHODS: In an academic, Midwestern hospital we observed hospitalists in GCh and non-GCh teams. Time in patient rooms was considered direct care; other locations were considered ‘indirect’ care. Geotracking identified time spent in each location and was obtained for 17 hospitalists. It was supplemented by in-person observation of four GCh and four non-GCh hospitalists for a workday each. Multilevel modeling was used to analyze associations between direct and indirect care time and team and workday characteristics.
RESULTS: Geotracking yielded 10,522 direct care episodes. GCh was associated with longer durations of patient visits while increasing patient loads were associated with shorter visits. GCh, increasing patient loads, and increasing numbers of units visited were associated with increased indirect care time. In-person observations yielded 3,032 minutes of data. GCh hospitalists were observed spending 56% of the day in computer interactions vs non-GCh hospitalists (39%; P < .005). The percentage of time spent multitasking was 18% for GCh and 14% for non-GCh hospitalists (P > .05). Interruptions were pervasive, but the highest interruption rate of once every eight minutes in the afternoon was noted in the GCh group.
CONCLUSION: GCh may have the potential to increase patient–hospitalist interactions but these gains may be attenuated if patient loads and the structure of cohorting are suboptimal. The hospitalist workday is cognitively intense. The interruptions noted may increase the time taken for time-intensive tasks like electronic medical record interactions.
Papers by Areeba Kara