Richard Gannotta

Hospitals have been facing an epic crisis, with the COVID-19 pandemic overwhelming emergency departments and forcing the implementation of surge protocols to manage care delivery and treatment. These realities have affected both inpatient care delivery and caregiver effectiveness. The need to reevaluate clinical operations is challenging the healthcare delivery structure and its leadership to think differently—digitally. Supporting care for patients in the home has played an important role in mitigating many safety and access issues, accelerating telehealth adoption and solidifying its place in the ongoing transformation of healthcare delivery. As this shift continues to unfold, it is also bringing an opportunity to improve clinical outcomes, patient satisfaction, and cost reduction efforts as well as advance access and promote diversity, equity, and inclusion in the US healthcare delivery system.

Objectives: Simulation-based mastery learning (SBML) programs have been shown to be beneficial to improve procedural skill acquisition. However, simulated procedure performance can be affected by a host of factors, including stress. This investigation examined the preliminary efficacy of bolstering an established SBML program for medical residents with a brief mindfulness intervention (called a PITSTOP) to reduce procedural stress and improve simulator performance.

Design: The study employed a partially blinded, parallel-group, randomized, repeated-measures intention-to-treat design. Participants were blinded to the primary outcome (simulator performance) and instead were informed of the study's secondary outcome (stress prevention). The SBML faculty instructors and study investigators were blinded to participants' group assignment.

Settings/location: Northwestern Memorial Hospitals of Chicago.

Subjects: Twenty-six postgraduate year (PGY) 1 internal medicine residents enrolled in a required SBML central venous catheter (CVC) insertion training from June 2015 to January 2018 participated in the study.

Interventions: SBML consists of a simulated skills pretest, deliberate practice, and a simulated skills post-test (within 1 week of pretest). PGY 1 participants were randomly assigned to the PITSTOP intervention (12-min PITSTOP mindfulness training video) or control group (12-min control video on ways to increase physical activity) before the SBML pretest.

Outcome measures: The primary outcome was a comparison of each group's simulator performance during pre- and post-tests. Secondary outcomes were changes in groups' procedural stress during these tests (assessed using self-reported, instructor-rated, and physiologic indicators), and self-reported self-regulation outcomes.

Results: Residents who watched the PITSTOP video before their SBML training made fewer procedural errors relative to controls during their pretest for intrajugular CVC insertion (p = 0.03). PITSTOP participants also had lower heart rate (p = 0.03) and less visible trembling (p = 0.003) relative to controls at the post-test.

Conclusions: This study provides preliminary evidence that a brief, mindfulness intervention may reduce stress during SBML training.

Organized discharge huddles have been implemented in a number of specialties across medicine to improve communication and minimize medical errors that might ultimately harm patients. Literature has shown that disjointed care can lead to poor utilization of resources and suboptimal treatment. Conversely, effective and systematic coordination of care has been shown to improve quality of care, as well as a variety of other parameters. While huddles require time and effort from members of the staff, including physicians, nurses, pharmacists, and therapists, the benefits of improved communication and coordination of care are significant.

Discharge huddles have been shown to be effective in improving various metrics of patient care across multiple specialties. For example, a study investigating the effect of a multidisciplinary discharge huddle on a busy stroke service found that the huddle decreased length of stay by 1.4 d and that the number of patients who were discharged without necessary auxiliary services fell significantly from 47% to 35%. Another study showed that implementation of a physician-led multidisciplinary discharge huddle resulted in shorter length of stays (from 21.6 to 14.1) and decreased total hospital costs for patients hospitalized for subarachnoid hemorrhages. Implementing discharge huddles is a way to ensure that patients leave the hospital in an efficient manner and minimize any unnecessary delays.

The communication and planning that occurs during discharge huddles is aimed at streamlining patient care and preventing readmissions, which can be costly and detrimental to the patient. A study investigating unplanned 90-d readmissions following spine surgery at Vanderbilt University found that almost half of readmissions were due to pain and medical complications at median 6 and 12 d, respectively, while the other half were due to complications of surgery. The authors argued that the known timelines of the pain and medical complications allow for the opportunity to make postdischarge interventions that prevent readmissions. The effect of not having a routine discharge disposition, which would be installed by a discharge huddle, has also been studied. A database study of patients who had undergone a craniotomy for tumor resection found that nonroutine poor discharge planning led to higher rates of postdischarge complications and 30-d readmissions.

Patient satisfaction is a metric of patient care that can be somewhat controversial because patient demands can sometimes conflict with the most appropriate treatment algorithm. Indeed, there is evidence that satisfaction is not a strong proxy for the assessment of quality care. For instance, a multicenter retrospective review of 248 patients found that patient satisfaction correlated only mildly with health-related quality of life scores. There is contrasting evidence that patients who report their dissatisfaction with care actually experience more adverse events and medical errors, which may explain why patients are dissatisfied.

We previously described an improvement in hospital metrics (ie, length of stay, cost, and patient satisfaction) associated with the implementation of a daily 30-min morning discharge huddle at our institution. The goal was to have a structured daily conference including members from all disciplines of the care team to convene and discuss the discharge needs for all patients on the neurosurgery inpatient service. We found that certain inpatient costs decreased and that patient satisfaction scores improved following implementation of the huddle. In terms of costs, we hypothesized that having pharmacists and nurses present to recommend medication alternatives or point out unnecessary drugs likely helped reduce costs. We demonstrated an estimated savings of $1408 047.66 in the first 15 mo of implementation. With regard to improved patient satisfaction, we reasoned that patients were more likely to be satisfied with shorter lengths of stay and a more streamlined discharged process. Overall, the implementation of the huddle at our institution has demonstrated significant improvements in patient throughput as well as patient satisfaction. The authors will discuss pearls and pitfalls associated with the implementation of a neurosurgery discharge huddle to assist other centers planning to create a discharge huddle or improve the efficiency of their existing teams.

The landscape of medicine in the United States has been slowly progressing toward a more holistic and individualized approach to healing. Part of this progress has been the integration between western and alternative forms of medicine, a concept that has been described as "integrative medicine." This approach to healthcare incorporates a patient's mind, spirituality, and sense of community into the healing process. Integrative medicine has been typically well received and the demand has been steadily increasing in primary US hospitals. Here we cover a number of topics that include the definition of integrative medicine, its potential benefits, current examples of successful implementations, and potential barriers to its expansion. The aim was to give a primary on integrative medicine and its current state for healthcare providers.

Based on international research, Rapid Response Systems (RRSs) were implemented across the United States following recommendations from the Institute for Healthcare Improvement (IHI) as a way to improve hospitalized patient outcomes and decrease adverse events. The RRSs are comprised of multiple components, including the multidisciplinary team of critical care clinicians known as the Rapid Response Team (RRT). Studies have shown that empowering RNs to call the RRT to the bedside of a patient they perceive as deteriorating can increase positive patient outcomes.

However, less is known about the efficacy of empowering families to call the RRT. Patient and family empowerment has become a focus for healthcare organizations in the wake of publication of key concepts in patient- and family-centered care by The Institute of Family Centered Care in collaboration with the IHI. To promote care partnerships between patients, families, and clinicians, healthcare organizations have added another component to their RRTs, the Condition Help (Condition H) team, which permits a patient or family member to summon the RRT.