Hospitalists

This retrospective cohort study included adult ED patients who were diagnosed with acute PE between January 1, 2013 and May 31, 2013 in six community EDs within Kaiser Permanente (KP) Northern California, a large integrated healthcare delivery system that provides comprehensive care for more than 3.4 million members. KP health plan members represent approximately 25–30% of the population in areas served and are similar to the general population with respect to race/ethnicity, socioeconomic status, and education.15 ,16 (link) The study was approved by the KP Northern California Health Services Institutional Review Board.
The EDs had an annual census in 2013 from 26,000 to 85,000 and were staffed by residency-trained, board-certified emergency physicians. The medical centers had inpatient bed capacities ranging from 50 to 325. Inpatient care is provided by board-certified internists, all of whom are hospitalists. Three medical centers were satellite sites for residency training programs and had residents rotate to various degrees through their emergency and hospitalist departments.
During 2013, all facilities had 24/7 access to on-site computed tomography pulmonary angiography with around-the-clock interpretation by board-certified radiologists. Formal compression ultrasonography and ventilation perfusion imaging were not available during late night hours. Two facilities had a designated clinical decision area, functioning akin to a short-stay (<24 hours) observation unit, managed by hospitalists. Initial site-of-care decisions and total length of stay were in the hands of the treating physicians; no clinical care pathways for PE were in effect.
All facilities provided pre-discharge patient education regarding the disease and its treatment and had pharmacy available around-the-clock for discharge medications and supplemental patient education. Treating physicians commonly employed the standard KP Northern California discharge orderset for thromboembolism, which recommends warfarin with concomitant bridging therapy using enoxaparin. Alternative oral anticoagulants approved for the treatment of PE were not often prescribed, as the formulary restricts their use to patients who have failed or are unable to adhere to warfarin. Outpatient warfarin dosing was managed by each facility’s pharmacy-led anticoagulation service. The percent time in therapeutic international normalized ratio range at these facilities in 2013 was a respectable 72% to 74% (the higher the percentage, the higher the quality of care and the better the clinical outcomes).17 (link)–19 (link)
Throughout the study period no follow-up policy was in effect at any of the medical centers for patients with acute PE who were discharged home. The timing and nature (telephone vs clinic) of the follow-up appointment with the patient’s primary care provider was arranged at the discretion of the discharging clinician, who either directly provided the follow-up appointment or recommended the patient arrange it themselves within a certain time frame. These patient-driven access appointments were secured either via a 24/7 telephone appointment call center, an email directly to the patient’s primary provider, or by electronically booked appointment times available through the patient portal of kp.org.20 (link)–22

Patient enrollment for VICS began in October 2011, and is scheduled to end in October 2015, with the goal of enrolling 3,000 patients. Adults admitted to Vanderbilt University Hospital or an affiliated community hospital, Williamson Medical Center, are eligible. Monday through Saturday, staff screen the hospital’s electronic medical records to identify patients who presented to the hospital with symptoms suggestive of ADHF and/or intermediate to high likelihood of ACS. A study investigator (hospitalist or cardiologist) confirms the diagnosis by chart review. Research assistants (RAs) then assess the presence of the following exclusion criteria: age < 18 years, inability to communicate in English, blindness, hearing impairment, lack of a working telephone, conditions that would interfere with the validity of the interview (e.g., significant dementia, active psychosis or mania), being near the end of life (hospice or home hospice), lack of cooperation, police custody, enrollment in a conflicting study, or prior enrollment in VICS. Patients who are delirious or too ill to participate early in their hospitalization, but who would be eligible otherwise, are re-assessed for up to 7 days for potential eligibility. Because many of the instruments are designed for patient self-assessment, we do not enroll surrogates to respond on the patient’s behalf. Approaching members of racial/ethnic minority groups and women is prioritized to promote their representation in the study sample.

ACGME and ABEM endorsed the emergency medicine milestones as a framework for developing and accessing trainees’ progress toward competence in each domain in 2012 [56 (link),57 (link)]. Milestones describe competencies and identify KSABs that can be used as outcome measures within the six core competencies. Individual milestones demonstrate the KSABs required for graduation via unsupervised practice. However, some behaviors are not fully encompassed within KSABs in different social cultures and are categorized as care services (CS). With the aspect of care services (CS), there are four evaluation criteria: teamwork (CS1), patient safety (CS2), system management (CS3), and technology applications (CS4).
Many studies investigate the relationship between teamwork and patient safety and find a positive impact on it [38 (link)] in ED. Teamwork is a competency integrated with common thoughts, behaviors, and feelings that help health providers work as a team to provide better patient safety and outcomes in the clinic [38 (link),42 (link)]. EM is considered a high-risk specialty in which inter-professional healthcare workers must engage to guarantee patient safety. Studies have shown that successful teamwork and communication training has improved patient outcomes [38 (link),39 (link),40 (link)]. However, Aouicha et al. described a worrying situation among those healthcare professionals in ED who lack a patient safety culture in their practice [41 (link)]. Therefore, teamwork training and building facilitate the cultivation of a patient safety culture and subsequently affect patient outcomes positively. The hospital can consider implementing effective teamwork and patient safety culture programs to reduce the incidence of unsafe care and adverse events.
System management focuses on both SBP and transition of care. SBP is the ACGME core competency that focuses on complex systems and physicians’ roles. SBP encompasses several topics, including multidisciplinary team-based care, healthcare quality improvements, cost containment, value consideration, and benefit/risk analysis to patient care. The definition of SBP does not easily translate into clinical observations and behaviors to assess in clinical practice. Gonzalo et al. developed five domains to evolve further SBP: comprehensive systems-based learning, the continuum of professional development, teaching and assessment methods, clinical learning environments of SBP, and professional identity [43 (link)]. A consensus conference on education research by Academic Emergency Medicine reviewed the literature on SBP assessment tools. It suggested multimodal assessment with direct observation by expert clinicians in the workplace [46 (link)]. In brief, EPs not only deliver effective, efficient, safe, timely, and patient-centered care, but also develop strategies to improve healthcare delivery within the ED, hospital system, and community. Care transitions occur when one healthcare provider transfers responsibility for a patient’s care to another. The evolution of patient care may happen between pre-hospital and ED providers, EPs at shift change, EPs and hospitalists, and ED and nursing homes [44 (link),45 (link),47 (link)]. All types of healthcare workers participate in the transition of a patient’s care. ED is considered a high-risk, unpredictable, and frequently interrupted environment, which may adversely impact patient care quality. The transition of care from the ED has significant risks for EPs and patients, and the competency of providing high-quality care is crucial to EPs. Unlike primary care, Rider et al. highlighted the importance of optimizing technology for an effective transition of care from the ED to the outpatient clinic [49 (link)].
The use of technology applications has increased in recent years, especially in the ED specialty, due to the utilization of artificial intelligence (AI). AI is considered the next major technological breakthrough in the healthcare system. EM has been at the forefront of disciplines using AI applications for patient care because of the uniqueness of the EM model. AI was adopted for clinical practice in numerous applications within EM, including in the interpretation of diagnostic imaging, interpretation of electrocardiography, and outcome prediction [51 (link)]. The intervention of AI can increase the speed and accuracy of clinical decisions and pose benefits to both EPs, ED, and healthcare systems [50 (link)]. The most established applications of AI in EM are within the ED itself. For example, AI has shown promise in interpreting diagnostic imaging, predicting patient outcomes, and monitoring patient vitals. However, facing the new technologies, EPs require careful vetting, legal regulations, patient safeguards, and user education. EPs should identify the limits and risks of AI while enjoying its potential benefits [48 (link)].