BACKGROUND:Comprehensive care for frail older inpatients may improve selected outcomes and reduce harm.OBJECTIVE:To evaluate a Hospitalist‐run Acute Care for the Elderly (Hospitalist‐ACE) service.DESIGN:Quasi‐randomized, controlled trial.SETTING:Urban academic medical center.PATIENTS:Medical inpatients age ≥70 years.INTERVENTION:Hospitalist‐ACE service components: 1) selected hospitalist attendings; 2) daily interdisciplinary rounds; 3) standardized geriatric assessment; 4) clinical focus on mitigating harm and discharge planning; 5) novel inpatient geriatrics curriculum.MEASURES:The primary outcome was recognition of abnormal functional status by the primary medical team. Secondary outcomes included: recognition of abnormal cognitive status and delirium by the primary medical team; use of physical restraints and sleep aids; documentation of code status; hospital charges, length of stay, readmission rates, discharge location, and falls.RESULTS:One hundred twenty‐two Hospitalist‐ACE patients were compared to 95 usual care patients. Hospitalist‐ACE patients had significantly greater recognition of abnormal functional status (65% vs 32%, P < 0.0001), and abnormal cognitive status (57% vs 36%, P = 0.02), and greater use of “Do Not Attempt Resuscitation” orders (39% vs 26%, P = 0.04). There were no differences in use of physical restraints, or sleep aids, falls, or discharge location. Hospitalist‐ACE patients and usual care patients had similar mean lengths of stay in days (3.4 ± 2.7 vs 3.1 ± 2.7, P = 0.52), mean charges ($24,617 ± $15,828 vs $21,488 ± $13,407, P = 0.12), and 30‐day readmission rates (12% vs 10%, P = 0.50).CONCLUSIONS:A Hospitalist‐ACE service may improve care processes without significantly increasing resource consumption. No impact on key clinical outcomes was observed. Journal of Hospital Medicine 2011;6:313–321. © 2011 Society of Hospital Medicine

Background and Purpose-Analysis of quality of care for in-hospital stroke has not been previously performed at the national level. This study compares patient characteristics, process measures of quality, and outcomes for in-hospital strokes with those for community-onset strokes in a national cohort. Methods-We performed a retrospective cohort study of the Get With The Guidelines-Stroke (GWTG-Stroke) database ofThe American Heart Association from January 2006 to April 2012, using data from 1280 sites that reported ≥1 in-hospital stroke. Patient characteristics, comorbid illnesses, medications, quality of care measures, and outcomes were analyzed for 21 349 in-hospital ischemic strokes compared with 928 885 community-onset ischemic strokes. Results-Patients with in-hospital stroke had more thromboembolic risk factors, including atrial fibrillation, prosthetic heart valves, carotid stenosis, and heart failure (P<0.0001), and experienced more severe strokes (median National Institutes of Health Stroke Score 9.0 versus 4.0; P<0.0001). Using GWTG-Stroke achievement measures, the proportion of patients with defect-free care was lower for in-hospital strokes (60.8% versus 82.0%; P<0.0001). After accounting for patient and hospital characteristics, patients with in-hospital strokes were less likely to be discharged home (adjusted odds ratio 0.37; 95% confidence intervals [0.35-0.39]) or be able to ambulate independently at discharge (adjusted odds ratio 0.42; 95% confidence intervals [0.39-0.45]). In-hospital mortality was higher for in-hospital stroke (adjusted odds ratio 2.72; 95% confidence intervals [2.57-2.88]). Conclusions-Compared with community-onset ischemic stroke, patients with in-hospital stroke experienced more severe strokes, received lower adherence to process-based quality measures, and had worse outcomes. These findings suggest there is an important opportunity for targeted quality improvement efforts for patients with in-hospital stroke.

Background/Objective Hospitalized older adults are frequently transferred to skilled nursing facilities (SNFs) for post-discharge care. Hospitals and SNFs are increasingly held jointly accountable for costs and outcomes of this care. However, it is unclear how clinicians select patients for SNF care; we sought to understand how hospital-based clinicians evaluate older adults in the hospital and decide who will be transferred to a SNF for post-acute care. Design Semi-structured interviews paired with a qualitative analytic approach informed by Social Constructivist theory. Setting Inpatient care units in three hospitals. We used purposive sampling to maximize variability in hospitals, units within hospitals, and staff on those units. Participants Twenty-five clinicians involved in evaluation and decision-making regarding post-acute care, including hospitalists, nurses, therapists, social workers, and case managers. Measurements Central themes related to clinician evaluation and discharge decision-making. Results Clinicians described pressure to expedite evaluation and discharge decisions, resulting in the use of SNF as a “safety net” for older adults being discharged from the hospital. The lack of hospital-based clinician knowledge of SNF care practices, quality, or patient outcomes resulted in the lack of a standardized evaluation process or a clear primary decision-maker. Conclusion Hospital clinician evaluation and decision-making about post-acute care in a SNF may be characterized as rushed, without a clear system or framework for making decisions, and uninformed by knowledge of SNF or patient outcomes in those discharged to SNF. This leads to SNF being used as a “safety net” for many older adults. As hospitals and SNFs are increasingly held jointly accountable for outcomes of patients transitioning between hospital and SNF, novel solutions for improving evaluation and decision-making are urgently needed.

Between 2.2% and 17% of all strokes have symptom onset during hospitalization in a patient originally admitted for another diagnosis or procedure. These in-hospital strokes represent a unique population with different risk factors, more mimics, and substantially worsened outcomes compared to community-onset strokes. The fact that these strokes manifest during the acute care hospitalization, in patients with higher rates of thrombolytic contraindications, creates distinct challenges for treatment. However, the best evidence suggests benefit to treating appropriately selected in-hospital ischemic strokes with thrombolysis. Evidence points toward a ''quality gap'' for in-hospital stroke with longer in-hospital delays to evaluation and treatment, lower rates of evaluation for etiology, and decreased adherence to consensus quality process measures of care. This quality gap for in-hospital stroke represents a focused opportunity for quality improvement.

Understanding and intervening to improve the quality of decision-making regarding post-acute care supports is essential for improving outcomes of hospitalized older adults. Our results suggest that simply providing information is not sufficient; rather, incorporating key contextual factors and improving the decision-making process for both patients and clinicians are also essential.