The Division of Hospital Medicine created the novel “Phone-A-Friend” program, which serves as a peer resource for hospitalists to discuss challenging or complex patients, and to promote clinical development for less experienced hospitalists. This peer support model was developed so that senior hospitalists with at least 10 years of clinical and administrative leadership experience were available to discuss complex cases with hospitalists. These senior hospitalists are available to discuss cases through meetings and via email to provide flexible and efficient means to obtain advice on the most challenging cases.

Central Line-Associated Blood Stream Infection (CLABSI) is a bloodstream infection that develops within 48 hours after placement of a central line. The Division of Hospital Medicine has taken an active role in interdisciplinary work to improve rates of CLABSI at The Mount Sinai Hospital. Through our work, there was an improvement in CLABSI rates compared to the prior years across medicine units. Initiatives have included unit dyad (unit medical director and unit nurse manager) weekly rounding on our medicine units, partnership with hybrid units to ensure weekly rounding on patients who have central lines on non-medicine units, dedicated monitoring of chlorhexidine gluconate bathing on medicine units, and review of CLABSI efforts at monthly dyad meetings with quality leadership. Huddles also occur for front-line staff when a CLABSI occurs, in cooperation with the Infection Prevention team. In addition, there have been dedicated efforts to improve awareness of which patients have central lines, the need for intravenous to oral conversion of common medications when possible, and documentation of central line duration as well as peripheral intravenous duration in daily progress notes.

Members of the quality team completed a retrospective review of interhospital transfers accepted to The Mount Sinai Hospital during a three-month time period, with the goals of identifying indications for transfer and outcomes among patients to understand potential opportunities for improvement in the transfer process. The electronic medical record was reviewed for outcomes including length of stay, time from transfer acceptance to patient arrival, consulting specialties, mortality, and 30-day readmission. This work demonstrated potential areas of opportunity in optimizing the interhospital transfer process, including the screening process for transfer and the acceptance process by specialists, as 22 percent of patients did not receive the procedure for which they were transferred. The average 2.5-day delay from arrival to procedure also suggested potential for improvement in care coordination prior to procedure, particularly for those patients within the Mount Sinai Health System. As a result of these findings, the Division of Hospital Medicine created and implemented a transfer checklist to improve the process.

A team of residents and medicine attendings at the Division of Hospital Medicine worked to optimize mobility of patients admitted to the medicine service, and this work subsequently spread through the Mount Sinai Health System as a whole. Several residents in the Health Care Leadership Track worked with two attendings in Division to identify barriers to regular mobilization of patients by staff and to develop adaptive methods to improve mobility. The medicine admission order was adjusted to spread awareness that bedrest orders should be reserved for patients who are unsafe to mobilize. This team also performed an educational intervention for residents on the medicine teaching team to encourage earlier evaluation of patients who may benefit from physical therapy and to encourage appropriate requests for skilled physical therapy, as opposed to a request for general mobilization of a patient.

The Division of Hospital Medicine has established the Quality Improvement Peer Review Committee, which meets monthly to discuss the cases of patients who expired on the medicine service, with the goal of improving care and identifying contributing circumstances and opportunities for improvement. Mortality cases are derived from the Quality Improvement Peer Review Trigger Tool and electronically assigned to reviewing faculty by the committee chair prior to each meeting. Each case is presented to the committee for discussion, after which the members determine whether the standard of care was met through general consensus. When the standard of care is not met or met with room for improvement, corrective actions aligned with the identified contributing factors are implemented.

The Division of Hospital Medicine established a novel night float educational initiative for internal medicine trainees to improve attending supervision and the trainee’s educational experience. The initiative consisted of a 60 to 90-minute teaching session, five to seven nights per week during the night float rotation. Teaching sessions were case-based and included brief discussions of overnight admissions with real-time faculty feedback. The sessions were also a forum for residents to ask questions and solicit input on cross-coverage care, and for nocturnists to share additional educational insights. Resident satisfaction was anonymously assessed through a nine-question survey and a separate Graduate Medical Education survey. There were twenty-eight responses from 105 residents completing at least one week of night float. Of those surveyed, 100 percent felt more comfortable knowing that an attending was available overnight, 41 percent described the session as “somewhat useful,” 38 percent described them as “useful,” and 10 percent described them as “very useful.” The Graduate Medical Education survey showed a significant improvement from 65th percentile to above the 90th percentile for “supervision at night” after implementation of the night teaching program.

Providing equitable care for patients of all backgrounds is a priority for the Division of Hospital Medicine. An interdisciplinary group led by the Division sought to understand the barriers to consistent use of interpretation services, and then designed a bedside tool for brief communication for patients with non-English language preference (NELP). A survey of nurses and patient care associates on two acute care units assessed modes of communication used with patients with NELP, perceived frequency of interpretation service use, and staff experience when communicating with patients with NELP. Survey responses, collaboration with the Language Services Department, front-line nursing/care assistant staff, patient and family member feedback were used to revise card content and design. The card included icons and captions and was translated into six languages, as well as English for non-verbal English-speaking patients. The team found that, though there was initial enthusiasm for the card, logistical challenges made it difficult to sustain use on most units. This work will lay the foundation for additional work to determine how best to assist patients with brief needs, when calling an interpreter is difficult for staff due to time pressure and other barriers.

The Division of Hospital Medicine at The Mount Sinai Hospital has traditionally been responsible for completing certain bedside procedures, including paracenteses and lumbar punctures (LPs). Due to the low volume of procedures, many faculty have little opportunity to perform these procedures and keep procedural skill sufficient to supervise procedures or maintain credentialing. In a needs assessment survey among hospitalists, only 26 percent reported feeling comfortable performing an LP and 58 percent reported comfort with paracentesis. Among those with more than four years of experience, none felt comfortable performing an unsupervised LP. In addition, waiting for procedures such as an LP due to the need for another team to assist has led to delays in patient care and longer lengths of stay for some patients. In response, the Division of Hospital Medicine established a novel On-Call Procedure Team (OPT) comprised of five full-time hospitalists to perform LPs and paracenteses.

Seven months after implementation, the team had performed a total of 78 procedures, averaging 2.5 procedures per week. Most of the procedures were LPs (74 percent). Only 15 percent of LP attempts were unsuccessful, requiring radiology assistance, and four percent of LPs were traumatic. These rates are consistent with the literature, suggesting OPT members performed high-quality procedures. The majority of the procedures (54 percent) were requested on a resident teaching team and the OPT provided supervision of 27 different residents. This format has allowed for a cost-effective solution and has increased bandwidth for procedures, expedited procedure execution, and increased mentorship and training for residents in performing procedures.

To prepare our hospitalist group for providing medicine co-management and Rapid Response Training (RRT) coverage without internal medicine trainees or critical care backup at the Mount Sinai-Behavioral Health Center, we developed a targeted behavioral health RRT curriculum with simulation training. We aimed to standardize best practices in RRT management and familiarize our faculty with the most common critical scenarios to expect.

Preliminary post-intervention survey data suggested that a faculty development program to review the expectations and management of RRTs was an effective means of building RRT confidence, with 86 percent of respondents in agreement/strong agreement. All the respondents who attended the in-person simulation training agreed/strongly agreed that the training improved their RRT confidence. We also observed that in-person simulation RRT training augmented the positive effect of the faculty didactic on RRT confidence. Both learning modalities appeared effective at increasing faculty confidence in leading an RRT regardless of experience level. Next steps include longitudinal surveys to assess the durability of self-reported RRT confidence and analyzing the impact of our RRT curriculum on clinical outcomes. This work was presented at the national meeting of the Society of Hospital Medicine.

To intensify efforts on decreasing readmission rates at one of the Mount Sinai sites, a congestive heart failure discharge checklist was enhanced and a post-discharge clinic at Mount Sinai-Union Square was implemented. Utilization of the congestive heart failure pathway remained stable at 55 percent, but the percentage of heart failure patients discharged on appropriate goal directed medical therapies increased from the previous year. Specifically, discharge prescriptions increased for aldosterone antagonists (17.4 percent to 25 percent), sacubitril/valsartan (36 percent to 50 percent), SGLT2 inhibitors (27 percent to 53 percent), and beta-blockers (93 percent to 95 percent). Readmissions subcommittees for congestive heart failure, chronic obstructive pulmonary disease, pneumonia, sepsis, and acute myocardial infarction met monthly to discuss ongoing strategies to reduce readmissions in their respective areas. In collaboration with our ambulatory practice, a post-discharge clinic was created to target high readmission risk patients. Decreased readmissions was observed for those who were scheduled to follow up at our post-discharge clinic within seven days (11.8 percent with no appointment vs. 0.5 percent with an appointment) and within 14 days (10.9 percent with no appointment vs. 1.4 percent with an appointment).

In response to an increased number of Safety Net reports of incidents of patient agitation and aggression, the team implemented a multi-disciplinary quality improvement initiative to target workplace violence and improve the organizational perception of safety. The two-week intervention focused on the night shift (7 pm-7 am) given the inherent vulnerabilities stemming from fewer staff, visitors, and leadership present in the overnight hours. While security personnel already perform nightly rounds to confirm functionality of the unit’s panic button, our intervention called for twice nightly proactive rounding by security, which included participation in informal huddles with the charge nurse.

Proactive rounding aimed to increase the visibility of security presence for both staff and patients on the unit. The informal huddles also served as a forum for staff to escalate impending safety concerns. We observed a reduction from 67 percent to 50 percent in the unit staff’s reports of feeling anxious, demoralized, and stressed daily to a few times weekly. The unit staff respondents also unanimously favored continuation of this initiative. Our pilot demonstrated that partnering with security personnel, proactive rounding, and team huddles was feasible, favorably received, did not add cost, and could ease the perception of workplace violence. Next steps include expansion of the pilot to include the day shift and quantifying the impact of this intervention on frequency of workplace violence incidents.