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Hospital Medicine Principles Communication Description Setting/Overview Example Strategy Closed-loop 1. Sender initiates message. Used to ensure that Physician: "Give 5 mg metoprolol lV push." communication/ information conveyed by the check-backs 2. Receiver accepts message sender is understood by the Nurse: "5 mg metoprolol lV push." and provides feedback. receiver as intended Physician: "Yes, that! correct." 3. Sender double-checks to ensure that message was received correctly. SBAR Situation: What is going on Used for communicating S: "l am calling about Mrs. with concerns with the patient? critical information about a about new hypoxemia." - patient's condition that Background: What is the B: "She is postop day 2 after total knee requires attention and action clinical background or context? replacement and has not had an 02 requirement. After dinnel the 02 sat was Assessment: What are the 87o/o on room air. Patient is alert with some objective/subjective fi nd n gs? i respiratory distress and wheezes on What do I think the problem is? examination. Other vital signs were normal." Recommendation/ Request: A "l am worried about aspiration pneumonia." What do you think needs to be done? R: "l think the patient needs evaluation and possible chest x-ray."

Communication Description Setting/Overview Example Strategy Closed-loop 1. Sender initiates message. Used to ensure that Physician: "Give 5 mg metoprolol lV push." communication/ information conveyed by the check-backs 2. Receiver accepts message sender is understood by the Nurse: "5 mg metoprolol lV push." and provides feedback. receiver as intended Physician: "Yes, that! correct." 3. Sender double-checks to ensure that message was received correctly. SBAR Situation: What is going on Used for communicating S: "l am calling about Mrs. with concerns with the patient? critical information about a about new hypoxemia." - patient's condition that Background: What is the B: "She is postop day 2 after total knee requires attention and action clinical background or context? replacement and has not had an 02 requirement. After dinnel the 02 sat was Assessment: What are the 87o/o on room air. Patient is alert with some objective/subjective fi nd n gs? i respiratory distress and wheezes on What do I think the problem is? examination. Other vital signs were normal." Recommendation/ Request: A "l am worried about aspiration pneumonia." What do you think needs to be done? R: "l think the patient needs evaluation and possible chest x-ray." Call-outs Communicating important or Emergent settings (e.9., code Code leader: 'Airway status?" critical information verbally, blue, rapid response team) Resident:'Airway clear." which informs allteam members simultaneously Code leader: "Breath sounds?" Resident: "Breath sounds decreased on right."

Call-outs Communicating important or Emergent settings (e.9., code Code leader: 'Airway status?" critical information verbally, blue, rapid response team) Resident:'Airway clear." which informs allteam members simultaneously Code leader: "Breath sounds?" Resident: "Breath sounds decreased on right." Code leader: "Blood pressure?" Nurse: "BP is96/62!'

Call-outs Communicating important or Emergent settings (e.9., code Code leader: 'Airway status?" critical information verbally, blue, rapid response team) Resident:'Airway clear." which informs allteam members simultaneously Code leader: "Breath sounds?" Resident: "Breath sounds decreased on right." Code leader: "Blood pressure?" Nurse: "BP is96/62!' I-PASS lllness severity: stability level of Used during handoffs betvveen l: "Mr. is the sickest patient on our team patient clinicians in hospital and will- need watching." Patient summary: events Designed to enhance P: "He is a 57-year-old man with DM and leading to admission, hospital information exchange during cellulitis of the right leg. He was admitted course, assessment, and plan transitions of care with hypotension, fever, and concerns for fasciitis. He has stabilized after 2 liters of NS Action list: to-do list for patient, and vancomycin and piperacillin/tazobactam, timeline, and ownership but continues to have fevers and BPs in the Situation awareness and 90s/50s. Leg CT is pendin9." contingency planning: plan for A: "Vancomycin level needs to be followed what might happen up at 8 PM and vital signs and volume status Synthesis: recipient of patient evaluated every 2 hours." information su mmarizes what S: "lf SBP <80 mm Hg and there! no volume was heard, asks questions, and overload, give 500 mL NS lV bolus. lf restates action items vancomycin level is <1 5, discuss with pharmary dose changes. Follow up on leg CT." S: "Okay, so Mr. has severe cellulitis with hypotension and is on broad-spectrum - antibiotics. He will need vital signs and volume exam every 2 hours and may require vancomycin dose adjustment and additional BP support with fluids. Follow-up on leg CT."

I-PASS lllness severity: stability level of Used during handoffs betvveen l: "Mr. is the sickest patient on our team patient clinicians in hospital and will- need watching." Patient summary: events Designed to enhance P: "He is a 57-year-old man with DM and leading to admission, hospital information exchange during cellulitis of the right leg. He was admitted course, assessment, and plan transitions of care with hypotension, fever, and concerns for fasciitis. He has stabilized after 2 liters of NS Action list: to-do list for patient, and vancomycin and piperacillin/tazobactam, timeline, and ownership but continues to have fevers and BPs in the Situation awareness and 90s/50s. Leg CT is pendin9." contingency planning: plan for A: "Vancomycin level needs to be followed what might happen up at 8 PM and vital signs and volume status Synthesis: recipient of patient evaluated every 2 hours." information su mmarizes what S: "lf SBP <80 mm Hg and there! no volume was heard, asks questions, and overload, give 500 mL NS lV bolus. lf restates action items vancomycin level is <1 5, discuss with pharmary dose changes. Follow up on leg CT." S: "Okay, so Mr. has severe cellulitis with hypotension and is on broad-spectrum - antibiotics. He will need vital signs and volume exam every 2 hours and may require vancomycin dose adjustment and additional BP support with fluids. Follow-up on leg CT." Team/family Summarizes patient status and Occurs during hospitalization meeting coordinates next steps of care Often held when there is a with family members change in clinical course, new Hospital ist patient, family, events, or change in goals of representatives from key care consulting disciplines, social work, and care coordination are in attendance

Team/family Summarizes patient status and Occurs during hospitalization meeting coordinates next steps of care Often held when there is a with family members change in clinical course, new Hospital ist patient, family, events, or change in goals of representatives from key care consulting disciplines, social work, and care coordination are in attendance BP = blood pressure; DM = diabetes mellitus; lV = intravenous; NS = normal saline; SBP = systolic blood pressure. Adapted {rom TeamSTEPPSo curriculum materials. Agency for Healthcare Research and Ouality, Rockville, MD. Content last reviewed October 201 9. https://www.ahrq.gov/ teamstepps/curriculum-materials.html. Accessed June I 7, 2021 . 26

: i I i i Hospital Medicine Principles L I L I A model of shared care known as co management has TABLE 19. Padua Prediction Score for Risk for L evolved between hospitalists and many surgical and other ser Venous Thromboembolism I vices. There are several styles of co management, depending on Risk Factor Points t the institution, resources, and specific agreements between I Active cancer 3 L services. For example, a hospitalist may serve as the primary Previous VTE 3 clinician with surgeons serving as consultants for a primary t I surgical problem, or a hospitalist may be an "embedded" con- Reduced mobility >3 d 3

L I A model of shared care known as co management has TABLE 19. Padua Prediction Score for Risk for L evolved between hospitalists and many surgical and other ser Venous Thromboembolism I vices. There are several styles of co management, depending on Risk Factor Points t the institution, resources, and specific agreements between I Active cancer 3 L services. For example, a hospitalist may serve as the primary Previous VTE 3 clinician with surgeons serving as consultants for a primary t I surgical problem, or a hospitalist may be an "embedded" con- Reduced mobility >3 d 3 sultant u,ithin a primary non-hospitalist team. In the latter I Thrombophilic condition" 3 t model, a hospitalist may fbllow all patients and make recom Recent surgery/trauma (<1 mo) 2 I L mendations on a broad array of medical issues, as well as write Advanced a9e (>70 y) 1 I I orders and fbllow up on study results. Co management is a Heart and/or respiratory failure 1 more collaborative and proactive approach to patient care that i Acute Ml or CVA t promotes clear communication and delineation of responsibili 1

sultant u,ithin a primary non-hospitalist team. In the latter I Thrombophilic condition" 3 t model, a hospitalist may fbllow all patients and make recom Recent surgery/trauma (<1 mo) 2 I L mendations on a broad array of medical issues, as well as write Advanced a9e (>70 y) 1 I I orders and fbllow up on study results. Co management is a Heart and/or respiratory failure 1 more collaborative and proactive approach to patient care that i Acute Ml or CVA t promotes clear communication and delineation of responsibili 1 ties among services. Although literature has been mixed on Acute infection or rheumatologic 1 \ I clinical outcomes, a retrospective propensity-score analysis disorders I

sultant u,ithin a primary non-hospitalist team. In the latter I Thrombophilic condition" 3 t model, a hospitalist may fbllow all patients and make recom Recent surgery/trauma (<1 mo) 2 I L mendations on a broad array of medical issues, as well as write Advanced a9e (>70 y) 1 I I orders and fbllow up on study results. Co management is a Heart and/or respiratory failure 1 more collaborative and proactive approach to patient care that i Acute Ml or CVA t promotes clear communication and delineation of responsibili 1 ties among services. Although literature has been mixed on Acute infection or rheumatologic 1 \ I clinical outcomes, a retrospective propensity-score analysis disorders I fbund surgical co management to be associated with decreased Obesity (BMl >30) L I complications, reduced inpatient consults, and reduced mortal- Ongoing hormonal treatment I b ity rates and 30 day readmissions. Surgical co management has Score Risk for Pharmacologic t I been consistently associated with a high level of satisfaction lnpatient WE Prophylaxis l with the care model among surgeons, nurses, and trainees. <4 Low (0.3%) Not I Despite its advantages, co management also presents recommended i challenges. The presence of multiple care providers can result >_4 Hish (11%) Recommended if L in duplication or omission of care, or care that is in conflict no absolute l contra ind ications because of unclear division of responsibilities. A diflusion of t responsibility may also result in substandard care. Carefully CVA = cerebrovascular accident; Ml = myocardial infarction; VTE = venous ! thromboembolism. drafted service agreements between participants in the uDe{ects of antrthrombi n, protein C or S, factor V Leiden, G202 1 0A prothrombin I co management services that outline rules olengagement and mutation, antiphospholipid syndrome. ; division of responsibility are critical for the success of Adapted {rom Barbar S, Noventa F, Ross€,tto V et al. A risk assessment model for L co-management programs. the identification of hospital zed medical patients at risk for venous i thromboembolism: the Padua Prediction Score. J Thromb l-laemost. 2010;8:2450 I 7.IPMID: 20738765]doi:10.1 1 1 1/j.1538 7836.2010.04044.x I

fbund surgical co management to be associated with decreased Obesity (BMl >30) L I complications, reduced inpatient consults, and reduced mortal- Ongoing hormonal treatment I b ity rates and 30 day readmissions. Surgical co management has Score Risk for Pharmacologic t I been consistently associated with a high level of satisfaction lnpatient WE Prophylaxis l with the care model among surgeons, nurses, and trainees. <4 Low (0.3%) Not I Despite its advantages, co management also presents recommended i challenges. The presence of multiple care providers can result >_4 Hish (11%) Recommended if L in duplication or omission of care, or care that is in conflict no absolute l contra ind ications because of unclear division of responsibilities. A diflusion of t responsibility may also result in substandard care. Carefully CVA = cerebrovascular accident; Ml = myocardial infarction; VTE = venous ! thromboembolism. drafted service agreements between participants in the uDe{ects of antrthrombi n, protein C or S, factor V Leiden, G202 1 0A prothrombin I co management services that outline rules olengagement and mutation, antiphospholipid syndrome. ; division of responsibility are critical for the success of Adapted {rom Barbar S, Noventa F, Ross€,tto V et al. A risk assessment model for L co-management programs. the identification of hospital zed medical patients at risk for venous i thromboembolism: the Padua Prediction Score. J Thromb l-laemost. 2010;8:2450 I 7.IPMID: 20738765]doi:10.1 1 1 1/j.1538 7836.2010.04044.x I I

fbund surgical co management to be associated with decreased Obesity (BMl >30) L I complications, reduced inpatient consults, and reduced mortal- Ongoing hormonal treatment I b ity rates and 30 day readmissions. Surgical co management has Score Risk for Pharmacologic t I been consistently associated with a high level of satisfaction lnpatient WE Prophylaxis l with the care model among surgeons, nurses, and trainees. <4 Low (0.3%) Not I Despite its advantages, co management also presents recommended i challenges. The presence of multiple care providers can result >_4 Hish (11%) Recommended if L in duplication or omission of care, or care that is in conflict no absolute l contra ind ications because of unclear division of responsibilities. A diflusion of t responsibility may also result in substandard care. Carefully CVA = cerebrovascular accident; Ml = myocardial infarction; VTE = venous ! thromboembolism. drafted service agreements between participants in the uDe{ects of antrthrombi n, protein C or S, factor V Leiden, G202 1 0A prothrombin I co management services that outline rules olengagement and mutation, antiphospholipid syndrome. ; division of responsibility are critical for the success of Adapted {rom Barbar S, Noventa F, Ross€,tto V et al. A risk assessment model for L co-management programs. the identification of hospital zed medical patients at risk for venous i thromboembolism: the Padua Prediction Score. J Thromb l-laemost. 2010;8:2450 I 7.IPMID: 20738765]doi:10.1 1 1 1/j.1538 7836.2010.04044.x I I Hospita l-Based Prevention using a validated risk assessment model, such as the Padua L ; Strategies Prediction Score (Table 19). Ifbleeding risk is not elevated and t Hospitalized patients are at risk fbr many medical complica VTE risk is high (Padua Score >4), use of pharmacologic prophy tions, several of which can be mitigated through strategies laxis with daily low-molecular-weight heparin is recommended t aimed at prevention. Hospitalists are uniquely positioned to throughout the patient's hospital stay or until mobility is fully \ l reduce inpatient complications. Risk reduction strategies that recovered. In patients with an unacceptably high bleeding risk, are commonly initiated include venous thromboembolism mechanical prophylaxis with intermittent pneumatic compres- \ (VTE) prophylaxis, delirium prevention and screening, anti- sion may be used, although data supporting this approach in 5 biotic stewardship, discontinuation of catheters to prevent non-surgical patients is limited. In certain high-risk settings, catheter associated infections, prevention of aspiration, such as orthopedic and oncologic surgery extended duration interventions to reduce deconditioning and falls, bedsore VTE prophylaxis is recommended postdischarge. For more infbr- prevention initiatives, and medication reconciliation. mation, see Perioperative Medicine and MKSAP 19 Hematologr. VTE risk is elevated in hospitalized, immobile, and acutely Delirium is particularly common among hospitalized ill patients. More than 50'1, of VTE events occur during or after patients. For more information, see MKSAP 19 Pulmonary and hospitalization for acute illness or recent surgery. VTE risk is Critical Care Medicine and MKSAP 19 Neurologr. Patients at particularly high in ICU patients and patients with cancer or highest risk include those with advanced age, polypharmacy, stroke. Early ambulation, mechanical prophylaxis (such as inter- prior cognitive impairment, recent surgery and acute illness. mittent pneumatic compression devices applied to the lower Predisposing and provoking risk factors for delirium are listed exlremities), and prophylactic anticoagulants are used either in Table 20. Up to 40'7, ol cases of delirium in hospitalized alone or in combination to prevent VTE in these patients. patients can be prevented. Preventive strategies include the Guidance on VTE prevention strategies is provided by the use of assistive visual and hearing devices, optimization American Society of Hematologr and American College of Chest of pain control, minimization of psychoactive medications, Physicians. A patient's thrombotic risk can be determined by frequent reorientation, early mobilization, and allowance of

Hospita l-Based Prevention using a validated risk assessment model, such as the Padua L ; Strategies Prediction Score (Table 19). Ifbleeding risk is not elevated and t Hospitalized patients are at risk fbr many medical complica VTE risk is high (Padua Score >4), use of pharmacologic prophy tions, several of which can be mitigated through strategies laxis with daily low-molecular-weight heparin is recommended t aimed at prevention. Hospitalists are uniquely positioned to throughout the patient's hospital stay or until mobility is fully \ l reduce inpatient complications. Risk reduction strategies that recovered. In patients with an unacceptably high bleeding risk, are commonly initiated include venous thromboembolism mechanical prophylaxis with intermittent pneumatic compres- \ (VTE) prophylaxis, delirium prevention and screening, anti- sion may be used, although data supporting this approach in 5 biotic stewardship, discontinuation of catheters to prevent non-surgical patients is limited. In certain high-risk settings, catheter associated infections, prevention of aspiration, such as orthopedic and oncologic surgery extended duration interventions to reduce deconditioning and falls, bedsore VTE prophylaxis is recommended postdischarge. For more infbr- prevention initiatives, and medication reconciliation. mation, see Perioperative Medicine and MKSAP 19 Hematologr. VTE risk is elevated in hospitalized, immobile, and acutely Delirium is particularly common among hospitalized ill patients. More than 50'1, of VTE events occur during or after patients. For more information, see MKSAP 19 Pulmonary and hospitalization for acute illness or recent surgery. VTE risk is Critical Care Medicine and MKSAP 19 Neurologr. Patients at particularly high in ICU patients and patients with cancer or highest risk include those with advanced age, polypharmacy, stroke. Early ambulation, mechanical prophylaxis (such as inter- prior cognitive impairment, recent surgery and acute illness. mittent pneumatic compression devices applied to the lower Predisposing and provoking risk factors for delirium are listed exlremities), and prophylactic anticoagulants are used either in Table 20. Up to 40'7, ol cases of delirium in hospitalized alone or in combination to prevent VTE in these patients. patients can be prevented. Preventive strategies include the Guidance on VTE prevention strategies is provided by the use of assistive visual and hearing devices, optimization American Society of Hematologr and American College of Chest of pain control, minimization of psychoactive medications, Physicians. A patient's thrombotic risk can be determined by frequent reorientation, early mobilization, and allowance of 27