Homeless patients with chronic medical conditions who need long-term care often repeatedly present to emergency departments to receive treatment. Following a performance improvement analysis, clinicians at UCSF developed an emergency department–based team who work with the community to provide care for this challenging population. Hemal Kanzaria, MD, and Jack Chase, MD, discuss how UCSF has addressed this clinical problem.

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There are hundreds of thousands of liver transplant patients, all of whom will be seen in general clinical practices. It is common for them to develop elevated liver enzymes—a potentially serious problem that may be a sign that the transplanted liver is failing. Traditionally, patients with these findings are sent to a liver transplant center for an inpatient workup. A new protocol facilitating management of most of these patients in routine outpatient clinics has been developed, greatly improving the efficiency of managing patients with this clinical problem. Fady Kaldas, MD, director of the Dumont-UCLA transplant center, discusses how to manage elevated liver function results in liver transplant patients on an outpatient basis.

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Outpatient Management of Liver Function Test Abnormalities in Patients With a Liver Transplant

As physicians age, they experience the inevitable decline of cognitive and physical function. It is not clear how that affects clinical practice. Jeffrey Saver, MD, vice chair of neurology at UCLA and a JAMA Associate Editor, discusses how to best assess the clinical performance of aging physicians.

The Aging Clinician: When Should Older Clinicians' Cognitive Abilities Be Evaluated?, Part 1

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Cognitive Testing of Older Clinicians Prior to Recredentialing

More than a third of the physician workforce is older than 60 years, and 10% are older than 70 years. Cognitive abilities may decline with age but how cognition affects clinical practice is unknown. It is also not clear how clinicians’ cognitive ability can be measured and acted upon when diminished without committing age discrimination. Two major academic hospitals launched programs to test cognitive abilities in older physicians applying for renewal of their medical staff privileges. It went well for one and not well for the other hospital. Yet, in the hospital where the testing program was carried out, several clinicians who were not suspected of having any problems had profoundly affected cognition. Leo Cooney, MD, from Yale-New Haven Medical Center, and Anne Weinacker, MD, from Stanford Health Care, discuss their experiences in dealing with these difficult issues.

The Aging Clinician: When Should Older Clinicians' Cognitive Abilities Be Evaluated?, Part 2

Read the article: Cognitive Testing of Older Clinicians Prior to Recredentialing

Chaos in the emergency department is common. How to fix it is not always clear. Mary P. Mercer, MD, MPH, from the University of California, San Francisco, discusses how they successfully fixed their long dwell times at the emergency department at San Francisco General Hospital. Their solution was to create a fast-track unit that managed low-acuity patients separately from the rest of the emergency department cases. The most important aspect of this quality improvement effort was the ongoing and regular engagement of executives from the medical center with frontline staff.

Read the article: Reducing Emergency Department Length of Stay

Electronic health records are the bane of most clinicians’ existence. They were supposed to help us but not only have they made life more difficult for clinicians, they are the cause of medical errors. Described here is a case of the patient receiving an unnecessary procedure because an order was not canceled in an EHR where it had disappeared from the clinicians’ view. A second theme in this case that is consistent in nearly all of the JAMA Performance Improvement articles to date is inadequate communication among clinicians.

One promise of electronic medical records (EMRs) was to reduce medication errors. That may not have occurred since one type of error, illegible orders, has been replaced by another: Order sets may incorrectly match a patient and necessary treatments. In this JAMA Performance Improvement podcast, we review a case in which guideline-based care was incorporated into an order set, then the guideline changed but the order set did not, resulting in a post-STEMI patient receiving β-blockers when they were contraindicated. Interviewees included Arjun Gupta, MD, University of Texas Southwestern Medical Center, and Jennifer L. Rabaglia, MD, MSc, Parkland Health and Hospital System, Dallas, Texas.

Learning Objectives: To understand the role of β-blocker treatment in patients with acute myocardial infarction; to understand how EMR order sets should be developed and maintained.

https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2018.0845

One-third of the US population is obese. Obesity is a major risk factor for obstructive sleep apnea. This condition is very common, and patients with sleep apnea are at risk of major complications from sedation. This JAMA Performance Improvement podcast reviews a case of a patient who did poorly after he was sedated for a medical procedure. Interviewees include Joshua Pevnick, MD, MSHS, from Cedars-Sinai Medical Center, and Jason R. Farrer, MD, from Northwestern Medical Faculty Foundation.

Related article: Oversedation of a Patient With Obstructive Sleep Apnea Prior to Imaging