Little current evidence documents how internal medicine residents spend their time at work, particularly with regard to the proportions of time spent in direct patient care versus using computers. To describe how residents allocate their time during day and evening hospital shifts. Time and motion study. Internal medicine residency at a university hospital in Switzerland, May to July 2015. 36 internal medicine residents with an average of 29 months of postgraduate training. Trained observers recorded the residents' activities using a tablet-based application. Twenty-two activities were categorized as directly related to patients, indirectly related to patients, communication, academic, nonmedical tasks, and transition. In addition, the presence of a patient or colleague and use of a computer or telephone during each activity was recorded. Residents were observed for a total of 696.7 hours. Day shifts lasted 11.6 hours (1.6 hours more than scheduled). During these shifts, activities indirectly related to patients accounted for 52.4% of the time, and activities directly related to patients accounted for 28.0%. Residents spent an average of 1.7 hours with patients, 5.2 hours using computers, and 13 minutes doing both. Time spent using a computer was scattered throughout the day, with the heaviest use after 6:00 p.m. The study involved a small sample from 1 institution. At this Swiss teaching hospital, internal medicine residents spent more time at work than scheduled. Activities indirectly related to patients predominated, and about half the workday was spent using a computer. Information Technology Department and Department of Internal Medicine of Lausanne University Hospital.

Background Elevated red blood cell distribution width (RDW) is a valid predictor of outcome in acute heart failure (AHF). It is unknown whether elevated RDW remains predictive in AHF patients with either preserved left ventricular ejection fraction (LVEF) ≥50% or reduced LVEF (<50%). Methods and results Prospective local registry including 402 consecutive hospitalized AHF patients without acute coronary syndrome or need of intensive care. The primary outcome was all-cause mortality (ACM) at 1 year after admission. Demographic and clinical data derive from admission, echocardiographic examinations (n = 269; 67%) from hospitalization. The Cox proportional hazard model including all patients (P < 0.001) was adjusted for age, gender, and RDW quartiles. Independent predictors of 1-year ACM were cardiogenic shock (HR 2.86; CI: 1.3–6.4), male sex (HR 1.9; CI: 1.2–2.9), high RDW quartile (HR 1.66; CI: 1.02–2.8), chronic HF (HR 1.61; CI: 1.05–2.5), valvular heart disease (HR 1.61; CI: 1.09–2.4), increased diastolic blood pressure (HR 1.02 per mmHg; CI: 1.01–1.03), increasing age (HR 1.04 by year; CI: 1.02–1.07), platelet count (HR 1.002 per G/l; CI: 1.0–1.004), systolic blood pressure (HR 0.99 per mmHg; CI: 0.98–0.99), and weight (HR 0.98 per kg; CI: 0.97–0.99). A total of 114 patients (28.4%) died within the first year; ACM of all patients increased with quartiles of rising RDW (χ² 18; P < 0.001). ACM was not different between RDW quartiles of patients with reduced LVEF (n = 153; χ² 6.6; P = 0.084). In AHF with LVEF ≥50% the probability of ACM increased with rising RDW (n = 116; χ² 9.9; P = 0.0195). Conclusions High RDW is associated with increased ACM in AHF patients with preserved but not with reduced LVEF in this study population.

EXECUTIVE SUMMARYBackgroundInadequate discharge planning for the growing elderly population poses significant challenges for health services. Effective discharge planning interventions have been examined in several studies, but little information is available on nursing's role or the specific compon

Aims We evaluated the effectiveness of a multidisciplinary transition plan to reduce early readmission among heart failure patients. Methods and results We conducted a before‐and‐after study in a tertiary internal medicine department, comparing 3 years of retrospective data (pre‐intervention) and 13 months of prospective data (intervention period). Intervention was the introduction in 2013 of a transition plan performed by a multidisciplinary team. We included all consecutive patients hospitalized with symptomatic heart failure and discharged to home. The outcomes were the fraction of days spent in hospital because of readmission, based on the sum of all days spent in hospital, and the rate of readmission. The same measurements were used for those with potentially avoidable readmissions. Four hundred thirty‐one patients were included and compared with 1441 patients in the pre‐intervention period. Of the 431 patients, 138 received the transition plan while 293 were non‐completers. Neither the fraction of days spent for readmissions nor the rate of readmission decreased during the intervention period. However, non‐completers had a higher rate of the fraction of days spent for 30 day readmission (19.2% vs. 16.1%, P = 0.002) and for potentially avoidable readmission (9.8% vs. 13.2%, P = 0.001). The rate of potentially avoidable readmission decreased from 11.3% (before) to 9.9% (non‐completers) and 8.7% (completers), reaching the adjusted expected range given by SQLape® (7.7–9.1%). Conclusions A transition plan, requiring many resources, could decrease potentially avoidable readmission but shows no benefit on overall readmission. Future research should focus on potentially avoidable readmissions and other indicators such as patient satisfaction, adverse drug events, or adherence.

Objectives To assess the feasibility and main obstacles to the implementation of a medication reconciliation (MR) process in a Swiss hospital and to develop a standardised method which can be used in similar healthcare systems. Methods For this prospective, observational single-centre and single-ward study, a best possible medication history (BPMH) was established by a clinical pharmacist for 147 patients with heart failure based on two sources and a patient interview for each case. Identified discrepancies with medication histories established during emergency service were conveyed to the ward physician. At the end of each hospital stay, the planned discharge treatments were compared with the BPMHs to identify discrepancies and to propose modifications. After a final validation, the comparative treatment plans were distributed. Results MR was conducted for 120 (82%) patients and the mean time needed was 74 min/patient. At least one discrepancy was identified among 94% of the patients on admission, with 4.1 discrepancies found per patient (mainly omissions). At discharge, 83% of the patients had at least one discrepancy, with 2.3 discrepancies found per patient (mainly unintentional substitutions). The majority (86%) of pharmaceutical interventions to adjust the discharge prescriptions were accepted by the physician. Conclusions A standardised method of MR which offers precise definitions of discrepancies and key tools for the process was developed. This method was applicable to most of our cohort and it effectively identified medication discrepancies. Two potential obstacles for its implementation are the time needed for MR and the questionable impact of pharmaceutical interventions on discrepancies.