Kara, Areeba

Abstract Background Geographic cohorting (GCh) is a popular model of care that localizes physician teams to a single hospital unit. Objectives We conducted a scoping review identifying the aims, implementation strategies, study methods, and measured outcomes of GCh. Methods We searched the medical literature analysis and retrieval system online, Embase, and Scopus databases. Eligible citations included English language reports of interventions including GCh in adult patients. Included studies were screened for their aim, GCh implementation strategy, study method, and outcomes measured. Results Of 1863 identified citations, 30 met inclusion criteria, representing 27 interventions. Implementation aims varied from specific goals measured by a single metric to multiple outcomes intended to capture wide‐ranging effects of GCh. A majority of studies ( n = 13, 48.1%) used a pre‐post cohort design. GCh was implemented in one of four ways: (1) as a stand‐alone intervention, (2) bundled with accountable care unit elements, (3) bundled with care components that did not include all ACU elements, (4) GCh bundled with ACU elements and additional components (“enhanced” ACU). The measured outcomes sorted to eight different categories: patient outcomes, patient safety, patient experience, work flow, workload, clinician experience, communication/team work, and cost. Conclusions The current literature on GCh describes implementation as both a stand‐alone intervention and bundled with other care elements. Current research has not delineated whether the degree to which GCh is implemented matters, nor what impact it has as part of a bundled care intervention. Future work would benefit from a prospective design that clarifies these questions, facilitating care models tailored to the needs of the practice ecosystem.

Abstract Background “Decision Fatigue” (DF) describes the impaired ability to make decisions because of repeated acts of decision‐making. Objectives We conducted a scoping review to describe DF in inpatient settings. Methods To be included, studies should have explored a clinical decision, included a mechanism to account for the order of decision making, and be published in English in or after the year 2000. Six databases were searched. Retrieved citations were screened and retained studies were reviewed against the inclusion criteria. References of included studies were manually searched, and forward citation searches were conducted to capture relevant sources. Results The search retrieved 12,781 citations, of which 41 were retained following screening. Following review, 16 studies met the inclusion criteria. Half were conference abstracts and none examined hospitalists. Emergency medicine and intensive care settings were the most frequently studied clinical environments ( n = 13, 81%). All studies were observational. The most frequently examined decisions were about resource utilization ( n = 8, 50%), however only half of these examined downstream clinical outcomes. Decision quality against prespecified standards was examined in four (25%) studies. Work environment and patient attributes were often described but not consistently accounted for in analyses. Clinician attributes were described in four (25%) investigations. Findings were inconsistent: both supporting and refuting DF's role in the outcome studied. Conclusions The role of clinician, patient, and work environment attributes in mediating DF is understudied. Similarly, the context surrounding the decision under study require further explication and when assessing resource use and decision quality, adjudication should be made against prespecified standards.

Members of the Society of Hospital Medicine were surveyed about geographic cohorting (GCh); 369 responses were analyzed, two thirds of which were from GCh participants. Improved collaboration with the bedside nurse, increased nonclinical interactions, decreased paging interruptions, and improved efficiency were perceived by >50%. Narrowed clinical expertise, increased fragmentation, increased face-to-face interruptions, and an adverse impact on camaraderie within the hospitalist group were reported by 25% to 50%. Academic practices were associated with positive perceptions while higher patient loads were associated with negative perceptions. Comments on GCh benefits invoked improvements in (1) interprofessional collaboration, (2) efficiency, (3) patient-centeredness, (4) nursing satisfaction, and (5) GCh mediated facilitation of other interventions. GCh downsides included (1) professional and personal dissatisfaction, (2) concerns about providing suboptimal care, and (3) implementation barriers. GCh is receiving attention. Although it facilitates important benefits, it is perceived to mediate unintended consequences, which should be addressed in redesign efforts.