Potentially avoidable admissions to general internal medicine at an academic teaching hospital: an observational study

Avoidable admissions screening, flagging and case review methodology. 1) Our method captured GIM admissions from the preceding 24 hours (8 am to 8 am) and excluded patients transferred from other institutions, admitted from the clinic or transferred from the intensive care unit or surgical services. Each morning, 7 days a week, we randomly selected 2 GIM teams through random number generation. 2) We emailed staff physicians at 8 am with a prepopulated list of their admissions, asking them to review our definition of a potentially avoidable admission and to flag candidates. 3) The email response from the staff physician was reviewed including the rationale for avoidability and a list was compiled of all flagged candidates. 4) For each flagged candidate, we reviewed the admission consultation note and electronic medical record up to the time of admission decision-making to prepare a case review. 5) A semistructured debrief was conducted with the admitting resident physician within 24–48 hours of the admission date. We explored case details and contributing patient, provider and system factors. 6) At least 3 members of the research team met weekly and reviewed case summaries of flagged candidates along with data obtained from debriefs. We estimated the degree of avoidability of each candidate (1 = no evidence of avoidability, 2 = avoidability unlikely, 3 = avoidability likely and 4 = certain evidence of avoidability). A final decision of avoidability was determined by consensus vote. For candidates with avoidability scores of 3 or more, we discussed patient, provider and system factors. Note: GIM = general internal medicine.