JHM 是医院医学学会的同行评审出版物，每年出版 12 次。 JHM 出版的手稿涉及住院成人或儿童的护理。感兴趣的广泛领域包括 (1) 常见住院疾病的治疗； (2) 改善围手术期护理的方法； (3) 改善对有老年或儿科脆弱性（如行动不便或具有复杂纵向护理）的住院患者的护理； (4) 创新医疗服务或教育模式的评估； (5) 在急性期和急性期后连续护理过程中提高医疗保健质量、安全性和价值的方法； (6) 评估影响医院和急性期后护理的政策和支付变化。

The Journal of Hospital Medicine (JHM) is a peer-reviewed publication of the Society of Hospital Medicine, published 12 times a year. The manuscripts published in JHM focus on the care of hospitalized adults and children. Areas of interest include: 1. Treatment of common inpatient diseases; 2. Methods to improve perioperative care; 3. Enhancing care for hospitalized patients with geriatric or pediatric vulnerabilities (such as mobility issues or complex longitudinal care needs); 4. Evaluation of innovative healthcare service or educational models; 5. Methods to improve healthcare quality, safety, and value during acute and post-acute care transitions; 6. Assessment of policy and payment changes affecting hospital and post-acute care.

《Journal of Hospital Medicine》是医院医学学会的同行评审期刊，每年出版12期。该期刊发表的手稿主要涉及住院成人和儿童的护理。我们关注的领域包括：1. 常见住院疾病的治疗；2. 改善围手术期护理的方法；3. 提升对老年或儿科脆弱患者（如行动不便或需要复杂纵向护理的患者）的护理质量；4. 创新医疗服务或教育模式的评估；5. 在急性期及急性期后连续护理过程中提高医疗质量、安全性和价值的方法；6. 评估影响医院及急性期后护理的政策和支付变化。

Journal of Hospital Medicine

Abstract Background Clinical trial evidence supports the routine use of intermittent pulse oximetry in stabilized infants hospitalized with bronchiolitis. However, continuous pulse oximetry use is common. Objective This study aimed to understand the barriers and facilitators to de‐implement continuous pulse oximetry and implement intermittent pulse oximetry in infants hospitalized with stabilized bronchiolitis. Methods This multicentre qualitative study interviewed attending pediatricians, residents, nurses, respiratory therapists, and caregivers of infants hospitalized with bronchiolitis at hospitals in Ontario, Canada, to explore beliefs, attitudes, and experiences regarding pulse oximetry use in bronchiolitis management. Data were analyzed using thematic analysis to understand barriers and facilitators to practice change, mapped to the Consolidated Framework for Implementation Research (CFIR) domains. Results Sixty‐seven participants from six hospitals were interviewed using individual interviews and focus groups. Healthcare providers emphasized the importance of identifying and understanding who is responsible for bedside pulse oximetry practice (physicians vs. nurses). Clinical experience, knowledge of guidelines, importance versus competing priorities, and the tensions among team members due to practice variation in monitoring, influenced monitoring practice. Nurses believed in the advantages of intermittent monitoring (reduced alarm fatigue, facilitation of timely discharges, and reduced workload). Clinicians identified ways to clarify indications for continuous monitoring (based on patient risk factors), versus indications to transition to intermittent monitoring (established oral feeding, sleeping without desaturations). Caregivers did not express a clear preference for monitoring type; rather, they described the need for clear communication around interpreting monitor readings, management decisions, and care transitions. Conclusions Understanding professional roles, clarity around local practice standards and supporting families' understanding of pulse oximetry practice is essential for practice change. These findings may inform hospital quality improvement efforts to de‐implement continuous monitoring in bronchiolitis hospital care.

Brie Yama

Gita Wahi

Kim Zhou

Ann Bayliss

Mahmoud Sakran

Karen Breen‐Reid

Catherine Pound

Carolyn Beck

Jeremy Friedman

Dana Arafeh

Ronik Kanani

Patricia Parkin

Sanjay Mahant

De‐implementing low‐value continuous pulse oximetry practice in infants hospitalized with bronchiolitis: A multicentre qualitative study

取消低价值连续脉搏血氧仪在住院治疗毛支气管炎婴儿中的应用：一项多中心定性研究

Hospitalists are often involved in quality and research efforts to improve care delivery in the inpatient setting.1 To assess the effectiveness of these efforts, new healthcare delivery initiatives may be evaluated by comparing clinical outcomes between patients who received the intervention and those who received usual care, which is commonly used as a control. Healthcare redesign and improvements often require complex interventions involving multiple components; therefore, simple study designs may not be appropriate.2 For example, in 2021, Schnipper et al.3 implemented a multifaceted intervention to improve the transition of care from hospital to ambulatory settings. This intervention had multiple components, including pharmacist-led medication reconciliation, patient education and coaching, post-discharge follow-up, and health information technology (HIT) enhancements. A traditional randomized controlled trial (RCT) at the individual level would have been impractical or impossible because some of the components required implementation at the hospital level (e.g., hospital-wide implementation of HIT) or primary care practice (e.g., education and coaching for all patients in a practice to avoid contamination). In situations when randomization at the individual level is impractical or not possible, randomization can be performed at the level of a group of individuals (cluster).2 Schnipper et al.3 used a stepped-wedge cluster randomized trial (SW-CRT) design, which is the primary focus of this methodological progress note. SW designs are becoming increasingly popular in hospital-based research studies, and hospitalists should be prepared to understand, participate in, and even lead large multisite CRTs. CRTs have become increasingly common in health services research as they are useful for evaluating interventions that represent new standards of care or new guidelines.4 The primary difference between traditional RCTs and CRTs is that, in CRTs, patients are randomized in groups or clusters rather than individually.5 Clusters are generally social or administrative units, which can range in size from small units, such as households or hospital floors, to larger units, such as clinics or entire healthcare systems.2 Although traditional RCTs are statistically more straightforward,6 there are many reasons why a CRT may be either more suitable than a traditional RCT or the only practical option for testing the clinical outcomes of an intervention (Table 1). One common reason is that some interventions can only be implemented at the system or cluster level, making individual randomization impractical.2, 6 For example, in the study discussed in the introduction, "health technology enhancements" may have to be implemented at the level of the hospital, eliminating the ability to randomize individuals in a single hospital to different technologies3 (see Table 1 for an additional example). CRT designs can also reduce the risk of contamination or the risk of the intervention "bleeding into" usual care.2, 6, 11 This is because the entire cohort is either implementing the intervention or continuing with the usual care. In the study by Schnipper et al.,3 contamination may occur when the same clinician is treating both an intervention and a control participant, allowing the "treatment" of one to influence the other. If a provider believes education and coaching are helpful, they may provide the same to a usual care participant. In a cluster trial, the entire hospital, clinic, or clinician is receiving the intervention, so a site can consistently treat all participants the same. One advantage of some CRTs compared to RCTs is the potential for waiving individual informed consent, particularly when the intervention is evidence-based with clear benefits and implemented as the new standard of care at the cluster level.2 As waiver of consent is based on the level of interaction with patients, the risk to patients, and the type of data collected, it is governed by local, national, and international ethical guidelines. Therefore, consultation with the local Institutional Review Board is essential. In a study by Oakeshott et al.,12 the research team aimed to assess the impact of providing laminated radiology guidelines to general practitioners on the rate of X-ray referrals. Because their primary outcome was the percentage of X-ray referrals received by the radiology department that conformed with the guidelines, the study did not require consent from individual patients or participating clusters. Simple cluster randomized design: Each cluster is randomized to either the intervention or control group, and the outcomes are compared between the two study arms. The advantage of this cluster design is its relative simplicity and potential ease of implementation. One disadvantage is that only half the clusters receive the intervention, which may not be well received if the intervention is likely to have a benefit.6, 13 Cluster with crossover randomized design: In this design, each cluster is randomized to either the intervention or control group, similar to the simple cluster design. However, after a certain period of time (usually halfway), the clusters switch or cross over to the other study arm. For this crossover design to work, the intervention must be able to be "turned on/off" so it does not carry over from the pre-crossover period into the post-crossover period (contamination across arms). For example, if the intervention leads to a permanent change (e.g., a vaccination), then a crossover study cannot be conducted as the vaccination cannot be undone. When a crossover trial is appropriate, a washout period after the crossover is often used to minimize contamination. When the intervention cannot be easily turned on/off, a cluster with a partial crossover design can also be used.6 A partial crossover occurs when only part of the clusters crossover to the other study arm (usually from usual care to implementation), while the remaining clusters stay in the usual care study arm for the entire duration of the study.6, 13 SW design: Can be considered a special type of cluster with crossover design5 and it is discussed in detail in the section below. In a SW-CRT design, the clusters are randomized into a few groups or waves that determine when each group will begin the intervention.4 All clusters begin the trial in the control arm and each cluster or wave of clusters cross over to the intervention on a staggered randomized schedule (steps). Once a cluster crosses over to the intervention, the intervention remains in place until the end of the study (Figure 1).5, 6 One advantage of the SW-CRT design is that all clusters eventually receive the intervention.4, 5, 15 This is particularly important if the intervention is believed or proven to be beneficial based on prior effectiveness research. This may allow the SW-CRT to focus on implementation outcomes in addition to effectiveness outcomes.16 Each cluster receiving the intervention may also help with stakeholder buy-in. Spacing the interventions over time allows for control of external temporal trends (secular trends).6 Since each cluster has pre- and postimplementation outcomes, one can make between and within-cluster comparisons. Therefore, compared to a single CRT, SW-CRTs tend to have increased statistical power, necessitating fewer clusters.15 SW-CRT designs are particularly suitable for situations in which it is not possible to roll out the intervention to all clusters at the same time. Reasons for rolling the intervention in steps may be related to financial, logistical, or other practical constraints.15 For example, the Non-pharmacological Options in Postoperative Hospital-Based and Rehabilitation Pain Management (NOHARM) trial assessed the effectiveness of an intervention bundle that included health technology clinical decision support and a portal-based conversation guide. The study had 22 clusters, randomized into five staggered steps, with the SW design advantageous to reduce the resourcing burdens associated with this large-scale implementation (e.g., staffing and training).14 Therefore, a small group of staff could concentrate their implementation efforts on one cluster at a time. Even though there are many advantages to using SW-CRTs, they are not always the best choice, so thoughtful consideration of all aspects of the design should be a priority. For example, informed consent can pose challenges for the SW-CRT designs because, in the United States, consent regulations were created with individual-level randomization in mind.4 In a SW-CRT, the randomization occurs at the cluster level rather than at the individual level, complicating the process of identifying research participants. Sometimes, a SW-CRT has both cluster-level participants (e.g., providers) and individual-level participants (e.g., patients). Informed consent may be required from clusters, individuals, or both.2 When individual consent is required for the completion of a SW-CRT, it can significantly hamper study recruitment (and, therefore, generalizability) and it can also introduce selection bias.15 To prevent selection bias one would have to enroll all members of a cluster or a randomly selected sample.11 Alternatives to traditional informed consent are waiver of consent or waiver of documentation of consent.4, 15 Finally, SW-CRTs are more likely to experience contamination compared to simple CRTs due to the complex coordination of care delivery involved. It can be difficult to fully control contamination both within and between clusters.15 The statistical design and analysis of CRTs, including SW-CRTs, can be complex with many special considerations that need to be considered (e.g., cluster size, variability within and between clusters, risk of co-interventions, or major temporal trends). Having an experienced statistician involved in every phase of the study is extremely valuable and often necessary.6 In general, CRTs require larger individual participant sample sizes compared to traditional RCTs to account for the correlation between cluster members. Members of the same cluster are more likely to have similar outcomes as compared to a randomly selected sample from the population of interest (e.g., all members of the cluster treated by the same provider or living in the same region with similar socioeconomic characteristics).2, 11 This tendency is known as "within-cluster homogeneity" and must be considered in the design and analysis of a CRT.2 Another general consideration when designing CRTs is trying to maximize the number of clusters that are being randomized. It is extremely important to select the lowest level cluster possible while keeping the risk of contamination at a minimum. For example, investigators may be more likely to randomize at the clinic level; however, to increase the number of clusters in the study and, therefore, improve statistical power, they may be able to randomize at the provider level.6 Finally, in healthcare CRTs the cluster size is often variable between clusters (e.g., different size hospitals). Having unequal cluster sizes will add additional statistical constraints as it decreases the power of the study as compared to a more balanced cluster design.6 CRT designs, including the SW design, can be great alternatives to traditional RCTs in health services research; however, they are not always the best choice. When considering the most suitable design for an intervention, investigators should consider the advantages and challenges of each design and provide a clear justification that supports their final choice. The SW design may be preferred over other CRT designs when all participants could benefit from the intervention; there is a need for buy-in from stakeholders when it is not possible to roll out the intervention to all clusters at the same time, and when trying to control for secular trends. Amanda Ullman's employer (UQ) has received investigator-initiated research grants from vascular access product manufacturers (3M, Becton Dickinson, and Medline) on behalf of her research, unrelated to the submitted project. David C. Brousseau receives consultancy funding from CSL Behring unrelated to this work. The remaining authors declare no conflicts of interest.

Alina G. Burek

Amanda Ullman

David C. Brousseau

Methodological progress note: Stepped‐wedge cluster randomized trial design

方法学进展笔记：阶梯楔形群随机试验设计

To describe the patient characteristics, indications, and clinical outcomes of home high flow nasal cannula (HFNC) among pediatric patients. To evaluate secular trends in home HFNC initiation between 2013 and 2022.

David D'Arienzo

Liam Sanvido

Reshma Amin

Catherine Diskin

Eyal Cohen

Indications and outcomes of pediatric high flow nasal cannula use in the home setting

家庭环境中儿童高流量鼻导管使用的适应症和结果

Radiologic studies are critical diagnostic tools, yet stewardship is essential to minimize ionizing radiation exposure and anesthesia events associated with childhood imaging. As a result, imaging reduction has become a popular deimplementation objective in the pediatric hospital setting. However, little is known about the relative prevalence of imaging across broad diagnostic categories. Understanding such patterns may help to prioritize imaging-oriented quality improvement efforts for distinct conditions. In this month's Journal of Hospital Medicine, Desai et al.1 explore imaging for medical and surgical conditions within the Pediatric Health Information System (PHIS) database. Analyzing >800,000 encounters from 2017 to 2019 at 50 hospitals, the authors identified common conditions with the greatest imaging prevalence and associated cost. In addition, they utilized an intraclass correlation coefficient (ICC) to assess variation in imaging costs within and between hospitals. Across all conditions, the use of any imaging was highest among encounters for pectus excavatum, scoliosis, and intestinal obstruction, while imaging costs were highest among fractures, trauma, and appendicitis. The authors identified frequent use of imaging for conditions in which it is typically discouraged, including asthma, bronchiolitis, and constipation. Conditions with high ICCs, specifically indicating wide variation in cost across hospitals (relative to within-hospital variation), included scoliosis, preseptal cellulitis, dental abscess, and retropharyngeal abscess.1 The authors' findings corroborate existing literature on imaging for medical conditions in hospitalized children. The high rates of x-rays observed for bronchiolitis, asthma, and constipation signal continued overuse of services not recommended by current clinical guidelines.1, 2 While this analysis cannot ascertain whether nuanced clinical features support a divergence from clinical guidelines in some cases, these data suggest a need for ongoing measurement and structured deimplementation of these services. Notably, the literature suggests that previously improving trends in non-recommended imaging, perhaps influenced by national campaigns focused on radiation reduction, have demonstrated reversal in recent years, with increasing rates of non-guideline-concordant imaging observed for some conditions.2 The authors estimate that imaging costs associated with bronchiolitis, asthma, and constipation exceeded $10 million over this study period,1 which may underestimate current costs given these trends. ICCs revealed high variation across hospitals in a subset of medical and medical/surgical conditions. The identified variation in imaging for preseptal cellulitis and retropharyngeal abscess aligns with literature suggesting variation in many aspects of care for these relatively common conditions, including antimicrobial and surgical management in addition to imaging approach.3, 4 The culmination of literature surrounding these conditions, including the current study, suggests a need for prospective trials and, as the authors note, clinical guideline development. The surgical data provided by this study are novel and warrant attention. Given the acuity associated with surgical diagnoses and procedures, high rates of imaging for these conditions may be expected. However, the hospital-level variation in imaging costs associated with encounters for conditions such as scoliosis and pectus excavatum has not, to our knowledge, been previously documented. Optimal pre- and postoperative care procedures associated with these conditions are not currently well described; variation identified in this study supports a need for a better understanding of imaging indications in these conditions, research exploring the association of imaging practices with clinical outcomes, and development of care pathways minimizing "routine" imaging that may not influence management. For both medical and surgical conditions, efforts to measure variation in care have advanced in recent years, optimizing opportunities for clinicians and improvers to efficiently measure comparative performance. Within PHIS, dashboards allow participating hospitals to access real-time performance data in a variety of areas, including some non-recommended imaging studies.2 The American College of Surgeons Pediatric National Surgical Quality Improvement Program offers participants access to comparative performance data surrounding common pediatric surgical procedures.5 As analytic capacity grows and real-time data become more accessible, there are new opportunities to leverage these tools to achieve standardization, particularly in areas where strong literature supports best practices. Analysis of center-specific data can prioritize improvement resources toward services where variation is high, allow identification of top performers who may share improvement best practices, and allow determination of objective utilization targets based on the range of performance demonstrated by hospitals. Hospitals with access to such infrastructure should develop methods of continuous data monitoring linking to improvement initiatives. Concurrently, attention is needed to develop measurement strategies viable in smaller hospitals, where many of the conditions studied by Desai et al. are cared for and where performance data availability remains scarce. The results of this study highlight that continued efforts are needed to delineate imaging best practices for some conditions, including a subset of costly surgical and medical/surgical conditions, while efforts toward guideline-compliant care are still warranted for several common medical diagnoses. Desai et al. also remind us that the incorporation of surgical data and diagnoses is a critical step as we aim to achieve high-value care in children's hospitals, supporting the ongoing development of quality leadership programs in pediatric surgery. The authors declare no conflicts of interest.

Alaina Shine

Reto Baertschiger

Samantha A. House

Standardizing imaging practices: An opportunity to leverage modern measurement tools

标准化成像实践：利用现代测量工具的机遇

Abstract Survivors of acute respiratory failure (ARF) have complex healthcare needs postdischarge, frequently resulting in unmet needs. This prospective multicenter study explores the association between COVID‐19 status and unmet healthcare needs in survivors of ARF following hospital discharge. We analyzed patient characteristics and unmet healthcare needs by COVID‐19 status using a multivariable regression model with propensity weights. Among 195 patients in the final analysis, 54% were COVID‐19+, 53% were female, 42% were non‐White, and the median (interquartile range [IQR]) age was 54 (42–63). The median (IQR) percentage of unmet healthcare needs was 26% (17%–36%), with follow‐up appointments accounting for most unmet needs. Unmet medication needs were found to be very low at 6%. Despite the challenges in healthcare delivery during the COVID‐19 pandemic, our data suggest COVID status had no observable effect on unmet healthcare needs for ARF survivors, after controlling for patient baseline and clinical status.

Harris L. Carmichael

Danielle Groat

Victor D. Dinglas

Somnath Bose

Mustafa Mir Kasimov

James C. Jackson

Naga Preethi Kadiri

Maria Isabel Trejo‐Zambrano

Carla M. Sevin

Tom Green

Dale M. Needham

Samuel M. Brown

Effect of the COVID‐19 pandemic on unmet healthcare needs after hospital discharge in acute respiratory failure survivors: A multicenter prospective cohort study

COVID-19大流行对急性呼吸衰竭幸存者出院后未满足医疗需求的影响：一项多中心前瞻性队列研究

Hurricane Maria devastated Puerto Rico in 2017, wreaking havoc on the national pharmaceutical and medical supply industries, which are largely concentrated on the island.1 The impact was profound, particularly on the supply of small bags of intravenous (IV) fluids. For months afterward, hospitals across the United States struggled to obtain basic IV fluids, forcing clinicians to rethink how and when they used these products. The crisis highlighted the vulnerability of our healthcare supply chain to environmental disasters and underscored the need for more judicious use of IV fluids in the inpatient setting. In the wake of Hurricane Helene in September 2024, we find ourselves grappling with similar supply chain disruptions. By mid-October, ~86% of US physicians and providers had experienced IV fluid shortages.2 Some hospitals delayed noncritical surgeries3 and many hospitals continue to ration IV fluids until supplies return to their pre-Helene levels.4 These events, which are associated with the increasing frequency and intensity of natural disasters due to climate change, demand long-term solutions. Hospitals face numerous challenges from extreme weather across the clinical care continuum. In addition to critical supply shortages, climate change and extreme weather can affect disease patterns (e.g., heat-related illness, injury, and vector-borne illnesses), resulting in care interruptions, and delay in diagnosis and treatment. As health care providers, it is incumbent upon us to not just treat the patient in front of us, but also to do our part in resource utilization to reduce waste and decrease patient care related greenhouse gas contributions and environmental harms that spur these events. Rather than relying on reactive and temporary workarounds, such as rationing supplies or importing from less-affected regions, it is time to reassess our dependency on IV fluids. While they are a cornerstone of inpatient care, used for everything from volume resuscitation in shock to rapid medication delivery, more environmentally sustainable, evidence-based practices exist that prioritize patient safety while conserving resources. We must also address the lack of supply chain resiliency and support broader efforts to reduce healthcare's large, negative environmental impact. There is growing evidence that IV fluids are often administered unnecessarily or continued longer than clinically indicated. The proportion of hospitalized patients who can safely receive oral hydration instead of IV fluids is likely substantial, particularly in cases where oral intake is feasible and safe. For patients with infectious diarrhea, the Infectious Diseases Society of America recommends oral rehydration solutions as the first line therapy for mild to moderate dehydration.5 In patients with chronic kidney disease undergoing contrast-enhanced CT or cardiac catheterization, oral hydration was as effective as IV hydration in preventing contrast-associated acute kidney injury.6, 7 Oral rehydration for clinically stable patients with hypernatremia has demonstrated safety in pediatric populations, and could be implemented for adult inpatients.8 Avoiding low-value practices restricting oral intake can reduce the use of IV fluids. Examples include shortening pre-procedure fasting times9 and early resumption of enteral nutrition for acute pancreatitis.10 Even for patients with dysphagia, a study by Leder et al. demonstrated that 90.7% of hospitalized patients who passed a 3-ounce water swallow challenge could be advanced to oral diets without subsequent signs of aspiration.11 Many medications such as antibiotics can be administered through IV push (like cefazolin and meropenem)12 or orally (as in azithromycin or fluroquinolones) with equal efficacy.13 IV proton pump inhibitors in the setting of upper gastrointestinal bleed can be administered as infusions or intermittently as twice a day IV pushes or oral therapy after the initial 80 mg bolus, according to American College of Gastroenterology guidelines.14 Wherever fluids can be minimized, doing so provides multiple benefits including improved resource utilization and ease of nursing medication administration. Overuse in these cases is not only wasteful but also increases the risk of complications such as fluid overload, electrolyte imbalances, and prolonged hospital stays in patients with heart failure and other conditions. Moreover, the unnecessary use of IV lines increases the risk of infections and thrombophlebitis, adding to patient morbidity. Despite the evidence, excess use of IV fluids and medications remains a default practice in many hospitals. The reasons are multifaceted. Orders may be part of standard protocols, sometimes with little thought given to whether they are truly necessary. Many clinicians view IV fluid administration as a simple, low-risk intervention to "do something" for patients, especially where the clinical picture is uncertain. The complex nature of insurance reimbursements also contributes to this confusion, as the use of IV fluids and medications can be perceived as the difference between inpatient and observation status. This mindset contributes to a cycle of overuse that is difficult to break. Using IV fluids and medications more judiciously and developing better decision-making frameworks for fluid management also includes work to reduce our overall dependency on IV medications. A report by the Department of Health & Human Services identified more than 25% of drug and device manufacturers are located in areas at high risk of natural hazards including flooding, tornadoes, earthquakes, and hurricanes.15 The climate change-induced disruptions caused by Hurricanes Maria and Helene offer opportunities to reevaluate our use of IV fluids. These events have forced hospitals to implement multifaceted measures aimed at conserving supplies, such as encouraging oral hydration when possible, limiting the use of IV fluids to critically ill patients, changing medications to oral equivalents, and more carefully monitoring fluid balance. From a greenhouse gas emissions perspective, the production of 500 mL of IV fluids generates about 0.5 kg of carbon dioxide equivalents (CO2e).16 If we can reduce annual usage by 25%, this could save emissions equivalent to driving a passenger car nearly 800,000 miles, or 285 trips from California to Maine in the United States. This rough estimate and other high-value care practices highlight the broader environmental benefits of simultaneously improving healthcare sustainability and potential cost reductions.17 Conservation strategies should not be seen as temporary measures but as part of a broader shift toward more mindful and evidence-based fluid management practices. Hospitals should consider implementing stricter guidelines for IV fluid administration. This includes regular reassessment of fluid needs, limiting automatic inclusion of IV fluids in admission orders, or requirements to reorder continuous IV fluids after a prespecified amount of time. Clinical decision support tools can help guide fluid management based on the patient's condition. For example, ask clinicians to consider if oral equivalents or oral hydration with fluid intake goals would be an appropriate first-line approach for patients with active diet orders. The practice of "keeping veins open" with IV fluids may also not be required as studies in the pediatric population suggest no difference between saline lock and continuous infusion on IV patency.18 As hospitalists, many of us are involved in administrative roles including resource utilization and supply chain issues as a part of process improvement and providing higher value. By taking steps now to reassess our utilization, we can create more resilient and adaptable healthcare systems better equipped to face the challenges of the future. This latest IV fluid shortage is not a supply chain anomaly. The COVID-19 pandemic is a lingering reminder that even the most basic elements of medical care are not immune to the forces of nature.19 Aside from causing severe equipment shortages, it also catapulted telehealth, once considered an aspirational next step for medicine, to the forefront of ambulatory care. Natural disasters, pandemics, and future unknown threats provide opportunities for innovation, improvement, and adoption of more sustainable practices. Rigorous and systematic research into best practices and disaster preparedness should be undertaken to inform our institutional policies and priorities given the increasing likelihood of future supply disruptions. Changing practice patterns will require more than updated guidelines and decision support tools. A cultural shift is necessary to reduce the default reliance on IV fluids and medications in inpatient care and to move to more sustainable hospital practice in general. This starts with education. Physicians, nurses, and other healthcare providers need to be trained in the risks associated with unnecessary IV fluid use and the benefits of alternative approaches. They should also be apprised of the downstream environmental harms of hospital waste and overuse and how this can adversely impact our communities and patients.20 Medical schools and residency programs should emphasize evidence-based fluid management, teaching future clinicians to carefully weigh the risks and benefits of IV fluid administration. Continuing education programs for practicing providers can also help to reinforce these principles, especially in the context of supply chain vulnerabilities and disaster preparedness. Medical societies also have a role in driving sustainable healthcare delivery through clinical practice guidelines. Members of the Medical Society Consortium on Climate and Health have committed to addressing climate change and health issues through their organizations and collectively through policy action and educational offerings. The frequent disruptions in IV fluid supplies due to climate disasters such as Hurricanes Maria and Helene highlight an urgent need to reduce overreliance on these products in the inpatient setting. We must seize this moment to promote smarter, evidence-based practices that not only conserve valuable resources but also enhance patient safety and care outcomes. This shift will require systemic changes, from updating clinical guidelines to fostering a culture that questions the routine use of IV fluids. By doing so, we can create a more resilient, patient-centered healthcare system capable of withstanding the growing pressures of climate-related disruptions (Table 1). The authors declare no conflict of interest.

Elizabeth A. Cerceo

Katherine T. Liu

Evans K. H. Brown

Catherine Chen

The impact of climate change induced natural disasters on healthcare: Rethinking intravenous fluids

气候变化引发的自然灾害对医疗保健的影响：重新思考静脉输液

Our patient was dying from advanced cancer. He came to our hospital in search of a second opinion, but our oncologists deemed that there were no cancer-directed treatments to offer him. He spent the last month in and out of the intensive care unit (ICU) with life-threatening complications from his cancer. Upon transfer to our medicine service, the ICU team told us that he remained full code after several discussions. We were advised not to ask about his code status again. The tracheostomy that was placed to protect his airway from the unchecked growth of his cancer had saved his life but had stolen his ability to speak. Instead, he used a hand-held whiteboard to communicate. On my daily rounds, I'd speak to him, and he'd answer me by slowly writing on the whiteboard. One day, seemingly out of nowhere, he asked about hospice. I asked if he knew much about it. He slowly nodded and then wrote: "My friend died on hospice." He wanted to speak further with his family about hospice, so we arranged a family meeting a few days later. Our primary team met with him, his family, and the palliative care team in his small isolation room. We gathered around his bed and learned that his family wanted to care for him at home. After confirming everyone agreed to home hospice, the palliative team asked him again about his code status. He confirmed to us his wishes to remain Full Code. On my 10th day taking care of him I lost my voice. During my rounds, we spoke through gestures and took turns writing on the whiteboard. As we passed the marker back and forth, alternately wiping down the board, I appreciated how communicating through writing makes you slow down and deliberate over every word. On my last day of service, my voice had returned enough to speak to my patients again. When I rounded on him, I decided to ask again. The discrepancy between his desire to be on home hospice to focus on comfort and to be full code in such a frail and terminal state made me think that I still had more to learn and understand. He took the whiteboard and marker from me. His unsteady hands slowly wrote: "Do not resuscitate. No CPR please." I held his hand and told him I would ensure that his wishes were honored. I snapped a photo of the whiteboard with his wishes written on it, uploaded it to his chart, and wrote an advanced care planning note that documented his change in code status and referred to the photo. I wanted others to bear witness to his words. That afternoon I went home, ate dinner with my family, and put my children to sleep. I laughed with my husband, sang my baby a lullaby, and read my toddler a bedtime story. I went to bed knowing I had made it through 14 days of service and that my colleague would pick up where I left off. The next day, I watched my baby play while his room was lit by springtime sunlight and saw my daughter off to school. The diastole of off-service time was setting in. By late morning, my colleague reached out. While I was sleeping, our patient decompensated, and by the morning he was nonresponsive and died shortly after. He was not resuscitated. I've thought a lot about those 2 weeks. The way a lost voice helped me slow down and find perspective. The way that asking about hospice in the same breath as mentioning his friend's death told me he knew he was dying. The way a question changed how his life ended less than 24 h later. The way he used the word please. I'm haunted by his use of the word. I know that he carefully chose it. Every day I remind my daughter to say please, but I typically think of it as a matter of manners or as a gift I can give her to help her become a better person. As physicians, we are gifted with the power and privilege to ask questions. The answers we get can change how we care for our patients. As I enter the end of my first decade as an attending hospitalist, I ask myself to remember to ask, to never assume, and to listen, please. The author declares no conflicts of interest.

Sydney Katz

Please

The author declares no conflict of interest.

Justin J. Roesch

The virtue of vulnerability

脆弱的美德

High levels of noise in hospital settings can make communication difficult, especially for older adults. Assistive Listening Devices (ALDs) are personal amplifiers that can improve hearing in background noise. This study investigated the impact of providing ALDs to hospitalized patients 60 years of age and older without using hearing screenings to determine eligibility. Results indicated that 96% of the patients reported that ALD was easy to use and 88% found it helpful. The ALD was used to communicate with family, hospital staff, and physicians. This suggests ALDs can be distributed to patients 60 years and older without any hearing screenings.

Abbreviation	J. Hosp. Med.
Journal Impact	2.38
Quartiles(Global)	MEDICINE, GENERAL & INTERNAL(Q1)

ISSN	1553-5592, 1553-5606
h-index	81

Publication Information	Publisher: John Wiley and Sons Inc，Publishing cycle: Bimonthly，Journal Type: journal，Open Access Journals: No
Basic data	Year of publication: 2006，Proportion of original research papers: 92.35%，Self Citation Rate:16.70%， Gold OA Rate: 12.50%
Average review cycle	网友分享经验：偏慢,4-8周
Average recruitment ratio	网友分享经验：容易

Journal of Hospital Medicine

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Please

The virtue of vulnerability

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Benefit of using an assistive listening device in a hospital setting