Showing papers in "Journal of Hospital Medicine in 2006"

Lean health care: what can hospitals learn from a world-class automaker?

Abstract: BACKGROUND With health care costs continuing to rise, a variety of process improvement methodologies have been proposed to address the reported inefficiencies in health care delivery. Lean production is one such method. The management philosophy and tools of lean production come from the manufacturing industry, where they were pioneered by Toyota Motor Corporation, which is viewed as the leader in utilizing these performance improvement methods. Lean has already enjoyed tremendous success in improving quality and efficiency in both the manufacturing and the service sector industries. RESULTS Health care systems have just begun to utilize lean methods, with reports of improvements just beginning to appear in the literature. We describe some of the basic philosophy and principles of lean production methods and how these concepts can be applied in the health care environment. We describe some of the early success stories and ongoing endeavors of lean production in various health care organizations. We believe the hospital is an ideal setting for use of the lean production method, which could significantly affect how health care is delivered to patients. CONCLUSIONS We conclude by discussing some of the potential challenges in introducing and implementing lean production methods in the health care environment. Lean production is a novel approach to delivering high-quality and efficient care to patients, and we believe that the health care sector can anticipate the same high level of success that the manufacturing and service industries have achieved using this approach. Hospitalists are primed to take action in delivering care of greater quality with more efficiency by applying these new principles in the hospital setting. Journal of Hospital Medicine 2006;1:191–199. © 2006 Society of Hospital Medicine.

Managing discontinuity in academic medical centers: strategies for a safe and effective resident sign-out.

Abstract: BACKGROUND Restrictions in the hours residents can be on duty have resulted in increased sign-outs, that is, transfer of patient care information and responsibility from one physician to a cross-coverage physician, leading to discontinuity in patient care. This sign-out process, which occurs primarily in the inpatient setting, traditionally has been informal, unstructured, and idiosyncratic. Although studies show that discontinuity may be harmful to patients, this is little data to assist residency programs in redesigning systems to improve sign-out and manage the discontinuity. PURPOSE This article reviews the relevant medical literature, current practices in non–health professions in managing discontinuity, and summarizes the existing practice and experiences at 3 academic internal medicine hospitalist-based programs. CONCLUSIONS We provide recommendations and strategies for best practices to design safe and effective sign-out systems for residents that may also be useful to hospitalists working in academic and community settings. Journal of Hospital Medicine 2006;1:257–266. © 2006 Society of Hospital Medicine.

Transition of care for hospitalized elderly patients—Development of a discharge checklist for hospitalists

Abstract: BACKGROUND Discharge from the hospital is a critical transition point in a patient's care. Incomplete handoffs at discharge can lead to adverse events for patients and result in avoidable rehospitalization. Care transitions are especially important for elderly patients and other high-risk patients who have multiple comorbidities. Standardizing the elements of the discharge process may help to address the gaps in quality and safety that occur when patients transition from the hospital to an outpatient setting. METHODS The Society of Hospital Medicine's Hospital Quality and Patient Safety committee assembled a panel of care transition researchers, process improvement experts, and hospitalists to review the literature and develop a checklist of processes and elements required for ideal discharge of adult patients. The discharge checklist was presented at the Society of Hospital Medicine's Annual Meeting in April 2005, where it was reviewed and revised by more than 120 practicing hospitalists and hospital-based nurses, case managers, and pharmacists. The final checklist was endorsed by the Society of Hospital Medicine. RESULTS The finalized checklist is a comprehensive list of the processes and elements considered necessary for optimal patient handoff at hospital discharge. This checklist focused on medication safety, patient education, and follow-up plans. CONCLUSIONS The development of content and process standards for discharge is the first step in improving the handoff of care from the inpatient to the posthospital setting. Refining this checklist for patients with specific diagnoses, in specific age categories, and with specific discharge destinations may further improve information transfer and ultimately affect patient outcomes. Journal of Hospital Medicine 2006;1:354–360. © 2006 Society of Hospital Medicine.

Inpatient management of diabetes and hyperglycemia among general medicine patients at a large teaching hospital

Abstract: BACKGROUND Because of the relationship between inpatient hyperglycemia and adverse patient outcomes, current guidelines recommend glucose levels less than 180 mg/dL in the non-ICU inpatient setting and the use of effective insulin protocols for appropriate patients. OBJECTIVE To determine the current state of glucose management on an academic hospitalist service and the relationship between insulin-ordering practices and glycemic control. DESIGN Prospective cohort study. SETTING Hospitalist-run general medicine service of an academic teaching hospital. PATIENTS 107 consecutive patients with diabetes mellitus or inpatient hyperglycemia. MEASUREMENTS We collected data on up to 4 bedside glucose measurements per day, detailed clinical information, and all orders related to glucose management. The primary outcomes were rate of hyperglycemia (glucose > 180 mg/dL) per patient and mean glucose level per patient-day. RESULTS The mean rate of hyperglycemia was 31% of measurements per patient. Basal insulin was ordered for 43% of patients, and scheduled rapid- or short-acting insulin was ordered for 4% of patients. Sixty-five percent of patients who had at least 1 episode of hyper- or hypoglycemia had no change made to any insulin order during the first 5 days of the hospitalization. When adjusted for clinical factors, the use of sliding-scale insulin by itself was associated with a 20 mg/dL higher mean glucose level per patient-day. CONCLUSIONS Management of diabetes and hyperglycemia on a general medicine service showed several deficiencies in process and outcome. Possible targets for improvement include increased use of basal and nutritional insulin and daily insulin adjustment in response to hyperglycemia. Journal of Hospital Medicine 2006;3:145–150. © 2006 Society of Hospital Medicine.

How hospitalists spend their time: Insights on efficiency and safety

Abstract: BACKGROUND: Despite the dramatic growth of hospitalists, no studies have evaluated the type and frequency of activities that hospitalists perform. To evaluate the types and frequency of activities that hospitalists perform during routine work, we conducted a time-motion study of hospitalist physicians at our institution. DESIGN: A research assistant shadowed hospitalist physicians for 3- to 5-hour periods. Observation periods were distributed in order to sample all parts of a typical day of a hospitalist, including both admitting and nonadmitting periods. Activities were recorded on a standardized data collection form in 1-minute intervals. Incoming pages were recorded as well. RESULTS: Ten hospitalists were shadowed by a single research assistant for a total of 4467 minutes. Hospitalists spent 18% of their time on direct patient care, 69% on indirect patient care, 4% on personal activities, and 3% each on professional development, education, and travel. Communication accounted for 24% of the total minutes. Multitasking, performing more than one activity at the same time, was done 21% of the time. Hospitalists received an average of 3.4 1.5 pages per hour. CONCLUSIONS: Hospitalists spent most of their time on indirect patient care activities and relatively little time on direct patient care. Hospitalists spent a large amount of time on communication, underscoring the need for hospitalists to have outstanding communication skills and systems that support efficient communication. Multitasking and paging interruptions were common. The inherent distraction caused by interruptions and multitasking is a potential contributor to medical

Diabetes care in the hospital: Is there clinical inertia?

Abstract: BACKGROUND Effective control of hospital glucose improves outcomes, but little is known about hospital management of diabetes. OBJECTIVE Assess hospital-based diabetes care delivery. DESIGN Retrospective chart review. SETTING Academic teaching hospital. PATIENTS Inpatients with a discharge diagnosis of diabetes or hyperglycemia were selected from electronic records. A random sample (5%, n = 90) was selected for chart review. MEASUREMENTS We determined the percentage of patients with diabetes or hyperglycemia documented in admission, daily progress, and discharge notes. We determined the proportion of cases with glucose levels documented in daily progress notes and with changes in hyperglycemia therapy recorded. The frequency of hypoglycemic and hyperglycemic events was also determined. RESULTS A diabetes diagnosis was recorded at admission in 96% of patients with preexisting disease, but daily progress notes mentioned diabetes in only 62% of cases and 60% of discharge notes; just 20% of discharges indicated a plan for diabetes follow-up. Most patients (86%) had bedside glucose measurements ordered, but progress notes tracked values for only 53%, and only 52% had a documented assessment of glucose severity. Hypoglycemic events were rare (11% of patients had at least one bedside glucose 200 mg/dL). Despite the frequency of hyperglycemia, only 34% of patients had their therapy changed. CONCLUSIONS Practitioners were often aware of diabetes at admission, but the problem was often overlooked during hospitalization. The low rate of documentation and therapeutic change suggests the need for interventions to improve provider awareness and enhance inpatient diabetes care. Journal of Hospital Medicine 2006;3:151–160. © 2006 Society of Hospital Medicine.

Analysis of strategies to improve cost effectiveness of blood cultures.

Abstract: BACKGROUND Approximately 90% of all blood cultures grow no organisms (ie, are true negatives), and 5% are thought to represent contaminants (ie, are false positives). The cost effectiveness of blood cultures could therefore be improved by developing rules that safely decreased the number of cultures drawn from patients with a low likelihood of having bacteremia and/or by improving the process of obtaining cultures, thereby decreasing the number of contaminants. We analyzed the potential effects of these two approaches. METHODS We annualized the hospital costs and lengths of stay for patients with true-negative and false-positive blood cultures from a retrospective analysis of 939 sets of cultures drawn in January 2002. RESULTS Of the 939 blood culture sets, 816 (87%) were true negatives and generated annualized costs of approximately $750,000. Although only 56 (6%) of the blood culture sets were false positives, they resulted in annualized costs of $1.4-$1.8 million and added an estimated 1450-2200 extra hospital days/year. CONCLUSIONS Despite there being nearly 15 times as many true-negative blood cultures as false positive ones, far greater improvements in resource utilization would result from reducing the number of contaminated blood cultures than by reducing the number of true negatives. The potential savings from this approach are of sufficient magnitude to justify investing considerable resources to attaining this goal. Journal of Hospital Medicine 2006;1:272–276. © 2006 Society of Hospital Medicine.

Glycemic chaos (not glycemic control) still the rule for inpatient care: how do we stop the insanity?

Abstract: Diabetes is one of the most common diagnoses in hospitalized patients. A third of all persons admitted to urban general hospitals have glucose levels qualifying them for the diagnosis of diabetes, and a third of these hyperglycemic patients have not previously been diagnosed with diabetes. The impact of hyperglycemia on the mortality rate of hospitalized patients has been increasingly appreciated. Extensive evidence from observational studies indicates that hyperglycemia in patients with or without a history of diabetes is a marker of a poor clinical outcome. In addition, the results of prospective randomized trials in patients with critical illness or those undergoing coronary bypass surgery suggest that aggressive glycemic control improves clinical outcomes including reductions in: a) shortand long-term mortality, b) multiorgan failure and systemic infection, and c) length of hospitalization. The importance of glycemic control is not limited to patients in critical care areas but may also apply to patients admitted to general surgical and medical wards. The development of hyperglycemia in such patients with or without a history of diabetes has been associated with prolonged hospital stay, infection, disability after hospital discharge, and death. In general-surgical patients, serum glucose 220 mg/dL on postoperative day 1 has been shown to be a sensitive, albeit nonspecific, predictor of the development of serious postoperative hospital-acquired infection. A retrospective review of 1886 admissions to a community hospital in Atlanta, Georgia, found an 18-fold increase in mortality in hyperglycemic patients without a history of diabetes and a 2.5-fold increase in mortality in patients with known diabetes compared with controls. A meta-analysis of 26 studies identified an association of admission glucose 110 mg/dL with the increased mortality of patients hospitalized for acute stroke. More recently, hyperglycemia on admission was also shown to be independently associated with adverse outcomes in patients with community acquired pneumonia. In view of the increasing evidence supporting better glycemic control in the hospital, the American Association of Clinical Endocrinologists (AACE) in late 2003 convened a consensus conference on the inpatient with diabetes, cosponsored or supported by other prominent professional organizations, including the Society of Hospital Medicine (SHM). An expert panel agreed on and pubE D I T O R I A L

Core competencies in hospital medicine: Development and methodology

Abstract: BACKGROUND: The hospitalist model of inpatient care has been rapidly expanding over the last decade, with significant growth related to the quality and efficiency of care provision. This growth and development have stimulated a need to better define and characterize the field of hospital medicine. Training and developing curricula specific to hospital medicine are the next step in the evolution of the field. METHODS: The Core Competencies in Hospital Medicine: A Framework for Curriculum Development (the Core Competencies), by the Society of Hospital Medicine, introduces the expectations of hospitalists and provides an initial structural framework to guide medical educators in developing curricula that incorporate these competencies into the training and evaluation of students, clinicians-in-training, and practicing hospitalists. This article outlines the process that was undertaken to develop the Core Competencies, which included formation of a task force and editorial board, development of a topic list, the solicitation for and writing of chapters, and the execution of multiple reviews by the editorial board and both internal and external reviewers. RESULTS: This process culminated in the Core Competencies document, which is divided into three sections: Clinical Conditions, Procedures, and Healthcare Systems. The chapters in each section delineate the core knowledge, skills, and attitudes necessary for effective inpatient practice while also incorporating a systems organization and improvement approach to care coordination and optimization. CONCLUSIONS: These competencies should be a common reference and foundation for the creation of hospital medicine curricula and serve to standardize and improve inpatient training practices. Journal of Hospital Medicine 2006;1:48–56. © 2006 Society of Hospital Medicine.

Hospital‐acquired gastrointestinal bleeding outside the critical care unit: Risk factors, role of acid suppression, and endoscopy findings

Abstract: BACKGROUND: Risk factors for hospital-acquired gastrointestinal bleeding in the intensive care unit are established, and acid-suppressive prophylaxis has been advocated for certain subsets of critically ill patients. In contrast, risk factors and appropriate prevention strategies are not yet established for general medical patients. The objective of this study was to identify risk factors for nosocomial gastrointestinal bleeding (GIB) in non–critically ill medical patients, to evaluate the utility of prophylactic gastric acid suppression, and to characterize the endoscopic lesions. METHODS: This was a retrospective case–control study that took place at a U.S. tertiary care center. All patients admitted to the General Medicine ward for nongastrointestinal disorders who developed clinically relevant gastrointestinal bleeding during admission or within 4 weeks of discharge were considered cases. Clinically relevant bleeding was defined as any bleeding requiring esophagogastroduodenoscopy (EGD). Random controls were matched to cases by date of hospitalization in a 1:1 ratio. Clinical information was extracted by chart review. RESULTS: Of 17,707 patients admitted to the General Medicine ward over a 4-year period, 73 (0.41%) met the case definition. The main risk factor for nosocomial GIB was treatment with full dose anticoagulants or clopidogrel (OR = 5.4; 2.6–11.7; P < .0001). Use of aspirin, nonsteroidal anti-inflammatory medications, and glucocorticoids did not differ significantly between cases and controls. De novo acid-suppressive prophylaxis was not protective (OR = 1.0; 95% CI: 0.4–2.4; P = 0.97). Endoscopic abnormalities were noted in 74% of patients; many cases had lesions unlikely to be prevented by acid blockade. CONCLUSIONS: Hospital-acquired gastrointestinal bleeding is uncommon in non–critically ill patients. Anticoagulation appears to be the most important risk factor for nosocomial GIB. Routine use of acid suppressant medications for prophylaxis is unnecessary in most hospitalized patients. Journal of Hospital Medicine 2006;1:13–20. © 2006 Society of Hospital Medicine.

Palliative care in hospitals

Abstract: Palliative care is medical care focused on the relief of suffering and support for the best possible quality of life for patients facing serious, life-threatening illness and their families. It aims to identify and address the physical, psychological, and practical burdens of illness. Palliative care may be delivered simultaneously with all appropriate curative and life-prolonging interventions. In practice, palliative care practitioners provide assessment and treatment of pain and other symptom distress; employ communication skills with patients, families, and colleagues; support complex medical decision making and goal setting based on identifying and respecting patient wishes and goals; and promote medically informed care coordination, continuity, and practical support for patients, family caregivers, and professional colleagues across healthcare settings and through the trajectory of an illness. The field of hospital palliative care has grown rapidly in recent years in response to patient need and clinician interest in effective approaches to managing chronic life-threatening illness. The growth in the number and needs of seriously and chronically ill patients who are not clearly terminally ill has led to the development of palliative care services outside the hospice benefit provided by Medicare (and other insurers). This article reviews the clinical, educational, demographic, and financial imperatives driving this growth, describes the clinical components of palliative care and the range of service models available, defines the relation of hospital-based palliative care to hospice, summarizes the literature on palliative care outcomes, and presents practical resources for clinicians seeking knowledge and skills in the field.

Outpatient physicians' satisfaction with discharge summaries and perceived need for an electronic discharge summary.

Abstract: BACKGROUND Deficits in information transfer between inpatient and outpatient physicians are common and potentially dangerous. OBJECTIVE To evaluate satisfaction with current discharge summaries, perceptions of preventable adverse events related to suboptimal information transfer, and the perceived need for the electronic discharge summary we plan to design. DESIGN AND PARTICIPANTS: Survey of Department of Medicine physicians with an outpatient practice. MEASUREMENTS Satisfaction with timeliness and quality of discharge summaries was assessed using a 5-point Likert scale. Respondents estimated the number of patients with preventable adverse events related to suboptimal information transfer at discharge. RESULTS Of the 416 eligible respondents, 226 completed the survey (54%). Only 19% of the participants were satisfied or very satisfied with timeliness, and only 32% were satisfied or very satisfied with the quality of discharge summaries. Overall, 41% believed that at least 1 of their patients hospitalized in the previous 6 months had experienced a preventable adverse event related to poor transfer of information at discharge. CONCLUSIONS Physicians were not satisfied with the timeliness or quality of discharge summaries. Physicians indicated that suboptimal transfer of information at hospital discharge contributed to preventable adverse events. Journal of Hospital Medicine 2006;1:317–320. © 2006 Society of Hospital Medicine.

The status of hospital medicine groups in the United States.

Abstract: BACKGROUND Hospitalists, defined as hospital-based physicians who take responsibility for managing the medical needs of inpatients, represent a significant trend in physician specialization. However, only limited anecdotal data quantifying the status of hospital medicine groups around the country is available. OBJECTIVE To better understand the extent and nature of the hospitalist movement, utilizing data from the 2003 Annual Survey of the American Hospital Association (AHA). STUDY POPULATION 4895 acute care hospitals in the United States. MEASUREMENTS Number and percentage of hospitals with hospital medicine groups; mean number of hospitalists per group; hospitalists per average daily census (ADC) of 100 patients; distribution of groups by employment model. DESCRIPTIVE VARIABLES Census region; rural/urban status; number of beds; organizational control; teaching status. RESULTS There are approximately 1415 hospital medicine groups and 11 159 hospitalists in the United States. The overall penetration of hospital medicine groups at hospitals is 29% (55% at hospitals with 200 or more beds), and the in-hospital impact at hospitals with hospital medicine groups is 3.93 hospitalists per 100 ADC. The average hospital medicine group has 7.9 hospitalists. There is a fairly equal distribution among the 3 major employment models for hospital medicine groups: hospital employees, independent provider groups, and physician groups. All these measures can vary substantially, depending on the characteristics of individual hospitals. CONCLUSIONS Hospital medicine appears to have become part of the mainstream delivery of health care in the United States. No employment model of hospital medicine group appears to dominate this specialty. We expect there will continue to be growth and diversity in the implementation of hospital medicine groups. Journal of Hospital Medicine 2006;1:75–80. © 2006 Society of Hospital Medicine.

If asked, hospitalized patients will choose whether to receive life-sustaining therapies.

Abstract: BACKGROUND No national policy requires health care providers to discuss with hospitalized patients whether the latter would want cardiopulmonary resuscitation (CPR) or mechanical ventilation (MV) in the event of cardiopulmonary failure. OBJECTIVE To determine whether hospitalized patients are willing to discuss end-of-life issues and choose whether to receive CPR and MV. DESIGN Prospective randomized trial. PARTICIPANTS 297 patients admitted to the medicine service of a 350-bed community teaching hospital. INTERVENTION Patients were randomized to receive routine care or a scripted intervention, delivered by research physicians, that included detailed information about CPR, MV, and advance directives. MEASUREMENTS Number of patients who welcomed the scripted intervention, number who chose to receive or reject CPR/MV, and number of advance directives created during hospitalization. RESULTS Of the 297 patients studied, 136 were in the intervention group and 161 were in the control group. Baseline characteristics and severity of illness were similar in the 2 groups. Of the 136 patients in the intervention group, 133 (98%) willingly discussed CPR and mechanical ventilation, and 112 (82%) found the information useful. One hundred and twenty-five (92%) clarified their preferences regarding CPR and MV after receiving the intervention; of the 48 patients who were initially documented as wanting CPR/MV, 3 requested no CPR/MV after the intervention. Of the 87 patients in the intervention group who had no documentation of code status on admission, 5 asked for no CPR/MV. Of the 161 patients in the control group, 55 had documentation of their code status on admission. Of the 106 patients without documentation, 6 were later documented to receive no CPR/MV. Thirteen of the 102 patients who had no advance directive on admission created one after the intervention, whereas only 1 of the 128 patients in the control group did so (P < .001). CONCLUSIONS Patients are willing to discuss and give informed consent for CPR and mechanical ventilation early in hospitalization. Only a minority drafted advance directives during hospitalization. Larger studies that include patients at other centers are required to determine whether these findings are reproducible and whether this approach is clinically feasible. Journal of Hospital Medicine 2006;3:161–167. © 2006 Society of Hospital Medicine.

How to use The Core Competencies in Hospital Medicine: a framework for curriculum development.

Abstract: BACKGROUND The seminal article that coined the term hospitalist, published in 1996, attributed the role of the hospitalist to enhancing throughput and cost reduction, primarily through reduction in length of stay, accomplished by having a dedicated clinician on site in the hospital. Since that time the role of the hospitalist has evolved, and hospitalists are being called upon to demonstrate that they actually improve quality of care and the education of the next generation of physicians. A companion article in this issue describes in detail the rationale for the development of the Core Competencies document and the methods by which it was created. METHODS Specific cases that hospitalists may encounter in their daily practice are used to illustrate how the Core Competencies can be applied to curriculum development. The cases illustrate 1) a specific problem and the need for improvement; 2) a needs assessment of the targeted learners (hospitalists and clinicians in training); 3) goals and specific measurable objectives; 4) educational strategies using the competencies to provide structure and guidance; 5) implementation (applying competencies to a variety of training opportunities and curricula); 6) evaluation and feedback; and 7) remaining questions and the need for additional research. RESULTS This article illustrates how to utilize The Core Competencies in Hospital Medicine to educate trainees and faculty, to prioritize educational scholarship and research strategies, and thus to improve the care of our patients. CONCLUSIONS Medical educators should compare their learning objectives to the Core Competencies to ensure that their trainees have achieved competency to practice hospital medicine and improve the hospital setting. Journal of Hospital Medicine 2006;1:57–67. © 2006 Society of Hospital Medicine.

Improved use of thromboprophylaxis for deep vein thrombosis following an educational intervention.

Abstract: BACKGROUND We evaluated venous thromboembolism (VTE) prophylaxis rates in hospitalized medical patients in a teaching hospital, the State University of New York–Downstate Medical Center–University Hospital of Brooklyn, before and after implementation of a multifaceted VTE prophylaxis quality improvement intervention that combined regular education, dissemination of a decision support tool, and regular audit-and-feedback to resident physicians. METHODS The charts of 312 hospitalized medical patients were retrospectively reviewed to assess baseline rates of appropriate VTE prophylaxis. Rates of appropriate VTE prophylaxis were then determined 12 and 18 months after implementation of the quality improvement intervention. Data collected included risk factors for VTE, contraindications to anticoagulant prophylaxis, type of VTE prophylaxis prescribed, and whether the prophylaxis was appropriate. RESULTS Most of the hospitalized medically ill patients had 3 or more risk factors for VTE. At baseline, the proportion of patients receiving any form of VTE prophylaxis, primarily unfractionated heparin, was 47%. The proportion of patients for whom a physician provided appropriate prophylaxis was 43%. After the intervention, the proportion of patients receiving prophylaxis significantly increased, to 86% at 12 months, and this level was maintained at 18 months. The rate of appropriate prophylaxis increased to 68% and 85% after 12 and 18 months, respectively. CONCLUSIONS The proportion of hospitalized medical patients receiving appropriate VTE prophylaxis as recommended by evidence-based guidelines can be increased significantly by combining regular education, a decision support tool, and regular audit-and-feedback. Journal of Hospital Medicine 2006;1:331–338. © 2006 Society of Hospital Medicine.

Establishing a rapid response team (RRT) in an academic hospital: One year's experience

Abstract: BACKGROUND Rapid response teams and medical emergency teams have been utilized to rapidly manage seriously ill patients at risk of cardiopulmonary arrest and other high-risk conditions but have not been extensively described in the American medical literature. OBJECTIVES To describe a full year's experience of implementing a rapid response team (RRT) in an academic medical center. DESIGN Retrospective analysis of our hospital's RRT database and description of the implementation process from July 2004 to July 2005. SETTING Urban, academic medical center. RESULTS The RRT system was activated for 307 potentially unstable patients. The most common reasons for an RRT activation were cardiac, respiratory, and neurological conditions. At least 37% of RRT calls were for off-unit inpatients and to outpatient/common areas frequented by outpatients and visitors, whereas at least 42% occurred in inpatient units. Most RRT calls, 82.9%, occurred during daytime hours. In the opinion of RRT leaders 98% of the evaluated calls were appropriate and 85% of the RRT responses resulted in the prevention of further clinical deterioration. CONCLUSIONS An RRT was introduced into an academic medical center, and the results suggested it is capable of preventing clinical deterioration in unstable patients and may have the potential to decrease the frequency of cardiac arrests. The RRT also may fill a gap in patient safety by enabling rapid triage and expedited treatment of off-unit inpatients, outpatients, and visitors. The keys to the early success of our implementation of an RRT were multidisciplinary input and improvements made in real time. Journal of Hospital Medicine 2006;1:296–305. © 2006 Society of Hospital Medicine.

Physician characteristics, attitudes, and use of computerized order entry.

Abstract: BACKGROUND Computerized physician order entry (CPOE) is a widely advocated patient safety intervention, yet little is known about its adoption by attending physicians or community hospitals. METHODS We calculated the order entry rates of attending physicians at 2 hospitals by measuring the number of orders entered directly and dividing this by the sum of orders entered directly and those written by hand. These findings were paired with the results of a survey that assessed attitudes concerning the impact of CPOE on personal efficiency, quality of care, and patient safety. RESULTS Three hundred and fifty-six (71%) of the 502 surveys were returned by physicians, whose median order entry rate was 66%. Forty-two percent of respondents placed at least 80% of their orders electronically (high use), 26% placed 21%-79% of their orders electronically (intermediate use), and 32% placed 20% or less of their orders electronically (low use). Sex, years since medical school graduation, years in practice at the study institution, and use of computers in the outpatient arena were not meaningfully different among the 3 groups. However, use of the system to place orders varied by specialty, and those with intermediate or high use of the system were more likely than low users to have used CPOE during training and to be regular users of computers for personal activities. These physicians were more likely to believe that CPOE enabled orders to be placed efficiently, that directly entered orders were carried out more rapidly, and that such orders were associated with fewer errors. CONCLUSIONS The adoption of CPOE by attending physicians at community hospitals varies widely. In addition to purchasing systems that support physician work flow, hospitals intent on successfully implementing CPOE should emphasize the benefits in safety and quality of this new technology. Journal of Hospital Medicine 2006;1:221–230. © 2006 Society of Hospital Medicine.

Reflections: The hospitalist movement a decade later

Abstract: August 2006 marks the 10th anniversary of the publication of an article in the New England Journal of Medicine in which Lee Goldman and I coined the term hospitalist—an event that many people characterize as the start of the hospitalist movement in the United States. The present article describes the history of those early days, highlighting some of the choices the field's initial leaders made to nurture the new specialty. In retrospect, although there were many examples of fortunate serendipity, there were also several key strategic choices, including the focus on gathering research data to demonstrate the value of the field to external stakeholders; the forceful rejection of mandatory hospitalist systems, particularly those promoted by managed care organizations; and the purposeful linking of our new field to the burgeoning movements to improve quality and patient safety in hospitals. Most of all, the field's spectacular growth and successes can be attributed to the daily work of thousands of hospitalists in clinical care, education, research, and systems improvement. These individuals have given life to our theoretical notion a decade ago that a new model for inpatient care would improve the American health care system and the care of inpatients. Journal of Hospital Medicine 2006;1:248–252. © 2006 Society of Hospital Medicine.

Discussing resuscitation preferences with patients: challenges and rewards.

Abstract: Discussing preferences regarding resuscitation is a challenging and important task for any physician. Understanding patients' wishes at the end of life allows physicians to provide the type of care patients want, to avoid unwanted interventions, and to promote patient autonomy and dignity. Hospitalists face an even greater challenge because they are often meeting a patient for the first time in a crisis situation. Despite the frequency with which clinicians have these conversations, they typically fall short when discussing code status with patients. In this evidence-based review, we discuss physician barriers to conducting effective discussions, offer a variety of approaches to enhancing these conversations, and review important communication techniques.

Acute aortic dissection.

Abstract: Acute aortic dissection is an uncommon but lethal cause of acute chest, back, and abdominal pain. Establishing a timely diagnosis is paramount, as mortality from acute aortic dissection rises by the hour. Physical findings are protean and may include acute aortic valve insufficiency, peripheral pulse deficits, a variety of neurologic deficits, or end-organ ischemia. The keys to establishing a timely diagnosis are maintaining a high index of suspicion and quickly obtaining a diagnostic study. CT angiography, magnetic resonance imaging, transesophageal echocardiography, and, to a lesser extent, aortography are all highly accurate imaging modalities. The choice of study should be driven by the clinical stability of the patient, the information required and the resources available at presentation. Proximal dissections are surgical emergencies, but distal dissections are generally treated medically. Endovascular stents are gaining favor for use in the repair of both acute and chronic distal dissections. Long-term outcome data for endovascular stenting are still limited, and it remains unclear when stenting should be favored over surgery or medical therapy.

Care of hospitalized older patients: opportunities for hospital-based physicians

Abstract: BACKGROUND: Half of patients admitted to hospital for reasons unrelated to childbirth are age 65 years or older. Nonetheless, few hospital-based physicians have received training in geriatric medicine, and few geriatricians practice in the hospital. This paper describes the state of the science of hospital care for older patients, and identifies opportunities and barriers to improving their care. METHODS: General medical journals from 1980 to the present were selectively reviewed to identify original articles on the treatment of specific diseases and syndromes on hospitalized persons age 65 years or older. Information was synthesized to describe the course of these patients during and after hospitalization, and to identify effective management strategies and gaps in knowledge. RESULTS: Older persons in hospitals pose substantial clinical challenges: they have high rates of cognitive impairment, delirium, disability, and difficulty walking, and they often require increased attention, longer lengths of stay, and higher hospital costs than younger patients with the same diagnoses. Disease-specific interventions have not been studied extensively in those older than 75 years. Multicomponent interventions can reduce short-term rates of disability and delirium without increasing costs, but they have not been widely disseminated. Interventions to treat or prevent other common conditions in hospitalized older patients have not been proven effective. CONCLUSIONS: Fundamental discoveries in the science of hospital medicine are needed to prevent or treat geriatric syndromes, to treat common diseases in the very old, and to put into practice what is known. Hospital-based physicians can address these gaps in knowledge and practice with geriatricians, building from their shared perspectives on the care of the aged in complex health systems. Journal of Hospital Medicine 2006;1:42–47.© 2006 Society of Hospital Medicine.

Effectiveness of ceftriaxone plus doxycycline in the treatment of patients hospitalized with community-acquired pneumonia.

Abstract: BACKGROUND: Limited data exist on the effectiveness of ceftriaxone plus doxycycline in the treatment of patients hospitalized with community-acquired pneumonia (CAP). METHODS: We performed a retrospective cohort study of all adults hospitalized for pneumonia between January 1999 and July 2001 at an academic medical center. Outcomes were compared for patients with CAP treated with ceftriaxone plus doxycycline versus other appropriate initial empiric antibiotic therapies. Outcomes were adjusted with the use of a propensity score to account for differences in patient characteristics and illness severity between groups. RESULTS: A total of 216 patients were treated with ceftriaxone plus doxycycline and 125 received other appropriate initial empiric antibiotic therapies. After adjustment, use of ceftriaxone plus doxycycline was associated with reduced inpatient mortality (OR = 0.26, 95% CI: 0.08–0.81) and 30-day mortality (OR = 0.37, 95% CI: 0.17–0.81), but not with length of stay or readmission rates. Analysis of a subset of the sample that excluded patients admitted from nursing homes, patients admitted to the ICU, and patients diagnosed with aspiration also showed reduced inpatient mortality with the use of ceftriaxone plus doxycycline. CONCLUSIONS: The use of ceftriaxone plus doxycycline as an initial empiric therapy for patients hospitalized with CAP appears safe and effective, and its potential superiority should be evaluated prospectively. Journal of Hospital Medicine 2006;1:7–12. © 2006 Society of Hospital Medicine.

Impact of reliance on CT pulmonary angiography on diagnosis of pulmonary embolism: a Bayesian analysis.

Abstract: BACKGROUND Spiral computed tomographic pulmonary angiography (CTPA) has become the primary test used to investigate suspected pulmonary embolism (PE) at many institutions, despite uncertainty regarding its sensitivity and specificity. Although CTPA-based diagnostic algorithms focus on minimizing the false-negative rate, we hypothesized that increasing use of CTPA also might lead to false-positive diagnoses. OBJECTIVE Determine the frequency of possible false-positive diagnoses of PE when CTPA is the primary diagnostic test. DESIGN Retrospective cohort study. SETTING Two academic teaching hospitals. PARTICIPANTS 322 patients with suspected PE evaluated with CTPA. MEASUREMENTS We used a validated prediction rule to determine the pretest probability of PE in each patient. We combined these pretest probabilities with published estimates of CTPA test characteristics to generate expected posttest probabilities of PE. We compared these posttest probabilities to actual treatment decisions to determine the rate of false-positive diagnoses of PE. RESULTS Among 322 patients investigated for PE, 37 (12%) had high pretest probability, 101 (32%) moderate, and 184 (57%) low. CT scans were interpreted as positive for PE in 57 patients (17.8%). Regardless of the pretest probability of PE, 96.5% of patients with a positive CTPA were treated with anticoagulants. Even under an optimistic assumption of CTPA test characteristics, as many as 25.4% of these patients may have been treated unnecessarily as a result of a false-positive diagnosis. Most of these patients had a low pretest probability of PE. CONCLUSIONS Failure to utilize Bayesian reasoning when interpreting CTPA may lead to false-positive diagnoses of pulmonary embolism in a substantial proportion of patients. Journal of Hospital Medicine 2006;1:81–87. © 2006 Society of Hospital Medicine

Is there a geriatrician in the house? Geriatric care approaches in hospitalist programs†

Abstract: BACKGROUND: The rapid growth of the hospitalist movement presents an opportunity to reconsider paradigms of care for hospitalized older patients. METHODS: To determine the impact of the hospitalist movement on acute care geriatrics, we conducted a cross-sectional survey of the hospitalist community in 2003 and 2004. RESULTS: We identified innovations in geriatric hospital care in only 11 hospitalist programs. These innovations varied widely in complexity, goals, structure, and staffing. The majority targeted patients using age as a criterion and incorporated geriatrics training for nurses or physicians. Several innovations had one or more of the following features: geriatrician-hospitalists or gerontology nurse-practitioners, perioperative management for complex older patients, specialized geriatric services such as skilled nursing units or acute care for elders units, and quality improvement initiatives targeted to the older patient. A case study of the Hospital Internal Medicine group at the Mayo Clinic is presented as an example of a complex innovation highlighting several of these features. CONCLUSIONS: The scarcity of geriatric care approaches among hospitalist groups highlights the need for collaboration between hospitalists and geriatricians, with the goals of rethinking staffing models and organization of care and focusing on quality-improvement activities. In particular, perioperative care and postdischarge care are two clinical areas where innovation in hospital care may particularly benefit older patients. Significant opportunities remain for collaboration, coordination, and research to improve the care of acutely ill older patients at the intersection of geriatric and hospital medicine. Journal of Hospital Medicine 2006;1:29–35. © 2006 Society of Hospital Medicine.

Cost utility of substituting enoxaparin for unfractionated heparin for prophylaxis of venous thrombosis in the hospitalized medical patient

Abstract: BACKGROUND Both heparin and enoxaparin are effective for the prevention of venous thromboembolism (VTE) in medical patients. On the basis of price, heparin appears preferable because it is less expensive. However, choosing enoxaparin may have greater cost utility when the outcomes of heparin-induced thrombocytopenia (HIT) and heparin-induced thrombocytopenia with thrombosis (HITT) are considered. OBJECTIVE To determine the cost utility of substituting enoxaparin for heparin from payer and institutional perspectives. DESIGN A decision analysis model was used. Cost data were based on Medicare reimbursement and the medication and laboratory costs for a multi-institutional healthcare system. Quality-adjusted life years (QALYs) saved by preventing HIT/HITT through the use of enoxaparin were based on published data. Costs are expressed on a per-day basis, and the incremental cost of enoxaparin over that of heparin was used in the calculation of cost/QALY. A sensitivity analysis also was performed. SETTING Inpatient medicine. PATIENTS All medical patients for whom VTE prophylaxis was appropriate. INTERVENTIONS Substitution of enoxaparin for heparin. MEASUREMENT Cost/QALY. RESULTS From a payer perspective, using enoxaparin resulted in a decrease in cost of $28.61 over that of heparin and saved 0.00629 QALYs in the base case, resulting in a savings of $4550.17/QALY. The sensitivity analysis showed this finding of decreased cost and increased effectiveness to be consistent. From an institutional perspective, the use of heparin generally appeared less costly but was dependent on medication price, length of stay required, and bed utilization. CONCLUSIONS From a payer and, by extrapolation, a societal perspective, cost-utility analysis supports the use of enoxaparin in place of heparin for the prevention of VTE in medical inpatients. From an institutional perspective, the decision is more complicated, but in most cases, the use of enoxaparin also is supported. Journal of Hospital Medicine 2006;3:168–176. © 2006 Society of Hospital Medicine.

Predictors of regaining ambulatory ability during hospitalization

Abstract: BACKGROUND Loss of ambulatory ability with acute hospitalization is common and often does not improve by discharge. OBJECTIVES To define admission predictors of regaining ambulatory ability during hospitalization in patients with expected activity limitations. DESIGN Prospective cohort study. SETTING University teaching hospital. PARTICIPANTS Two hundred and eighty-six patients at least 55 years of age whose activity was expected to be limited to a bed or chair for at least the first 5 days of hospitalization or who had a hip fracture, who were ambulatory in the 4 weeks prior to hospital admission, and whose length of stay in the hospital was less than 32 days. MEASUREMENTS Baseline data collected from admission physician and nurse interviews and abstracted from the medical records included length of stay, demographic characteristics, global health measures, presence of specific diseases, and hospital-related factors hypothesized to affect ambulation. Nurses were asked weekly if patient activity was still expected to be limited to a bed or chair. RESULTS Despite initially being limited to a bed or chair, 42% had regained ambulatory ability by discharge. Recovery of ambulatory ability was independently associated with not being married (odds ratio [OR] = 3.0, 95% confidence interval [CI] 1.4-6.2), higher physician-rated life expectancy (OR = 1.9, 95% CI 1.3-2.8), absence of restraints (OR = 2.5, 95% CI 1.2-5.5), having a urinary catheter (OR = 2.2, 95% CI 1.2-5.5), having deep vein thrombosis (OR = 11.4, 95% CI 1.2-105.1), and having a higher level of bed mobility at admission (OR = 1.7, 95% CI 1.1-2.6). CONCLUSIONS Recovery of ambulatory ability is closely associated with physician-rated life expectancy and hospital-related factors, particularly those that affect mobility. Early recognition of who will recover ambulatory ability may help with discharge planning and potential interventions. Journal of Hospital Medicine 2006;1:277–284. © 2006 Society of Hospital Medicine.

Lipid assessment and treatment patterns in hospitalized TIA and ischemic stroke patients.

Abstract: BACKGROUND Identification of dyslipidemia and treatment with lipid-lowering agents are established targets for quality performance during hospitalization for ischemic stroke and transient ischemic attack (TIA). We aimed to study the frequency and predictors of lipid assessment and discharge utilization of lipid-lowering therapies among patients hospitalized for stroke and TIA. METHODS Demographics, clinical findings, and laboratory data were documented as part of the California Acute Stroke Prototype Registry (CASPR). Frequency of low-density lipoprotein cholesterol (LDL-C) testing and the frequency and appropriate use of lipid-lowering treatment according to national cholesterol guidelines were determined. Multivariate models were generated to determine the contribution of clinical variables to LDL testing and prescription of lipid-lowering medications at discharge. RESULTS Data were collected on 764 consecutive patients with ischemic stroke or TIA treated at 11 hospitals over a 2-year period. LDL-C measurements were performed in only 50.1% during hospitalization. Measurement of LDL-C was most strongly and independently associated with diagnosis of ischemic stroke (vs. TIA, P = .02) and history of dyslipidemia (P = .05). Overall, 48.4% of the CASPR cohort received lipid-lowering medications at discharge. Independent predictors for being prescribed lipid-lowering agents at discharge were diagnosis of ischemic stroke (P = .0009), LDL-C testing (P = .0002), high risk of future coronary events according to national guidelines (P = .02), and history of dyslipidemia (P< .0001). Only 59% of patients at high risk for future coronary events were discharged on a lipid-lowering medication. CONCLUSIONS Serum cholesterol testing and treatment are underutilized during hospitalization for ischemic stroke or TIA. Journal of Hospital Medicine 2006;1:214–220. © 2006 Society of Hospital Medicine.

Routine rapid HIV testing in hospitals: another opportunity for hospitalists to improve care.

Abstract: BACKGROUND The Centers for Disease Control and Prevention recommends routinely offering HIV testing to inpatients at hospitals with an HIV seroprevalence rate of greater than 1% or an AIDS diagnosis rate of greater than 1.0 per 1000 discharges. This recommendation has not been widely adopted, perhaps because of one of several barriers: the cost of implementing a counseling and testing program; the logistics of HIV counseling and testing on a hospital ward particularly with respect to privacy; concern about the follow-up of HIV test results necessitating patients to return after discharge; and the cultural mindset of screening as an outpatient modality complicated by the fear of raising the possibility of HIV testing and therefore eliciting a negative reaction from a patient who has not requested it. PURPOSE This article focuses on these barriers and some possible solutions, emphasizing the role of FDA-approved rapid HIV tests, which may decrease follow-up issues for HIV testing programs. It also considers hospitalists, given their frontline status and ability to coordinate the multidisciplinary services and systemwide approach required to implement such a program, as leaders in this area. Journal of Hospital Medicine 2006;1:106–112. © 2006 Society of Hospital Medicine