On March 16, the John A. Hartford Foundation awarded SHM a $1.4 million grant to develop interventions to improve care transitions for older adults at the time of hospital discharge.

One of the core values of SHM and hospital medicine is to implement changes that improve the care older Americans receive. With this grant support from The Hartford Foundation, SHM can help define and set standards for best practices in discharge and provide a continuum of training opportunities to support those practices.

As part of this three-year project, SHM will partner with national leaders in care coordination to form a national advisory board, create clinical tools, implement guidelines, and provide technical support and training tools to hospitals across the U.S. The project aims to build capacity in at least 200 hospital sites to improve the discharge process and, ultimately, health outcomes for older adults.

Chapter Report

Los Angeles: The kick-off meeting for the Los Angeles chapter was held at Spago Beverly Hills on April 10. The meeting brought together approximately 25 physicians from eight hospitalist groups throughout Los Angeles County. Larry Wellikson, MD, CEO of SHM, gave a presentation, “The Emergence and Future of Hospital Medicine.” Dr. Wellikson illuminated many important points in his talk and encouraged attendees to become involved in quality improvement at their own hospitals. The meeting was supported by Ortho Biotech.

National Advisory Board AND Project Team

SHM has assembled a national advisory board to inform and guide the project. The board will be chaired by Eric Coleman, MD, MPH, associate professor of medicine within the divisions of healthcare policy and research and geriatric medicine at the University of Colorado Health Sciences Center in Aurora. At press time, members included:

• Barbara Berkman, DSW, PhD, professor of health and mental health, University School of Social Work, Mount Sinai School of Medicine;
• Tom Bookwalter, PharmD, clinical pharmacist, American Society of Health-System Pharmacists (ASHP);
• Alan Korn, MD, chief medical officer and senior vice president for clinical affairs, Blue Cross Blue Shield Association;
• Chuck Denham, MD, chair, National Quality Forum (NQF);
• Gavin Hougham, PhD, senior program officer, John A. Hartford Foundation;
• Seth Landefeld, MD, director, American Geriatrics Society (AGS);
• Cheri Lattimer, RN, BSN, executive director, Case Management Society of America (CMSA);
• William Lyons, MD, AGS; Nebraska Medical Center in Omaha;
• Lorraine Mion, PhD, RN, FAAN, director of nursing services for geriatrics, Metro Health Medical Center in Cleveland, Ohio;
• Mary Naylor, PhD, RN, FAANS, Marian S. Ware professor in gerontology, University of Pennsylvania;
• Gail Povar, MD, MPH, chair, George Washington School of Medicine, Cameron Medical Group;
• Deborah Queenan, national advisory council coordinator, Agency for Healthcare Research and Quality (AHRQ);
• Pat Rutherford, RN, MS, vice president, Institute for Healthcare Improvement (IHI), Transforming Care at the Bedside (TCAB);
• Eric Warm, MD, Society General Internal Medicine (SGIM); and
• Larry Wellikson, MD, CEO of SHM.

Dr. Williams will serve as principal investigator, leading a team of co-investigators including Jeffrey Greenwald, MD, (Boston University co-investigator, AHRQ, Project ReEngineering Discharge); Eric Howell, MD (Johns Hopkins Bayview, SHM/Hartford Safe Steps Demonstration Project); Param Dedhia, MD (Johns Hopkins Bayview, SHM/Hartford Safe STEPS Demonstration Project); Lakshmi Halasyamani, MD (St. Joseph Mercy Hospital); Kathleen Kerr (SHM); and Tina Budnitz, MPH (SHM).

The project team includes investigators from the SHM/Hartford Foundation Safe STEPS project and two AHRQ-funded projects. All three projects aim to pilot test discharge-planning toolkits and interventions and develop implementation strategies for adoption. The current project will leverage the findings of all three projects with the insights of the advisory board to create a transitions bundle to optimize the discharge process. Following development of this bundle, SHM will develop a toolkit for implementation with corresponding training programs, and other technical support.

click for large version

Capacity Building Via Continuum of Training Options

SHM has designed a range of technical support and training options to meet the needs of member institutions aiming to implement and sustain the transitions bundle. Strategies include:

• A Web-based resource room for care transitions in older adults: The transitions bundle, field guide, and related interventional materials will be freely available in the SHM online resource room.
• A Quality Pre-Course for QI Teams: The course is scheduled for 2008 and 2009 SHM Annual Meetings.
• A Transition Planning Mentored Implementation Program (TPMI): This yearlong mentoring program will support sites as they implement and evaluate transitions bundle interventions. The program includes a training conference, monthly teleconferences with expert mentors and peer support mechanisms.
• A consultation service: This will provide on-site consultation and technical assistance to sites planning, implementing, and evaluating discharge interventions. The service includes site visit, follow-up report of findings, recommendations and resources, and post-visit follow-up to review progress, successes and unforeseen barriers.

These support mechanisms are intended to assist those who lead improvement teams at their institutions. Enrollment will begin in the fall. For more information, contact tbudnitz@hospitalmedicine.org.

A Seat at the Table

SHM active in shaping new performance standards

By Jane Jerrard

Healthcare providers are in the midst of important changes in how they work and how they’re rewarded for that work. Recent initiatives including Medicare’s Physician Quality Reporting Initiative and a Medicare hospital value-based purchasing program mandated by the Deficit Reduction Act spell change for practitioners, including hospitalists.

SHM is working to add a hospitalist voice to discussions and decisions that shape these initiatives. By participating in organizations such as the American Medical Association’s (AMA) Physician consortium for Performance Improvement (PCPI), SHM has a seat at the table where decisions are made.

How Participation Works

The PCPI was convened in 2001 by the AMA, with the mission of physician-led performance improvement. While the primary focus is on improving quality, the Consortium’s performance measures are ultimately those used in CMS and other pay-for-performance (P4P) programs and value-based purchasing initiatives.

SHM didn’t get involved when the PCPI was first formed because the issues weren’t relevant to hospitalists. “SHM was invited to participate at that time, but the focus was really on outpatient care,” says Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La. “More recently, when the PCPI began looking at the relation between hospital-level measures and physician-level measures, SHM CEO Larry Wellikson said we need to get involved.”

Dr. Torcson is SHM’s representative on the consortium. “For the last year and a half, I’ve been attending the PCPI meetings to represent SHM and have been involved in various PCPI work groups,” he says. “I had previously served on the SHM HQPS [Healthcare Quality and Patient Safety Task Force] and now serve on the PPC [Public Policy Committee], and I think the SHM leadership thought that combination of interests would be good for a PCPI representative.”

What about the Work Groups?

Work groups within the PCPI are assigned specific areas. These groups are responsible for creating performance measures within an area, which are then reviewed by the entire consortium.

“I participated on a work group to develop performance measures for emergency medicine physicians,” says Dr. Torcson. “This group thought that the current disease-specific measures weren’t relevant for them, and that the current hospital measures were also not relevant. I provided a hospitalist’s perspective on hand-offs and discharge which was really focused on a process of care that begins in the ED [emergency department].”

Each work group has representation from various areas of healthcare. “My work group had about 20 or 25 people, which is probably typical,” says Dr. Torcson. “The AMA provided a methodologist, and there was a CMS representative on the work group.” The work group first met face to face to review relevant evidence-based clinical guidelines and scame up with five to eight measures. These were then reworked through phone calls and e-mails before going before the entire PCPI for approval.

Other SHM representatives participated in relevant PCPI work groups as well. “PPC member Greg Seymann from San Diego participated in a geriatric work group that was convened for the same reason” as the ED group, says Dr. Torcson. “His group looked at creating a number of measures that were relative to both inpatient and outpatient geriatric patients. Some of these measures are now part of the Medicare Physician Quality Reporting Initiative.”

Another SHM member, James C. Pile. MD, FACP, participated in a work group on developing measures for outpatient administration of IV antibiotics. Pile is a staff physician in the Department of General Internal Medicine, Section of Hospital Medicine, at The Cleveland Clinic in Ohio.

In each group, SHM representatives were able to help shape measures that reflect the unique knowledge and perspective of hospital medicine.

“A hospitalist brings the perspective of having seen how these measures are actually incorporated into a practice, how they are actually applied to patient care,” Dr. Torcson points out. “These work groups to develop additional performance measures are ongoing. The PCPI has a rigorous agenda for what they want to accomplish over the next few years.”

SHM to Lead the Way on Care Transitions

The PCPI has asked SHM to be the lead organization for a performance measure development work group on care coordination and care transitions.

“This will be groundbreaking work around this important aspect of care that is very process-focused as opposed to disease-focused,” says Dr. Torcson. “It’s very appropriate that SHM was asked to be the lead group for this. This area of performance improvement is perfect for what hospitalists do.”

The PCPI plans to have care transition performance measures ready for adoption by 2009.

SHM and the Big Three

CMS is also collaborating with the National Quality Forum (NQF) and Ambulatory Quality Alliance (AQA). “The PCPI, AQA, and NQF are the most influential organizations right now for quality and performance measures,” says Dr. Torcson.

The NQF, a unique public and private collaborative, develops consensus standards on different measures submitted to it. “I have had the opportunity to participate on an NQF Steering Committee for performance measure endorsement,” says Dr. Torcson.

The AQA is responsible for standardizing performance measurement and reporting, and developing measures for efficiency to be included in forthcoming Medicare P4P programs. “The AQA is charged with implementing performance measures and bringing them to the marketplace,” explains Dr. Torcson. “SHM is not involved in the AQA process yet.”

Membership in SHM means you are able to access the latest information on issues like CMS reporting initiatives and have representation in the decision-making process.

“I think it’s the responsibility of a professional society to not only be informed on what’s happening on a national level, but to have some influence,” says Dr. Torcson. “And SHM has done a great job in being well-positioned to influence the national agenda on quality and performance improvement.” TH

Jane Jerrard writes frequently for The Hospitalist.

On March 16, the John A. Hartford Foundation awarded SHM a $1.4 million grant to develop interventions to improve care transitions for older adults at the time of hospital discharge.

One of the core values of SHM and hospital medicine is to implement changes that improve the care older Americans receive. With this grant support from The Hartford Foundation, SHM can help define and set standards for best practices in discharge and provide a continuum of training opportunities to support those practices.

As part of this three-year project, SHM will partner with national leaders in care coordination to form a national advisory board, create clinical tools, implement guidelines, and provide technical support and training tools to hospitals across the U.S. The project aims to build capacity in at least 200 hospital sites to improve the discharge process and, ultimately, health outcomes for older adults.

Chapter Report

Los Angeles: The kick-off meeting for the Los Angeles chapter was held at Spago Beverly Hills on April 10. The meeting brought together approximately 25 physicians from eight hospitalist groups throughout Los Angeles County. Larry Wellikson, MD, CEO of SHM, gave a presentation, “The Emergence and Future of Hospital Medicine.” Dr. Wellikson illuminated many important points in his talk and encouraged attendees to become involved in quality improvement at their own hospitals. The meeting was supported by Ortho Biotech.

National Advisory Board AND Project Team

SHM has assembled a national advisory board to inform and guide the project. The board will be chaired by Eric Coleman, MD, MPH, associate professor of medicine within the divisions of healthcare policy and research and geriatric medicine at the University of Colorado Health Sciences Center in Aurora. At press time, members included:

• Barbara Berkman, DSW, PhD, professor of health and mental health, University School of Social Work, Mount Sinai School of Medicine;
• Tom Bookwalter, PharmD, clinical pharmacist, American Society of Health-System Pharmacists (ASHP);
• Alan Korn, MD, chief medical officer and senior vice president for clinical affairs, Blue Cross Blue Shield Association;
• Chuck Denham, MD, chair, National Quality Forum (NQF);
• Gavin Hougham, PhD, senior program officer, John A. Hartford Foundation;
• Seth Landefeld, MD, director, American Geriatrics Society (AGS);
• Cheri Lattimer, RN, BSN, executive director, Case Management Society of America (CMSA);
• William Lyons, MD, AGS; Nebraska Medical Center in Omaha;
• Lorraine Mion, PhD, RN, FAAN, director of nursing services for geriatrics, Metro Health Medical Center in Cleveland, Ohio;
• Mary Naylor, PhD, RN, FAANS, Marian S. Ware professor in gerontology, University of Pennsylvania;
• Gail Povar, MD, MPH, chair, George Washington School of Medicine, Cameron Medical Group;
• Deborah Queenan, national advisory council coordinator, Agency for Healthcare Research and Quality (AHRQ);
• Pat Rutherford, RN, MS, vice president, Institute for Healthcare Improvement (IHI), Transforming Care at the Bedside (TCAB);
• Eric Warm, MD, Society General Internal Medicine (SGIM); and
• Larry Wellikson, MD, CEO of SHM.

Dr. Williams will serve as principal investigator, leading a team of co-investigators including Jeffrey Greenwald, MD, (Boston University co-investigator, AHRQ, Project ReEngineering Discharge); Eric Howell, MD (Johns Hopkins Bayview, SHM/Hartford Safe Steps Demonstration Project); Param Dedhia, MD (Johns Hopkins Bayview, SHM/Hartford Safe STEPS Demonstration Project); Lakshmi Halasyamani, MD (St. Joseph Mercy Hospital); Kathleen Kerr (SHM); and Tina Budnitz, MPH (SHM).

The project team includes investigators from the SHM/Hartford Foundation Safe STEPS project and two AHRQ-funded projects. All three projects aim to pilot test discharge-planning toolkits and interventions and develop implementation strategies for adoption. The current project will leverage the findings of all three projects with the insights of the advisory board to create a transitions bundle to optimize the discharge process. Following development of this bundle, SHM will develop a toolkit for implementation with corresponding training programs, and other technical support.

click for large version

Capacity Building Via Continuum of Training Options

SHM has designed a range of technical support and training options to meet the needs of member institutions aiming to implement and sustain the transitions bundle. Strategies include:

• A Web-based resource room for care transitions in older adults: The transitions bundle, field guide, and related interventional materials will be freely available in the SHM online resource room.
• A Quality Pre-Course for QI Teams: The course is scheduled for 2008 and 2009 SHM Annual Meetings.
• A Transition Planning Mentored Implementation Program (TPMI): This yearlong mentoring program will support sites as they implement and evaluate transitions bundle interventions. The program includes a training conference, monthly teleconferences with expert mentors and peer support mechanisms.
• A consultation service: This will provide on-site consultation and technical assistance to sites planning, implementing, and evaluating discharge interventions. The service includes site visit, follow-up report of findings, recommendations and resources, and post-visit follow-up to review progress, successes and unforeseen barriers.

These support mechanisms are intended to assist those who lead improvement teams at their institutions. Enrollment will begin in the fall. For more information, contact tbudnitz@hospitalmedicine.org.

A Seat at the Table

SHM active in shaping new performance standards

By Jane Jerrard

Healthcare providers are in the midst of important changes in how they work and how they’re rewarded for that work. Recent initiatives including Medicare’s Physician Quality Reporting Initiative and a Medicare hospital value-based purchasing program mandated by the Deficit Reduction Act spell change for practitioners, including hospitalists.

SHM is working to add a hospitalist voice to discussions and decisions that shape these initiatives. By participating in organizations such as the American Medical Association’s (AMA) Physician consortium for Performance Improvement (PCPI), SHM has a seat at the table where decisions are made.

How Participation Works

The PCPI was convened in 2001 by the AMA, with the mission of physician-led performance improvement. While the primary focus is on improving quality, the Consortium’s performance measures are ultimately those used in CMS and other pay-for-performance (P4P) programs and value-based purchasing initiatives.

SHM didn’t get involved when the PCPI was first formed because the issues weren’t relevant to hospitalists. “SHM was invited to participate at that time, but the focus was really on outpatient care,” says Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La. “More recently, when the PCPI began looking at the relation between hospital-level measures and physician-level measures, SHM CEO Larry Wellikson said we need to get involved.”

Dr. Torcson is SHM’s representative on the consortium. “For the last year and a half, I’ve been attending the PCPI meetings to represent SHM and have been involved in various PCPI work groups,” he says. “I had previously served on the SHM HQPS [Healthcare Quality and Patient Safety Task Force] and now serve on the PPC [Public Policy Committee], and I think the SHM leadership thought that combination of interests would be good for a PCPI representative.”

What about the Work Groups?

Work groups within the PCPI are assigned specific areas. These groups are responsible for creating performance measures within an area, which are then reviewed by the entire consortium.

“I participated on a work group to develop performance measures for emergency medicine physicians,” says Dr. Torcson. “This group thought that the current disease-specific measures weren’t relevant for them, and that the current hospital measures were also not relevant. I provided a hospitalist’s perspective on hand-offs and discharge which was really focused on a process of care that begins in the ED [emergency department].”

Each work group has representation from various areas of healthcare. “My work group had about 20 or 25 people, which is probably typical,” says Dr. Torcson. “The AMA provided a methodologist, and there was a CMS representative on the work group.” The work group first met face to face to review relevant evidence-based clinical guidelines and scame up with five to eight measures. These were then reworked through phone calls and e-mails before going before the entire PCPI for approval.

Other SHM representatives participated in relevant PCPI work groups as well. “PPC member Greg Seymann from San Diego participated in a geriatric work group that was convened for the same reason” as the ED group, says Dr. Torcson. “His group looked at creating a number of measures that were relative to both inpatient and outpatient geriatric patients. Some of these measures are now part of the Medicare Physician Quality Reporting Initiative.”

Another SHM member, James C. Pile. MD, FACP, participated in a work group on developing measures for outpatient administration of IV antibiotics. Pile is a staff physician in the Department of General Internal Medicine, Section of Hospital Medicine, at The Cleveland Clinic in Ohio.

In each group, SHM representatives were able to help shape measures that reflect the unique knowledge and perspective of hospital medicine.

“A hospitalist brings the perspective of having seen how these measures are actually incorporated into a practice, how they are actually applied to patient care,” Dr. Torcson points out. “These work groups to develop additional performance measures are ongoing. The PCPI has a rigorous agenda for what they want to accomplish over the next few years.”

SHM to Lead the Way on Care Transitions

The PCPI has asked SHM to be the lead organization for a performance measure development work group on care coordination and care transitions.

“This will be groundbreaking work around this important aspect of care that is very process-focused as opposed to disease-focused,” says Dr. Torcson. “It’s very appropriate that SHM was asked to be the lead group for this. This area of performance improvement is perfect for what hospitalists do.”

The PCPI plans to have care transition performance measures ready for adoption by 2009.

SHM and the Big Three

CMS is also collaborating with the National Quality Forum (NQF) and Ambulatory Quality Alliance (AQA). “The PCPI, AQA, and NQF are the most influential organizations right now for quality and performance measures,” says Dr. Torcson.

The NQF, a unique public and private collaborative, develops consensus standards on different measures submitted to it. “I have had the opportunity to participate on an NQF Steering Committee for performance measure endorsement,” says Dr. Torcson.

The AQA is responsible for standardizing performance measurement and reporting, and developing measures for efficiency to be included in forthcoming Medicare P4P programs. “The AQA is charged with implementing performance measures and bringing them to the marketplace,” explains Dr. Torcson. “SHM is not involved in the AQA process yet.”

Membership in SHM means you are able to access the latest information on issues like CMS reporting initiatives and have representation in the decision-making process.

“I think it’s the responsibility of a professional society to not only be informed on what’s happening on a national level, but to have some influence,” says Dr. Torcson. “And SHM has done a great job in being well-positioned to influence the national agenda on quality and performance improvement.” TH

Jane Jerrard writes frequently for The Hospitalist.

On March 16, the John A. Hartford Foundation awarded SHM a $1.4 million grant to develop interventions to improve care transitions for older adults at the time of hospital discharge.

One of the core values of SHM and hospital medicine is to implement changes that improve the care older Americans receive. With this grant support from The Hartford Foundation, SHM can help define and set standards for best practices in discharge and provide a continuum of training opportunities to support those practices.

As part of this three-year project, SHM will partner with national leaders in care coordination to form a national advisory board, create clinical tools, implement guidelines, and provide technical support and training tools to hospitals across the U.S. The project aims to build capacity in at least 200 hospital sites to improve the discharge process and, ultimately, health outcomes for older adults.

Chapter Report

Los Angeles: The kick-off meeting for the Los Angeles chapter was held at Spago Beverly Hills on April 10. The meeting brought together approximately 25 physicians from eight hospitalist groups throughout Los Angeles County. Larry Wellikson, MD, CEO of SHM, gave a presentation, “The Emergence and Future of Hospital Medicine.” Dr. Wellikson illuminated many important points in his talk and encouraged attendees to become involved in quality improvement at their own hospitals. The meeting was supported by Ortho Biotech.

National Advisory Board AND Project Team

SHM has assembled a national advisory board to inform and guide the project. The board will be chaired by Eric Coleman, MD, MPH, associate professor of medicine within the divisions of healthcare policy and research and geriatric medicine at the University of Colorado Health Sciences Center in Aurora. At press time, members included:

• Barbara Berkman, DSW, PhD, professor of health and mental health, University School of Social Work, Mount Sinai School of Medicine;
• Tom Bookwalter, PharmD, clinical pharmacist, American Society of Health-System Pharmacists (ASHP);
• Alan Korn, MD, chief medical officer and senior vice president for clinical affairs, Blue Cross Blue Shield Association;
• Chuck Denham, MD, chair, National Quality Forum (NQF);
• Gavin Hougham, PhD, senior program officer, John A. Hartford Foundation;
• Seth Landefeld, MD, director, American Geriatrics Society (AGS);
• Cheri Lattimer, RN, BSN, executive director, Case Management Society of America (CMSA);
• William Lyons, MD, AGS; Nebraska Medical Center in Omaha;
• Lorraine Mion, PhD, RN, FAAN, director of nursing services for geriatrics, Metro Health Medical Center in Cleveland, Ohio;
• Mary Naylor, PhD, RN, FAANS, Marian S. Ware professor in gerontology, University of Pennsylvania;
• Gail Povar, MD, MPH, chair, George Washington School of Medicine, Cameron Medical Group;
• Deborah Queenan, national advisory council coordinator, Agency for Healthcare Research and Quality (AHRQ);
• Pat Rutherford, RN, MS, vice president, Institute for Healthcare Improvement (IHI), Transforming Care at the Bedside (TCAB);
• Eric Warm, MD, Society General Internal Medicine (SGIM); and
• Larry Wellikson, MD, CEO of SHM.

Dr. Williams will serve as principal investigator, leading a team of co-investigators including Jeffrey Greenwald, MD, (Boston University co-investigator, AHRQ, Project ReEngineering Discharge); Eric Howell, MD (Johns Hopkins Bayview, SHM/Hartford Safe Steps Demonstration Project); Param Dedhia, MD (Johns Hopkins Bayview, SHM/Hartford Safe STEPS Demonstration Project); Lakshmi Halasyamani, MD (St. Joseph Mercy Hospital); Kathleen Kerr (SHM); and Tina Budnitz, MPH (SHM).

The project team includes investigators from the SHM/Hartford Foundation Safe STEPS project and two AHRQ-funded projects. All three projects aim to pilot test discharge-planning toolkits and interventions and develop implementation strategies for adoption. The current project will leverage the findings of all three projects with the insights of the advisory board to create a transitions bundle to optimize the discharge process. Following development of this bundle, SHM will develop a toolkit for implementation with corresponding training programs, and other technical support.

click for large version

Capacity Building Via Continuum of Training Options

SHM has designed a range of technical support and training options to meet the needs of member institutions aiming to implement and sustain the transitions bundle. Strategies include:

• A Web-based resource room for care transitions in older adults: The transitions bundle, field guide, and related interventional materials will be freely available in the SHM online resource room.
• A Quality Pre-Course for QI Teams: The course is scheduled for 2008 and 2009 SHM Annual Meetings.
• A Transition Planning Mentored Implementation Program (TPMI): This yearlong mentoring program will support sites as they implement and evaluate transitions bundle interventions. The program includes a training conference, monthly teleconferences with expert mentors and peer support mechanisms.
• A consultation service: This will provide on-site consultation and technical assistance to sites planning, implementing, and evaluating discharge interventions. The service includes site visit, follow-up report of findings, recommendations and resources, and post-visit follow-up to review progress, successes and unforeseen barriers.

These support mechanisms are intended to assist those who lead improvement teams at their institutions. Enrollment will begin in the fall. For more information, contact tbudnitz@hospitalmedicine.org.

A Seat at the Table

SHM active in shaping new performance standards

By Jane Jerrard

Healthcare providers are in the midst of important changes in how they work and how they’re rewarded for that work. Recent initiatives including Medicare’s Physician Quality Reporting Initiative and a Medicare hospital value-based purchasing program mandated by the Deficit Reduction Act spell change for practitioners, including hospitalists.

SHM is working to add a hospitalist voice to discussions and decisions that shape these initiatives. By participating in organizations such as the American Medical Association’s (AMA) Physician consortium for Performance Improvement (PCPI), SHM has a seat at the table where decisions are made.

How Participation Works

The PCPI was convened in 2001 by the AMA, with the mission of physician-led performance improvement. While the primary focus is on improving quality, the Consortium’s performance measures are ultimately those used in CMS and other pay-for-performance (P4P) programs and value-based purchasing initiatives.

SHM didn’t get involved when the PCPI was first formed because the issues weren’t relevant to hospitalists. “SHM was invited to participate at that time, but the focus was really on outpatient care,” says Patrick J. Torcson, MD, MMM, FACP, director of hospital medicine at St. Tammany Parish Hospital in Covington, La. “More recently, when the PCPI began looking at the relation between hospital-level measures and physician-level measures, SHM CEO Larry Wellikson said we need to get involved.”

Dr. Torcson is SHM’s representative on the consortium. “For the last year and a half, I’ve been attending the PCPI meetings to represent SHM and have been involved in various PCPI work groups,” he says. “I had previously served on the SHM HQPS [Healthcare Quality and Patient Safety Task Force] and now serve on the PPC [Public Policy Committee], and I think the SHM leadership thought that combination of interests would be good for a PCPI representative.”

What about the Work Groups?

Work groups within the PCPI are assigned specific areas. These groups are responsible for creating performance measures within an area, which are then reviewed by the entire consortium.

“I participated on a work group to develop performance measures for emergency medicine physicians,” says Dr. Torcson. “This group thought that the current disease-specific measures weren’t relevant for them, and that the current hospital measures were also not relevant. I provided a hospitalist’s perspective on hand-offs and discharge which was really focused on a process of care that begins in the ED [emergency department].”

Each work group has representation from various areas of healthcare. “My work group had about 20 or 25 people, which is probably typical,” says Dr. Torcson. “The AMA provided a methodologist, and there was a CMS representative on the work group.” The work group first met face to face to review relevant evidence-based clinical guidelines and scame up with five to eight measures. These were then reworked through phone calls and e-mails before going before the entire PCPI for approval.

Other SHM representatives participated in relevant PCPI work groups as well. “PPC member Greg Seymann from San Diego participated in a geriatric work group that was convened for the same reason” as the ED group, says Dr. Torcson. “His group looked at creating a number of measures that were relative to both inpatient and outpatient geriatric patients. Some of these measures are now part of the Medicare Physician Quality Reporting Initiative.”

Another SHM member, James C. Pile. MD, FACP, participated in a work group on developing measures for outpatient administration of IV antibiotics. Pile is a staff physician in the Department of General Internal Medicine, Section of Hospital Medicine, at The Cleveland Clinic in Ohio.

In each group, SHM representatives were able to help shape measures that reflect the unique knowledge and perspective of hospital medicine.

“A hospitalist brings the perspective of having seen how these measures are actually incorporated into a practice, how they are actually applied to patient care,” Dr. Torcson points out. “These work groups to develop additional performance measures are ongoing. The PCPI has a rigorous agenda for what they want to accomplish over the next few years.”

SHM to Lead the Way on Care Transitions

The PCPI has asked SHM to be the lead organization for a performance measure development work group on care coordination and care transitions.

“This will be groundbreaking work around this important aspect of care that is very process-focused as opposed to disease-focused,” says Dr. Torcson. “It’s very appropriate that SHM was asked to be the lead group for this. This area of performance improvement is perfect for what hospitalists do.”

The PCPI plans to have care transition performance measures ready for adoption by 2009.

SHM and the Big Three

CMS is also collaborating with the National Quality Forum (NQF) and Ambulatory Quality Alliance (AQA). “The PCPI, AQA, and NQF are the most influential organizations right now for quality and performance measures,” says Dr. Torcson.

The NQF, a unique public and private collaborative, develops consensus standards on different measures submitted to it. “I have had the opportunity to participate on an NQF Steering Committee for performance measure endorsement,” says Dr. Torcson.

The AQA is responsible for standardizing performance measurement and reporting, and developing measures for efficiency to be included in forthcoming Medicare P4P programs. “The AQA is charged with implementing performance measures and bringing them to the marketplace,” explains Dr. Torcson. “SHM is not involved in the AQA process yet.”

Membership in SHM means you are able to access the latest information on issues like CMS reporting initiatives and have representation in the decision-making process.

“I think it’s the responsibility of a professional society to not only be informed on what’s happening on a national level, but to have some influence,” says Dr. Torcson. “And SHM has done a great job in being well-positioned to influence the national agenda on quality and performance improvement.” TH

Jane Jerrard writes frequently for The Hospitalist.

I remember the 10th anniversary of SHM back in 2007. The growth of the hospitalist field seemed remarkable back then, but little did we know it was just the beginning.

Even then, as I recall, the field had grown from a few hundred physicians in the mid-’90s to about 20,000, and SHM—which began literally on the back of a napkin in 1997—had more than 6,000 members. But it still felt like adolescence. We had new muscles and our voice was changing, but we were still a bit gangly and didn’t quite know what would become of us.

But these past 10 years have been truly something. Without question, the “co-management” thing has really turbocharged our growth. There are now more than 50,000 hospitalists in the United States and burgeoning hospitalist movements in several other countries. It’s amazing to think that the care of nonmedical patients was only a small portion of what hospitalists did in the early years. But, starting about 2005 or so, one specialty after another began asking hospitalists to provide hospital care and coordination: first orthopedic surgery, then neurosurgery, then all of surgery, then neurology, cardiology, and transplant services.

In the big teaching hospitals, the early diffusion was caused, in part, by the original limits on resident duty hours—to 80 hours a week, believe it or not. That seems like an awful lot now that residents are limited to 56 hours per week. Today, all these specialties have recognized that having hospitalists manage the medical aspects of hospital care and coordinate the rest with their interdisciplinary teams isn’t just about replacing residents; hospitalists create better outcomes at lower costs. And because everybody’s now paid based on their Value Score (quality and patient satisfaction divided by efficiency) everybody needs hospitalists.

Speaking of the Value Score: Boy, has quality measurement changed. Remember getting graded on whether we gave Pneumovax to hospitalized patients with pneumonia? Kind of silly, but that was all we knew. Now, our pneumonia care is judged on whether our patient is alive, ambulatory, and free of dyspnea four weeks after discharge—adjusted for all relevant comorbidities. And those data are collected automatically through our electronic medical record and immediately posted to the Web, where everybody sees it—including the folks at Medicare II (which now insures everybody in the U.S.), who adjust payment rates every month based on Value Scores.

Luckily, every hospital in the U.S. is computerized and has computerized physician order entry. Information gathered at the point of care—vital signs, blood sugars—flows wirelessly into the GUR (Google Universal Record), which can be accessed anywhere. Decision support is really impressive. When I say “pneumonia” to the computer (no, nobody types any more), it automatically suggests the best evidence-based workup and therapy. The no-brainers—DVT prophylaxis, pneumococcal vaccine injection, smoking cessation counseling—just happen. (I really like the interactive smoking counseling video that patients watch on their in-room plasma monitors.)

Although some docs used to fret that computers would make hospitalists obsolete, I think having the computer handle the rote, mundane stuff is great. There is certainly enough complex decision-making and coordination left to do. I now spend a lot more time in the patient’s room. The patient, the family, several consultants, and I are on the split-screen monitor discussing the patient’s case and developing a care plan. Most of the consultants are from my hospital, although we’re starting to use a few with good Value Scores based in India.

Some folks still take hospitalist jobs for a year or two and then go on to something else. But now that there are hospitalist training programs and board certification, most hospitalists are in it for the long haul. Because they are crucial to the success of the entire system, they are well compensated, have a reasonable schedule, and have tremendous opportunities for career advancement. For example, it seems like virtually every chief medical officer or information technology (IT) director (and a pretty good number of hospital CEOs) is a hospitalist.

All in all, the past 10 years have been terrific for our field. In 2007, after seeing the field’s early and unprecedented successes, some folks thought we had peaked. But one thing I’ve learned in the 20 years since I first wrote the word “hospitalist” (if I had just trademarked that term, I’d be on the golf course in Maui, not in assisted living here in Boca): Given a choice whether to bet on growth or stasis, when it comes to hospitalists, the bet should always be on bigger and better. TH

Dr. Wachter is professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He was the first elected president of SHM.

I remember the 10th anniversary of SHM back in 2007. The growth of the hospitalist field seemed remarkable back then, but little did we know it was just the beginning.

Even then, as I recall, the field had grown from a few hundred physicians in the mid-’90s to about 20,000, and SHM—which began literally on the back of a napkin in 1997—had more than 6,000 members. But it still felt like adolescence. We had new muscles and our voice was changing, but we were still a bit gangly and didn’t quite know what would become of us.

But these past 10 years have been truly something. Without question, the “co-management” thing has really turbocharged our growth. There are now more than 50,000 hospitalists in the United States and burgeoning hospitalist movements in several other countries. It’s amazing to think that the care of nonmedical patients was only a small portion of what hospitalists did in the early years. But, starting about 2005 or so, one specialty after another began asking hospitalists to provide hospital care and coordination: first orthopedic surgery, then neurosurgery, then all of surgery, then neurology, cardiology, and transplant services.

In the big teaching hospitals, the early diffusion was caused, in part, by the original limits on resident duty hours—to 80 hours a week, believe it or not. That seems like an awful lot now that residents are limited to 56 hours per week. Today, all these specialties have recognized that having hospitalists manage the medical aspects of hospital care and coordinate the rest with their interdisciplinary teams isn’t just about replacing residents; hospitalists create better outcomes at lower costs. And because everybody’s now paid based on their Value Score (quality and patient satisfaction divided by efficiency) everybody needs hospitalists.

Speaking of the Value Score: Boy, has quality measurement changed. Remember getting graded on whether we gave Pneumovax to hospitalized patients with pneumonia? Kind of silly, but that was all we knew. Now, our pneumonia care is judged on whether our patient is alive, ambulatory, and free of dyspnea four weeks after discharge—adjusted for all relevant comorbidities. And those data are collected automatically through our electronic medical record and immediately posted to the Web, where everybody sees it—including the folks at Medicare II (which now insures everybody in the U.S.), who adjust payment rates every month based on Value Scores.

Luckily, every hospital in the U.S. is computerized and has computerized physician order entry. Information gathered at the point of care—vital signs, blood sugars—flows wirelessly into the GUR (Google Universal Record), which can be accessed anywhere. Decision support is really impressive. When I say “pneumonia” to the computer (no, nobody types any more), it automatically suggests the best evidence-based workup and therapy. The no-brainers—DVT prophylaxis, pneumococcal vaccine injection, smoking cessation counseling—just happen. (I really like the interactive smoking counseling video that patients watch on their in-room plasma monitors.)

Although some docs used to fret that computers would make hospitalists obsolete, I think having the computer handle the rote, mundane stuff is great. There is certainly enough complex decision-making and coordination left to do. I now spend a lot more time in the patient’s room. The patient, the family, several consultants, and I are on the split-screen monitor discussing the patient’s case and developing a care plan. Most of the consultants are from my hospital, although we’re starting to use a few with good Value Scores based in India.

Some folks still take hospitalist jobs for a year or two and then go on to something else. But now that there are hospitalist training programs and board certification, most hospitalists are in it for the long haul. Because they are crucial to the success of the entire system, they are well compensated, have a reasonable schedule, and have tremendous opportunities for career advancement. For example, it seems like virtually every chief medical officer or information technology (IT) director (and a pretty good number of hospital CEOs) is a hospitalist.

All in all, the past 10 years have been terrific for our field. In 2007, after seeing the field’s early and unprecedented successes, some folks thought we had peaked. But one thing I’ve learned in the 20 years since I first wrote the word “hospitalist” (if I had just trademarked that term, I’d be on the golf course in Maui, not in assisted living here in Boca): Given a choice whether to bet on growth or stasis, when it comes to hospitalists, the bet should always be on bigger and better. TH

Dr. Wachter is professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He was the first elected president of SHM.

I remember the 10th anniversary of SHM back in 2007. The growth of the hospitalist field seemed remarkable back then, but little did we know it was just the beginning.

Even then, as I recall, the field had grown from a few hundred physicians in the mid-’90s to about 20,000, and SHM—which began literally on the back of a napkin in 1997—had more than 6,000 members. But it still felt like adolescence. We had new muscles and our voice was changing, but we were still a bit gangly and didn’t quite know what would become of us.

But these past 10 years have been truly something. Without question, the “co-management” thing has really turbocharged our growth. There are now more than 50,000 hospitalists in the United States and burgeoning hospitalist movements in several other countries. It’s amazing to think that the care of nonmedical patients was only a small portion of what hospitalists did in the early years. But, starting about 2005 or so, one specialty after another began asking hospitalists to provide hospital care and coordination: first orthopedic surgery, then neurosurgery, then all of surgery, then neurology, cardiology, and transplant services.

In the big teaching hospitals, the early diffusion was caused, in part, by the original limits on resident duty hours—to 80 hours a week, believe it or not. That seems like an awful lot now that residents are limited to 56 hours per week. Today, all these specialties have recognized that having hospitalists manage the medical aspects of hospital care and coordinate the rest with their interdisciplinary teams isn’t just about replacing residents; hospitalists create better outcomes at lower costs. And because everybody’s now paid based on their Value Score (quality and patient satisfaction divided by efficiency) everybody needs hospitalists.

Speaking of the Value Score: Boy, has quality measurement changed. Remember getting graded on whether we gave Pneumovax to hospitalized patients with pneumonia? Kind of silly, but that was all we knew. Now, our pneumonia care is judged on whether our patient is alive, ambulatory, and free of dyspnea four weeks after discharge—adjusted for all relevant comorbidities. And those data are collected automatically through our electronic medical record and immediately posted to the Web, where everybody sees it—including the folks at Medicare II (which now insures everybody in the U.S.), who adjust payment rates every month based on Value Scores.

Luckily, every hospital in the U.S. is computerized and has computerized physician order entry. Information gathered at the point of care—vital signs, blood sugars—flows wirelessly into the GUR (Google Universal Record), which can be accessed anywhere. Decision support is really impressive. When I say “pneumonia” to the computer (no, nobody types any more), it automatically suggests the best evidence-based workup and therapy. The no-brainers—DVT prophylaxis, pneumococcal vaccine injection, smoking cessation counseling—just happen. (I really like the interactive smoking counseling video that patients watch on their in-room plasma monitors.)

Although some docs used to fret that computers would make hospitalists obsolete, I think having the computer handle the rote, mundane stuff is great. There is certainly enough complex decision-making and coordination left to do. I now spend a lot more time in the patient’s room. The patient, the family, several consultants, and I are on the split-screen monitor discussing the patient’s case and developing a care plan. Most of the consultants are from my hospital, although we’re starting to use a few with good Value Scores based in India.

Some folks still take hospitalist jobs for a year or two and then go on to something else. But now that there are hospitalist training programs and board certification, most hospitalists are in it for the long haul. Because they are crucial to the success of the entire system, they are well compensated, have a reasonable schedule, and have tremendous opportunities for career advancement. For example, it seems like virtually every chief medical officer or information technology (IT) director (and a pretty good number of hospital CEOs) is a hospitalist.

All in all, the past 10 years have been terrific for our field. In 2007, after seeing the field’s early and unprecedented successes, some folks thought we had peaked. But one thing I’ve learned in the 20 years since I first wrote the word “hospitalist” (if I had just trademarked that term, I’d be on the golf course in Maui, not in assisted living here in Boca): Given a choice whether to bet on growth or stasis, when it comes to hospitalists, the bet should always be on bigger and better. TH

Dr. Wachter is professor of medicine at the University of California, San Francisco, associate chairman of UCSF’s Department of Medicine, and chief of the Medical Service at UCSF Medical Center. He was the first elected president of SHM.

I have been practicing medicine for 21 years. I had a private practice for 17 years before beginning a hospitalist program at our local hospital four years ago. I found “Final Exam?” (April 2007, p. 25) very interesting.

Most interesting were Dr. Andrew Bomback’s comments. He might consider that those “retired physicians” are realistic in their critique. Most physicians, if not all trained prior to the mandated 80-hour workweeks, had just as much paperwork and carried pagers. In fact, many worked past the magical 12-hour shift and carried extensive hours into practice from residency. Few had the ancillary support available today. While it is true the physical exam has evolved, it is no less important in these days of technology.

The accurate history and physical exam suggest a differential diagnosis, from which we order tests to confirm or dispute. In the days of my residency training, internists were known to be the physicians who wrote the most orders, and there was a certain ill-found pride in seeing what obscure but pertinent tests one could order. Managed care, for all its problems, has made us focus on efficiency. It is there that the history and physical exam shine. In my opinion, they are paramount for cost-effective management of patients.

A recent example: I was asked to see a 47-year-old patient in the ED last week who presented with dyspnea. The ED physician had done a cursory exam and ordered the initial workup. The [chest X-ray] demonstrated cardiomegaly and pulmonary vascular congestion. The patient’s cardiac enzymes were normal, and his BNP was 82. The ED physician told me the EKG did not demonstrate new ST or T wave changes. A d-dimer was elevated, so he ordered a CT pulmonary angiogram. I arrived to see the patient prior to the patient leaving for CT. The patient had jugular venous distention, his heart tones were muffled, and he had pulsus paradoxicus. As I left the room, the patient went for CT. This was negative for PE but showed a large pericardial effusion. The echo I ordered confirmed the findings of tamponade. The physical exam should have led to the echocardiogram, thus eliminating the need for CT—a significant saving for the patient.

One of the benefits hospitalists offer is time spent with patients, as opposed to private practice physicians coming from their offices to see patients. There is no better time spent for physician and patient than the history and physical.

Al Caccavale, DO, FACOI

Chairman, Board of Trustees

Yavapai Regional Medical Center, Prescott, Ariz.

I have been practicing medicine for 21 years. I had a private practice for 17 years before beginning a hospitalist program at our local hospital four years ago. I found “Final Exam?” (April 2007, p. 25) very interesting.

Most interesting were Dr. Andrew Bomback’s comments. He might consider that those “retired physicians” are realistic in their critique. Most physicians, if not all trained prior to the mandated 80-hour workweeks, had just as much paperwork and carried pagers. In fact, many worked past the magical 12-hour shift and carried extensive hours into practice from residency. Few had the ancillary support available today. While it is true the physical exam has evolved, it is no less important in these days of technology.

The accurate history and physical exam suggest a differential diagnosis, from which we order tests to confirm or dispute. In the days of my residency training, internists were known to be the physicians who wrote the most orders, and there was a certain ill-found pride in seeing what obscure but pertinent tests one could order. Managed care, for all its problems, has made us focus on efficiency. It is there that the history and physical exam shine. In my opinion, they are paramount for cost-effective management of patients.

A recent example: I was asked to see a 47-year-old patient in the ED last week who presented with dyspnea. The ED physician had done a cursory exam and ordered the initial workup. The [chest X-ray] demonstrated cardiomegaly and pulmonary vascular congestion. The patient’s cardiac enzymes were normal, and his BNP was 82. The ED physician told me the EKG did not demonstrate new ST or T wave changes. A d-dimer was elevated, so he ordered a CT pulmonary angiogram. I arrived to see the patient prior to the patient leaving for CT. The patient had jugular venous distention, his heart tones were muffled, and he had pulsus paradoxicus. As I left the room, the patient went for CT. This was negative for PE but showed a large pericardial effusion. The echo I ordered confirmed the findings of tamponade. The physical exam should have led to the echocardiogram, thus eliminating the need for CT—a significant saving for the patient.

One of the benefits hospitalists offer is time spent with patients, as opposed to private practice physicians coming from their offices to see patients. There is no better time spent for physician and patient than the history and physical.

Al Caccavale, DO, FACOI

Chairman, Board of Trustees

Yavapai Regional Medical Center, Prescott, Ariz.

I have been practicing medicine for 21 years. I had a private practice for 17 years before beginning a hospitalist program at our local hospital four years ago. I found “Final Exam?” (April 2007, p. 25) very interesting.

Most interesting were Dr. Andrew Bomback’s comments. He might consider that those “retired physicians” are realistic in their critique. Most physicians, if not all trained prior to the mandated 80-hour workweeks, had just as much paperwork and carried pagers. In fact, many worked past the magical 12-hour shift and carried extensive hours into practice from residency. Few had the ancillary support available today. While it is true the physical exam has evolved, it is no less important in these days of technology.

The accurate history and physical exam suggest a differential diagnosis, from which we order tests to confirm or dispute. In the days of my residency training, internists were known to be the physicians who wrote the most orders, and there was a certain ill-found pride in seeing what obscure but pertinent tests one could order. Managed care, for all its problems, has made us focus on efficiency. It is there that the history and physical exam shine. In my opinion, they are paramount for cost-effective management of patients.

A recent example: I was asked to see a 47-year-old patient in the ED last week who presented with dyspnea. The ED physician had done a cursory exam and ordered the initial workup. The [chest X-ray] demonstrated cardiomegaly and pulmonary vascular congestion. The patient’s cardiac enzymes were normal, and his BNP was 82. The ED physician told me the EKG did not demonstrate new ST or T wave changes. A d-dimer was elevated, so he ordered a CT pulmonary angiogram. I arrived to see the patient prior to the patient leaving for CT. The patient had jugular venous distention, his heart tones were muffled, and he had pulsus paradoxicus. As I left the room, the patient went for CT. This was negative for PE but showed a large pericardial effusion. The echo I ordered confirmed the findings of tamponade. The physical exam should have led to the echocardiogram, thus eliminating the need for CT—a significant saving for the patient.

One of the benefits hospitalists offer is time spent with patients, as opposed to private practice physicians coming from their offices to see patients. There is no better time spent for physician and patient than the history and physical.

Al Caccavale, DO, FACOI

Chairman, Board of Trustees

Yavapai Regional Medical Center, Prescott, Ariz.

A70-year-old female was admitted for management of progressive cellulitis and evaluation of a lower leg laceration after she fell from a motorized scooter. She had initially failed outpatient management with cephalexin and was treated with vancomycin and piperacillin and tazobactam while hospitalized. Her cellulitis resolved, and plastic surgery helped repair the laceration with skin grafting from her right thigh.

Three days after the procedure, the woman’s electrolyte panel read plasma glucose 110 mg/dL, blood urea nitrogen 11 mg/dL, serum creatinine 0.8 mg/dL, sodium 138 mEq/L, potassium 5.7 mEq/L, chloride 101 mEq/L, bicarbonate 28 mEq/L, magnesium 2.1 mg/dl, and calcium 8.9 mg/dl.

She was taking:

• Citalopram 20 mg PO QD;
• HCTZ 25 mg PO QD;
• Docusate 100 mg PO twice daily;
• Oxycodone 5 mg PO Q6 hours PRN pain;
• Acetaminophen 500 mg PO Q6 hours scheduled;
• Heparin 5,000 units SQ q eight hours;
• Levothyroxine 25 mcg PO QAM;
• Intravenous fluid D5NS at 80 cc/hour; and
• Trazodone 50 mg PO PRN insomnia.

Her urinalysis showed:

• pH 6.8;
• Na 155 meq/L;
• K 20 meq/L; and
• Urine osmolality 447.

Which of the following is the most appropriate action for this patient?

a) Sodium polystyrene sulfonate 30 gm orally every 4 hours; four doses

b) Sodium polystyrene sulfonate enema 60 gm

c) Discontinue citalopram

d) Discontinue oxycodone

e) Discontinue heparin

Discussion

The answer is E: Discontinue heparin. This patient has hyperkalemia with low urinary excretion of potassium and no evidence of acidosis. Many medications can cause hyperkalemia, most notably angiotensin-converting enzyme inhibitors, K-sparing diuretics, NSAIDs, and beta-blockers.

When an obvious cause is not present, such as over-supplementation of potassium chloride via oral or intravenous route, a search for less obvious causes, such as renal tubular acidosis, is warranted. In this patient none of these causes is present.

Heparin has many potential side effects, both directly from anticoagulation, such as retroperitoneal hemorrhage, or immunologically, such as heparin-induced thrombocytopenia (HIT). In this case the patient has heparin-induced hypoaldosteronism causing secondary hyperkalemia. This can occur with all types of heparin, usually at doses greater then 5,000 units/day. This emphasizes the point that when an unexpected phenomenon is noted in a hospitalized patient, a search should always include medications’ side effects.

Subcutaneous heparin was discontinued, and the patient was placed on aspirin, TED hose stockings, and sequential compression devices for deep vein thrombosis (DVT) prophylaxis. A repeat electrolyte panel obtained afterward showed resolution of the patient’s hyperkalemia. TH

Dr. Newman and Herber practice at the Department of Medicine, Mayo Graduate School of Medical Education, Mayo Clinic, Rochester, Minn.

A70-year-old female was admitted for management of progressive cellulitis and evaluation of a lower leg laceration after she fell from a motorized scooter. She had initially failed outpatient management with cephalexin and was treated with vancomycin and piperacillin and tazobactam while hospitalized. Her cellulitis resolved, and plastic surgery helped repair the laceration with skin grafting from her right thigh.

Three days after the procedure, the woman’s electrolyte panel read plasma glucose 110 mg/dL, blood urea nitrogen 11 mg/dL, serum creatinine 0.8 mg/dL, sodium 138 mEq/L, potassium 5.7 mEq/L, chloride 101 mEq/L, bicarbonate 28 mEq/L, magnesium 2.1 mg/dl, and calcium 8.9 mg/dl.

She was taking:

• Citalopram 20 mg PO QD;
• HCTZ 25 mg PO QD;
• Docusate 100 mg PO twice daily;
• Oxycodone 5 mg PO Q6 hours PRN pain;
• Acetaminophen 500 mg PO Q6 hours scheduled;
• Heparin 5,000 units SQ q eight hours;
• Levothyroxine 25 mcg PO QAM;
• Intravenous fluid D5NS at 80 cc/hour; and
• Trazodone 50 mg PO PRN insomnia.

Her urinalysis showed:

• pH 6.8;
• Na 155 meq/L;
• K 20 meq/L; and
• Urine osmolality 447.

Which of the following is the most appropriate action for this patient?

a) Sodium polystyrene sulfonate 30 gm orally every 4 hours; four doses

b) Sodium polystyrene sulfonate enema 60 gm

c) Discontinue citalopram

d) Discontinue oxycodone

e) Discontinue heparin

Discussion

The answer is E: Discontinue heparin. This patient has hyperkalemia with low urinary excretion of potassium and no evidence of acidosis. Many medications can cause hyperkalemia, most notably angiotensin-converting enzyme inhibitors, K-sparing diuretics, NSAIDs, and beta-blockers.

When an obvious cause is not present, such as over-supplementation of potassium chloride via oral or intravenous route, a search for less obvious causes, such as renal tubular acidosis, is warranted. In this patient none of these causes is present.

Heparin has many potential side effects, both directly from anticoagulation, such as retroperitoneal hemorrhage, or immunologically, such as heparin-induced thrombocytopenia (HIT). In this case the patient has heparin-induced hypoaldosteronism causing secondary hyperkalemia. This can occur with all types of heparin, usually at doses greater then 5,000 units/day. This emphasizes the point that when an unexpected phenomenon is noted in a hospitalized patient, a search should always include medications’ side effects.

Subcutaneous heparin was discontinued, and the patient was placed on aspirin, TED hose stockings, and sequential compression devices for deep vein thrombosis (DVT) prophylaxis. A repeat electrolyte panel obtained afterward showed resolution of the patient’s hyperkalemia. TH

Dr. Newman and Herber practice at the Department of Medicine, Mayo Graduate School of Medical Education, Mayo Clinic, Rochester, Minn.

A70-year-old female was admitted for management of progressive cellulitis and evaluation of a lower leg laceration after she fell from a motorized scooter. She had initially failed outpatient management with cephalexin and was treated with vancomycin and piperacillin and tazobactam while hospitalized. Her cellulitis resolved, and plastic surgery helped repair the laceration with skin grafting from her right thigh.

Three days after the procedure, the woman’s electrolyte panel read plasma glucose 110 mg/dL, blood urea nitrogen 11 mg/dL, serum creatinine 0.8 mg/dL, sodium 138 mEq/L, potassium 5.7 mEq/L, chloride 101 mEq/L, bicarbonate 28 mEq/L, magnesium 2.1 mg/dl, and calcium 8.9 mg/dl.

She was taking:

• Citalopram 20 mg PO QD;
• HCTZ 25 mg PO QD;
• Docusate 100 mg PO twice daily;
• Oxycodone 5 mg PO Q6 hours PRN pain;
• Acetaminophen 500 mg PO Q6 hours scheduled;
• Heparin 5,000 units SQ q eight hours;
• Levothyroxine 25 mcg PO QAM;
• Intravenous fluid D5NS at 80 cc/hour; and
• Trazodone 50 mg PO PRN insomnia.

Her urinalysis showed:

• pH 6.8;
• Na 155 meq/L;
• K 20 meq/L; and
• Urine osmolality 447.

Which of the following is the most appropriate action for this patient?

a) Sodium polystyrene sulfonate 30 gm orally every 4 hours; four doses

b) Sodium polystyrene sulfonate enema 60 gm

c) Discontinue citalopram

d) Discontinue oxycodone

e) Discontinue heparin

Discussion

The answer is E: Discontinue heparin. This patient has hyperkalemia with low urinary excretion of potassium and no evidence of acidosis. Many medications can cause hyperkalemia, most notably angiotensin-converting enzyme inhibitors, K-sparing diuretics, NSAIDs, and beta-blockers.

When an obvious cause is not present, such as over-supplementation of potassium chloride via oral or intravenous route, a search for less obvious causes, such as renal tubular acidosis, is warranted. In this patient none of these causes is present.

Heparin has many potential side effects, both directly from anticoagulation, such as retroperitoneal hemorrhage, or immunologically, such as heparin-induced thrombocytopenia (HIT). In this case the patient has heparin-induced hypoaldosteronism causing secondary hyperkalemia. This can occur with all types of heparin, usually at doses greater then 5,000 units/day. This emphasizes the point that when an unexpected phenomenon is noted in a hospitalized patient, a search should always include medications’ side effects.

Subcutaneous heparin was discontinued, and the patient was placed on aspirin, TED hose stockings, and sequential compression devices for deep vein thrombosis (DVT) prophylaxis. A repeat electrolyte panel obtained afterward showed resolution of the patient’s hyperkalemia. TH

Dr. Newman and Herber practice at the Department of Medicine, Mayo Graduate School of Medical Education, Mayo Clinic, Rochester, Minn.

As I follow Mary Jo Gorman, MD, MBA, as president of SHM, it might be tempting for me to simply follow the leading rule of the “organizational” Hippocratic Oath and “First do no harm.”

Put another way, in the context of the success SHM has enjoyed for the past 10 years, there is a case to be made for standing out of the way of our society’s positive momentum. But I believe we can—and will—do better than that. None of us can afford to be spectators in this arena.

We often speak of teamwork in healthcare, but precious few of us intuitively know what this means—much less have any education in its principles. During my training, the idea of teamwork amounted to little more than relying on a medical assistant to obtain daily weights or counting on the pharmacist to calculate and follow the appropriate dosing schedule for gentamicin. Common sense led me to understand that building an amicable relationship with the nursing staff made my working life easier.

Slowly, the advantages of structuring a more organized team in the hospital setting became more evident and helped encourage me to find ways of exploiting this concept further. As I look back, it was Jeff Dichter, MD, past president of SHM and director of the hospitalist program at Ball Memorial Hospital in Muncie, Ind., who emerged as one of the true champions for teamwork as an optimal model for inpatient care. Jeff would talk about it to everyone who would listen, in every venue he could reach. He wrote about it in this very column. He charged our meeting planners and committee chairs with integrating teamwork principles into our educational content as well as our advocacy and membership development initiatives. His vision of a true team galvanized SHM’s commitment to supporting a broad constituency, extending well beyond hospitalist physicians. Jeff knew care is never delivered by an individual; it’s always a team. And he believed this framework to be fully realized by way of building from a strong organizational agenda for quality improvement.

Speaking of quality in healthcare, I look no further than Mark Williams, MD, editor of the Journal of Hospital Medicine, for having built that agenda for our society through his own efforts as well as collaboration with the Institute for Healthcare Improvement (IHI) and other national entities. As another past president of SHM, Mark brought a level of organizational focus and rigor around quality improvement and patient safety that rose to the challenges outlined in two Institute of Medicine reports, “To Err is Human” and “Crossing the Quality Chasm.” He helped move “quality” from something we talk about to something we do. He pushed it from an espoused value to a core commitment of our specialty. Quality improvement is now inseparable from what I consider to be the true promise of hospital medicine: that care organized in well-orchestrated, well-resourced teams can deliver our patients remarkable improvements in the quality, safety, and experience of healthcare.

But how do we get this done? How do we take a relatively abstract notion of a team, channel its activities to drive measurable improvements in quality, and change the arcane systems of inpatient care so as to sustain and hardwire those improvements?

Leadership. Like it or not, each of you is regarded as one of—if not the—most important leaders in the hospital. Nursing, case management, physical therapy, patients, and families look to you to provide leadership for clinical and operational systems. You are the person most able to make meaningful decisions at the front-line level that directly affect the patient experience. You are called upon to lead and manage change in a volatile environment, to resolve the inevitable conflicts that change provokes, and to reconcile hospital business drivers with quality and safety imperatives.

Our immediate past president, Dr. Gorman, emphasized the crucial role we serve as leaders. Recognizing the tremendous development needs for skills and knowledge to effectively lead, SHM has created Leadership Academies and is working on e-discussion forums and mentoring programs to promote longitudinal learning. While we must unlearn some of the behaviors and beliefs seared into our brains during our traditional medical training, we must position ourselves to forge high-performing teams and lead the quality agenda.

At a dinner during the SHM Annual Meeting in May, I sat with a senior leader from the American Medical Association’s Organized Medical Staff Section (AMA OMSS). He had flown in with other AMA representatives to meet with us on common interests. By the end of the evening, the late-career surgeon took me aside and said: “I have to tell you how touched I am by your organization. The passion, drive, and commitment of your membership is what’s missing in so many professional societies today. You must bring this passion to the larger house of medicine.”

As SHM enjoys 10 years of explosive growth and remarkable success, we need to balance the right to celebrate success with the duty not to rest on laurels. Much has been accomplished, but more than a life’s work lies before us. The road is complex and fraught with uncertainty. We might become frustrated with mounting complexity, tired with resistance to change, and fatigued with leading against the status quo. It is hard—and lonely—to confront the systems and issues that desperately need to be confronted on our journey to transform care. And it might be easy for us to become distracted from our core commitments to teamwork and leading quality by allowing our medical society to become more of a guild that defends our professional incomes and way of life. Yet I believe—I know—a much brighter future lies ahead than emerging as a casualty of temptation.

If the best predictor of behavior is past behavior, then our future will mirror the spirit in which SHM was founded. It’s the spirit an invited guest observed in a few short hours at our annual meeting. It’s the spirit that binds teamwork, quality improvement, and leadership into a unified approach to our professional endeavors. That spirit has a name: accountability. It’s the fundamental understanding that we are answerable to others, including patients, families, the community, hospital and medical staff, as well as each other, for the performance of the care systems in which we work.

Being accountable means we must rebuild trust of the broader public in hospital care, and that we follow through on the promise of hospital medicine. It means we own our mistakes, we agree that transparency and measurement will lead to better outcomes, and we commit to being part of the solution.

Accountability also mandates that we eliminate blame and “victimhood.” We cannot first think of ourselves as victims of a broken reimbursement model, or a lack of data or a hospital administration that “just doesn’t get it.” The real questions are: What can I do today about improving management of scarce resources? About the nursing shortage? About incorporating patient-safety principles into a new facility? About access to care and overcrowding? About the needless hospital deaths due to ventilator-assisted pneumonia (VAP), acute myocardial infarction, and methicillin-resistant Staphylococcus aureus? About ensuring seamless transitions of patients throughout the care continuum?

Several years ago I spoke with Brent James, MD, executive director of the Institute for Health Care Delivery Research and vice president of medical research and continuing medical education at InterMountain Healthcare in Salt Lake City, Utah. At the time, I was trying to learn quality improvement methods and practices. He reminded me of a quote Sir William Osler, the father of internal medicine, made at the end of his career when he gave an address at the Phipps Clinic in England to a group of young physicians who had recently completed training. They were about to embark on their careers early in the 20th century. “I am sorry for you young men of this generation,” he told the physicians. “Oh, you’ll do great things. You’ll have great victories, and standing on our shoulders you’ll see far. But you can never have our sensations. To have lived through a revolution, to have seen a new birth of science, new dispensation of health, redesigned medical training, remodeled hospitals, a new outlook for humanity. That is not given to every generation.”

While it seems appropriate in retrospect that these young physicians were indeed entering a time after which tremendous change and transformation had taken place, it seems equally appropriate to consider ourselves one of those generations that must lead and drive change of the magnitude of which Osler spoke. As we lead teams in the hospital to revolutionize the state of healthcare quality, we must begin every thought, every action, by holding ourselves and each other accountable for being part of the solution. To begin, we need look no further than ourselves. TH

Dr. Holman is president of SHM.

As I follow Mary Jo Gorman, MD, MBA, as president of SHM, it might be tempting for me to simply follow the leading rule of the “organizational” Hippocratic Oath and “First do no harm.”

Put another way, in the context of the success SHM has enjoyed for the past 10 years, there is a case to be made for standing out of the way of our society’s positive momentum. But I believe we can—and will—do better than that. None of us can afford to be spectators in this arena.

We often speak of teamwork in healthcare, but precious few of us intuitively know what this means—much less have any education in its principles. During my training, the idea of teamwork amounted to little more than relying on a medical assistant to obtain daily weights or counting on the pharmacist to calculate and follow the appropriate dosing schedule for gentamicin. Common sense led me to understand that building an amicable relationship with the nursing staff made my working life easier.

Slowly, the advantages of structuring a more organized team in the hospital setting became more evident and helped encourage me to find ways of exploiting this concept further. As I look back, it was Jeff Dichter, MD, past president of SHM and director of the hospitalist program at Ball Memorial Hospital in Muncie, Ind., who emerged as one of the true champions for teamwork as an optimal model for inpatient care. Jeff would talk about it to everyone who would listen, in every venue he could reach. He wrote about it in this very column. He charged our meeting planners and committee chairs with integrating teamwork principles into our educational content as well as our advocacy and membership development initiatives. His vision of a true team galvanized SHM’s commitment to supporting a broad constituency, extending well beyond hospitalist physicians. Jeff knew care is never delivered by an individual; it’s always a team. And he believed this framework to be fully realized by way of building from a strong organizational agenda for quality improvement.

Speaking of quality in healthcare, I look no further than Mark Williams, MD, editor of the Journal of Hospital Medicine, for having built that agenda for our society through his own efforts as well as collaboration with the Institute for Healthcare Improvement (IHI) and other national entities. As another past president of SHM, Mark brought a level of organizational focus and rigor around quality improvement and patient safety that rose to the challenges outlined in two Institute of Medicine reports, “To Err is Human” and “Crossing the Quality Chasm.” He helped move “quality” from something we talk about to something we do. He pushed it from an espoused value to a core commitment of our specialty. Quality improvement is now inseparable from what I consider to be the true promise of hospital medicine: that care organized in well-orchestrated, well-resourced teams can deliver our patients remarkable improvements in the quality, safety, and experience of healthcare.

But how do we get this done? How do we take a relatively abstract notion of a team, channel its activities to drive measurable improvements in quality, and change the arcane systems of inpatient care so as to sustain and hardwire those improvements?

Leadership. Like it or not, each of you is regarded as one of—if not the—most important leaders in the hospital. Nursing, case management, physical therapy, patients, and families look to you to provide leadership for clinical and operational systems. You are the person most able to make meaningful decisions at the front-line level that directly affect the patient experience. You are called upon to lead and manage change in a volatile environment, to resolve the inevitable conflicts that change provokes, and to reconcile hospital business drivers with quality and safety imperatives.

Our immediate past president, Dr. Gorman, emphasized the crucial role we serve as leaders. Recognizing the tremendous development needs for skills and knowledge to effectively lead, SHM has created Leadership Academies and is working on e-discussion forums and mentoring programs to promote longitudinal learning. While we must unlearn some of the behaviors and beliefs seared into our brains during our traditional medical training, we must position ourselves to forge high-performing teams and lead the quality agenda.

At a dinner during the SHM Annual Meeting in May, I sat with a senior leader from the American Medical Association’s Organized Medical Staff Section (AMA OMSS). He had flown in with other AMA representatives to meet with us on common interests. By the end of the evening, the late-career surgeon took me aside and said: “I have to tell you how touched I am by your organization. The passion, drive, and commitment of your membership is what’s missing in so many professional societies today. You must bring this passion to the larger house of medicine.”

As SHM enjoys 10 years of explosive growth and remarkable success, we need to balance the right to celebrate success with the duty not to rest on laurels. Much has been accomplished, but more than a life’s work lies before us. The road is complex and fraught with uncertainty. We might become frustrated with mounting complexity, tired with resistance to change, and fatigued with leading against the status quo. It is hard—and lonely—to confront the systems and issues that desperately need to be confronted on our journey to transform care. And it might be easy for us to become distracted from our core commitments to teamwork and leading quality by allowing our medical society to become more of a guild that defends our professional incomes and way of life. Yet I believe—I know—a much brighter future lies ahead than emerging as a casualty of temptation.

If the best predictor of behavior is past behavior, then our future will mirror the spirit in which SHM was founded. It’s the spirit an invited guest observed in a few short hours at our annual meeting. It’s the spirit that binds teamwork, quality improvement, and leadership into a unified approach to our professional endeavors. That spirit has a name: accountability. It’s the fundamental understanding that we are answerable to others, including patients, families, the community, hospital and medical staff, as well as each other, for the performance of the care systems in which we work.

Being accountable means we must rebuild trust of the broader public in hospital care, and that we follow through on the promise of hospital medicine. It means we own our mistakes, we agree that transparency and measurement will lead to better outcomes, and we commit to being part of the solution.

Accountability also mandates that we eliminate blame and “victimhood.” We cannot first think of ourselves as victims of a broken reimbursement model, or a lack of data or a hospital administration that “just doesn’t get it.” The real questions are: What can I do today about improving management of scarce resources? About the nursing shortage? About incorporating patient-safety principles into a new facility? About access to care and overcrowding? About the needless hospital deaths due to ventilator-assisted pneumonia (VAP), acute myocardial infarction, and methicillin-resistant Staphylococcus aureus? About ensuring seamless transitions of patients throughout the care continuum?

Several years ago I spoke with Brent James, MD, executive director of the Institute for Health Care Delivery Research and vice president of medical research and continuing medical education at InterMountain Healthcare in Salt Lake City, Utah. At the time, I was trying to learn quality improvement methods and practices. He reminded me of a quote Sir William Osler, the father of internal medicine, made at the end of his career when he gave an address at the Phipps Clinic in England to a group of young physicians who had recently completed training. They were about to embark on their careers early in the 20th century. “I am sorry for you young men of this generation,” he told the physicians. “Oh, you’ll do great things. You’ll have great victories, and standing on our shoulders you’ll see far. But you can never have our sensations. To have lived through a revolution, to have seen a new birth of science, new dispensation of health, redesigned medical training, remodeled hospitals, a new outlook for humanity. That is not given to every generation.”

While it seems appropriate in retrospect that these young physicians were indeed entering a time after which tremendous change and transformation had taken place, it seems equally appropriate to consider ourselves one of those generations that must lead and drive change of the magnitude of which Osler spoke. As we lead teams in the hospital to revolutionize the state of healthcare quality, we must begin every thought, every action, by holding ourselves and each other accountable for being part of the solution. To begin, we need look no further than ourselves. TH

Dr. Holman is president of SHM.

As I follow Mary Jo Gorman, MD, MBA, as president of SHM, it might be tempting for me to simply follow the leading rule of the “organizational” Hippocratic Oath and “First do no harm.”

Put another way, in the context of the success SHM has enjoyed for the past 10 years, there is a case to be made for standing out of the way of our society’s positive momentum. But I believe we can—and will—do better than that. None of us can afford to be spectators in this arena.

We often speak of teamwork in healthcare, but precious few of us intuitively know what this means—much less have any education in its principles. During my training, the idea of teamwork amounted to little more than relying on a medical assistant to obtain daily weights or counting on the pharmacist to calculate and follow the appropriate dosing schedule for gentamicin. Common sense led me to understand that building an amicable relationship with the nursing staff made my working life easier.

Slowly, the advantages of structuring a more organized team in the hospital setting became more evident and helped encourage me to find ways of exploiting this concept further. As I look back, it was Jeff Dichter, MD, past president of SHM and director of the hospitalist program at Ball Memorial Hospital in Muncie, Ind., who emerged as one of the true champions for teamwork as an optimal model for inpatient care. Jeff would talk about it to everyone who would listen, in every venue he could reach. He wrote about it in this very column. He charged our meeting planners and committee chairs with integrating teamwork principles into our educational content as well as our advocacy and membership development initiatives. His vision of a true team galvanized SHM’s commitment to supporting a broad constituency, extending well beyond hospitalist physicians. Jeff knew care is never delivered by an individual; it’s always a team. And he believed this framework to be fully realized by way of building from a strong organizational agenda for quality improvement.

Speaking of quality in healthcare, I look no further than Mark Williams, MD, editor of the Journal of Hospital Medicine, for having built that agenda for our society through his own efforts as well as collaboration with the Institute for Healthcare Improvement (IHI) and other national entities. As another past president of SHM, Mark brought a level of organizational focus and rigor around quality improvement and patient safety that rose to the challenges outlined in two Institute of Medicine reports, “To Err is Human” and “Crossing the Quality Chasm.” He helped move “quality” from something we talk about to something we do. He pushed it from an espoused value to a core commitment of our specialty. Quality improvement is now inseparable from what I consider to be the true promise of hospital medicine: that care organized in well-orchestrated, well-resourced teams can deliver our patients remarkable improvements in the quality, safety, and experience of healthcare.

But how do we get this done? How do we take a relatively abstract notion of a team, channel its activities to drive measurable improvements in quality, and change the arcane systems of inpatient care so as to sustain and hardwire those improvements?

Leadership. Like it or not, each of you is regarded as one of—if not the—most important leaders in the hospital. Nursing, case management, physical therapy, patients, and families look to you to provide leadership for clinical and operational systems. You are the person most able to make meaningful decisions at the front-line level that directly affect the patient experience. You are called upon to lead and manage change in a volatile environment, to resolve the inevitable conflicts that change provokes, and to reconcile hospital business drivers with quality and safety imperatives.

Our immediate past president, Dr. Gorman, emphasized the crucial role we serve as leaders. Recognizing the tremendous development needs for skills and knowledge to effectively lead, SHM has created Leadership Academies and is working on e-discussion forums and mentoring programs to promote longitudinal learning. While we must unlearn some of the behaviors and beliefs seared into our brains during our traditional medical training, we must position ourselves to forge high-performing teams and lead the quality agenda.

At a dinner during the SHM Annual Meeting in May, I sat with a senior leader from the American Medical Association’s Organized Medical Staff Section (AMA OMSS). He had flown in with other AMA representatives to meet with us on common interests. By the end of the evening, the late-career surgeon took me aside and said: “I have to tell you how touched I am by your organization. The passion, drive, and commitment of your membership is what’s missing in so many professional societies today. You must bring this passion to the larger house of medicine.”

As SHM enjoys 10 years of explosive growth and remarkable success, we need to balance the right to celebrate success with the duty not to rest on laurels. Much has been accomplished, but more than a life’s work lies before us. The road is complex and fraught with uncertainty. We might become frustrated with mounting complexity, tired with resistance to change, and fatigued with leading against the status quo. It is hard—and lonely—to confront the systems and issues that desperately need to be confronted on our journey to transform care. And it might be easy for us to become distracted from our core commitments to teamwork and leading quality by allowing our medical society to become more of a guild that defends our professional incomes and way of life. Yet I believe—I know—a much brighter future lies ahead than emerging as a casualty of temptation.

If the best predictor of behavior is past behavior, then our future will mirror the spirit in which SHM was founded. It’s the spirit an invited guest observed in a few short hours at our annual meeting. It’s the spirit that binds teamwork, quality improvement, and leadership into a unified approach to our professional endeavors. That spirit has a name: accountability. It’s the fundamental understanding that we are answerable to others, including patients, families, the community, hospital and medical staff, as well as each other, for the performance of the care systems in which we work.

Being accountable means we must rebuild trust of the broader public in hospital care, and that we follow through on the promise of hospital medicine. It means we own our mistakes, we agree that transparency and measurement will lead to better outcomes, and we commit to being part of the solution.

Accountability also mandates that we eliminate blame and “victimhood.” We cannot first think of ourselves as victims of a broken reimbursement model, or a lack of data or a hospital administration that “just doesn’t get it.” The real questions are: What can I do today about improving management of scarce resources? About the nursing shortage? About incorporating patient-safety principles into a new facility? About access to care and overcrowding? About the needless hospital deaths due to ventilator-assisted pneumonia (VAP), acute myocardial infarction, and methicillin-resistant Staphylococcus aureus? About ensuring seamless transitions of patients throughout the care continuum?

Several years ago I spoke with Brent James, MD, executive director of the Institute for Health Care Delivery Research and vice president of medical research and continuing medical education at InterMountain Healthcare in Salt Lake City, Utah. At the time, I was trying to learn quality improvement methods and practices. He reminded me of a quote Sir William Osler, the father of internal medicine, made at the end of his career when he gave an address at the Phipps Clinic in England to a group of young physicians who had recently completed training. They were about to embark on their careers early in the 20th century. “I am sorry for you young men of this generation,” he told the physicians. “Oh, you’ll do great things. You’ll have great victories, and standing on our shoulders you’ll see far. But you can never have our sensations. To have lived through a revolution, to have seen a new birth of science, new dispensation of health, redesigned medical training, remodeled hospitals, a new outlook for humanity. That is not given to every generation.”

While it seems appropriate in retrospect that these young physicians were indeed entering a time after which tremendous change and transformation had taken place, it seems equally appropriate to consider ourselves one of those generations that must lead and drive change of the magnitude of which Osler spoke. As we lead teams in the hospital to revolutionize the state of healthcare quality, we must begin every thought, every action, by holding ourselves and each other accountable for being part of the solution. To begin, we need look no further than ourselves. TH

Dr. Holman is president of SHM.

Emergency care in the U.S. has been called a system in crisis, and the data are startling. From 1994 to 2004, the number of hospitals and emergency departments (EDs) decreased, the latter by 9%, but the number of ED visits increased by more than 1 million annually.1 (See Figure 1, p. 17)

According to the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics, between 40% and 50% of U.S. hospitals experience crowded conditions in the ED, with almost two-thirds of metropolitan EDs experiencing crowding at times.2

Source: Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006 Sep 28;355(13):1300-1303.

Hospitalists and emergency medicine physicians asked about their complex relationship—the good, the bad, and the not yet solved—praised their ability to work together.

“In general, our relationship with hospitalists has been fantastic,” says James Hoekstra, MD, president of the Society of Academic Emergency Medicine. “To have physicians who are willing to take patients with a lot of different disease states that are not necessarily procedure oriented, don’t necessarily fit into a specific specialty, or are somewhat undifferentiated in their presentation—for us that is an absolute joy.”

The number of hospitalists and emergency medicine physicians might be said to be running in parallel, says Alpesh Amin, MD, MBA, FACP, executive director of the hospitalist program and vice chair for clinical affairs and quality in the department of medicine at the University of California, Irvine. He tends to refer to this ratio as 30-30, meaning that, within a few years, there will be roughly 30,000 hospitalists, while there are currently that many emergency medicine physicians.3 In addition, emergency medicine and hospital medicine are site-based specialties, says Dr. Amin, so bridging their separateness is crucial to patient care.

Source: McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 Outpatient Department Summary. National Center for Health Statistics, Hyattsville, Md;2005;358.

“Aside from a small proportion of direct [patient] admissions,” says Jasen W. Gundersen, MD, chief of hospital medicine at the U. Mass. Medical Center in Worcester, “we are an extension of the ER, and the ER is an extension of us. We need to all be on the same page so that what’s said in the ER matches what happens on the floor, which matches what we send out to the primary [care physician].”

Optimizing patient flow is primarily a function of communication, says Marc Newquist, MD, FACEP, a hospitalist, an emergency medicine physician, and program director of the hospitalist division of The Schumacher Group in Lafayette, La. “The better that these communication systems can be standardized, the better hospitalists and their emergency medicine colleagues can promote a seamless integration between the two specialties as patients journey through their hospital stays,” he says.

“As medicine becomes more fragmented and hospital medicine does, let’s face it, fragment care,” adds Dr. Gundersen. “We also have to make sure that information flows from the primary-care physician who may send the patient to the ER. Everybody is a partner, and everybody needs to communicate back and forth and understand that if the ER wants to get someone admitted, timely communication with the hospitalist and understanding how the flow of the hospital works is really important.”

Source: Burt CW, McCaig LF. Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003-04. Adv Data. 2006 Sep 27;(376):1-23.

Interactions and Roles

“Far and away the most common type of interaction between hospitalists and ED docs is admissions,” says David M. Pressel, MD, PhD, director, Inpatient Service, General Pediatrics at Alfred I. duPont Hospital for Children in Wilmington, Del. The next most common interaction will depend upon the institution and its style, but, primarily, interactions include consults, and—in some institutions—patient discharge.

Dr. Pressel works at a tertiary-care referral center where residents staff the ED and his unit. “But at a community hospital where you generally have ED medicine-trained docs—not pediatricians who have ED

medicine fellowships—they have less experience with pediatrics, so they may be more likely to consult us on a patient,” he says. The development of care pathways to facilitate care is another important interaction between emergency medicine physicians and hospitalists.

An example of a protocol development the hospitalist and the ED should do together, says Dr. Pressel, is when patients come in with certain symptoms that would indicate a possible communicable disease for which the patient might need special isolation on an inpatient unit. That issue may more likely be foremost in hospitalist’s mind, and he or she can perform an evaluation early to determine what isolation may be needed. If the hospitalist suspects a patient has varicella or active pulmonary tuberculosis, for instance, “those kinds of [isolation] rooms are limited,” says Dr. Pressel. “Hospitals don’t have a lot of them, so you have to make sure you’re getting beds assigned well.”

Our interviews say the major roles of the hospitalist in managing relationships with emergency medicine physicians involve professionalism. “The hospitalist needs to understand the needs of the ER physician in terms of the needs of the [overall] ER: timing, flow, and getting patients seen in a prompt manner,” says Dr. Gundersen. “There’s a give and take, and both sides need to understand the other side of the job to maximize that collegiality and to maximize that sense of teamwork.”

Dr. Gundersen, who works full time as a hospitalist and moonlights as an ED physician, says that “what at times the ED doesn’t realize is that the time it takes for them to do something in the ED is not the same as it takes for us to do something on the floor. If they order a CT scan in the ED, it happens right away. If they say, ‘You can just get the CT scan on the floor,’ well, we don’t have as much priority in terms of getting lab draws and diagnostic tests done as fast as they do.”

Stepping on toes is always a danger.

“One of the key things for the relationship is to realize that you’re not walking in the other person’s shoes,” says Dr. Pressel. “I’ve witnessed [situations] where a hospitalist on the receiving end scoffs at the management in the ED—either because, number one, the patient was perceived to be not sick enough to merit hospitalization according to the hospitalist, or, number two, because of over-workup and overdiagnosis or under-workup and under- or misdiagnosis.”

Both groups need to realize that the patient’s condition evolves over time. “What the ED saw three hours ago may not be what’s being seen now, and that’s true in the reverse,” he says. “If the patient looked great three hours ago, now [their condition may be life-threatening].”

Therefore, feedback between ED doctors and hospitalists should be provided in a “respectful, collegial, follow-up type of manner,” says Dr. Pressel. A beneficial means of communication involves feedback that is “telling it as an evolving story,” he says, as opposed to assuming the ED doctor is wrong. That is, “collaborating and adding to the story and the end diagnosis and recognizing that the ED doc’s job is not necessarily to make the final diagnosis.”

Dr. Pressel thinks it comes down to politeness, plain and simple. “I hope that when I miss something, someone will be kind enough to [be polite] to me, [to phrase it as] ‘I’m sure you were thinking of this but the clues looked this way and we went on to do further evaluation.’ ”

That kind of interaction happens all the time, he says. “And ultimately it’s best for the patient, number one, because everybody learns that way, and, number two, if you make yourself obnoxious with your colleagues, they’re not necessarily going to want to call you.”

The Nature of the Beast

Most interactions with their ED colleagues go smoothly, our hospitalists say, but sometimes there are bumps in the road—most often involving flow and the transfer of care.

Jason R. Orlinick, MD, PhD, chief, Section of Hospital Medicine at Norwalk Hospital, Conn., and clinical instructor of medicine at Yale University (New Haven, Conn.), probably represents the bulk of his hospitalist colleagues when he says he and the emergency medicine physicians with whom he works have a cordial relationship overall. But “there is always some level of tension between the hospitalists and the emergency department—at least at the institutions I’ve been at. To some extent, it depends on the mentality of the ED docs where you’re working.”

Debra L. Burgy, MD, a hospitalist at Abbott Northwestern Hospital in Minneapolis, puts it this way: “The interface between hospitalists and the ED is sometimes tense because the ED physicians are regularly bombarded with patients, which is completely unpredictable, and they do not have adequate support staff, such as social workers and psychiatric assessment workers, to create a safe disposition for patients who could otherwise go home.

“The path of least resistance, and the least time-consuming route, is to admit patients. The chain reaction continues with the hospitalist service being overwhelmed.”

It is common for the ED to get a large volume of patients in the afternoon, our hospitalists remark. (See Figure 2, left) “We sometimes get hit with this huge bolus of patients,” Dr. Gundersen says. The biggest challenges involve “promptly identifying those patients who are identified for admission and maintaining a more open communication because when we get three, four, five admissions at once, we have difficulty working down that backlog.”

In the medical residency program at Dr. Orlinick’s institution, the bolus phenomenon can overwhelm residents’ and attendings’ capacities to see patients in a timely manner. “Unfortunately, we’ve not had a lot of success with that,” he says, and recently, his institution approached the hospitalists to work on a solution.

The timing of handoffs represents a large part of the breakdown in patient flow. “This is because of the ED physician who works until 4 p.m. or 6 p.m. and then tries to get all their patients whom they’re not sending home admitted right away before [the hospitalists] go off service,” Dr. Gundersen says. “It’s not uncommon that I get called or paged every three minutes—if I don’t answer right away—because they are trying to get someone admitted seconds after they call. The ER needs the beds, we haven’t been able to discharge the patients, everything gets bottlenecked.”

Although Dr. Gundersen recognizes that this problem is unavoidable at times, he suggests it would help “if the ED physicians were cognizant that there may be just one or two hospitalists who are admitting for the day, and giving them five admissions all at once, for instance, is going to take time to get through.”

On the other side, “Hospitalists rely on ED physicians to have the patient worked up and know which service they belong to,” explains Dr. Gundersen. “Succinct transfer of care is [paramount] so that critical information is brought to the attention of the accepting physician.” For the most part, he says, his ED colleagues do a good job.

Because the ED is always in a rush to get patients admitted and a disposition made, “there is the tendency to hamstring what’s happening on the floor. I think that big downstream effect from everything that begins in the ER transitions through the patient’s whole length of stay in the hospital,” says Dr. Gundersen.

All the interviewed hospitalists realize that the hospitalists and ED physicians need to have an understanding of what the other group faces. “We have to be understanding of the ER position that there are a lot of patients to be seen, and they’re trying to do the best they can in that period of time,” says Dr. Gundersen. A 2006 study revealed that interruptions within the ED were prevalent and diverse in nature and—on average—there was an interruption every nine and 14 minutes, respectively, for the attending emergency medicine physicians and residents.5

“And ED physicians have to realize that whatever patient they give to us, we then deal with,” says Dr. Gundersen, “and we [continue] to deal with all the issues, moving them through tests and studies [and] getting them discharged, so sometimes there are delays on both ends. It’s just the nature of the beast.”

A Sense of Control

The benefits of maintaining collegiality with ED physicians go beyond the norm, says Jeff Glasheen, MD, director of both the hospital medicine program and inpatient clinical services in the department of medicine at the University of Colorado at Denver Health Sciences Center. Dr. Glasheen has conducted some research on burnout—mostly in residents.6-7

“One of the main things that leads to burnout is lack of control and feeling like you don’t have control over your daily job,” he says. “One of the things that comes out of this relationship with the ER is that it’s no longer like someone’s just dumping on us. They’re very reasonable when we say, ‘That sounds like somebody who could go home; let me come down and see the patient, and let’s see if we can get this patient discharged.’ You begin to feel like you have control over your day, control over the patients who are admitted to you, and—quite honestly—it’s more fun. That kind of professional interaction is hard to put a price on, but I think it’s priceless.”TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006 Sep 28;355(13):1300-1303.
2. Burt CW, McCaig LF. Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003-04. Adv Data. 2006 Sep 27;(376):1-23. Available at www.cdc.gov/nchs/data/ad/ad376.pdf. Last accessed April 10, 2007.
3. Freed DH. Hospitalists: evolution, evidence, and eventualities. Health Care Manag. 2004 Jul-Sep;23(3):238-256;1-38.
4. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 emergency department summary. Adv Data. 2005;(358):1-38. Available at www.cdc.gov/nchs/data/ad/ad358.pdf. Last accessed April 10, 2007.
5. Laxmisan A, Hakimzada F, Sayan OR, et al. The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. Int J Med Inform. 2006 Oct 21. [Epub ahead of print.]
6. Gopal RK, Carreira F, Baker WA, et al. Internal medicine residents reject “longer and gentler” training. J Gen Intern Med. 2007 Jan;22(1):102-106.
7. Gopal R, Glasheen JJ, Miyoshi TJ, et al. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005 Dec 12-26;165(22):2595-2600. Comment in Arch Intern Med. 2005 Dec 12-26; 165(22):2561-2562. Arch Intern Med. 2006 Jul 10;166(13):1423; author reply 1423-1425.

Emergency care in the U.S. has been called a system in crisis, and the data are startling. From 1994 to 2004, the number of hospitals and emergency departments (EDs) decreased, the latter by 9%, but the number of ED visits increased by more than 1 million annually.1 (See Figure 1, p. 17)

According to the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics, between 40% and 50% of U.S. hospitals experience crowded conditions in the ED, with almost two-thirds of metropolitan EDs experiencing crowding at times.2

Source: Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006 Sep 28;355(13):1300-1303.

Hospitalists and emergency medicine physicians asked about their complex relationship—the good, the bad, and the not yet solved—praised their ability to work together.

“In general, our relationship with hospitalists has been fantastic,” says James Hoekstra, MD, president of the Society of Academic Emergency Medicine. “To have physicians who are willing to take patients with a lot of different disease states that are not necessarily procedure oriented, don’t necessarily fit into a specific specialty, or are somewhat undifferentiated in their presentation—for us that is an absolute joy.”

The number of hospitalists and emergency medicine physicians might be said to be running in parallel, says Alpesh Amin, MD, MBA, FACP, executive director of the hospitalist program and vice chair for clinical affairs and quality in the department of medicine at the University of California, Irvine. He tends to refer to this ratio as 30-30, meaning that, within a few years, there will be roughly 30,000 hospitalists, while there are currently that many emergency medicine physicians.3 In addition, emergency medicine and hospital medicine are site-based specialties, says Dr. Amin, so bridging their separateness is crucial to patient care.

Source: McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 Outpatient Department Summary. National Center for Health Statistics, Hyattsville, Md;2005;358.

“Aside from a small proportion of direct [patient] admissions,” says Jasen W. Gundersen, MD, chief of hospital medicine at the U. Mass. Medical Center in Worcester, “we are an extension of the ER, and the ER is an extension of us. We need to all be on the same page so that what’s said in the ER matches what happens on the floor, which matches what we send out to the primary [care physician].”

Optimizing patient flow is primarily a function of communication, says Marc Newquist, MD, FACEP, a hospitalist, an emergency medicine physician, and program director of the hospitalist division of The Schumacher Group in Lafayette, La. “The better that these communication systems can be standardized, the better hospitalists and their emergency medicine colleagues can promote a seamless integration between the two specialties as patients journey through their hospital stays,” he says.

“As medicine becomes more fragmented and hospital medicine does, let’s face it, fragment care,” adds Dr. Gundersen. “We also have to make sure that information flows from the primary-care physician who may send the patient to the ER. Everybody is a partner, and everybody needs to communicate back and forth and understand that if the ER wants to get someone admitted, timely communication with the hospitalist and understanding how the flow of the hospital works is really important.”

Source: Burt CW, McCaig LF. Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003-04. Adv Data. 2006 Sep 27;(376):1-23.

Interactions and Roles

“Far and away the most common type of interaction between hospitalists and ED docs is admissions,” says David M. Pressel, MD, PhD, director, Inpatient Service, General Pediatrics at Alfred I. duPont Hospital for Children in Wilmington, Del. The next most common interaction will depend upon the institution and its style, but, primarily, interactions include consults, and—in some institutions—patient discharge.

Dr. Pressel works at a tertiary-care referral center where residents staff the ED and his unit. “But at a community hospital where you generally have ED medicine-trained docs—not pediatricians who have ED

medicine fellowships—they have less experience with pediatrics, so they may be more likely to consult us on a patient,” he says. The development of care pathways to facilitate care is another important interaction between emergency medicine physicians and hospitalists.

An example of a protocol development the hospitalist and the ED should do together, says Dr. Pressel, is when patients come in with certain symptoms that would indicate a possible communicable disease for which the patient might need special isolation on an inpatient unit. That issue may more likely be foremost in hospitalist’s mind, and he or she can perform an evaluation early to determine what isolation may be needed. If the hospitalist suspects a patient has varicella or active pulmonary tuberculosis, for instance, “those kinds of [isolation] rooms are limited,” says Dr. Pressel. “Hospitals don’t have a lot of them, so you have to make sure you’re getting beds assigned well.”

Our interviews say the major roles of the hospitalist in managing relationships with emergency medicine physicians involve professionalism. “The hospitalist needs to understand the needs of the ER physician in terms of the needs of the [overall] ER: timing, flow, and getting patients seen in a prompt manner,” says Dr. Gundersen. “There’s a give and take, and both sides need to understand the other side of the job to maximize that collegiality and to maximize that sense of teamwork.”

Dr. Gundersen, who works full time as a hospitalist and moonlights as an ED physician, says that “what at times the ED doesn’t realize is that the time it takes for them to do something in the ED is not the same as it takes for us to do something on the floor. If they order a CT scan in the ED, it happens right away. If they say, ‘You can just get the CT scan on the floor,’ well, we don’t have as much priority in terms of getting lab draws and diagnostic tests done as fast as they do.”

Stepping on toes is always a danger.

“One of the key things for the relationship is to realize that you’re not walking in the other person’s shoes,” says Dr. Pressel. “I’ve witnessed [situations] where a hospitalist on the receiving end scoffs at the management in the ED—either because, number one, the patient was perceived to be not sick enough to merit hospitalization according to the hospitalist, or, number two, because of over-workup and overdiagnosis or under-workup and under- or misdiagnosis.”

Both groups need to realize that the patient’s condition evolves over time. “What the ED saw three hours ago may not be what’s being seen now, and that’s true in the reverse,” he says. “If the patient looked great three hours ago, now [their condition may be life-threatening].”

Therefore, feedback between ED doctors and hospitalists should be provided in a “respectful, collegial, follow-up type of manner,” says Dr. Pressel. A beneficial means of communication involves feedback that is “telling it as an evolving story,” he says, as opposed to assuming the ED doctor is wrong. That is, “collaborating and adding to the story and the end diagnosis and recognizing that the ED doc’s job is not necessarily to make the final diagnosis.”

Dr. Pressel thinks it comes down to politeness, plain and simple. “I hope that when I miss something, someone will be kind enough to [be polite] to me, [to phrase it as] ‘I’m sure you were thinking of this but the clues looked this way and we went on to do further evaluation.’ ”

That kind of interaction happens all the time, he says. “And ultimately it’s best for the patient, number one, because everybody learns that way, and, number two, if you make yourself obnoxious with your colleagues, they’re not necessarily going to want to call you.”

The Nature of the Beast

Most interactions with their ED colleagues go smoothly, our hospitalists say, but sometimes there are bumps in the road—most often involving flow and the transfer of care.

Jason R. Orlinick, MD, PhD, chief, Section of Hospital Medicine at Norwalk Hospital, Conn., and clinical instructor of medicine at Yale University (New Haven, Conn.), probably represents the bulk of his hospitalist colleagues when he says he and the emergency medicine physicians with whom he works have a cordial relationship overall. But “there is always some level of tension between the hospitalists and the emergency department—at least at the institutions I’ve been at. To some extent, it depends on the mentality of the ED docs where you’re working.”

Debra L. Burgy, MD, a hospitalist at Abbott Northwestern Hospital in Minneapolis, puts it this way: “The interface between hospitalists and the ED is sometimes tense because the ED physicians are regularly bombarded with patients, which is completely unpredictable, and they do not have adequate support staff, such as social workers and psychiatric assessment workers, to create a safe disposition for patients who could otherwise go home.

“The path of least resistance, and the least time-consuming route, is to admit patients. The chain reaction continues with the hospitalist service being overwhelmed.”

It is common for the ED to get a large volume of patients in the afternoon, our hospitalists remark. (See Figure 2, left) “We sometimes get hit with this huge bolus of patients,” Dr. Gundersen says. The biggest challenges involve “promptly identifying those patients who are identified for admission and maintaining a more open communication because when we get three, four, five admissions at once, we have difficulty working down that backlog.”

In the medical residency program at Dr. Orlinick’s institution, the bolus phenomenon can overwhelm residents’ and attendings’ capacities to see patients in a timely manner. “Unfortunately, we’ve not had a lot of success with that,” he says, and recently, his institution approached the hospitalists to work on a solution.

The timing of handoffs represents a large part of the breakdown in patient flow. “This is because of the ED physician who works until 4 p.m. or 6 p.m. and then tries to get all their patients whom they’re not sending home admitted right away before [the hospitalists] go off service,” Dr. Gundersen says. “It’s not uncommon that I get called or paged every three minutes—if I don’t answer right away—because they are trying to get someone admitted seconds after they call. The ER needs the beds, we haven’t been able to discharge the patients, everything gets bottlenecked.”

Although Dr. Gundersen recognizes that this problem is unavoidable at times, he suggests it would help “if the ED physicians were cognizant that there may be just one or two hospitalists who are admitting for the day, and giving them five admissions all at once, for instance, is going to take time to get through.”

On the other side, “Hospitalists rely on ED physicians to have the patient worked up and know which service they belong to,” explains Dr. Gundersen. “Succinct transfer of care is [paramount] so that critical information is brought to the attention of the accepting physician.” For the most part, he says, his ED colleagues do a good job.

Because the ED is always in a rush to get patients admitted and a disposition made, “there is the tendency to hamstring what’s happening on the floor. I think that big downstream effect from everything that begins in the ER transitions through the patient’s whole length of stay in the hospital,” says Dr. Gundersen.

All the interviewed hospitalists realize that the hospitalists and ED physicians need to have an understanding of what the other group faces. “We have to be understanding of the ER position that there are a lot of patients to be seen, and they’re trying to do the best they can in that period of time,” says Dr. Gundersen. A 2006 study revealed that interruptions within the ED were prevalent and diverse in nature and—on average—there was an interruption every nine and 14 minutes, respectively, for the attending emergency medicine physicians and residents.5

“And ED physicians have to realize that whatever patient they give to us, we then deal with,” says Dr. Gundersen, “and we [continue] to deal with all the issues, moving them through tests and studies [and] getting them discharged, so sometimes there are delays on both ends. It’s just the nature of the beast.”

A Sense of Control

The benefits of maintaining collegiality with ED physicians go beyond the norm, says Jeff Glasheen, MD, director of both the hospital medicine program and inpatient clinical services in the department of medicine at the University of Colorado at Denver Health Sciences Center. Dr. Glasheen has conducted some research on burnout—mostly in residents.6-7

“One of the main things that leads to burnout is lack of control and feeling like you don’t have control over your daily job,” he says. “One of the things that comes out of this relationship with the ER is that it’s no longer like someone’s just dumping on us. They’re very reasonable when we say, ‘That sounds like somebody who could go home; let me come down and see the patient, and let’s see if we can get this patient discharged.’ You begin to feel like you have control over your day, control over the patients who are admitted to you, and—quite honestly—it’s more fun. That kind of professional interaction is hard to put a price on, but I think it’s priceless.”TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006 Sep 28;355(13):1300-1303.
2. Burt CW, McCaig LF. Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003-04. Adv Data. 2006 Sep 27;(376):1-23. Available at www.cdc.gov/nchs/data/ad/ad376.pdf. Last accessed April 10, 2007.
3. Freed DH. Hospitalists: evolution, evidence, and eventualities. Health Care Manag. 2004 Jul-Sep;23(3):238-256;1-38.
4. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 emergency department summary. Adv Data. 2005;(358):1-38. Available at www.cdc.gov/nchs/data/ad/ad358.pdf. Last accessed April 10, 2007.
5. Laxmisan A, Hakimzada F, Sayan OR, et al. The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. Int J Med Inform. 2006 Oct 21. [Epub ahead of print.]
6. Gopal RK, Carreira F, Baker WA, et al. Internal medicine residents reject “longer and gentler” training. J Gen Intern Med. 2007 Jan;22(1):102-106.
7. Gopal R, Glasheen JJ, Miyoshi TJ, et al. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005 Dec 12-26;165(22):2595-2600. Comment in Arch Intern Med. 2005 Dec 12-26; 165(22):2561-2562. Arch Intern Med. 2006 Jul 10;166(13):1423; author reply 1423-1425.

Emergency care in the U.S. has been called a system in crisis, and the data are startling. From 1994 to 2004, the number of hospitals and emergency departments (EDs) decreased, the latter by 9%, but the number of ED visits increased by more than 1 million annually.1 (See Figure 1, p. 17)

According to the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics, between 40% and 50% of U.S. hospitals experience crowded conditions in the ED, with almost two-thirds of metropolitan EDs experiencing crowding at times.2

Source: Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006 Sep 28;355(13):1300-1303.

Hospitalists and emergency medicine physicians asked about their complex relationship—the good, the bad, and the not yet solved—praised their ability to work together.

“In general, our relationship with hospitalists has been fantastic,” says James Hoekstra, MD, president of the Society of Academic Emergency Medicine. “To have physicians who are willing to take patients with a lot of different disease states that are not necessarily procedure oriented, don’t necessarily fit into a specific specialty, or are somewhat undifferentiated in their presentation—for us that is an absolute joy.”

The number of hospitalists and emergency medicine physicians might be said to be running in parallel, says Alpesh Amin, MD, MBA, FACP, executive director of the hospitalist program and vice chair for clinical affairs and quality in the department of medicine at the University of California, Irvine. He tends to refer to this ratio as 30-30, meaning that, within a few years, there will be roughly 30,000 hospitalists, while there are currently that many emergency medicine physicians.3 In addition, emergency medicine and hospital medicine are site-based specialties, says Dr. Amin, so bridging their separateness is crucial to patient care.

Source: McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 Outpatient Department Summary. National Center for Health Statistics, Hyattsville, Md;2005;358.

“Aside from a small proportion of direct [patient] admissions,” says Jasen W. Gundersen, MD, chief of hospital medicine at the U. Mass. Medical Center in Worcester, “we are an extension of the ER, and the ER is an extension of us. We need to all be on the same page so that what’s said in the ER matches what happens on the floor, which matches what we send out to the primary [care physician].”

Optimizing patient flow is primarily a function of communication, says Marc Newquist, MD, FACEP, a hospitalist, an emergency medicine physician, and program director of the hospitalist division of The Schumacher Group in Lafayette, La. “The better that these communication systems can be standardized, the better hospitalists and their emergency medicine colleagues can promote a seamless integration between the two specialties as patients journey through their hospital stays,” he says.

“As medicine becomes more fragmented and hospital medicine does, let’s face it, fragment care,” adds Dr. Gundersen. “We also have to make sure that information flows from the primary-care physician who may send the patient to the ER. Everybody is a partner, and everybody needs to communicate back and forth and understand that if the ER wants to get someone admitted, timely communication with the hospitalist and understanding how the flow of the hospital works is really important.”

Source: Burt CW, McCaig LF. Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003-04. Adv Data. 2006 Sep 27;(376):1-23.

Interactions and Roles

“Far and away the most common type of interaction between hospitalists and ED docs is admissions,” says David M. Pressel, MD, PhD, director, Inpatient Service, General Pediatrics at Alfred I. duPont Hospital for Children in Wilmington, Del. The next most common interaction will depend upon the institution and its style, but, primarily, interactions include consults, and—in some institutions—patient discharge.

Dr. Pressel works at a tertiary-care referral center where residents staff the ED and his unit. “But at a community hospital where you generally have ED medicine-trained docs—not pediatricians who have ED

medicine fellowships—they have less experience with pediatrics, so they may be more likely to consult us on a patient,” he says. The development of care pathways to facilitate care is another important interaction between emergency medicine physicians and hospitalists.

An example of a protocol development the hospitalist and the ED should do together, says Dr. Pressel, is when patients come in with certain symptoms that would indicate a possible communicable disease for which the patient might need special isolation on an inpatient unit. That issue may more likely be foremost in hospitalist’s mind, and he or she can perform an evaluation early to determine what isolation may be needed. If the hospitalist suspects a patient has varicella or active pulmonary tuberculosis, for instance, “those kinds of [isolation] rooms are limited,” says Dr. Pressel. “Hospitals don’t have a lot of them, so you have to make sure you’re getting beds assigned well.”

Our interviews say the major roles of the hospitalist in managing relationships with emergency medicine physicians involve professionalism. “The hospitalist needs to understand the needs of the ER physician in terms of the needs of the [overall] ER: timing, flow, and getting patients seen in a prompt manner,” says Dr. Gundersen. “There’s a give and take, and both sides need to understand the other side of the job to maximize that collegiality and to maximize that sense of teamwork.”

Dr. Gundersen, who works full time as a hospitalist and moonlights as an ED physician, says that “what at times the ED doesn’t realize is that the time it takes for them to do something in the ED is not the same as it takes for us to do something on the floor. If they order a CT scan in the ED, it happens right away. If they say, ‘You can just get the CT scan on the floor,’ well, we don’t have as much priority in terms of getting lab draws and diagnostic tests done as fast as they do.”

Stepping on toes is always a danger.

“One of the key things for the relationship is to realize that you’re not walking in the other person’s shoes,” says Dr. Pressel. “I’ve witnessed [situations] where a hospitalist on the receiving end scoffs at the management in the ED—either because, number one, the patient was perceived to be not sick enough to merit hospitalization according to the hospitalist, or, number two, because of over-workup and overdiagnosis or under-workup and under- or misdiagnosis.”

Both groups need to realize that the patient’s condition evolves over time. “What the ED saw three hours ago may not be what’s being seen now, and that’s true in the reverse,” he says. “If the patient looked great three hours ago, now [their condition may be life-threatening].”

Therefore, feedback between ED doctors and hospitalists should be provided in a “respectful, collegial, follow-up type of manner,” says Dr. Pressel. A beneficial means of communication involves feedback that is “telling it as an evolving story,” he says, as opposed to assuming the ED doctor is wrong. That is, “collaborating and adding to the story and the end diagnosis and recognizing that the ED doc’s job is not necessarily to make the final diagnosis.”

Dr. Pressel thinks it comes down to politeness, plain and simple. “I hope that when I miss something, someone will be kind enough to [be polite] to me, [to phrase it as] ‘I’m sure you were thinking of this but the clues looked this way and we went on to do further evaluation.’ ”

That kind of interaction happens all the time, he says. “And ultimately it’s best for the patient, number one, because everybody learns that way, and, number two, if you make yourself obnoxious with your colleagues, they’re not necessarily going to want to call you.”

The Nature of the Beast

Most interactions with their ED colleagues go smoothly, our hospitalists say, but sometimes there are bumps in the road—most often involving flow and the transfer of care.

Jason R. Orlinick, MD, PhD, chief, Section of Hospital Medicine at Norwalk Hospital, Conn., and clinical instructor of medicine at Yale University (New Haven, Conn.), probably represents the bulk of his hospitalist colleagues when he says he and the emergency medicine physicians with whom he works have a cordial relationship overall. But “there is always some level of tension between the hospitalists and the emergency department—at least at the institutions I’ve been at. To some extent, it depends on the mentality of the ED docs where you’re working.”

Debra L. Burgy, MD, a hospitalist at Abbott Northwestern Hospital in Minneapolis, puts it this way: “The interface between hospitalists and the ED is sometimes tense because the ED physicians are regularly bombarded with patients, which is completely unpredictable, and they do not have adequate support staff, such as social workers and psychiatric assessment workers, to create a safe disposition for patients who could otherwise go home.

“The path of least resistance, and the least time-consuming route, is to admit patients. The chain reaction continues with the hospitalist service being overwhelmed.”

It is common for the ED to get a large volume of patients in the afternoon, our hospitalists remark. (See Figure 2, left) “We sometimes get hit with this huge bolus of patients,” Dr. Gundersen says. The biggest challenges involve “promptly identifying those patients who are identified for admission and maintaining a more open communication because when we get three, four, five admissions at once, we have difficulty working down that backlog.”

In the medical residency program at Dr. Orlinick’s institution, the bolus phenomenon can overwhelm residents’ and attendings’ capacities to see patients in a timely manner. “Unfortunately, we’ve not had a lot of success with that,” he says, and recently, his institution approached the hospitalists to work on a solution.

The timing of handoffs represents a large part of the breakdown in patient flow. “This is because of the ED physician who works until 4 p.m. or 6 p.m. and then tries to get all their patients whom they’re not sending home admitted right away before [the hospitalists] go off service,” Dr. Gundersen says. “It’s not uncommon that I get called or paged every three minutes—if I don’t answer right away—because they are trying to get someone admitted seconds after they call. The ER needs the beds, we haven’t been able to discharge the patients, everything gets bottlenecked.”

Although Dr. Gundersen recognizes that this problem is unavoidable at times, he suggests it would help “if the ED physicians were cognizant that there may be just one or two hospitalists who are admitting for the day, and giving them five admissions all at once, for instance, is going to take time to get through.”

On the other side, “Hospitalists rely on ED physicians to have the patient worked up and know which service they belong to,” explains Dr. Gundersen. “Succinct transfer of care is [paramount] so that critical information is brought to the attention of the accepting physician.” For the most part, he says, his ED colleagues do a good job.

Because the ED is always in a rush to get patients admitted and a disposition made, “there is the tendency to hamstring what’s happening on the floor. I think that big downstream effect from everything that begins in the ER transitions through the patient’s whole length of stay in the hospital,” says Dr. Gundersen.

All the interviewed hospitalists realize that the hospitalists and ED physicians need to have an understanding of what the other group faces. “We have to be understanding of the ER position that there are a lot of patients to be seen, and they’re trying to do the best they can in that period of time,” says Dr. Gundersen. A 2006 study revealed that interruptions within the ED were prevalent and diverse in nature and—on average—there was an interruption every nine and 14 minutes, respectively, for the attending emergency medicine physicians and residents.5

“And ED physicians have to realize that whatever patient they give to us, we then deal with,” says Dr. Gundersen, “and we [continue] to deal with all the issues, moving them through tests and studies [and] getting them discharged, so sometimes there are delays on both ends. It’s just the nature of the beast.”

A Sense of Control

The benefits of maintaining collegiality with ED physicians go beyond the norm, says Jeff Glasheen, MD, director of both the hospital medicine program and inpatient clinical services in the department of medicine at the University of Colorado at Denver Health Sciences Center. Dr. Glasheen has conducted some research on burnout—mostly in residents.6-7

“One of the main things that leads to burnout is lack of control and feeling like you don’t have control over your daily job,” he says. “One of the things that comes out of this relationship with the ER is that it’s no longer like someone’s just dumping on us. They’re very reasonable when we say, ‘That sounds like somebody who could go home; let me come down and see the patient, and let’s see if we can get this patient discharged.’ You begin to feel like you have control over your day, control over the patients who are admitted to you, and—quite honestly—it’s more fun. That kind of professional interaction is hard to put a price on, but I think it’s priceless.”TH

Andrea Sattinger is a frequent contributor to The Hospitalist.

References

1. Kellermann AL. Crisis in the emergency department. N Engl J Med. 2006 Sep 28;355(13):1300-1303.
2. Burt CW, McCaig LF. Staffing, capacity, and ambulance diversion in emergency departments: United States, 2003-04. Adv Data. 2006 Sep 27;(376):1-23. Available at www.cdc.gov/nchs/data/ad/ad376.pdf. Last accessed April 10, 2007.
3. Freed DH. Hospitalists: evolution, evidence, and eventualities. Health Care Manag. 2004 Jul-Sep;23(3):238-256;1-38.
4. McCaig LF, Burt CW. National Hospital Ambulatory Medical Care Survey: 2003 emergency department summary. Adv Data. 2005;(358):1-38. Available at www.cdc.gov/nchs/data/ad/ad358.pdf. Last accessed April 10, 2007.
5. Laxmisan A, Hakimzada F, Sayan OR, et al. The multitasking clinician: decision-making and cognitive demand during and after team handoffs in emergency care. Int J Med Inform. 2006 Oct 21. [Epub ahead of print.]
6. Gopal RK, Carreira F, Baker WA, et al. Internal medicine residents reject “longer and gentler” training. J Gen Intern Med. 2007 Jan;22(1):102-106.
7. Gopal R, Glasheen JJ, Miyoshi TJ, et al. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005 Dec 12-26;165(22):2595-2600. Comment in Arch Intern Med. 2005 Dec 12-26; 165(22):2561-2562. Arch Intern Med. 2006 Jul 10;166(13):1423; author reply 1423-1425.

The online version of the Oxford English Dictionary (OED) is the latest in a string of dictionaries to include the word “hospitalist” among its entries.

“This is just another sign that “hospitalist” has become another part of the landscape, and that we’ve arrived and will be here for a very long time,” says Larry Wellikson, MD, CEO of SHM. “I think SHM has been working on defining what a hospitalist is in textbooks and other reference materials since I got here in 2000.”

Asked if SHM solicited the OED staff to include hospitalist in its entries, Dr. Wellikson said it wasn’t necessary. “No, we didn’t lobby them,” he says. “They did it totally on their own. If you Google hospitalist, you’ll see thousands of stories that have been written during the past 10 years, including by such publications as the The Wall Street Journal.”

Dr. Wellikson noted that CNN’s Larry King mentioned hospitalists during a segment in 2005. “[The word hospitalist] has turned up in so many places,” he says.

To date, “hospitalist” has been included in print editions of The American Heritage Dictionary of the English Language, Merriam-Webster’s collegiate and medical dictionaries, as well as other print medical dictionaries and some online dictionaries. The American Heritage Dictionary appears to be the first to have included the word in a print edition in 2000, according to a spokesman for the publication.

The process of selecting a new word for inclusion in a dictionary appears fairly constant in the industry.

“It can include suggestions from our readership or people in a particular industry who might suggest that a new word unique to their profession should be included,” says Katherine Martin, senior assistant editor at OED’s New York offices. “It also includes our own (staff) study to ascertain if a certain word that is tested over time will have continued longevity.”

Tested over time indeed. Martin and other dictionary staff members say it can sometimes take up to 10 years for a new word to be included in a dictionary.

That’s how long it took to include hospitalist in Merriam-Webster’s Collegiate Dictionary, according to a spokesman for that publication. And while hospitalist was included in the OED’s online version in December 2006, it’s uncertain if it will ever get into the print version, according to Martin.

The OED’s second edition was last printed in 1989, Martin says, and because of the huge cost involved, “We haven’t even begun discussing the possibility of printing a third edition.”

Access to the 20-volume print edition is available to subscribers to the OED’s fee-based online version, Martin says.

The term hospitalist was first introduced in 1996 in an article by Robert M. Wachter, MD, and Lee Goldman, MD, to describe physicians who devote much of their professional time and focus to the care of hospitalized patients.

Merriam-Webster began monitoring the term when the article first appeared in the New England Journal of Medicine, according to Peter Sokolowski, associate editor. He says hospitalist made it into the company’s collegiate dictionary in 2005, and the medical dictionary a year later.

For the most part, both print and online dictionaries give a relatively simple definition of hospitalist: “A physician specializing in the care of hospital in-patients,” says the OED’s online version. Merriam-Webster’s dictionaries define the term as “a physician who specializes in treating hospitalized patients of other physicians in order to minimize the number of hospital visits by other physicians.”

Perhaps the most extensive definition online appears in Wikipedia, the free online encyclopedia. In addition to the definition, Wikipedia also provides information on the specialty under various subtitles, including Training and History. TH

Tom Giordano is a freelance journalist based in Connecticut

The online version of the Oxford English Dictionary (OED) is the latest in a string of dictionaries to include the word “hospitalist” among its entries.

“This is just another sign that “hospitalist” has become another part of the landscape, and that we’ve arrived and will be here for a very long time,” says Larry Wellikson, MD, CEO of SHM. “I think SHM has been working on defining what a hospitalist is in textbooks and other reference materials since I got here in 2000.”

Asked if SHM solicited the OED staff to include hospitalist in its entries, Dr. Wellikson said it wasn’t necessary. “No, we didn’t lobby them,” he says. “They did it totally on their own. If you Google hospitalist, you’ll see thousands of stories that have been written during the past 10 years, including by such publications as the The Wall Street Journal.”

Dr. Wellikson noted that CNN’s Larry King mentioned hospitalists during a segment in 2005. “[The word hospitalist] has turned up in so many places,” he says.

To date, “hospitalist” has been included in print editions of The American Heritage Dictionary of the English Language, Merriam-Webster’s collegiate and medical dictionaries, as well as other print medical dictionaries and some online dictionaries. The American Heritage Dictionary appears to be the first to have included the word in a print edition in 2000, according to a spokesman for the publication.

The process of selecting a new word for inclusion in a dictionary appears fairly constant in the industry.

“It can include suggestions from our readership or people in a particular industry who might suggest that a new word unique to their profession should be included,” says Katherine Martin, senior assistant editor at OED’s New York offices. “It also includes our own (staff) study to ascertain if a certain word that is tested over time will have continued longevity.”

Tested over time indeed. Martin and other dictionary staff members say it can sometimes take up to 10 years for a new word to be included in a dictionary.

That’s how long it took to include hospitalist in Merriam-Webster’s Collegiate Dictionary, according to a spokesman for that publication. And while hospitalist was included in the OED’s online version in December 2006, it’s uncertain if it will ever get into the print version, according to Martin.

The OED’s second edition was last printed in 1989, Martin says, and because of the huge cost involved, “We haven’t even begun discussing the possibility of printing a third edition.”

Access to the 20-volume print edition is available to subscribers to the OED’s fee-based online version, Martin says.

The term hospitalist was first introduced in 1996 in an article by Robert M. Wachter, MD, and Lee Goldman, MD, to describe physicians who devote much of their professional time and focus to the care of hospitalized patients.

Merriam-Webster began monitoring the term when the article first appeared in the New England Journal of Medicine, according to Peter Sokolowski, associate editor. He says hospitalist made it into the company’s collegiate dictionary in 2005, and the medical dictionary a year later.

For the most part, both print and online dictionaries give a relatively simple definition of hospitalist: “A physician specializing in the care of hospital in-patients,” says the OED’s online version. Merriam-Webster’s dictionaries define the term as “a physician who specializes in treating hospitalized patients of other physicians in order to minimize the number of hospital visits by other physicians.”

Perhaps the most extensive definition online appears in Wikipedia, the free online encyclopedia. In addition to the definition, Wikipedia also provides information on the specialty under various subtitles, including Training and History. TH

Tom Giordano is a freelance journalist based in Connecticut

The online version of the Oxford English Dictionary (OED) is the latest in a string of dictionaries to include the word “hospitalist” among its entries.

“This is just another sign that “hospitalist” has become another part of the landscape, and that we’ve arrived and will be here for a very long time,” says Larry Wellikson, MD, CEO of SHM. “I think SHM has been working on defining what a hospitalist is in textbooks and other reference materials since I got here in 2000.”

Asked if SHM solicited the OED staff to include hospitalist in its entries, Dr. Wellikson said it wasn’t necessary. “No, we didn’t lobby them,” he says. “They did it totally on their own. If you Google hospitalist, you’ll see thousands of stories that have been written during the past 10 years, including by such publications as the The Wall Street Journal.”

Dr. Wellikson noted that CNN’s Larry King mentioned hospitalists during a segment in 2005. “[The word hospitalist] has turned up in so many places,” he says.

To date, “hospitalist” has been included in print editions of The American Heritage Dictionary of the English Language, Merriam-Webster’s collegiate and medical dictionaries, as well as other print medical dictionaries and some online dictionaries. The American Heritage Dictionary appears to be the first to have included the word in a print edition in 2000, according to a spokesman for the publication.

The process of selecting a new word for inclusion in a dictionary appears fairly constant in the industry.

“It can include suggestions from our readership or people in a particular industry who might suggest that a new word unique to their profession should be included,” says Katherine Martin, senior assistant editor at OED’s New York offices. “It also includes our own (staff) study to ascertain if a certain word that is tested over time will have continued longevity.”

Tested over time indeed. Martin and other dictionary staff members say it can sometimes take up to 10 years for a new word to be included in a dictionary.

That’s how long it took to include hospitalist in Merriam-Webster’s Collegiate Dictionary, according to a spokesman for that publication. And while hospitalist was included in the OED’s online version in December 2006, it’s uncertain if it will ever get into the print version, according to Martin.

The OED’s second edition was last printed in 1989, Martin says, and because of the huge cost involved, “We haven’t even begun discussing the possibility of printing a third edition.”

Access to the 20-volume print edition is available to subscribers to the OED’s fee-based online version, Martin says.

The term hospitalist was first introduced in 1996 in an article by Robert M. Wachter, MD, and Lee Goldman, MD, to describe physicians who devote much of their professional time and focus to the care of hospitalized patients.

Merriam-Webster began monitoring the term when the article first appeared in the New England Journal of Medicine, according to Peter Sokolowski, associate editor. He says hospitalist made it into the company’s collegiate dictionary in 2005, and the medical dictionary a year later.

For the most part, both print and online dictionaries give a relatively simple definition of hospitalist: “A physician specializing in the care of hospital in-patients,” says the OED’s online version. Merriam-Webster’s dictionaries define the term as “a physician who specializes in treating hospitalized patients of other physicians in order to minimize the number of hospital visits by other physicians.”

Perhaps the most extensive definition online appears in Wikipedia, the free online encyclopedia. In addition to the definition, Wikipedia also provides information on the specialty under various subtitles, including Training and History. TH

Tom Giordano is a freelance journalist based in Connecticut

It is standard wisdom that when patients say they drink two beers a day, you should double that amount. Possibly triple it. I’ve had patients tell me they “don’t drink anymore,” meaning any more then they did before.

Though we tend to believe our patients when they recite their litany of pains and woes, when it comes to alcohol (and several other topics such as chronic pain, disability exams, and worker’s compensation) our credulity is often tested.

Mr. Q had been my patient for several years. He was a chain-smoking, hard-drinking Korean War veteran. He was a diminutive, cachectic, dyspneic, but extremely pleasant man. He was always accompanied to my clinic (in my prehospitalist days) with his ever-suffering, massive, and markedly less affable wife in tow.

His COPD was progressively worsening, and one day he told me he was going to quit smoking. His wife laughed unpleasantly, and commented that he’d quit just like he’d quit drinking. He prided himself on the keg of beer he kept in his garage. It was this keg that drove his wife most crazy, and perhaps that was the source of his pride. He went from two packs a day to five cigarettes. He said he planned to wake up every morning and load five in an empty pack, and these would be his five for the day. He would smoke the hell out of them, but if he ran out he would wait till the next morning to reload. His wife, as usual, sat and scowled and undermined his efforts.

On a subsequent visit, when he said he was down to five cigarettes, she laughed and said he was lying; he was smoking in the closet, in the car, wherever he could when she wasn’t looking—especially in the garage. Yet, some how I believed him. Maybe.

Before he came under my care Mr. Q also had been diagnosed with cirrhosis. I warned him many times about his need to stop drinking. I gave him lurid descriptions of esophageal varices and exsanguination, and other hepatic complications too fierce to mention. He always asserted that he didn’t drink anymore, with a large wink; his wife squirming in her chair. She snorted and said he should tell that to the keg in the garage. She said he would sit there all night long, drinking and watching the old black and white. I could see him wanting to escape her beady-eyed gaze. Yet I found this harder to believe than the possibility that he’d cut back his smoking.

Over the next year or so I pleaded with him to stop drinking as he developed diabetes. I knew a dozen beers a day couldn’t be helping his condition. I talked about diet and exercise, and he just laughed at me. He said he wasn’t going to exercise much with his lungs and remarked that if I’d tasted his wife’s cooking, diet wouldn’t be an issue. I marveled at what strange, attractive force held these two people together. Mutual hatred seemed the answer.

Two months later I admitted him to the hospital with a cardiac arrhythmia. He’d popped into atrial fibrillation. His wife grumbled that her husband hadn’t been out of the garage in a week. A diagnosis immediately came to mind: holiday heart. He’d drunk himself into an arrhythmia.

I got his heart rate under control but was frustrated with my seemingly fruitless efforts to control his drinking. His wife stormed out of his hospital room. The first time I was alone with him, I asked him why he’d never stopped drinking. He looked at me and laughed bitterly. He said he knew I wouldn’t believe him but that he had not had a drink in three years. The keg had been dry all that time, he just liked to sit in the garage and pretend he was having a few to keep away from his wife. He enjoyed his garage, the tools he was too sick to use, and his old black-and-white television.

How could this be? The history and exam did not jibe with this at all. He looked and acted like an alcoholic. Yet if his story were true, how could I explain his current condition? I wanted to believe him, but his persistent liver dysfunction, diabetes, and new arrhythmia argued against it. I looked at him. He was a gnarled, emphysematous shell of a man. At least he had a nice tan. I commented on this, mentioning that he must spend some time out of the garage to keep his melanocytes so primed. He looked at me quizzically. He said he never went outside, unless it was to get the newspaper; he hated sitting in the sun.

A light bulb lit in my head, then exploded into a million pieces. What if he really hadn’t been drinking? What else could explain this clinical picture? I was sure I knew the answer now, and a lab test quickly confirmed it. To my chagrin, his ferritin was more than 2,000. Bronze diabetes: his liver abnormalities, diabetes, pseudo-tan, and cardiac arrhythmia were due to iron deposition. He had hemochromatosis!

Several years later, Mr. Q died of complications of COPD. His son found him sitting in a lounge chair in his garage, with the old black and white tuned to his favorite station. He did not die from the diagnosis I had missed. Would his clinical outcome have been any different if the diagnosis had been made earlier? Probably not. Further, if his wife had known he wasn’t drinking, he might have lost his place of refuge. I promised myself that the next time a patient told me how much they drank that I would try to be less cynical in my response.

The day he died I went home and opened a fine merlot and poured myself a glass—then didn’t drink it. TH

Dr. Newman is the physician editor of The Hospitalist. He’s also consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

It is standard wisdom that when patients say they drink two beers a day, you should double that amount. Possibly triple it. I’ve had patients tell me they “don’t drink anymore,” meaning any more then they did before.

Though we tend to believe our patients when they recite their litany of pains and woes, when it comes to alcohol (and several other topics such as chronic pain, disability exams, and worker’s compensation) our credulity is often tested.

Mr. Q had been my patient for several years. He was a chain-smoking, hard-drinking Korean War veteran. He was a diminutive, cachectic, dyspneic, but extremely pleasant man. He was always accompanied to my clinic (in my prehospitalist days) with his ever-suffering, massive, and markedly less affable wife in tow.

His COPD was progressively worsening, and one day he told me he was going to quit smoking. His wife laughed unpleasantly, and commented that he’d quit just like he’d quit drinking. He prided himself on the keg of beer he kept in his garage. It was this keg that drove his wife most crazy, and perhaps that was the source of his pride. He went from two packs a day to five cigarettes. He said he planned to wake up every morning and load five in an empty pack, and these would be his five for the day. He would smoke the hell out of them, but if he ran out he would wait till the next morning to reload. His wife, as usual, sat and scowled and undermined his efforts.

On a subsequent visit, when he said he was down to five cigarettes, she laughed and said he was lying; he was smoking in the closet, in the car, wherever he could when she wasn’t looking—especially in the garage. Yet, some how I believed him. Maybe.

Before he came under my care Mr. Q also had been diagnosed with cirrhosis. I warned him many times about his need to stop drinking. I gave him lurid descriptions of esophageal varices and exsanguination, and other hepatic complications too fierce to mention. He always asserted that he didn’t drink anymore, with a large wink; his wife squirming in her chair. She snorted and said he should tell that to the keg in the garage. She said he would sit there all night long, drinking and watching the old black and white. I could see him wanting to escape her beady-eyed gaze. Yet I found this harder to believe than the possibility that he’d cut back his smoking.

Over the next year or so I pleaded with him to stop drinking as he developed diabetes. I knew a dozen beers a day couldn’t be helping his condition. I talked about diet and exercise, and he just laughed at me. He said he wasn’t going to exercise much with his lungs and remarked that if I’d tasted his wife’s cooking, diet wouldn’t be an issue. I marveled at what strange, attractive force held these two people together. Mutual hatred seemed the answer.

Two months later I admitted him to the hospital with a cardiac arrhythmia. He’d popped into atrial fibrillation. His wife grumbled that her husband hadn’t been out of the garage in a week. A diagnosis immediately came to mind: holiday heart. He’d drunk himself into an arrhythmia.

I got his heart rate under control but was frustrated with my seemingly fruitless efforts to control his drinking. His wife stormed out of his hospital room. The first time I was alone with him, I asked him why he’d never stopped drinking. He looked at me and laughed bitterly. He said he knew I wouldn’t believe him but that he had not had a drink in three years. The keg had been dry all that time, he just liked to sit in the garage and pretend he was having a few to keep away from his wife. He enjoyed his garage, the tools he was too sick to use, and his old black-and-white television.

How could this be? The history and exam did not jibe with this at all. He looked and acted like an alcoholic. Yet if his story were true, how could I explain his current condition? I wanted to believe him, but his persistent liver dysfunction, diabetes, and new arrhythmia argued against it. I looked at him. He was a gnarled, emphysematous shell of a man. At least he had a nice tan. I commented on this, mentioning that he must spend some time out of the garage to keep his melanocytes so primed. He looked at me quizzically. He said he never went outside, unless it was to get the newspaper; he hated sitting in the sun.

A light bulb lit in my head, then exploded into a million pieces. What if he really hadn’t been drinking? What else could explain this clinical picture? I was sure I knew the answer now, and a lab test quickly confirmed it. To my chagrin, his ferritin was more than 2,000. Bronze diabetes: his liver abnormalities, diabetes, pseudo-tan, and cardiac arrhythmia were due to iron deposition. He had hemochromatosis!

Several years later, Mr. Q died of complications of COPD. His son found him sitting in a lounge chair in his garage, with the old black and white tuned to his favorite station. He did not die from the diagnosis I had missed. Would his clinical outcome have been any different if the diagnosis had been made earlier? Probably not. Further, if his wife had known he wasn’t drinking, he might have lost his place of refuge. I promised myself that the next time a patient told me how much they drank that I would try to be less cynical in my response.

The day he died I went home and opened a fine merlot and poured myself a glass—then didn’t drink it. TH

Dr. Newman is the physician editor of The Hospitalist. He’s also consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

It is standard wisdom that when patients say they drink two beers a day, you should double that amount. Possibly triple it. I’ve had patients tell me they “don’t drink anymore,” meaning any more then they did before.

Though we tend to believe our patients when they recite their litany of pains and woes, when it comes to alcohol (and several other topics such as chronic pain, disability exams, and worker’s compensation) our credulity is often tested.

Mr. Q had been my patient for several years. He was a chain-smoking, hard-drinking Korean War veteran. He was a diminutive, cachectic, dyspneic, but extremely pleasant man. He was always accompanied to my clinic (in my prehospitalist days) with his ever-suffering, massive, and markedly less affable wife in tow.

His COPD was progressively worsening, and one day he told me he was going to quit smoking. His wife laughed unpleasantly, and commented that he’d quit just like he’d quit drinking. He prided himself on the keg of beer he kept in his garage. It was this keg that drove his wife most crazy, and perhaps that was the source of his pride. He went from two packs a day to five cigarettes. He said he planned to wake up every morning and load five in an empty pack, and these would be his five for the day. He would smoke the hell out of them, but if he ran out he would wait till the next morning to reload. His wife, as usual, sat and scowled and undermined his efforts.

On a subsequent visit, when he said he was down to five cigarettes, she laughed and said he was lying; he was smoking in the closet, in the car, wherever he could when she wasn’t looking—especially in the garage. Yet, some how I believed him. Maybe.

Before he came under my care Mr. Q also had been diagnosed with cirrhosis. I warned him many times about his need to stop drinking. I gave him lurid descriptions of esophageal varices and exsanguination, and other hepatic complications too fierce to mention. He always asserted that he didn’t drink anymore, with a large wink; his wife squirming in her chair. She snorted and said he should tell that to the keg in the garage. She said he would sit there all night long, drinking and watching the old black and white. I could see him wanting to escape her beady-eyed gaze. Yet I found this harder to believe than the possibility that he’d cut back his smoking.

Over the next year or so I pleaded with him to stop drinking as he developed diabetes. I knew a dozen beers a day couldn’t be helping his condition. I talked about diet and exercise, and he just laughed at me. He said he wasn’t going to exercise much with his lungs and remarked that if I’d tasted his wife’s cooking, diet wouldn’t be an issue. I marveled at what strange, attractive force held these two people together. Mutual hatred seemed the answer.

Two months later I admitted him to the hospital with a cardiac arrhythmia. He’d popped into atrial fibrillation. His wife grumbled that her husband hadn’t been out of the garage in a week. A diagnosis immediately came to mind: holiday heart. He’d drunk himself into an arrhythmia.

I got his heart rate under control but was frustrated with my seemingly fruitless efforts to control his drinking. His wife stormed out of his hospital room. The first time I was alone with him, I asked him why he’d never stopped drinking. He looked at me and laughed bitterly. He said he knew I wouldn’t believe him but that he had not had a drink in three years. The keg had been dry all that time, he just liked to sit in the garage and pretend he was having a few to keep away from his wife. He enjoyed his garage, the tools he was too sick to use, and his old black-and-white television.

How could this be? The history and exam did not jibe with this at all. He looked and acted like an alcoholic. Yet if his story were true, how could I explain his current condition? I wanted to believe him, but his persistent liver dysfunction, diabetes, and new arrhythmia argued against it. I looked at him. He was a gnarled, emphysematous shell of a man. At least he had a nice tan. I commented on this, mentioning that he must spend some time out of the garage to keep his melanocytes so primed. He looked at me quizzically. He said he never went outside, unless it was to get the newspaper; he hated sitting in the sun.

A light bulb lit in my head, then exploded into a million pieces. What if he really hadn’t been drinking? What else could explain this clinical picture? I was sure I knew the answer now, and a lab test quickly confirmed it. To my chagrin, his ferritin was more than 2,000. Bronze diabetes: his liver abnormalities, diabetes, pseudo-tan, and cardiac arrhythmia were due to iron deposition. He had hemochromatosis!

Several years later, Mr. Q died of complications of COPD. His son found him sitting in a lounge chair in his garage, with the old black and white tuned to his favorite station. He did not die from the diagnosis I had missed. Would his clinical outcome have been any different if the diagnosis had been made earlier? Probably not. Further, if his wife had known he wasn’t drinking, he might have lost his place of refuge. I promised myself that the next time a patient told me how much they drank that I would try to be less cynical in my response.

The day he died I went home and opened a fine merlot and poured myself a glass—then didn’t drink it. TH

Dr. Newman is the physician editor of The Hospitalist. He’s also consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

How hard do hospitalists work and how much are they paid? There are several sources of data to answer this question, and each has its strengths and weaknesses. Because these data influence contract negotiations and compliance with federal regulations, it is worth taking the time to understand the differences in each data set.

I’ll focus on the two most common sources of data: the biannual SHM survey of hospitalist productivity and compensation (officially titled “The Authoritative Source on the State of Hospital Medicine”), and the Medical Group Management Association’s (MGMA) annual “Physician Compensation and Production Survey.” There are many other surveys that report hospitalist data such as those by the American Medical Group Association (AMGA), Sullivan & Cotter, Hay Group, and others. Each July, Modern Healthcare magazine publishes the average compensation (but no other data) reported for hospitalists and other specialties by each of these organizations and several others (but not the SHM data). It should be easy to find a copy of Modern Healthcare in your hospital administration or library, or on the Internet.

The SHM and MGMA surveys are the most widely used sources of data for hospitalists, and some of their attributes are described in Table 1 (see below).

I should acknowledge my potential conflict of interest and potential for bias in comparing these surveys. This column is in an SHM publication. I’m very active in SHM, and I’m a past chairman and ongoing member of the Benchmarks Committee, which oversees the design and analysis of the SHM survey. And while I am familiar with and regularly review the MGMA survey, I have no other connection to that organization.

Much of the difference between the surveys is a result of the SHM survey being designed specifically for hospitalists in any type of practice setting (e.g., small hospitalist-only groups, as well as hospitalists with huge organizations like a university faculty group practice). In contrast, the MGMA survey is designed for all physician specialties, so a hospitalist answers the same questions as a traditional primary care doctor, plastic surgeon, and obstetrician.

MGMA data can be adversely affected by the inclusion of primary care office-based encounters. One of the principal ways the two surveys differ is how they address ambulatory visits. The MGMA survey reports inpatient and ambulatory visits separately, but “ambulatory” visits include any for a patient who is not a hospital inpatient. By this definition, hospitalists make ambulatory visits, most commonly to hospitalized patients who are on observation status, and also patients seen in an ED, skilled nursing facility, or pre-op clinic. Thus the MGMA survey doesn’t distinguish between ambulatory encounters a hospitalist would generate in the course of serving as a hospitalist, and those generated while that doctor might be serving in a non-hospitalist role such as office-based primary care or urgent care.

The SHM survey doesn’t include—and isn’t contaminated by—office-based primary care or urgent-care visits.

Of the 3,376 total encounters reported in the MGMA survey, 40% (1,351) are ambulatory encounters. Although the SHM survey does not distinguish between hospital and ambulatory encounters, my experience suggests few, if any, hospitalist practices make 40% of their total encounters with patients on observation status, or in an ED, SNF, or pre-op clinic. Thus, many of the ambulatory encounters reported by MGMA might have been office visits, not hospital-related visits.

Additionally, the median internal medicine hospitalist encounters (ambulatory and hospital combined) in the MGMA survey (3,376) is 42% higher than the median total encounters reported for internal medicine hospitalists in SHM’s survey (2,378). Yet the wRVUs reported in the MGMA survey (3,514) are only 8% higher than those reported in the SHM survey (3,256). Thus the calculated average wRVUs per encounter for the MGMA data is only 1.04, compared with 1.37 for the SHM data. An average of 1.04 wRVUs per encounter is very low for hospitalists, when almost all current procedural terminology (CPT) codes a hospitalist uses have a value of one or more wRVUs. Again, this suggests the MGMA data may be significantly influenced by the inclusion of office-based encounters, some of which have wRVUs of less than one. SHM has approached MGMA to discuss this data definition issue in their survey.

click for large version

Why It Matters

You can use whichever data set best describes your situation. The MGMA has historically shown higher hospitalist salaries and higher workloads than the SHM data. But because the SHM data is the result of a survey customized for hospitalists and less likely than the MGMA data to be contaminated by non-hospital-related visits, the SHM data probably gives a more accurate picture.

Because the MGMA survey has been conducted for many years (far longer than the SHM survey) it has appropriately become one of the most authoritative sources of data on physician compensation for all specialties. Stark II regulations require hospitals to ensure they aren’t paying physicians above the fair market compensation (which could be seen as an inducement to refer patients to the hospital, among other concerns). And it specifically states that the MGMA survey is one of several approved sources of determining what fair market compensation is.

Even though the SHM data is most likely more representative and provides an important benchmark for hospitalists, the MGMA data has “pre-approved” status and thus is potentially safer to use for the specific purpose of determinations of fair market value.

With each iteration, the SHM survey will be adjusted to more specifically capture hospitalist activity; in many cases it is the best data for hospitalists to use in planning and benchmarking. But the MGMA data are still valuable and may be the most appropriate to refer to in contracts.

Note to readers: In May, SHM contacted MGMA regarding their concerns that MGMA survey data was not representative of hospitalists. MGMA responded with a willingness to discuss these issues with SHM. As this story goes to press, SHM and MGMA continue to have a dialogue about maximizing the accuracy of survey data. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

How hard do hospitalists work and how much are they paid? There are several sources of data to answer this question, and each has its strengths and weaknesses. Because these data influence contract negotiations and compliance with federal regulations, it is worth taking the time to understand the differences in each data set.

I’ll focus on the two most common sources of data: the biannual SHM survey of hospitalist productivity and compensation (officially titled “The Authoritative Source on the State of Hospital Medicine”), and the Medical Group Management Association’s (MGMA) annual “Physician Compensation and Production Survey.” There are many other surveys that report hospitalist data such as those by the American Medical Group Association (AMGA), Sullivan & Cotter, Hay Group, and others. Each July, Modern Healthcare magazine publishes the average compensation (but no other data) reported for hospitalists and other specialties by each of these organizations and several others (but not the SHM data). It should be easy to find a copy of Modern Healthcare in your hospital administration or library, or on the Internet.

The SHM and MGMA surveys are the most widely used sources of data for hospitalists, and some of their attributes are described in Table 1 (see below).

I should acknowledge my potential conflict of interest and potential for bias in comparing these surveys. This column is in an SHM publication. I’m very active in SHM, and I’m a past chairman and ongoing member of the Benchmarks Committee, which oversees the design and analysis of the SHM survey. And while I am familiar with and regularly review the MGMA survey, I have no other connection to that organization.

Much of the difference between the surveys is a result of the SHM survey being designed specifically for hospitalists in any type of practice setting (e.g., small hospitalist-only groups, as well as hospitalists with huge organizations like a university faculty group practice). In contrast, the MGMA survey is designed for all physician specialties, so a hospitalist answers the same questions as a traditional primary care doctor, plastic surgeon, and obstetrician.

MGMA data can be adversely affected by the inclusion of primary care office-based encounters. One of the principal ways the two surveys differ is how they address ambulatory visits. The MGMA survey reports inpatient and ambulatory visits separately, but “ambulatory” visits include any for a patient who is not a hospital inpatient. By this definition, hospitalists make ambulatory visits, most commonly to hospitalized patients who are on observation status, and also patients seen in an ED, skilled nursing facility, or pre-op clinic. Thus the MGMA survey doesn’t distinguish between ambulatory encounters a hospitalist would generate in the course of serving as a hospitalist, and those generated while that doctor might be serving in a non-hospitalist role such as office-based primary care or urgent care.

The SHM survey doesn’t include—and isn’t contaminated by—office-based primary care or urgent-care visits.

Of the 3,376 total encounters reported in the MGMA survey, 40% (1,351) are ambulatory encounters. Although the SHM survey does not distinguish between hospital and ambulatory encounters, my experience suggests few, if any, hospitalist practices make 40% of their total encounters with patients on observation status, or in an ED, SNF, or pre-op clinic. Thus, many of the ambulatory encounters reported by MGMA might have been office visits, not hospital-related visits.

Additionally, the median internal medicine hospitalist encounters (ambulatory and hospital combined) in the MGMA survey (3,376) is 42% higher than the median total encounters reported for internal medicine hospitalists in SHM’s survey (2,378). Yet the wRVUs reported in the MGMA survey (3,514) are only 8% higher than those reported in the SHM survey (3,256). Thus the calculated average wRVUs per encounter for the MGMA data is only 1.04, compared with 1.37 for the SHM data. An average of 1.04 wRVUs per encounter is very low for hospitalists, when almost all current procedural terminology (CPT) codes a hospitalist uses have a value of one or more wRVUs. Again, this suggests the MGMA data may be significantly influenced by the inclusion of office-based encounters, some of which have wRVUs of less than one. SHM has approached MGMA to discuss this data definition issue in their survey.

click for large version

Why It Matters

You can use whichever data set best describes your situation. The MGMA has historically shown higher hospitalist salaries and higher workloads than the SHM data. But because the SHM data is the result of a survey customized for hospitalists and less likely than the MGMA data to be contaminated by non-hospital-related visits, the SHM data probably gives a more accurate picture.

Because the MGMA survey has been conducted for many years (far longer than the SHM survey) it has appropriately become one of the most authoritative sources of data on physician compensation for all specialties. Stark II regulations require hospitals to ensure they aren’t paying physicians above the fair market compensation (which could be seen as an inducement to refer patients to the hospital, among other concerns). And it specifically states that the MGMA survey is one of several approved sources of determining what fair market compensation is.

Even though the SHM data is most likely more representative and provides an important benchmark for hospitalists, the MGMA data has “pre-approved” status and thus is potentially safer to use for the specific purpose of determinations of fair market value.

With each iteration, the SHM survey will be adjusted to more specifically capture hospitalist activity; in many cases it is the best data for hospitalists to use in planning and benchmarking. But the MGMA data are still valuable and may be the most appropriate to refer to in contracts.

Note to readers: In May, SHM contacted MGMA regarding their concerns that MGMA survey data was not representative of hospitalists. MGMA responded with a willingness to discuss these issues with SHM. As this story goes to press, SHM and MGMA continue to have a dialogue about maximizing the accuracy of survey data. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

How hard do hospitalists work and how much are they paid? There are several sources of data to answer this question, and each has its strengths and weaknesses. Because these data influence contract negotiations and compliance with federal regulations, it is worth taking the time to understand the differences in each data set.

I’ll focus on the two most common sources of data: the biannual SHM survey of hospitalist productivity and compensation (officially titled “The Authoritative Source on the State of Hospital Medicine”), and the Medical Group Management Association’s (MGMA) annual “Physician Compensation and Production Survey.” There are many other surveys that report hospitalist data such as those by the American Medical Group Association (AMGA), Sullivan & Cotter, Hay Group, and others. Each July, Modern Healthcare magazine publishes the average compensation (but no other data) reported for hospitalists and other specialties by each of these organizations and several others (but not the SHM data). It should be easy to find a copy of Modern Healthcare in your hospital administration or library, or on the Internet.

The SHM and MGMA surveys are the most widely used sources of data for hospitalists, and some of their attributes are described in Table 1 (see below).

I should acknowledge my potential conflict of interest and potential for bias in comparing these surveys. This column is in an SHM publication. I’m very active in SHM, and I’m a past chairman and ongoing member of the Benchmarks Committee, which oversees the design and analysis of the SHM survey. And while I am familiar with and regularly review the MGMA survey, I have no other connection to that organization.

Much of the difference between the surveys is a result of the SHM survey being designed specifically for hospitalists in any type of practice setting (e.g., small hospitalist-only groups, as well as hospitalists with huge organizations like a university faculty group practice). In contrast, the MGMA survey is designed for all physician specialties, so a hospitalist answers the same questions as a traditional primary care doctor, plastic surgeon, and obstetrician.

MGMA data can be adversely affected by the inclusion of primary care office-based encounters. One of the principal ways the two surveys differ is how they address ambulatory visits. The MGMA survey reports inpatient and ambulatory visits separately, but “ambulatory” visits include any for a patient who is not a hospital inpatient. By this definition, hospitalists make ambulatory visits, most commonly to hospitalized patients who are on observation status, and also patients seen in an ED, skilled nursing facility, or pre-op clinic. Thus the MGMA survey doesn’t distinguish between ambulatory encounters a hospitalist would generate in the course of serving as a hospitalist, and those generated while that doctor might be serving in a non-hospitalist role such as office-based primary care or urgent care.

The SHM survey doesn’t include—and isn’t contaminated by—office-based primary care or urgent-care visits.

Of the 3,376 total encounters reported in the MGMA survey, 40% (1,351) are ambulatory encounters. Although the SHM survey does not distinguish between hospital and ambulatory encounters, my experience suggests few, if any, hospitalist practices make 40% of their total encounters with patients on observation status, or in an ED, SNF, or pre-op clinic. Thus, many of the ambulatory encounters reported by MGMA might have been office visits, not hospital-related visits.

Additionally, the median internal medicine hospitalist encounters (ambulatory and hospital combined) in the MGMA survey (3,376) is 42% higher than the median total encounters reported for internal medicine hospitalists in SHM’s survey (2,378). Yet the wRVUs reported in the MGMA survey (3,514) are only 8% higher than those reported in the SHM survey (3,256). Thus the calculated average wRVUs per encounter for the MGMA data is only 1.04, compared with 1.37 for the SHM data. An average of 1.04 wRVUs per encounter is very low for hospitalists, when almost all current procedural terminology (CPT) codes a hospitalist uses have a value of one or more wRVUs. Again, this suggests the MGMA data may be significantly influenced by the inclusion of office-based encounters, some of which have wRVUs of less than one. SHM has approached MGMA to discuss this data definition issue in their survey.

click for large version

Why It Matters

You can use whichever data set best describes your situation. The MGMA has historically shown higher hospitalist salaries and higher workloads than the SHM data. But because the SHM data is the result of a survey customized for hospitalists and less likely than the MGMA data to be contaminated by non-hospital-related visits, the SHM data probably gives a more accurate picture.

Because the MGMA survey has been conducted for many years (far longer than the SHM survey) it has appropriately become one of the most authoritative sources of data on physician compensation for all specialties. Stark II regulations require hospitals to ensure they aren’t paying physicians above the fair market compensation (which could be seen as an inducement to refer patients to the hospital, among other concerns). And it specifically states that the MGMA survey is one of several approved sources of determining what fair market compensation is.

Even though the SHM data is most likely more representative and provides an important benchmark for hospitalists, the MGMA data has “pre-approved” status and thus is potentially safer to use for the specific purpose of determinations of fair market value.

With each iteration, the SHM survey will be adjusted to more specifically capture hospitalist activity; in many cases it is the best data for hospitalists to use in planning and benchmarking. But the MGMA data are still valuable and may be the most appropriate to refer to in contracts.

Note to readers: In May, SHM contacted MGMA regarding their concerns that MGMA survey data was not representative of hospitalists. MGMA responded with a willingness to discuss these issues with SHM. As this story goes to press, SHM and MGMA continue to have a dialogue about maximizing the accuracy of survey data. TH

Dr. Nelson has been a practicing hospitalist since 1988 and is a co-founder and past-president of SHM. He is a principal in Nelson/Flores Associates, a national hospitalist practice management consulting firm. This column represents his views and is not intended to reflect an official position of SHM.

Performance Measures and Outcomes for Heart Patients

Fonarow GC, Abraham WT, Albert NM, et al. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA. 2007 Jan 3;297(1):61-70

As our population ages, more emphasis will be placed on issues surrounding efficient and evidence-based care. Heart failure, which accounted for 3.6 million hospitalizations in 2003 and has an overall prevalence of 5 million, will be at the forefront of public policy. As pay for performance (P4P) and standards of care become increasingly prevalent, the medical community will need to scrutinize the standards by which we are measured.

The American College of Cardiology and the American Heart Association (ACC/AHA) developed guidelines for the treatment and care of patients with heart failure. These measures include heart failure discharge instructions, evaluation of left ventricle (LV) function, angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor antagonist (ARB) for LV dysfunction, adult smoking cessation counseling, and anticoagulation at discharge for patients with atrial fibrillation. Adherence to these performance measures should be based on evidence.

The authors’ goal was to determine the validity of these guidelines. The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry allowed for the documentation and follow-up of patients adhering to the heart failure guidelines as set forth by the ACC/AHA. The study assessed the relationship between these guidelines and clinical outcomes, including 60- to 90-day mortality and a composite end point of mortality or rehospitalization.

In this study the OPTIMIZE-HF registry was used as the source of prospective data collection. Ten percent of eligible patients were randomly selected from the registry between March 2003 and December 2004 from 91 hospitals. Eligibility for the OPTIMIZE-HF registry included patients 18 and older admitted for worsening heart failure or significant heart failure during their hospital stay. The performance measure of discharge instruction, smoking cessation, and anticoagulation were measured for all eligible patients. Patients with an ejection fraction of 40% or less, or moderate to severe systolic function, were included for the ACE inhibitor/ARB performance measure. One measure not included was treatment with beta-blockers at discharge. The authors included beta-blockers at discharge with metrics similar to those described for ACE/ARB criteria.

The conformity rates and process-outcome links were then determined for the performance measures and beta-blocker treatment as it related to 60- to 90-day mortality/rehospitalization.

The study focused on a random follow-up cohort of 5,791 patients from 91 hospitals. This was similar to the OPTIMIZE-HF cohort of 48,612 patients in 259 hospitals. Demographically, the average cohort’s age was 72, 51% male and 78% white, with 42% of patients diagnosed with ischemic heart disease and 43% with diabetes mellitus. These results were similar to the demographics of the overall OPTIMIZE-HF registry.

Of the eligible patients in the follow-up cohort, 66% (4,010) received complete discharge instructions. Eighty-nine percent of eligible patients (4,664) had their left ventricular function evaluated. For those patients with documented left ventricular systolic dysfunction (2,181), 83% were given an ACE inhibitor or ARB at discharge. Patients who had a diagnosis of atrial fibrillation were discharged with anticoagulation at a rate of 53%, and 72% of patients were counseled on smoking cessation. As compared with ACE inhibitors/ARB, similar results (84%) were seen for beta-blockers at discharge.

Only two of the five ACC/AHA performance measures were predictive of decreasing morbidity and mortality/rehospitalization in unadjusted analysis: patients discharged on ACE inhibitors/ARBs (odds ratio, 0.51; 95% CI 0.34–0.78; P- .002) and smoking cessation counseling. Beta-blockers, not a formal part of the ACC/AHA guidelines, were also a predictor of lower risk of both mortality and rehospitalization (odds ratio, 0.73; 95% CI, 0.55-0.96; P-0.02)

The OPTIMIZE-HF cohort analysis allowed for an opportunity to determine the degree of conformity for the ACC/AHA performance measures. The ACE inhibitors or ARB use at discharge was shown in the OPTIMIZE-HF cohort to have a relative reduction in one-year post discharge mortality by 17% (risk reduction, 0.83; 95% CI, 0.79-0.88) and a trend to lower 60- to 90-days post-discharge mortality and rehospitalization. Although smoking cessation had an early positive correlation, outcomes did not reach statistical significance. The measure of discharge instruction in the current study did not show a benefit on early mortality/rehospitalization in 60- to 90-days post discharge. It is unclear from this study if discharge instructions given to patients were either rushed or discussed in a comprehensive manner. This factor will need clarification and further research.

The measures of discharge instructions, smoking cessation, LV assessment, and anticoagulation for atrial fibrillation have not been examined as effective performance measures prior to this study. These measures were unable to show an independent decrease in 60- to 90-day mortality and rehospitalization.

Patients discharged with beta-blockers showed an association between lower mortality and rehospitalization. This association was found to be stronger than any of the formal ACC/AHA current performance measures.

The ACC/AHA guidelines are becoming standards of care for reporting to agencies such as Centers for Medicare and Medicaid Services or other P4P programs. To allow for improvement of quality, JCAHO and ACC/AHA designed the above criteria to act as a guide for the post discharge care of coronary heart failure patients. Because these criteria are the measures by which hospitals need to report, it will be necessary for data to show validity and a link between the clinical performance measures and improved outcomes.

Of the five measures stated, only ACE inhibitors/ARB at discharge was associated with a decrease in mortality/rehospitalization. Beta-blockers, currently not a performance measure, also showed this trend. Increased scrutiny needs to be part of the criteria for which hospitals and practitioners are being held accountable, and further research validating their effectiveness is warranted.

Risk Indexes for COPD

Niewoehner DE, Lockhnygina Y, Rice K, et al. Risk indexes for exacerbations and hospitalizations due to COPD. Chest. 2007 Jan;131(1):20-28.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the U.S. and continues to increase its numbers annually.

The cornerstone of COPD diagnosis and key predictor of prognosis is a low level of lung function. Another important predictor of morbidity, mortality, and progression of disease is COPD exacerbations.

Unfortunately, the definition of an exacerbation is varied, ranging from an increase in symptoms to COPD-related hospitalizations and death.1 Therefore, prevention of COPD exacerbations is an important management goal. This study focuses on setting a risk model as a clinical management tool, similar to what exists for cardiovascular events or community acquired pneumonia. No previous study has attempted to identify risk factors for exacerbations using prospective data collection and a clearly stated definition of exacerbation.

The study was a parallel-group, randomized, double-blind, placebo-controlled trial in patients with moderate to severe COPD conducted at 26 Veterans Affairs medical centers in the United States. Subjects were 40 or older, with a cigarette smoking history of 10 packs a year or more, a clinical diagnosis of COPD, and a forced expiratory volume [FEV] of 60% or less predicted and 70% or less of the forced vital capacity [FVC].1 Patients were allocated to receive one capsule of tiotropium (18 mg) or placebo for six months.

Of the 1,829 patients selected, 914 were assigned to the tiotropium arm. Patients kept a daily diary, and the investigators collected data by monthly telephone interviews and by site visits at three and six months with spirometry evaluation. They evaluated the association between baseline characteristics, concomitant medications and the study drug and the time to first COPD exacerbation and the time to first hospitalization due to exacerbation. The authors defined an exacerbation as a complex of respiratory symptoms of more than one of the following: cough, sputum, wheezing, dyspnea, or chest tightness with a duration of at least three days requiring treatment with antibiotics and/or systemic corticosteroids and/or hospital admission.

The investigators found that a statistically significant greater risk for both COPD exacerbations and hospitalizations is associated with being of older age, being a noncurrent smoker, having poorer lung function, using home oxygen, visiting the clinic or emergency department more often, either scheduled or unscheduled, being hospitalized for COPD in the prior year, using either antibiotics or systemic steroids for COPD more often in the prior year, and using short-acting beta agonist, inhaled or oral corticosteroid at a baseline rate.

On the other hand, a statistically significant greater risk of only COPD exacerbation was seen in white patients, with presence of productive cough, longer duration of COPD, use of long-acting beta agonist or theophylline at baseline, and presence of any gastrointestinal or hepatobiliary disease. Lower body-mass index and the presence of cardiovascular comorbidity were associated with statistically significant greater risk for only hospitalization due to COPD.

The investigators also confirmed the previous suggestion that chronic cough is an independent predictor of exacerbation. Interestingly, they found that any cardiovascular comorbidity is a strong and independent predictor of hospitalizations due to COPD. It is unclear if cardiovascular disease truly predisposes subjects to COPD hospitalizations or merely represents a misdiagnosis because both diseases have similar symptoms.

Current smokers were identified as having lower risk of exacerbation and hospitalization, probably due to the “healthy smoker” theory—that deteriorating lung function causes the patient to quit smoking.

This study is the first to gather information about predictors of COPD exacerbations in a prospective fashion using a clear definition of exacerbation. The authors developed a model to assess the risk of COPD exacerbations and hospitalizations due to exacerbations in patients with moderate to severe COPD. Moreover, this model can easily be applied to individual patients and reproduced with simple spirometry and a series of questions.

Though this trial had a reasonable level of statistical significance, it is important to mention that the trial was conducted within a single health system (Veterans Affairs medical centers), there were few women in the study, and the eligibility criteria were very specific.

References

1. Mannino DM, Watt G, Hole D, et al. The natural history of chronic obstructive pulmonary disease. Eur Respir J. 2006 Mar;27(3):627-643.

Glucose Management in Hospitalized Patients

Leahy JL. Insulin Management of diabetic patients on general medical and surgical floors. Endocr Pract. Jul/Aug 2006;12(Suppl3):86-89.

Although the rationale behind the science for tight control of blood sugar in subsets of hospitalized patient populations is without debate when it comes to the majority of general ward patients, the management of hyperglycemia becomes more of an art. Increasingly we recognize the effect of the relationship between improving glucose management and improving clinical outcomes.

Guidelines for inpatient targeted blood glucose levels exist, but hospitals are moving toward a more individualized approach to subcutaneous insulin protocols for their patients, thus moving beyond the passive sliding scale era.

Institution of an insulin protocol at one such hospital, the University of Vermont, highlights such an approach. The ongoing internal nonrandomized study exemplifies a two-tiered approach initially aimed at expanding the house physician comfort zone to change the culture of hyperglycemic management beyond simply avoiding hypoglycemia to one of an active and—per our current standards—aggressive individualized insulin protocol.

It seems the author envisions a gradual process allowing initial flexibility within the protocol, increasing the intensity of dosing as comfort zones expand. Throughout the process, the principles of determining a patient’s weight-based daily insulin needs are maintained, taking into consideration factors like comorbidities, severity of illness, amount of oral intake, steroid usage, and age. Then, the insulin regimen is physiologically (basal/bolus, basal, continuous) administered according to the route (i.e., total parenteral nutrition) and timing of their nutritional intake.

Adjustments being made to insulin regimens are based on fasting, pre-meal and bedtime glucose as well as the novel approach of bolus insulin after meals with short-acting insulin (i.e., lispro).

Unfortunately although the protocol does perhaps yield itself to being looked at more stringently—in terms of cost effectiveness, improved length of hospital stay, and improved clinical outcomes—the outcome studied here was primarily one of hospitalwide education in advancing the understanding and culture of aggressive individualized insulin protocols. These can often be even more statistically difficult to quantify. As self-reported, improve­­ments were made.

One of the most important aspects of this paper is that it draws attention to the paucity of evidence for improved clinical and monetary outcomes supporting the aggressive hospital management of hyperglycemia in the non-acutely ill patient. Often, the guiding principle is to avoid hypoglycemia. Detailing the specific protocols of one such approach serves as an example for the motivated reader.

Early Switch from IV to Oral Antibiotic in Severe CAP

Oosterheert JJ, Bonten JM, Schneider MME, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia; multicentre randomised trial. BMJ. 2006 Dec 9; 333:1193.

Community acquired pneumonia (CAP) is a common and potentially fatal infection with high healthcare costs. When patients are first admitted to hospitals, antibiotics are usually given intravenously to provide optimal concentrations in the tissues.

The duration of intravenous treatment is an important determinant of length of hospital stay (LOS). The concept of early transition from intravenous to oral antibiotic in the treatment of CAP has been evaluated before, but only in mild to moderately severe disease—and rarely in randomized trials.

This multicenter random controlled trial from five teaching hospitals and two medical centers in the Netherlands enrolled 302 patients in non-intensive care units with severe CAP. The primary outcome was clinical cure and secondary outcome was LOS. The inclusion criteria were adults 18 or older with severe CAP; mean pneumonia severity index of IV-V, new progressive infiltrate on chest X-ray, plus at least two other criteria (cough, sputum production, rectal temperature >38o C or <36.1o C, auscultative findings consistent with pneumonia, leukocytes >109 WBC/L or >15% bands, positive cultures of blob or pleural fluids, CRP three times greater times upper limit of normal).

Exclusion criteria included the need for mechanical ventilation, cystic fibrosis, a history of colonization with gram-negative bacteria due to structural damage to the respiratory tract, malfunction of the digestive tract, life expectancy of less than one month because of underlying disease, infections other than pneumonia that needed antibiotic treatment, and severe immunosuppression (neutropenia [<0.5 109 neutrophils/liter] or a CD4 count< 200/mm3).

Treatment failure was defined as death, still in hospital at day 28 of the study, or clinical deterioration (increase in temperature after initial improvement or the need for mechanical ventilation, switch back to intravenous antibiotics, or readmission for pulmonary reinfection after discharge).

Clinical cure was defined as discharged in good health without signs and symptoms of pneumonia and no treatment failure during follow-up.

The control group comprised 150 subjects who were to receive a standard course of seven days’ intravenous treatment. Meanwhile, 152 subjects were randomized to the early switch group. Baseline characteristics were similar in both groups. More than 80% of patients were in pneumonia severity class IV or V. Most patients received empirical monotherapy with amoxicillin or amoxicillin plus clavulanic acid (n=174; 58%) or a cephalosporin (n=59; 20%), which is in line with Dutch prescribing policies.

The most frequently identified microorganism was S pneumoniae (n=76; 25%). Atypical pathogens were detected in 33 patients (11%). Before day three, 37 patients (12%) were excluded from analysis, leaving 132 patients for analysis in the intervention group and 133 in the control group.

Reasons for exclusion included when the initial diagnosis of CAP was replaced by another diagnosis (n=9), consent was withdrawn (n=11), the protocol was violated (n=4), the patient was admitted to an intensive-care unit for mechanical ventilation (n=6), and the patient died (n=7). After three days of intravenous treatment, 108 of 132 patients (81%) in the intervention group were switched to oral treatment, of whom 102 (94%) received amoxicillin plus clavulanic acid (500+125 mg every eight hours).

In the control group, five patients did not receive intravenous antibiotics for all seven days because of phlebitis associated with intravenous treatment; none of them needed treatment for line-related sepsis. Overall duration of antibiotic treatment was 10.1 days in the intervention group and 9.3 days in the control group (mean difference 0.8 days, 95% confidence interval -0.6 to 2.0).

The duration of intravenous treatment was significantly shorter in the intervention group (mean 3.6 [SD 1.5] versus 7.0 [2.0] days, mean difference 3.4, 2.8 to 3.9). Average time to meet the discharge criteria was 5.2 (2.9) days in the intervention group and 5.7 (3.1) days in the control group (0.5 days -0.3 to 1.2) Total length of hospital stay was 9.6 (5.0) and 11.5 (4.9) days for patients in the intervention group and control group (1.9 days 0.6 to 3.2).

The authors’ findings provide strong evidence that early transition from intravenous to oral antibiotic is also viable in patients with highly graded Pneumonia Severity Index (PSI) CAP, not only in mild to moderately severe disease. This leads to reduced LOS, cost, and possibly reduced risk of line infections and increased patient satisfaction for early discharge.

Note: This study was done with patients suffering straightforward, uncomplicated CAP. The investigators’ findings cannot be applied to patients with other comorbidities like diabetes, COPD, heart failure, or sickle cell, which might require more days on intravenous antibiotic. One might also wonder what impact would have been seen had 37 patients not dropped off, and if another class of oral antibiotic such as quinolones had been used.

Last, the study sample showed S pneumoniae identified in 25% of cases and atypical pathogens to be 11%. What then are the majority of pathogens identified 64% of the time? This would have been another key factor that might have had a great effect on the result.

Although a larger sampling and further risk stratification (to include patients with other comorbidities) are needed, this study makes a valid point for early transition to oral antibiotics in highly graded, uncomplicated CAP. TH

Performance Measures and Outcomes for Heart Patients

Fonarow GC, Abraham WT, Albert NM, et al. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA. 2007 Jan 3;297(1):61-70

As our population ages, more emphasis will be placed on issues surrounding efficient and evidence-based care. Heart failure, which accounted for 3.6 million hospitalizations in 2003 and has an overall prevalence of 5 million, will be at the forefront of public policy. As pay for performance (P4P) and standards of care become increasingly prevalent, the medical community will need to scrutinize the standards by which we are measured.

The American College of Cardiology and the American Heart Association (ACC/AHA) developed guidelines for the treatment and care of patients with heart failure. These measures include heart failure discharge instructions, evaluation of left ventricle (LV) function, angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor antagonist (ARB) for LV dysfunction, adult smoking cessation counseling, and anticoagulation at discharge for patients with atrial fibrillation. Adherence to these performance measures should be based on evidence.

The authors’ goal was to determine the validity of these guidelines. The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry allowed for the documentation and follow-up of patients adhering to the heart failure guidelines as set forth by the ACC/AHA. The study assessed the relationship between these guidelines and clinical outcomes, including 60- to 90-day mortality and a composite end point of mortality or rehospitalization.

In this study the OPTIMIZE-HF registry was used as the source of prospective data collection. Ten percent of eligible patients were randomly selected from the registry between March 2003 and December 2004 from 91 hospitals. Eligibility for the OPTIMIZE-HF registry included patients 18 and older admitted for worsening heart failure or significant heart failure during their hospital stay. The performance measure of discharge instruction, smoking cessation, and anticoagulation were measured for all eligible patients. Patients with an ejection fraction of 40% or less, or moderate to severe systolic function, were included for the ACE inhibitor/ARB performance measure. One measure not included was treatment with beta-blockers at discharge. The authors included beta-blockers at discharge with metrics similar to those described for ACE/ARB criteria.

The conformity rates and process-outcome links were then determined for the performance measures and beta-blocker treatment as it related to 60- to 90-day mortality/rehospitalization.

The study focused on a random follow-up cohort of 5,791 patients from 91 hospitals. This was similar to the OPTIMIZE-HF cohort of 48,612 patients in 259 hospitals. Demographically, the average cohort’s age was 72, 51% male and 78% white, with 42% of patients diagnosed with ischemic heart disease and 43% with diabetes mellitus. These results were similar to the demographics of the overall OPTIMIZE-HF registry.

Of the eligible patients in the follow-up cohort, 66% (4,010) received complete discharge instructions. Eighty-nine percent of eligible patients (4,664) had their left ventricular function evaluated. For those patients with documented left ventricular systolic dysfunction (2,181), 83% were given an ACE inhibitor or ARB at discharge. Patients who had a diagnosis of atrial fibrillation were discharged with anticoagulation at a rate of 53%, and 72% of patients were counseled on smoking cessation. As compared with ACE inhibitors/ARB, similar results (84%) were seen for beta-blockers at discharge.

Only two of the five ACC/AHA performance measures were predictive of decreasing morbidity and mortality/rehospitalization in unadjusted analysis: patients discharged on ACE inhibitors/ARBs (odds ratio, 0.51; 95% CI 0.34–0.78; P- .002) and smoking cessation counseling. Beta-blockers, not a formal part of the ACC/AHA guidelines, were also a predictor of lower risk of both mortality and rehospitalization (odds ratio, 0.73; 95% CI, 0.55-0.96; P-0.02)

The OPTIMIZE-HF cohort analysis allowed for an opportunity to determine the degree of conformity for the ACC/AHA performance measures. The ACE inhibitors or ARB use at discharge was shown in the OPTIMIZE-HF cohort to have a relative reduction in one-year post discharge mortality by 17% (risk reduction, 0.83; 95% CI, 0.79-0.88) and a trend to lower 60- to 90-days post-discharge mortality and rehospitalization. Although smoking cessation had an early positive correlation, outcomes did not reach statistical significance. The measure of discharge instruction in the current study did not show a benefit on early mortality/rehospitalization in 60- to 90-days post discharge. It is unclear from this study if discharge instructions given to patients were either rushed or discussed in a comprehensive manner. This factor will need clarification and further research.

The measures of discharge instructions, smoking cessation, LV assessment, and anticoagulation for atrial fibrillation have not been examined as effective performance measures prior to this study. These measures were unable to show an independent decrease in 60- to 90-day mortality and rehospitalization.

Patients discharged with beta-blockers showed an association between lower mortality and rehospitalization. This association was found to be stronger than any of the formal ACC/AHA current performance measures.

The ACC/AHA guidelines are becoming standards of care for reporting to agencies such as Centers for Medicare and Medicaid Services or other P4P programs. To allow for improvement of quality, JCAHO and ACC/AHA designed the above criteria to act as a guide for the post discharge care of coronary heart failure patients. Because these criteria are the measures by which hospitals need to report, it will be necessary for data to show validity and a link between the clinical performance measures and improved outcomes.

Of the five measures stated, only ACE inhibitors/ARB at discharge was associated with a decrease in mortality/rehospitalization. Beta-blockers, currently not a performance measure, also showed this trend. Increased scrutiny needs to be part of the criteria for which hospitals and practitioners are being held accountable, and further research validating their effectiveness is warranted.

Risk Indexes for COPD

Niewoehner DE, Lockhnygina Y, Rice K, et al. Risk indexes for exacerbations and hospitalizations due to COPD. Chest. 2007 Jan;131(1):20-28.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the U.S. and continues to increase its numbers annually.

The cornerstone of COPD diagnosis and key predictor of prognosis is a low level of lung function. Another important predictor of morbidity, mortality, and progression of disease is COPD exacerbations.

Unfortunately, the definition of an exacerbation is varied, ranging from an increase in symptoms to COPD-related hospitalizations and death.1 Therefore, prevention of COPD exacerbations is an important management goal. This study focuses on setting a risk model as a clinical management tool, similar to what exists for cardiovascular events or community acquired pneumonia. No previous study has attempted to identify risk factors for exacerbations using prospective data collection and a clearly stated definition of exacerbation.

The study was a parallel-group, randomized, double-blind, placebo-controlled trial in patients with moderate to severe COPD conducted at 26 Veterans Affairs medical centers in the United States. Subjects were 40 or older, with a cigarette smoking history of 10 packs a year or more, a clinical diagnosis of COPD, and a forced expiratory volume [FEV] of 60% or less predicted and 70% or less of the forced vital capacity [FVC].1 Patients were allocated to receive one capsule of tiotropium (18 mg) or placebo for six months.

Of the 1,829 patients selected, 914 were assigned to the tiotropium arm. Patients kept a daily diary, and the investigators collected data by monthly telephone interviews and by site visits at three and six months with spirometry evaluation. They evaluated the association between baseline characteristics, concomitant medications and the study drug and the time to first COPD exacerbation and the time to first hospitalization due to exacerbation. The authors defined an exacerbation as a complex of respiratory symptoms of more than one of the following: cough, sputum, wheezing, dyspnea, or chest tightness with a duration of at least three days requiring treatment with antibiotics and/or systemic corticosteroids and/or hospital admission.

The investigators found that a statistically significant greater risk for both COPD exacerbations and hospitalizations is associated with being of older age, being a noncurrent smoker, having poorer lung function, using home oxygen, visiting the clinic or emergency department more often, either scheduled or unscheduled, being hospitalized for COPD in the prior year, using either antibiotics or systemic steroids for COPD more often in the prior year, and using short-acting beta agonist, inhaled or oral corticosteroid at a baseline rate.

On the other hand, a statistically significant greater risk of only COPD exacerbation was seen in white patients, with presence of productive cough, longer duration of COPD, use of long-acting beta agonist or theophylline at baseline, and presence of any gastrointestinal or hepatobiliary disease. Lower body-mass index and the presence of cardiovascular comorbidity were associated with statistically significant greater risk for only hospitalization due to COPD.

The investigators also confirmed the previous suggestion that chronic cough is an independent predictor of exacerbation. Interestingly, they found that any cardiovascular comorbidity is a strong and independent predictor of hospitalizations due to COPD. It is unclear if cardiovascular disease truly predisposes subjects to COPD hospitalizations or merely represents a misdiagnosis because both diseases have similar symptoms.

Current smokers were identified as having lower risk of exacerbation and hospitalization, probably due to the “healthy smoker” theory—that deteriorating lung function causes the patient to quit smoking.

This study is the first to gather information about predictors of COPD exacerbations in a prospective fashion using a clear definition of exacerbation. The authors developed a model to assess the risk of COPD exacerbations and hospitalizations due to exacerbations in patients with moderate to severe COPD. Moreover, this model can easily be applied to individual patients and reproduced with simple spirometry and a series of questions.

Though this trial had a reasonable level of statistical significance, it is important to mention that the trial was conducted within a single health system (Veterans Affairs medical centers), there were few women in the study, and the eligibility criteria were very specific.

References

1. Mannino DM, Watt G, Hole D, et al. The natural history of chronic obstructive pulmonary disease. Eur Respir J. 2006 Mar;27(3):627-643.

Glucose Management in Hospitalized Patients

Leahy JL. Insulin Management of diabetic patients on general medical and surgical floors. Endocr Pract. Jul/Aug 2006;12(Suppl3):86-89.

Although the rationale behind the science for tight control of blood sugar in subsets of hospitalized patient populations is without debate when it comes to the majority of general ward patients, the management of hyperglycemia becomes more of an art. Increasingly we recognize the effect of the relationship between improving glucose management and improving clinical outcomes.

Guidelines for inpatient targeted blood glucose levels exist, but hospitals are moving toward a more individualized approach to subcutaneous insulin protocols for their patients, thus moving beyond the passive sliding scale era.

Institution of an insulin protocol at one such hospital, the University of Vermont, highlights such an approach. The ongoing internal nonrandomized study exemplifies a two-tiered approach initially aimed at expanding the house physician comfort zone to change the culture of hyperglycemic management beyond simply avoiding hypoglycemia to one of an active and—per our current standards—aggressive individualized insulin protocol.

It seems the author envisions a gradual process allowing initial flexibility within the protocol, increasing the intensity of dosing as comfort zones expand. Throughout the process, the principles of determining a patient’s weight-based daily insulin needs are maintained, taking into consideration factors like comorbidities, severity of illness, amount of oral intake, steroid usage, and age. Then, the insulin regimen is physiologically (basal/bolus, basal, continuous) administered according to the route (i.e., total parenteral nutrition) and timing of their nutritional intake.

Adjustments being made to insulin regimens are based on fasting, pre-meal and bedtime glucose as well as the novel approach of bolus insulin after meals with short-acting insulin (i.e., lispro).

Unfortunately although the protocol does perhaps yield itself to being looked at more stringently—in terms of cost effectiveness, improved length of hospital stay, and improved clinical outcomes—the outcome studied here was primarily one of hospitalwide education in advancing the understanding and culture of aggressive individualized insulin protocols. These can often be even more statistically difficult to quantify. As self-reported, improve­­ments were made.

One of the most important aspects of this paper is that it draws attention to the paucity of evidence for improved clinical and monetary outcomes supporting the aggressive hospital management of hyperglycemia in the non-acutely ill patient. Often, the guiding principle is to avoid hypoglycemia. Detailing the specific protocols of one such approach serves as an example for the motivated reader.

Early Switch from IV to Oral Antibiotic in Severe CAP

Oosterheert JJ, Bonten JM, Schneider MME, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia; multicentre randomised trial. BMJ. 2006 Dec 9; 333:1193.

Community acquired pneumonia (CAP) is a common and potentially fatal infection with high healthcare costs. When patients are first admitted to hospitals, antibiotics are usually given intravenously to provide optimal concentrations in the tissues.

The duration of intravenous treatment is an important determinant of length of hospital stay (LOS). The concept of early transition from intravenous to oral antibiotic in the treatment of CAP has been evaluated before, but only in mild to moderately severe disease—and rarely in randomized trials.

This multicenter random controlled trial from five teaching hospitals and two medical centers in the Netherlands enrolled 302 patients in non-intensive care units with severe CAP. The primary outcome was clinical cure and secondary outcome was LOS. The inclusion criteria were adults 18 or older with severe CAP; mean pneumonia severity index of IV-V, new progressive infiltrate on chest X-ray, plus at least two other criteria (cough, sputum production, rectal temperature >38o C or <36.1o C, auscultative findings consistent with pneumonia, leukocytes >109 WBC/L or >15% bands, positive cultures of blob or pleural fluids, CRP three times greater times upper limit of normal).

Exclusion criteria included the need for mechanical ventilation, cystic fibrosis, a history of colonization with gram-negative bacteria due to structural damage to the respiratory tract, malfunction of the digestive tract, life expectancy of less than one month because of underlying disease, infections other than pneumonia that needed antibiotic treatment, and severe immunosuppression (neutropenia [<0.5 109 neutrophils/liter] or a CD4 count< 200/mm3).

Treatment failure was defined as death, still in hospital at day 28 of the study, or clinical deterioration (increase in temperature after initial improvement or the need for mechanical ventilation, switch back to intravenous antibiotics, or readmission for pulmonary reinfection after discharge).

Clinical cure was defined as discharged in good health without signs and symptoms of pneumonia and no treatment failure during follow-up.

The control group comprised 150 subjects who were to receive a standard course of seven days’ intravenous treatment. Meanwhile, 152 subjects were randomized to the early switch group. Baseline characteristics were similar in both groups. More than 80% of patients were in pneumonia severity class IV or V. Most patients received empirical monotherapy with amoxicillin or amoxicillin plus clavulanic acid (n=174; 58%) or a cephalosporin (n=59; 20%), which is in line with Dutch prescribing policies.

The most frequently identified microorganism was S pneumoniae (n=76; 25%). Atypical pathogens were detected in 33 patients (11%). Before day three, 37 patients (12%) were excluded from analysis, leaving 132 patients for analysis in the intervention group and 133 in the control group.

Reasons for exclusion included when the initial diagnosis of CAP was replaced by another diagnosis (n=9), consent was withdrawn (n=11), the protocol was violated (n=4), the patient was admitted to an intensive-care unit for mechanical ventilation (n=6), and the patient died (n=7). After three days of intravenous treatment, 108 of 132 patients (81%) in the intervention group were switched to oral treatment, of whom 102 (94%) received amoxicillin plus clavulanic acid (500+125 mg every eight hours).

In the control group, five patients did not receive intravenous antibiotics for all seven days because of phlebitis associated with intravenous treatment; none of them needed treatment for line-related sepsis. Overall duration of antibiotic treatment was 10.1 days in the intervention group and 9.3 days in the control group (mean difference 0.8 days, 95% confidence interval -0.6 to 2.0).

The duration of intravenous treatment was significantly shorter in the intervention group (mean 3.6 [SD 1.5] versus 7.0 [2.0] days, mean difference 3.4, 2.8 to 3.9). Average time to meet the discharge criteria was 5.2 (2.9) days in the intervention group and 5.7 (3.1) days in the control group (0.5 days -0.3 to 1.2) Total length of hospital stay was 9.6 (5.0) and 11.5 (4.9) days for patients in the intervention group and control group (1.9 days 0.6 to 3.2).

The authors’ findings provide strong evidence that early transition from intravenous to oral antibiotic is also viable in patients with highly graded Pneumonia Severity Index (PSI) CAP, not only in mild to moderately severe disease. This leads to reduced LOS, cost, and possibly reduced risk of line infections and increased patient satisfaction for early discharge.

Note: This study was done with patients suffering straightforward, uncomplicated CAP. The investigators’ findings cannot be applied to patients with other comorbidities like diabetes, COPD, heart failure, or sickle cell, which might require more days on intravenous antibiotic. One might also wonder what impact would have been seen had 37 patients not dropped off, and if another class of oral antibiotic such as quinolones had been used.

Last, the study sample showed S pneumoniae identified in 25% of cases and atypical pathogens to be 11%. What then are the majority of pathogens identified 64% of the time? This would have been another key factor that might have had a great effect on the result.

Although a larger sampling and further risk stratification (to include patients with other comorbidities) are needed, this study makes a valid point for early transition to oral antibiotics in highly graded, uncomplicated CAP. TH

Performance Measures and Outcomes for Heart Patients

Fonarow GC, Abraham WT, Albert NM, et al. Association between performance measures and clinical outcomes for patients hospitalized with heart failure. JAMA. 2007 Jan 3;297(1):61-70

As our population ages, more emphasis will be placed on issues surrounding efficient and evidence-based care. Heart failure, which accounted for 3.6 million hospitalizations in 2003 and has an overall prevalence of 5 million, will be at the forefront of public policy. As pay for performance (P4P) and standards of care become increasingly prevalent, the medical community will need to scrutinize the standards by which we are measured.

The American College of Cardiology and the American Heart Association (ACC/AHA) developed guidelines for the treatment and care of patients with heart failure. These measures include heart failure discharge instructions, evaluation of left ventricle (LV) function, angiotensin converting enzyme (ACE) inhibitors or angiotensin II receptor antagonist (ARB) for LV dysfunction, adult smoking cessation counseling, and anticoagulation at discharge for patients with atrial fibrillation. Adherence to these performance measures should be based on evidence.

The authors’ goal was to determine the validity of these guidelines. The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) registry allowed for the documentation and follow-up of patients adhering to the heart failure guidelines as set forth by the ACC/AHA. The study assessed the relationship between these guidelines and clinical outcomes, including 60- to 90-day mortality and a composite end point of mortality or rehospitalization.

In this study the OPTIMIZE-HF registry was used as the source of prospective data collection. Ten percent of eligible patients were randomly selected from the registry between March 2003 and December 2004 from 91 hospitals. Eligibility for the OPTIMIZE-HF registry included patients 18 and older admitted for worsening heart failure or significant heart failure during their hospital stay. The performance measure of discharge instruction, smoking cessation, and anticoagulation were measured for all eligible patients. Patients with an ejection fraction of 40% or less, or moderate to severe systolic function, were included for the ACE inhibitor/ARB performance measure. One measure not included was treatment with beta-blockers at discharge. The authors included beta-blockers at discharge with metrics similar to those described for ACE/ARB criteria.

The conformity rates and process-outcome links were then determined for the performance measures and beta-blocker treatment as it related to 60- to 90-day mortality/rehospitalization.

The study focused on a random follow-up cohort of 5,791 patients from 91 hospitals. This was similar to the OPTIMIZE-HF cohort of 48,612 patients in 259 hospitals. Demographically, the average cohort’s age was 72, 51% male and 78% white, with 42% of patients diagnosed with ischemic heart disease and 43% with diabetes mellitus. These results were similar to the demographics of the overall OPTIMIZE-HF registry.

Of the eligible patients in the follow-up cohort, 66% (4,010) received complete discharge instructions. Eighty-nine percent of eligible patients (4,664) had their left ventricular function evaluated. For those patients with documented left ventricular systolic dysfunction (2,181), 83% were given an ACE inhibitor or ARB at discharge. Patients who had a diagnosis of atrial fibrillation were discharged with anticoagulation at a rate of 53%, and 72% of patients were counseled on smoking cessation. As compared with ACE inhibitors/ARB, similar results (84%) were seen for beta-blockers at discharge.

Only two of the five ACC/AHA performance measures were predictive of decreasing morbidity and mortality/rehospitalization in unadjusted analysis: patients discharged on ACE inhibitors/ARBs (odds ratio, 0.51; 95% CI 0.34–0.78; P- .002) and smoking cessation counseling. Beta-blockers, not a formal part of the ACC/AHA guidelines, were also a predictor of lower risk of both mortality and rehospitalization (odds ratio, 0.73; 95% CI, 0.55-0.96; P-0.02)

The OPTIMIZE-HF cohort analysis allowed for an opportunity to determine the degree of conformity for the ACC/AHA performance measures. The ACE inhibitors or ARB use at discharge was shown in the OPTIMIZE-HF cohort to have a relative reduction in one-year post discharge mortality by 17% (risk reduction, 0.83; 95% CI, 0.79-0.88) and a trend to lower 60- to 90-days post-discharge mortality and rehospitalization. Although smoking cessation had an early positive correlation, outcomes did not reach statistical significance. The measure of discharge instruction in the current study did not show a benefit on early mortality/rehospitalization in 60- to 90-days post discharge. It is unclear from this study if discharge instructions given to patients were either rushed or discussed in a comprehensive manner. This factor will need clarification and further research.

The measures of discharge instructions, smoking cessation, LV assessment, and anticoagulation for atrial fibrillation have not been examined as effective performance measures prior to this study. These measures were unable to show an independent decrease in 60- to 90-day mortality and rehospitalization.

Patients discharged with beta-blockers showed an association between lower mortality and rehospitalization. This association was found to be stronger than any of the formal ACC/AHA current performance measures.

The ACC/AHA guidelines are becoming standards of care for reporting to agencies such as Centers for Medicare and Medicaid Services or other P4P programs. To allow for improvement of quality, JCAHO and ACC/AHA designed the above criteria to act as a guide for the post discharge care of coronary heart failure patients. Because these criteria are the measures by which hospitals need to report, it will be necessary for data to show validity and a link between the clinical performance measures and improved outcomes.

Of the five measures stated, only ACE inhibitors/ARB at discharge was associated with a decrease in mortality/rehospitalization. Beta-blockers, currently not a performance measure, also showed this trend. Increased scrutiny needs to be part of the criteria for which hospitals and practitioners are being held accountable, and further research validating their effectiveness is warranted.

Risk Indexes for COPD

Niewoehner DE, Lockhnygina Y, Rice K, et al. Risk indexes for exacerbations and hospitalizations due to COPD. Chest. 2007 Jan;131(1):20-28.

Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality in the U.S. and continues to increase its numbers annually.

The cornerstone of COPD diagnosis and key predictor of prognosis is a low level of lung function. Another important predictor of morbidity, mortality, and progression of disease is COPD exacerbations.

Unfortunately, the definition of an exacerbation is varied, ranging from an increase in symptoms to COPD-related hospitalizations and death.1 Therefore, prevention of COPD exacerbations is an important management goal. This study focuses on setting a risk model as a clinical management tool, similar to what exists for cardiovascular events or community acquired pneumonia. No previous study has attempted to identify risk factors for exacerbations using prospective data collection and a clearly stated definition of exacerbation.

The study was a parallel-group, randomized, double-blind, placebo-controlled trial in patients with moderate to severe COPD conducted at 26 Veterans Affairs medical centers in the United States. Subjects were 40 or older, with a cigarette smoking history of 10 packs a year or more, a clinical diagnosis of COPD, and a forced expiratory volume [FEV] of 60% or less predicted and 70% or less of the forced vital capacity [FVC].1 Patients were allocated to receive one capsule of tiotropium (18 mg) or placebo for six months.

Of the 1,829 patients selected, 914 were assigned to the tiotropium arm. Patients kept a daily diary, and the investigators collected data by monthly telephone interviews and by site visits at three and six months with spirometry evaluation. They evaluated the association between baseline characteristics, concomitant medications and the study drug and the time to first COPD exacerbation and the time to first hospitalization due to exacerbation. The authors defined an exacerbation as a complex of respiratory symptoms of more than one of the following: cough, sputum, wheezing, dyspnea, or chest tightness with a duration of at least three days requiring treatment with antibiotics and/or systemic corticosteroids and/or hospital admission.

The investigators found that a statistically significant greater risk for both COPD exacerbations and hospitalizations is associated with being of older age, being a noncurrent smoker, having poorer lung function, using home oxygen, visiting the clinic or emergency department more often, either scheduled or unscheduled, being hospitalized for COPD in the prior year, using either antibiotics or systemic steroids for COPD more often in the prior year, and using short-acting beta agonist, inhaled or oral corticosteroid at a baseline rate.

On the other hand, a statistically significant greater risk of only COPD exacerbation was seen in white patients, with presence of productive cough, longer duration of COPD, use of long-acting beta agonist or theophylline at baseline, and presence of any gastrointestinal or hepatobiliary disease. Lower body-mass index and the presence of cardiovascular comorbidity were associated with statistically significant greater risk for only hospitalization due to COPD.

The investigators also confirmed the previous suggestion that chronic cough is an independent predictor of exacerbation. Interestingly, they found that any cardiovascular comorbidity is a strong and independent predictor of hospitalizations due to COPD. It is unclear if cardiovascular disease truly predisposes subjects to COPD hospitalizations or merely represents a misdiagnosis because both diseases have similar symptoms.

Current smokers were identified as having lower risk of exacerbation and hospitalization, probably due to the “healthy smoker” theory—that deteriorating lung function causes the patient to quit smoking.

This study is the first to gather information about predictors of COPD exacerbations in a prospective fashion using a clear definition of exacerbation. The authors developed a model to assess the risk of COPD exacerbations and hospitalizations due to exacerbations in patients with moderate to severe COPD. Moreover, this model can easily be applied to individual patients and reproduced with simple spirometry and a series of questions.

Though this trial had a reasonable level of statistical significance, it is important to mention that the trial was conducted within a single health system (Veterans Affairs medical centers), there were few women in the study, and the eligibility criteria were very specific.

References

1. Mannino DM, Watt G, Hole D, et al. The natural history of chronic obstructive pulmonary disease. Eur Respir J. 2006 Mar;27(3):627-643.

Glucose Management in Hospitalized Patients

Leahy JL. Insulin Management of diabetic patients on general medical and surgical floors. Endocr Pract. Jul/Aug 2006;12(Suppl3):86-89.

Although the rationale behind the science for tight control of blood sugar in subsets of hospitalized patient populations is without debate when it comes to the majority of general ward patients, the management of hyperglycemia becomes more of an art. Increasingly we recognize the effect of the relationship between improving glucose management and improving clinical outcomes.

Guidelines for inpatient targeted blood glucose levels exist, but hospitals are moving toward a more individualized approach to subcutaneous insulin protocols for their patients, thus moving beyond the passive sliding scale era.

Institution of an insulin protocol at one such hospital, the University of Vermont, highlights such an approach. The ongoing internal nonrandomized study exemplifies a two-tiered approach initially aimed at expanding the house physician comfort zone to change the culture of hyperglycemic management beyond simply avoiding hypoglycemia to one of an active and—per our current standards—aggressive individualized insulin protocol.

It seems the author envisions a gradual process allowing initial flexibility within the protocol, increasing the intensity of dosing as comfort zones expand. Throughout the process, the principles of determining a patient’s weight-based daily insulin needs are maintained, taking into consideration factors like comorbidities, severity of illness, amount of oral intake, steroid usage, and age. Then, the insulin regimen is physiologically (basal/bolus, basal, continuous) administered according to the route (i.e., total parenteral nutrition) and timing of their nutritional intake.

Adjustments being made to insulin regimens are based on fasting, pre-meal and bedtime glucose as well as the novel approach of bolus insulin after meals with short-acting insulin (i.e., lispro).

Unfortunately although the protocol does perhaps yield itself to being looked at more stringently—in terms of cost effectiveness, improved length of hospital stay, and improved clinical outcomes—the outcome studied here was primarily one of hospitalwide education in advancing the understanding and culture of aggressive individualized insulin protocols. These can often be even more statistically difficult to quantify. As self-reported, improve­­ments were made.

One of the most important aspects of this paper is that it draws attention to the paucity of evidence for improved clinical and monetary outcomes supporting the aggressive hospital management of hyperglycemia in the non-acutely ill patient. Often, the guiding principle is to avoid hypoglycemia. Detailing the specific protocols of one such approach serves as an example for the motivated reader.

Early Switch from IV to Oral Antibiotic in Severe CAP

Oosterheert JJ, Bonten JM, Schneider MME, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia; multicentre randomised trial. BMJ. 2006 Dec 9; 333:1193.

Community acquired pneumonia (CAP) is a common and potentially fatal infection with high healthcare costs. When patients are first admitted to hospitals, antibiotics are usually given intravenously to provide optimal concentrations in the tissues.

The duration of intravenous treatment is an important determinant of length of hospital stay (LOS). The concept of early transition from intravenous to oral antibiotic in the treatment of CAP has been evaluated before, but only in mild to moderately severe disease—and rarely in randomized trials.

This multicenter random controlled trial from five teaching hospitals and two medical centers in the Netherlands enrolled 302 patients in non-intensive care units with severe CAP. The primary outcome was clinical cure and secondary outcome was LOS. The inclusion criteria were adults 18 or older with severe CAP; mean pneumonia severity index of IV-V, new progressive infiltrate on chest X-ray, plus at least two other criteria (cough, sputum production, rectal temperature >38o C or <36.1o C, auscultative findings consistent with pneumonia, leukocytes >109 WBC/L or >15% bands, positive cultures of blob or pleural fluids, CRP three times greater times upper limit of normal).

Exclusion criteria included the need for mechanical ventilation, cystic fibrosis, a history of colonization with gram-negative bacteria due to structural damage to the respiratory tract, malfunction of the digestive tract, life expectancy of less than one month because of underlying disease, infections other than pneumonia that needed antibiotic treatment, and severe immunosuppression (neutropenia [<0.5 109 neutrophils/liter] or a CD4 count< 200/mm3).

Treatment failure was defined as death, still in hospital at day 28 of the study, or clinical deterioration (increase in temperature after initial improvement or the need for mechanical ventilation, switch back to intravenous antibiotics, or readmission for pulmonary reinfection after discharge).

Clinical cure was defined as discharged in good health without signs and symptoms of pneumonia and no treatment failure during follow-up.

The control group comprised 150 subjects who were to receive a standard course of seven days’ intravenous treatment. Meanwhile, 152 subjects were randomized to the early switch group. Baseline characteristics were similar in both groups. More than 80% of patients were in pneumonia severity class IV or V. Most patients received empirical monotherapy with amoxicillin or amoxicillin plus clavulanic acid (n=174; 58%) or a cephalosporin (n=59; 20%), which is in line with Dutch prescribing policies.

The most frequently identified microorganism was S pneumoniae (n=76; 25%). Atypical pathogens were detected in 33 patients (11%). Before day three, 37 patients (12%) were excluded from analysis, leaving 132 patients for analysis in the intervention group and 133 in the control group.

Reasons for exclusion included when the initial diagnosis of CAP was replaced by another diagnosis (n=9), consent was withdrawn (n=11), the protocol was violated (n=4), the patient was admitted to an intensive-care unit for mechanical ventilation (n=6), and the patient died (n=7). After three days of intravenous treatment, 108 of 132 patients (81%) in the intervention group were switched to oral treatment, of whom 102 (94%) received amoxicillin plus clavulanic acid (500+125 mg every eight hours).

In the control group, five patients did not receive intravenous antibiotics for all seven days because of phlebitis associated with intravenous treatment; none of them needed treatment for line-related sepsis. Overall duration of antibiotic treatment was 10.1 days in the intervention group and 9.3 days in the control group (mean difference 0.8 days, 95% confidence interval -0.6 to 2.0).

The duration of intravenous treatment was significantly shorter in the intervention group (mean 3.6 [SD 1.5] versus 7.0 [2.0] days, mean difference 3.4, 2.8 to 3.9). Average time to meet the discharge criteria was 5.2 (2.9) days in the intervention group and 5.7 (3.1) days in the control group (0.5 days -0.3 to 1.2) Total length of hospital stay was 9.6 (5.0) and 11.5 (4.9) days for patients in the intervention group and control group (1.9 days 0.6 to 3.2).

The authors’ findings provide strong evidence that early transition from intravenous to oral antibiotic is also viable in patients with highly graded Pneumonia Severity Index (PSI) CAP, not only in mild to moderately severe disease. This leads to reduced LOS, cost, and possibly reduced risk of line infections and increased patient satisfaction for early discharge.

Note: This study was done with patients suffering straightforward, uncomplicated CAP. The investigators’ findings cannot be applied to patients with other comorbidities like diabetes, COPD, heart failure, or sickle cell, which might require more days on intravenous antibiotic. One might also wonder what impact would have been seen had 37 patients not dropped off, and if another class of oral antibiotic such as quinolones had been used.

Last, the study sample showed S pneumoniae identified in 25% of cases and atypical pathogens to be 11%. What then are the majority of pathogens identified 64% of the time? This would have been another key factor that might have had a great effect on the result.

Although a larger sampling and further risk stratification (to include patients with other comorbidities) are needed, this study makes a valid point for early transition to oral antibiotics in highly graded, uncomplicated CAP. TH