Original Research

Peripherally inserted central catheters (PICCs) are among the most prevalent of venous access devices in hospitalized patients.[1, 2] Although growing use of these devices reflects clinical advantages, such as a reduced risk of complications during insertion and durable venous access, use of PICCs is also likely related to the growth of vascular access nursing.[3, 4] A relatively new specialty, vascular access nurses obtain, maintain, and manage venous access in hospitalized patients.[4, 5] Depending on their scope of practice, these professionals are responsible not only for insertion of devices, such as peripheral intravenous catheters and PICCs, but also nontunneled central venous catheters and arterial catheters in some settings.[6]

Although a growing number of US hospitals have introduced vascular nursing teams,[7] little is known about the experience, practice, knowledge, and beliefs of vascular access nurses. This knowledge gap is relevant for hospitalists and hospital medicine as (1) vascular access nurses increasingly represent a key partner in the care of hospitalized patients; (2) the knowledge and practice of these individuals directly affects patient safety and clinical outcomes; and (3) understanding experience, practice, and beliefs of these specialists can help inform decision making and quality‐improvement efforts related to PICCs. As hospitalists increasingly order the placement of and care for patients with PICCs, they are also well suited to improve PICC practice.

Therefore, we conducted a survey of vascular access nurses employed by hospitals that participate in the Michigan Hospital Medicine Safety (HMS) Consortium, a Blue Cross Blue Shield of Michiganfunded collaborative quality initiative.[6] We aimed to understand experience, practice, knowledge, and beliefs related to PICC care and use.

METHODS

RESULTS

Of 172 vascular nurses who received invitations, 140 completed the survey for a response rate of 81%. Respondents reported working in not‐for‐profit hospitals (36%), academic medical centers (29%), and for‐profit hospitals (21%). Although multiple providers (eg, interventional radiology staff and providers, physicians) placed PICCs, 95% of those surveyed reported that they placed the majority of the PICCs at their institutions. Although most respondents placed PICCs in adult patients (86%), a few also placed PICCs in pediatric populations (17%). Vascular nursing programs were largely housed in their own department, but some reported to general nursing or subspecialties such as interventional radiology, cardiology, and critical care. Most respondents indicated their facilities had written policies regarding standard insertion and care practices (87% and 95%, respectively), but only 30% had policies regarding the necessity or appropriateness of PICCs.

Experience among respondents was variable: approximately a third had placed PICCs for <5 years (28.6%), whereas 58% reported placing PICCs for 5 years Correspondingly, 26% reported having placed 100 to 500 PICCs, whereas 34% had placed 1000 or more PICCs. Only 23% of those surveyed held a dedicated vascular access certification, such as board certified in vascular access or certified registered nurse infusion, whereas 16% indicated that they served as the vascular access lead nurse for their facility. Following placement, 94% of respondents reported that their facilities tracked the number of PICCs inserted, but only 40% indicated that dwell times of devices were also recorded. Only 30% of nurses reported that their hospitals had a written policy to evaluate PICC necessity or appropriateness following placement (Table 1).

The most commonly reported indications for PICC placement included intravenous antibiotics at discharge, difficult venous access, and placement for chemotherapy in patients with cancer. Forty‐six percent of nurses indicated they had placed a PICC in a patient receiving some form of dialysis in the past several months; however, 91% of these respondents reported receiving approval from nephrology prior to placement in these patients. Although almost all nurses (91%) used ultrasound to find a suitable vein for PICC placement, a smaller percentage used ultrasound to estimate the catheter‐to‐vein ratio to prevent thrombosis (79%), and only a few (14%) documented this figure in the medical record. Three‐quarters of those surveyed (76%) indicated they used ECG‐based systems to position PICC tips at the cavoatrial junction to prevent thrombosis. Of those who used this technology, 36% still obtained chest x‐rays to verify the position of the PICC tip. According to 84% of respondents, flushing of PICCs was performed mainly by bedside nurses, whereas scheduled weekly dressing changes were most often performed by vascular access nurses (Table 2).

With respect to complications, catheter occlusion, migration, and DVT were reported as the 3 most prevalent adverse events. Interestingly, respondents did not report central lineassociated bloodstream infection (CLABSI) as a common complication. Additionally, 51% of those surveyed indicated that physicians unnecessarily removed PICCs when CLABSI was suspected but not confirmed. When managing catheter occlusion, 50% of respondents began with normal saline flushes but used tissue‐plasminogen activator if saline failed to resolve occlusion. Management of catheter migration varied based on degree of device movement: when the PICC had migrated <5 cm, most respondents (77%) indicated they would first obtain a chest x‐ray to determine the position of the PICC tip, with few (4%) performing catheter exchange. However, if the PICC had migrated more than 5 cm, a significantly greater proportion of respondents (21%) indicated they would perform a catheter exchange. With regard to managing DVT, most vascular nurses reported they notified nurses and physicians to continue using the PICC but recommended tests to confirm the diagnosis.

To better understand the experiences of vascular nurses, we asked for their perceptions regarding appropriateness of PICC use and relationships with bedside nurses, physicians, and leadership. Over a third of respondents (36%) felt that <5% of all PICCs may be inappropriate in their facility, whereas 1 in 5 indicated that 10% to 24% of PICCs placed in their facilities may be inappropriate or could have been avoided. Almost all (98%) of the nurses stated they were not empowered to remove idle or clinically unnecessary PICCs without physician authorization. Although 51% of nurses described the support received from hospital leadership as excellent, very good, or good, 43% described leadership support as either fair or poor. Conversely, relationships with bedside nurses and physicians were rated as being very good or good by nearly two‐thirds of those surveyed (64% and 65%, respectively) (Table 3).

DISCUSSION

In this survey of 140 vascular access nurses in hospitals across Michigan, new insights regarding the experience, practice, knowledge, and beliefs of this group of providers were obtained. We found that vascular access nurses varied with respect to years in practice, volume of PICCs placed, and certification status, reflecting heterogeneity in this provider group. Variation in insertion techniques, such as use of ultrasound to examine catheter‐to‐vein ratio (a key way to prevent thrombosis) or newer ECG technology to position the PICC, was also noted. Although indications for PICC insertion appeared consistent with published literature, the frequency with which these devices were placed in patients receiving dialysis (reportedly with nephrology approval) was surprising given national calls to avoid such use.[16] Opportunities to improve hospital practices, such as tracking PICC dwell times and PICC necessity, as well as the potential need to better educate physicians on when to remove PICCs for suspected CLABSI, were also identified. Collectively, these data are highly relevant to hospitalists and health systems as they help to identify areas for quality improvement and inform clinical practice regarding the use of PICCs in hospitalized patients. As hospitalists increasingly order PICCs and manage complications associated with these devices, they are well suited to use these data so as to improve patient safety and clinical outcomes.

Venous access is the most common medical procedure performed in hospitalized medical patients. Although a number of devices including peripheral intravenous catheters, central venous catheters, and PICCs are used for this purpose, the growing use of PICCs to secure venous access has been documented in several studies.[17] Such growth, in part, undoubtedly reflects increasing availability of vascular access nurses. Traditionally placed by interventional radiologists, the creation of dedicated vascular nursing teams has resulted in these subspecialists now serving in more of a backup or trouble‐shooting role rather than that of primary operator.[4, 14] This paradigm shift is well illustrated in a recent survey of infection preventionists, where over 60% of respondents reported that they had a vascular nursing team in their facility.[7] The growth of these nursing‐led vascular access teams has produced not only high rates of insertion success and low rates of complications, but also greater cost‐effectiveness when compared to interventional radiologybased insertion.[18]

Nonetheless, our survey also identified a number of important concerns regarding PICC practices and vascular nursing providers. First, we found variation in areas such as insertion practices and management of complications. Such variability highlights the importance of both growing and disseminating the evidence base for consistent practice in vascular nursing. Through their close clinical affiliation with vascular nurses and shared interests in obtaining safe and appropriate venous access for patients, hospitalists are ideally poised to lead this effort. Second, similarities between vascular nurse opinions regarding appropriateness of PICCs and those of hospitalists from a prior survey were noted.[19] Namely, a substantial proportion of both vascular nurses and hospitalists felt that some PICCs were inappropriate and could be avoided. Third, although relationships between vascular access nurses and leadership were reported as being variable, the survey responses suggested relatively good interprovider relationships with bedside nurses and physicians. Such relationships likely reflect the close clinical ties that emerge from being in the trenches of patient care and suggest that interventions to improve care in partnership with these providers are highly viable.

Our study has some limitations. First, despite a high response rate, our study used a survey design and reports findings from a convenience sample of vascular access nurses in a single state. Thus, nonrespondent and selection biases remain threats to our conclusions. Additionally, some respondents did not complete all responses, perhaps due to nonapplicability to practice or other unknown reasons. The pattern of missingness observed, however, suggested that such responses were missing at random. Second, we surveyed vascular nurses in hospitals that are actively engaged in improving PICC practices; our findings may therefore not be representative of vascular nursing professionals as a whole and may instead reflect those of a highly motivated group of individuals. Relatedly, the underlying reasons for adoption of specific practices or techniques cannot be discerned from our study. Third, although we did not find differences based on years in practice or certification status, our sample size was relatively small and likely underpowered for these comparisons. Finally, our study sample consists of vascular nurses who are clustered within hospitals in which they are employed. Therefore, overlap between reported practices and those required by the facility are possible.

Despite these limitations, our study has important strengths. First, this is among the most comprehensive of surveys examining vascular nursing experience, practice, knowledge, and beliefs. The growing presence of these providers across US hospitals, coupled with limited insight regarding their clinical practices, highlight the importance and utility of these data. Second, we noted important differences in experience, practices, and interprovider relationships between vascular providers in this field. Although we are unable to ascertain the drivers or significance of such variation, hospitals and health systems focused on improving patient safety should consider quantifying and exploring these factors. Third, findings from our survey within Michigan suggest the need for similar, larger studies across the country. Partnerships with nursing organizations or larger professional groups that represent vascular nursing specialists may be helpful in this regard.

In conclusion, we found important similarities and differences in vascular nursing experience, practice, knowledge, and beliefs in Michigan. These data are useful as they help provide context regarding the constitution of these teams, current practices, and opportunities for improving care. Hospitalists seeking to improve patient safety may use these data to better inform vascular access practice in hospitalized patients.

Peripherally inserted central catheters (PICCs) are among the most prevalent of venous access devices in hospitalized patients.[1, 2] Although growing use of these devices reflects clinical advantages, such as a reduced risk of complications during insertion and durable venous access, use of PICCs is also likely related to the growth of vascular access nursing.[3, 4] A relatively new specialty, vascular access nurses obtain, maintain, and manage venous access in hospitalized patients.[4, 5] Depending on their scope of practice, these professionals are responsible not only for insertion of devices, such as peripheral intravenous catheters and PICCs, but also nontunneled central venous catheters and arterial catheters in some settings.[6]

Although a growing number of US hospitals have introduced vascular nursing teams,[7] little is known about the experience, practice, knowledge, and beliefs of vascular access nurses. This knowledge gap is relevant for hospitalists and hospital medicine as (1) vascular access nurses increasingly represent a key partner in the care of hospitalized patients; (2) the knowledge and practice of these individuals directly affects patient safety and clinical outcomes; and (3) understanding experience, practice, and beliefs of these specialists can help inform decision making and quality‐improvement efforts related to PICCs. As hospitalists increasingly order the placement of and care for patients with PICCs, they are also well suited to improve PICC practice.

Therefore, we conducted a survey of vascular access nurses employed by hospitals that participate in the Michigan Hospital Medicine Safety (HMS) Consortium, a Blue Cross Blue Shield of Michiganfunded collaborative quality initiative.[6] We aimed to understand experience, practice, knowledge, and beliefs related to PICC care and use.

METHODS

RESULTS

Of 172 vascular nurses who received invitations, 140 completed the survey for a response rate of 81%. Respondents reported working in not‐for‐profit hospitals (36%), academic medical centers (29%), and for‐profit hospitals (21%). Although multiple providers (eg, interventional radiology staff and providers, physicians) placed PICCs, 95% of those surveyed reported that they placed the majority of the PICCs at their institutions. Although most respondents placed PICCs in adult patients (86%), a few also placed PICCs in pediatric populations (17%). Vascular nursing programs were largely housed in their own department, but some reported to general nursing or subspecialties such as interventional radiology, cardiology, and critical care. Most respondents indicated their facilities had written policies regarding standard insertion and care practices (87% and 95%, respectively), but only 30% had policies regarding the necessity or appropriateness of PICCs.

Experience among respondents was variable: approximately a third had placed PICCs for <5 years (28.6%), whereas 58% reported placing PICCs for 5 years Correspondingly, 26% reported having placed 100 to 500 PICCs, whereas 34% had placed 1000 or more PICCs. Only 23% of those surveyed held a dedicated vascular access certification, such as board certified in vascular access or certified registered nurse infusion, whereas 16% indicated that they served as the vascular access lead nurse for their facility. Following placement, 94% of respondents reported that their facilities tracked the number of PICCs inserted, but only 40% indicated that dwell times of devices were also recorded. Only 30% of nurses reported that their hospitals had a written policy to evaluate PICC necessity or appropriateness following placement (Table 1).

The most commonly reported indications for PICC placement included intravenous antibiotics at discharge, difficult venous access, and placement for chemotherapy in patients with cancer. Forty‐six percent of nurses indicated they had placed a PICC in a patient receiving some form of dialysis in the past several months; however, 91% of these respondents reported receiving approval from nephrology prior to placement in these patients. Although almost all nurses (91%) used ultrasound to find a suitable vein for PICC placement, a smaller percentage used ultrasound to estimate the catheter‐to‐vein ratio to prevent thrombosis (79%), and only a few (14%) documented this figure in the medical record. Three‐quarters of those surveyed (76%) indicated they used ECG‐based systems to position PICC tips at the cavoatrial junction to prevent thrombosis. Of those who used this technology, 36% still obtained chest x‐rays to verify the position of the PICC tip. According to 84% of respondents, flushing of PICCs was performed mainly by bedside nurses, whereas scheduled weekly dressing changes were most often performed by vascular access nurses (Table 2).

With respect to complications, catheter occlusion, migration, and DVT were reported as the 3 most prevalent adverse events. Interestingly, respondents did not report central lineassociated bloodstream infection (CLABSI) as a common complication. Additionally, 51% of those surveyed indicated that physicians unnecessarily removed PICCs when CLABSI was suspected but not confirmed. When managing catheter occlusion, 50% of respondents began with normal saline flushes but used tissue‐plasminogen activator if saline failed to resolve occlusion. Management of catheter migration varied based on degree of device movement: when the PICC had migrated <5 cm, most respondents (77%) indicated they would first obtain a chest x‐ray to determine the position of the PICC tip, with few (4%) performing catheter exchange. However, if the PICC had migrated more than 5 cm, a significantly greater proportion of respondents (21%) indicated they would perform a catheter exchange. With regard to managing DVT, most vascular nurses reported they notified nurses and physicians to continue using the PICC but recommended tests to confirm the diagnosis.

To better understand the experiences of vascular nurses, we asked for their perceptions regarding appropriateness of PICC use and relationships with bedside nurses, physicians, and leadership. Over a third of respondents (36%) felt that <5% of all PICCs may be inappropriate in their facility, whereas 1 in 5 indicated that 10% to 24% of PICCs placed in their facilities may be inappropriate or could have been avoided. Almost all (98%) of the nurses stated they were not empowered to remove idle or clinically unnecessary PICCs without physician authorization. Although 51% of nurses described the support received from hospital leadership as excellent, very good, or good, 43% described leadership support as either fair or poor. Conversely, relationships with bedside nurses and physicians were rated as being very good or good by nearly two‐thirds of those surveyed (64% and 65%, respectively) (Table 3).

DISCUSSION

In this survey of 140 vascular access nurses in hospitals across Michigan, new insights regarding the experience, practice, knowledge, and beliefs of this group of providers were obtained. We found that vascular access nurses varied with respect to years in practice, volume of PICCs placed, and certification status, reflecting heterogeneity in this provider group. Variation in insertion techniques, such as use of ultrasound to examine catheter‐to‐vein ratio (a key way to prevent thrombosis) or newer ECG technology to position the PICC, was also noted. Although indications for PICC insertion appeared consistent with published literature, the frequency with which these devices were placed in patients receiving dialysis (reportedly with nephrology approval) was surprising given national calls to avoid such use.[16] Opportunities to improve hospital practices, such as tracking PICC dwell times and PICC necessity, as well as the potential need to better educate physicians on when to remove PICCs for suspected CLABSI, were also identified. Collectively, these data are highly relevant to hospitalists and health systems as they help to identify areas for quality improvement and inform clinical practice regarding the use of PICCs in hospitalized patients. As hospitalists increasingly order PICCs and manage complications associated with these devices, they are well suited to use these data so as to improve patient safety and clinical outcomes.

Venous access is the most common medical procedure performed in hospitalized medical patients. Although a number of devices including peripheral intravenous catheters, central venous catheters, and PICCs are used for this purpose, the growing use of PICCs to secure venous access has been documented in several studies.[17] Such growth, in part, undoubtedly reflects increasing availability of vascular access nurses. Traditionally placed by interventional radiologists, the creation of dedicated vascular nursing teams has resulted in these subspecialists now serving in more of a backup or trouble‐shooting role rather than that of primary operator.[4, 14] This paradigm shift is well illustrated in a recent survey of infection preventionists, where over 60% of respondents reported that they had a vascular nursing team in their facility.[7] The growth of these nursing‐led vascular access teams has produced not only high rates of insertion success and low rates of complications, but also greater cost‐effectiveness when compared to interventional radiologybased insertion.[18]

Nonetheless, our survey also identified a number of important concerns regarding PICC practices and vascular nursing providers. First, we found variation in areas such as insertion practices and management of complications. Such variability highlights the importance of both growing and disseminating the evidence base for consistent practice in vascular nursing. Through their close clinical affiliation with vascular nurses and shared interests in obtaining safe and appropriate venous access for patients, hospitalists are ideally poised to lead this effort. Second, similarities between vascular nurse opinions regarding appropriateness of PICCs and those of hospitalists from a prior survey were noted.[19] Namely, a substantial proportion of both vascular nurses and hospitalists felt that some PICCs were inappropriate and could be avoided. Third, although relationships between vascular access nurses and leadership were reported as being variable, the survey responses suggested relatively good interprovider relationships with bedside nurses and physicians. Such relationships likely reflect the close clinical ties that emerge from being in the trenches of patient care and suggest that interventions to improve care in partnership with these providers are highly viable.

Our study has some limitations. First, despite a high response rate, our study used a survey design and reports findings from a convenience sample of vascular access nurses in a single state. Thus, nonrespondent and selection biases remain threats to our conclusions. Additionally, some respondents did not complete all responses, perhaps due to nonapplicability to practice or other unknown reasons. The pattern of missingness observed, however, suggested that such responses were missing at random. Second, we surveyed vascular nurses in hospitals that are actively engaged in improving PICC practices; our findings may therefore not be representative of vascular nursing professionals as a whole and may instead reflect those of a highly motivated group of individuals. Relatedly, the underlying reasons for adoption of specific practices or techniques cannot be discerned from our study. Third, although we did not find differences based on years in practice or certification status, our sample size was relatively small and likely underpowered for these comparisons. Finally, our study sample consists of vascular nurses who are clustered within hospitals in which they are employed. Therefore, overlap between reported practices and those required by the facility are possible.

Despite these limitations, our study has important strengths. First, this is among the most comprehensive of surveys examining vascular nursing experience, practice, knowledge, and beliefs. The growing presence of these providers across US hospitals, coupled with limited insight regarding their clinical practices, highlight the importance and utility of these data. Second, we noted important differences in experience, practices, and interprovider relationships between vascular providers in this field. Although we are unable to ascertain the drivers or significance of such variation, hospitals and health systems focused on improving patient safety should consider quantifying and exploring these factors. Third, findings from our survey within Michigan suggest the need for similar, larger studies across the country. Partnerships with nursing organizations or larger professional groups that represent vascular nursing specialists may be helpful in this regard.

In conclusion, we found important similarities and differences in vascular nursing experience, practice, knowledge, and beliefs in Michigan. These data are useful as they help provide context regarding the constitution of these teams, current practices, and opportunities for improving care. Hospitalists seeking to improve patient safety may use these data to better inform vascular access practice in hospitalized patients.

Peripherally inserted central catheters (PICCs) are among the most prevalent of venous access devices in hospitalized patients.[1, 2] Although growing use of these devices reflects clinical advantages, such as a reduced risk of complications during insertion and durable venous access, use of PICCs is also likely related to the growth of vascular access nursing.[3, 4] A relatively new specialty, vascular access nurses obtain, maintain, and manage venous access in hospitalized patients.[4, 5] Depending on their scope of practice, these professionals are responsible not only for insertion of devices, such as peripheral intravenous catheters and PICCs, but also nontunneled central venous catheters and arterial catheters in some settings.[6]

Although a growing number of US hospitals have introduced vascular nursing teams,[7] little is known about the experience, practice, knowledge, and beliefs of vascular access nurses. This knowledge gap is relevant for hospitalists and hospital medicine as (1) vascular access nurses increasingly represent a key partner in the care of hospitalized patients; (2) the knowledge and practice of these individuals directly affects patient safety and clinical outcomes; and (3) understanding experience, practice, and beliefs of these specialists can help inform decision making and quality‐improvement efforts related to PICCs. As hospitalists increasingly order the placement of and care for patients with PICCs, they are also well suited to improve PICC practice.

Therefore, we conducted a survey of vascular access nurses employed by hospitals that participate in the Michigan Hospital Medicine Safety (HMS) Consortium, a Blue Cross Blue Shield of Michiganfunded collaborative quality initiative.[6] We aimed to understand experience, practice, knowledge, and beliefs related to PICC care and use.

METHODS

RESULTS

Of 172 vascular nurses who received invitations, 140 completed the survey for a response rate of 81%. Respondents reported working in not‐for‐profit hospitals (36%), academic medical centers (29%), and for‐profit hospitals (21%). Although multiple providers (eg, interventional radiology staff and providers, physicians) placed PICCs, 95% of those surveyed reported that they placed the majority of the PICCs at their institutions. Although most respondents placed PICCs in adult patients (86%), a few also placed PICCs in pediatric populations (17%). Vascular nursing programs were largely housed in their own department, but some reported to general nursing or subspecialties such as interventional radiology, cardiology, and critical care. Most respondents indicated their facilities had written policies regarding standard insertion and care practices (87% and 95%, respectively), but only 30% had policies regarding the necessity or appropriateness of PICCs.

Experience among respondents was variable: approximately a third had placed PICCs for <5 years (28.6%), whereas 58% reported placing PICCs for 5 years Correspondingly, 26% reported having placed 100 to 500 PICCs, whereas 34% had placed 1000 or more PICCs. Only 23% of those surveyed held a dedicated vascular access certification, such as board certified in vascular access or certified registered nurse infusion, whereas 16% indicated that they served as the vascular access lead nurse for their facility. Following placement, 94% of respondents reported that their facilities tracked the number of PICCs inserted, but only 40% indicated that dwell times of devices were also recorded. Only 30% of nurses reported that their hospitals had a written policy to evaluate PICC necessity or appropriateness following placement (Table 1).

The most commonly reported indications for PICC placement included intravenous antibiotics at discharge, difficult venous access, and placement for chemotherapy in patients with cancer. Forty‐six percent of nurses indicated they had placed a PICC in a patient receiving some form of dialysis in the past several months; however, 91% of these respondents reported receiving approval from nephrology prior to placement in these patients. Although almost all nurses (91%) used ultrasound to find a suitable vein for PICC placement, a smaller percentage used ultrasound to estimate the catheter‐to‐vein ratio to prevent thrombosis (79%), and only a few (14%) documented this figure in the medical record. Three‐quarters of those surveyed (76%) indicated they used ECG‐based systems to position PICC tips at the cavoatrial junction to prevent thrombosis. Of those who used this technology, 36% still obtained chest x‐rays to verify the position of the PICC tip. According to 84% of respondents, flushing of PICCs was performed mainly by bedside nurses, whereas scheduled weekly dressing changes were most often performed by vascular access nurses (Table 2).

With respect to complications, catheter occlusion, migration, and DVT were reported as the 3 most prevalent adverse events. Interestingly, respondents did not report central lineassociated bloodstream infection (CLABSI) as a common complication. Additionally, 51% of those surveyed indicated that physicians unnecessarily removed PICCs when CLABSI was suspected but not confirmed. When managing catheter occlusion, 50% of respondents began with normal saline flushes but used tissue‐plasminogen activator if saline failed to resolve occlusion. Management of catheter migration varied based on degree of device movement: when the PICC had migrated <5 cm, most respondents (77%) indicated they would first obtain a chest x‐ray to determine the position of the PICC tip, with few (4%) performing catheter exchange. However, if the PICC had migrated more than 5 cm, a significantly greater proportion of respondents (21%) indicated they would perform a catheter exchange. With regard to managing DVT, most vascular nurses reported they notified nurses and physicians to continue using the PICC but recommended tests to confirm the diagnosis.

To better understand the experiences of vascular nurses, we asked for their perceptions regarding appropriateness of PICC use and relationships with bedside nurses, physicians, and leadership. Over a third of respondents (36%) felt that <5% of all PICCs may be inappropriate in their facility, whereas 1 in 5 indicated that 10% to 24% of PICCs placed in their facilities may be inappropriate or could have been avoided. Almost all (98%) of the nurses stated they were not empowered to remove idle or clinically unnecessary PICCs without physician authorization. Although 51% of nurses described the support received from hospital leadership as excellent, very good, or good, 43% described leadership support as either fair or poor. Conversely, relationships with bedside nurses and physicians were rated as being very good or good by nearly two‐thirds of those surveyed (64% and 65%, respectively) (Table 3).

DISCUSSION

In this survey of 140 vascular access nurses in hospitals across Michigan, new insights regarding the experience, practice, knowledge, and beliefs of this group of providers were obtained. We found that vascular access nurses varied with respect to years in practice, volume of PICCs placed, and certification status, reflecting heterogeneity in this provider group. Variation in insertion techniques, such as use of ultrasound to examine catheter‐to‐vein ratio (a key way to prevent thrombosis) or newer ECG technology to position the PICC, was also noted. Although indications for PICC insertion appeared consistent with published literature, the frequency with which these devices were placed in patients receiving dialysis (reportedly with nephrology approval) was surprising given national calls to avoid such use.[16] Opportunities to improve hospital practices, such as tracking PICC dwell times and PICC necessity, as well as the potential need to better educate physicians on when to remove PICCs for suspected CLABSI, were also identified. Collectively, these data are highly relevant to hospitalists and health systems as they help to identify areas for quality improvement and inform clinical practice regarding the use of PICCs in hospitalized patients. As hospitalists increasingly order PICCs and manage complications associated with these devices, they are well suited to use these data so as to improve patient safety and clinical outcomes.

Venous access is the most common medical procedure performed in hospitalized medical patients. Although a number of devices including peripheral intravenous catheters, central venous catheters, and PICCs are used for this purpose, the growing use of PICCs to secure venous access has been documented in several studies.[17] Such growth, in part, undoubtedly reflects increasing availability of vascular access nurses. Traditionally placed by interventional radiologists, the creation of dedicated vascular nursing teams has resulted in these subspecialists now serving in more of a backup or trouble‐shooting role rather than that of primary operator.[4, 14] This paradigm shift is well illustrated in a recent survey of infection preventionists, where over 60% of respondents reported that they had a vascular nursing team in their facility.[7] The growth of these nursing‐led vascular access teams has produced not only high rates of insertion success and low rates of complications, but also greater cost‐effectiveness when compared to interventional radiologybased insertion.[18]

Nonetheless, our survey also identified a number of important concerns regarding PICC practices and vascular nursing providers. First, we found variation in areas such as insertion practices and management of complications. Such variability highlights the importance of both growing and disseminating the evidence base for consistent practice in vascular nursing. Through their close clinical affiliation with vascular nurses and shared interests in obtaining safe and appropriate venous access for patients, hospitalists are ideally poised to lead this effort. Second, similarities between vascular nurse opinions regarding appropriateness of PICCs and those of hospitalists from a prior survey were noted.[19] Namely, a substantial proportion of both vascular nurses and hospitalists felt that some PICCs were inappropriate and could be avoided. Third, although relationships between vascular access nurses and leadership were reported as being variable, the survey responses suggested relatively good interprovider relationships with bedside nurses and physicians. Such relationships likely reflect the close clinical ties that emerge from being in the trenches of patient care and suggest that interventions to improve care in partnership with these providers are highly viable.

Our study has some limitations. First, despite a high response rate, our study used a survey design and reports findings from a convenience sample of vascular access nurses in a single state. Thus, nonrespondent and selection biases remain threats to our conclusions. Additionally, some respondents did not complete all responses, perhaps due to nonapplicability to practice or other unknown reasons. The pattern of missingness observed, however, suggested that such responses were missing at random. Second, we surveyed vascular nurses in hospitals that are actively engaged in improving PICC practices; our findings may therefore not be representative of vascular nursing professionals as a whole and may instead reflect those of a highly motivated group of individuals. Relatedly, the underlying reasons for adoption of specific practices or techniques cannot be discerned from our study. Third, although we did not find differences based on years in practice or certification status, our sample size was relatively small and likely underpowered for these comparisons. Finally, our study sample consists of vascular nurses who are clustered within hospitals in which they are employed. Therefore, overlap between reported practices and those required by the facility are possible.

Despite these limitations, our study has important strengths. First, this is among the most comprehensive of surveys examining vascular nursing experience, practice, knowledge, and beliefs. The growing presence of these providers across US hospitals, coupled with limited insight regarding their clinical practices, highlight the importance and utility of these data. Second, we noted important differences in experience, practices, and interprovider relationships between vascular providers in this field. Although we are unable to ascertain the drivers or significance of such variation, hospitals and health systems focused on improving patient safety should consider quantifying and exploring these factors. Third, findings from our survey within Michigan suggest the need for similar, larger studies across the country. Partnerships with nursing organizations or larger professional groups that represent vascular nursing specialists may be helpful in this regard.

In conclusion, we found important similarities and differences in vascular nursing experience, practice, knowledge, and beliefs in Michigan. These data are useful as they help provide context regarding the constitution of these teams, current practices, and opportunities for improving care. Hospitalists seeking to improve patient safety may use these data to better inform vascular access practice in hospitalized patients.

Readmissions within a relatively short time after discharge are receiving considerable attention as an area of quality improvement,[1, 2] with increasing emphasis on the relatively large share of readmissions to different hospitals, accounting for 20% to 30% of all readmissions.[3, 4, 5, 6] Returning to a different hospital may affect patient and healthcare outcomes due to breaches in continuity. When information from the previous recent hospitalization is not transferred efficiently and accurately to the next admitting hospital, omissions and duplications can occur, resulting in delayed care and potentially worse outcomes (compared to same hospital readmissions [SHRs]), such as longer length of readmission stay (LORS) and increased costs.[7]

Electronic health records (EHRs) and health information exchange (HIE) systems are increasingly used for storage and retrieval of patient information from various sources, such as laboratories and previous physician visits and hospitalizations, enabling informational continuity by providing vital historical medical information for decision‐making. Whereas EHRs collect, store, and present information that is locally created within a specific clinic or hospital, HIEs connect EHR systems between multiple institutions, allowing providers to share clinical data and achieve interorganizational continuity. Such integrative systems are increasingly being implemented across healthcare systems worldwide.[8, 9, 10] Yet, technical difficulties, costs, competitive concerns, data privacy, and workflow implementation challenges have been described as hindering HIE participation.[11, 12, 13, 14] Moreover, major concerns exist regarding the poor usability of EHRs, their limited ability to support multidisciplinary care, and major difficulties in achieving interoperability with HIEs, which undermine efforts to deliver integrated patient‐centered care.[15] Nonetheless, previous research has demonstrated that HIEs can positively affect healthcare resource use and outcomes, including reduced rates of repeated diagnostic imaging in the emergency evaluation of back pain,[16] reduction in admissions via the emergency department (ED),[17] and reduced rates of readmissions within 7 days.[18] However, it is not known whether HIEs can contribute to positive outcomes when patients are readmitted to a different hospital than the hospital from which they were recently (within the previous 30 days) discharged, potentially bridging the transitional‐care information divide.

In Israel, an innovative HIE system, OFEK (literally horizon), was implemented in 2005 at the largest not‐for‐profit insurer and provider of services, Clalit Health Services (Clalit). Clalit operates as an integrated healthcare delivery system, serving more than 50% of the Israeli population, as part of the country's national health insurance system. OFEK links information on all Clalit enrollees from all hospitals, primary care, and specialty care clinics, laboratories, and diagnostic services into a single, virtual, patient file, enabling providers to obtain complete, real‐time information needed for healthcare decision making at the point of care. Like similar HIE systems, OFEK includes information on previous medical encounters and hospitalizations, previous diagnoses, chronically prescribed medications, previous lab and imaging tests, known allergies, and some demographic information.[19] At the time of this study, OFEK was available in all Clalit hospitals as well as in 2 non‐Clalit (government‐owned and operated) large tertiary‐care centers, resulting in 40% coverage of all hospitalizations through the OFEK HIE system. As part of a large organization‐wide readmission reduction program recently implemented by Clalit for all its members admitted to any hospital in Israel, aimed at early detection and intervention,[20] OFEK was viewed as an important mechanism to help maintain continuity and improve transitions.

To inform current knowledge on different‐hospital readmissions (DHRs) and HIEs, we examined whether having HIE systems can contribute to information continuity and prevent delays in care and the need for more expensive, lengthy readmission stays when patients are readmitted to a different hospital. More specifically, we tested whether there is a difference in the LORS between SHRs and DHRs, and whether DHRs the LORS differ by the availability of an HIE (whether index and readmitting hospital are or are not connected through HIE systems).

METHODS

RESULTS

The study included a total of 27,057 readmissions, of which 23,927 (88.4%) were SHRs and 3130 (11.6%) were DHRs. Of all DHRs, in 792 (2.9%) of the cases, both hospitals had HIEs (partial information continuity), and in 2338 (8.6%), either 1 or both did not have an HIE system (thus meaning there was no information continuity). Characteristics of the study population are shown in Table 1. Most (75%) of the readmissions were of patients over the age of 65 years, though only 7% were nursing home residents. More than half the study's population consisted of patients with low SES. The most common chronic conditions were hypertension (77%), ischemic heart disease (52%), and diabetes (48%). Other chronic conditions were arrhythmia (38%), CHF (35%), disability (31%), COPD (28%), malignancy (28%), and asthma (16%). In more than 55% of the index hospitalizations, the LOS was 4 days or less, and most index admissions (64%) were in large hospitals. Table 1 also displays the study population by the type of readmission: SHR, DHR with HIE, and DHR without HIE. As compared to patients readmitted to the same hospital, patients with DHRs were younger (P < 0.001), less likely to be nursing home residents (P < 0.001), and had longer LOS during the index admission (P < 0.001). Additionally, patients with SHRs were more likely to have their index admission at a large hospital (P < 0.001), had a higher comorbidity score (P < 0.043), and were less likely be treated in the ICU during their readmission (P < 0.001) compared to their DHR counterparts. Patients with DHRs without an HIE were similar in most characteristics to those with an HIE, except for having an ICU stay during their readmission (6.4% compared with 9.2%, respectively).

The mean LORS in SHRs was shorter by 1 day than the mean LORS for DHRs: 6.3 (95% confidence interval [CI]: 6.2‐6.4) versus 7.3 (95% CI: 7.0‐7.6), respectively. Mean LORS in DHRs with or without HIE was 7.6 (95% CI: 7.0‐8.3) and 7.2 (95% CI: 6.8‐7.6), respectively. Although median LORS was similar (4 days), the IQR differed, resulting in significant differences between the SHR and DHR groups (Table 2).

In the multivariate model, partial continuity (DHRs with an HIE) was associated with decreased likelihood of discharge on any given day compared with full continuity (SHR) (hazard ratio [HR] = 0.85, 95% CI: 0.79‐0.91). Similar results were obtained for no continuity (DHRs without an HIE) (HR = 0.90, 95% CI: 0.86‐0.94). The difference between DHRs with and without an HIE was not significant (overlapping confidence intervals). Other factors associated with a lower HR for discharge during each day of the readmission were older age, residency in a nursing home, CHF, CRF, disability, malignancy, and long LOS (8+ days) during the index hospitalization. Patients with asthma or ischemic heart disease had a higher HR for discharge during each readmission day (Table 3). We performed a sensitivity analysis using hierarchical modeling (patients nested within hospitals), which resulted in similar findings in terms of directionality and magnitude of the relationships and significance levels.

DISCUSSION

This study shows that readmission to a different hospital results in longer duration of the readmission stay compared with readmission to the same index hospital. Our results also show that having HIE systems in both the index and readmitting hospitals does not protect against these negative outcomes, as there was no difference in the length of the readmission stay based on the availability of HIE systems. Factors that were found to be associated with longer readmission stays are well known indicators of the complexity of the patient's medical condition, such as the presence of disability, comorbidity, and ICU treatment during the readmission.[24, 27]

The shorter LORS in SHRs may be due to the familiarity of physicians and other healthcare providers with the patient and his or her condition, especially as the policy in SHRs in Israel is to readmit to the same unit from which the patient was recently discharged. This same hospital familiarity is especially important as hospital care in Israel follows the hospitalist model, in which responsibility for patient care is transferred from the patient's primary care physician to the hospital's physician, resulting in increased need for integration through HIE systems, especially when patients are readmitted to a different hospital.[28, 29]

Our findings, congruent with previous research on DHRs and poor outcomes,[7] could also be explained by the inefficiency associated with transitions. For example, patients frequently leave the hospital with pending lab tests, often with abnormal results that would change the course of care.[30] Because these pending tests are often omitted from the hospital discharge summaries,[31] if patients are hospitalized in a different hospital, the same tests may be ordered again, or a course of treatment that does not acknowledge the test results could be taken. Such time‐consuming duplication can be prevented in SHRs, where the index‐hospital records may be already more complete.

Our null findings regarding the contribution of HIE systems may be explained by the low levels of HIE actual use. Although we did not directly assess use, previous research reports that actual use of HIE is limited.[12] An Israeli study on the effects of the use of the OFEK system on ED physicians' admission decisions found that the patient's medical history was viewed in only 31.2% of all 281,750 ED referrals.[19] In another Israeli‐based ED study, even lower usage levels were found, with the OFEK system having been accessed in only 16% of all 3,219,910 ED referrals.[32] Low levels of HIE use have also been reported in the United States. An additional study, which tested the implementation of HIE in hospitals and clinics, showed that in only 2.3% of encounters did providers access the HIE record.[33] Another study conducted in 12 ED sites and 2 ambulatory clinics reported rates of 6.8% HIE use.[34] Moreover, the null effect of integrated health information reported here is congruent with findings from a US study on implementation of an electronic discharge instructions form with embedded computerized medication reconciliation, which was not found to be associated with postdischarge outcomes.[35]

A wide range of factors may influence decisions on HIE use: patient‐level factors,[36] perceived medical complexity of the patient,[33, 34] and the number of prior hospitalizations.[33, 34, 36] Healthcare systemlevel factors may include: time constraints, which may be positively[32] or negatively[33] associated with HIE use, and organizational policies or incentives.[33] Use may also be associated with features of the HIE technology itself, such as difficulty to access, difficulty to use once accessed, and the quality of information it contains.[37] Additionally, there is some evidence of the link between tight functional integration and higher proportions of usage.[38] Although comprehensive studies on factors affecting the use of the OFEK system in Israeli internal medicine units are still needed, the lack of its integration within each hospital's EHR system may serve as a major explanatory factor for the low usage levels.

The findings from this study should be interpreted in light of its limitations. First, compared with previously reported DHR rates (20%30%),[3, 5] the rate observed in our population was relatively low (about 12%). Previous research was restricted to heart failure patients[3] or assessed DHR in surgical, as well as internal medicine, patients.[5] Our lower rates may have been affected by the type of population (hospitalized internal medicine patients) and/or by characteristics of the Clalit healthcare system, which serves as an integrated provider network as well as insurer. Generalization from 1 health care system to others should be made with caution. Nonetheless, our results may underestimate the potential effect in other healthcare systems with less structural integration. Additionally, as noted above, information on the actual use of an HIE in the course of medical decision making during readmission was absent. Future studies should examine the potential benefit of an HIE with measures that capture providers' use of HIEs. Also, the LORS may be influenced by other factors not investigated here, and further future studies should examine additional outcomes such as costs, patient well‐being, and satisfaction. Finally, causality could not be determined, and future research in this realm should aim to search for the pathways connecting readmission to a different hospital, with and without HIEs, to readmission LOS and additional outcomes.

To conclude, our findings show that patients readmitted to a different hospital are at risk for prolonged LORS, regardless of the availability of HIE systems. Implementing HIE systems is the focus of substantial efforts by policymakers and is considered a key part of the meaningful use of electronic health information. HIE features in the provisions of the Health Information Technology for Economic and Clinical Health Act[39] because it can furnish providers with complete, timely information at the point of care. Moreover, although there has been substantial growth in the number of healthcare organizations that have operational an HIE, its ability to lead to improved outcomes has yet to be realized.[8, 10] The Israeli experience reported here suggests that provisions are needed that will ensure actual use of HIEs, which might in turn minimize the difference between DHRs and SHRs.

Readmissions within a relatively short time after discharge are receiving considerable attention as an area of quality improvement,[1, 2] with increasing emphasis on the relatively large share of readmissions to different hospitals, accounting for 20% to 30% of all readmissions.[3, 4, 5, 6] Returning to a different hospital may affect patient and healthcare outcomes due to breaches in continuity. When information from the previous recent hospitalization is not transferred efficiently and accurately to the next admitting hospital, omissions and duplications can occur, resulting in delayed care and potentially worse outcomes (compared to same hospital readmissions [SHRs]), such as longer length of readmission stay (LORS) and increased costs.[7]

Electronic health records (EHRs) and health information exchange (HIE) systems are increasingly used for storage and retrieval of patient information from various sources, such as laboratories and previous physician visits and hospitalizations, enabling informational continuity by providing vital historical medical information for decision‐making. Whereas EHRs collect, store, and present information that is locally created within a specific clinic or hospital, HIEs connect EHR systems between multiple institutions, allowing providers to share clinical data and achieve interorganizational continuity. Such integrative systems are increasingly being implemented across healthcare systems worldwide.[8, 9, 10] Yet, technical difficulties, costs, competitive concerns, data privacy, and workflow implementation challenges have been described as hindering HIE participation.[11, 12, 13, 14] Moreover, major concerns exist regarding the poor usability of EHRs, their limited ability to support multidisciplinary care, and major difficulties in achieving interoperability with HIEs, which undermine efforts to deliver integrated patient‐centered care.[15] Nonetheless, previous research has demonstrated that HIEs can positively affect healthcare resource use and outcomes, including reduced rates of repeated diagnostic imaging in the emergency evaluation of back pain,[16] reduction in admissions via the emergency department (ED),[17] and reduced rates of readmissions within 7 days.[18] However, it is not known whether HIEs can contribute to positive outcomes when patients are readmitted to a different hospital than the hospital from which they were recently (within the previous 30 days) discharged, potentially bridging the transitional‐care information divide.

In Israel, an innovative HIE system, OFEK (literally horizon), was implemented in 2005 at the largest not‐for‐profit insurer and provider of services, Clalit Health Services (Clalit). Clalit operates as an integrated healthcare delivery system, serving more than 50% of the Israeli population, as part of the country's national health insurance system. OFEK links information on all Clalit enrollees from all hospitals, primary care, and specialty care clinics, laboratories, and diagnostic services into a single, virtual, patient file, enabling providers to obtain complete, real‐time information needed for healthcare decision making at the point of care. Like similar HIE systems, OFEK includes information on previous medical encounters and hospitalizations, previous diagnoses, chronically prescribed medications, previous lab and imaging tests, known allergies, and some demographic information.[19] At the time of this study, OFEK was available in all Clalit hospitals as well as in 2 non‐Clalit (government‐owned and operated) large tertiary‐care centers, resulting in 40% coverage of all hospitalizations through the OFEK HIE system. As part of a large organization‐wide readmission reduction program recently implemented by Clalit for all its members admitted to any hospital in Israel, aimed at early detection and intervention,[20] OFEK was viewed as an important mechanism to help maintain continuity and improve transitions.

To inform current knowledge on different‐hospital readmissions (DHRs) and HIEs, we examined whether having HIE systems can contribute to information continuity and prevent delays in care and the need for more expensive, lengthy readmission stays when patients are readmitted to a different hospital. More specifically, we tested whether there is a difference in the LORS between SHRs and DHRs, and whether DHRs the LORS differ by the availability of an HIE (whether index and readmitting hospital are or are not connected through HIE systems).

METHODS

RESULTS

The study included a total of 27,057 readmissions, of which 23,927 (88.4%) were SHRs and 3130 (11.6%) were DHRs. Of all DHRs, in 792 (2.9%) of the cases, both hospitals had HIEs (partial information continuity), and in 2338 (8.6%), either 1 or both did not have an HIE system (thus meaning there was no information continuity). Characteristics of the study population are shown in Table 1. Most (75%) of the readmissions were of patients over the age of 65 years, though only 7% were nursing home residents. More than half the study's population consisted of patients with low SES. The most common chronic conditions were hypertension (77%), ischemic heart disease (52%), and diabetes (48%). Other chronic conditions were arrhythmia (38%), CHF (35%), disability (31%), COPD (28%), malignancy (28%), and asthma (16%). In more than 55% of the index hospitalizations, the LOS was 4 days or less, and most index admissions (64%) were in large hospitals. Table 1 also displays the study population by the type of readmission: SHR, DHR with HIE, and DHR without HIE. As compared to patients readmitted to the same hospital, patients with DHRs were younger (P < 0.001), less likely to be nursing home residents (P < 0.001), and had longer LOS during the index admission (P < 0.001). Additionally, patients with SHRs were more likely to have their index admission at a large hospital (P < 0.001), had a higher comorbidity score (P < 0.043), and were less likely be treated in the ICU during their readmission (P < 0.001) compared to their DHR counterparts. Patients with DHRs without an HIE were similar in most characteristics to those with an HIE, except for having an ICU stay during their readmission (6.4% compared with 9.2%, respectively).

The mean LORS in SHRs was shorter by 1 day than the mean LORS for DHRs: 6.3 (95% confidence interval [CI]: 6.2‐6.4) versus 7.3 (95% CI: 7.0‐7.6), respectively. Mean LORS in DHRs with or without HIE was 7.6 (95% CI: 7.0‐8.3) and 7.2 (95% CI: 6.8‐7.6), respectively. Although median LORS was similar (4 days), the IQR differed, resulting in significant differences between the SHR and DHR groups (Table 2).

In the multivariate model, partial continuity (DHRs with an HIE) was associated with decreased likelihood of discharge on any given day compared with full continuity (SHR) (hazard ratio [HR] = 0.85, 95% CI: 0.79‐0.91). Similar results were obtained for no continuity (DHRs without an HIE) (HR = 0.90, 95% CI: 0.86‐0.94). The difference between DHRs with and without an HIE was not significant (overlapping confidence intervals). Other factors associated with a lower HR for discharge during each day of the readmission were older age, residency in a nursing home, CHF, CRF, disability, malignancy, and long LOS (8+ days) during the index hospitalization. Patients with asthma or ischemic heart disease had a higher HR for discharge during each readmission day (Table 3). We performed a sensitivity analysis using hierarchical modeling (patients nested within hospitals), which resulted in similar findings in terms of directionality and magnitude of the relationships and significance levels.

DISCUSSION

This study shows that readmission to a different hospital results in longer duration of the readmission stay compared with readmission to the same index hospital. Our results also show that having HIE systems in both the index and readmitting hospitals does not protect against these negative outcomes, as there was no difference in the length of the readmission stay based on the availability of HIE systems. Factors that were found to be associated with longer readmission stays are well known indicators of the complexity of the patient's medical condition, such as the presence of disability, comorbidity, and ICU treatment during the readmission.[24, 27]

The shorter LORS in SHRs may be due to the familiarity of physicians and other healthcare providers with the patient and his or her condition, especially as the policy in SHRs in Israel is to readmit to the same unit from which the patient was recently discharged. This same hospital familiarity is especially important as hospital care in Israel follows the hospitalist model, in which responsibility for patient care is transferred from the patient's primary care physician to the hospital's physician, resulting in increased need for integration through HIE systems, especially when patients are readmitted to a different hospital.[28, 29]

Our findings, congruent with previous research on DHRs and poor outcomes,[7] could also be explained by the inefficiency associated with transitions. For example, patients frequently leave the hospital with pending lab tests, often with abnormal results that would change the course of care.[30] Because these pending tests are often omitted from the hospital discharge summaries,[31] if patients are hospitalized in a different hospital, the same tests may be ordered again, or a course of treatment that does not acknowledge the test results could be taken. Such time‐consuming duplication can be prevented in SHRs, where the index‐hospital records may be already more complete.

Our null findings regarding the contribution of HIE systems may be explained by the low levels of HIE actual use. Although we did not directly assess use, previous research reports that actual use of HIE is limited.[12] An Israeli study on the effects of the use of the OFEK system on ED physicians' admission decisions found that the patient's medical history was viewed in only 31.2% of all 281,750 ED referrals.[19] In another Israeli‐based ED study, even lower usage levels were found, with the OFEK system having been accessed in only 16% of all 3,219,910 ED referrals.[32] Low levels of HIE use have also been reported in the United States. An additional study, which tested the implementation of HIE in hospitals and clinics, showed that in only 2.3% of encounters did providers access the HIE record.[33] Another study conducted in 12 ED sites and 2 ambulatory clinics reported rates of 6.8% HIE use.[34] Moreover, the null effect of integrated health information reported here is congruent with findings from a US study on implementation of an electronic discharge instructions form with embedded computerized medication reconciliation, which was not found to be associated with postdischarge outcomes.[35]

A wide range of factors may influence decisions on HIE use: patient‐level factors,[36] perceived medical complexity of the patient,[33, 34] and the number of prior hospitalizations.[33, 34, 36] Healthcare systemlevel factors may include: time constraints, which may be positively[32] or negatively[33] associated with HIE use, and organizational policies or incentives.[33] Use may also be associated with features of the HIE technology itself, such as difficulty to access, difficulty to use once accessed, and the quality of information it contains.[37] Additionally, there is some evidence of the link between tight functional integration and higher proportions of usage.[38] Although comprehensive studies on factors affecting the use of the OFEK system in Israeli internal medicine units are still needed, the lack of its integration within each hospital's EHR system may serve as a major explanatory factor for the low usage levels.

The findings from this study should be interpreted in light of its limitations. First, compared with previously reported DHR rates (20%30%),[3, 5] the rate observed in our population was relatively low (about 12%). Previous research was restricted to heart failure patients[3] or assessed DHR in surgical, as well as internal medicine, patients.[5] Our lower rates may have been affected by the type of population (hospitalized internal medicine patients) and/or by characteristics of the Clalit healthcare system, which serves as an integrated provider network as well as insurer. Generalization from 1 health care system to others should be made with caution. Nonetheless, our results may underestimate the potential effect in other healthcare systems with less structural integration. Additionally, as noted above, information on the actual use of an HIE in the course of medical decision making during readmission was absent. Future studies should examine the potential benefit of an HIE with measures that capture providers' use of HIEs. Also, the LORS may be influenced by other factors not investigated here, and further future studies should examine additional outcomes such as costs, patient well‐being, and satisfaction. Finally, causality could not be determined, and future research in this realm should aim to search for the pathways connecting readmission to a different hospital, with and without HIEs, to readmission LOS and additional outcomes.

To conclude, our findings show that patients readmitted to a different hospital are at risk for prolonged LORS, regardless of the availability of HIE systems. Implementing HIE systems is the focus of substantial efforts by policymakers and is considered a key part of the meaningful use of electronic health information. HIE features in the provisions of the Health Information Technology for Economic and Clinical Health Act[39] because it can furnish providers with complete, timely information at the point of care. Moreover, although there has been substantial growth in the number of healthcare organizations that have operational an HIE, its ability to lead to improved outcomes has yet to be realized.[8, 10] The Israeli experience reported here suggests that provisions are needed that will ensure actual use of HIEs, which might in turn minimize the difference between DHRs and SHRs.

Readmissions within a relatively short time after discharge are receiving considerable attention as an area of quality improvement,[1, 2] with increasing emphasis on the relatively large share of readmissions to different hospitals, accounting for 20% to 30% of all readmissions.[3, 4, 5, 6] Returning to a different hospital may affect patient and healthcare outcomes due to breaches in continuity. When information from the previous recent hospitalization is not transferred efficiently and accurately to the next admitting hospital, omissions and duplications can occur, resulting in delayed care and potentially worse outcomes (compared to same hospital readmissions [SHRs]), such as longer length of readmission stay (LORS) and increased costs.[7]

Electronic health records (EHRs) and health information exchange (HIE) systems are increasingly used for storage and retrieval of patient information from various sources, such as laboratories and previous physician visits and hospitalizations, enabling informational continuity by providing vital historical medical information for decision‐making. Whereas EHRs collect, store, and present information that is locally created within a specific clinic or hospital, HIEs connect EHR systems between multiple institutions, allowing providers to share clinical data and achieve interorganizational continuity. Such integrative systems are increasingly being implemented across healthcare systems worldwide.[8, 9, 10] Yet, technical difficulties, costs, competitive concerns, data privacy, and workflow implementation challenges have been described as hindering HIE participation.[11, 12, 13, 14] Moreover, major concerns exist regarding the poor usability of EHRs, their limited ability to support multidisciplinary care, and major difficulties in achieving interoperability with HIEs, which undermine efforts to deliver integrated patient‐centered care.[15] Nonetheless, previous research has demonstrated that HIEs can positively affect healthcare resource use and outcomes, including reduced rates of repeated diagnostic imaging in the emergency evaluation of back pain,[16] reduction in admissions via the emergency department (ED),[17] and reduced rates of readmissions within 7 days.[18] However, it is not known whether HIEs can contribute to positive outcomes when patients are readmitted to a different hospital than the hospital from which they were recently (within the previous 30 days) discharged, potentially bridging the transitional‐care information divide.

In Israel, an innovative HIE system, OFEK (literally horizon), was implemented in 2005 at the largest not‐for‐profit insurer and provider of services, Clalit Health Services (Clalit). Clalit operates as an integrated healthcare delivery system, serving more than 50% of the Israeli population, as part of the country's national health insurance system. OFEK links information on all Clalit enrollees from all hospitals, primary care, and specialty care clinics, laboratories, and diagnostic services into a single, virtual, patient file, enabling providers to obtain complete, real‐time information needed for healthcare decision making at the point of care. Like similar HIE systems, OFEK includes information on previous medical encounters and hospitalizations, previous diagnoses, chronically prescribed medications, previous lab and imaging tests, known allergies, and some demographic information.[19] At the time of this study, OFEK was available in all Clalit hospitals as well as in 2 non‐Clalit (government‐owned and operated) large tertiary‐care centers, resulting in 40% coverage of all hospitalizations through the OFEK HIE system. As part of a large organization‐wide readmission reduction program recently implemented by Clalit for all its members admitted to any hospital in Israel, aimed at early detection and intervention,[20] OFEK was viewed as an important mechanism to help maintain continuity and improve transitions.

To inform current knowledge on different‐hospital readmissions (DHRs) and HIEs, we examined whether having HIE systems can contribute to information continuity and prevent delays in care and the need for more expensive, lengthy readmission stays when patients are readmitted to a different hospital. More specifically, we tested whether there is a difference in the LORS between SHRs and DHRs, and whether DHRs the LORS differ by the availability of an HIE (whether index and readmitting hospital are or are not connected through HIE systems).

METHODS

RESULTS

The study included a total of 27,057 readmissions, of which 23,927 (88.4%) were SHRs and 3130 (11.6%) were DHRs. Of all DHRs, in 792 (2.9%) of the cases, both hospitals had HIEs (partial information continuity), and in 2338 (8.6%), either 1 or both did not have an HIE system (thus meaning there was no information continuity). Characteristics of the study population are shown in Table 1. Most (75%) of the readmissions were of patients over the age of 65 years, though only 7% were nursing home residents. More than half the study's population consisted of patients with low SES. The most common chronic conditions were hypertension (77%), ischemic heart disease (52%), and diabetes (48%). Other chronic conditions were arrhythmia (38%), CHF (35%), disability (31%), COPD (28%), malignancy (28%), and asthma (16%). In more than 55% of the index hospitalizations, the LOS was 4 days or less, and most index admissions (64%) were in large hospitals. Table 1 also displays the study population by the type of readmission: SHR, DHR with HIE, and DHR without HIE. As compared to patients readmitted to the same hospital, patients with DHRs were younger (P < 0.001), less likely to be nursing home residents (P < 0.001), and had longer LOS during the index admission (P < 0.001). Additionally, patients with SHRs were more likely to have their index admission at a large hospital (P < 0.001), had a higher comorbidity score (P < 0.043), and were less likely be treated in the ICU during their readmission (P < 0.001) compared to their DHR counterparts. Patients with DHRs without an HIE were similar in most characteristics to those with an HIE, except for having an ICU stay during their readmission (6.4% compared with 9.2%, respectively).

The mean LORS in SHRs was shorter by 1 day than the mean LORS for DHRs: 6.3 (95% confidence interval [CI]: 6.2‐6.4) versus 7.3 (95% CI: 7.0‐7.6), respectively. Mean LORS in DHRs with or without HIE was 7.6 (95% CI: 7.0‐8.3) and 7.2 (95% CI: 6.8‐7.6), respectively. Although median LORS was similar (4 days), the IQR differed, resulting in significant differences between the SHR and DHR groups (Table 2).

In the multivariate model, partial continuity (DHRs with an HIE) was associated with decreased likelihood of discharge on any given day compared with full continuity (SHR) (hazard ratio [HR] = 0.85, 95% CI: 0.79‐0.91). Similar results were obtained for no continuity (DHRs without an HIE) (HR = 0.90, 95% CI: 0.86‐0.94). The difference between DHRs with and without an HIE was not significant (overlapping confidence intervals). Other factors associated with a lower HR for discharge during each day of the readmission were older age, residency in a nursing home, CHF, CRF, disability, malignancy, and long LOS (8+ days) during the index hospitalization. Patients with asthma or ischemic heart disease had a higher HR for discharge during each readmission day (Table 3). We performed a sensitivity analysis using hierarchical modeling (patients nested within hospitals), which resulted in similar findings in terms of directionality and magnitude of the relationships and significance levels.

DISCUSSION

This study shows that readmission to a different hospital results in longer duration of the readmission stay compared with readmission to the same index hospital. Our results also show that having HIE systems in both the index and readmitting hospitals does not protect against these negative outcomes, as there was no difference in the length of the readmission stay based on the availability of HIE systems. Factors that were found to be associated with longer readmission stays are well known indicators of the complexity of the patient's medical condition, such as the presence of disability, comorbidity, and ICU treatment during the readmission.[24, 27]

The shorter LORS in SHRs may be due to the familiarity of physicians and other healthcare providers with the patient and his or her condition, especially as the policy in SHRs in Israel is to readmit to the same unit from which the patient was recently discharged. This same hospital familiarity is especially important as hospital care in Israel follows the hospitalist model, in which responsibility for patient care is transferred from the patient's primary care physician to the hospital's physician, resulting in increased need for integration through HIE systems, especially when patients are readmitted to a different hospital.[28, 29]

Our findings, congruent with previous research on DHRs and poor outcomes,[7] could also be explained by the inefficiency associated with transitions. For example, patients frequently leave the hospital with pending lab tests, often with abnormal results that would change the course of care.[30] Because these pending tests are often omitted from the hospital discharge summaries,[31] if patients are hospitalized in a different hospital, the same tests may be ordered again, or a course of treatment that does not acknowledge the test results could be taken. Such time‐consuming duplication can be prevented in SHRs, where the index‐hospital records may be already more complete.

Our null findings regarding the contribution of HIE systems may be explained by the low levels of HIE actual use. Although we did not directly assess use, previous research reports that actual use of HIE is limited.[12] An Israeli study on the effects of the use of the OFEK system on ED physicians' admission decisions found that the patient's medical history was viewed in only 31.2% of all 281,750 ED referrals.[19] In another Israeli‐based ED study, even lower usage levels were found, with the OFEK system having been accessed in only 16% of all 3,219,910 ED referrals.[32] Low levels of HIE use have also been reported in the United States. An additional study, which tested the implementation of HIE in hospitals and clinics, showed that in only 2.3% of encounters did providers access the HIE record.[33] Another study conducted in 12 ED sites and 2 ambulatory clinics reported rates of 6.8% HIE use.[34] Moreover, the null effect of integrated health information reported here is congruent with findings from a US study on implementation of an electronic discharge instructions form with embedded computerized medication reconciliation, which was not found to be associated with postdischarge outcomes.[35]

A wide range of factors may influence decisions on HIE use: patient‐level factors,[36] perceived medical complexity of the patient,[33, 34] and the number of prior hospitalizations.[33, 34, 36] Healthcare systemlevel factors may include: time constraints, which may be positively[32] or negatively[33] associated with HIE use, and organizational policies or incentives.[33] Use may also be associated with features of the HIE technology itself, such as difficulty to access, difficulty to use once accessed, and the quality of information it contains.[37] Additionally, there is some evidence of the link between tight functional integration and higher proportions of usage.[38] Although comprehensive studies on factors affecting the use of the OFEK system in Israeli internal medicine units are still needed, the lack of its integration within each hospital's EHR system may serve as a major explanatory factor for the low usage levels.

The findings from this study should be interpreted in light of its limitations. First, compared with previously reported DHR rates (20%30%),[3, 5] the rate observed in our population was relatively low (about 12%). Previous research was restricted to heart failure patients[3] or assessed DHR in surgical, as well as internal medicine, patients.[5] Our lower rates may have been affected by the type of population (hospitalized internal medicine patients) and/or by characteristics of the Clalit healthcare system, which serves as an integrated provider network as well as insurer. Generalization from 1 health care system to others should be made with caution. Nonetheless, our results may underestimate the potential effect in other healthcare systems with less structural integration. Additionally, as noted above, information on the actual use of an HIE in the course of medical decision making during readmission was absent. Future studies should examine the potential benefit of an HIE with measures that capture providers' use of HIEs. Also, the LORS may be influenced by other factors not investigated here, and further future studies should examine additional outcomes such as costs, patient well‐being, and satisfaction. Finally, causality could not be determined, and future research in this realm should aim to search for the pathways connecting readmission to a different hospital, with and without HIEs, to readmission LOS and additional outcomes.

To conclude, our findings show that patients readmitted to a different hospital are at risk for prolonged LORS, regardless of the availability of HIE systems. Implementing HIE systems is the focus of substantial efforts by policymakers and is considered a key part of the meaningful use of electronic health information. HIE features in the provisions of the Health Information Technology for Economic and Clinical Health Act[39] because it can furnish providers with complete, timely information at the point of care. Moreover, although there has been substantial growth in the number of healthcare organizations that have operational an HIE, its ability to lead to improved outcomes has yet to be realized.[8, 10] The Israeli experience reported here suggests that provisions are needed that will ensure actual use of HIEs, which might in turn minimize the difference between DHRs and SHRs.