Practice Management

DAVID LICHTMAN, PA, a hospitalist and director of the Johns Hopkins Central Procedure Service, explains the complicated set of factors used by

individual hospitals to determine which procedures fall under the scope of their HM practitioners.

DAVID LICHTMAN, PA, a hospitalist and director of the Johns Hopkins Central Procedure Service, explains the complicated set of factors used by

individual hospitals to determine which procedures fall under the scope of their HM practitioners.

DAVID LICHTMAN, PA, a hospitalist and director of the Johns Hopkins Central Procedure Service, explains the complicated set of factors used by

individual hospitals to determine which procedures fall under the scope of their HM practitioners.

Case

A 66-year-old homeless man with a history of smoking and cirrhosis due to alcoholism presents to the hospital with a productive cough and fever for one month. He has traveled around Arizona and New Mexico but has never left the country. His complete blood count (CBC) is notable for a white blood cell count of 13,000. His chest X-ray reveals a 1.7-cm right upper lobe cavitary lung lesion (see Figure 1). What is the best approach to this patient’s cavitary lung lesion?

Overview

Cavitary lung lesions are relatively common findings on chest imaging and often pose a diagnostic challenge to the hospitalist. Having a standard approach to the evaluation of a cavitary lung lesion can facilitate an expedited workup.

A lung cavity is defined radiographically as a lucent area contained within a consolidation, mass, or nodule.¹ Cavities usually are accompanied by thick walls, greater than 4 mm. These should be differentiated from cysts, which are not surrounded by consolidation, mass, or nodule, and are accompanied by a thinner wall.²

The differential diagnosis of a cavitary lung lesion is broad and can be delineated into categories of infectious and noninfectious etiologies (see Figure 2). Infectious causes include bacterial, fungal, and, rarely, parasitic agents. Noninfectious causes encompass malignant, rheumatologic, and other less common etiologies such as infarct related to pulmonary embolism.

The clinical presentation and assessment of risk factors for a particular patient are of the utmost importance in delineating next steps for evaluation and management (see Table 1). For those patients of older age with smoking history, specific occupational or environmental exposures, and weight loss, the most common etiology is neoplasm. Common infectious causes include lung abscess and necrotizing pneumonia, as well as tuberculosis. The approach to diagnosis should be based on a composite of the clinical presentation, patient characteristics, and radiographic appearance of the cavity.

Guidelines for the approach to cavitary lung lesions are lacking, yet a thorough understanding of the initial approach is important for those practicing hospital medicine. Key components in the approach to diagnosis of a solitary cavitary lesion are outlined in this article.

Diagnosis of Infectious Causes

In the initial evaluation of a cavitary lung lesion, it is important to first determine if the cause is an infectious process. The infectious etiologies to consider include lung abscess and necrotizing pneumonia, tuberculosis, and septic emboli. Important components in the clinical presentation include presence of cough, fever, night sweats, chills, and symptoms that have lasted less than one month, as well as comorbid conditions, drug or alcohol abuse, and history of immunocompromise (e.g. HIV, immunosuppressive therapy, or organ transplant).

Given the public health considerations and impact of treatment, tuberculosis (TB) will be discussed in its own category.

Tuberculosis. Given the fact that TB patients require airborne isolation, the disease must be considered early in the evaluation of a cavitary lung lesion. Patients with TB often present with more chronic symptoms, such as fevers, night sweats, weight loss, and hemoptysis. Immunocompromised state, travel to endemic regions, and incarceration increase the likelihood of TB. Nontuberculous mycobacterium (i.e., M. kansasii) should also be considered in endemic areas.

For those patients in whom TB is suspected, airborne isolation must be initiated promptly. The provider should obtain three sputum samples for acid-fast bacillus (AFB) smear and culture when risk factors are present. Most patients with reactivation TB have abnormal chest X-rays, with approximately 20% of those patients having air-fluid levels and the majority of cases affecting the upper lobes.³ Cavities may be seen in patients with primary or reactivation TB.³

Lung abscess and necrotizing pneumonia. Lung abscesses are cavities associated with necrosis caused by a microbial infection. The term necrotizing pneumonia typically is used when there are multiple smaller (smaller than 2 cm) associated lung abscesses, although both lung abscess and necrotizing pneumonia represent a similar pathophysiologic process and are along the same continuum. Lung abscess is suspected with the presence of predisposing risk factors to aspiration (e.g. alcoholism) and poor dentition. History of cough, fever, putrid sputum, night sweats, and weight loss may indicate subacute or chronic development of a lung abscess. Physical examination might be significant for signs of pneumonia and gingivitis.

Organisms that cause lung abscesses include anaerobes (most common), TB, methicillin-resistant Staphylococcus aureus (MRSA), post-influenza illness, endemic fungi, and Nocardia, among others.⁴ In immunocompromised patients, more common considerations include TB, Mycobacterium avium complex, other mycobacteria, Pseudomonas aeruginosa, Nocardia, Cryptococcus, Aspergillus, endemic fungi (e.g. Coccidiodes in the Southwest and Histoplasma in the Midwest), and, less commonly, Pneumocystis jiroveci.⁴ The likelihood of each organism is dependent on the patient’s risk factors. Initial laboratory testing includes sputum and blood cultures, as well as serologic testing for endemic fungi, especially in immunocompromised patients.

Imaging may reveal a cavitary lesion in the dependent pulmonary segments (posterior segments of the upper lobes or superior segments of the lower lobes), at times associated with a pleural effusion or infiltrate. The most common appearance of a lung abscess is an asymmetric cavity with an air-fluid level and a wall with a ragged or smooth border. CT scan is often indicated when X-rays are equivocal and when cases are of uncertain cause or are unresponsive to antibiotic therapy. Bronchoscopy is reserved for patients with an immunocompromising condition, atypical presentation, or lack of response to treatment.

For those cavitary lesions in which there is a high degree of suspicion for lung abscess, empiric treatment should include antibiotics active against anaerobes and MRSA if the patient has risk factors. Patients often receive an empiric trial of antibiotics prior to biopsy unless there are clear indications that the cavitary lung lesion is related to cancer. Lung abscesses typically drain spontaneously, and transthoracic or endobronchial drainage is not usually recommended as initial management due to risk of pneumothorax and formation of bronchopleural fistula.

Lung abscesses should be followed to resolution with serial chest imaging. If the lung abscess does not resolve, it would be appropriate to consult thoracic surgery, interventional radiology, or pulmonary, depending on the location of the abscess and the local expertise with transthoracic or endobronchial drainage and surgical resection.

Septic emboli. Septic emboli are a less common cause of cavitary lung lesions. This entity should be considered in patients with a history of IV drug use or infected indwelling devices (central venous catheters, pacemaker wires, and right-sided prosthetic heart valves). Physical examination should include an assessment for signs of endocarditis and inspection for infected indwelling devices. In patients with IV drug use, the likely pathogen is S. aureus.

Oropharyngeal infection or indwelling catheters may predispose patients to septic thrombophlebitis of the internal jugular vein, also known as Lemierre’s syndrome, a rare but important cause of septic emboli.⁵ Laboratory testing includes culture for sputum and blood and culture of the infected device if applicable. On chest X-ray, septic emboli commonly appear as nodules located in the lung periphery. CT scan is more sensitive for detecting cavitation associated with septic emboli.

Diagnosis of Noninfectious Causes

Upon identification of a cavitary lung lesion, noninfectious etiologies must also be entertained. Noninfectious etiologies include malignancy, rheumatologic diseases, pulmonary embolism, and other causes. Important components in the clinical presentation include the presence of constitutional symptoms (fevers, weight loss, night sweats), smoking history, family history, and an otherwise complete review of systems. Physical exam should include evaluation for lymphadenopathy, cachexia, rash, clubbing, and other symptoms pertinent to the suspected etiology.

Malignancy. Perhaps most important among noninfectious causes of cavitary lung lesions is malignancy, and a high index of suspicion is warranted given that it is commonly the first diagnosis to consider overall.² Cavities can form in primary lung cancers (e.g. bronchogenic carcinomas), lung tumors such as lymphoma or Kaposi’s sarcoma, or in metastatic disease. Cavitation has been detected in 7%-11% of primary lung cancers by plain radiography and in 22% by computed tomography.⁵ Cancers of squamous cell origin are the most likely to cavitate; this holds true for both primary lung tumors and metastatic tumors.⁶ Additionally, cavitation portends a worse prognosis.⁷

Clinicians should review any available prior chest imaging studies to look for a change in the quality or size of a cavitary lung lesion. Neoplasms are typically of variable size with irregular thick walls (greater than 4 mm) on CT scan, with higher specificity for neoplasm in those with a wall thickness greater than 15 mm.²

When the diagnosis is less clear, the decision to embark on more advanced diagnostic methods, such as biopsy, should rest on the provider’s clinical suspicion for a certain disease process. When a lung cancer is suspected, consultation with pulmonary and interventional radiology should be obtained to determine the best approach for biopsy.

Rheumatologic. Less common causes of cavitary lesions include those related to rheumatologic diseases (e.g. granulomatosis with polyangiitis, formerly known as Wegener’s granulomatosis). One study demonstrated that cavitary lung nodules occur in 37% of patients with granulomatosis with polyangiitis.⁸

Although uncommon, cavitary nodules can also be seen in rheumatoid arthritis and sarcoidosis. Given that patients with rheumatologic diseases are often treated with immunosuppressive agents, infection must remain high on the differential. Suspicion of a rheumatologic cause should prompt the clinician to obtain appropriate serologic testing and consultation as needed.

Pulmonary embolism. Although often not considered in the evaluation of cavitary lung lesions, pulmonary embolism (PE) can lead to infarction and the formation of a cavitary lesion. Pulmonary infarction has been reported to occur in as many as one third of cases of PE.⁹ Cavitary lesions also have been described in chronic thromboembolic disease.¹⁰

Other. Uncommon causes of cavitary lesions include bronchiolitis obliterans with organizing pneumonia, Langerhans cell histiocytosis, and amyloidosis, among others. The hospitalist should keep a broad differential and involve consultants if the diagnosis remains unclear after initial diagnostic evaluation.

Back to the Case

The patient’s fever and productive cough, in combination with recent travel and location of the cavitary lesion, increase his risk for tuberculosis and endemic fungi, such as Coccidioides. This patient was placed on respiratory isolation with AFBs obtained to rule out TB, with Coccidioides antibodies, Cyptococcal antigen titers, and sputum for fungus sent to evaluate for an endemic fungus. He had a chest CT, which revealed a 17-mm cavitary mass within the right upper lobe that contained an air-fluid level indicating lung abscess. Coccidioides, cryptococcal, fungal sputum, and TB studies were negative.

The patient was treated empirically with clindamycin given the high prevalence of anaerobes in lung abscess. He was followed as an outpatient and had a chest X-ray showing resolution of the lesion at six months. The purpose of the X-ray was two-fold: to monitor the effect of antibiotic treatment and to evaluate for persistence of the cavitation given the neoplastic risk factors of older age and smoking.

Bottom Line

The best approach to a patient with a cavitary lung lesion includes assessing the clinical presentation and risk factors, differentiating infectious from noninfectious causes, and then utilizing this information to further direct the diagnostic evaluation. Consultation with a subspecialist or further testing such as biopsy should be considered if the etiology remains undefined after the initial evaluation.

Drs. Rendon, Pizanis, Montanaro, and Kraai are hospitalists in the department of internal medicine at the University of New Mexico School of Medicine in Albuquerque.

References

1. Hansell DM, Bankier AA, MacMahon H, McLoud TC, Müller NL, Remy J. Fleischner Society: glossary of terms for thoracic imaging. Radiology. 2008;246(3):697-722.
2. Ryu JH, Swensen SJ. Cystic and cavitary lung diseases: focal and diffuse. Mayo Clin Proc. 2003;78(6):744-752.
3. Barnes PF, Verdegem TD, Vachon LA, Leedom JM, Overturf GD. Chest roentgenogram in pulmonary tuberculosis. New data on an old test. Chest. 1988;94(2):316-320.
4. Yazbeck MF, Dahdel M, Kalra A, Browne AS, Pratter MR. Lung abscess: update on microbiology and management. Am J Ther. 2012;21(3):217-221. doi: 10.1097/MJT.0b013e3182383c9b.
5. Gadkowski LB, Stout JE. Cavitary pulmonary disease. Clin Microbiol Rev. 2008;21(2):305-333.
6. Chiu FT. Cavitation in lung cancers. Aust N Z J Med. 1975;5(6):523-530.
7. Kolodziejski LS, Dyczek S, Duda K, Góralczyk J, Wysocki WM, Lobaziewicz W. Cavitated tumor as a clinical subentity in squamous cell lung cancer patients. Neoplasma. 2003;50(1):66-73.
8. Cordier JF, Valeyre D, Guillevin L, Loire R, Brechot JM. Pulmonary Wegener’s granulomatosis. A clinical and imaging study of 77 cases. Chest. 1990;97(4):906-912.
9. He H, Stein MW, Zalta B, Haramati LB. Pulmonary infarction: spectrum of findings on multidetector helical CT. J Thorac Imaging. 2006;21(1):1-7.
10. Harris H, Barraclough R, Davies C, Armstrong I, Kiely DG, van Beek E Jr. Cavitating lung lesions in chronic thromboembolic pulmonary hypertension. J Radiol Case Rep. 2008;2(3):11-21.
11. Woodring JH, Fried AM, Chuang VP. Solitary cavities of the lung: diagnostic implications of cavity wall thickness. AJR Am J Roentgenol. 1980;135(6):1269-1271.

Case

A 66-year-old homeless man with a history of smoking and cirrhosis due to alcoholism presents to the hospital with a productive cough and fever for one month. He has traveled around Arizona and New Mexico but has never left the country. His complete blood count (CBC) is notable for a white blood cell count of 13,000. His chest X-ray reveals a 1.7-cm right upper lobe cavitary lung lesion (see Figure 1). What is the best approach to this patient’s cavitary lung lesion?

Overview

Cavitary lung lesions are relatively common findings on chest imaging and often pose a diagnostic challenge to the hospitalist. Having a standard approach to the evaluation of a cavitary lung lesion can facilitate an expedited workup.

A lung cavity is defined radiographically as a lucent area contained within a consolidation, mass, or nodule.¹ Cavities usually are accompanied by thick walls, greater than 4 mm. These should be differentiated from cysts, which are not surrounded by consolidation, mass, or nodule, and are accompanied by a thinner wall.²

The differential diagnosis of a cavitary lung lesion is broad and can be delineated into categories of infectious and noninfectious etiologies (see Figure 2). Infectious causes include bacterial, fungal, and, rarely, parasitic agents. Noninfectious causes encompass malignant, rheumatologic, and other less common etiologies such as infarct related to pulmonary embolism.

The clinical presentation and assessment of risk factors for a particular patient are of the utmost importance in delineating next steps for evaluation and management (see Table 1). For those patients of older age with smoking history, specific occupational or environmental exposures, and weight loss, the most common etiology is neoplasm. Common infectious causes include lung abscess and necrotizing pneumonia, as well as tuberculosis. The approach to diagnosis should be based on a composite of the clinical presentation, patient characteristics, and radiographic appearance of the cavity.

Guidelines for the approach to cavitary lung lesions are lacking, yet a thorough understanding of the initial approach is important for those practicing hospital medicine. Key components in the approach to diagnosis of a solitary cavitary lesion are outlined in this article.

Diagnosis of Infectious Causes

In the initial evaluation of a cavitary lung lesion, it is important to first determine if the cause is an infectious process. The infectious etiologies to consider include lung abscess and necrotizing pneumonia, tuberculosis, and septic emboli. Important components in the clinical presentation include presence of cough, fever, night sweats, chills, and symptoms that have lasted less than one month, as well as comorbid conditions, drug or alcohol abuse, and history of immunocompromise (e.g. HIV, immunosuppressive therapy, or organ transplant).

Given the public health considerations and impact of treatment, tuberculosis (TB) will be discussed in its own category.

Tuberculosis. Given the fact that TB patients require airborne isolation, the disease must be considered early in the evaluation of a cavitary lung lesion. Patients with TB often present with more chronic symptoms, such as fevers, night sweats, weight loss, and hemoptysis. Immunocompromised state, travel to endemic regions, and incarceration increase the likelihood of TB. Nontuberculous mycobacterium (i.e., M. kansasii) should also be considered in endemic areas.

For those patients in whom TB is suspected, airborne isolation must be initiated promptly. The provider should obtain three sputum samples for acid-fast bacillus (AFB) smear and culture when risk factors are present. Most patients with reactivation TB have abnormal chest X-rays, with approximately 20% of those patients having air-fluid levels and the majority of cases affecting the upper lobes.³ Cavities may be seen in patients with primary or reactivation TB.³

Lung abscess and necrotizing pneumonia. Lung abscesses are cavities associated with necrosis caused by a microbial infection. The term necrotizing pneumonia typically is used when there are multiple smaller (smaller than 2 cm) associated lung abscesses, although both lung abscess and necrotizing pneumonia represent a similar pathophysiologic process and are along the same continuum. Lung abscess is suspected with the presence of predisposing risk factors to aspiration (e.g. alcoholism) and poor dentition. History of cough, fever, putrid sputum, night sweats, and weight loss may indicate subacute or chronic development of a lung abscess. Physical examination might be significant for signs of pneumonia and gingivitis.

Organisms that cause lung abscesses include anaerobes (most common), TB, methicillin-resistant Staphylococcus aureus (MRSA), post-influenza illness, endemic fungi, and Nocardia, among others.⁴ In immunocompromised patients, more common considerations include TB, Mycobacterium avium complex, other mycobacteria, Pseudomonas aeruginosa, Nocardia, Cryptococcus, Aspergillus, endemic fungi (e.g. Coccidiodes in the Southwest and Histoplasma in the Midwest), and, less commonly, Pneumocystis jiroveci.⁴ The likelihood of each organism is dependent on the patient’s risk factors. Initial laboratory testing includes sputum and blood cultures, as well as serologic testing for endemic fungi, especially in immunocompromised patients.

Imaging may reveal a cavitary lesion in the dependent pulmonary segments (posterior segments of the upper lobes or superior segments of the lower lobes), at times associated with a pleural effusion or infiltrate. The most common appearance of a lung abscess is an asymmetric cavity with an air-fluid level and a wall with a ragged or smooth border. CT scan is often indicated when X-rays are equivocal and when cases are of uncertain cause or are unresponsive to antibiotic therapy. Bronchoscopy is reserved for patients with an immunocompromising condition, atypical presentation, or lack of response to treatment.

For those cavitary lesions in which there is a high degree of suspicion for lung abscess, empiric treatment should include antibiotics active against anaerobes and MRSA if the patient has risk factors. Patients often receive an empiric trial of antibiotics prior to biopsy unless there are clear indications that the cavitary lung lesion is related to cancer. Lung abscesses typically drain spontaneously, and transthoracic or endobronchial drainage is not usually recommended as initial management due to risk of pneumothorax and formation of bronchopleural fistula.

Lung abscesses should be followed to resolution with serial chest imaging. If the lung abscess does not resolve, it would be appropriate to consult thoracic surgery, interventional radiology, or pulmonary, depending on the location of the abscess and the local expertise with transthoracic or endobronchial drainage and surgical resection.

Septic emboli. Septic emboli are a less common cause of cavitary lung lesions. This entity should be considered in patients with a history of IV drug use or infected indwelling devices (central venous catheters, pacemaker wires, and right-sided prosthetic heart valves). Physical examination should include an assessment for signs of endocarditis and inspection for infected indwelling devices. In patients with IV drug use, the likely pathogen is S. aureus.

Oropharyngeal infection or indwelling catheters may predispose patients to septic thrombophlebitis of the internal jugular vein, also known as Lemierre’s syndrome, a rare but important cause of septic emboli.⁵ Laboratory testing includes culture for sputum and blood and culture of the infected device if applicable. On chest X-ray, septic emboli commonly appear as nodules located in the lung periphery. CT scan is more sensitive for detecting cavitation associated with septic emboli.

Diagnosis of Noninfectious Causes

Upon identification of a cavitary lung lesion, noninfectious etiologies must also be entertained. Noninfectious etiologies include malignancy, rheumatologic diseases, pulmonary embolism, and other causes. Important components in the clinical presentation include the presence of constitutional symptoms (fevers, weight loss, night sweats), smoking history, family history, and an otherwise complete review of systems. Physical exam should include evaluation for lymphadenopathy, cachexia, rash, clubbing, and other symptoms pertinent to the suspected etiology.

Malignancy. Perhaps most important among noninfectious causes of cavitary lung lesions is malignancy, and a high index of suspicion is warranted given that it is commonly the first diagnosis to consider overall.² Cavities can form in primary lung cancers (e.g. bronchogenic carcinomas), lung tumors such as lymphoma or Kaposi’s sarcoma, or in metastatic disease. Cavitation has been detected in 7%-11% of primary lung cancers by plain radiography and in 22% by computed tomography.⁵ Cancers of squamous cell origin are the most likely to cavitate; this holds true for both primary lung tumors and metastatic tumors.⁶ Additionally, cavitation portends a worse prognosis.⁷

Clinicians should review any available prior chest imaging studies to look for a change in the quality or size of a cavitary lung lesion. Neoplasms are typically of variable size with irregular thick walls (greater than 4 mm) on CT scan, with higher specificity for neoplasm in those with a wall thickness greater than 15 mm.²

When the diagnosis is less clear, the decision to embark on more advanced diagnostic methods, such as biopsy, should rest on the provider’s clinical suspicion for a certain disease process. When a lung cancer is suspected, consultation with pulmonary and interventional radiology should be obtained to determine the best approach for biopsy.

Rheumatologic. Less common causes of cavitary lesions include those related to rheumatologic diseases (e.g. granulomatosis with polyangiitis, formerly known as Wegener’s granulomatosis). One study demonstrated that cavitary lung nodules occur in 37% of patients with granulomatosis with polyangiitis.⁸

Although uncommon, cavitary nodules can also be seen in rheumatoid arthritis and sarcoidosis. Given that patients with rheumatologic diseases are often treated with immunosuppressive agents, infection must remain high on the differential. Suspicion of a rheumatologic cause should prompt the clinician to obtain appropriate serologic testing and consultation as needed.

Pulmonary embolism. Although often not considered in the evaluation of cavitary lung lesions, pulmonary embolism (PE) can lead to infarction and the formation of a cavitary lesion. Pulmonary infarction has been reported to occur in as many as one third of cases of PE.⁹ Cavitary lesions also have been described in chronic thromboembolic disease.¹⁰

Other. Uncommon causes of cavitary lesions include bronchiolitis obliterans with organizing pneumonia, Langerhans cell histiocytosis, and amyloidosis, among others. The hospitalist should keep a broad differential and involve consultants if the diagnosis remains unclear after initial diagnostic evaluation.

Back to the Case

The patient’s fever and productive cough, in combination with recent travel and location of the cavitary lesion, increase his risk for tuberculosis and endemic fungi, such as Coccidioides. This patient was placed on respiratory isolation with AFBs obtained to rule out TB, with Coccidioides antibodies, Cyptococcal antigen titers, and sputum for fungus sent to evaluate for an endemic fungus. He had a chest CT, which revealed a 17-mm cavitary mass within the right upper lobe that contained an air-fluid level indicating lung abscess. Coccidioides, cryptococcal, fungal sputum, and TB studies were negative.

The patient was treated empirically with clindamycin given the high prevalence of anaerobes in lung abscess. He was followed as an outpatient and had a chest X-ray showing resolution of the lesion at six months. The purpose of the X-ray was two-fold: to monitor the effect of antibiotic treatment and to evaluate for persistence of the cavitation given the neoplastic risk factors of older age and smoking.

Bottom Line

The best approach to a patient with a cavitary lung lesion includes assessing the clinical presentation and risk factors, differentiating infectious from noninfectious causes, and then utilizing this information to further direct the diagnostic evaluation. Consultation with a subspecialist or further testing such as biopsy should be considered if the etiology remains undefined after the initial evaluation.

Drs. Rendon, Pizanis, Montanaro, and Kraai are hospitalists in the department of internal medicine at the University of New Mexico School of Medicine in Albuquerque.

References

1. Hansell DM, Bankier AA, MacMahon H, McLoud TC, Müller NL, Remy J. Fleischner Society: glossary of terms for thoracic imaging. Radiology. 2008;246(3):697-722.
2. Ryu JH, Swensen SJ. Cystic and cavitary lung diseases: focal and diffuse. Mayo Clin Proc. 2003;78(6):744-752.
3. Barnes PF, Verdegem TD, Vachon LA, Leedom JM, Overturf GD. Chest roentgenogram in pulmonary tuberculosis. New data on an old test. Chest. 1988;94(2):316-320.
4. Yazbeck MF, Dahdel M, Kalra A, Browne AS, Pratter MR. Lung abscess: update on microbiology and management. Am J Ther. 2012;21(3):217-221. doi: 10.1097/MJT.0b013e3182383c9b.
5. Gadkowski LB, Stout JE. Cavitary pulmonary disease. Clin Microbiol Rev. 2008;21(2):305-333.
6. Chiu FT. Cavitation in lung cancers. Aust N Z J Med. 1975;5(6):523-530.
7. Kolodziejski LS, Dyczek S, Duda K, Góralczyk J, Wysocki WM, Lobaziewicz W. Cavitated tumor as a clinical subentity in squamous cell lung cancer patients. Neoplasma. 2003;50(1):66-73.
8. Cordier JF, Valeyre D, Guillevin L, Loire R, Brechot JM. Pulmonary Wegener’s granulomatosis. A clinical and imaging study of 77 cases. Chest. 1990;97(4):906-912.
9. He H, Stein MW, Zalta B, Haramati LB. Pulmonary infarction: spectrum of findings on multidetector helical CT. J Thorac Imaging. 2006;21(1):1-7.
10. Harris H, Barraclough R, Davies C, Armstrong I, Kiely DG, van Beek E Jr. Cavitating lung lesions in chronic thromboembolic pulmonary hypertension. J Radiol Case Rep. 2008;2(3):11-21.
11. Woodring JH, Fried AM, Chuang VP. Solitary cavities of the lung: diagnostic implications of cavity wall thickness. AJR Am J Roentgenol. 1980;135(6):1269-1271.

Case

A 66-year-old homeless man with a history of smoking and cirrhosis due to alcoholism presents to the hospital with a productive cough and fever for one month. He has traveled around Arizona and New Mexico but has never left the country. His complete blood count (CBC) is notable for a white blood cell count of 13,000. His chest X-ray reveals a 1.7-cm right upper lobe cavitary lung lesion (see Figure 1). What is the best approach to this patient’s cavitary lung lesion?

Overview

Cavitary lung lesions are relatively common findings on chest imaging and often pose a diagnostic challenge to the hospitalist. Having a standard approach to the evaluation of a cavitary lung lesion can facilitate an expedited workup.

A lung cavity is defined radiographically as a lucent area contained within a consolidation, mass, or nodule.¹ Cavities usually are accompanied by thick walls, greater than 4 mm. These should be differentiated from cysts, which are not surrounded by consolidation, mass, or nodule, and are accompanied by a thinner wall.²

The differential diagnosis of a cavitary lung lesion is broad and can be delineated into categories of infectious and noninfectious etiologies (see Figure 2). Infectious causes include bacterial, fungal, and, rarely, parasitic agents. Noninfectious causes encompass malignant, rheumatologic, and other less common etiologies such as infarct related to pulmonary embolism.

The clinical presentation and assessment of risk factors for a particular patient are of the utmost importance in delineating next steps for evaluation and management (see Table 1). For those patients of older age with smoking history, specific occupational or environmental exposures, and weight loss, the most common etiology is neoplasm. Common infectious causes include lung abscess and necrotizing pneumonia, as well as tuberculosis. The approach to diagnosis should be based on a composite of the clinical presentation, patient characteristics, and radiographic appearance of the cavity.

Guidelines for the approach to cavitary lung lesions are lacking, yet a thorough understanding of the initial approach is important for those practicing hospital medicine. Key components in the approach to diagnosis of a solitary cavitary lesion are outlined in this article.

Diagnosis of Infectious Causes

In the initial evaluation of a cavitary lung lesion, it is important to first determine if the cause is an infectious process. The infectious etiologies to consider include lung abscess and necrotizing pneumonia, tuberculosis, and septic emboli. Important components in the clinical presentation include presence of cough, fever, night sweats, chills, and symptoms that have lasted less than one month, as well as comorbid conditions, drug or alcohol abuse, and history of immunocompromise (e.g. HIV, immunosuppressive therapy, or organ transplant).

Given the public health considerations and impact of treatment, tuberculosis (TB) will be discussed in its own category.

Tuberculosis. Given the fact that TB patients require airborne isolation, the disease must be considered early in the evaluation of a cavitary lung lesion. Patients with TB often present with more chronic symptoms, such as fevers, night sweats, weight loss, and hemoptysis. Immunocompromised state, travel to endemic regions, and incarceration increase the likelihood of TB. Nontuberculous mycobacterium (i.e., M. kansasii) should also be considered in endemic areas.

For those patients in whom TB is suspected, airborne isolation must be initiated promptly. The provider should obtain three sputum samples for acid-fast bacillus (AFB) smear and culture when risk factors are present. Most patients with reactivation TB have abnormal chest X-rays, with approximately 20% of those patients having air-fluid levels and the majority of cases affecting the upper lobes.³ Cavities may be seen in patients with primary or reactivation TB.³

Lung abscess and necrotizing pneumonia. Lung abscesses are cavities associated with necrosis caused by a microbial infection. The term necrotizing pneumonia typically is used when there are multiple smaller (smaller than 2 cm) associated lung abscesses, although both lung abscess and necrotizing pneumonia represent a similar pathophysiologic process and are along the same continuum. Lung abscess is suspected with the presence of predisposing risk factors to aspiration (e.g. alcoholism) and poor dentition. History of cough, fever, putrid sputum, night sweats, and weight loss may indicate subacute or chronic development of a lung abscess. Physical examination might be significant for signs of pneumonia and gingivitis.

Organisms that cause lung abscesses include anaerobes (most common), TB, methicillin-resistant Staphylococcus aureus (MRSA), post-influenza illness, endemic fungi, and Nocardia, among others.⁴ In immunocompromised patients, more common considerations include TB, Mycobacterium avium complex, other mycobacteria, Pseudomonas aeruginosa, Nocardia, Cryptococcus, Aspergillus, endemic fungi (e.g. Coccidiodes in the Southwest and Histoplasma in the Midwest), and, less commonly, Pneumocystis jiroveci.⁴ The likelihood of each organism is dependent on the patient’s risk factors. Initial laboratory testing includes sputum and blood cultures, as well as serologic testing for endemic fungi, especially in immunocompromised patients.

Imaging may reveal a cavitary lesion in the dependent pulmonary segments (posterior segments of the upper lobes or superior segments of the lower lobes), at times associated with a pleural effusion or infiltrate. The most common appearance of a lung abscess is an asymmetric cavity with an air-fluid level and a wall with a ragged or smooth border. CT scan is often indicated when X-rays are equivocal and when cases are of uncertain cause or are unresponsive to antibiotic therapy. Bronchoscopy is reserved for patients with an immunocompromising condition, atypical presentation, or lack of response to treatment.

For those cavitary lesions in which there is a high degree of suspicion for lung abscess, empiric treatment should include antibiotics active against anaerobes and MRSA if the patient has risk factors. Patients often receive an empiric trial of antibiotics prior to biopsy unless there are clear indications that the cavitary lung lesion is related to cancer. Lung abscesses typically drain spontaneously, and transthoracic or endobronchial drainage is not usually recommended as initial management due to risk of pneumothorax and formation of bronchopleural fistula.

Lung abscesses should be followed to resolution with serial chest imaging. If the lung abscess does not resolve, it would be appropriate to consult thoracic surgery, interventional radiology, or pulmonary, depending on the location of the abscess and the local expertise with transthoracic or endobronchial drainage and surgical resection.

Septic emboli. Septic emboli are a less common cause of cavitary lung lesions. This entity should be considered in patients with a history of IV drug use or infected indwelling devices (central venous catheters, pacemaker wires, and right-sided prosthetic heart valves). Physical examination should include an assessment for signs of endocarditis and inspection for infected indwelling devices. In patients with IV drug use, the likely pathogen is S. aureus.

Oropharyngeal infection or indwelling catheters may predispose patients to septic thrombophlebitis of the internal jugular vein, also known as Lemierre’s syndrome, a rare but important cause of septic emboli.⁵ Laboratory testing includes culture for sputum and blood and culture of the infected device if applicable. On chest X-ray, septic emboli commonly appear as nodules located in the lung periphery. CT scan is more sensitive for detecting cavitation associated with septic emboli.

Diagnosis of Noninfectious Causes

Upon identification of a cavitary lung lesion, noninfectious etiologies must also be entertained. Noninfectious etiologies include malignancy, rheumatologic diseases, pulmonary embolism, and other causes. Important components in the clinical presentation include the presence of constitutional symptoms (fevers, weight loss, night sweats), smoking history, family history, and an otherwise complete review of systems. Physical exam should include evaluation for lymphadenopathy, cachexia, rash, clubbing, and other symptoms pertinent to the suspected etiology.

Malignancy. Perhaps most important among noninfectious causes of cavitary lung lesions is malignancy, and a high index of suspicion is warranted given that it is commonly the first diagnosis to consider overall.² Cavities can form in primary lung cancers (e.g. bronchogenic carcinomas), lung tumors such as lymphoma or Kaposi’s sarcoma, or in metastatic disease. Cavitation has been detected in 7%-11% of primary lung cancers by plain radiography and in 22% by computed tomography.⁵ Cancers of squamous cell origin are the most likely to cavitate; this holds true for both primary lung tumors and metastatic tumors.⁶ Additionally, cavitation portends a worse prognosis.⁷

Clinicians should review any available prior chest imaging studies to look for a change in the quality or size of a cavitary lung lesion. Neoplasms are typically of variable size with irregular thick walls (greater than 4 mm) on CT scan, with higher specificity for neoplasm in those with a wall thickness greater than 15 mm.²

When the diagnosis is less clear, the decision to embark on more advanced diagnostic methods, such as biopsy, should rest on the provider’s clinical suspicion for a certain disease process. When a lung cancer is suspected, consultation with pulmonary and interventional radiology should be obtained to determine the best approach for biopsy.

Rheumatologic. Less common causes of cavitary lesions include those related to rheumatologic diseases (e.g. granulomatosis with polyangiitis, formerly known as Wegener’s granulomatosis). One study demonstrated that cavitary lung nodules occur in 37% of patients with granulomatosis with polyangiitis.⁸

Although uncommon, cavitary nodules can also be seen in rheumatoid arthritis and sarcoidosis. Given that patients with rheumatologic diseases are often treated with immunosuppressive agents, infection must remain high on the differential. Suspicion of a rheumatologic cause should prompt the clinician to obtain appropriate serologic testing and consultation as needed.

Pulmonary embolism. Although often not considered in the evaluation of cavitary lung lesions, pulmonary embolism (PE) can lead to infarction and the formation of a cavitary lesion. Pulmonary infarction has been reported to occur in as many as one third of cases of PE.⁹ Cavitary lesions also have been described in chronic thromboembolic disease.¹⁰

Other. Uncommon causes of cavitary lesions include bronchiolitis obliterans with organizing pneumonia, Langerhans cell histiocytosis, and amyloidosis, among others. The hospitalist should keep a broad differential and involve consultants if the diagnosis remains unclear after initial diagnostic evaluation.

Back to the Case

The patient’s fever and productive cough, in combination with recent travel and location of the cavitary lesion, increase his risk for tuberculosis and endemic fungi, such as Coccidioides. This patient was placed on respiratory isolation with AFBs obtained to rule out TB, with Coccidioides antibodies, Cyptococcal antigen titers, and sputum for fungus sent to evaluate for an endemic fungus. He had a chest CT, which revealed a 17-mm cavitary mass within the right upper lobe that contained an air-fluid level indicating lung abscess. Coccidioides, cryptococcal, fungal sputum, and TB studies were negative.

The patient was treated empirically with clindamycin given the high prevalence of anaerobes in lung abscess. He was followed as an outpatient and had a chest X-ray showing resolution of the lesion at six months. The purpose of the X-ray was two-fold: to monitor the effect of antibiotic treatment and to evaluate for persistence of the cavitation given the neoplastic risk factors of older age and smoking.

Bottom Line

The best approach to a patient with a cavitary lung lesion includes assessing the clinical presentation and risk factors, differentiating infectious from noninfectious causes, and then utilizing this information to further direct the diagnostic evaluation. Consultation with a subspecialist or further testing such as biopsy should be considered if the etiology remains undefined after the initial evaluation.

Drs. Rendon, Pizanis, Montanaro, and Kraai are hospitalists in the department of internal medicine at the University of New Mexico School of Medicine in Albuquerque.

References

1. Hansell DM, Bankier AA, MacMahon H, McLoud TC, Müller NL, Remy J. Fleischner Society: glossary of terms for thoracic imaging. Radiology. 2008;246(3):697-722.
2. Ryu JH, Swensen SJ. Cystic and cavitary lung diseases: focal and diffuse. Mayo Clin Proc. 2003;78(6):744-752.
3. Barnes PF, Verdegem TD, Vachon LA, Leedom JM, Overturf GD. Chest roentgenogram in pulmonary tuberculosis. New data on an old test. Chest. 1988;94(2):316-320.
4. Yazbeck MF, Dahdel M, Kalra A, Browne AS, Pratter MR. Lung abscess: update on microbiology and management. Am J Ther. 2012;21(3):217-221. doi: 10.1097/MJT.0b013e3182383c9b.
5. Gadkowski LB, Stout JE. Cavitary pulmonary disease. Clin Microbiol Rev. 2008;21(2):305-333.
6. Chiu FT. Cavitation in lung cancers. Aust N Z J Med. 1975;5(6):523-530.
7. Kolodziejski LS, Dyczek S, Duda K, Góralczyk J, Wysocki WM, Lobaziewicz W. Cavitated tumor as a clinical subentity in squamous cell lung cancer patients. Neoplasma. 2003;50(1):66-73.
8. Cordier JF, Valeyre D, Guillevin L, Loire R, Brechot JM. Pulmonary Wegener’s granulomatosis. A clinical and imaging study of 77 cases. Chest. 1990;97(4):906-912.
9. He H, Stein MW, Zalta B, Haramati LB. Pulmonary infarction: spectrum of findings on multidetector helical CT. J Thorac Imaging. 2006;21(1):1-7.
10. Harris H, Barraclough R, Davies C, Armstrong I, Kiely DG, van Beek E Jr. Cavitating lung lesions in chronic thromboembolic pulmonary hypertension. J Radiol Case Rep. 2008;2(3):11-21.
11. Woodring JH, Fried AM, Chuang VP. Solitary cavities of the lung: diagnostic implications of cavity wall thickness. AJR Am J Roentgenol. 1980;135(6):1269-1271.

“While VTE may not be the No. 1 reason for hospitalization, hospitalists very frequently care for patients with VTE,” says Sowmya Kanikkannan, MD, FACP, SFHM, hospitalist medical director and assistant professor of medicine at Rowan University School of Osteopathic Medicine in Stratford, N.J. “Hospitalists usually are the frontline providers that diagnose and manage hospital-acquired VTEs in hospitalized patients.”

Dr. Kanikkannan, a member of Team Hospitalist, sees a wide range of VTE cases caused by two related conditions—deep vein thrombosis (DVT) and pulmonary embolism (PE).

“Some patients present with a straightforward diagnosis of DVT, while others have extensive DVT,” she says. “In other instances, patients present with acute PE with or without hemodynamic compromise. I’ve also diagnosed and managed hospital-acquired VTEs in medical patients, as well as post-operatively in surgical co-management.”

It is estimated that between 350,000 to 900,000 Americans are affected by DVT or PE each year, with up to 100,000 dying as a result. Twenty to 50% of people who experience DVT develop long-term complications.¹VTE costs the U.S. healthcare system more than $1.5 billion annually.²

As lieutenants in the war against VTE, hospitalists are finding that new treatments, continued efforts to standardize VTE prophylaxis, and increased transparency in performance reporting are the tools needed to combat these common conditions—and hospitalists are being held accountable for optimal patient care.

New Treatments Show Promise

Diagnosing and treating VTE early helps to prevent progression and hemodynamic instability. Although the accepted treatment for VTE used to be heparin, or a low molecular weight heparin (LMWH) (Fragmin, Innohep and Lovenox) with a transition to warfarin, three target-specific oral anticoagulants (TSOACs)—dabigatran, rivaroxaban, and apixaban—are now being prescribed. The FDA has approved rivaroxaban and apixaban for the prevention of VTE after knee and hip surgery and for treatment of VTE, while dabigatran is FDA approved only for the treatment of VTE. All three are approved for use in nonvalvular atrial fibrillation (Afib). A fourth TSOAC, edoxaban, received FDA approval in January for VTE treatment and nonvalvular atrial fibrillation.

“The drawback of warfarin is that patients need frequent international normalized ratio (INR) monitoring,” Dr. Kanikkannan says. “Discharge planning is time consuming because patients need to be educated on warfarin, and follow-up appointments need to be arranged before discharge to ensure patient safety.”

“Their [TSOACs] ease of administration and easy dosing helps hospitalists to manage patients with VTE more efficiently,” Dr. Kanikkannan says. “Patients like having lab testing less frequently but equal efficacy in treatment.”

Rivaroxaban used to have the most approved indications by the FDA; however, based on three clinical trials—ADVANCE-1, 2, and 3—apixaban has the same six FDA indications as rivaroxaban.

The majority of clinical trials suggest noninferiority or superiority of the oral agents compared to LMWH, and safety appears to be similar across treatment groups, other than an increased risk in bleeding with oral agents (see Table 1).

“The increased risk of bleeding seen in trials is something hospitalists need to consider,” says Yong Lee, PharmD, BCPS, clinical pharmacy specialist at Parkland Health and Hospital System in Dallas, Texas. Warfarin is easily reversed; the new anticoagulants don’t have any specific reversal agent (see new table about reversal options). Consequently, the American College of Chest Physicians still recommends unfractionated heparin or a LMWH for VTE prophylaxis. “These agents will still likely remain the best available options to hospitalists for VTE prevention,” he adds.

Julianna Lindsey, MD, MBA, FACP, FHM, chief of staff and hospitalist at Victory Medical Center in McKinney, Texas, says there are instances when it would be helpful to know what the therapeutic level of a TSOAC’s anticoagulation effect is, such as in a patient with active bleeding or one who requires major emergent surgery. But there is no coagulation assay to date that is readily available to test the effect of apixaban; the anticoagulation effect for dabigatran can be roughly estimated by the activated partial thromboplastin time (aPTT) and thrombin time (TT), and the anticoagulation effect for rivaroxaban can be roughly estimated by the prothrombin time (PT).

“The drawback of warfarin is that patients need frequent international normalized ratio (INR) monitoring. Discharge planning is time consuming because patients need to be educated on warfarin, and follow-up appointments need to be arranged before discharge to ensure patient safety.” —Dr. Kanikkannan

Dr. Lee expects the new FDA approvals to expand the utilization of oral anti-Xa inhibitors in practice. “This will, hopefully, make the new oral anticoagulant market more competitive, driving down their costs,” he says, referring to one of the biggest barriers to current use of these agents. Warfarin still remains the most cost-effective option, despite the need for regular INR monitoring.

“Studies are looking not only at effectiveness but also the safety profile of these anticoagulants,” Dr. Kanikkannan says, as long-term safety data is not yet available on these oral agents.^8,9

Researchers also are looking at the comparative effects of other medications. For example, a Journal of Hospital Medicine study concluded that, compared with other anticoagulants, aspirin is associated with a higher risk of DVT following hip fracture repair but similar rates of DVT risk following hip-knee arthroplasty. Bleeding rates with aspirin, however, were substantially lower.¹⁰

Improvement Efforts

In an effort to improve VTE prophylaxis in hospitalized patients, The Joint Commission developed a VTE standardized performance measure set in 2009, which has been reported on www.qualitycheck.org since then. The VTE measure set comprises six different measures evaluating the prophylaxis of VTE, treatment of VTE, warfarin discharge education, and hospital-acquired VTE. Since reporting started, most hospitals have implemented VTE risk assessment models and VTE process improvement programs; data trends have shown improvement, says Denise Krusenoski, MSN, RN, CMSRN, CHTS-CP, associate project director at The Joint Commission, which is based in Oakbrook Terrace, Ill.

“While a lot of good, evidence-based data is available, no single VTE risk assessment tool has been prospectively validated as superior,” she says. “Involving key members of medical staff to create and approve protocols based on proven data will increase the buy-in and adoption for using these tools.”

E-Measures Promote Excellence

Many hospitals are now moving from traditional chart abstracting for VTE measures to electronic measures (e-measures), which allow for more rapid and automated reporting of these quality metrics. In order for e-measures to be accurate, documentation necessary for measure computation must be present in defined standardized fields in the medical record. “With no human interpretation, data must be documented in a precise fashion,” Krusenoski says. “Providers will need to be flexible in learning new documentation skills.”

Dr. Lindsey, a member of Team Hospitalist, cautions that e-measures have the potential to increase unwanted events by overutilization of pharmacologic VTE prophylaxis and associated hemorrhagic events.

“We have to continue to make sure that our practice of medicine remains based in evidence and not succumb to the pull of getting a check-box ticked,” she warns.

VTE remains a significant problem in hospitalized patients today. Hospitalists should consider the pros and cons of using newer treatment methods over traditional agents. Efforts are under way to improve VTE prophylaxis by standardizing best practice and moving from traditional chart abstracting to using e-measures for performance reporting.

Karen Appold is a freelance medical writer in Pennsylvania.

Bringing Awareness to VTE

Thromboembolisms (VTEs) are the most common cause of preventable death in the hospitalized patient. Given the adverse outcomes and economic burden associated with VTEs, it is truly a public health concern. As Dr. Kanikkannan suggests, “Why not use the month of March—VTE awareness month—as an opportunity to educate patients about healthy lifestyle practices to prevent VTE?

“Patients can learn to identify their risk factors and become aware of symptoms that may be a cause for concern, prompting them to seek medical attention,” she says.

“It might be helpful for hospitals to arrange review sessions for VTE prophylaxis for providers and staff.” —Dr. Suehler

Hospitalists could also organize or participate in community health fairs—a great venue to spread the word about VTE and create awareness among the public. Because hospitalists frequently sit on VTE task forces in hospitals and take a lead role in implementing VTE prophylaxis efforts, they are in a prime position to implement a hospital campaign during VTE awareness month.

Keeping staff abreast of advancements is also advisable.

“It might be helpful for hospitals to arrange review sessions for VTE prophylaxis for providers and staff,” says Klaus Suehler, MD, FHM, hospitalist at Mercy Hospital Allina Health in Coon Rapids, Minn., who believes that creating awareness makes a 0% failure rate on VTE prophylaxis achievable.

—Karen Appold

References

1. Centers for Disease Control and Prevention. Public Health Grand Rounds. Preventing venous thromboembolism. January 15, 2013. Available at: http://www.cdc.gov/cdcgrandrounds/archives/2013/january2013.htm. Accessed February 12, 2015.
2. Dobesh PP. Economic burden of venous thromboembolism in hospitalized patients. Pharmacotherapy. 2009;29(8):943-953.
3. Lassen MR, Raskob GE, Gallus A, Pineo G, Chen D, Portman RJ. Apixaban or enoxaparin for thromboprophylaxis after knee replacement. N Engl J Med. 2009;361(6):594-604.
4. Lassen MR, Raskob GE, Gallus A, Pineo G, Chen D, Hornick P; ADVANCE-2 Investigators. Apixaban versus enoxaparin for thromboprophylaxis after knee replacement (ADVANCE-2): a randomised double-blind trial. Lancet. 2010;375(9717):807-815.
5. Lassen MR, Gallus A, Raskob GE, Pineo G, Chen D, Ramirez LM; ADVANCE-3 Investigators. Apixaban versus enoxaparin for thromboprophylaxis after hip replacement. N Engl J Med. 2010;363(26):2487-2498.
6. Cohen AT, Spiro TE, Büller HR, et al. Rivaroxaban for thromboprophylaxis in acutely ill medical patients. N Engl J Med. 2013;368(6):513-523.
7. Goldhaber SZ, Leizorovicz A, Kakkar AK, et al. Apixaban versus enoxaparin for thromboprophylaxis in medically ill patients. N Engl J Med. 2011;365(23):2167-2177.
8. Gonsalves WI, Pruthi RK, Patnaik MM. The new oral anticoagulants in clinical practice. Mayo Clin Proc. 2013;88(5):495-511.
9. Holster IL, Valkoff VE, Kuipers EJ, Tjwa ET. New oral anticoagulants increase risk for gastrointestinal bleeding: a systematic review and meta-analysis. Gastroenterology. 2013;145(1):105-112.
10. Drescher FS, Sirovich BE, Lee A, Morrison DH, Chiang WH, Larson RJ. Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis. J Hosp Med. 2014;9(9):579-585.
11. Bullock-Palmer RP, Weiss S, Hyman C. Innovative approaches to increase deep vein thrombosis prophylaxis rate resulting in a decrease in hospital-acquired deep vein thrombosis at a tertiary-care teaching hospital. J Hosp Med. 2008;3(2):148-155.

“While VTE may not be the No. 1 reason for hospitalization, hospitalists very frequently care for patients with VTE,” says Sowmya Kanikkannan, MD, FACP, SFHM, hospitalist medical director and assistant professor of medicine at Rowan University School of Osteopathic Medicine in Stratford, N.J. “Hospitalists usually are the frontline providers that diagnose and manage hospital-acquired VTEs in hospitalized patients.”

Dr. Kanikkannan, a member of Team Hospitalist, sees a wide range of VTE cases caused by two related conditions—deep vein thrombosis (DVT) and pulmonary embolism (PE).

“Some patients present with a straightforward diagnosis of DVT, while others have extensive DVT,” she says. “In other instances, patients present with acute PE with or without hemodynamic compromise. I’ve also diagnosed and managed hospital-acquired VTEs in medical patients, as well as post-operatively in surgical co-management.”

It is estimated that between 350,000 to 900,000 Americans are affected by DVT or PE each year, with up to 100,000 dying as a result. Twenty to 50% of people who experience DVT develop long-term complications.¹VTE costs the U.S. healthcare system more than $1.5 billion annually.²

As lieutenants in the war against VTE, hospitalists are finding that new treatments, continued efforts to standardize VTE prophylaxis, and increased transparency in performance reporting are the tools needed to combat these common conditions—and hospitalists are being held accountable for optimal patient care.

New Treatments Show Promise

Diagnosing and treating VTE early helps to prevent progression and hemodynamic instability. Although the accepted treatment for VTE used to be heparin, or a low molecular weight heparin (LMWH) (Fragmin, Innohep and Lovenox) with a transition to warfarin, three target-specific oral anticoagulants (TSOACs)—dabigatran, rivaroxaban, and apixaban—are now being prescribed. The FDA has approved rivaroxaban and apixaban for the prevention of VTE after knee and hip surgery and for treatment of VTE, while dabigatran is FDA approved only for the treatment of VTE. All three are approved for use in nonvalvular atrial fibrillation (Afib). A fourth TSOAC, edoxaban, received FDA approval in January for VTE treatment and nonvalvular atrial fibrillation.

“The drawback of warfarin is that patients need frequent international normalized ratio (INR) monitoring,” Dr. Kanikkannan says. “Discharge planning is time consuming because patients need to be educated on warfarin, and follow-up appointments need to be arranged before discharge to ensure patient safety.”

“Their [TSOACs] ease of administration and easy dosing helps hospitalists to manage patients with VTE more efficiently,” Dr. Kanikkannan says. “Patients like having lab testing less frequently but equal efficacy in treatment.”

Rivaroxaban used to have the most approved indications by the FDA; however, based on three clinical trials—ADVANCE-1, 2, and 3—apixaban has the same six FDA indications as rivaroxaban.

The majority of clinical trials suggest noninferiority or superiority of the oral agents compared to LMWH, and safety appears to be similar across treatment groups, other than an increased risk in bleeding with oral agents (see Table 1).

“The increased risk of bleeding seen in trials is something hospitalists need to consider,” says Yong Lee, PharmD, BCPS, clinical pharmacy specialist at Parkland Health and Hospital System in Dallas, Texas. Warfarin is easily reversed; the new anticoagulants don’t have any specific reversal agent (see new table about reversal options). Consequently, the American College of Chest Physicians still recommends unfractionated heparin or a LMWH for VTE prophylaxis. “These agents will still likely remain the best available options to hospitalists for VTE prevention,” he adds.

Julianna Lindsey, MD, MBA, FACP, FHM, chief of staff and hospitalist at Victory Medical Center in McKinney, Texas, says there are instances when it would be helpful to know what the therapeutic level of a TSOAC’s anticoagulation effect is, such as in a patient with active bleeding or one who requires major emergent surgery. But there is no coagulation assay to date that is readily available to test the effect of apixaban; the anticoagulation effect for dabigatran can be roughly estimated by the activated partial thromboplastin time (aPTT) and thrombin time (TT), and the anticoagulation effect for rivaroxaban can be roughly estimated by the prothrombin time (PT).

“The drawback of warfarin is that patients need frequent international normalized ratio (INR) monitoring. Discharge planning is time consuming because patients need to be educated on warfarin, and follow-up appointments need to be arranged before discharge to ensure patient safety.” —Dr. Kanikkannan

Dr. Lee expects the new FDA approvals to expand the utilization of oral anti-Xa inhibitors in practice. “This will, hopefully, make the new oral anticoagulant market more competitive, driving down their costs,” he says, referring to one of the biggest barriers to current use of these agents. Warfarin still remains the most cost-effective option, despite the need for regular INR monitoring.

“Studies are looking not only at effectiveness but also the safety profile of these anticoagulants,” Dr. Kanikkannan says, as long-term safety data is not yet available on these oral agents.^8,9

Researchers also are looking at the comparative effects of other medications. For example, a Journal of Hospital Medicine study concluded that, compared with other anticoagulants, aspirin is associated with a higher risk of DVT following hip fracture repair but similar rates of DVT risk following hip-knee arthroplasty. Bleeding rates with aspirin, however, were substantially lower.¹⁰

Improvement Efforts

In an effort to improve VTE prophylaxis in hospitalized patients, The Joint Commission developed a VTE standardized performance measure set in 2009, which has been reported on www.qualitycheck.org since then. The VTE measure set comprises six different measures evaluating the prophylaxis of VTE, treatment of VTE, warfarin discharge education, and hospital-acquired VTE. Since reporting started, most hospitals have implemented VTE risk assessment models and VTE process improvement programs; data trends have shown improvement, says Denise Krusenoski, MSN, RN, CMSRN, CHTS-CP, associate project director at The Joint Commission, which is based in Oakbrook Terrace, Ill.

“While a lot of good, evidence-based data is available, no single VTE risk assessment tool has been prospectively validated as superior,” she says. “Involving key members of medical staff to create and approve protocols based on proven data will increase the buy-in and adoption for using these tools.”

E-Measures Promote Excellence

Many hospitals are now moving from traditional chart abstracting for VTE measures to electronic measures (e-measures), which allow for more rapid and automated reporting of these quality metrics. In order for e-measures to be accurate, documentation necessary for measure computation must be present in defined standardized fields in the medical record. “With no human interpretation, data must be documented in a precise fashion,” Krusenoski says. “Providers will need to be flexible in learning new documentation skills.”

Dr. Lindsey, a member of Team Hospitalist, cautions that e-measures have the potential to increase unwanted events by overutilization of pharmacologic VTE prophylaxis and associated hemorrhagic events.

“We have to continue to make sure that our practice of medicine remains based in evidence and not succumb to the pull of getting a check-box ticked,” she warns.

VTE remains a significant problem in hospitalized patients today. Hospitalists should consider the pros and cons of using newer treatment methods over traditional agents. Efforts are under way to improve VTE prophylaxis by standardizing best practice and moving from traditional chart abstracting to using e-measures for performance reporting.

Karen Appold is a freelance medical writer in Pennsylvania.

Bringing Awareness to VTE

Thromboembolisms (VTEs) are the most common cause of preventable death in the hospitalized patient. Given the adverse outcomes and economic burden associated with VTEs, it is truly a public health concern. As Dr. Kanikkannan suggests, “Why not use the month of March—VTE awareness month—as an opportunity to educate patients about healthy lifestyle practices to prevent VTE?

“Patients can learn to identify their risk factors and become aware of symptoms that may be a cause for concern, prompting them to seek medical attention,” she says.

“It might be helpful for hospitals to arrange review sessions for VTE prophylaxis for providers and staff.” —Dr. Suehler

Hospitalists could also organize or participate in community health fairs—a great venue to spread the word about VTE and create awareness among the public. Because hospitalists frequently sit on VTE task forces in hospitals and take a lead role in implementing VTE prophylaxis efforts, they are in a prime position to implement a hospital campaign during VTE awareness month.

Keeping staff abreast of advancements is also advisable.

“It might be helpful for hospitals to arrange review sessions for VTE prophylaxis for providers and staff,” says Klaus Suehler, MD, FHM, hospitalist at Mercy Hospital Allina Health in Coon Rapids, Minn., who believes that creating awareness makes a 0% failure rate on VTE prophylaxis achievable.

—Karen Appold

References

1. Centers for Disease Control and Prevention. Public Health Grand Rounds. Preventing venous thromboembolism. January 15, 2013. Available at: http://www.cdc.gov/cdcgrandrounds/archives/2013/january2013.htm. Accessed February 12, 2015.
2. Dobesh PP. Economic burden of venous thromboembolism in hospitalized patients. Pharmacotherapy. 2009;29(8):943-953.
3. Lassen MR, Raskob GE, Gallus A, Pineo G, Chen D, Portman RJ. Apixaban or enoxaparin for thromboprophylaxis after knee replacement. N Engl J Med. 2009;361(6):594-604.
4. Lassen MR, Raskob GE, Gallus A, Pineo G, Chen D, Hornick P; ADVANCE-2 Investigators. Apixaban versus enoxaparin for thromboprophylaxis after knee replacement (ADVANCE-2): a randomised double-blind trial. Lancet. 2010;375(9717):807-815.
5. Lassen MR, Gallus A, Raskob GE, Pineo G, Chen D, Ramirez LM; ADVANCE-3 Investigators. Apixaban versus enoxaparin for thromboprophylaxis after hip replacement. N Engl J Med. 2010;363(26):2487-2498.
6. Cohen AT, Spiro TE, Büller HR, et al. Rivaroxaban for thromboprophylaxis in acutely ill medical patients. N Engl J Med. 2013;368(6):513-523.
7. Goldhaber SZ, Leizorovicz A, Kakkar AK, et al. Apixaban versus enoxaparin for thromboprophylaxis in medically ill patients. N Engl J Med. 2011;365(23):2167-2177.
8. Gonsalves WI, Pruthi RK, Patnaik MM. The new oral anticoagulants in clinical practice. Mayo Clin Proc. 2013;88(5):495-511.
9. Holster IL, Valkoff VE, Kuipers EJ, Tjwa ET. New oral anticoagulants increase risk for gastrointestinal bleeding: a systematic review and meta-analysis. Gastroenterology. 2013;145(1):105-112.
10. Drescher FS, Sirovich BE, Lee A, Morrison DH, Chiang WH, Larson RJ. Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis. J Hosp Med. 2014;9(9):579-585.
11. Bullock-Palmer RP, Weiss S, Hyman C. Innovative approaches to increase deep vein thrombosis prophylaxis rate resulting in a decrease in hospital-acquired deep vein thrombosis at a tertiary-care teaching hospital. J Hosp Med. 2008;3(2):148-155.

“While VTE may not be the No. 1 reason for hospitalization, hospitalists very frequently care for patients with VTE,” says Sowmya Kanikkannan, MD, FACP, SFHM, hospitalist medical director and assistant professor of medicine at Rowan University School of Osteopathic Medicine in Stratford, N.J. “Hospitalists usually are the frontline providers that diagnose and manage hospital-acquired VTEs in hospitalized patients.”

Dr. Kanikkannan, a member of Team Hospitalist, sees a wide range of VTE cases caused by two related conditions—deep vein thrombosis (DVT) and pulmonary embolism (PE).

“Some patients present with a straightforward diagnosis of DVT, while others have extensive DVT,” she says. “In other instances, patients present with acute PE with or without hemodynamic compromise. I’ve also diagnosed and managed hospital-acquired VTEs in medical patients, as well as post-operatively in surgical co-management.”

It is estimated that between 350,000 to 900,000 Americans are affected by DVT or PE each year, with up to 100,000 dying as a result. Twenty to 50% of people who experience DVT develop long-term complications.¹VTE costs the U.S. healthcare system more than $1.5 billion annually.²

As lieutenants in the war against VTE, hospitalists are finding that new treatments, continued efforts to standardize VTE prophylaxis, and increased transparency in performance reporting are the tools needed to combat these common conditions—and hospitalists are being held accountable for optimal patient care.

New Treatments Show Promise

Diagnosing and treating VTE early helps to prevent progression and hemodynamic instability. Although the accepted treatment for VTE used to be heparin, or a low molecular weight heparin (LMWH) (Fragmin, Innohep and Lovenox) with a transition to warfarin, three target-specific oral anticoagulants (TSOACs)—dabigatran, rivaroxaban, and apixaban—are now being prescribed. The FDA has approved rivaroxaban and apixaban for the prevention of VTE after knee and hip surgery and for treatment of VTE, while dabigatran is FDA approved only for the treatment of VTE. All three are approved for use in nonvalvular atrial fibrillation (Afib). A fourth TSOAC, edoxaban, received FDA approval in January for VTE treatment and nonvalvular atrial fibrillation.

“The drawback of warfarin is that patients need frequent international normalized ratio (INR) monitoring,” Dr. Kanikkannan says. “Discharge planning is time consuming because patients need to be educated on warfarin, and follow-up appointments need to be arranged before discharge to ensure patient safety.”

“Their [TSOACs] ease of administration and easy dosing helps hospitalists to manage patients with VTE more efficiently,” Dr. Kanikkannan says. “Patients like having lab testing less frequently but equal efficacy in treatment.”

Rivaroxaban used to have the most approved indications by the FDA; however, based on three clinical trials—ADVANCE-1, 2, and 3—apixaban has the same six FDA indications as rivaroxaban.

The majority of clinical trials suggest noninferiority or superiority of the oral agents compared to LMWH, and safety appears to be similar across treatment groups, other than an increased risk in bleeding with oral agents (see Table 1).

“The increased risk of bleeding seen in trials is something hospitalists need to consider,” says Yong Lee, PharmD, BCPS, clinical pharmacy specialist at Parkland Health and Hospital System in Dallas, Texas. Warfarin is easily reversed; the new anticoagulants don’t have any specific reversal agent (see new table about reversal options). Consequently, the American College of Chest Physicians still recommends unfractionated heparin or a LMWH for VTE prophylaxis. “These agents will still likely remain the best available options to hospitalists for VTE prevention,” he adds.

Julianna Lindsey, MD, MBA, FACP, FHM, chief of staff and hospitalist at Victory Medical Center in McKinney, Texas, says there are instances when it would be helpful to know what the therapeutic level of a TSOAC’s anticoagulation effect is, such as in a patient with active bleeding or one who requires major emergent surgery. But there is no coagulation assay to date that is readily available to test the effect of apixaban; the anticoagulation effect for dabigatran can be roughly estimated by the activated partial thromboplastin time (aPTT) and thrombin time (TT), and the anticoagulation effect for rivaroxaban can be roughly estimated by the prothrombin time (PT).

“The drawback of warfarin is that patients need frequent international normalized ratio (INR) monitoring. Discharge planning is time consuming because patients need to be educated on warfarin, and follow-up appointments need to be arranged before discharge to ensure patient safety.” —Dr. Kanikkannan

Dr. Lee expects the new FDA approvals to expand the utilization of oral anti-Xa inhibitors in practice. “This will, hopefully, make the new oral anticoagulant market more competitive, driving down their costs,” he says, referring to one of the biggest barriers to current use of these agents. Warfarin still remains the most cost-effective option, despite the need for regular INR monitoring.

“Studies are looking not only at effectiveness but also the safety profile of these anticoagulants,” Dr. Kanikkannan says, as long-term safety data is not yet available on these oral agents.^8,9

Researchers also are looking at the comparative effects of other medications. For example, a Journal of Hospital Medicine study concluded that, compared with other anticoagulants, aspirin is associated with a higher risk of DVT following hip fracture repair but similar rates of DVT risk following hip-knee arthroplasty. Bleeding rates with aspirin, however, were substantially lower.¹⁰

Improvement Efforts

In an effort to improve VTE prophylaxis in hospitalized patients, The Joint Commission developed a VTE standardized performance measure set in 2009, which has been reported on www.qualitycheck.org since then. The VTE measure set comprises six different measures evaluating the prophylaxis of VTE, treatment of VTE, warfarin discharge education, and hospital-acquired VTE. Since reporting started, most hospitals have implemented VTE risk assessment models and VTE process improvement programs; data trends have shown improvement, says Denise Krusenoski, MSN, RN, CMSRN, CHTS-CP, associate project director at The Joint Commission, which is based in Oakbrook Terrace, Ill.

“While a lot of good, evidence-based data is available, no single VTE risk assessment tool has been prospectively validated as superior,” she says. “Involving key members of medical staff to create and approve protocols based on proven data will increase the buy-in and adoption for using these tools.”

E-Measures Promote Excellence

Many hospitals are now moving from traditional chart abstracting for VTE measures to electronic measures (e-measures), which allow for more rapid and automated reporting of these quality metrics. In order for e-measures to be accurate, documentation necessary for measure computation must be present in defined standardized fields in the medical record. “With no human interpretation, data must be documented in a precise fashion,” Krusenoski says. “Providers will need to be flexible in learning new documentation skills.”

Dr. Lindsey, a member of Team Hospitalist, cautions that e-measures have the potential to increase unwanted events by overutilization of pharmacologic VTE prophylaxis and associated hemorrhagic events.

“We have to continue to make sure that our practice of medicine remains based in evidence and not succumb to the pull of getting a check-box ticked,” she warns.

VTE remains a significant problem in hospitalized patients today. Hospitalists should consider the pros and cons of using newer treatment methods over traditional agents. Efforts are under way to improve VTE prophylaxis by standardizing best practice and moving from traditional chart abstracting to using e-measures for performance reporting.

Karen Appold is a freelance medical writer in Pennsylvania.

Bringing Awareness to VTE

Thromboembolisms (VTEs) are the most common cause of preventable death in the hospitalized patient. Given the adverse outcomes and economic burden associated with VTEs, it is truly a public health concern. As Dr. Kanikkannan suggests, “Why not use the month of March—VTE awareness month—as an opportunity to educate patients about healthy lifestyle practices to prevent VTE?

“Patients can learn to identify their risk factors and become aware of symptoms that may be a cause for concern, prompting them to seek medical attention,” she says.

“It might be helpful for hospitals to arrange review sessions for VTE prophylaxis for providers and staff.” —Dr. Suehler

Hospitalists could also organize or participate in community health fairs—a great venue to spread the word about VTE and create awareness among the public. Because hospitalists frequently sit on VTE task forces in hospitals and take a lead role in implementing VTE prophylaxis efforts, they are in a prime position to implement a hospital campaign during VTE awareness month.

Keeping staff abreast of advancements is also advisable.

“It might be helpful for hospitals to arrange review sessions for VTE prophylaxis for providers and staff,” says Klaus Suehler, MD, FHM, hospitalist at Mercy Hospital Allina Health in Coon Rapids, Minn., who believes that creating awareness makes a 0% failure rate on VTE prophylaxis achievable.

—Karen Appold

References

1. Centers for Disease Control and Prevention. Public Health Grand Rounds. Preventing venous thromboembolism. January 15, 2013. Available at: http://www.cdc.gov/cdcgrandrounds/archives/2013/january2013.htm. Accessed February 12, 2015.
2. Dobesh PP. Economic burden of venous thromboembolism in hospitalized patients. Pharmacotherapy. 2009;29(8):943-953.
3. Lassen MR, Raskob GE, Gallus A, Pineo G, Chen D, Portman RJ. Apixaban or enoxaparin for thromboprophylaxis after knee replacement. N Engl J Med. 2009;361(6):594-604.
4. Lassen MR, Raskob GE, Gallus A, Pineo G, Chen D, Hornick P; ADVANCE-2 Investigators. Apixaban versus enoxaparin for thromboprophylaxis after knee replacement (ADVANCE-2): a randomised double-blind trial. Lancet. 2010;375(9717):807-815.
5. Lassen MR, Gallus A, Raskob GE, Pineo G, Chen D, Ramirez LM; ADVANCE-3 Investigators. Apixaban versus enoxaparin for thromboprophylaxis after hip replacement. N Engl J Med. 2010;363(26):2487-2498.
6. Cohen AT, Spiro TE, Büller HR, et al. Rivaroxaban for thromboprophylaxis in acutely ill medical patients. N Engl J Med. 2013;368(6):513-523.
7. Goldhaber SZ, Leizorovicz A, Kakkar AK, et al. Apixaban versus enoxaparin for thromboprophylaxis in medically ill patients. N Engl J Med. 2011;365(23):2167-2177.
8. Gonsalves WI, Pruthi RK, Patnaik MM. The new oral anticoagulants in clinical practice. Mayo Clin Proc. 2013;88(5):495-511.
9. Holster IL, Valkoff VE, Kuipers EJ, Tjwa ET. New oral anticoagulants increase risk for gastrointestinal bleeding: a systematic review and meta-analysis. Gastroenterology. 2013;145(1):105-112.
10. Drescher FS, Sirovich BE, Lee A, Morrison DH, Chiang WH, Larson RJ. Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis. J Hosp Med. 2014;9(9):579-585.
11. Bullock-Palmer RP, Weiss S, Hyman C. Innovative approaches to increase deep vein thrombosis prophylaxis rate resulting in a decrease in hospital-acquired deep vein thrombosis at a tertiary-care teaching hospital. J Hosp Med. 2008;3(2):148-155.

A dedicated procedure team or service can give hospitals needed expertise without requiring a one-size-fits-all approach. In many cases, hospitalists run procedure services, but interventional radiologists and pulmonary critical care specialists also oversee some of them.

At The Johns Hopkins Hospital, the bedside procedure service began in the department of medicine and has since expanded throughout the hospital.

“I think a proceduralist service is as important as the hospitalist service,” says David Lichtman, PA, director of the service. He calls it “essential” for good patient care because it can allow experienced providers to be consistently involved in the process, whether proceduralists, medical students, or new interns perform the procedure.

“Patients have the benefit of expert care, and the trainees have the ability to learn and do without having to worry about working without a safety net,” he says. As a result, the service keeps patients safe while maximizing medical education.

At many institutions, a service or team can also meet a pressing need. In its seven years of existence, for example, the hospitalist-led procedures team at the University of Miami Jackson Memorial Hospital Medical Campus has been called upon to do more than 7,500 procedures.

“The idea behind procedure services is that you consolidate the expertise and training within a few people, be it a few hospitalists or a few proceduralists,” says Michelle Mourad, MD, director of quality improvement and patient safety for the division of hospital medicine at the University of California

San Francisco (UCSF). But a successful service can require significant investments in infrastructure and other resources. When they run the numbers, many hospitalist groups are forced to conclude that they simply don’t have sufficient demand to justify the expense of maintaining provider competency.

“People are really struggling with this,” she says.

I derive a tremendous amount of enjoyment from working with my hands, from being able to provide my patients this service, from often giving them relief from excessive fluid buildup, and from being able to do these procedures at the bedside. —Michelle Mourad, MD, associate professor of clinical medicine and director of quality improvement and patient safety, division of hospital medicine, University of California San Francisco

The few studies conducted on procedure services, however, suggest that hospitals can benefit from improved patient satisfaction and a potential reduction in some complications.

“We were worried that that use of trainees and the teaching that went on at the bedside might be a concern for patients,” Dr. Mourad says of the UCSF procedures program. “We found that, instead, patients were reassured by having a designated expert in the room and recognized that it hadn’t always been the case in the past.” Accordingly, she says, a survey of satisfaction recorded “exceptionally high” rates.³

Initial research also suggests a reduction in such complications as thoracentesis-related pneumothorax.

“We have some inkling that perhaps the rigor with which we approach procedures, the high level of experience that we bring to procedures, and the presence of an expert in the room for every procedure may have decreased the complication rate for thoracentesis at our institution,” Dr. Mourad says.

At Boston University, the procedure service is based in the department of pulmonary critical care, and the department’s attending physicians supervise internal medicine residents. It was developed after “identifying some potential patient safety concerns with unsupervised resident procedures,” says Melissa Tukey, MD, MSc, now a pulmonology critical care physician at Lahey Clinic in Burlington, Mass. A major aim of the procedure service, she says, is to provide supervision and teaching to medical house staff performing the procedures.

To test whether the service was delivering on those goals, Dr. Tukey and colleagues studied thoracentesis, paracentesis, central line, and lumbar puncture procedures.⁴ The study, an 18-month comparison of the procedures performed by the dedicated procedure service versus those done by other providers, found no significant difference in what were already quite low complication rates.

Unexpectedly, the researchers didn’t see higher levels of resident engagement in procedures performed by the procedure team, but they did find improvement in “best practice safety process measures,” such as whether ultrasound use followed established recommendations.

“I think that whenever you’re looking at quality improvement initiatives, you have to have an understanding of what might be the potential benefits,”

Dr. Tukey says. Her study, at least, suggests that launching a procedure service primarily to reduce the number of severe complications may not be the most appropriate goal. On the other hand, she says, the data do support the “very realistic goals” of improving residency education and maintaining procedure quality.

A dedicated service may not be a cure-all, in other words. And it’s certainly not for everyone. But given enough resources and buy-in, experts say, it could at least help put a hospital’s ailing bedside procedure strategy on the road to recovery without overextending its providers.

A dedicated procedure team or service can give hospitals needed expertise without requiring a one-size-fits-all approach. In many cases, hospitalists run procedure services, but interventional radiologists and pulmonary critical care specialists also oversee some of them.

At The Johns Hopkins Hospital, the bedside procedure service began in the department of medicine and has since expanded throughout the hospital.

“I think a proceduralist service is as important as the hospitalist service,” says David Lichtman, PA, director of the service. He calls it “essential” for good patient care because it can allow experienced providers to be consistently involved in the process, whether proceduralists, medical students, or new interns perform the procedure.

“Patients have the benefit of expert care, and the trainees have the ability to learn and do without having to worry about working without a safety net,” he says. As a result, the service keeps patients safe while maximizing medical education.

At many institutions, a service or team can also meet a pressing need. In its seven years of existence, for example, the hospitalist-led procedures team at the University of Miami Jackson Memorial Hospital Medical Campus has been called upon to do more than 7,500 procedures.

“The idea behind procedure services is that you consolidate the expertise and training within a few people, be it a few hospitalists or a few proceduralists,” says Michelle Mourad, MD, director of quality improvement and patient safety for the division of hospital medicine at the University of California

San Francisco (UCSF). But a successful service can require significant investments in infrastructure and other resources. When they run the numbers, many hospitalist groups are forced to conclude that they simply don’t have sufficient demand to justify the expense of maintaining provider competency.

“People are really struggling with this,” she says.

I derive a tremendous amount of enjoyment from working with my hands, from being able to provide my patients this service, from often giving them relief from excessive fluid buildup, and from being able to do these procedures at the bedside. —Michelle Mourad, MD, associate professor of clinical medicine and director of quality improvement and patient safety, division of hospital medicine, University of California San Francisco

The few studies conducted on procedure services, however, suggest that hospitals can benefit from improved patient satisfaction and a potential reduction in some complications.

“We were worried that that use of trainees and the teaching that went on at the bedside might be a concern for patients,” Dr. Mourad says of the UCSF procedures program. “We found that, instead, patients were reassured by having a designated expert in the room and recognized that it hadn’t always been the case in the past.” Accordingly, she says, a survey of satisfaction recorded “exceptionally high” rates.³

Initial research also suggests a reduction in such complications as thoracentesis-related pneumothorax.

“We have some inkling that perhaps the rigor with which we approach procedures, the high level of experience that we bring to procedures, and the presence of an expert in the room for every procedure may have decreased the complication rate for thoracentesis at our institution,” Dr. Mourad says.

At Boston University, the procedure service is based in the department of pulmonary critical care, and the department’s attending physicians supervise internal medicine residents. It was developed after “identifying some potential patient safety concerns with unsupervised resident procedures,” says Melissa Tukey, MD, MSc, now a pulmonology critical care physician at Lahey Clinic in Burlington, Mass. A major aim of the procedure service, she says, is to provide supervision and teaching to medical house staff performing the procedures.

To test whether the service was delivering on those goals, Dr. Tukey and colleagues studied thoracentesis, paracentesis, central line, and lumbar puncture procedures.⁴ The study, an 18-month comparison of the procedures performed by the dedicated procedure service versus those done by other providers, found no significant difference in what were already quite low complication rates.

Unexpectedly, the researchers didn’t see higher levels of resident engagement in procedures performed by the procedure team, but they did find improvement in “best practice safety process measures,” such as whether ultrasound use followed established recommendations.

“I think that whenever you’re looking at quality improvement initiatives, you have to have an understanding of what might be the potential benefits,”

Dr. Tukey says. Her study, at least, suggests that launching a procedure service primarily to reduce the number of severe complications may not be the most appropriate goal. On the other hand, she says, the data do support the “very realistic goals” of improving residency education and maintaining procedure quality.

A dedicated service may not be a cure-all, in other words. And it’s certainly not for everyone. But given enough resources and buy-in, experts say, it could at least help put a hospital’s ailing bedside procedure strategy on the road to recovery without overextending its providers.

A dedicated procedure team or service can give hospitals needed expertise without requiring a one-size-fits-all approach. In many cases, hospitalists run procedure services, but interventional radiologists and pulmonary critical care specialists also oversee some of them.

At The Johns Hopkins Hospital, the bedside procedure service began in the department of medicine and has since expanded throughout the hospital.

“I think a proceduralist service is as important as the hospitalist service,” says David Lichtman, PA, director of the service. He calls it “essential” for good patient care because it can allow experienced providers to be consistently involved in the process, whether proceduralists, medical students, or new interns perform the procedure.

“Patients have the benefit of expert care, and the trainees have the ability to learn and do without having to worry about working without a safety net,” he says. As a result, the service keeps patients safe while maximizing medical education.

At many institutions, a service or team can also meet a pressing need. In its seven years of existence, for example, the hospitalist-led procedures team at the University of Miami Jackson Memorial Hospital Medical Campus has been called upon to do more than 7,500 procedures.

“The idea behind procedure services is that you consolidate the expertise and training within a few people, be it a few hospitalists or a few proceduralists,” says Michelle Mourad, MD, director of quality improvement and patient safety for the division of hospital medicine at the University of California

San Francisco (UCSF). But a successful service can require significant investments in infrastructure and other resources. When they run the numbers, many hospitalist groups are forced to conclude that they simply don’t have sufficient demand to justify the expense of maintaining provider competency.

“People are really struggling with this,” she says.

I derive a tremendous amount of enjoyment from working with my hands, from being able to provide my patients this service, from often giving them relief from excessive fluid buildup, and from being able to do these procedures at the bedside. —Michelle Mourad, MD, associate professor of clinical medicine and director of quality improvement and patient safety, division of hospital medicine, University of California San Francisco

The few studies conducted on procedure services, however, suggest that hospitals can benefit from improved patient satisfaction and a potential reduction in some complications.

“We were worried that that use of trainees and the teaching that went on at the bedside might be a concern for patients,” Dr. Mourad says of the UCSF procedures program. “We found that, instead, patients were reassured by having a designated expert in the room and recognized that it hadn’t always been the case in the past.” Accordingly, she says, a survey of satisfaction recorded “exceptionally high” rates.³

Initial research also suggests a reduction in such complications as thoracentesis-related pneumothorax.

“We have some inkling that perhaps the rigor with which we approach procedures, the high level of experience that we bring to procedures, and the presence of an expert in the room for every procedure may have decreased the complication rate for thoracentesis at our institution,” Dr. Mourad says.

At Boston University, the procedure service is based in the department of pulmonary critical care, and the department’s attending physicians supervise internal medicine residents. It was developed after “identifying some potential patient safety concerns with unsupervised resident procedures,” says Melissa Tukey, MD, MSc, now a pulmonology critical care physician at Lahey Clinic in Burlington, Mass. A major aim of the procedure service, she says, is to provide supervision and teaching to medical house staff performing the procedures.

To test whether the service was delivering on those goals, Dr. Tukey and colleagues studied thoracentesis, paracentesis, central line, and lumbar puncture procedures.⁴ The study, an 18-month comparison of the procedures performed by the dedicated procedure service versus those done by other providers, found no significant difference in what were already quite low complication rates.

Unexpectedly, the researchers didn’t see higher levels of resident engagement in procedures performed by the procedure team, but they did find improvement in “best practice safety process measures,” such as whether ultrasound use followed established recommendations.

“I think that whenever you’re looking at quality improvement initiatives, you have to have an understanding of what might be the potential benefits,”

Dr. Tukey says. Her study, at least, suggests that launching a procedure service primarily to reduce the number of severe complications may not be the most appropriate goal. On the other hand, she says, the data do support the “very realistic goals” of improving residency education and maintaining procedure quality.

A dedicated service may not be a cure-all, in other words. And it’s certainly not for everyone. But given enough resources and buy-in, experts say, it could at least help put a hospital’s ailing bedside procedure strategy on the road to recovery without overextending its providers.

As a group director at a growing, university-based hospitalist program, I often interview aspiring academic hospitalists. Inevitably, the conversation turns to a coveted aspect of the job. I’m not talking about the salary. Applicants want to know, “How much time will I spend on teaching services?”

Because hospitalists at academic institutions typically are passionate about their work as instructors and mentors, they highly value time with trainees. Unfortunately, the 2011 Accreditation Council for Graduate Medical Education (ACGME) work hour rules triggered an expansion in non-teaching services at many teaching hospitals, forcing groups either to divide teaching service among an increasing number of attending physicians or to allocate this commodity unevenly on grounds such as seniority. For many group leaders, striking the right balance between teaching and non-teaching service can be an important contributor to recruitment and retention. During these interviews, I’ve often wondered how our group compares to others around the country.

The 2014 State of Hospital Medicine report (SOHM) shines light on this topic.

Among the 422 groups that only care for adults, 52 self-reported as academic groups. The groups were then asked to describe how they distribute work duties. In these academic practices, about half (52.5%) of the group’s full-time equivalents (FTEs) were devoted to clinical work in which the attending supervises learners delivering care. The remaining FTEs were devoted to a mix of clinical work on non-teaching services, administration, and protected time for research.

Interestingly, the portion devoted to clinical teaching differs substantially between university-based and affiliated community teaching hospitals (36.2% vs. 79.1%), suggesting that hospitalists face tough competition for teaching time at the main campuses of academic systems but might have more opportunities to teach at the bedside in faculty jobs at affiliated hospitals.

The above FTE figures represent averages, which don’t tell the whole story. Groups might not distribute teaching time evenly; the approach to allocation ranges from a completely egalitarian approach to a system with two tiers that separate teaching and non-teaching hospitalists.

To address the ranges, the State of Hospital Medicine survey asked respondents to divide their faculty into five categories of individual job types, ranging from “No clinical activity with trainees” to “>75% of clinical activity with trainees” (see Figure 1). The results show a broad array of teaching responsibilities, with 20% of academic hospitalists spending no time teaching and another 21% spending almost all of their time teaching.

I suspect this distribution partially reflects the underlying interests of the individual hospitalists, but it is also a product of the available opportunities. A few factors might influence those opportunities, such as decisions by the hospital to hire hospitalists rather than nurse practitioners and physicians assistants to cover new services, or the presence of specialists and general internists who share teaching service slots with hospitalists.

One of the great things about SHM’s State of Hospital Medicine report is how it depicts the wide variety of careers available to hospitalists; the teaching environment is no exception. Although I strive to help my colleagues tailor positions to suit their interests, we never have quite enough resident service time to meet the demands of our enthusiastic teachers. Fortunately, this report allows me to discuss our job openings with candidates knowing how we stack up against academic programs around the country.

Dr. White is assistant professor of medicine at the University of Washington and hospitalist group director at the University of Washington Medical Center in Seattle.

As a group director at a growing, university-based hospitalist program, I often interview aspiring academic hospitalists. Inevitably, the conversation turns to a coveted aspect of the job. I’m not talking about the salary. Applicants want to know, “How much time will I spend on teaching services?”

Because hospitalists at academic institutions typically are passionate about their work as instructors and mentors, they highly value time with trainees. Unfortunately, the 2011 Accreditation Council for Graduate Medical Education (ACGME) work hour rules triggered an expansion in non-teaching services at many teaching hospitals, forcing groups either to divide teaching service among an increasing number of attending physicians or to allocate this commodity unevenly on grounds such as seniority. For many group leaders, striking the right balance between teaching and non-teaching service can be an important contributor to recruitment and retention. During these interviews, I’ve often wondered how our group compares to others around the country.

The 2014 State of Hospital Medicine report (SOHM) shines light on this topic.

Among the 422 groups that only care for adults, 52 self-reported as academic groups. The groups were then asked to describe how they distribute work duties. In these academic practices, about half (52.5%) of the group’s full-time equivalents (FTEs) were devoted to clinical work in which the attending supervises learners delivering care. The remaining FTEs were devoted to a mix of clinical work on non-teaching services, administration, and protected time for research.

Interestingly, the portion devoted to clinical teaching differs substantially between university-based and affiliated community teaching hospitals (36.2% vs. 79.1%), suggesting that hospitalists face tough competition for teaching time at the main campuses of academic systems but might have more opportunities to teach at the bedside in faculty jobs at affiliated hospitals.

The above FTE figures represent averages, which don’t tell the whole story. Groups might not distribute teaching time evenly; the approach to allocation ranges from a completely egalitarian approach to a system with two tiers that separate teaching and non-teaching hospitalists.

To address the ranges, the State of Hospital Medicine survey asked respondents to divide their faculty into five categories of individual job types, ranging from “No clinical activity with trainees” to “>75% of clinical activity with trainees” (see Figure 1). The results show a broad array of teaching responsibilities, with 20% of academic hospitalists spending no time teaching and another 21% spending almost all of their time teaching.

I suspect this distribution partially reflects the underlying interests of the individual hospitalists, but it is also a product of the available opportunities. A few factors might influence those opportunities, such as decisions by the hospital to hire hospitalists rather than nurse practitioners and physicians assistants to cover new services, or the presence of specialists and general internists who share teaching service slots with hospitalists.

One of the great things about SHM’s State of Hospital Medicine report is how it depicts the wide variety of careers available to hospitalists; the teaching environment is no exception. Although I strive to help my colleagues tailor positions to suit their interests, we never have quite enough resident service time to meet the demands of our enthusiastic teachers. Fortunately, this report allows me to discuss our job openings with candidates knowing how we stack up against academic programs around the country.

Dr. White is assistant professor of medicine at the University of Washington and hospitalist group director at the University of Washington Medical Center in Seattle.

As a group director at a growing, university-based hospitalist program, I often interview aspiring academic hospitalists. Inevitably, the conversation turns to a coveted aspect of the job. I’m not talking about the salary. Applicants want to know, “How much time will I spend on teaching services?”

Because hospitalists at academic institutions typically are passionate about their work as instructors and mentors, they highly value time with trainees. Unfortunately, the 2011 Accreditation Council for Graduate Medical Education (ACGME) work hour rules triggered an expansion in non-teaching services at many teaching hospitals, forcing groups either to divide teaching service among an increasing number of attending physicians or to allocate this commodity unevenly on grounds such as seniority. For many group leaders, striking the right balance between teaching and non-teaching service can be an important contributor to recruitment and retention. During these interviews, I’ve often wondered how our group compares to others around the country.

The 2014 State of Hospital Medicine report (SOHM) shines light on this topic.

Among the 422 groups that only care for adults, 52 self-reported as academic groups. The groups were then asked to describe how they distribute work duties. In these academic practices, about half (52.5%) of the group’s full-time equivalents (FTEs) were devoted to clinical work in which the attending supervises learners delivering care. The remaining FTEs were devoted to a mix of clinical work on non-teaching services, administration, and protected time for research.

Interestingly, the portion devoted to clinical teaching differs substantially between university-based and affiliated community teaching hospitals (36.2% vs. 79.1%), suggesting that hospitalists face tough competition for teaching time at the main campuses of academic systems but might have more opportunities to teach at the bedside in faculty jobs at affiliated hospitals.

The above FTE figures represent averages, which don’t tell the whole story. Groups might not distribute teaching time evenly; the approach to allocation ranges from a completely egalitarian approach to a system with two tiers that separate teaching and non-teaching hospitalists.

To address the ranges, the State of Hospital Medicine survey asked respondents to divide their faculty into five categories of individual job types, ranging from “No clinical activity with trainees” to “>75% of clinical activity with trainees” (see Figure 1). The results show a broad array of teaching responsibilities, with 20% of academic hospitalists spending no time teaching and another 21% spending almost all of their time teaching.

I suspect this distribution partially reflects the underlying interests of the individual hospitalists, but it is also a product of the available opportunities. A few factors might influence those opportunities, such as decisions by the hospital to hire hospitalists rather than nurse practitioners and physicians assistants to cover new services, or the presence of specialists and general internists who share teaching service slots with hospitalists.

One of the great things about SHM’s State of Hospital Medicine report is how it depicts the wide variety of careers available to hospitalists; the teaching environment is no exception. Although I strive to help my colleagues tailor positions to suit their interests, we never have quite enough resident service time to meet the demands of our enthusiastic teachers. Fortunately, this report allows me to discuss our job openings with candidates knowing how we stack up against academic programs around the country.

Dr. White is assistant professor of medicine at the University of Washington and hospitalist group director at the University of Washington Medical Center in Seattle.

The movement toward greater transparency of financial information in healthcare is providing patients with access to data that might affect their healthcare decisions. Not all of this information is provided in ways that give patients the full picture, and they may turn to you for some added clarity.

Financial Relationships

The Physician Payments Sunshine Act (“Sunshine Act’) was passed as a part of the Affordable Care Act and requires the public disclosure of financial relationships between physicians and the manufacturers of pharmaceuticals, devices, and supplies, as well as group purchasing organizations. The first wave of financial information was publicly disclosed in 2014 on the federal Open Payments website. When it went live, the website disclosed approximately $3.5 billion in payments made by manufacturers to physicians and teaching hospitals during the last five months of 2013. These payments include research grants, consulting fees, speaking fees, travel, and other expenses. In the future, the payments reported will span an entire year, further increasing the total dollar amount paid by industry.

The Sunshine Act is intended to expose potential conflicts of interest in healthcare so that patients are more informed consumers of healthcare services. The relationships between healthcare providers and industry have been scrutinized much more heavily over the past decade. The concern is that physicians with a financial interest, whether through a consultancy relationship with industry or through the development of new technology, might be biased in treating patients because of these relationships. On the other hand, the majority of relationships between healthcare providers and industry can be beneficial. The relationships provide education to other providers, encourage the development of new treatment options, and improve the effectiveness of existing treatments.

The Centers for Medicare and Medicaid Services (CMS) explains on its website that the disclosed financial ties are not necessarily indicators of any wrongdoing, and that the intent of publishing the information is to promote transparency and discourage inappropriate relationships. Without the proper context, these relationships could be viewed as improper by patients and the general public. Therefore, providers should be prepared to answer patients’ questions and possibly even proactively provide details, such as the scope of any relationship with industry. Many providers begin to consult with a pharmaceutical or device manufacturer because of their experience using a particular product, rather than using a particular product after forming that financial relationship. This context could shift patients’ views of what it means for their providers to have this type of connection with industry.

Providers also need to be aware that government agencies, insurers, and attorneys can track this data. Although it is still too early to know the full scope of the potential uses of this information in government investigations, insurance carrier decisions, malpractice, or other legal actions, it does provide further reason to ensure that the information posted is accurate.

During the initial launch of the Open Payments website, some data was temporarily removed due to inaccuracies, including payments linked incorrectly to physicians with the same first and last names. While these issues are being reviewed by CMS, their existence proves how important it is for all physicians (even those not affiliated with the industry) to review the data reported in order to ensure the accuracy of their information.

Procedure Costs

Another transparency requirement in the Affordable Care Act was implemented on Oct. 1, 2014, as part of the inpatient prospective payment system final rule. Hospitals are now required to make their prices for procedures public and update the list annually. The final rule is not explicit with respect to the manner of the disclosure, except that either a price list or the policy for obtaining access must be made public. Some complain that the rule is difficult to comply with because it is vague, while others point out that this fact gives hospitals necessary flexibility in the method of reporting. It is at the hospital’s discretion whether to post the information online or in a physical location.

It is important to note that patients with private payer insurance coverage have distinct rates that are set through agreements between their health plans and the hospitals, so information on the public list very likely will not be applicable to those patients and could be a source of confusion.

As patients have more access to information about the costs for procedures, providers need to be aware of where within the facility they should refer patients with questions or concerns, including information on a hospital’s financial assistance programs.

There are so many sources of information that patients and their families can obtain before ever setting foot in the hospital. An open dialogue with patients that emphasizes the context of any financial relationships with industry, including the benefits, can help to minimize the potential that the information will be treated as suspect by your patients.

Further, as patients bear more of the costs of healthcare, questions surrounding the costs of procedures relative to published data may be encountered more frequently at the bedside and in office visits. This information may have an impact on patients’ decisions about their care.

The movement toward greater transparency of financial information in healthcare is providing patients with access to data that might affect their healthcare decisions. Not all of this information is provided in ways that give patients the full picture, and they may turn to you for some added clarity.

Financial Relationships

The Physician Payments Sunshine Act (“Sunshine Act’) was passed as a part of the Affordable Care Act and requires the public disclosure of financial relationships between physicians and the manufacturers of pharmaceuticals, devices, and supplies, as well as group purchasing organizations. The first wave of financial information was publicly disclosed in 2014 on the federal Open Payments website. When it went live, the website disclosed approximately $3.5 billion in payments made by manufacturers to physicians and teaching hospitals during the last five months of 2013. These payments include research grants, consulting fees, speaking fees, travel, and other expenses. In the future, the payments reported will span an entire year, further increasing the total dollar amount paid by industry.

The Sunshine Act is intended to expose potential conflicts of interest in healthcare so that patients are more informed consumers of healthcare services. The relationships between healthcare providers and industry have been scrutinized much more heavily over the past decade. The concern is that physicians with a financial interest, whether through a consultancy relationship with industry or through the development of new technology, might be biased in treating patients because of these relationships. On the other hand, the majority of relationships between healthcare providers and industry can be beneficial. The relationships provide education to other providers, encourage the development of new treatment options, and improve the effectiveness of existing treatments.

The Centers for Medicare and Medicaid Services (CMS) explains on its website that the disclosed financial ties are not necessarily indicators of any wrongdoing, and that the intent of publishing the information is to promote transparency and discourage inappropriate relationships. Without the proper context, these relationships could be viewed as improper by patients and the general public. Therefore, providers should be prepared to answer patients’ questions and possibly even proactively provide details, such as the scope of any relationship with industry. Many providers begin to consult with a pharmaceutical or device manufacturer because of their experience using a particular product, rather than using a particular product after forming that financial relationship. This context could shift patients’ views of what it means for their providers to have this type of connection with industry.

Providers also need to be aware that government agencies, insurers, and attorneys can track this data. Although it is still too early to know the full scope of the potential uses of this information in government investigations, insurance carrier decisions, malpractice, or other legal actions, it does provide further reason to ensure that the information posted is accurate.

During the initial launch of the Open Payments website, some data was temporarily removed due to inaccuracies, including payments linked incorrectly to physicians with the same first and last names. While these issues are being reviewed by CMS, their existence proves how important it is for all physicians (even those not affiliated with the industry) to review the data reported in order to ensure the accuracy of their information.

Procedure Costs

Another transparency requirement in the Affordable Care Act was implemented on Oct. 1, 2014, as part of the inpatient prospective payment system final rule. Hospitals are now required to make their prices for procedures public and update the list annually. The final rule is not explicit with respect to the manner of the disclosure, except that either a price list or the policy for obtaining access must be made public. Some complain that the rule is difficult to comply with because it is vague, while others point out that this fact gives hospitals necessary flexibility in the method of reporting. It is at the hospital’s discretion whether to post the information online or in a physical location.

It is important to note that patients with private payer insurance coverage have distinct rates that are set through agreements between their health plans and the hospitals, so information on the public list very likely will not be applicable to those patients and could be a source of confusion.

As patients have more access to information about the costs for procedures, providers need to be aware of where within the facility they should refer patients with questions or concerns, including information on a hospital’s financial assistance programs.

There are so many sources of information that patients and their families can obtain before ever setting foot in the hospital. An open dialogue with patients that emphasizes the context of any financial relationships with industry, including the benefits, can help to minimize the potential that the information will be treated as suspect by your patients.

Further, as patients bear more of the costs of healthcare, questions surrounding the costs of procedures relative to published data may be encountered more frequently at the bedside and in office visits. This information may have an impact on patients’ decisions about their care.

The movement toward greater transparency of financial information in healthcare is providing patients with access to data that might affect their healthcare decisions. Not all of this information is provided in ways that give patients the full picture, and they may turn to you for some added clarity.

Financial Relationships

The Physician Payments Sunshine Act (“Sunshine Act’) was passed as a part of the Affordable Care Act and requires the public disclosure of financial relationships between physicians and the manufacturers of pharmaceuticals, devices, and supplies, as well as group purchasing organizations. The first wave of financial information was publicly disclosed in 2014 on the federal Open Payments website. When it went live, the website disclosed approximately $3.5 billion in payments made by manufacturers to physicians and teaching hospitals during the last five months of 2013. These payments include research grants, consulting fees, speaking fees, travel, and other expenses. In the future, the payments reported will span an entire year, further increasing the total dollar amount paid by industry.

The Sunshine Act is intended to expose potential conflicts of interest in healthcare so that patients are more informed consumers of healthcare services. The relationships between healthcare providers and industry have been scrutinized much more heavily over the past decade. The concern is that physicians with a financial interest, whether through a consultancy relationship with industry or through the development of new technology, might be biased in treating patients because of these relationships. On the other hand, the majority of relationships between healthcare providers and industry can be beneficial. The relationships provide education to other providers, encourage the development of new treatment options, and improve the effectiveness of existing treatments.

The Centers for Medicare and Medicaid Services (CMS) explains on its website that the disclosed financial ties are not necessarily indicators of any wrongdoing, and that the intent of publishing the information is to promote transparency and discourage inappropriate relationships. Without the proper context, these relationships could be viewed as improper by patients and the general public. Therefore, providers should be prepared to answer patients’ questions and possibly even proactively provide details, such as the scope of any relationship with industry. Many providers begin to consult with a pharmaceutical or device manufacturer because of their experience using a particular product, rather than using a particular product after forming that financial relationship. This context could shift patients’ views of what it means for their providers to have this type of connection with industry.

Providers also need to be aware that government agencies, insurers, and attorneys can track this data. Although it is still too early to know the full scope of the potential uses of this information in government investigations, insurance carrier decisions, malpractice, or other legal actions, it does provide further reason to ensure that the information posted is accurate.

During the initial launch of the Open Payments website, some data was temporarily removed due to inaccuracies, including payments linked incorrectly to physicians with the same first and last names. While these issues are being reviewed by CMS, their existence proves how important it is for all physicians (even those not affiliated with the industry) to review the data reported in order to ensure the accuracy of their information.

Procedure Costs

Another transparency requirement in the Affordable Care Act was implemented on Oct. 1, 2014, as part of the inpatient prospective payment system final rule. Hospitals are now required to make their prices for procedures public and update the list annually. The final rule is not explicit with respect to the manner of the disclosure, except that either a price list or the policy for obtaining access must be made public. Some complain that the rule is difficult to comply with because it is vague, while others point out that this fact gives hospitals necessary flexibility in the method of reporting. It is at the hospital’s discretion whether to post the information online or in a physical location.

It is important to note that patients with private payer insurance coverage have distinct rates that are set through agreements between their health plans and the hospitals, so information on the public list very likely will not be applicable to those patients and could be a source of confusion.

As patients have more access to information about the costs for procedures, providers need to be aware of where within the facility they should refer patients with questions or concerns, including information on a hospital’s financial assistance programs.

There are so many sources of information that patients and their families can obtain before ever setting foot in the hospital. An open dialogue with patients that emphasizes the context of any financial relationships with industry, including the benefits, can help to minimize the potential that the information will be treated as suspect by your patients.

Further, as patients bear more of the costs of healthcare, questions surrounding the costs of procedures relative to published data may be encountered more frequently at the bedside and in office visits. This information may have an impact on patients’ decisions about their care.

EDITOR’S NOTE: Fourth in an occasional series of reviews of the Hospital Medicine: Current Concepts series by members of Team Hospitalist.

Summary

Hospital Images: A Clinical Atlas is a collection of 76 clinical cases discussing actual patient scenarios with accompanying clinical case questions, images, and evidence-based discussions. Cases are presented in the same manner a practicing hospitalist would encounter them during daily rounds—that is to say, randomly. Chosen cases vary widely, from aspiration pneumonitis to necrotizing fasciitis, and are also representative of a day in the life of most hospitalists. The clinical images are of excellent quality and accurately represent the conditions discussed. The case discussions are logical, clinically relevant, and evidence-based.

Analysis

In this reviewer’s opinion, Hospital Images: A Clinical Atlas is required reading for all practicing hospitalists. The full-color images are high resolution and presented as patients would be viewed from the bedside. The cases are diverse and absolutely pertinent to the practice of hospital medicine. I am confident even the most experienced reader will learn something that will quite probably improve his or her diagnostic capability.

Dr. Lindsey is a hospitalist and chief of staff at Victory Medical Center in McKinney, Texas. She has been a member of Team Hospitalist since 2013.

At a Glance

Series: Hospital Medicine: Current Concepts

Title: Hospital Images: A Clinical Atlas

Editor: Paul B. Aronowitz

Published: 2012

Pages: 280

EDITOR’S NOTE: Fourth in an occasional series of reviews of the Hospital Medicine: Current Concepts series by members of Team Hospitalist.

Summary

Hospital Images: A Clinical Atlas is a collection of 76 clinical cases discussing actual patient scenarios with accompanying clinical case questions, images, and evidence-based discussions. Cases are presented in the same manner a practicing hospitalist would encounter them during daily rounds—that is to say, randomly. Chosen cases vary widely, from aspiration pneumonitis to necrotizing fasciitis, and are also representative of a day in the life of most hospitalists. The clinical images are of excellent quality and accurately represent the conditions discussed. The case discussions are logical, clinically relevant, and evidence-based.

Analysis

In this reviewer’s opinion, Hospital Images: A Clinical Atlas is required reading for all practicing hospitalists. The full-color images are high resolution and presented as patients would be viewed from the bedside. The cases are diverse and absolutely pertinent to the practice of hospital medicine. I am confident even the most experienced reader will learn something that will quite probably improve his or her diagnostic capability.

Dr. Lindsey is a hospitalist and chief of staff at Victory Medical Center in McKinney, Texas. She has been a member of Team Hospitalist since 2013.

At a Glance

Series: Hospital Medicine: Current Concepts

Title: Hospital Images: A Clinical Atlas

Editor: Paul B. Aronowitz

Published: 2012

Pages: 280

EDITOR’S NOTE: Fourth in an occasional series of reviews of the Hospital Medicine: Current Concepts series by members of Team Hospitalist.

Summary

Hospital Images: A Clinical Atlas is a collection of 76 clinical cases discussing actual patient scenarios with accompanying clinical case questions, images, and evidence-based discussions. Cases are presented in the same manner a practicing hospitalist would encounter them during daily rounds—that is to say, randomly. Chosen cases vary widely, from aspiration pneumonitis to necrotizing fasciitis, and are also representative of a day in the life of most hospitalists. The clinical images are of excellent quality and accurately represent the conditions discussed. The case discussions are logical, clinically relevant, and evidence-based.

Analysis

In this reviewer’s opinion, Hospital Images: A Clinical Atlas is required reading for all practicing hospitalists. The full-color images are high resolution and presented as patients would be viewed from the bedside. The cases are diverse and absolutely pertinent to the practice of hospital medicine. I am confident even the most experienced reader will learn something that will quite probably improve his or her diagnostic capability.

Dr. Lindsey is a hospitalist and chief of staff at Victory Medical Center in McKinney, Texas. She has been a member of Team Hospitalist since 2013.

At a Glance

Series: Hospital Medicine: Current Concepts

Title: Hospital Images: A Clinical Atlas

Editor: Paul B. Aronowitz

Published: 2012

Pages: 280

While VTE sometimes occurs in spite of the best available prophylaxis, there are many lost opportunities to optimize prevention and reduce VTE risk factors in virtually every hospital. Reaching a meaningful improvement in VTE prevention requires an empowered, interdisciplinary team approach supported by the institution to standardize processes, monitor, and measure VTE process and outcomes, implement institutional policies, and educate providers and patients.

In particular, Greg Maynard, MD, MSc, SFHM, director of the University of California San Diego Center for Innovation and Improvement Science, and senior medical officer of the Society of Hospital Medicine’s Center for Hospital Innovation and Improvement, suggests reviewing guidelines and regulatory materials that focus on the implications for implementation. Then, summarize the evidence into a VTE prevention protocol.

A VTE prevention protocol includes a VTE risk assessment, bleeding risk assessment, and clinical decision support (CDS) on prophylactic choices based on this combination of VTE and bleeding risk factors. The VTE protocol CDS must be available at crucial junctures of care, such as admission to the hospital, transfer to different levels of care, and post-operatively.

“Even if every patient has the best prophylaxis ordered on admission, other problems can lead to VTE during the hospital stay or after discharge.” —Dr. Maynard

“This VTE protocol guidance is most often embedded in order sets that are commonly used [or mandated for use] in these settings, essentially ‘hard-wiring’ the VTE risk assessment into the process,” Dr. Maynard says.

Risk assessment is essential, as there are harms, costs, and discomfort associated with prophylactic methods. For some inpatients, the risk of anticoagulant prophylaxis may outweigh the risk

of hospital-acquired VTE. No perfect VTE risk assessment tool exists, and there is always inherent tension between the desire to provide comprehensive, detailed guidance and the need to keep the process simple to understand and measure.

Principles for the effective implementation of reliable interventions generally favor simple models, with more complicated models reserved for settings with advanced methods to make the models easier for the end user.

“Order sets with CDS are of no use if they are not used correctly and reliably, so monitoring this process is crucial,” Dr. Maynard says.

No matter which VTE risk assessment model is used, every effort should be made to enhance ease of use for the ordering provider. This may include carving out special populations such as obstetric patients and major orthopedic, trauma, cardiovascular surgery, and neurosurgery patients for modified VTE risk assessment and order sets, Dr. Maynard says, which allows for streamlining and simplification of VTE prevention order sets.

Successful integration of a VTE prevention protocol into heavily utilized admission and transfer order sets serves as a foundational beginning point for VTE prevention efforts, rather than the end point.

“Even if every patient has the best prophylaxis ordered on admission, other problems can lead to VTE during the hospital stay or after discharge,”

Dr. Maynard says.

For example:

• Bleeding and VTE risk factors can change several times during a hospital stay, but reassessment does not occur;
• Patients are not optimally mobilized;
• Adherence to ordered mechanical prophylaxis is notoriously low; and
• Overutilization of peripherally inserted central catheter lines or other central venous catheters contributes to upper extremity DVT.

VTE prevention programs should address these pitfalls, in addition to implementing order sets.

Publicly reported measures and the CMS core measures set a relatively low bar for performance and are inadequate to drive breakthrough levels of improvement, Dr. Maynard adds. The adequacy of VTE prophylaxis should be assessed not only on admission or transfer to the intensive care unit but also across the hospital stay. Month-to-month reporting is important to follow progress, but at least some measures should drive concurrent intervention to address deficits in prophylaxis in real time. This method of active surveillance (also known as measure-vention), along with multiple other measurement methods that go beyond the core measures, is often necessary to secure real improvement.

An extensive update and revision of the Agency for Healthcare Research and Quality/Society of Hospital Medicine VTE Prevention Implementation Guide will be released by early spring. It will provide comprehensive coverage of these concepts.

Karen Appold is a freelance medical writer in Pennsylvania.

While VTE sometimes occurs in spite of the best available prophylaxis, there are many lost opportunities to optimize prevention and reduce VTE risk factors in virtually every hospital. Reaching a meaningful improvement in VTE prevention requires an empowered, interdisciplinary team approach supported by the institution to standardize processes, monitor, and measure VTE process and outcomes, implement institutional policies, and educate providers and patients.

In particular, Greg Maynard, MD, MSc, SFHM, director of the University of California San Diego Center for Innovation and Improvement Science, and senior medical officer of the Society of Hospital Medicine’s Center for Hospital Innovation and Improvement, suggests reviewing guidelines and regulatory materials that focus on the implications for implementation. Then, summarize the evidence into a VTE prevention protocol.

A VTE prevention protocol includes a VTE risk assessment, bleeding risk assessment, and clinical decision support (CDS) on prophylactic choices based on this combination of VTE and bleeding risk factors. The VTE protocol CDS must be available at crucial junctures of care, such as admission to the hospital, transfer to different levels of care, and post-operatively.

“Even if every patient has the best prophylaxis ordered on admission, other problems can lead to VTE during the hospital stay or after discharge.” —Dr. Maynard

“This VTE protocol guidance is most often embedded in order sets that are commonly used [or mandated for use] in these settings, essentially ‘hard-wiring’ the VTE risk assessment into the process,” Dr. Maynard says.

Risk assessment is essential, as there are harms, costs, and discomfort associated with prophylactic methods. For some inpatients, the risk of anticoagulant prophylaxis may outweigh the risk

of hospital-acquired VTE. No perfect VTE risk assessment tool exists, and there is always inherent tension between the desire to provide comprehensive, detailed guidance and the need to keep the process simple to understand and measure.

Principles for the effective implementation of reliable interventions generally favor simple models, with more complicated models reserved for settings with advanced methods to make the models easier for the end user.

“Order sets with CDS are of no use if they are not used correctly and reliably, so monitoring this process is crucial,” Dr. Maynard says.

No matter which VTE risk assessment model is used, every effort should be made to enhance ease of use for the ordering provider. This may include carving out special populations such as obstetric patients and major orthopedic, trauma, cardiovascular surgery, and neurosurgery patients for modified VTE risk assessment and order sets, Dr. Maynard says, which allows for streamlining and simplification of VTE prevention order sets.

Successful integration of a VTE prevention protocol into heavily utilized admission and transfer order sets serves as a foundational beginning point for VTE prevention efforts, rather than the end point.

“Even if every patient has the best prophylaxis ordered on admission, other problems can lead to VTE during the hospital stay or after discharge,”

Dr. Maynard says.

For example:

• Bleeding and VTE risk factors can change several times during a hospital stay, but reassessment does not occur;
• Patients are not optimally mobilized;
• Adherence to ordered mechanical prophylaxis is notoriously low; and
• Overutilization of peripherally inserted central catheter lines or other central venous catheters contributes to upper extremity DVT.

VTE prevention programs should address these pitfalls, in addition to implementing order sets.

Publicly reported measures and the CMS core measures set a relatively low bar for performance and are inadequate to drive breakthrough levels of improvement, Dr. Maynard adds. The adequacy of VTE prophylaxis should be assessed not only on admission or transfer to the intensive care unit but also across the hospital stay. Month-to-month reporting is important to follow progress, but at least some measures should drive concurrent intervention to address deficits in prophylaxis in real time. This method of active surveillance (also known as measure-vention), along with multiple other measurement methods that go beyond the core measures, is often necessary to secure real improvement.

An extensive update and revision of the Agency for Healthcare Research and Quality/Society of Hospital Medicine VTE Prevention Implementation Guide will be released by early spring. It will provide comprehensive coverage of these concepts.

Karen Appold is a freelance medical writer in Pennsylvania.

While VTE sometimes occurs in spite of the best available prophylaxis, there are many lost opportunities to optimize prevention and reduce VTE risk factors in virtually every hospital. Reaching a meaningful improvement in VTE prevention requires an empowered, interdisciplinary team approach supported by the institution to standardize processes, monitor, and measure VTE process and outcomes, implement institutional policies, and educate providers and patients.

In particular, Greg Maynard, MD, MSc, SFHM, director of the University of California San Diego Center for Innovation and Improvement Science, and senior medical officer of the Society of Hospital Medicine’s Center for Hospital Innovation and Improvement, suggests reviewing guidelines and regulatory materials that focus on the implications for implementation. Then, summarize the evidence into a VTE prevention protocol.

A VTE prevention protocol includes a VTE risk assessment, bleeding risk assessment, and clinical decision support (CDS) on prophylactic choices based on this combination of VTE and bleeding risk factors. The VTE protocol CDS must be available at crucial junctures of care, such as admission to the hospital, transfer to different levels of care, and post-operatively.

“Even if every patient has the best prophylaxis ordered on admission, other problems can lead to VTE during the hospital stay or after discharge.” —Dr. Maynard

“This VTE protocol guidance is most often embedded in order sets that are commonly used [or mandated for use] in these settings, essentially ‘hard-wiring’ the VTE risk assessment into the process,” Dr. Maynard says.

Risk assessment is essential, as there are harms, costs, and discomfort associated with prophylactic methods. For some inpatients, the risk of anticoagulant prophylaxis may outweigh the risk

of hospital-acquired VTE. No perfect VTE risk assessment tool exists, and there is always inherent tension between the desire to provide comprehensive, detailed guidance and the need to keep the process simple to understand and measure.

Principles for the effective implementation of reliable interventions generally favor simple models, with more complicated models reserved for settings with advanced methods to make the models easier for the end user.

“Order sets with CDS are of no use if they are not used correctly and reliably, so monitoring this process is crucial,” Dr. Maynard says.

No matter which VTE risk assessment model is used, every effort should be made to enhance ease of use for the ordering provider. This may include carving out special populations such as obstetric patients and major orthopedic, trauma, cardiovascular surgery, and neurosurgery patients for modified VTE risk assessment and order sets, Dr. Maynard says, which allows for streamlining and simplification of VTE prevention order sets.

Successful integration of a VTE prevention protocol into heavily utilized admission and transfer order sets serves as a foundational beginning point for VTE prevention efforts, rather than the end point.

“Even if every patient has the best prophylaxis ordered on admission, other problems can lead to VTE during the hospital stay or after discharge,”

Dr. Maynard says.

For example:

• Bleeding and VTE risk factors can change several times during a hospital stay, but reassessment does not occur;
• Patients are not optimally mobilized;
• Adherence to ordered mechanical prophylaxis is notoriously low; and
• Overutilization of peripherally inserted central catheter lines or other central venous catheters contributes to upper extremity DVT.

VTE prevention programs should address these pitfalls, in addition to implementing order sets.

Publicly reported measures and the CMS core measures set a relatively low bar for performance and are inadequate to drive breakthrough levels of improvement, Dr. Maynard adds. The adequacy of VTE prophylaxis should be assessed not only on admission or transfer to the intensive care unit but also across the hospital stay. Month-to-month reporting is important to follow progress, but at least some measures should drive concurrent intervention to address deficits in prophylaxis in real time. This method of active surveillance (also known as measure-vention), along with multiple other measurement methods that go beyond the core measures, is often necessary to secure real improvement.

An extensive update and revision of the Agency for Healthcare Research and Quality/Society of Hospital Medicine VTE Prevention Implementation Guide will be released by early spring. It will provide comprehensive coverage of these concepts.

Karen Appold is a freelance medical writer in Pennsylvania.

If a patient shows signs of agitation, Aaron Gottesman, MD, SFHM, says the best way to handle it is to stay calm. It may sound simple, but, in the heat of the moment, people tend to become defensive and on guard rather than acting composed and sympathetic. He suggests trying to speak softly and evenly to the patient, make eye contact, keep your arms at your side, and ask opened-ended questions such as, “How can I help you?” in a genuine manner.

Dr. Gottesman, director of hospitalist services at Staten Island (N.Y.) University Hospital (SIUH), learned these strategies in a voluntary one-hour course on de-escalation training. Although he says he feels fortunate that he has never had to deal with a physically volatile patient, he has used the verbal de-escalation training. In some cases, he believes that employing it may have prevented a physically violent situation from occurring.

Specifically, de-escalation training teaches how to respond to individuals who are acting aggressive or agitated in a verbal or physical manner. The techniques focus on how to calm someone down, while also teaching basic self-defense skills.

Various companies offer this type of training; some will train staff onsite.

“It is money well-spent,” says Scott Zeller, MD, chief of psychiatric emergency services at Alameda Health System in Oakland, Calif. “This is truly a situation where an ounce of prevention is worth a pound of cure. It only takes one unfortunate episode to result in a serious injury, where a healthcare professional will have to miss work or go on disability, which results in a far greater cost than that of the training.”

Appropriate Responses

By the nature of their work, hospitalists regularly come into contact with agitated patients. “Knowing how to safely help a patient calm down will result in better outcomes for the patient, the physicians, and everyone nearby,” Dr. Zeller says.

“Hospitalists should focus on what they can control,” says Judith Schubert, president of Crisis Prevention Institute (CPI), a Milwaukee, Wis.-based company that offers de-escalation training in 400 cities annually. This includes physicians’ own behavior/demeanor, responsiveness, environmental factors, communication protocols, and a continuous assessment of risk and an understanding of how to balance duty of care with responsibilities to maintain safety.

Hospitalists should be aware of behaviors that could lead to volatility.

“Challenging or oppositional questions and emotional release or intimidating comments often mark the beginning stages of loss of rationality. These are behaviors that warrant specific, directive intervention aimed at stimulating a rational response and diffusing tension,” Schubert says. “Before it even gets to that point, empathy, demonstrated with the patient and family members, can reduce contagion of emotional displays that are likely rooted in fear and anxiety.”

Agitation usually doesn’t arise out of the blue.

“It is typically seen over a spectrum of behaviors, from merely restless and irritable up to sarcastic and demeaning, pacing, unable to sit still, all the way up to screaming, combative, and violent to persons and property,” Dr. Zeller says. “It is best to intervene in the earlier stages and help a person to calm before a situation gets out of hand.”

Thus, hospitalists should be wary of people who are increasingly hostile and energetic and should seek help or work to de-escalate promptly.

Although you may suspect that patients with mental illnesses are more prone to volatility, Dr. Zeller says that isn’t necessarily the case. The most common psychiatric illnesses that can lead to agitation are schizophrenia and bipolar mania. In addition, being intoxicated—especially with alcohol and stimulants—can predispose someone to agitation. Many other medical conditions can cause someone to become agitated, such as confusion, a postictal state, hypoglycemia, or a head injury.

Coordination, communication, and continuity among all members of a hospital team are crucial to minimize conflict, avoid chaos, and reduce risks. By being armed with information and skills, hospitalists are less likely to isolate themselves from other team members or react in a nonproductive way when crisis situations emerge. —Judith Schubert, president, Crisis Prevention Institute, Milwaukee, Wis.

How Bad Is It?

According to the Emergency Nurses Association’s Institute for Emergency Nursing Research, violence is especially prevalent in the ED; about 11% of ED nurses report being physically assaulted each week. The agency states that the data is most likely grossly underreported, since reporting is voluntary.¹

Healthcare workers in psychiatric wards are the most likely to suffer an injury caused by an agitated patient, Dr. Zeller says. Of those, nurses are the ones most commonly affected, followed by physicians.

“But agitation-related assaults and injuries can happen just about anywhere in a hospital,” he adds.

According to a study conducted by the Emergency Nurses Association, pushing/grabbing and yelling/shouting were the most prevalent types of violence. Eighty percent of cases occurred in the patient’s room.² Dr. Zeller says that the most common injuries are those resulting from being struck, kicked or punched, or knocked down. Injuries include heavy bruising, sprains, and broken bones.

Dr. Zeller says it’s difficult to quantify exactly what types and costs of injuries occur. Injuries related to agitation are known to cause staff to miss work frequently. “That can cost a lot in terms of lost hours and replacement wages, as well as medical care for the injured party,” he says.

The Most Dangerous Circumstances

According to a series of 2012 articles on best practices guidelines for the evaluation and treatment of agitation published in Western Journal of Emergency Medicine, two-thirds of all staff injuries occur during the “takedown,” which is when staff attempt to tackle and restrain an agitated patient.³

“If interactions with a patient could help the person to regain control without needing the takedown or restraints, there would be fewer injuries and better outcomes,” says Dr. Zeller, who co-authored the article. “To help these patients in a collaborative and noncoercive way, and avoid restraints, verbal de-escalation is the necessary approach.”

As part of the study, a team of more than 40 experts nationwide was established to create Project BETA (Best practices in Evaluation and Treatment of Agitation). Participants were divided into five workgroups: triage and medical evaluation, psychiatric evaluation, de-escalation techniques, psychopharmacology of agitation, and use and avoidance of seclusion and restraint.

The guidelines were intended to cover all aspects of working with an agitated individual, with a focus on safety and outcomes, but also had a goal of being as patient-centric, collaborative, and noncoercive as possible.

“Every part of Project BETA revolves around verbal de-escalation, which can be done in a very short amount of time while simultaneously doing an assessment and offering medications,” Dr. Zeller says.

As a result of incorporating the guidelines in Project BETA, the psychiatric emergency room at Alameda Health System—which deals with a highly acute, emergency population of patients with serious mental illnesses—restrains less than 0.5% of patients seen. Dr. Zeller points out that this is much lower than the numbers restrained at other institutions. For instance, an article published in October 2013 reported several studies showing that 8% to 24% of patients in psychiatric EDs were placed into physical restraints or seclusion.⁴

What’s Required of Hospital Administration?

Under its Environment of Care standards, The Joint Commission requires accredited healthcare facilities to address workplace violence risk. The requirements mandate facilities to maintain a written plan describing how the security of patients, staff, and facility visitors will be ensured, to conduct proactive risk assessments considering the potential for workplace violence, and to determine a means for identifying individuals on their premises and controlling access to and egress from security-sensitive areas.¹

The standard states that “staff are trained in the use of nonphysical intervention skills,” says Cynthia Leslie, APRN, BC, MSN, associate director of the Standards Interpretation Group at The Joint Commission, which is based in Oakbrook Terrace, Ill. “These skills may assist the patient in calming down and prevent the use of restraints and/or seclusion.”

In addition, staff must be trained before they participate in a restraint or seclusion episode and must have periodic training thereafter.

Anyone who wants de-escalation training can contact a company like CPI directly or establish in-house training teams (CPI offers an Instructor Certification Program). “This allows a cost-effective way [approximately $10 per person] to cascade training to others within the hospital who are part of care teams,” Schubert says.

In Sum

Providing for the care and welfare of patients while maintaining a safe and secure environment for everyone is a balancing act that requires the involvement of a multidisciplinary hospital team, Schubert says.

“Coordination, communication, and continuity among all members of a hospital team are crucial to minimize conflict, avoid chaos, and reduce risks,” she explains. “By being armed with information and skills, hospitalists are less likely to isolate themselves from other team members or react in a nonproductive way when crisis situations emerge.

“Training will help staff to take steps to ensure that their behavior and attitudes don’t become part of the problem and increase risks for others involved. Care team perceptions of physician involvement in solution-focused interventions are important for hospitalists to fully understand so risks can be avoided.”

Karen Appold is a freelance medical writer in Pennsylvania.

References

1. ECRI Institute. Healthcare Risk, Quality, and Safety Guidance. Violence in healthcare facilities. March 1, 2011. Available at: https://www.ecri.org/components/HRC/Pages/SafSec3.aspx?tab=1. Accessed February 11, 2015.
2. Emergency Nurses Association. Emergency department violence surveillance study. November 2011. Available at: http://www.ena.org/practice-research/research/Documents/ENAEDVSReportNovember2011.pdf. Accessed February 11, 2015.
3. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25.
4. Simpson SA, Joesch JM, West II, Pasic J. Risk for physical restraint or seclusion in the psychiatric emergency service (PES). Gen Hosp Psychiatry. 2014;36(1):113-118.

If a patient shows signs of agitation, Aaron Gottesman, MD, SFHM, says the best way to handle it is to stay calm. It may sound simple, but, in the heat of the moment, people tend to become defensive and on guard rather than acting composed and sympathetic. He suggests trying to speak softly and evenly to the patient, make eye contact, keep your arms at your side, and ask opened-ended questions such as, “How can I help you?” in a genuine manner.

Dr. Gottesman, director of hospitalist services at Staten Island (N.Y.) University Hospital (SIUH), learned these strategies in a voluntary one-hour course on de-escalation training. Although he says he feels fortunate that he has never had to deal with a physically volatile patient, he has used the verbal de-escalation training. In some cases, he believes that employing it may have prevented a physically violent situation from occurring.

Specifically, de-escalation training teaches how to respond to individuals who are acting aggressive or agitated in a verbal or physical manner. The techniques focus on how to calm someone down, while also teaching basic self-defense skills.

Various companies offer this type of training; some will train staff onsite.

“It is money well-spent,” says Scott Zeller, MD, chief of psychiatric emergency services at Alameda Health System in Oakland, Calif. “This is truly a situation where an ounce of prevention is worth a pound of cure. It only takes one unfortunate episode to result in a serious injury, where a healthcare professional will have to miss work or go on disability, which results in a far greater cost than that of the training.”

Appropriate Responses

By the nature of their work, hospitalists regularly come into contact with agitated patients. “Knowing how to safely help a patient calm down will result in better outcomes for the patient, the physicians, and everyone nearby,” Dr. Zeller says.

“Hospitalists should focus on what they can control,” says Judith Schubert, president of Crisis Prevention Institute (CPI), a Milwaukee, Wis.-based company that offers de-escalation training in 400 cities annually. This includes physicians’ own behavior/demeanor, responsiveness, environmental factors, communication protocols, and a continuous assessment of risk and an understanding of how to balance duty of care with responsibilities to maintain safety.

Hospitalists should be aware of behaviors that could lead to volatility.

“Challenging or oppositional questions and emotional release or intimidating comments often mark the beginning stages of loss of rationality. These are behaviors that warrant specific, directive intervention aimed at stimulating a rational response and diffusing tension,” Schubert says. “Before it even gets to that point, empathy, demonstrated with the patient and family members, can reduce contagion of emotional displays that are likely rooted in fear and anxiety.”

Agitation usually doesn’t arise out of the blue.

“It is typically seen over a spectrum of behaviors, from merely restless and irritable up to sarcastic and demeaning, pacing, unable to sit still, all the way up to screaming, combative, and violent to persons and property,” Dr. Zeller says. “It is best to intervene in the earlier stages and help a person to calm before a situation gets out of hand.”

Thus, hospitalists should be wary of people who are increasingly hostile and energetic and should seek help or work to de-escalate promptly.

Although you may suspect that patients with mental illnesses are more prone to volatility, Dr. Zeller says that isn’t necessarily the case. The most common psychiatric illnesses that can lead to agitation are schizophrenia and bipolar mania. In addition, being intoxicated—especially with alcohol and stimulants—can predispose someone to agitation. Many other medical conditions can cause someone to become agitated, such as confusion, a postictal state, hypoglycemia, or a head injury.

Coordination, communication, and continuity among all members of a hospital team are crucial to minimize conflict, avoid chaos, and reduce risks. By being armed with information and skills, hospitalists are less likely to isolate themselves from other team members or react in a nonproductive way when crisis situations emerge. —Judith Schubert, president, Crisis Prevention Institute, Milwaukee, Wis.

How Bad Is It?

According to the Emergency Nurses Association’s Institute for Emergency Nursing Research, violence is especially prevalent in the ED; about 11% of ED nurses report being physically assaulted each week. The agency states that the data is most likely grossly underreported, since reporting is voluntary.¹

Healthcare workers in psychiatric wards are the most likely to suffer an injury caused by an agitated patient, Dr. Zeller says. Of those, nurses are the ones most commonly affected, followed by physicians.

“But agitation-related assaults and injuries can happen just about anywhere in a hospital,” he adds.

According to a study conducted by the Emergency Nurses Association, pushing/grabbing and yelling/shouting were the most prevalent types of violence. Eighty percent of cases occurred in the patient’s room.² Dr. Zeller says that the most common injuries are those resulting from being struck, kicked or punched, or knocked down. Injuries include heavy bruising, sprains, and broken bones.

Dr. Zeller says it’s difficult to quantify exactly what types and costs of injuries occur. Injuries related to agitation are known to cause staff to miss work frequently. “That can cost a lot in terms of lost hours and replacement wages, as well as medical care for the injured party,” he says.

The Most Dangerous Circumstances

According to a series of 2012 articles on best practices guidelines for the evaluation and treatment of agitation published in Western Journal of Emergency Medicine, two-thirds of all staff injuries occur during the “takedown,” which is when staff attempt to tackle and restrain an agitated patient.³

“If interactions with a patient could help the person to regain control without needing the takedown or restraints, there would be fewer injuries and better outcomes,” says Dr. Zeller, who co-authored the article. “To help these patients in a collaborative and noncoercive way, and avoid restraints, verbal de-escalation is the necessary approach.”

As part of the study, a team of more than 40 experts nationwide was established to create Project BETA (Best practices in Evaluation and Treatment of Agitation). Participants were divided into five workgroups: triage and medical evaluation, psychiatric evaluation, de-escalation techniques, psychopharmacology of agitation, and use and avoidance of seclusion and restraint.

The guidelines were intended to cover all aspects of working with an agitated individual, with a focus on safety and outcomes, but also had a goal of being as patient-centric, collaborative, and noncoercive as possible.

“Every part of Project BETA revolves around verbal de-escalation, which can be done in a very short amount of time while simultaneously doing an assessment and offering medications,” Dr. Zeller says.

As a result of incorporating the guidelines in Project BETA, the psychiatric emergency room at Alameda Health System—which deals with a highly acute, emergency population of patients with serious mental illnesses—restrains less than 0.5% of patients seen. Dr. Zeller points out that this is much lower than the numbers restrained at other institutions. For instance, an article published in October 2013 reported several studies showing that 8% to 24% of patients in psychiatric EDs were placed into physical restraints or seclusion.⁴

What’s Required of Hospital Administration?

Under its Environment of Care standards, The Joint Commission requires accredited healthcare facilities to address workplace violence risk. The requirements mandate facilities to maintain a written plan describing how the security of patients, staff, and facility visitors will be ensured, to conduct proactive risk assessments considering the potential for workplace violence, and to determine a means for identifying individuals on their premises and controlling access to and egress from security-sensitive areas.¹

The standard states that “staff are trained in the use of nonphysical intervention skills,” says Cynthia Leslie, APRN, BC, MSN, associate director of the Standards Interpretation Group at The Joint Commission, which is based in Oakbrook Terrace, Ill. “These skills may assist the patient in calming down and prevent the use of restraints and/or seclusion.”

In addition, staff must be trained before they participate in a restraint or seclusion episode and must have periodic training thereafter.

Anyone who wants de-escalation training can contact a company like CPI directly or establish in-house training teams (CPI offers an Instructor Certification Program). “This allows a cost-effective way [approximately $10 per person] to cascade training to others within the hospital who are part of care teams,” Schubert says.

In Sum

Providing for the care and welfare of patients while maintaining a safe and secure environment for everyone is a balancing act that requires the involvement of a multidisciplinary hospital team, Schubert says.

“Coordination, communication, and continuity among all members of a hospital team are crucial to minimize conflict, avoid chaos, and reduce risks,” she explains. “By being armed with information and skills, hospitalists are less likely to isolate themselves from other team members or react in a nonproductive way when crisis situations emerge.

“Training will help staff to take steps to ensure that their behavior and attitudes don’t become part of the problem and increase risks for others involved. Care team perceptions of physician involvement in solution-focused interventions are important for hospitalists to fully understand so risks can be avoided.”

Karen Appold is a freelance medical writer in Pennsylvania.

References

1. ECRI Institute. Healthcare Risk, Quality, and Safety Guidance. Violence in healthcare facilities. March 1, 2011. Available at: https://www.ecri.org/components/HRC/Pages/SafSec3.aspx?tab=1. Accessed February 11, 2015.
2. Emergency Nurses Association. Emergency department violence surveillance study. November 2011. Available at: http://www.ena.org/practice-research/research/Documents/ENAEDVSReportNovember2011.pdf. Accessed February 11, 2015.
3. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25.
4. Simpson SA, Joesch JM, West II, Pasic J. Risk for physical restraint or seclusion in the psychiatric emergency service (PES). Gen Hosp Psychiatry. 2014;36(1):113-118.

If a patient shows signs of agitation, Aaron Gottesman, MD, SFHM, says the best way to handle it is to stay calm. It may sound simple, but, in the heat of the moment, people tend to become defensive and on guard rather than acting composed and sympathetic. He suggests trying to speak softly and evenly to the patient, make eye contact, keep your arms at your side, and ask opened-ended questions such as, “How can I help you?” in a genuine manner.

Dr. Gottesman, director of hospitalist services at Staten Island (N.Y.) University Hospital (SIUH), learned these strategies in a voluntary one-hour course on de-escalation training. Although he says he feels fortunate that he has never had to deal with a physically volatile patient, he has used the verbal de-escalation training. In some cases, he believes that employing it may have prevented a physically violent situation from occurring.

Specifically, de-escalation training teaches how to respond to individuals who are acting aggressive or agitated in a verbal or physical manner. The techniques focus on how to calm someone down, while also teaching basic self-defense skills.

Various companies offer this type of training; some will train staff onsite.

“It is money well-spent,” says Scott Zeller, MD, chief of psychiatric emergency services at Alameda Health System in Oakland, Calif. “This is truly a situation where an ounce of prevention is worth a pound of cure. It only takes one unfortunate episode to result in a serious injury, where a healthcare professional will have to miss work or go on disability, which results in a far greater cost than that of the training.”

Appropriate Responses

By the nature of their work, hospitalists regularly come into contact with agitated patients. “Knowing how to safely help a patient calm down will result in better outcomes for the patient, the physicians, and everyone nearby,” Dr. Zeller says.

“Hospitalists should focus on what they can control,” says Judith Schubert, president of Crisis Prevention Institute (CPI), a Milwaukee, Wis.-based company that offers de-escalation training in 400 cities annually. This includes physicians’ own behavior/demeanor, responsiveness, environmental factors, communication protocols, and a continuous assessment of risk and an understanding of how to balance duty of care with responsibilities to maintain safety.

Hospitalists should be aware of behaviors that could lead to volatility.

“Challenging or oppositional questions and emotional release or intimidating comments often mark the beginning stages of loss of rationality. These are behaviors that warrant specific, directive intervention aimed at stimulating a rational response and diffusing tension,” Schubert says. “Before it even gets to that point, empathy, demonstrated with the patient and family members, can reduce contagion of emotional displays that are likely rooted in fear and anxiety.”

Agitation usually doesn’t arise out of the blue.

“It is typically seen over a spectrum of behaviors, from merely restless and irritable up to sarcastic and demeaning, pacing, unable to sit still, all the way up to screaming, combative, and violent to persons and property,” Dr. Zeller says. “It is best to intervene in the earlier stages and help a person to calm before a situation gets out of hand.”

Thus, hospitalists should be wary of people who are increasingly hostile and energetic and should seek help or work to de-escalate promptly.

Although you may suspect that patients with mental illnesses are more prone to volatility, Dr. Zeller says that isn’t necessarily the case. The most common psychiatric illnesses that can lead to agitation are schizophrenia and bipolar mania. In addition, being intoxicated—especially with alcohol and stimulants—can predispose someone to agitation. Many other medical conditions can cause someone to become agitated, such as confusion, a postictal state, hypoglycemia, or a head injury.

Coordination, communication, and continuity among all members of a hospital team are crucial to minimize conflict, avoid chaos, and reduce risks. By being armed with information and skills, hospitalists are less likely to isolate themselves from other team members or react in a nonproductive way when crisis situations emerge. —Judith Schubert, president, Crisis Prevention Institute, Milwaukee, Wis.

How Bad Is It?

According to the Emergency Nurses Association’s Institute for Emergency Nursing Research, violence is especially prevalent in the ED; about 11% of ED nurses report being physically assaulted each week. The agency states that the data is most likely grossly underreported, since reporting is voluntary.¹

Healthcare workers in psychiatric wards are the most likely to suffer an injury caused by an agitated patient, Dr. Zeller says. Of those, nurses are the ones most commonly affected, followed by physicians.

“But agitation-related assaults and injuries can happen just about anywhere in a hospital,” he adds.

According to a study conducted by the Emergency Nurses Association, pushing/grabbing and yelling/shouting were the most prevalent types of violence. Eighty percent of cases occurred in the patient’s room.² Dr. Zeller says that the most common injuries are those resulting from being struck, kicked or punched, or knocked down. Injuries include heavy bruising, sprains, and broken bones.

Dr. Zeller says it’s difficult to quantify exactly what types and costs of injuries occur. Injuries related to agitation are known to cause staff to miss work frequently. “That can cost a lot in terms of lost hours and replacement wages, as well as medical care for the injured party,” he says.

The Most Dangerous Circumstances

According to a series of 2012 articles on best practices guidelines for the evaluation and treatment of agitation published in Western Journal of Emergency Medicine, two-thirds of all staff injuries occur during the “takedown,” which is when staff attempt to tackle and restrain an agitated patient.³

“If interactions with a patient could help the person to regain control without needing the takedown or restraints, there would be fewer injuries and better outcomes,” says Dr. Zeller, who co-authored the article. “To help these patients in a collaborative and noncoercive way, and avoid restraints, verbal de-escalation is the necessary approach.”

As part of the study, a team of more than 40 experts nationwide was established to create Project BETA (Best practices in Evaluation and Treatment of Agitation). Participants were divided into five workgroups: triage and medical evaluation, psychiatric evaluation, de-escalation techniques, psychopharmacology of agitation, and use and avoidance of seclusion and restraint.

The guidelines were intended to cover all aspects of working with an agitated individual, with a focus on safety and outcomes, but also had a goal of being as patient-centric, collaborative, and noncoercive as possible.

“Every part of Project BETA revolves around verbal de-escalation, which can be done in a very short amount of time while simultaneously doing an assessment and offering medications,” Dr. Zeller says.

As a result of incorporating the guidelines in Project BETA, the psychiatric emergency room at Alameda Health System—which deals with a highly acute, emergency population of patients with serious mental illnesses—restrains less than 0.5% of patients seen. Dr. Zeller points out that this is much lower than the numbers restrained at other institutions. For instance, an article published in October 2013 reported several studies showing that 8% to 24% of patients in psychiatric EDs were placed into physical restraints or seclusion.⁴

What’s Required of Hospital Administration?

Under its Environment of Care standards, The Joint Commission requires accredited healthcare facilities to address workplace violence risk. The requirements mandate facilities to maintain a written plan describing how the security of patients, staff, and facility visitors will be ensured, to conduct proactive risk assessments considering the potential for workplace violence, and to determine a means for identifying individuals on their premises and controlling access to and egress from security-sensitive areas.¹

The standard states that “staff are trained in the use of nonphysical intervention skills,” says Cynthia Leslie, APRN, BC, MSN, associate director of the Standards Interpretation Group at The Joint Commission, which is based in Oakbrook Terrace, Ill. “These skills may assist the patient in calming down and prevent the use of restraints and/or seclusion.”

In addition, staff must be trained before they participate in a restraint or seclusion episode and must have periodic training thereafter.

Anyone who wants de-escalation training can contact a company like CPI directly or establish in-house training teams (CPI offers an Instructor Certification Program). “This allows a cost-effective way [approximately $10 per person] to cascade training to others within the hospital who are part of care teams,” Schubert says.

In Sum

Providing for the care and welfare of patients while maintaining a safe and secure environment for everyone is a balancing act that requires the involvement of a multidisciplinary hospital team, Schubert says.

“Coordination, communication, and continuity among all members of a hospital team are crucial to minimize conflict, avoid chaos, and reduce risks,” she explains. “By being armed with information and skills, hospitalists are less likely to isolate themselves from other team members or react in a nonproductive way when crisis situations emerge.

“Training will help staff to take steps to ensure that their behavior and attitudes don’t become part of the problem and increase risks for others involved. Care team perceptions of physician involvement in solution-focused interventions are important for hospitalists to fully understand so risks can be avoided.”

Karen Appold is a freelance medical writer in Pennsylvania.

References

1. ECRI Institute. Healthcare Risk, Quality, and Safety Guidance. Violence in healthcare facilities. March 1, 2011. Available at: https://www.ecri.org/components/HRC/Pages/SafSec3.aspx?tab=1. Accessed February 11, 2015.
2. Emergency Nurses Association. Emergency department violence surveillance study. November 2011. Available at: http://www.ena.org/practice-research/research/Documents/ENAEDVSReportNovember2011.pdf. Accessed February 11, 2015.
3. Richmond JS, Berlin JS, Fishkind AB, et al. Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17-25.
4. Simpson SA, Joesch JM, West II, Pasic J. Risk for physical restraint or seclusion in the psychiatric emergency service (PES). Gen Hosp Psychiatry. 2014;36(1):113-118.

On Jan. 20, a 44-year old surgeon was shot and killed in the middle of the day at one of the country’s top hospitals. Michael Davidson, MD, an endovascular surgeon at Brigham and Women’s Hospital in Boston, was in a second-floor hospital clinic when 55-year-old Stephen Pasceri asked for him by name. Dr. Davidson, the division director of endovascular cardiac surgery and assistant professor at Harvard Medical School, had taken care of Pasceri’s mother before her death in November 2014. Witnesses reported that Dr. Davidson came out to talk to Pasceri; during that conversation, Pasceri shot Dr. Davidson twice.

Dr. Davidson was quickly taken to the ED but died 12 hours later.

The shooter died of a self-inflicted gunshot wound to the head.

The motive is not clear, but Pasceri had voiced frustrations with the medical industry during the care of both his father and his mother. In addition, his mother seemed to have suffered some type of complication after a surgery performed by Dr. Davidson. Interviews of Pasceri’s relatives, friends, and neighbors found they were all shocked and dismayed. The shooter was, by all accounts, an upstanding citizen in his work, home, church, and community; he was an accountant with four children, with no past history of criminal or violent activity.¹

A Disheartening Trend

Two other fatal events in medical centers occurred within weeks of the Davidson shooting. In December 2014, at Wentworth-Douglass Hospital in Dover, N.H., a man shot and killed his wife before killing himself.

Days later, at a Veterans Hospital clinic in El Paso, Texas, another shooting left both the perpetrator and a psychologist dead.²

In the healthcare setting, providers encounter many types of violence. Nonfatal violence, ranging from physical aggression to various levels of physical harm, has become commonplace. Inciters of such violence tend to be those who “can’t help themselves,” often patients with primary psychiatric illness or those with medically induced mental impairment, such as delirium or withdrawal. For these patients, there is at least some level of compassion and tolerance for their behavior, and because they tend to be relatively predictable, preparedness and mitigation of such acts can give providers some sense of control over the situation.

But the Davidson event represents a type of violence that is frightening, unpredictable, and very difficult to prevent, prepare for, or adequately handle.

Actual shootings on medical campuses are, fortunately, rare. A recent study by the Johns Hopkins Office of Critical Event Preparedness and Response found 154 hospital shootings between 2000 and 2011, resulting in 235 injured or dead victims. The most commonly occurring scenario is that of people acting against family members, with healthcare workers getting caught in the crosshairs. The most common victim is the shooter (45% of the time), and the least common victims are physicians and nurses. Over half (59%) of medical center shootings occur within the hospital; the other 41% occur somewhere else on the hospital grounds.³

So what can hospitalists and hospitals do about the real threat of physical violence and shootings within medical centers? Some have recommended metal detectors as effective barriers for preventing weapons from entering medical centers. The primary problem with this solution is that the majority of medical centers have found this plan impossible to implement, given the number of entrances in typical hospitals; Johns Hopkins for example, has more than 80 entrances. Metal detectors also require security staffing at each entrance 24/7.⁴

Because of the barriers, metal detectors present an insurmountable financial obstacle for most hospitals. In addition, they present an issue with public perception. Many would argue that hospitals are (and should be) places of healing and sanctuary (e.g. “safe havens”), not places for suspicion and searches. In addition, although there is evidence that the use of metal detectors results in increased confiscation of weapons, there is no evidence that they result in fewer on-site assaults.⁵ Further complicating matters, almost a quarter of the shootings that occur in EDs result from the perpetrator grabbing a weapon from a security guard.³

Others advocate for stricter gun control laws and enforcement, an argument that has vehement advocates and critics on both sides and is unlikely to be resolved in the near future.

Take Action: Be Prepared

In the meantime, hospitalists are left with preparedness tactics that range from situational awareness to active shooter drills. Both are equally important and should be a part of disaster preparedness at any medical center regardless of size, type, or location. Hospitalists can and should take a lead in such preparedness. Current statistics show that hospitalists are employed in at least 85% of all U.S. hospitals. With such widespread penetration, hospitalists can have a huge impact on the preparedness efforts that can prevent such acts from occurring, as well as on organizational resilience and recovery if such an act does occur.

Such training is more important in healthcare settings than other workplaces, as medical personnel have to be specially trained to resist the temptation to help. For example, active shooter training instructs personnel to run, hide, or fight, none of which come “naturally” to those trained to save and rescue for a living. This training instructs anyone in the “Hot Zone” (where life is in direct danger) to run away from the scene (always preferred if feasible), hide (barricade the door, silence any devices, and stay still), or fight (use anything in sight to fight the shooter, and work as a team if feasible). These responses are the exact opposite of what most trained healthcare personnel are accustomed to doing in cases of emergency.

In Sum

The Michael Davidson story is very sobering by all accounts. Healthcare violence such as this, while rare, is devastating.

Hospitalists should lead the way in training and preparedness for violence prevention and mitigation, including active shooter simulation scenarios. We can all have a huge impact in reducing the risk of casualties should such an unpredictable event occur in our hospital.

References

1. Freyer FJ, Kowalczyk L, Murphy SP. Surgeon slain, gunman found dead in day of crisis at Brigham. January 20, 2015. The Boston Globe online. Available at: http://www.bostonglobe.com/metro/2015/01/20/boston-police-investigate-report-shooting-brigham-and-women/Jhig9z8LO8A5PH9Er4vTiP/story.html?rss_id=Top-GNP&utm_source=Managed&utm_campaign=386d2ff709-Quality+%26+Patient+Safety+Update&utm_medium=email&utm_term=0_ebe1fa6178-386d2ff709-319388717. Accessed February 5, 2015.
2. Barnet S. Gun violence in hospitals: how much of a threat is it really? January 21, 2015. Becker’s Hospital Review. Available at: http://www.beckershospitalreview.com/healthcare-blog/gun-violence-in-hospitals-how-much-of-a-threat-is-it-really.html. Accessed February 5, 2015.
3. Kelen GD, Catlett CL, Kubit JG, Hsieh Y-H. Hospital-based shootings in the United States: 2000 to 2011. Annals of Emergency Medicine online. September 20, 2012. Available at: http://www.annemergmed.com/article/S0196-0644%2812%2901408-4/abstract. Accessed February 5, 2015.
4. Calvert S, Scharper J, Roylance F. Experts: no need for metal detectors at Hopkins. September 17, 2010. The Baltimore Sun online. Available at: http://articles.baltimoresun.com/2010-09-17/business/bs-md-hopkins-hospital-security-20100916_1_metal-detectors-healthcare-security-and-safety-hospital-security-experts. Accessed February 5, 2015.
5. Rankins RC, Hendey GW. Effect of a security system on violent incidents and hidden weapons in the emergency department. Ann Emerg Med. 1999;33(6):676-679.

On Jan. 20, a 44-year old surgeon was shot and killed in the middle of the day at one of the country’s top hospitals. Michael Davidson, MD, an endovascular surgeon at Brigham and Women’s Hospital in Boston, was in a second-floor hospital clinic when 55-year-old Stephen Pasceri asked for him by name. Dr. Davidson, the division director of endovascular cardiac surgery and assistant professor at Harvard Medical School, had taken care of Pasceri’s mother before her death in November 2014. Witnesses reported that Dr. Davidson came out to talk to Pasceri; during that conversation, Pasceri shot Dr. Davidson twice.

Dr. Davidson was quickly taken to the ED but died 12 hours later.

The shooter died of a self-inflicted gunshot wound to the head.

The motive is not clear, but Pasceri had voiced frustrations with the medical industry during the care of both his father and his mother. In addition, his mother seemed to have suffered some type of complication after a surgery performed by Dr. Davidson. Interviews of Pasceri’s relatives, friends, and neighbors found they were all shocked and dismayed. The shooter was, by all accounts, an upstanding citizen in his work, home, church, and community; he was an accountant with four children, with no past history of criminal or violent activity.¹

A Disheartening Trend

Two other fatal events in medical centers occurred within weeks of the Davidson shooting. In December 2014, at Wentworth-Douglass Hospital in Dover, N.H., a man shot and killed his wife before killing himself.

Days later, at a Veterans Hospital clinic in El Paso, Texas, another shooting left both the perpetrator and a psychologist dead.²

In the healthcare setting, providers encounter many types of violence. Nonfatal violence, ranging from physical aggression to various levels of physical harm, has become commonplace. Inciters of such violence tend to be those who “can’t help themselves,” often patients with primary psychiatric illness or those with medically induced mental impairment, such as delirium or withdrawal. For these patients, there is at least some level of compassion and tolerance for their behavior, and because they tend to be relatively predictable, preparedness and mitigation of such acts can give providers some sense of control over the situation.

But the Davidson event represents a type of violence that is frightening, unpredictable, and very difficult to prevent, prepare for, or adequately handle.

Actual shootings on medical campuses are, fortunately, rare. A recent study by the Johns Hopkins Office of Critical Event Preparedness and Response found 154 hospital shootings between 2000 and 2011, resulting in 235 injured or dead victims. The most commonly occurring scenario is that of people acting against family members, with healthcare workers getting caught in the crosshairs. The most common victim is the shooter (45% of the time), and the least common victims are physicians and nurses. Over half (59%) of medical center shootings occur within the hospital; the other 41% occur somewhere else on the hospital grounds.³

So what can hospitalists and hospitals do about the real threat of physical violence and shootings within medical centers? Some have recommended metal detectors as effective barriers for preventing weapons from entering medical centers. The primary problem with this solution is that the majority of medical centers have found this plan impossible to implement, given the number of entrances in typical hospitals; Johns Hopkins for example, has more than 80 entrances. Metal detectors also require security staffing at each entrance 24/7.⁴

Because of the barriers, metal detectors present an insurmountable financial obstacle for most hospitals. In addition, they present an issue with public perception. Many would argue that hospitals are (and should be) places of healing and sanctuary (e.g. “safe havens”), not places for suspicion and searches. In addition, although there is evidence that the use of metal detectors results in increased confiscation of weapons, there is no evidence that they result in fewer on-site assaults.⁵ Further complicating matters, almost a quarter of the shootings that occur in EDs result from the perpetrator grabbing a weapon from a security guard.³

Others advocate for stricter gun control laws and enforcement, an argument that has vehement advocates and critics on both sides and is unlikely to be resolved in the near future.

Take Action: Be Prepared

In the meantime, hospitalists are left with preparedness tactics that range from situational awareness to active shooter drills. Both are equally important and should be a part of disaster preparedness at any medical center regardless of size, type, or location. Hospitalists can and should take a lead in such preparedness. Current statistics show that hospitalists are employed in at least 85% of all U.S. hospitals. With such widespread penetration, hospitalists can have a huge impact on the preparedness efforts that can prevent such acts from occurring, as well as on organizational resilience and recovery if such an act does occur.

Such training is more important in healthcare settings than other workplaces, as medical personnel have to be specially trained to resist the temptation to help. For example, active shooter training instructs personnel to run, hide, or fight, none of which come “naturally” to those trained to save and rescue for a living. This training instructs anyone in the “Hot Zone” (where life is in direct danger) to run away from the scene (always preferred if feasible), hide (barricade the door, silence any devices, and stay still), or fight (use anything in sight to fight the shooter, and work as a team if feasible). These responses are the exact opposite of what most trained healthcare personnel are accustomed to doing in cases of emergency.

In Sum

The Michael Davidson story is very sobering by all accounts. Healthcare violence such as this, while rare, is devastating.

Hospitalists should lead the way in training and preparedness for violence prevention and mitigation, including active shooter simulation scenarios. We can all have a huge impact in reducing the risk of casualties should such an unpredictable event occur in our hospital.

References

1. Freyer FJ, Kowalczyk L, Murphy SP. Surgeon slain, gunman found dead in day of crisis at Brigham. January 20, 2015. The Boston Globe online. Available at: http://www.bostonglobe.com/metro/2015/01/20/boston-police-investigate-report-shooting-brigham-and-women/Jhig9z8LO8A5PH9Er4vTiP/story.html?rss_id=Top-GNP&utm_source=Managed&utm_campaign=386d2ff709-Quality+%26+Patient+Safety+Update&utm_medium=email&utm_term=0_ebe1fa6178-386d2ff709-319388717. Accessed February 5, 2015.
2. Barnet S. Gun violence in hospitals: how much of a threat is it really? January 21, 2015. Becker’s Hospital Review. Available at: http://www.beckershospitalreview.com/healthcare-blog/gun-violence-in-hospitals-how-much-of-a-threat-is-it-really.html. Accessed February 5, 2015.
3. Kelen GD, Catlett CL, Kubit JG, Hsieh Y-H. Hospital-based shootings in the United States: 2000 to 2011. Annals of Emergency Medicine online. September 20, 2012. Available at: http://www.annemergmed.com/article/S0196-0644%2812%2901408-4/abstract. Accessed February 5, 2015.
4. Calvert S, Scharper J, Roylance F. Experts: no need for metal detectors at Hopkins. September 17, 2010. The Baltimore Sun online. Available at: http://articles.baltimoresun.com/2010-09-17/business/bs-md-hopkins-hospital-security-20100916_1_metal-detectors-healthcare-security-and-safety-hospital-security-experts. Accessed February 5, 2015.
5. Rankins RC, Hendey GW. Effect of a security system on violent incidents and hidden weapons in the emergency department. Ann Emerg Med. 1999;33(6):676-679.

On Jan. 20, a 44-year old surgeon was shot and killed in the middle of the day at one of the country’s top hospitals. Michael Davidson, MD, an endovascular surgeon at Brigham and Women’s Hospital in Boston, was in a second-floor hospital clinic when 55-year-old Stephen Pasceri asked for him by name. Dr. Davidson, the division director of endovascular cardiac surgery and assistant professor at Harvard Medical School, had taken care of Pasceri’s mother before her death in November 2014. Witnesses reported that Dr. Davidson came out to talk to Pasceri; during that conversation, Pasceri shot Dr. Davidson twice.

Dr. Davidson was quickly taken to the ED but died 12 hours later.

The shooter died of a self-inflicted gunshot wound to the head.

The motive is not clear, but Pasceri had voiced frustrations with the medical industry during the care of both his father and his mother. In addition, his mother seemed to have suffered some type of complication after a surgery performed by Dr. Davidson. Interviews of Pasceri’s relatives, friends, and neighbors found they were all shocked and dismayed. The shooter was, by all accounts, an upstanding citizen in his work, home, church, and community; he was an accountant with four children, with no past history of criminal or violent activity.¹

A Disheartening Trend

Two other fatal events in medical centers occurred within weeks of the Davidson shooting. In December 2014, at Wentworth-Douglass Hospital in Dover, N.H., a man shot and killed his wife before killing himself.

Days later, at a Veterans Hospital clinic in El Paso, Texas, another shooting left both the perpetrator and a psychologist dead.²

In the healthcare setting, providers encounter many types of violence. Nonfatal violence, ranging from physical aggression to various levels of physical harm, has become commonplace. Inciters of such violence tend to be those who “can’t help themselves,” often patients with primary psychiatric illness or those with medically induced mental impairment, such as delirium or withdrawal. For these patients, there is at least some level of compassion and tolerance for their behavior, and because they tend to be relatively predictable, preparedness and mitigation of such acts can give providers some sense of control over the situation.

But the Davidson event represents a type of violence that is frightening, unpredictable, and very difficult to prevent, prepare for, or adequately handle.

Actual shootings on medical campuses are, fortunately, rare. A recent study by the Johns Hopkins Office of Critical Event Preparedness and Response found 154 hospital shootings between 2000 and 2011, resulting in 235 injured or dead victims. The most commonly occurring scenario is that of people acting against family members, with healthcare workers getting caught in the crosshairs. The most common victim is the shooter (45% of the time), and the least common victims are physicians and nurses. Over half (59%) of medical center shootings occur within the hospital; the other 41% occur somewhere else on the hospital grounds.³

So what can hospitalists and hospitals do about the real threat of physical violence and shootings within medical centers? Some have recommended metal detectors as effective barriers for preventing weapons from entering medical centers. The primary problem with this solution is that the majority of medical centers have found this plan impossible to implement, given the number of entrances in typical hospitals; Johns Hopkins for example, has more than 80 entrances. Metal detectors also require security staffing at each entrance 24/7.⁴

Because of the barriers, metal detectors present an insurmountable financial obstacle for most hospitals. In addition, they present an issue with public perception. Many would argue that hospitals are (and should be) places of healing and sanctuary (e.g. “safe havens”), not places for suspicion and searches. In addition, although there is evidence that the use of metal detectors results in increased confiscation of weapons, there is no evidence that they result in fewer on-site assaults.⁵ Further complicating matters, almost a quarter of the shootings that occur in EDs result from the perpetrator grabbing a weapon from a security guard.³

Others advocate for stricter gun control laws and enforcement, an argument that has vehement advocates and critics on both sides and is unlikely to be resolved in the near future.

Take Action: Be Prepared

In the meantime, hospitalists are left with preparedness tactics that range from situational awareness to active shooter drills. Both are equally important and should be a part of disaster preparedness at any medical center regardless of size, type, or location. Hospitalists can and should take a lead in such preparedness. Current statistics show that hospitalists are employed in at least 85% of all U.S. hospitals. With such widespread penetration, hospitalists can have a huge impact on the preparedness efforts that can prevent such acts from occurring, as well as on organizational resilience and recovery if such an act does occur.

Such training is more important in healthcare settings than other workplaces, as medical personnel have to be specially trained to resist the temptation to help. For example, active shooter training instructs personnel to run, hide, or fight, none of which come “naturally” to those trained to save and rescue for a living. This training instructs anyone in the “Hot Zone” (where life is in direct danger) to run away from the scene (always preferred if feasible), hide (barricade the door, silence any devices, and stay still), or fight (use anything in sight to fight the shooter, and work as a team if feasible). These responses are the exact opposite of what most trained healthcare personnel are accustomed to doing in cases of emergency.

In Sum

The Michael Davidson story is very sobering by all accounts. Healthcare violence such as this, while rare, is devastating.

Hospitalists should lead the way in training and preparedness for violence prevention and mitigation, including active shooter simulation scenarios. We can all have a huge impact in reducing the risk of casualties should such an unpredictable event occur in our hospital.

References

1. Freyer FJ, Kowalczyk L, Murphy SP. Surgeon slain, gunman found dead in day of crisis at Brigham. January 20, 2015. The Boston Globe online. Available at: http://www.bostonglobe.com/metro/2015/01/20/boston-police-investigate-report-shooting-brigham-and-women/Jhig9z8LO8A5PH9Er4vTiP/story.html?rss_id=Top-GNP&utm_source=Managed&utm_campaign=386d2ff709-Quality+%26+Patient+Safety+Update&utm_medium=email&utm_term=0_ebe1fa6178-386d2ff709-319388717. Accessed February 5, 2015.
2. Barnet S. Gun violence in hospitals: how much of a threat is it really? January 21, 2015. Becker’s Hospital Review. Available at: http://www.beckershospitalreview.com/healthcare-blog/gun-violence-in-hospitals-how-much-of-a-threat-is-it-really.html. Accessed February 5, 2015.
3. Kelen GD, Catlett CL, Kubit JG, Hsieh Y-H. Hospital-based shootings in the United States: 2000 to 2011. Annals of Emergency Medicine online. September 20, 2012. Available at: http://www.annemergmed.com/article/S0196-0644%2812%2901408-4/abstract. Accessed February 5, 2015.
4. Calvert S, Scharper J, Roylance F. Experts: no need for metal detectors at Hopkins. September 17, 2010. The Baltimore Sun online. Available at: http://articles.baltimoresun.com/2010-09-17/business/bs-md-hopkins-hospital-security-20100916_1_metal-detectors-healthcare-security-and-safety-hospital-security-experts. Accessed February 5, 2015.
5. Rankins RC, Hendey GW. Effect of a security system on violent incidents and hidden weapons in the emergency department. Ann Emerg Med. 1999;33(6):676-679.