Quality

A new report shows that 1 in 5 community hospitals operates in the red, but the chief strategy officer of the firm that conducted the survey thinks hospitals can help change that.

The second annual survey from healthcare information technology (HIT) provider Anthelio and leadership group Community Hospital 100 found that 22% of community hospitals operate with margins below 2%; another 38% operate below 1%. Rick Kneipper, Anthelio’s cofounder and chief strategy officer, says that hospitalists can be at the forefront “of the creative changes needed” to reduce costs and improve profitability.

“Hospital medicine groups and hospitals could free up significant funds to devote to improved patient-care services if they focus on their core competency of patient care and farm out their non-core, back-office services to experts who can use leverage to provide more efficient services at significantly reduced costs,” Kneipper wrote in an email to The Hospitalist. “Financial pressures have historically forced most industries to stop trying to be vertically integrated [trying to be ‘all things to all people’] and instead to focus on their core competencies—it’s time for healthcare to do the same.”

HM’s foothold at the intersection of clinical care and safety and QI positions the specialty to “respond to the new challenges of readmission penalties, evidenced-based medicine requirements, EMR implementation, and operation challenges,” Kneipper wrote.

For the full survey, please visit www.antheliohealth.com and search “survey.”

A new report shows that 1 in 5 community hospitals operates in the red, but the chief strategy officer of the firm that conducted the survey thinks hospitals can help change that.

The second annual survey from healthcare information technology (HIT) provider Anthelio and leadership group Community Hospital 100 found that 22% of community hospitals operate with margins below 2%; another 38% operate below 1%. Rick Kneipper, Anthelio’s cofounder and chief strategy officer, says that hospitalists can be at the forefront “of the creative changes needed” to reduce costs and improve profitability.

“Hospital medicine groups and hospitals could free up significant funds to devote to improved patient-care services if they focus on their core competency of patient care and farm out their non-core, back-office services to experts who can use leverage to provide more efficient services at significantly reduced costs,” Kneipper wrote in an email to The Hospitalist. “Financial pressures have historically forced most industries to stop trying to be vertically integrated [trying to be ‘all things to all people’] and instead to focus on their core competencies—it’s time for healthcare to do the same.”

HM’s foothold at the intersection of clinical care and safety and QI positions the specialty to “respond to the new challenges of readmission penalties, evidenced-based medicine requirements, EMR implementation, and operation challenges,” Kneipper wrote.

For the full survey, please visit www.antheliohealth.com and search “survey.”

A new report shows that 1 in 5 community hospitals operates in the red, but the chief strategy officer of the firm that conducted the survey thinks hospitals can help change that.

The second annual survey from healthcare information technology (HIT) provider Anthelio and leadership group Community Hospital 100 found that 22% of community hospitals operate with margins below 2%; another 38% operate below 1%. Rick Kneipper, Anthelio’s cofounder and chief strategy officer, says that hospitalists can be at the forefront “of the creative changes needed” to reduce costs and improve profitability.

“Hospital medicine groups and hospitals could free up significant funds to devote to improved patient-care services if they focus on their core competency of patient care and farm out their non-core, back-office services to experts who can use leverage to provide more efficient services at significantly reduced costs,” Kneipper wrote in an email to The Hospitalist. “Financial pressures have historically forced most industries to stop trying to be vertically integrated [trying to be ‘all things to all people’] and instead to focus on their core competencies—it’s time for healthcare to do the same.”

HM’s foothold at the intersection of clinical care and safety and QI positions the specialty to “respond to the new challenges of readmission penalties, evidenced-based medicine requirements, EMR implementation, and operation challenges,” Kneipper wrote.

For the full survey, please visit www.antheliohealth.com and search “survey.”

1. Encourage good hand hygiene. This should be obvious, but hospitals are struggling to achieve compliance rates of even 50%. One study has found significant improvement by appealing to medical providers’ altruistic sense: “Hand hygiene prevents patients from catching diseases.”¹
2. Embrace checklists. If they work for airline pilots, they can work for you. Study after study has supported their effectiveness, particularly in preventing CLABSIs and CAUTIs when well-integrated into a multifaceted approach.
3. Bundle up. A bundled approach that emphasized proper hand hygiene, disinfection, catheter avoidance, and timely removal cut CLABSI rates by morethan half, on average, in Veterans Administration ICUs throughout the U.S.²
4. Team up. For a C. diff-reduction effort at Kaiser Permanente Medical Center in Santa Clara, Calif., success meant getting doctors, nurses, specialists, and administrators on board, both to brainstorm and to sustain momentum.
5. Be a role model. Consistently following HAI-prevention protocols, such as contact precautions, can make adherence contagious—in a very good way.
6. Be an innovator. By virtue of being ubiquitous in inpatient wards, hospitalists know what works and what doesn’t; your insight can be particularly valuable for a team-based, HAI-reduction effort.

References

1. Grant AM, Hofmann DA. It’s not all about me: Motivating hospital hand hygiene by focusing on patients. Psychol Sci. 2011;22:1494-1499.
2. Render ML, Hasselbeck R, Freyberg RW, Hofer TP, et al. Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement. BMJ Qual Saf. 2011;20(8):725-732.

1. Encourage good hand hygiene. This should be obvious, but hospitals are struggling to achieve compliance rates of even 50%. One study has found significant improvement by appealing to medical providers’ altruistic sense: “Hand hygiene prevents patients from catching diseases.”¹
2. Embrace checklists. If they work for airline pilots, they can work for you. Study after study has supported their effectiveness, particularly in preventing CLABSIs and CAUTIs when well-integrated into a multifaceted approach.
3. Bundle up. A bundled approach that emphasized proper hand hygiene, disinfection, catheter avoidance, and timely removal cut CLABSI rates by morethan half, on average, in Veterans Administration ICUs throughout the U.S.²
4. Team up. For a C. diff-reduction effort at Kaiser Permanente Medical Center in Santa Clara, Calif., success meant getting doctors, nurses, specialists, and administrators on board, both to brainstorm and to sustain momentum.
5. Be a role model. Consistently following HAI-prevention protocols, such as contact precautions, can make adherence contagious—in a very good way.
6. Be an innovator. By virtue of being ubiquitous in inpatient wards, hospitalists know what works and what doesn’t; your insight can be particularly valuable for a team-based, HAI-reduction effort.

References

1. Grant AM, Hofmann DA. It’s not all about me: Motivating hospital hand hygiene by focusing on patients. Psychol Sci. 2011;22:1494-1499.
2. Render ML, Hasselbeck R, Freyberg RW, Hofer TP, et al. Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement. BMJ Qual Saf. 2011;20(8):725-732.

1. Encourage good hand hygiene. This should be obvious, but hospitals are struggling to achieve compliance rates of even 50%. One study has found significant improvement by appealing to medical providers’ altruistic sense: “Hand hygiene prevents patients from catching diseases.”¹
2. Embrace checklists. If they work for airline pilots, they can work for you. Study after study has supported their effectiveness, particularly in preventing CLABSIs and CAUTIs when well-integrated into a multifaceted approach.
3. Bundle up. A bundled approach that emphasized proper hand hygiene, disinfection, catheter avoidance, and timely removal cut CLABSI rates by morethan half, on average, in Veterans Administration ICUs throughout the U.S.²
4. Team up. For a C. diff-reduction effort at Kaiser Permanente Medical Center in Santa Clara, Calif., success meant getting doctors, nurses, specialists, and administrators on board, both to brainstorm and to sustain momentum.
5. Be a role model. Consistently following HAI-prevention protocols, such as contact precautions, can make adherence contagious—in a very good way.
6. Be an innovator. By virtue of being ubiquitous in inpatient wards, hospitalists know what works and what doesn’t; your insight can be particularly valuable for a team-based, HAI-reduction effort.

References

1. Grant AM, Hofmann DA. It’s not all about me: Motivating hospital hand hygiene by focusing on patients. Psychol Sci. 2011;22:1494-1499.
2. Render ML, Hasselbeck R, Freyberg RW, Hofer TP, et al. Reduction of central line infections in Veterans Administration intensive care units: an observational cohort using a central infrastructure to support learning and improvement. BMJ Qual Saf. 2011;20(8):725-732.

Listen to Dr. Gould

At 480-bed Emory University Hospital Midtown in Atlanta, the physicians and staff seemingly are doing all the right things to foil one of hospital’s archenemies: Clostridium difficile. The bacteria, better known as C. diff, is responsible for a sharp rise in hospital-acquired infections over the past decade, rivaling even MRSA.

In 2010, Emory Midtown launched a campaign to boost awareness of the importance of hand washing before and after treating patients infected with C. diff and those likely to be infected. They also began using the polymerase-chain-reaction-based assay to detect the bacteria, a test with much higher sensitivity that helps to more efficiently identify those infected so control measures can be more prompt and targeted. They use a hypochlorite mixture to clean the rooms of those infected, which is considered a must. And a committee monitors the use of antibiotics to prevent overuse—often the scapegoat for the rise of the hard-to-kill bacteria.

Still, at Emory, the rate of C. diff is about the same as the national average, says hospitalist Ketino Kobaidze, MD, assistant professor at the Emory University School of Medicine and a member of the antimicrobial stewardship and infectious disease control committees at Midtown. While Dr. Kobaidze says her institution is doing a good job of trying to keep C. diff under control, she thinks hospitalists can do more.

“My feeling is that we are not as involved as we’re supposed to be,” she says. “I think we need to be a little bit more proactive, be involved in committees and research activities across the hospital.”

You Are Not Alone

The experience at Emory Midtown is far from unusual—healthcare facilities, and hospitalists, across the country have seen healthcare-related C. diff cases more than double since 2001 to between 400,000 and 500,000 a year, says Carolyn Gould, MD, a medical epidemiologist in the division of healthcare quality promotion at the Centers for Disease Control and Prevention (CDC) in Atlanta.

Hospitalists, whether they realize it or not, are intimately involved in how well the C. diff outbreak is controlled. Infectious-disease (ID) specialists say hospitalists are perfectly situated to make an impact in efforts to help curb the outbreak.

“Hospitalists are critical to this effort,” Dr. Gould says. “They’re in the hospital day in and day out, and they’re constantly interacting with the patients, staff, and administration. They’re often the first on the scene to see a patient who might have suddenly developed diarrhea; they’re the first to react. I think they’re in a prime position to play a leadership role to prevent C. diff infections.”

They’re also situated well to work with infection-control experts on antimicrobial stewardship programs, she says.

“I look at hospitalists just like I would have looked at internists managing their own patients 15 years ago,” says Stuart Cohen, MD, an ID expert with the University of California at Davis and a fellow with the Infectious Diseases Society of America who was lead author of the latest published IDSA guidelines on C. diff treatment. “And so they’re the first-line people.”

continued below...

Mayo Shows How a Simple Step Can Make Big Difference in C. Diff

Listen to Dr. Gould

Sometimes even when it comes to a huge problem like widespread bacterial infections, simplicity is best.

The Mayo Clinic, in a project to cut the rate of C. diff infections, asked its workers to do one extra thing: Wipe down high-touch areas with bleach wipes. The effort worked; infections were all but eradicated in units that had been having five to seven infections per month.

The results of the project, recently published in Infectious Control and Hospital Epidemiology, show the importance of simple steps as long as they’re carried out regularly and thoroughly.¹

The project began when Robert Orenstein, DO, associate professor of medicine in infectious diseases who then worked in Rochester, Minn., established a surveillance network for C. diff infections at Mayo Clinic at the time when such infections were being noted more widely throughout the U.S. and Canada. The network began tracking the cases and found that one inpatient medical unit primarily composed of patients with gastrointestinal diseases had a C. diff rate 10 times higher than the rest of the hospital. Surveillance also showed that universally gloved hematology and oncology units had substantially lower rates of C. diff infection despite high-risk patients.

Dr. Orenstein knew he had to make a change in the GI unit, but it wasn’t feasible to institute universal gloving, so he turned to bleach wipes.

Dr. Orenstein

Twice a day, housekeeping staff wiped down all “high-touch” areas (light switches, toilet handles, bed rails) in all of the rooms. The wipes contain 0.55% sodium hypochlorite. Within six months, the number of C. diff cases fell to almost zero.

“We were just in shock,” Dr. Orenstein says. He attributed the improvement to a reduction in the “colonization pressure”—if a high concentration of patients with C. diff can cause abundant transmissions quickly, the opposite is also true.

The greatly improved figures were shared with housekeeping, which initially complained about the smell but were encouraged to keep doors open and rooms ventilated. The bleach wipes, which Dr. Orenstein acknowledges mean an additional expense, leave a white residue when dry, so the surfaces are wiped down with water after the recommended contact time.

Dr. Orenstein notes that the results came even without a change in hand hygiene, which he had deemed not feasible because of the hospital’s lack of sinks. He isn’t diminishing the importance of hand washing, but the project does show how effective a single step can be.

The key, Dr. Orenstein adds, might be that it was just one change involving just one group of staff. “Why we think it was so effective is it was really one group that had to change their behavior and we worked with them, educated them,” he says.

He emphasizes that the wipes don’t come at the expense of other measures, like thorough cleaning of all rooms and antibiotic stewardship programs.

“You do all of those and do them well,” he says, “then you get the reduction of C. diff in the hospital.”

A Tough Bug

Believed to be aided largely by the use of broad-spectrum antibiotics that knock out the colon’s natural flora, C. diff in the hospital—as well as nursing homes and acute-care facilities—has raged for much of the past decade. Its rise is tied to the emergence of a new hypervirulent strain known as BI/NAP1/027, or NAP1 for short. The strain is highly resistant to fluoroquinolones, such as ciprofloxacin and levofloxacin, which are used often in healthcare settings.

“A fluoroquinolone will wipe out a lot of your normal flora in your gut,” Dr. Gould says. “But it won’t wipe out C. diff, in particular this hypervirulent strain. And so this strain can flourish in the presence of fluoroquinolones.” The strain produces up to 15 to 20 times more toxins than other C. diff strains, according to some data, she adds.

Vancomycin (Vanconin) and metronidazole (Flagyl) are the most common antibiotics used to treat patients infected with C. diff. Mortality rates are higher among the elderly, largely because of their weaker immune system, Dr. Gould says. Studies have generally shown mortality rates of 10% or a bit lower.¹

More recent studies have shown that the number of hospital-related C. diff cases might have begun to level off in 2008 and 2009. Dr. Gould says she thinks the leveling off is for real, but there is debate over what the immediate future holds.

“There’s a lot of work and initiatives, especially state-based initiatives, that are being done in hospitals. And there’s reason to believe they’re effective,” she says, adding it’s harder to get a good picture of the problem in long-term care facilities and in the community.

Dr. Cohen with the IDSA says it’s too soon to say whether the problem is hitting a plateau. “CDC data are always a couple of years behind,” he says. “Until you see another data point, you can’t tell whether that’s just a transient flattening and whether it’s going to keep going up or not.”

Kevin Kavanagh, MD, founder of the patient advocacy group Health Watch USA and a retired otolaryngologist in Kentucky who has taken a keen interest in the C. diff problem, says he doesn’t think the end of the tunnel is within view yet.

“I think C. diff is going to get worse before it gets better,” Dr. Kavanagh says. “And that’s not necessarily because the healthcare profession isn’t doing due diligence. This is a tough organism.—it can be tough to treat and can be very tough to kill.”

The Best Defense?

Because C. diff lives within protective spores, sound hand hygiene practices and room-cleaning practices are essential for keeping infections to a minimum. Alcohol-based hand sanitizers, effective against other organisms including MRSA, do not kill C. diff. The bacteria must be mechanically removed through hand washing.

And even hand washing might not be totally effective at getting rid of the spores, which means it’s important for healthcare workers to gown and glove in high-risk rooms.

Sodium hypochlorite solutions, or bleach mixtures, have to be used to clean rooms occupied by patients with C. diff, and the prevailing thought is to clean the rooms of patients suspected of having C. diff, even if those cases might not be confirmed.

Equally important to cleaning and hand washing is systemwide emphasis on antibiotic stewardship. A 2011 study at the State University of New York Buffalo found that the risk of a C. diff infection rose with the number of antibiotics taken.²

If someone is very sick and you’re not sure what is going on, it’s very reasonable to treat them empirically with broad-spectrum antibiotics. The important thing is that you send the appropriate cultures before so that you know what you’re treating and you can optimize those antibiotics with daily assessments.

—Carolyn Gould, MD, medical epidemiologist, division of healthcare quality promotion, Centers of Disease Control and Prevention, Atlanta

While a broad-spectrum antibiotic might be necessary at first, once the results of cultures are received, the treatment should be finely tailored to kill only the problem bacteria so that the body’s natural defenses aren’t broken down, Dr. Gould explains.

“If someone is very sick and you’re not sure what is going on, it’s very reasonable to treat them empirically with broad-spectrum antibiotics,” she says. “The important thing is that you send the appropriate cultures before so that you know what you’re treating and you can optimize those antibiotics with daily assessments.”

Dr. Cohen

It’s clear why an overreliance on broad-spectrum drugs prevails in U.S. health settings, Dr. Cohen acknowledges. Recent literature suggests treating critically ill patients with wide-ranging antimicrobials as the mortality rate can be twice as high with narrower options. “I think people have gotten very quick to give broad-spectrum therapy,” he says.

continued below...

Knocking Out Clostridium Difficile

Listen to Dr. Gould

Here are the guidelines on treatment of C. diff infections (CDI) as recommended by the Infectious Diseases Society of America:

First steps:

• Discontinue therapy with the inciting antimicrobial agent(s) as soon as possible as this may influence the risk of CDI recurrence.
• When severe or complicated CDI is suspected, initiate empirical treatment as soon as the diagnosis is suspected.
• If the stool toxin assay result is negative, the decision to initiate, stop, or continue treatment must be individualized.
• If possible, avoid use of antiperistaltic agents as they may obscure symptoms and precipitate toxic megacolon.

Treatment of initial episode:

• Metronidazole is the drug of choice for the initial episode of mild to moderate CDI. The dosage is 500 mg orally three times per day for 10 to 14 days.
• Vancomycin is the drug of choice for an initial episode of severe CDI. The dosage is 125 mg orally four times per day for 10 to 14 days.
• Vancomycin administered orally (and per rectum if ileus is present) with or without intravenously administered metronidazole is the regimen of choice for the treatment of severe complicated CDI. The vancomycin dosage is 500 mg orally four times per day and 500 mg in approximately 100 mL normal saline per rectum every six hours as a retention enema, and the metronidazole dosage is 500 mg intravenously every eight hours.

Severely ill patients:

Consider colectomy for severely ill patients. Monitoring the serum lactate level and the peripheral blood white blood cell count may be helpful in prompting a decision to operate because a serum lactate level rising to 5 mmol/L and a white blood cell count rising to 50,000 cells per mL have been associated with greatly increased perioperative mortality. If surgical management is necessary, perform subtotal colectomy with preservation of the rectum.

Treatment of recurrences:

• Treatment of the first recurrence of CDI is usually with the same regimen as for the initial episode but should be stratified by disease severity (mild-to-moderate, severe, or severe complicated) as is recommended for treatment of the initial CDI episode.
• Do not use metronidazole beyond the first recurrence of CDI or for long-term chronic therapy because of potential for cumulative neurotoxicity.
• Treatment of the second or later recurrence of CDI with vancomycin therapy using a tapered and/or pulse regimen is the preferred next strategy.

Probiotics:

Administration of currently available probiotics is not recommended to prevent primary CDI as there are limited data to support this approach and there is a potential risk of bloodstream infection.

Source: Cohen SH, Gerding DH, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Hospital Epidemiology. 2010;31(5):431–455.

National Response, Localized Attention

Dr. Kavanagh of Health Watch USA says that more information about C. diff is needed, particularly publicly available numbers of infections at hospitals. Some states require those figures to be reported, but most don’t. And there is no current federal mandate on reporting of C. diff cases, although acute-care hospitals will be required to report C. diff infection rates starting in 2013.

“We really have scant data,” he says. “There is not a lot of reporting if you look at the nation on a whole. And I think that underscores one of the reasons why you need to have data for action. You need to have reporting of these organisms to the National Healthcare Safety Network so that the CDC can monitor and can make plans and can do effective interventions.

“You want to know where the areas of highest infection are,” he adds. “You want to know what interventions work and don’t work. If you don’t have a national coordinated reporting system, it really makes it difficult to address the problem. C. diff is going to be much harder to control than MRSA or other bacteria because it changes into a hard-to-kill dormant spore stage and then re-occurs at some point.”

The Centers for Medicare & Medicaid Services (CMS) has proposed adding C. diff infections to the list of hospital-acquired conditions that will not be reimbursable. It is widely hoped that such a measure will go a long way toward stamping out the problem.

Dr. Kobaidze of Emory notes that C. diff is a dynamic problem, always adapting and posing new challenges. And hospitalists should be more involved in answering these questions through research. One recent question, she points out, is whether proton pump inhibitor use is related to the rise of C. diff.

Ultimately, though, controlling C. diff in hospitals might come down to what is done day to day inside the hospital. And hospitalists can play a big role.

Danielle Scheurer, MD, MSCR, SFHM, a hospitalist and medical director of quality at the Medical University of South Carolina in Charleston, says that a full-time pharmacist on the hospital’s antimicrobial stewardship committee is always reviewing antibiotic prescriptions and is prepared to flag cases in which a broad-spectrum is used when one with a more narrow scope might be more appropriate.

The hospital has done its best, as part of its “renovation cycle,” to standardize the layouts of rooms “so that the second you open the door you know exactly where the alcohol gel is and where the soap and the sink is going to be.” The idea is to make compliance as “mindless” as possible. Such efforts can be hampered by structural limitations though, she says.

HM group leaders, she suggests, can play an important part simply by being good role models—gowning and gloving without complaint before entering high-risk rooms and reinforcing the message that such efforts have real effects on patient safety.

But she also acknowledges that “it always sounds easy....There has to be some level of redundancy built into the hospital system. This is more of a system thing than the individual hospitalist.”

One level of redundancy at MUSC that has been particularly effective, she says, are “secret shoppers” who keep an eye out for medical teams that might not be washing their hands as they go in and out of high-risk rooms. Each unit is responsible for their hand hygiene numbers—which include both self-reported figures and those obtained by the secret onlookers—and those numbers are made available to the hospital.

Those units with the best numbers are sometimes given a reward, such as a pizza party, but it’s colleagues’ knowledge of the numbers that matters most, she says.

“That, in and of itself, is a powerful motivator,” Dr. Scheurer says. “We bring it to all of our quality operations meetings, all the administrators, the CEO, the CMO. It’s very motivating for every unit. They don’t want to be the trailing unit.”

Tom Collins is a freelance medical writer based in Miami.

References

1. Orenstein R, Aronhalt KC, McManus JE Jr., Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control Hosp Epidemiol. 2011;32(11):1137-1139.
2. Stevens V, Dumyati G, Fine LS, Fisher SG, van Wijngaarden E. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis. 2011;53(1):42-48.

What Hospitalists Can Do

Listen to Dr. Gould

Here are suggestions, as provided by ID experts and hospitalist leaders, on what hospitalists can do to battle C. diff infections:

Short-term steps:

• Wash hands before entering and upon leaving rooms occupied by patients with C. diff infections and those strongly suspected of having C. diff infections.
• Continue using alcohol-based hand sanitizers in addition to hand washing to prevent other types of outbreaks.
• Ensure that infected patients, and those suspected of being infected, are isolated, possibly even for 48 hours after diarrhea resolves, as research shows the patients can still transmit the spores.
• In units with high C. diff rates, consider universal gloving, not just for patients with known infection.
• Use more highly sensitive tests, such as polymerase chain reaction, or PCR, rather than enzyme immunoassays to more efficiently identify affected patients.
• Avoid testing patients with formed stools.
• Ensure that rooms of infected patients and patients strongly suspected of being infected are cleaned with a hypochlorite solution.
• Taper the use of broad-spectrum antibiotics in non-C. diff patients after test results are obtained.
• Encourage patients to question their healthcare practitioners about hand hygiene and use of antibiotics.

Long-term steps:

• Be involved with your hospital’s antimicrobial stewardship program.
• Conduct research into C. diff to explore its causes and treatments.
• Be a good role model for the rest of your group, emphasizing good practices and a strong patient-safety message.

Listen to Dr. Gould

At 480-bed Emory University Hospital Midtown in Atlanta, the physicians and staff seemingly are doing all the right things to foil one of hospital’s archenemies: Clostridium difficile. The bacteria, better known as C. diff, is responsible for a sharp rise in hospital-acquired infections over the past decade, rivaling even MRSA.

In 2010, Emory Midtown launched a campaign to boost awareness of the importance of hand washing before and after treating patients infected with C. diff and those likely to be infected. They also began using the polymerase-chain-reaction-based assay to detect the bacteria, a test with much higher sensitivity that helps to more efficiently identify those infected so control measures can be more prompt and targeted. They use a hypochlorite mixture to clean the rooms of those infected, which is considered a must. And a committee monitors the use of antibiotics to prevent overuse—often the scapegoat for the rise of the hard-to-kill bacteria.

Still, at Emory, the rate of C. diff is about the same as the national average, says hospitalist Ketino Kobaidze, MD, assistant professor at the Emory University School of Medicine and a member of the antimicrobial stewardship and infectious disease control committees at Midtown. While Dr. Kobaidze says her institution is doing a good job of trying to keep C. diff under control, she thinks hospitalists can do more.

“My feeling is that we are not as involved as we’re supposed to be,” she says. “I think we need to be a little bit more proactive, be involved in committees and research activities across the hospital.”

You Are Not Alone

The experience at Emory Midtown is far from unusual—healthcare facilities, and hospitalists, across the country have seen healthcare-related C. diff cases more than double since 2001 to between 400,000 and 500,000 a year, says Carolyn Gould, MD, a medical epidemiologist in the division of healthcare quality promotion at the Centers for Disease Control and Prevention (CDC) in Atlanta.

Hospitalists, whether they realize it or not, are intimately involved in how well the C. diff outbreak is controlled. Infectious-disease (ID) specialists say hospitalists are perfectly situated to make an impact in efforts to help curb the outbreak.

“Hospitalists are critical to this effort,” Dr. Gould says. “They’re in the hospital day in and day out, and they’re constantly interacting with the patients, staff, and administration. They’re often the first on the scene to see a patient who might have suddenly developed diarrhea; they’re the first to react. I think they’re in a prime position to play a leadership role to prevent C. diff infections.”

They’re also situated well to work with infection-control experts on antimicrobial stewardship programs, she says.

“I look at hospitalists just like I would have looked at internists managing their own patients 15 years ago,” says Stuart Cohen, MD, an ID expert with the University of California at Davis and a fellow with the Infectious Diseases Society of America who was lead author of the latest published IDSA guidelines on C. diff treatment. “And so they’re the first-line people.”

continued below...

Mayo Shows How a Simple Step Can Make Big Difference in C. Diff

Listen to Dr. Gould

Sometimes even when it comes to a huge problem like widespread bacterial infections, simplicity is best.

The Mayo Clinic, in a project to cut the rate of C. diff infections, asked its workers to do one extra thing: Wipe down high-touch areas with bleach wipes. The effort worked; infections were all but eradicated in units that had been having five to seven infections per month.

The results of the project, recently published in Infectious Control and Hospital Epidemiology, show the importance of simple steps as long as they’re carried out regularly and thoroughly.¹

The project began when Robert Orenstein, DO, associate professor of medicine in infectious diseases who then worked in Rochester, Minn., established a surveillance network for C. diff infections at Mayo Clinic at the time when such infections were being noted more widely throughout the U.S. and Canada. The network began tracking the cases and found that one inpatient medical unit primarily composed of patients with gastrointestinal diseases had a C. diff rate 10 times higher than the rest of the hospital. Surveillance also showed that universally gloved hematology and oncology units had substantially lower rates of C. diff infection despite high-risk patients.

Dr. Orenstein knew he had to make a change in the GI unit, but it wasn’t feasible to institute universal gloving, so he turned to bleach wipes.

Dr. Orenstein

Twice a day, housekeeping staff wiped down all “high-touch” areas (light switches, toilet handles, bed rails) in all of the rooms. The wipes contain 0.55% sodium hypochlorite. Within six months, the number of C. diff cases fell to almost zero.

“We were just in shock,” Dr. Orenstein says. He attributed the improvement to a reduction in the “colonization pressure”—if a high concentration of patients with C. diff can cause abundant transmissions quickly, the opposite is also true.

The greatly improved figures were shared with housekeeping, which initially complained about the smell but were encouraged to keep doors open and rooms ventilated. The bleach wipes, which Dr. Orenstein acknowledges mean an additional expense, leave a white residue when dry, so the surfaces are wiped down with water after the recommended contact time.

Dr. Orenstein notes that the results came even without a change in hand hygiene, which he had deemed not feasible because of the hospital’s lack of sinks. He isn’t diminishing the importance of hand washing, but the project does show how effective a single step can be.

The key, Dr. Orenstein adds, might be that it was just one change involving just one group of staff. “Why we think it was so effective is it was really one group that had to change their behavior and we worked with them, educated them,” he says.

He emphasizes that the wipes don’t come at the expense of other measures, like thorough cleaning of all rooms and antibiotic stewardship programs.

“You do all of those and do them well,” he says, “then you get the reduction of C. diff in the hospital.”

A Tough Bug

Believed to be aided largely by the use of broad-spectrum antibiotics that knock out the colon’s natural flora, C. diff in the hospital—as well as nursing homes and acute-care facilities—has raged for much of the past decade. Its rise is tied to the emergence of a new hypervirulent strain known as BI/NAP1/027, or NAP1 for short. The strain is highly resistant to fluoroquinolones, such as ciprofloxacin and levofloxacin, which are used often in healthcare settings.

“A fluoroquinolone will wipe out a lot of your normal flora in your gut,” Dr. Gould says. “But it won’t wipe out C. diff, in particular this hypervirulent strain. And so this strain can flourish in the presence of fluoroquinolones.” The strain produces up to 15 to 20 times more toxins than other C. diff strains, according to some data, she adds.

Vancomycin (Vanconin) and metronidazole (Flagyl) are the most common antibiotics used to treat patients infected with C. diff. Mortality rates are higher among the elderly, largely because of their weaker immune system, Dr. Gould says. Studies have generally shown mortality rates of 10% or a bit lower.¹

More recent studies have shown that the number of hospital-related C. diff cases might have begun to level off in 2008 and 2009. Dr. Gould says she thinks the leveling off is for real, but there is debate over what the immediate future holds.

“There’s a lot of work and initiatives, especially state-based initiatives, that are being done in hospitals. And there’s reason to believe they’re effective,” she says, adding it’s harder to get a good picture of the problem in long-term care facilities and in the community.

Dr. Cohen with the IDSA says it’s too soon to say whether the problem is hitting a plateau. “CDC data are always a couple of years behind,” he says. “Until you see another data point, you can’t tell whether that’s just a transient flattening and whether it’s going to keep going up or not.”

Kevin Kavanagh, MD, founder of the patient advocacy group Health Watch USA and a retired otolaryngologist in Kentucky who has taken a keen interest in the C. diff problem, says he doesn’t think the end of the tunnel is within view yet.

“I think C. diff is going to get worse before it gets better,” Dr. Kavanagh says. “And that’s not necessarily because the healthcare profession isn’t doing due diligence. This is a tough organism.—it can be tough to treat and can be very tough to kill.”

The Best Defense?

Because C. diff lives within protective spores, sound hand hygiene practices and room-cleaning practices are essential for keeping infections to a minimum. Alcohol-based hand sanitizers, effective against other organisms including MRSA, do not kill C. diff. The bacteria must be mechanically removed through hand washing.

And even hand washing might not be totally effective at getting rid of the spores, which means it’s important for healthcare workers to gown and glove in high-risk rooms.

Sodium hypochlorite solutions, or bleach mixtures, have to be used to clean rooms occupied by patients with C. diff, and the prevailing thought is to clean the rooms of patients suspected of having C. diff, even if those cases might not be confirmed.

Equally important to cleaning and hand washing is systemwide emphasis on antibiotic stewardship. A 2011 study at the State University of New York Buffalo found that the risk of a C. diff infection rose with the number of antibiotics taken.²

If someone is very sick and you’re not sure what is going on, it’s very reasonable to treat them empirically with broad-spectrum antibiotics. The important thing is that you send the appropriate cultures before so that you know what you’re treating and you can optimize those antibiotics with daily assessments.

—Carolyn Gould, MD, medical epidemiologist, division of healthcare quality promotion, Centers of Disease Control and Prevention, Atlanta

While a broad-spectrum antibiotic might be necessary at first, once the results of cultures are received, the treatment should be finely tailored to kill only the problem bacteria so that the body’s natural defenses aren’t broken down, Dr. Gould explains.

“If someone is very sick and you’re not sure what is going on, it’s very reasonable to treat them empirically with broad-spectrum antibiotics,” she says. “The important thing is that you send the appropriate cultures before so that you know what you’re treating and you can optimize those antibiotics with daily assessments.”

Dr. Cohen

It’s clear why an overreliance on broad-spectrum drugs prevails in U.S. health settings, Dr. Cohen acknowledges. Recent literature suggests treating critically ill patients with wide-ranging antimicrobials as the mortality rate can be twice as high with narrower options. “I think people have gotten very quick to give broad-spectrum therapy,” he says.

continued below...

Knocking Out Clostridium Difficile

Listen to Dr. Gould

Here are the guidelines on treatment of C. diff infections (CDI) as recommended by the Infectious Diseases Society of America:

First steps:

• Discontinue therapy with the inciting antimicrobial agent(s) as soon as possible as this may influence the risk of CDI recurrence.
• When severe or complicated CDI is suspected, initiate empirical treatment as soon as the diagnosis is suspected.
• If the stool toxin assay result is negative, the decision to initiate, stop, or continue treatment must be individualized.
• If possible, avoid use of antiperistaltic agents as they may obscure symptoms and precipitate toxic megacolon.

Treatment of initial episode:

• Metronidazole is the drug of choice for the initial episode of mild to moderate CDI. The dosage is 500 mg orally three times per day for 10 to 14 days.
• Vancomycin is the drug of choice for an initial episode of severe CDI. The dosage is 125 mg orally four times per day for 10 to 14 days.
• Vancomycin administered orally (and per rectum if ileus is present) with or without intravenously administered metronidazole is the regimen of choice for the treatment of severe complicated CDI. The vancomycin dosage is 500 mg orally four times per day and 500 mg in approximately 100 mL normal saline per rectum every six hours as a retention enema, and the metronidazole dosage is 500 mg intravenously every eight hours.

Severely ill patients:

Consider colectomy for severely ill patients. Monitoring the serum lactate level and the peripheral blood white blood cell count may be helpful in prompting a decision to operate because a serum lactate level rising to 5 mmol/L and a white blood cell count rising to 50,000 cells per mL have been associated with greatly increased perioperative mortality. If surgical management is necessary, perform subtotal colectomy with preservation of the rectum.

Treatment of recurrences:

• Treatment of the first recurrence of CDI is usually with the same regimen as for the initial episode but should be stratified by disease severity (mild-to-moderate, severe, or severe complicated) as is recommended for treatment of the initial CDI episode.
• Do not use metronidazole beyond the first recurrence of CDI or for long-term chronic therapy because of potential for cumulative neurotoxicity.
• Treatment of the second or later recurrence of CDI with vancomycin therapy using a tapered and/or pulse regimen is the preferred next strategy.

Probiotics:

Administration of currently available probiotics is not recommended to prevent primary CDI as there are limited data to support this approach and there is a potential risk of bloodstream infection.

Source: Cohen SH, Gerding DH, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Hospital Epidemiology. 2010;31(5):431–455.

National Response, Localized Attention

Dr. Kavanagh of Health Watch USA says that more information about C. diff is needed, particularly publicly available numbers of infections at hospitals. Some states require those figures to be reported, but most don’t. And there is no current federal mandate on reporting of C. diff cases, although acute-care hospitals will be required to report C. diff infection rates starting in 2013.

“We really have scant data,” he says. “There is not a lot of reporting if you look at the nation on a whole. And I think that underscores one of the reasons why you need to have data for action. You need to have reporting of these organisms to the National Healthcare Safety Network so that the CDC can monitor and can make plans and can do effective interventions.

“You want to know where the areas of highest infection are,” he adds. “You want to know what interventions work and don’t work. If you don’t have a national coordinated reporting system, it really makes it difficult to address the problem. C. diff is going to be much harder to control than MRSA or other bacteria because it changes into a hard-to-kill dormant spore stage and then re-occurs at some point.”

The Centers for Medicare & Medicaid Services (CMS) has proposed adding C. diff infections to the list of hospital-acquired conditions that will not be reimbursable. It is widely hoped that such a measure will go a long way toward stamping out the problem.

Dr. Kobaidze of Emory notes that C. diff is a dynamic problem, always adapting and posing new challenges. And hospitalists should be more involved in answering these questions through research. One recent question, she points out, is whether proton pump inhibitor use is related to the rise of C. diff.

Ultimately, though, controlling C. diff in hospitals might come down to what is done day to day inside the hospital. And hospitalists can play a big role.

Danielle Scheurer, MD, MSCR, SFHM, a hospitalist and medical director of quality at the Medical University of South Carolina in Charleston, says that a full-time pharmacist on the hospital’s antimicrobial stewardship committee is always reviewing antibiotic prescriptions and is prepared to flag cases in which a broad-spectrum is used when one with a more narrow scope might be more appropriate.

The hospital has done its best, as part of its “renovation cycle,” to standardize the layouts of rooms “so that the second you open the door you know exactly where the alcohol gel is and where the soap and the sink is going to be.” The idea is to make compliance as “mindless” as possible. Such efforts can be hampered by structural limitations though, she says.

HM group leaders, she suggests, can play an important part simply by being good role models—gowning and gloving without complaint before entering high-risk rooms and reinforcing the message that such efforts have real effects on patient safety.

But she also acknowledges that “it always sounds easy....There has to be some level of redundancy built into the hospital system. This is more of a system thing than the individual hospitalist.”

One level of redundancy at MUSC that has been particularly effective, she says, are “secret shoppers” who keep an eye out for medical teams that might not be washing their hands as they go in and out of high-risk rooms. Each unit is responsible for their hand hygiene numbers—which include both self-reported figures and those obtained by the secret onlookers—and those numbers are made available to the hospital.

Those units with the best numbers are sometimes given a reward, such as a pizza party, but it’s colleagues’ knowledge of the numbers that matters most, she says.

“That, in and of itself, is a powerful motivator,” Dr. Scheurer says. “We bring it to all of our quality operations meetings, all the administrators, the CEO, the CMO. It’s very motivating for every unit. They don’t want to be the trailing unit.”

Tom Collins is a freelance medical writer based in Miami.

References

1. Orenstein R, Aronhalt KC, McManus JE Jr., Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control Hosp Epidemiol. 2011;32(11):1137-1139.
2. Stevens V, Dumyati G, Fine LS, Fisher SG, van Wijngaarden E. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis. 2011;53(1):42-48.

What Hospitalists Can Do

Listen to Dr. Gould

Here are suggestions, as provided by ID experts and hospitalist leaders, on what hospitalists can do to battle C. diff infections:

Short-term steps:

• Wash hands before entering and upon leaving rooms occupied by patients with C. diff infections and those strongly suspected of having C. diff infections.
• Continue using alcohol-based hand sanitizers in addition to hand washing to prevent other types of outbreaks.
• Ensure that infected patients, and those suspected of being infected, are isolated, possibly even for 48 hours after diarrhea resolves, as research shows the patients can still transmit the spores.
• In units with high C. diff rates, consider universal gloving, not just for patients with known infection.
• Use more highly sensitive tests, such as polymerase chain reaction, or PCR, rather than enzyme immunoassays to more efficiently identify affected patients.
• Avoid testing patients with formed stools.
• Ensure that rooms of infected patients and patients strongly suspected of being infected are cleaned with a hypochlorite solution.
• Taper the use of broad-spectrum antibiotics in non-C. diff patients after test results are obtained.
• Encourage patients to question their healthcare practitioners about hand hygiene and use of antibiotics.

Long-term steps:

• Be involved with your hospital’s antimicrobial stewardship program.
• Conduct research into C. diff to explore its causes and treatments.
• Be a good role model for the rest of your group, emphasizing good practices and a strong patient-safety message.

Listen to Dr. Gould

At 480-bed Emory University Hospital Midtown in Atlanta, the physicians and staff seemingly are doing all the right things to foil one of hospital’s archenemies: Clostridium difficile. The bacteria, better known as C. diff, is responsible for a sharp rise in hospital-acquired infections over the past decade, rivaling even MRSA.

In 2010, Emory Midtown launched a campaign to boost awareness of the importance of hand washing before and after treating patients infected with C. diff and those likely to be infected. They also began using the polymerase-chain-reaction-based assay to detect the bacteria, a test with much higher sensitivity that helps to more efficiently identify those infected so control measures can be more prompt and targeted. They use a hypochlorite mixture to clean the rooms of those infected, which is considered a must. And a committee monitors the use of antibiotics to prevent overuse—often the scapegoat for the rise of the hard-to-kill bacteria.

Still, at Emory, the rate of C. diff is about the same as the national average, says hospitalist Ketino Kobaidze, MD, assistant professor at the Emory University School of Medicine and a member of the antimicrobial stewardship and infectious disease control committees at Midtown. While Dr. Kobaidze says her institution is doing a good job of trying to keep C. diff under control, she thinks hospitalists can do more.

“My feeling is that we are not as involved as we’re supposed to be,” she says. “I think we need to be a little bit more proactive, be involved in committees and research activities across the hospital.”

You Are Not Alone

The experience at Emory Midtown is far from unusual—healthcare facilities, and hospitalists, across the country have seen healthcare-related C. diff cases more than double since 2001 to between 400,000 and 500,000 a year, says Carolyn Gould, MD, a medical epidemiologist in the division of healthcare quality promotion at the Centers for Disease Control and Prevention (CDC) in Atlanta.

Hospitalists, whether they realize it or not, are intimately involved in how well the C. diff outbreak is controlled. Infectious-disease (ID) specialists say hospitalists are perfectly situated to make an impact in efforts to help curb the outbreak.

“Hospitalists are critical to this effort,” Dr. Gould says. “They’re in the hospital day in and day out, and they’re constantly interacting with the patients, staff, and administration. They’re often the first on the scene to see a patient who might have suddenly developed diarrhea; they’re the first to react. I think they’re in a prime position to play a leadership role to prevent C. diff infections.”

They’re also situated well to work with infection-control experts on antimicrobial stewardship programs, she says.

“I look at hospitalists just like I would have looked at internists managing their own patients 15 years ago,” says Stuart Cohen, MD, an ID expert with the University of California at Davis and a fellow with the Infectious Diseases Society of America who was lead author of the latest published IDSA guidelines on C. diff treatment. “And so they’re the first-line people.”

continued below...

Mayo Shows How a Simple Step Can Make Big Difference in C. Diff

Listen to Dr. Gould

Sometimes even when it comes to a huge problem like widespread bacterial infections, simplicity is best.

The Mayo Clinic, in a project to cut the rate of C. diff infections, asked its workers to do one extra thing: Wipe down high-touch areas with bleach wipes. The effort worked; infections were all but eradicated in units that had been having five to seven infections per month.

The results of the project, recently published in Infectious Control and Hospital Epidemiology, show the importance of simple steps as long as they’re carried out regularly and thoroughly.¹

The project began when Robert Orenstein, DO, associate professor of medicine in infectious diseases who then worked in Rochester, Minn., established a surveillance network for C. diff infections at Mayo Clinic at the time when such infections were being noted more widely throughout the U.S. and Canada. The network began tracking the cases and found that one inpatient medical unit primarily composed of patients with gastrointestinal diseases had a C. diff rate 10 times higher than the rest of the hospital. Surveillance also showed that universally gloved hematology and oncology units had substantially lower rates of C. diff infection despite high-risk patients.

Dr. Orenstein knew he had to make a change in the GI unit, but it wasn’t feasible to institute universal gloving, so he turned to bleach wipes.

Dr. Orenstein

Twice a day, housekeeping staff wiped down all “high-touch” areas (light switches, toilet handles, bed rails) in all of the rooms. The wipes contain 0.55% sodium hypochlorite. Within six months, the number of C. diff cases fell to almost zero.

“We were just in shock,” Dr. Orenstein says. He attributed the improvement to a reduction in the “colonization pressure”—if a high concentration of patients with C. diff can cause abundant transmissions quickly, the opposite is also true.

The greatly improved figures were shared with housekeeping, which initially complained about the smell but were encouraged to keep doors open and rooms ventilated. The bleach wipes, which Dr. Orenstein acknowledges mean an additional expense, leave a white residue when dry, so the surfaces are wiped down with water after the recommended contact time.

Dr. Orenstein notes that the results came even without a change in hand hygiene, which he had deemed not feasible because of the hospital’s lack of sinks. He isn’t diminishing the importance of hand washing, but the project does show how effective a single step can be.

The key, Dr. Orenstein adds, might be that it was just one change involving just one group of staff. “Why we think it was so effective is it was really one group that had to change their behavior and we worked with them, educated them,” he says.

He emphasizes that the wipes don’t come at the expense of other measures, like thorough cleaning of all rooms and antibiotic stewardship programs.

“You do all of those and do them well,” he says, “then you get the reduction of C. diff in the hospital.”

A Tough Bug

Believed to be aided largely by the use of broad-spectrum antibiotics that knock out the colon’s natural flora, C. diff in the hospital—as well as nursing homes and acute-care facilities—has raged for much of the past decade. Its rise is tied to the emergence of a new hypervirulent strain known as BI/NAP1/027, or NAP1 for short. The strain is highly resistant to fluoroquinolones, such as ciprofloxacin and levofloxacin, which are used often in healthcare settings.

“A fluoroquinolone will wipe out a lot of your normal flora in your gut,” Dr. Gould says. “But it won’t wipe out C. diff, in particular this hypervirulent strain. And so this strain can flourish in the presence of fluoroquinolones.” The strain produces up to 15 to 20 times more toxins than other C. diff strains, according to some data, she adds.

Vancomycin (Vanconin) and metronidazole (Flagyl) are the most common antibiotics used to treat patients infected with C. diff. Mortality rates are higher among the elderly, largely because of their weaker immune system, Dr. Gould says. Studies have generally shown mortality rates of 10% or a bit lower.¹

More recent studies have shown that the number of hospital-related C. diff cases might have begun to level off in 2008 and 2009. Dr. Gould says she thinks the leveling off is for real, but there is debate over what the immediate future holds.

“There’s a lot of work and initiatives, especially state-based initiatives, that are being done in hospitals. And there’s reason to believe they’re effective,” she says, adding it’s harder to get a good picture of the problem in long-term care facilities and in the community.

Dr. Cohen with the IDSA says it’s too soon to say whether the problem is hitting a plateau. “CDC data are always a couple of years behind,” he says. “Until you see another data point, you can’t tell whether that’s just a transient flattening and whether it’s going to keep going up or not.”

Kevin Kavanagh, MD, founder of the patient advocacy group Health Watch USA and a retired otolaryngologist in Kentucky who has taken a keen interest in the C. diff problem, says he doesn’t think the end of the tunnel is within view yet.

“I think C. diff is going to get worse before it gets better,” Dr. Kavanagh says. “And that’s not necessarily because the healthcare profession isn’t doing due diligence. This is a tough organism.—it can be tough to treat and can be very tough to kill.”

The Best Defense?

Because C. diff lives within protective spores, sound hand hygiene practices and room-cleaning practices are essential for keeping infections to a minimum. Alcohol-based hand sanitizers, effective against other organisms including MRSA, do not kill C. diff. The bacteria must be mechanically removed through hand washing.

And even hand washing might not be totally effective at getting rid of the spores, which means it’s important for healthcare workers to gown and glove in high-risk rooms.

Sodium hypochlorite solutions, or bleach mixtures, have to be used to clean rooms occupied by patients with C. diff, and the prevailing thought is to clean the rooms of patients suspected of having C. diff, even if those cases might not be confirmed.

Equally important to cleaning and hand washing is systemwide emphasis on antibiotic stewardship. A 2011 study at the State University of New York Buffalo found that the risk of a C. diff infection rose with the number of antibiotics taken.²

If someone is very sick and you’re not sure what is going on, it’s very reasonable to treat them empirically with broad-spectrum antibiotics. The important thing is that you send the appropriate cultures before so that you know what you’re treating and you can optimize those antibiotics with daily assessments.

—Carolyn Gould, MD, medical epidemiologist, division of healthcare quality promotion, Centers of Disease Control and Prevention, Atlanta

While a broad-spectrum antibiotic might be necessary at first, once the results of cultures are received, the treatment should be finely tailored to kill only the problem bacteria so that the body’s natural defenses aren’t broken down, Dr. Gould explains.

“If someone is very sick and you’re not sure what is going on, it’s very reasonable to treat them empirically with broad-spectrum antibiotics,” she says. “The important thing is that you send the appropriate cultures before so that you know what you’re treating and you can optimize those antibiotics with daily assessments.”

Dr. Cohen

It’s clear why an overreliance on broad-spectrum drugs prevails in U.S. health settings, Dr. Cohen acknowledges. Recent literature suggests treating critically ill patients with wide-ranging antimicrobials as the mortality rate can be twice as high with narrower options. “I think people have gotten very quick to give broad-spectrum therapy,” he says.

continued below...

Knocking Out Clostridium Difficile

Listen to Dr. Gould

Here are the guidelines on treatment of C. diff infections (CDI) as recommended by the Infectious Diseases Society of America:

First steps:

• Discontinue therapy with the inciting antimicrobial agent(s) as soon as possible as this may influence the risk of CDI recurrence.
• When severe or complicated CDI is suspected, initiate empirical treatment as soon as the diagnosis is suspected.
• If the stool toxin assay result is negative, the decision to initiate, stop, or continue treatment must be individualized.
• If possible, avoid use of antiperistaltic agents as they may obscure symptoms and precipitate toxic megacolon.

Treatment of initial episode:

• Metronidazole is the drug of choice for the initial episode of mild to moderate CDI. The dosage is 500 mg orally three times per day for 10 to 14 days.
• Vancomycin is the drug of choice for an initial episode of severe CDI. The dosage is 125 mg orally four times per day for 10 to 14 days.
• Vancomycin administered orally (and per rectum if ileus is present) with or without intravenously administered metronidazole is the regimen of choice for the treatment of severe complicated CDI. The vancomycin dosage is 500 mg orally four times per day and 500 mg in approximately 100 mL normal saline per rectum every six hours as a retention enema, and the metronidazole dosage is 500 mg intravenously every eight hours.

Severely ill patients:

Consider colectomy for severely ill patients. Monitoring the serum lactate level and the peripheral blood white blood cell count may be helpful in prompting a decision to operate because a serum lactate level rising to 5 mmol/L and a white blood cell count rising to 50,000 cells per mL have been associated with greatly increased perioperative mortality. If surgical management is necessary, perform subtotal colectomy with preservation of the rectum.

Treatment of recurrences:

• Treatment of the first recurrence of CDI is usually with the same regimen as for the initial episode but should be stratified by disease severity (mild-to-moderate, severe, or severe complicated) as is recommended for treatment of the initial CDI episode.
• Do not use metronidazole beyond the first recurrence of CDI or for long-term chronic therapy because of potential for cumulative neurotoxicity.
• Treatment of the second or later recurrence of CDI with vancomycin therapy using a tapered and/or pulse regimen is the preferred next strategy.

Probiotics:

Administration of currently available probiotics is not recommended to prevent primary CDI as there are limited data to support this approach and there is a potential risk of bloodstream infection.

Source: Cohen SH, Gerding DH, Johnson S, et al. Clinical practice guidelines for Clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Hospital Epidemiology. 2010;31(5):431–455.

National Response, Localized Attention

Dr. Kavanagh of Health Watch USA says that more information about C. diff is needed, particularly publicly available numbers of infections at hospitals. Some states require those figures to be reported, but most don’t. And there is no current federal mandate on reporting of C. diff cases, although acute-care hospitals will be required to report C. diff infection rates starting in 2013.

“We really have scant data,” he says. “There is not a lot of reporting if you look at the nation on a whole. And I think that underscores one of the reasons why you need to have data for action. You need to have reporting of these organisms to the National Healthcare Safety Network so that the CDC can monitor and can make plans and can do effective interventions.

“You want to know where the areas of highest infection are,” he adds. “You want to know what interventions work and don’t work. If you don’t have a national coordinated reporting system, it really makes it difficult to address the problem. C. diff is going to be much harder to control than MRSA or other bacteria because it changes into a hard-to-kill dormant spore stage and then re-occurs at some point.”

The Centers for Medicare & Medicaid Services (CMS) has proposed adding C. diff infections to the list of hospital-acquired conditions that will not be reimbursable. It is widely hoped that such a measure will go a long way toward stamping out the problem.

Dr. Kobaidze of Emory notes that C. diff is a dynamic problem, always adapting and posing new challenges. And hospitalists should be more involved in answering these questions through research. One recent question, she points out, is whether proton pump inhibitor use is related to the rise of C. diff.

Ultimately, though, controlling C. diff in hospitals might come down to what is done day to day inside the hospital. And hospitalists can play a big role.

Danielle Scheurer, MD, MSCR, SFHM, a hospitalist and medical director of quality at the Medical University of South Carolina in Charleston, says that a full-time pharmacist on the hospital’s antimicrobial stewardship committee is always reviewing antibiotic prescriptions and is prepared to flag cases in which a broad-spectrum is used when one with a more narrow scope might be more appropriate.

The hospital has done its best, as part of its “renovation cycle,” to standardize the layouts of rooms “so that the second you open the door you know exactly where the alcohol gel is and where the soap and the sink is going to be.” The idea is to make compliance as “mindless” as possible. Such efforts can be hampered by structural limitations though, she says.

HM group leaders, she suggests, can play an important part simply by being good role models—gowning and gloving without complaint before entering high-risk rooms and reinforcing the message that such efforts have real effects on patient safety.

But she also acknowledges that “it always sounds easy....There has to be some level of redundancy built into the hospital system. This is more of a system thing than the individual hospitalist.”

One level of redundancy at MUSC that has been particularly effective, she says, are “secret shoppers” who keep an eye out for medical teams that might not be washing their hands as they go in and out of high-risk rooms. Each unit is responsible for their hand hygiene numbers—which include both self-reported figures and those obtained by the secret onlookers—and those numbers are made available to the hospital.

Those units with the best numbers are sometimes given a reward, such as a pizza party, but it’s colleagues’ knowledge of the numbers that matters most, she says.

“That, in and of itself, is a powerful motivator,” Dr. Scheurer says. “We bring it to all of our quality operations meetings, all the administrators, the CEO, the CMO. It’s very motivating for every unit. They don’t want to be the trailing unit.”

Tom Collins is a freelance medical writer based in Miami.

References

1. Orenstein R, Aronhalt KC, McManus JE Jr., Fedraw LA. A targeted strategy to wipe out Clostridium difficile. Infect Control Hosp Epidemiol. 2011;32(11):1137-1139.
2. Stevens V, Dumyati G, Fine LS, Fisher SG, van Wijngaarden E. Cumulative antibiotic exposures over time and the risk of Clostridium difficile infection. Clin Infect Dis. 2011;53(1):42-48.

What Hospitalists Can Do

Listen to Dr. Gould

Here are suggestions, as provided by ID experts and hospitalist leaders, on what hospitalists can do to battle C. diff infections:

Short-term steps:

• Wash hands before entering and upon leaving rooms occupied by patients with C. diff infections and those strongly suspected of having C. diff infections.
• Continue using alcohol-based hand sanitizers in addition to hand washing to prevent other types of outbreaks.
• Ensure that infected patients, and those suspected of being infected, are isolated, possibly even for 48 hours after diarrhea resolves, as research shows the patients can still transmit the spores.
• In units with high C. diff rates, consider universal gloving, not just for patients with known infection.
• Use more highly sensitive tests, such as polymerase chain reaction, or PCR, rather than enzyme immunoassays to more efficiently identify affected patients.
• Avoid testing patients with formed stools.
• Ensure that rooms of infected patients and patients strongly suspected of being infected are cleaned with a hypochlorite solution.
• Taper the use of broad-spectrum antibiotics in non-C. diff patients after test results are obtained.
• Encourage patients to question their healthcare practitioners about hand hygiene and use of antibiotics.

Long-term steps:

• Be involved with your hospital’s antimicrobial stewardship program.
• Conduct research into C. diff to explore its causes and treatments.
• Be a good role model for the rest of your group, emphasizing good practices and a strong patient-safety message.

The hospitalist concept was established on the foundation of timely, informative handoffs to primary-care physicians (PCPs) once a patient’s hospital stay is complete. With sicker patients and shorter hospital stays, pending test results, and complex post-discharge medication regimens to sort out, this handoff is crucial to successful discharges. But what if a discharged patient can’t get in to see the PCP, or has no established PCP?

Recent research on hospital readmissions by the Dartmouth Atlas Project found that only 42% of hospitalized Medicare patients had any contact with a primary-care clinician within 14 days of discharge.¹ For patients with ongoing medical needs, such missed connections are a major contributor to hospital readmissions, and thus a target for hospitals and HM groups wanting to control their readmission rates before Medicare imposes reimbursement penalties starting in October 2012 (see “Value-Based Purchasing Raises the Stakes,” May 2011, p. 1).

One proposed solution is the post-discharge clinic, typically located on or near a hospital’s campus and staffed by hospitalists, PCPs, or advanced-practice nurses. The patient can be seen once or a few times in the post-discharge clinic to make sure that health education started in the hospital is understood and followed, and that prescriptions ordered in the hospital are being taken on schedule.

Mark V. Williams, MD, FACP, FHM, professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, describes hospitalist-led post-discharge clinics as “Band-Aids for an inadequate primary-care system.” What would be better, he says, is focusing on the underlying problem and working to improve post-discharge access to primary care. Dr. Williams acknowledges, however, that sometimes a patch is needed to stanch the blood flow—e.g., to better manage care transitions—while waiting on healthcare reform and medical homes to improve care coordination throughout the system.

Working in a post-discharge clinic might seem like “a stretch for many hospitalists, especially those who chose this field because they didn’t want to do outpatient medicine,” says Lauren Doctoroff, MD, a hospitalist who directs a post-discharge clinic at Beth Israel Deaconess Medical Center (BIDMC) in Boston. “But there are times when it may be appropriate for hospital-based doctors to extend their responsibility out of the hospital.”

Dr. Doctoroff also says that working in such a clinic can be practice-changing for hospitalists. “All of a sudden, you have a different view of your hospitalized patients, and you start to ask different questions while they’re in the hospital than you ever did before,” she explains.

What is a Post-Discharge Clinic?

click for large version

The post-discharge clinic, also known as a transitional-care clinic or after-care clinic, is intended to bridge medical coverage between the hospital and primary care. The clinic at BIDMC is for patients affiliated with its Health Care Associates faculty practice “discharged from either our hospital or another hospital, who need care that their PCP or specialist, because of scheduling conflicts, cannot provide within the needed time frame,” Dr. Doctoroff says.

Four hospitalists from BIDMC’s large HM group were selected to staff the clinic. The hospitalists work in one-month rotations (a total of three months on service per year), and are relieved of other responsibilities during their month in clinic. They provide five half-day clinic sessions per week, with a 40-minute-per-patient visit schedule. Thirty minutes are allotted for patients referred from the hospital’s ED who did not get admitted to the hospital but need clinical follow-up.

The clinic is based in a BIDMC-affiliated primary-care practice, “which allows us to use its administrative structure and logistical support,” Dr. Doctoroff explains. “A hospital-based administrative service helps set up outpatient visits prior to discharge using computerized physician order entry and a scheduling algorhythm.” (See Figure 1) Patients who can be seen by their PCP in a timely fashion are referred to the PCP office; if not, they are scheduled in the post-discharge clinic. “That helps preserve the PCP relationship, which I think is paramount,” she says.

The first two years were spent getting the clinic established, but in the near future, BIDMC will start measuring such outcomes as access to care and quality. “But not necessarily readmission rates,” Dr. Doctoroff adds. “I know many people think of post-discharge clinics in the context of preventing readmissions, although we don’t have the data yet to fully support that. In fact, some readmissions may result from seeing a doctor. If you get a closer look at some patients after discharge and they are doing badly, they are more likely to be readmitted than if they had just stayed home.” In such cases, readmission could actually be a better outcome for the patient, she notes.

Dr. Doctoroff describes a typical user of her post-discharge clinic as a non-English-speaking patient who was discharged from the hospital with severe back pain from a herniated disk. “He came back to see me 10 days later, still barely able to walk. He hadn’t been able to fill any of the prescriptions from his hospital stay. Within two hours after I saw him, we got his meds filled and outpatient services set up,” she says. “We take care of many patients like him in the hospital with acute pain issues, whom we discharge as soon as they can walk, and later we see them limping into outpatient clinics. It makes me think differently now about how I plan their discharges.”

We do medication reconciliation, reassessments, and follow-ups with lab tests. We also try to assess who is more likely to be a no-show, and who needs more help with scheduling follow-up appointments.

—Shay Martinez, MD, hospitalist, medical director, Harborview Medical Center, Seattle

Who else needs these clinics? Dr. Doctoroff suggests two ways of looking at the question.

“Even for a simple patient admitted to the hospital, that can represent a significant change in the medical picture—a sort of sentinel event. In the discharge clinic, we give them an opportunity to review the hospitalization and answer their questions,” she says. “A lot of information presented to patients in the hospital is not well heard, and the initial visit may be their first time to really talk about what happened.” For other patients with conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or poorly controlled diabetes, treatment guidelines might dictate a pattern for post-discharge follow-up—for example, medical visits in seven or 10 days.

In Seattle, Harborview Medical Center established its After Care Clinic, staffed by hospitalists and nurse practitioners, to provide transitional care for patients discharged from inpatient wards or the ED in need of follow-up, says medical director and hospitalist Shay Martinez, MD. A second priority is to see any CHF patient within 48 hours of discharge.

“We try to limit patients to a maximum of three visits in our clinic,” she says. “At that point, we help them get established in a medical home, either here in one of our primary-care clinics, or in one of the many excellent community clinics in the area.

“This model works well with our patient population. We actually try to do primary care on the inpatient side as well. Our hospitalists are specialized in that approach, given our patient population. We see a lot of immigrants, non-English speakers, people with low health literacy, and the homeless, many of whom lack primary care,” Dr. Martinez says. “We do medication reconciliation, reassessments, and follow-ups with lab tests. We also try to assess who is more likely to be a no-show, and who needs more help with scheduling follow-up appointments.”

Clinical coverage of post-discharge clinics varies by setting, staffing, and scope. If demand is low, hospitalists or ED physicians can be called off the floor to see patients who return to the clinic, or they could staff the clinic after their hospitalist shift ends. Post-discharge clinic staff whose schedules are light can flex into providing primary-care visits in the clinic. Post-discharge can also could be provided in conjunction with—or as an alternative to—physician house calls to patients’ homes. Some post-discharge clinics work with medical call centers or telephonic case managers; some even use telemedicine.

It also could be a growth opportunity for hospitalist practices. “It is an exciting potential role for hospitalists interested in doing a little outpatient care,” Dr. Martinez says. “This is also a good way to be a safety net for your safety-net hospital.”

continued below...

What Do PCPs Think? It May Be Harder than It Looks

Listen to Dr. Doctoroff

Although some PCPs instinctively will be suspicious of a hospitalist-run post-discharge clinic, it should be possible to clearly limit the service to short-term, immediate-post-hospital encounters focused on issues related to patients unable to get timely access to primary care, according to Dr. Doctoroff.

“I think there is a diversity of opinion by PCPs,” she says. “Some doctors really believe that it interferes with the patient-doctor relationship. But after we’ve been here for a couple of years, we’ve built up credibility with many providers.”

Charles Cutler, MD, FACP, a general internist with a practice in Norristown, Pa., and a member of the ACP’s Board of Regents, says the post-discharge clinic is “a novel idea.”

“I’d be very curious to see if this really is a way to provide better and more cost-effective care,” adds Dr. Cutler, who normally retains management of his own patients when they are hospitalized but agrees that hospitals need to find a solution for lapses in care transitions.

Even so, he says, establishing an outpatient clinic presence may be more difficult than many hospitalists appreciate. “You can’t just put a doc in a room. That physician needs equipment, scheduling, and support staff,” he says. “In our small practice, we employ one person just to ensure that each patient chart is up to date. The overhead necessary to replicate a typical medical office, even one merely providing a transition of care, could be substantial.”

Dr. Cutler emphasizes such office-based challenges as billing, which is distinctly different from hospital billing, and credentialing by insurance companies.

“There are many aspects that have to be thought through. If you see the patient, you need to make yourself available for follow-up calls, because you’ve created a relationship,” he says. “I’m a believer that hospital medicine requires a degree of specialization. But so does an office practice.”

Dr. Cutler acknowledges that some PCPs will be resentful of post-discharge clinics. “But if you don’t like a hospitalist-run discharge clinic, then you have a responsibility to rearrange your schedule to accommodate patients after their hospital discharge,” he says.

Partner with Community

Tallahassee (Fla.) Memorial Hospital (TMH) in February launched a transitional-care clinic in collaboration with faculty from Florida State University, community-based health providers, and the local Capital Health Plan. Hospitalists don’t staff the clinic, but the HM group is its major source of referrals, says Dean Watson, MD, chief medical officer at TMH. Patients can be followed for up to eight weeks, during which time they get comprehensive assessments, medication review and optimization, and referral by the clinic social worker to a PCP and to available community services.

“Three years ago, we came up with the idea for a patient population we know is at high risk for readmission. Why don’t we partner with organizations in the community, form a clinic, teach students and residents, and learn together?” Dr. Watson says. “In addition to the usual patients, TMH targets those who have been readmitted to the hospital three times or more in the past year.”

The clinic, open five days a week, is staffed by a physician, nurse practitioner, telephonic nurse, and social worker, and also has a geriatric assessment clinic.

“We set up a system to identify patients through our electronic health record, and when they come to the clinic, we focus on their social environment and other non-medical issues that might cause readmissions,” he says. The clinic has a pharmacy and funds to support medications for patients without insurance. “In our first six months, we reduced emergency room visits and readmissions for these patients by 68 percent.”

One key partner, Capital Health Plan, bought and refurbished a building, and made it available for the clinic at no cost. Capital’s motivation, says Tom Glennon, a senior vice president for the plan, is its commitment to the community and to community service.

“We’re a nonprofit HMO. We’re focused on what we can do to serve the community, and we’re looking at this as a way for the hospital to have fewer costly, unreimbursed bouncebacks,” Glennon says. “That’s a win-win for all of us.”

Most of the patients who use the clinic are not members of Capital Health Plan, Glennon adds. “If we see CHP members turning up at the transitions clinic, then we have a problem—a breakdown in our case management,” he explains. “Our goal is to have our members taken care of by primary-care providers.”

Hard Data? Not So Fast

How many post-discharge clinics are in operation today is not known. Fundamental financial data, too, are limited, but some say it is unlikely a post-discharge clinic will cover operating expenses from billing revenues alone.

Thus, such clinics will require funding from the hospital, HM group, health system, or health plans, based on the benefits the clinic provides to discharged patients and the impact on 30-day readmissions (for more about the logistical challenges post-discharge clinics present, see “What Do PCPs Think?”).

Some also suggest that many of the post-discharge clinics now in operation are too new to have demonstrated financial impact or return on investment. “We have not yet been asked to show our financial viability,” Dr. Doctoroff says. “I think the clinic leadership thinks we are fulfilling other goals for now, such as creating easier access for their patients after discharge.”

Amy Boutwell, MD, MPP, a hospitalist at Newton Wellesley Hospital in Massachusetts and founder of Collaborative Healthcare Strategies, is among the post-discharge skeptics. She agrees with Dr. Williams that the post-discharge concept is more of a temporary fix to the long-term issues in primary care. “I think the idea is getting more play than actual activity out there right now,” she says. “We need to find opportunities to manage transitions within our scope today and tomorrow while strategically looking at where we want to be in five years [as hospitals and health systems].”

Dr. Boutwell says she’s experienced the frustration of trying to make follow-up appointments with physicians who don’t have any open slots for hospitalized patients awaiting discharge. “We think of follow up as physician-led, but there are alternatives and physician extenders,” she says. “It is well-documented that our healthcare system underuses home health care and other services that might be helpful. We forget how many other opportunities there are in our communities to get another clinician to touch the patient.”

Hospitalists, as key players in the healthcare system, can speak out in support of strengthening primary-care networks and building more collaborative relationships with PCPs, according to Dr. Williams. “If you’re going to set up an outpatient clinic, ideally, have it staffed by PCPs who can funnel the patients into primary-care networks. If that’s not feasible, then hospitalists should proceed with caution, since this approach begins to take them out of their scope of practice,” he says.

With 13 years of experience in urban hospital settings, Dr. Williams is familiar with the dangers unassigned patients present at discharge. “But I don’t know that we’ve yet optimized the hospital discharge process at any hospital in the United States,” he says.

That said, Dr. Williams knows his hospital in downtown Chicago is now working to establish a post-discharge clinic. It will be staffed by PCPs and will target patients who don’t have a PCP, are on Medicaid, or lack insurance.

“Where it starts to make me uncomfortable,” Dr. Williams says, “is what happens when you follow patients out into the outpatient setting?

It’s hard to do just one visit and draw the line. Yes, you may prevent a readmission, but the patient is still left with chronic illness and the need for primary care.”

Larry Beresford is a freelance writer based in Oakland, Calif.

What Does the Research Say?

Listen to Dr. Doctoroff

Post-discharge clinic advocates acknowledge that the research documenting outcomes from such clinics is scarce. A recent study from Northwestern University looked at 12 distinct care-transitions activities and their effect on readmission rates.² Post-discharge clinics were not studied as a separate category, although they fit into the category of physician continuity across inpatient and outpatient settings.

“There’s definitely a hole in the literature regarding post-discharge care,” says lead author Luke Hansen, MD, MHS. The authors found that “no single intervention implemented alone was regularly associated with reduced risk for 30-day rehospitalizations.”

On the other hand, Misky et al found that discharged patients who lacked timely follow-up (within four weeks of discharge) were 10 times more likely to be readmitted than those who got the follow-up.³

Medical teams from around the world, including in Canada, the United Kingdom, Israel, and Australia, are studying readmission rates and care-transitions strategies. A study by physicians at National Taiwan University Hospital in Taipei describes its integrated transitional care to address post-discharge discontinuities and prevent rehospitalizations, including telephonic monitoring, hotline counseling, and referral to a hospital-run post-discharge clinic located within a hospitalist-managed ward.4 “Patients are treated primarily by the hospitalists who are familiar with them,” in a clinic open from 8 a.m. to 9 p.m., lead author Chin-Chung Shu, MD, wrote in an email. The clinic sees 15 to 30 patients per month; 80% of them are discharged patients without a PCP.

“We typically see patients one or two times in 30 days and then refer them to a suitable physician,” Dr. Shu says. In his study, patients who received post-discharge transitional care, including the post-discharge clinic, had lower rates of readmission and death within 30 days, 15% compared with 25% for a control group.

References

1. Goodman, DC, Fisher ES, Chang C. After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries. Dartmouth Atlas website. Available at: www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf. Accessed Nov. 3, 2011.
2. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 3-day rehospitalization: A systematic review. Ann Int Med. 2011;155(8): 520-528.
3. Misky GJ, Wald HL, Coleman EA. Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010;5(7):392-397.
4. Shu CC, Hsu NC, Lin YF, et al. Integrated post-discharge transitional care in Taiwan. BMC Medicine website. Available at: www.biomedcentral.com/1741-7015/9/96. Accessed Nov. 1, 2011.

The hospitalist concept was established on the foundation of timely, informative handoffs to primary-care physicians (PCPs) once a patient’s hospital stay is complete. With sicker patients and shorter hospital stays, pending test results, and complex post-discharge medication regimens to sort out, this handoff is crucial to successful discharges. But what if a discharged patient can’t get in to see the PCP, or has no established PCP?

Recent research on hospital readmissions by the Dartmouth Atlas Project found that only 42% of hospitalized Medicare patients had any contact with a primary-care clinician within 14 days of discharge.¹ For patients with ongoing medical needs, such missed connections are a major contributor to hospital readmissions, and thus a target for hospitals and HM groups wanting to control their readmission rates before Medicare imposes reimbursement penalties starting in October 2012 (see “Value-Based Purchasing Raises the Stakes,” May 2011, p. 1).

One proposed solution is the post-discharge clinic, typically located on or near a hospital’s campus and staffed by hospitalists, PCPs, or advanced-practice nurses. The patient can be seen once or a few times in the post-discharge clinic to make sure that health education started in the hospital is understood and followed, and that prescriptions ordered in the hospital are being taken on schedule.

Mark V. Williams, MD, FACP, FHM, professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, describes hospitalist-led post-discharge clinics as “Band-Aids for an inadequate primary-care system.” What would be better, he says, is focusing on the underlying problem and working to improve post-discharge access to primary care. Dr. Williams acknowledges, however, that sometimes a patch is needed to stanch the blood flow—e.g., to better manage care transitions—while waiting on healthcare reform and medical homes to improve care coordination throughout the system.

Working in a post-discharge clinic might seem like “a stretch for many hospitalists, especially those who chose this field because they didn’t want to do outpatient medicine,” says Lauren Doctoroff, MD, a hospitalist who directs a post-discharge clinic at Beth Israel Deaconess Medical Center (BIDMC) in Boston. “But there are times when it may be appropriate for hospital-based doctors to extend their responsibility out of the hospital.”

Dr. Doctoroff also says that working in such a clinic can be practice-changing for hospitalists. “All of a sudden, you have a different view of your hospitalized patients, and you start to ask different questions while they’re in the hospital than you ever did before,” she explains.

What is a Post-Discharge Clinic?

click for large version

The post-discharge clinic, also known as a transitional-care clinic or after-care clinic, is intended to bridge medical coverage between the hospital and primary care. The clinic at BIDMC is for patients affiliated with its Health Care Associates faculty practice “discharged from either our hospital or another hospital, who need care that their PCP or specialist, because of scheduling conflicts, cannot provide within the needed time frame,” Dr. Doctoroff says.

Four hospitalists from BIDMC’s large HM group were selected to staff the clinic. The hospitalists work in one-month rotations (a total of three months on service per year), and are relieved of other responsibilities during their month in clinic. They provide five half-day clinic sessions per week, with a 40-minute-per-patient visit schedule. Thirty minutes are allotted for patients referred from the hospital’s ED who did not get admitted to the hospital but need clinical follow-up.

The clinic is based in a BIDMC-affiliated primary-care practice, “which allows us to use its administrative structure and logistical support,” Dr. Doctoroff explains. “A hospital-based administrative service helps set up outpatient visits prior to discharge using computerized physician order entry and a scheduling algorhythm.” (See Figure 1) Patients who can be seen by their PCP in a timely fashion are referred to the PCP office; if not, they are scheduled in the post-discharge clinic. “That helps preserve the PCP relationship, which I think is paramount,” she says.

The first two years were spent getting the clinic established, but in the near future, BIDMC will start measuring such outcomes as access to care and quality. “But not necessarily readmission rates,” Dr. Doctoroff adds. “I know many people think of post-discharge clinics in the context of preventing readmissions, although we don’t have the data yet to fully support that. In fact, some readmissions may result from seeing a doctor. If you get a closer look at some patients after discharge and they are doing badly, they are more likely to be readmitted than if they had just stayed home.” In such cases, readmission could actually be a better outcome for the patient, she notes.

Dr. Doctoroff describes a typical user of her post-discharge clinic as a non-English-speaking patient who was discharged from the hospital with severe back pain from a herniated disk. “He came back to see me 10 days later, still barely able to walk. He hadn’t been able to fill any of the prescriptions from his hospital stay. Within two hours after I saw him, we got his meds filled and outpatient services set up,” she says. “We take care of many patients like him in the hospital with acute pain issues, whom we discharge as soon as they can walk, and later we see them limping into outpatient clinics. It makes me think differently now about how I plan their discharges.”

We do medication reconciliation, reassessments, and follow-ups with lab tests. We also try to assess who is more likely to be a no-show, and who needs more help with scheduling follow-up appointments.

—Shay Martinez, MD, hospitalist, medical director, Harborview Medical Center, Seattle

Who else needs these clinics? Dr. Doctoroff suggests two ways of looking at the question.

“Even for a simple patient admitted to the hospital, that can represent a significant change in the medical picture—a sort of sentinel event. In the discharge clinic, we give them an opportunity to review the hospitalization and answer their questions,” she says. “A lot of information presented to patients in the hospital is not well heard, and the initial visit may be their first time to really talk about what happened.” For other patients with conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or poorly controlled diabetes, treatment guidelines might dictate a pattern for post-discharge follow-up—for example, medical visits in seven or 10 days.

In Seattle, Harborview Medical Center established its After Care Clinic, staffed by hospitalists and nurse practitioners, to provide transitional care for patients discharged from inpatient wards or the ED in need of follow-up, says medical director and hospitalist Shay Martinez, MD. A second priority is to see any CHF patient within 48 hours of discharge.

“We try to limit patients to a maximum of three visits in our clinic,” she says. “At that point, we help them get established in a medical home, either here in one of our primary-care clinics, or in one of the many excellent community clinics in the area.

“This model works well with our patient population. We actually try to do primary care on the inpatient side as well. Our hospitalists are specialized in that approach, given our patient population. We see a lot of immigrants, non-English speakers, people with low health literacy, and the homeless, many of whom lack primary care,” Dr. Martinez says. “We do medication reconciliation, reassessments, and follow-ups with lab tests. We also try to assess who is more likely to be a no-show, and who needs more help with scheduling follow-up appointments.”

Clinical coverage of post-discharge clinics varies by setting, staffing, and scope. If demand is low, hospitalists or ED physicians can be called off the floor to see patients who return to the clinic, or they could staff the clinic after their hospitalist shift ends. Post-discharge clinic staff whose schedules are light can flex into providing primary-care visits in the clinic. Post-discharge can also could be provided in conjunction with—or as an alternative to—physician house calls to patients’ homes. Some post-discharge clinics work with medical call centers or telephonic case managers; some even use telemedicine.

It also could be a growth opportunity for hospitalist practices. “It is an exciting potential role for hospitalists interested in doing a little outpatient care,” Dr. Martinez says. “This is also a good way to be a safety net for your safety-net hospital.”

continued below...

What Do PCPs Think? It May Be Harder than It Looks

Listen to Dr. Doctoroff

Although some PCPs instinctively will be suspicious of a hospitalist-run post-discharge clinic, it should be possible to clearly limit the service to short-term, immediate-post-hospital encounters focused on issues related to patients unable to get timely access to primary care, according to Dr. Doctoroff.

“I think there is a diversity of opinion by PCPs,” she says. “Some doctors really believe that it interferes with the patient-doctor relationship. But after we’ve been here for a couple of years, we’ve built up credibility with many providers.”

Charles Cutler, MD, FACP, a general internist with a practice in Norristown, Pa., and a member of the ACP’s Board of Regents, says the post-discharge clinic is “a novel idea.”

“I’d be very curious to see if this really is a way to provide better and more cost-effective care,” adds Dr. Cutler, who normally retains management of his own patients when they are hospitalized but agrees that hospitals need to find a solution for lapses in care transitions.

Even so, he says, establishing an outpatient clinic presence may be more difficult than many hospitalists appreciate. “You can’t just put a doc in a room. That physician needs equipment, scheduling, and support staff,” he says. “In our small practice, we employ one person just to ensure that each patient chart is up to date. The overhead necessary to replicate a typical medical office, even one merely providing a transition of care, could be substantial.”

Dr. Cutler emphasizes such office-based challenges as billing, which is distinctly different from hospital billing, and credentialing by insurance companies.

“There are many aspects that have to be thought through. If you see the patient, you need to make yourself available for follow-up calls, because you’ve created a relationship,” he says. “I’m a believer that hospital medicine requires a degree of specialization. But so does an office practice.”

Dr. Cutler acknowledges that some PCPs will be resentful of post-discharge clinics. “But if you don’t like a hospitalist-run discharge clinic, then you have a responsibility to rearrange your schedule to accommodate patients after their hospital discharge,” he says.

Partner with Community

Tallahassee (Fla.) Memorial Hospital (TMH) in February launched a transitional-care clinic in collaboration with faculty from Florida State University, community-based health providers, and the local Capital Health Plan. Hospitalists don’t staff the clinic, but the HM group is its major source of referrals, says Dean Watson, MD, chief medical officer at TMH. Patients can be followed for up to eight weeks, during which time they get comprehensive assessments, medication review and optimization, and referral by the clinic social worker to a PCP and to available community services.

“Three years ago, we came up with the idea for a patient population we know is at high risk for readmission. Why don’t we partner with organizations in the community, form a clinic, teach students and residents, and learn together?” Dr. Watson says. “In addition to the usual patients, TMH targets those who have been readmitted to the hospital three times or more in the past year.”

The clinic, open five days a week, is staffed by a physician, nurse practitioner, telephonic nurse, and social worker, and also has a geriatric assessment clinic.

“We set up a system to identify patients through our electronic health record, and when they come to the clinic, we focus on their social environment and other non-medical issues that might cause readmissions,” he says. The clinic has a pharmacy and funds to support medications for patients without insurance. “In our first six months, we reduced emergency room visits and readmissions for these patients by 68 percent.”

One key partner, Capital Health Plan, bought and refurbished a building, and made it available for the clinic at no cost. Capital’s motivation, says Tom Glennon, a senior vice president for the plan, is its commitment to the community and to community service.

“We’re a nonprofit HMO. We’re focused on what we can do to serve the community, and we’re looking at this as a way for the hospital to have fewer costly, unreimbursed bouncebacks,” Glennon says. “That’s a win-win for all of us.”

Most of the patients who use the clinic are not members of Capital Health Plan, Glennon adds. “If we see CHP members turning up at the transitions clinic, then we have a problem—a breakdown in our case management,” he explains. “Our goal is to have our members taken care of by primary-care providers.”

Hard Data? Not So Fast

How many post-discharge clinics are in operation today is not known. Fundamental financial data, too, are limited, but some say it is unlikely a post-discharge clinic will cover operating expenses from billing revenues alone.

Thus, such clinics will require funding from the hospital, HM group, health system, or health plans, based on the benefits the clinic provides to discharged patients and the impact on 30-day readmissions (for more about the logistical challenges post-discharge clinics present, see “What Do PCPs Think?”).

Some also suggest that many of the post-discharge clinics now in operation are too new to have demonstrated financial impact or return on investment. “We have not yet been asked to show our financial viability,” Dr. Doctoroff says. “I think the clinic leadership thinks we are fulfilling other goals for now, such as creating easier access for their patients after discharge.”

Amy Boutwell, MD, MPP, a hospitalist at Newton Wellesley Hospital in Massachusetts and founder of Collaborative Healthcare Strategies, is among the post-discharge skeptics. She agrees with Dr. Williams that the post-discharge concept is more of a temporary fix to the long-term issues in primary care. “I think the idea is getting more play than actual activity out there right now,” she says. “We need to find opportunities to manage transitions within our scope today and tomorrow while strategically looking at where we want to be in five years [as hospitals and health systems].”

Dr. Boutwell says she’s experienced the frustration of trying to make follow-up appointments with physicians who don’t have any open slots for hospitalized patients awaiting discharge. “We think of follow up as physician-led, but there are alternatives and physician extenders,” she says. “It is well-documented that our healthcare system underuses home health care and other services that might be helpful. We forget how many other opportunities there are in our communities to get another clinician to touch the patient.”

Hospitalists, as key players in the healthcare system, can speak out in support of strengthening primary-care networks and building more collaborative relationships with PCPs, according to Dr. Williams. “If you’re going to set up an outpatient clinic, ideally, have it staffed by PCPs who can funnel the patients into primary-care networks. If that’s not feasible, then hospitalists should proceed with caution, since this approach begins to take them out of their scope of practice,” he says.

With 13 years of experience in urban hospital settings, Dr. Williams is familiar with the dangers unassigned patients present at discharge. “But I don’t know that we’ve yet optimized the hospital discharge process at any hospital in the United States,” he says.

That said, Dr. Williams knows his hospital in downtown Chicago is now working to establish a post-discharge clinic. It will be staffed by PCPs and will target patients who don’t have a PCP, are on Medicaid, or lack insurance.

“Where it starts to make me uncomfortable,” Dr. Williams says, “is what happens when you follow patients out into the outpatient setting?

It’s hard to do just one visit and draw the line. Yes, you may prevent a readmission, but the patient is still left with chronic illness and the need for primary care.”

Larry Beresford is a freelance writer based in Oakland, Calif.

What Does the Research Say?

Listen to Dr. Doctoroff

Post-discharge clinic advocates acknowledge that the research documenting outcomes from such clinics is scarce. A recent study from Northwestern University looked at 12 distinct care-transitions activities and their effect on readmission rates.² Post-discharge clinics were not studied as a separate category, although they fit into the category of physician continuity across inpatient and outpatient settings.

“There’s definitely a hole in the literature regarding post-discharge care,” says lead author Luke Hansen, MD, MHS. The authors found that “no single intervention implemented alone was regularly associated with reduced risk for 30-day rehospitalizations.”

On the other hand, Misky et al found that discharged patients who lacked timely follow-up (within four weeks of discharge) were 10 times more likely to be readmitted than those who got the follow-up.³

Medical teams from around the world, including in Canada, the United Kingdom, Israel, and Australia, are studying readmission rates and care-transitions strategies. A study by physicians at National Taiwan University Hospital in Taipei describes its integrated transitional care to address post-discharge discontinuities and prevent rehospitalizations, including telephonic monitoring, hotline counseling, and referral to a hospital-run post-discharge clinic located within a hospitalist-managed ward.4 “Patients are treated primarily by the hospitalists who are familiar with them,” in a clinic open from 8 a.m. to 9 p.m., lead author Chin-Chung Shu, MD, wrote in an email. The clinic sees 15 to 30 patients per month; 80% of them are discharged patients without a PCP.

“We typically see patients one or two times in 30 days and then refer them to a suitable physician,” Dr. Shu says. In his study, patients who received post-discharge transitional care, including the post-discharge clinic, had lower rates of readmission and death within 30 days, 15% compared with 25% for a control group.

References

1. Goodman, DC, Fisher ES, Chang C. After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries. Dartmouth Atlas website. Available at: www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf. Accessed Nov. 3, 2011.
2. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 3-day rehospitalization: A systematic review. Ann Int Med. 2011;155(8): 520-528.
3. Misky GJ, Wald HL, Coleman EA. Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010;5(7):392-397.
4. Shu CC, Hsu NC, Lin YF, et al. Integrated post-discharge transitional care in Taiwan. BMC Medicine website. Available at: www.biomedcentral.com/1741-7015/9/96. Accessed Nov. 1, 2011.

The hospitalist concept was established on the foundation of timely, informative handoffs to primary-care physicians (PCPs) once a patient’s hospital stay is complete. With sicker patients and shorter hospital stays, pending test results, and complex post-discharge medication regimens to sort out, this handoff is crucial to successful discharges. But what if a discharged patient can’t get in to see the PCP, or has no established PCP?

Recent research on hospital readmissions by the Dartmouth Atlas Project found that only 42% of hospitalized Medicare patients had any contact with a primary-care clinician within 14 days of discharge.¹ For patients with ongoing medical needs, such missed connections are a major contributor to hospital readmissions, and thus a target for hospitals and HM groups wanting to control their readmission rates before Medicare imposes reimbursement penalties starting in October 2012 (see “Value-Based Purchasing Raises the Stakes,” May 2011, p. 1).

One proposed solution is the post-discharge clinic, typically located on or near a hospital’s campus and staffed by hospitalists, PCPs, or advanced-practice nurses. The patient can be seen once or a few times in the post-discharge clinic to make sure that health education started in the hospital is understood and followed, and that prescriptions ordered in the hospital are being taken on schedule.

Mark V. Williams, MD, FACP, FHM, professor and chief of the division of hospital medicine at Northwestern University’s Feinberg School of Medicine in Chicago, describes hospitalist-led post-discharge clinics as “Band-Aids for an inadequate primary-care system.” What would be better, he says, is focusing on the underlying problem and working to improve post-discharge access to primary care. Dr. Williams acknowledges, however, that sometimes a patch is needed to stanch the blood flow—e.g., to better manage care transitions—while waiting on healthcare reform and medical homes to improve care coordination throughout the system.

Working in a post-discharge clinic might seem like “a stretch for many hospitalists, especially those who chose this field because they didn’t want to do outpatient medicine,” says Lauren Doctoroff, MD, a hospitalist who directs a post-discharge clinic at Beth Israel Deaconess Medical Center (BIDMC) in Boston. “But there are times when it may be appropriate for hospital-based doctors to extend their responsibility out of the hospital.”

Dr. Doctoroff also says that working in such a clinic can be practice-changing for hospitalists. “All of a sudden, you have a different view of your hospitalized patients, and you start to ask different questions while they’re in the hospital than you ever did before,” she explains.

What is a Post-Discharge Clinic?

click for large version

The post-discharge clinic, also known as a transitional-care clinic or after-care clinic, is intended to bridge medical coverage between the hospital and primary care. The clinic at BIDMC is for patients affiliated with its Health Care Associates faculty practice “discharged from either our hospital or another hospital, who need care that their PCP or specialist, because of scheduling conflicts, cannot provide within the needed time frame,” Dr. Doctoroff says.

Four hospitalists from BIDMC’s large HM group were selected to staff the clinic. The hospitalists work in one-month rotations (a total of three months on service per year), and are relieved of other responsibilities during their month in clinic. They provide five half-day clinic sessions per week, with a 40-minute-per-patient visit schedule. Thirty minutes are allotted for patients referred from the hospital’s ED who did not get admitted to the hospital but need clinical follow-up.

The clinic is based in a BIDMC-affiliated primary-care practice, “which allows us to use its administrative structure and logistical support,” Dr. Doctoroff explains. “A hospital-based administrative service helps set up outpatient visits prior to discharge using computerized physician order entry and a scheduling algorhythm.” (See Figure 1) Patients who can be seen by their PCP in a timely fashion are referred to the PCP office; if not, they are scheduled in the post-discharge clinic. “That helps preserve the PCP relationship, which I think is paramount,” she says.

The first two years were spent getting the clinic established, but in the near future, BIDMC will start measuring such outcomes as access to care and quality. “But not necessarily readmission rates,” Dr. Doctoroff adds. “I know many people think of post-discharge clinics in the context of preventing readmissions, although we don’t have the data yet to fully support that. In fact, some readmissions may result from seeing a doctor. If you get a closer look at some patients after discharge and they are doing badly, they are more likely to be readmitted than if they had just stayed home.” In such cases, readmission could actually be a better outcome for the patient, she notes.

Dr. Doctoroff describes a typical user of her post-discharge clinic as a non-English-speaking patient who was discharged from the hospital with severe back pain from a herniated disk. “He came back to see me 10 days later, still barely able to walk. He hadn’t been able to fill any of the prescriptions from his hospital stay. Within two hours after I saw him, we got his meds filled and outpatient services set up,” she says. “We take care of many patients like him in the hospital with acute pain issues, whom we discharge as soon as they can walk, and later we see them limping into outpatient clinics. It makes me think differently now about how I plan their discharges.”

We do medication reconciliation, reassessments, and follow-ups with lab tests. We also try to assess who is more likely to be a no-show, and who needs more help with scheduling follow-up appointments.

—Shay Martinez, MD, hospitalist, medical director, Harborview Medical Center, Seattle

Who else needs these clinics? Dr. Doctoroff suggests two ways of looking at the question.

“Even for a simple patient admitted to the hospital, that can represent a significant change in the medical picture—a sort of sentinel event. In the discharge clinic, we give them an opportunity to review the hospitalization and answer their questions,” she says. “A lot of information presented to patients in the hospital is not well heard, and the initial visit may be their first time to really talk about what happened.” For other patients with conditions such as congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), or poorly controlled diabetes, treatment guidelines might dictate a pattern for post-discharge follow-up—for example, medical visits in seven or 10 days.

In Seattle, Harborview Medical Center established its After Care Clinic, staffed by hospitalists and nurse practitioners, to provide transitional care for patients discharged from inpatient wards or the ED in need of follow-up, says medical director and hospitalist Shay Martinez, MD. A second priority is to see any CHF patient within 48 hours of discharge.

“We try to limit patients to a maximum of three visits in our clinic,” she says. “At that point, we help them get established in a medical home, either here in one of our primary-care clinics, or in one of the many excellent community clinics in the area.

“This model works well with our patient population. We actually try to do primary care on the inpatient side as well. Our hospitalists are specialized in that approach, given our patient population. We see a lot of immigrants, non-English speakers, people with low health literacy, and the homeless, many of whom lack primary care,” Dr. Martinez says. “We do medication reconciliation, reassessments, and follow-ups with lab tests. We also try to assess who is more likely to be a no-show, and who needs more help with scheduling follow-up appointments.”

Clinical coverage of post-discharge clinics varies by setting, staffing, and scope. If demand is low, hospitalists or ED physicians can be called off the floor to see patients who return to the clinic, or they could staff the clinic after their hospitalist shift ends. Post-discharge clinic staff whose schedules are light can flex into providing primary-care visits in the clinic. Post-discharge can also could be provided in conjunction with—or as an alternative to—physician house calls to patients’ homes. Some post-discharge clinics work with medical call centers or telephonic case managers; some even use telemedicine.

It also could be a growth opportunity for hospitalist practices. “It is an exciting potential role for hospitalists interested in doing a little outpatient care,” Dr. Martinez says. “This is also a good way to be a safety net for your safety-net hospital.”

continued below...

What Do PCPs Think? It May Be Harder than It Looks

Listen to Dr. Doctoroff

Although some PCPs instinctively will be suspicious of a hospitalist-run post-discharge clinic, it should be possible to clearly limit the service to short-term, immediate-post-hospital encounters focused on issues related to patients unable to get timely access to primary care, according to Dr. Doctoroff.

“I think there is a diversity of opinion by PCPs,” she says. “Some doctors really believe that it interferes with the patient-doctor relationship. But after we’ve been here for a couple of years, we’ve built up credibility with many providers.”

Charles Cutler, MD, FACP, a general internist with a practice in Norristown, Pa., and a member of the ACP’s Board of Regents, says the post-discharge clinic is “a novel idea.”

“I’d be very curious to see if this really is a way to provide better and more cost-effective care,” adds Dr. Cutler, who normally retains management of his own patients when they are hospitalized but agrees that hospitals need to find a solution for lapses in care transitions.

Even so, he says, establishing an outpatient clinic presence may be more difficult than many hospitalists appreciate. “You can’t just put a doc in a room. That physician needs equipment, scheduling, and support staff,” he says. “In our small practice, we employ one person just to ensure that each patient chart is up to date. The overhead necessary to replicate a typical medical office, even one merely providing a transition of care, could be substantial.”

Dr. Cutler emphasizes such office-based challenges as billing, which is distinctly different from hospital billing, and credentialing by insurance companies.

“There are many aspects that have to be thought through. If you see the patient, you need to make yourself available for follow-up calls, because you’ve created a relationship,” he says. “I’m a believer that hospital medicine requires a degree of specialization. But so does an office practice.”

Dr. Cutler acknowledges that some PCPs will be resentful of post-discharge clinics. “But if you don’t like a hospitalist-run discharge clinic, then you have a responsibility to rearrange your schedule to accommodate patients after their hospital discharge,” he says.

Partner with Community

Tallahassee (Fla.) Memorial Hospital (TMH) in February launched a transitional-care clinic in collaboration with faculty from Florida State University, community-based health providers, and the local Capital Health Plan. Hospitalists don’t staff the clinic, but the HM group is its major source of referrals, says Dean Watson, MD, chief medical officer at TMH. Patients can be followed for up to eight weeks, during which time they get comprehensive assessments, medication review and optimization, and referral by the clinic social worker to a PCP and to available community services.

“Three years ago, we came up with the idea for a patient population we know is at high risk for readmission. Why don’t we partner with organizations in the community, form a clinic, teach students and residents, and learn together?” Dr. Watson says. “In addition to the usual patients, TMH targets those who have been readmitted to the hospital three times or more in the past year.”

The clinic, open five days a week, is staffed by a physician, nurse practitioner, telephonic nurse, and social worker, and also has a geriatric assessment clinic.

“We set up a system to identify patients through our electronic health record, and when they come to the clinic, we focus on their social environment and other non-medical issues that might cause readmissions,” he says. The clinic has a pharmacy and funds to support medications for patients without insurance. “In our first six months, we reduced emergency room visits and readmissions for these patients by 68 percent.”

One key partner, Capital Health Plan, bought and refurbished a building, and made it available for the clinic at no cost. Capital’s motivation, says Tom Glennon, a senior vice president for the plan, is its commitment to the community and to community service.

“We’re a nonprofit HMO. We’re focused on what we can do to serve the community, and we’re looking at this as a way for the hospital to have fewer costly, unreimbursed bouncebacks,” Glennon says. “That’s a win-win for all of us.”

Most of the patients who use the clinic are not members of Capital Health Plan, Glennon adds. “If we see CHP members turning up at the transitions clinic, then we have a problem—a breakdown in our case management,” he explains. “Our goal is to have our members taken care of by primary-care providers.”

Hard Data? Not So Fast

How many post-discharge clinics are in operation today is not known. Fundamental financial data, too, are limited, but some say it is unlikely a post-discharge clinic will cover operating expenses from billing revenues alone.

Thus, such clinics will require funding from the hospital, HM group, health system, or health plans, based on the benefits the clinic provides to discharged patients and the impact on 30-day readmissions (for more about the logistical challenges post-discharge clinics present, see “What Do PCPs Think?”).

Some also suggest that many of the post-discharge clinics now in operation are too new to have demonstrated financial impact or return on investment. “We have not yet been asked to show our financial viability,” Dr. Doctoroff says. “I think the clinic leadership thinks we are fulfilling other goals for now, such as creating easier access for their patients after discharge.”

Amy Boutwell, MD, MPP, a hospitalist at Newton Wellesley Hospital in Massachusetts and founder of Collaborative Healthcare Strategies, is among the post-discharge skeptics. She agrees with Dr. Williams that the post-discharge concept is more of a temporary fix to the long-term issues in primary care. “I think the idea is getting more play than actual activity out there right now,” she says. “We need to find opportunities to manage transitions within our scope today and tomorrow while strategically looking at where we want to be in five years [as hospitals and health systems].”

Dr. Boutwell says she’s experienced the frustration of trying to make follow-up appointments with physicians who don’t have any open slots for hospitalized patients awaiting discharge. “We think of follow up as physician-led, but there are alternatives and physician extenders,” she says. “It is well-documented that our healthcare system underuses home health care and other services that might be helpful. We forget how many other opportunities there are in our communities to get another clinician to touch the patient.”

Hospitalists, as key players in the healthcare system, can speak out in support of strengthening primary-care networks and building more collaborative relationships with PCPs, according to Dr. Williams. “If you’re going to set up an outpatient clinic, ideally, have it staffed by PCPs who can funnel the patients into primary-care networks. If that’s not feasible, then hospitalists should proceed with caution, since this approach begins to take them out of their scope of practice,” he says.

With 13 years of experience in urban hospital settings, Dr. Williams is familiar with the dangers unassigned patients present at discharge. “But I don’t know that we’ve yet optimized the hospital discharge process at any hospital in the United States,” he says.

That said, Dr. Williams knows his hospital in downtown Chicago is now working to establish a post-discharge clinic. It will be staffed by PCPs and will target patients who don’t have a PCP, are on Medicaid, or lack insurance.

“Where it starts to make me uncomfortable,” Dr. Williams says, “is what happens when you follow patients out into the outpatient setting?

It’s hard to do just one visit and draw the line. Yes, you may prevent a readmission, but the patient is still left with chronic illness and the need for primary care.”

Larry Beresford is a freelance writer based in Oakland, Calif.

What Does the Research Say?

Listen to Dr. Doctoroff

Post-discharge clinic advocates acknowledge that the research documenting outcomes from such clinics is scarce. A recent study from Northwestern University looked at 12 distinct care-transitions activities and their effect on readmission rates.² Post-discharge clinics were not studied as a separate category, although they fit into the category of physician continuity across inpatient and outpatient settings.

“There’s definitely a hole in the literature regarding post-discharge care,” says lead author Luke Hansen, MD, MHS. The authors found that “no single intervention implemented alone was regularly associated with reduced risk for 30-day rehospitalizations.”

On the other hand, Misky et al found that discharged patients who lacked timely follow-up (within four weeks of discharge) were 10 times more likely to be readmitted than those who got the follow-up.³

Medical teams from around the world, including in Canada, the United Kingdom, Israel, and Australia, are studying readmission rates and care-transitions strategies. A study by physicians at National Taiwan University Hospital in Taipei describes its integrated transitional care to address post-discharge discontinuities and prevent rehospitalizations, including telephonic monitoring, hotline counseling, and referral to a hospital-run post-discharge clinic located within a hospitalist-managed ward.4 “Patients are treated primarily by the hospitalists who are familiar with them,” in a clinic open from 8 a.m. to 9 p.m., lead author Chin-Chung Shu, MD, wrote in an email. The clinic sees 15 to 30 patients per month; 80% of them are discharged patients without a PCP.

“We typically see patients one or two times in 30 days and then refer them to a suitable physician,” Dr. Shu says. In his study, patients who received post-discharge transitional care, including the post-discharge clinic, had lower rates of readmission and death within 30 days, 15% compared with 25% for a control group.

References

1. Goodman, DC, Fisher ES, Chang C. After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries. Dartmouth Atlas website. Available at: www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf. Accessed Nov. 3, 2011.
2. Hansen LO, Young RS, Hinami K, Leung A, Williams MV. Interventions to reduce 3-day rehospitalization: A systematic review. Ann Int Med. 2011;155(8): 520-528.
3. Misky GJ, Wald HL, Coleman EA. Post-hospitalization transitions: Examining the effects of timing of primary care provider follow-up. J Hosp Med. 2010;5(7):392-397.
4. Shu CC, Hsu NC, Lin YF, et al. Integrated post-discharge transitional care in Taiwan. BMC Medicine website. Available at: www.biomedcentral.com/1741-7015/9/96. Accessed Nov. 1, 2011.

A new Health Affairs study tested three relatively simple and inexpensive interventions on a hospital unit to prevent the kinds of hospital-acquired infections that cause the deaths of an estimated 99,000 patients each year. Principal investigator Bradford Harris, MD, and colleagues conducted the research on a pediatric ICU at the University of North Carolina at Chapel Hill School of Medicine, finding that patients admitted after these interventions were implemented left the hospital on average two days earlier, at lower cost, and with a 2.3% lower death rate. Study authors projected annual savings of $12 million for a single PICU.¹

The simple measures include strict enforcement of standard hand hygiene policies; guideline-recommended measures for ventilator patients, such as elevating the head of the hospital bed; and compliance with guidelines for maintaining central line catheters, along with educational posters and the use of oral care kits.

A recent article in the “Cleveland Plain Dealer” describes efforts in that city’s hospitals to enforce proper hand hygiene.² MetroHealth Medical Center hired four employees it calls “infection prevention observers,” whose entire job is to make sure that every caregiver who comes near a patient washes his or her hands. They openly appear on the units carrying clipboards and filling out sheets tracking non-compliance.

The hospital’s hand hygiene compliance rate has reached 98% on all medical units (nationwide, the rate is around 50%), while bloodstream infections have dropped to one-third of what they were in 2010. Cleveland Clinic and University Hospitals achieved similar compliance by employing secret observers of staff hand-washing.

CDC epidemiologist and hand hygiene expert Kate Ellingson, MD, told the newspaper that while awareness of the importance of hand hygiene has long been understood, it is difficult for healthcare workers to follow. But hospitals that use employee monitors, post data, and implement other hand hygiene initiatives tend to show strong compliance.

References

1. Harris BD, Hanson H, Christy C, et al. Strict hand hygiene and other practices shortened stays and cut costs and mortality in a pediatric intensive care unit. Health Affairs. 2011;30(9):1751-1761.
2. Tribble SJ. Cleveland MetroHealth Medical Center increases hand washing, reduces infections. “Cleveland Plain Dealer” website. Available at: http://www.cleveland.com/healthfit/index.ssf/2011/09/metrohealth_increases_hand_was.html. Accessed Oct. 15, 2011.

A new Health Affairs study tested three relatively simple and inexpensive interventions on a hospital unit to prevent the kinds of hospital-acquired infections that cause the deaths of an estimated 99,000 patients each year. Principal investigator Bradford Harris, MD, and colleagues conducted the research on a pediatric ICU at the University of North Carolina at Chapel Hill School of Medicine, finding that patients admitted after these interventions were implemented left the hospital on average two days earlier, at lower cost, and with a 2.3% lower death rate. Study authors projected annual savings of $12 million for a single PICU.¹

The simple measures include strict enforcement of standard hand hygiene policies; guideline-recommended measures for ventilator patients, such as elevating the head of the hospital bed; and compliance with guidelines for maintaining central line catheters, along with educational posters and the use of oral care kits.

A recent article in the “Cleveland Plain Dealer” describes efforts in that city’s hospitals to enforce proper hand hygiene.² MetroHealth Medical Center hired four employees it calls “infection prevention observers,” whose entire job is to make sure that every caregiver who comes near a patient washes his or her hands. They openly appear on the units carrying clipboards and filling out sheets tracking non-compliance.

The hospital’s hand hygiene compliance rate has reached 98% on all medical units (nationwide, the rate is around 50%), while bloodstream infections have dropped to one-third of what they were in 2010. Cleveland Clinic and University Hospitals achieved similar compliance by employing secret observers of staff hand-washing.

CDC epidemiologist and hand hygiene expert Kate Ellingson, MD, told the newspaper that while awareness of the importance of hand hygiene has long been understood, it is difficult for healthcare workers to follow. But hospitals that use employee monitors, post data, and implement other hand hygiene initiatives tend to show strong compliance.

References

1. Harris BD, Hanson H, Christy C, et al. Strict hand hygiene and other practices shortened stays and cut costs and mortality in a pediatric intensive care unit. Health Affairs. 2011;30(9):1751-1761.
2. Tribble SJ. Cleveland MetroHealth Medical Center increases hand washing, reduces infections. “Cleveland Plain Dealer” website. Available at: http://www.cleveland.com/healthfit/index.ssf/2011/09/metrohealth_increases_hand_was.html. Accessed Oct. 15, 2011.

A new Health Affairs study tested three relatively simple and inexpensive interventions on a hospital unit to prevent the kinds of hospital-acquired infections that cause the deaths of an estimated 99,000 patients each year. Principal investigator Bradford Harris, MD, and colleagues conducted the research on a pediatric ICU at the University of North Carolina at Chapel Hill School of Medicine, finding that patients admitted after these interventions were implemented left the hospital on average two days earlier, at lower cost, and with a 2.3% lower death rate. Study authors projected annual savings of $12 million for a single PICU.¹

The simple measures include strict enforcement of standard hand hygiene policies; guideline-recommended measures for ventilator patients, such as elevating the head of the hospital bed; and compliance with guidelines for maintaining central line catheters, along with educational posters and the use of oral care kits.

A recent article in the “Cleveland Plain Dealer” describes efforts in that city’s hospitals to enforce proper hand hygiene.² MetroHealth Medical Center hired four employees it calls “infection prevention observers,” whose entire job is to make sure that every caregiver who comes near a patient washes his or her hands. They openly appear on the units carrying clipboards and filling out sheets tracking non-compliance.

The hospital’s hand hygiene compliance rate has reached 98% on all medical units (nationwide, the rate is around 50%), while bloodstream infections have dropped to one-third of what they were in 2010. Cleveland Clinic and University Hospitals achieved similar compliance by employing secret observers of staff hand-washing.

CDC epidemiologist and hand hygiene expert Kate Ellingson, MD, told the newspaper that while awareness of the importance of hand hygiene has long been understood, it is difficult for healthcare workers to follow. But hospitals that use employee monitors, post data, and implement other hand hygiene initiatives tend to show strong compliance.

References

1. Harris BD, Hanson H, Christy C, et al. Strict hand hygiene and other practices shortened stays and cut costs and mortality in a pediatric intensive care unit. Health Affairs. 2011;30(9):1751-1761.
2. Tribble SJ. Cleveland MetroHealth Medical Center increases hand washing, reduces infections. “Cleveland Plain Dealer” website. Available at: http://www.cleveland.com/healthfit/index.ssf/2011/09/metrohealth_increases_hand_was.html. Accessed Oct. 15, 2011.

The newest Dartmouth Atlas report, released Sept. 28, documents striking variation in 30-day hospital readmission rates for Medicare patients across 308 hospital-referral regions.¹ The authors found little progress in decreasing 30-day readmissions from 2004 to 2009, while for some conditions and many regions, rates actually went up.

National readmission rates following surgery were 12.7% in both 2004 and 2009; readmissions for medical conditions rose slightly, from 15.9% to 16.1%, over the same period. Only 42% of hospitalized Medicare patients discharged to home had a PCP contact within 14 days of discharge, according to the report.

The Dartmouth Atlas Project (www.dartmouthatlas.org) documents geographic variation in healthcare utilization unrelated to outcome. It offers an extensive database for comparison by state, county, region and facility.

The new report is the first to identify an association nationally between readmissions rates and “the overall intensity of inpatient care provided to patients within a region or hospital,” with patterns of relatively high hospital utilization often corresponding with areas of higher readmissions. “Other patients are readmitted simply because they live in a locale where the hospital is used more frequently as a site of care,” the authors note.

Without continuous, high-quality care coordination across sites, the authors write, discharged patients can repeatedly bounce back to emergency rooms and hospitals.

Reference

1. Goodman, DC, Fisher ES, Chang C. After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries. Dartmouth Atlas website. Available at: www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf. Accessed Oct. 15, 2011.

The newest Dartmouth Atlas report, released Sept. 28, documents striking variation in 30-day hospital readmission rates for Medicare patients across 308 hospital-referral regions.¹ The authors found little progress in decreasing 30-day readmissions from 2004 to 2009, while for some conditions and many regions, rates actually went up.

National readmission rates following surgery were 12.7% in both 2004 and 2009; readmissions for medical conditions rose slightly, from 15.9% to 16.1%, over the same period. Only 42% of hospitalized Medicare patients discharged to home had a PCP contact within 14 days of discharge, according to the report.

The Dartmouth Atlas Project (www.dartmouthatlas.org) documents geographic variation in healthcare utilization unrelated to outcome. It offers an extensive database for comparison by state, county, region and facility.

The new report is the first to identify an association nationally between readmissions rates and “the overall intensity of inpatient care provided to patients within a region or hospital,” with patterns of relatively high hospital utilization often corresponding with areas of higher readmissions. “Other patients are readmitted simply because they live in a locale where the hospital is used more frequently as a site of care,” the authors note.

Without continuous, high-quality care coordination across sites, the authors write, discharged patients can repeatedly bounce back to emergency rooms and hospitals.

Reference

1. Goodman, DC, Fisher ES, Chang C. After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries. Dartmouth Atlas website. Available at: www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf. Accessed Oct. 15, 2011.

The newest Dartmouth Atlas report, released Sept. 28, documents striking variation in 30-day hospital readmission rates for Medicare patients across 308 hospital-referral regions.¹ The authors found little progress in decreasing 30-day readmissions from 2004 to 2009, while for some conditions and many regions, rates actually went up.

National readmission rates following surgery were 12.7% in both 2004 and 2009; readmissions for medical conditions rose slightly, from 15.9% to 16.1%, over the same period. Only 42% of hospitalized Medicare patients discharged to home had a PCP contact within 14 days of discharge, according to the report.

The Dartmouth Atlas Project (www.dartmouthatlas.org) documents geographic variation in healthcare utilization unrelated to outcome. It offers an extensive database for comparison by state, county, region and facility.

The new report is the first to identify an association nationally between readmissions rates and “the overall intensity of inpatient care provided to patients within a region or hospital,” with patterns of relatively high hospital utilization often corresponding with areas of higher readmissions. “Other patients are readmitted simply because they live in a locale where the hospital is used more frequently as a site of care,” the authors note.

Without continuous, high-quality care coordination across sites, the authors write, discharged patients can repeatedly bounce back to emergency rooms and hospitals.

Reference

1. Goodman, DC, Fisher ES, Chang C. After Hospitalization: A Dartmouth Atlas Report on Post-Acute Care for Medicare Beneficiaries. Dartmouth Atlas website. Available at: www.dartmouthatlas.org/downloads/reports/Post_discharge_events_092811.pdf. Accessed Oct. 15, 2011.

A company pitching a new bacteria-resistant line of hospital linens is studying just how effective their product can be in the hospital setting.

PurThread Technologies Inc. is working with the University of Iowa on a second privacy curtain study that the company expects will show that their line of curtains, scrubs, doctor’s coats, bed linens, and patient gowns will help hospitalists and other inpatient physicians reduce the amount of bacteria they come into contact with. The research is the next step following a study presented at the Interscience Conference on Antimicrobial Agents and Chemotherapy meeting in September, which showed 92% of hospital privacy curtains were contaminated with potentially pathogenic bacteria, such as MRSA and VRE (vancomyicn-resistant enterococcus), within a week of being laundered.

The study was funded by PurThread and performed at the University of Iowa Hospital in Iowa City.

PurThread president and CEO Kathryn Bowsher says the company aims to take its first orders this year, thanks to a novel alloy it has woven into the fabrics it uses. As hospitals struggle to reach full compliance with hand hygiene and other safety measures, Bowsher believes her textiles are an easy answer.

“It’s always easier to re-engineer the system than it is to modify human behavior,” she adds. “And this would essentially be a plug-and-play solution. You stick these on the shelves and in the inventory of the hospital, instead of the traditional ones, and nobody has to think of it after that.”

A company pitching a new bacteria-resistant line of hospital linens is studying just how effective their product can be in the hospital setting.

PurThread Technologies Inc. is working with the University of Iowa on a second privacy curtain study that the company expects will show that their line of curtains, scrubs, doctor’s coats, bed linens, and patient gowns will help hospitalists and other inpatient physicians reduce the amount of bacteria they come into contact with. The research is the next step following a study presented at the Interscience Conference on Antimicrobial Agents and Chemotherapy meeting in September, which showed 92% of hospital privacy curtains were contaminated with potentially pathogenic bacteria, such as MRSA and VRE (vancomyicn-resistant enterococcus), within a week of being laundered.

The study was funded by PurThread and performed at the University of Iowa Hospital in Iowa City.

PurThread president and CEO Kathryn Bowsher says the company aims to take its first orders this year, thanks to a novel alloy it has woven into the fabrics it uses. As hospitals struggle to reach full compliance with hand hygiene and other safety measures, Bowsher believes her textiles are an easy answer.

“It’s always easier to re-engineer the system than it is to modify human behavior,” she adds. “And this would essentially be a plug-and-play solution. You stick these on the shelves and in the inventory of the hospital, instead of the traditional ones, and nobody has to think of it after that.”

A company pitching a new bacteria-resistant line of hospital linens is studying just how effective their product can be in the hospital setting.

PurThread Technologies Inc. is working with the University of Iowa on a second privacy curtain study that the company expects will show that their line of curtains, scrubs, doctor’s coats, bed linens, and patient gowns will help hospitalists and other inpatient physicians reduce the amount of bacteria they come into contact with. The research is the next step following a study presented at the Interscience Conference on Antimicrobial Agents and Chemotherapy meeting in September, which showed 92% of hospital privacy curtains were contaminated with potentially pathogenic bacteria, such as MRSA and VRE (vancomyicn-resistant enterococcus), within a week of being laundered.

The study was funded by PurThread and performed at the University of Iowa Hospital in Iowa City.

PurThread president and CEO Kathryn Bowsher says the company aims to take its first orders this year, thanks to a novel alloy it has woven into the fabrics it uses. As hospitals struggle to reach full compliance with hand hygiene and other safety measures, Bowsher believes her textiles are an easy answer.

“It’s always easier to re-engineer the system than it is to modify human behavior,” she adds. “And this would essentially be a plug-and-play solution. You stick these on the shelves and in the inventory of the hospital, instead of the traditional ones, and nobody has to think of it after that.”

An automated email system that notifies both hospitalists and PCPs about post-discharge test results can help ensure results don’t “fall through the cracks,” according to an abstract presented at HM11.

The report, “Design and Implementation of an Automated Email Notification System for Results of Tests Pending at Discharge,” suggests that by providing an automatic email when results are completed, inpatient physicians will be more responsible for the patient, and create a dialogue with primary-care physicians (PCPs) as well. The authors estimate that physicians are aware of 40% of the final results of tests pending at discharge.

“Things fall through the cracks,” says Anuj Dalal, MD, FHM, a hospitalist at Brigham and Women’s Hospital in Boston. “This is a method to make sure these test results don’t fall through the cracks.”

Dr. Dalal’s team created the automatic emails across five services—chemistry, hematology, microbiology, pathology, and radiology—in the past two years. Preliminary data show that the system helps ensure physicians are aware of more test results, but additional research is needed.

Still, Dr. Dalal believes creating an email system at a given institution helps if only by drawing attention to the issue of pending results once a patient has left the hospital. And even if the implementation of the system at a less-wired hospital is difficult, the omnipresence of email should help with adopting.

“Everyone has email today,” he adds.

An automated email system that notifies both hospitalists and PCPs about post-discharge test results can help ensure results don’t “fall through the cracks,” according to an abstract presented at HM11.

The report, “Design and Implementation of an Automated Email Notification System for Results of Tests Pending at Discharge,” suggests that by providing an automatic email when results are completed, inpatient physicians will be more responsible for the patient, and create a dialogue with primary-care physicians (PCPs) as well. The authors estimate that physicians are aware of 40% of the final results of tests pending at discharge.

“Things fall through the cracks,” says Anuj Dalal, MD, FHM, a hospitalist at Brigham and Women’s Hospital in Boston. “This is a method to make sure these test results don’t fall through the cracks.”

Dr. Dalal’s team created the automatic emails across five services—chemistry, hematology, microbiology, pathology, and radiology—in the past two years. Preliminary data show that the system helps ensure physicians are aware of more test results, but additional research is needed.

Still, Dr. Dalal believes creating an email system at a given institution helps if only by drawing attention to the issue of pending results once a patient has left the hospital. And even if the implementation of the system at a less-wired hospital is difficult, the omnipresence of email should help with adopting.

“Everyone has email today,” he adds.

An automated email system that notifies both hospitalists and PCPs about post-discharge test results can help ensure results don’t “fall through the cracks,” according to an abstract presented at HM11.

The report, “Design and Implementation of an Automated Email Notification System for Results of Tests Pending at Discharge,” suggests that by providing an automatic email when results are completed, inpatient physicians will be more responsible for the patient, and create a dialogue with primary-care physicians (PCPs) as well. The authors estimate that physicians are aware of 40% of the final results of tests pending at discharge.

“Things fall through the cracks,” says Anuj Dalal, MD, FHM, a hospitalist at Brigham and Women’s Hospital in Boston. “This is a method to make sure these test results don’t fall through the cracks.”

Dr. Dalal’s team created the automatic emails across five services—chemistry, hematology, microbiology, pathology, and radiology—in the past two years. Preliminary data show that the system helps ensure physicians are aware of more test results, but additional research is needed.

Still, Dr. Dalal believes creating an email system at a given institution helps if only by drawing attention to the issue of pending results once a patient has left the hospital. And even if the implementation of the system at a less-wired hospital is difficult, the omnipresence of email should help with adopting.

“Everyone has email today,” he adds.

Clinical informatics, the principle of blending health information technology (HIT) with patient care, is going mainstream. The subspecialty, popular in hospitalist circles, is scheduled to offer board certification following its recent approval by the American Board of Medical Specialties. The first examination will be administered by the American Board of Preventative Medicine and could be held as early as fall 2012, with certificates awarded early in 2013.

AMIA, the informatics trade group, believes the recognition will help push more medical schools to integrate informatics into the curriculum, which will only further solidify the subspecialty place in modern medicine.

Clinical informatics, the principle of blending health information technology (HIT) with patient care, is going mainstream. The subspecialty, popular in hospitalist circles, is scheduled to offer board certification following its recent approval by the American Board of Medical Specialties. The first examination will be administered by the American Board of Preventative Medicine and could be held as early as fall 2012, with certificates awarded early in 2013.

AMIA, the informatics trade group, believes the recognition will help push more medical schools to integrate informatics into the curriculum, which will only further solidify the subspecialty place in modern medicine.

Clinical informatics, the principle of blending health information technology (HIT) with patient care, is going mainstream. The subspecialty, popular in hospitalist circles, is scheduled to offer board certification following its recent approval by the American Board of Medical Specialties. The first examination will be administered by the American Board of Preventative Medicine and could be held as early as fall 2012, with certificates awarded early in 2013.

AMIA, the informatics trade group, believes the recognition will help push more medical schools to integrate informatics into the curriculum, which will only further solidify the subspecialty place in modern medicine.

Projected total number of adult in-hospital cardiac arrests that are treated with a resuscitation response each year in U.S. hospitals.¹ Raina Merchant, MD, and colleagues from the University of Pennsylvania Health System derived several estimates from the American Heart Association’s Get with the Guidelines-Resuscitation registry for 2003 to 2007, weighted for total U.S. hospital bed days. Survival rate for in-hospital cardiac arrests is 21%, compared with 10% for arrests in other settings. But the authors note that arrests might be rising, which is “important for understanding the burden of in-hospital cardiac arrest and developing strategies to improve care for hospitalized patients,” Dr. Merchant says.

Reference

1. Merchant RM, Yang L, Becker LB, et al. Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med. 2011;39(11):2401-2406.

Projected total number of adult in-hospital cardiac arrests that are treated with a resuscitation response each year in U.S. hospitals.¹ Raina Merchant, MD, and colleagues from the University of Pennsylvania Health System derived several estimates from the American Heart Association’s Get with the Guidelines-Resuscitation registry for 2003 to 2007, weighted for total U.S. hospital bed days. Survival rate for in-hospital cardiac arrests is 21%, compared with 10% for arrests in other settings. But the authors note that arrests might be rising, which is “important for understanding the burden of in-hospital cardiac arrest and developing strategies to improve care for hospitalized patients,” Dr. Merchant says.

Reference

1. Merchant RM, Yang L, Becker LB, et al. Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med. 2011;39(11):2401-2406.

Projected total number of adult in-hospital cardiac arrests that are treated with a resuscitation response each year in U.S. hospitals.¹ Raina Merchant, MD, and colleagues from the University of Pennsylvania Health System derived several estimates from the American Heart Association’s Get with the Guidelines-Resuscitation registry for 2003 to 2007, weighted for total U.S. hospital bed days. Survival rate for in-hospital cardiac arrests is 21%, compared with 10% for arrests in other settings. But the authors note that arrests might be rising, which is “important for understanding the burden of in-hospital cardiac arrest and developing strategies to improve care for hospitalized patients,” Dr. Merchant says.

Reference

1. Merchant RM, Yang L, Becker LB, et al. Incidence of treated cardiac arrest in hospitalized patients in the United States. Crit Care Med. 2011;39(11):2401-2406.