Research Letters

Medication reconciliation, when performed well, effectively identifies discrepancies and reduces medication errors in the hospital setting.[1, 2, 3] This process involves 4 major steps: (1) obtain and document a comprehensive medication history on admission, (2) compare the medication history to medication orders in the hospital and identify and resolve discrepancies, (3) provide the patient with a written list of discharge medications, and (4) educate the patient about their discharge medication regimen.[4, 5, 6]

However, medication reconciliation has been challenging to implement given difficulties with accurate medication information, patients' ability to communicate or remember, and clinician's not having enough time, motivation, or clear roles.[5, 7, 8, 9, 10, 11] Lack of role clarity is generally a barrier to quality improvement; therefore, we studied the perceptions of physicians, nurses, and pharmacists about their roles and responsibilities in completing inpatient medication reconciliation.

METHODS

We independently surveyed attending and resident physicians, nurses, and pharmacists at the University of California San Francisco (UCSF) Medical Center via email who were actively caring for hospitalized patients in April 2010. We collected data on demographics, roles on specific tasks in the medication reconciliation process from admission through discharge, and attitudes and barriers toward medication reconciliation and health information technology systems. Responses to questions used a 4‐point Likert scale. We calculated frequencies and proportions, and used the Fisher exact test to evaluate differences in role agreement for specific medication reconciliation tasks.

RESULTS

Of 256 active clinicians, 78 completed the survey (30.5% overall response rate) providing care in various hospital services (medicine, surgery, cardiology, neurology, pediatrics, obstetrics/gynecology). We received responses from 7 attending physicians (16% response rate), 14 resident physicians (19% response rate), 35 nurses (43% response rate), and 22 pharmacists (43% response rate). Most clinicians worked more than 5 years at UCSF, except residents (14 years).

Overall agreement was poor to fair on whose primary role it was for specific medication reconciliation tasks from admission through discharge (Table 1). Clinicians mainly agreed that it was a physician's responsibility to decide which medications should be continued or discontinued on admission and discharge, although agreement between attending and resident physicians varied. Fisher exact test revealed significant differences in agreement among attending and resident physicians, nurses, and pharmacists to obtain and document a medication history on admission (P=0.001), provide a list of the discharge medications (P<0.001), or educate patients on the postdischarge medication regimen (P<0.001). For these tasks, the physician, nurse, pharmacist or a combination of these clinicians (multiple category) were each identified to be responsible.

Most clinicians believed that maintaining a patient's list of medications improves patient care (94%100% agreement). However, when asked whether clinicians other than yourself should be responsible for an accurate medication list, most nurses (73%) and pharmacists (52%) agreed with this statement compared to resident (50%) and attending physicians (29%). Most clinicians agreed that information technology systems for reconciling medications were complicated, and that patients who do not know their medications, accessing outside medical records, working with inaccurate lists, or nonEnglish‐speaking patients are barriers to reconciliation.

DISCUSSION

We found fair agreement among clinicians that physicians were responsible for reconciling medications on admission and discharge. However, attending and resident physicians each believed it was their primary responsibility, respectively, suggesting the need for better communication between each other. We found poor agreement among clinicians about whose primary role it was to perform the other main steps of medication reconciliation including obtaining and documenting a medication history, and providing a medication list and educating the patient at discharge. For these tasks, there was more confusion among physicians, nurses, and pharmacists. Our findings highlight the need for better role clarity and good communication among team members, particularly at discharge.

Nearly all clinicians agreed that updating patients' medication lists improves patient care. However, most nurses and pharmacists preferred that physicians be responsible for updating information and reconciling medications. They also noted a number of patient‐related and information system barriers to effective reconciliation as others have identified.[7, 8, 9, 10, 11] Although standardizing medication information reporting and implementing technology that can integrate medical records to create, update, and share information between patients and providers can help streamline the medication reconciliation process,[4, 5, 7, 8, 12] these procedures are unlikely to be effective unless good interprofessional communication, role clarity, and clinician understanding of how the system works are in place.

When this study was conducted, our institution's policy required that medication reconciliation be completed, but no specific roles or standard work documents existed. Since then, we have clarified the role of the physician to be responsible for completing medication reconciliation with ancillary help from nurses, pharmacists, and other clinicians, particularly when obtaining a medication history and preparing the patient for discharge. This role clarity has led to focused training and standard work guide documents as guidance to clinicians in different hospital settings about expectations and how to complete medication reconciliation. Clearly, no single reconciliation workflow process will meet the needs of all hospitals. However, it is crucial that interprofessional teams are established with clearly defined roles and responsibilities, and how these roles and responsibilities may change in various situations or services.[8]

Our study had several limitations. We surveyed 1 academic medical center, thus limiting the generalizability of our findings to other organizations or settings. Our small sample size and low response rate could be susceptible to selection bias. However, our findings are similar to other studies.[7, 10, 11] Finally, we included clinicians practicing on various services throughout our hospital, and the local medication reconciliation process could have contributed to the poor agreement. Nonetheless, differences in perceived roles and attitudes for completing medication reconciliation were observed.

In conclusion, lack of agreement among clinicians about their specific roles and responsibilities in the medication reconciliation process exists, and this may result in incomplete reconciliation, inefficiency, duplication of work, and possibly more confusion about a patient's medication regimen. Clinically meaningful and efficient medication reconciliation requires interprofessional teamwork with clear roles and responsibilities, good communication and better information reporting, and tracking systems to successfully combine the steps of medication reconciliation and ensure patient safety.[8, 12]

Disclosures: Funded by research grant NHLBI R01 HL086473 to Dr. Auerbach, and through UCSF‐ CTSI grant number KL2 RR024130 to Dr. Lee from the National Center for Research Resources, the National Center for Advancing Translational Sciences, and the Office of the Director, National Institutes of Health. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. Dr. Lee had full access to all study data and takes responsibility for data integrity and data analysis accuracy. The authors report no conflicts of interest.

Medication reconciliation, when performed well, effectively identifies discrepancies and reduces medication errors in the hospital setting.[1, 2, 3] This process involves 4 major steps: (1) obtain and document a comprehensive medication history on admission, (2) compare the medication history to medication orders in the hospital and identify and resolve discrepancies, (3) provide the patient with a written list of discharge medications, and (4) educate the patient about their discharge medication regimen.[4, 5, 6]

However, medication reconciliation has been challenging to implement given difficulties with accurate medication information, patients' ability to communicate or remember, and clinician's not having enough time, motivation, or clear roles.[5, 7, 8, 9, 10, 11] Lack of role clarity is generally a barrier to quality improvement; therefore, we studied the perceptions of physicians, nurses, and pharmacists about their roles and responsibilities in completing inpatient medication reconciliation.

METHODS

We independently surveyed attending and resident physicians, nurses, and pharmacists at the University of California San Francisco (UCSF) Medical Center via email who were actively caring for hospitalized patients in April 2010. We collected data on demographics, roles on specific tasks in the medication reconciliation process from admission through discharge, and attitudes and barriers toward medication reconciliation and health information technology systems. Responses to questions used a 4‐point Likert scale. We calculated frequencies and proportions, and used the Fisher exact test to evaluate differences in role agreement for specific medication reconciliation tasks.

RESULTS

Of 256 active clinicians, 78 completed the survey (30.5% overall response rate) providing care in various hospital services (medicine, surgery, cardiology, neurology, pediatrics, obstetrics/gynecology). We received responses from 7 attending physicians (16% response rate), 14 resident physicians (19% response rate), 35 nurses (43% response rate), and 22 pharmacists (43% response rate). Most clinicians worked more than 5 years at UCSF, except residents (14 years).

Overall agreement was poor to fair on whose primary role it was for specific medication reconciliation tasks from admission through discharge (Table 1). Clinicians mainly agreed that it was a physician's responsibility to decide which medications should be continued or discontinued on admission and discharge, although agreement between attending and resident physicians varied. Fisher exact test revealed significant differences in agreement among attending and resident physicians, nurses, and pharmacists to obtain and document a medication history on admission (P=0.001), provide a list of the discharge medications (P<0.001), or educate patients on the postdischarge medication regimen (P<0.001). For these tasks, the physician, nurse, pharmacist or a combination of these clinicians (multiple category) were each identified to be responsible.

Most clinicians believed that maintaining a patient's list of medications improves patient care (94%100% agreement). However, when asked whether clinicians other than yourself should be responsible for an accurate medication list, most nurses (73%) and pharmacists (52%) agreed with this statement compared to resident (50%) and attending physicians (29%). Most clinicians agreed that information technology systems for reconciling medications were complicated, and that patients who do not know their medications, accessing outside medical records, working with inaccurate lists, or nonEnglish‐speaking patients are barriers to reconciliation.

DISCUSSION

We found fair agreement among clinicians that physicians were responsible for reconciling medications on admission and discharge. However, attending and resident physicians each believed it was their primary responsibility, respectively, suggesting the need for better communication between each other. We found poor agreement among clinicians about whose primary role it was to perform the other main steps of medication reconciliation including obtaining and documenting a medication history, and providing a medication list and educating the patient at discharge. For these tasks, there was more confusion among physicians, nurses, and pharmacists. Our findings highlight the need for better role clarity and good communication among team members, particularly at discharge.

Nearly all clinicians agreed that updating patients' medication lists improves patient care. However, most nurses and pharmacists preferred that physicians be responsible for updating information and reconciling medications. They also noted a number of patient‐related and information system barriers to effective reconciliation as others have identified.[7, 8, 9, 10, 11] Although standardizing medication information reporting and implementing technology that can integrate medical records to create, update, and share information between patients and providers can help streamline the medication reconciliation process,[4, 5, 7, 8, 12] these procedures are unlikely to be effective unless good interprofessional communication, role clarity, and clinician understanding of how the system works are in place.

When this study was conducted, our institution's policy required that medication reconciliation be completed, but no specific roles or standard work documents existed. Since then, we have clarified the role of the physician to be responsible for completing medication reconciliation with ancillary help from nurses, pharmacists, and other clinicians, particularly when obtaining a medication history and preparing the patient for discharge. This role clarity has led to focused training and standard work guide documents as guidance to clinicians in different hospital settings about expectations and how to complete medication reconciliation. Clearly, no single reconciliation workflow process will meet the needs of all hospitals. However, it is crucial that interprofessional teams are established with clearly defined roles and responsibilities, and how these roles and responsibilities may change in various situations or services.[8]

Our study had several limitations. We surveyed 1 academic medical center, thus limiting the generalizability of our findings to other organizations or settings. Our small sample size and low response rate could be susceptible to selection bias. However, our findings are similar to other studies.[7, 10, 11] Finally, we included clinicians practicing on various services throughout our hospital, and the local medication reconciliation process could have contributed to the poor agreement. Nonetheless, differences in perceived roles and attitudes for completing medication reconciliation were observed.

In conclusion, lack of agreement among clinicians about their specific roles and responsibilities in the medication reconciliation process exists, and this may result in incomplete reconciliation, inefficiency, duplication of work, and possibly more confusion about a patient's medication regimen. Clinically meaningful and efficient medication reconciliation requires interprofessional teamwork with clear roles and responsibilities, good communication and better information reporting, and tracking systems to successfully combine the steps of medication reconciliation and ensure patient safety.[8, 12]

Disclosures: Funded by research grant NHLBI R01 HL086473 to Dr. Auerbach, and through UCSF‐ CTSI grant number KL2 RR024130 to Dr. Lee from the National Center for Research Resources, the National Center for Advancing Translational Sciences, and the Office of the Director, National Institutes of Health. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. Dr. Lee had full access to all study data and takes responsibility for data integrity and data analysis accuracy. The authors report no conflicts of interest.

Medication reconciliation, when performed well, effectively identifies discrepancies and reduces medication errors in the hospital setting.[1, 2, 3] This process involves 4 major steps: (1) obtain and document a comprehensive medication history on admission, (2) compare the medication history to medication orders in the hospital and identify and resolve discrepancies, (3) provide the patient with a written list of discharge medications, and (4) educate the patient about their discharge medication regimen.[4, 5, 6]

However, medication reconciliation has been challenging to implement given difficulties with accurate medication information, patients' ability to communicate or remember, and clinician's not having enough time, motivation, or clear roles.[5, 7, 8, 9, 10, 11] Lack of role clarity is generally a barrier to quality improvement; therefore, we studied the perceptions of physicians, nurses, and pharmacists about their roles and responsibilities in completing inpatient medication reconciliation.

METHODS

We independently surveyed attending and resident physicians, nurses, and pharmacists at the University of California San Francisco (UCSF) Medical Center via email who were actively caring for hospitalized patients in April 2010. We collected data on demographics, roles on specific tasks in the medication reconciliation process from admission through discharge, and attitudes and barriers toward medication reconciliation and health information technology systems. Responses to questions used a 4‐point Likert scale. We calculated frequencies and proportions, and used the Fisher exact test to evaluate differences in role agreement for specific medication reconciliation tasks.

RESULTS

Of 256 active clinicians, 78 completed the survey (30.5% overall response rate) providing care in various hospital services (medicine, surgery, cardiology, neurology, pediatrics, obstetrics/gynecology). We received responses from 7 attending physicians (16% response rate), 14 resident physicians (19% response rate), 35 nurses (43% response rate), and 22 pharmacists (43% response rate). Most clinicians worked more than 5 years at UCSF, except residents (14 years).

Overall agreement was poor to fair on whose primary role it was for specific medication reconciliation tasks from admission through discharge (Table 1). Clinicians mainly agreed that it was a physician's responsibility to decide which medications should be continued or discontinued on admission and discharge, although agreement between attending and resident physicians varied. Fisher exact test revealed significant differences in agreement among attending and resident physicians, nurses, and pharmacists to obtain and document a medication history on admission (P=0.001), provide a list of the discharge medications (P<0.001), or educate patients on the postdischarge medication regimen (P<0.001). For these tasks, the physician, nurse, pharmacist or a combination of these clinicians (multiple category) were each identified to be responsible.

Most clinicians believed that maintaining a patient's list of medications improves patient care (94%100% agreement). However, when asked whether clinicians other than yourself should be responsible for an accurate medication list, most nurses (73%) and pharmacists (52%) agreed with this statement compared to resident (50%) and attending physicians (29%). Most clinicians agreed that information technology systems for reconciling medications were complicated, and that patients who do not know their medications, accessing outside medical records, working with inaccurate lists, or nonEnglish‐speaking patients are barriers to reconciliation.

DISCUSSION

We found fair agreement among clinicians that physicians were responsible for reconciling medications on admission and discharge. However, attending and resident physicians each believed it was their primary responsibility, respectively, suggesting the need for better communication between each other. We found poor agreement among clinicians about whose primary role it was to perform the other main steps of medication reconciliation including obtaining and documenting a medication history, and providing a medication list and educating the patient at discharge. For these tasks, there was more confusion among physicians, nurses, and pharmacists. Our findings highlight the need for better role clarity and good communication among team members, particularly at discharge.

Nearly all clinicians agreed that updating patients' medication lists improves patient care. However, most nurses and pharmacists preferred that physicians be responsible for updating information and reconciling medications. They also noted a number of patient‐related and information system barriers to effective reconciliation as others have identified.[7, 8, 9, 10, 11] Although standardizing medication information reporting and implementing technology that can integrate medical records to create, update, and share information between patients and providers can help streamline the medication reconciliation process,[4, 5, 7, 8, 12] these procedures are unlikely to be effective unless good interprofessional communication, role clarity, and clinician understanding of how the system works are in place.

When this study was conducted, our institution's policy required that medication reconciliation be completed, but no specific roles or standard work documents existed. Since then, we have clarified the role of the physician to be responsible for completing medication reconciliation with ancillary help from nurses, pharmacists, and other clinicians, particularly when obtaining a medication history and preparing the patient for discharge. This role clarity has led to focused training and standard work guide documents as guidance to clinicians in different hospital settings about expectations and how to complete medication reconciliation. Clearly, no single reconciliation workflow process will meet the needs of all hospitals. However, it is crucial that interprofessional teams are established with clearly defined roles and responsibilities, and how these roles and responsibilities may change in various situations or services.[8]

Our study had several limitations. We surveyed 1 academic medical center, thus limiting the generalizability of our findings to other organizations or settings. Our small sample size and low response rate could be susceptible to selection bias. However, our findings are similar to other studies.[7, 10, 11] Finally, we included clinicians practicing on various services throughout our hospital, and the local medication reconciliation process could have contributed to the poor agreement. Nonetheless, differences in perceived roles and attitudes for completing medication reconciliation were observed.

In conclusion, lack of agreement among clinicians about their specific roles and responsibilities in the medication reconciliation process exists, and this may result in incomplete reconciliation, inefficiency, duplication of work, and possibly more confusion about a patient's medication regimen. Clinically meaningful and efficient medication reconciliation requires interprofessional teamwork with clear roles and responsibilities, good communication and better information reporting, and tracking systems to successfully combine the steps of medication reconciliation and ensure patient safety.[8, 12]

Disclosures: Funded by research grant NHLBI R01 HL086473 to Dr. Auerbach, and through UCSF‐ CTSI grant number KL2 RR024130 to Dr. Lee from the National Center for Research Resources, the National Center for Advancing Translational Sciences, and the Office of the Director, National Institutes of Health. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. Dr. Lee had full access to all study data and takes responsibility for data integrity and data analysis accuracy. The authors report no conflicts of interest.

Electronic cigarettes are increasingly prevalent battery‐operated devices that heat a solution to generate an inhalable nicotine‐containing aerosol.[1, 2] Despite a diverse array of devices on the market, the US Food and Drug Administration (FDA) has only recently proposed expanding its regulatory ability to include electronic cigarettes.[3] States, municipalities, and institutions have enacted variable regulations on electronic nicotine delivery systems.[4, 5] Advocates of electronic cigarettes propose that they are a less‐toxic alternative to tobacco cigarettes, with potential for use as a nicotine replacement therapy (NRT).[6, 7, 8] Opponents argue that electronic cigarettes may undermine tobacco cessation goals and potentially expose nonusers to secondhand nicotine vapor.[9, 10]

Hospital providers frequently care for nicotine‐dependent patients.[11] We investigated inpatient healthcare providers' knowledge, perceptions, and experience with electronic cigarettes, with the goals of informing educational efforts and guiding policy decisions around hospital‐based use of electronic nicotine delivery systems.

METHODS

The study was conducted at a 183‐bed urban safety‐net medical center affiliated with a residency training program using a cross‐sectional survey to query a diverse array of inpatient providers (Table 1). Respondents who had not cared for an inpatient in the past 5 years were excluded. Surveys were designed based on prior literature, personal experience, and expert suggestions.[12] Surveys were disseminated in March 2014 via e‐mail, with embedded informed consent and a link that connected anonymously to the online survey (Qualtrics, Provo, UT). We did not collect unique identifiers and offered no incentive for participation. Data were downloaded to a secure database and analyzed using Microsoft Excel 2010 (Microsoft Corp., Redmond, WA) and GraphPad Prism version 6.04 (GraphPad Software, Inc., La Jolla, CA). The study was approved by the institutional review board.

RESULTS

DISCUSSION

Our study is the first to provide hospital‐based providers' experience and perspectives surrounding electronic cigarette use. The vast majority of participants reported familiarity with electronic cigarettes, consistent with prior findings.[13] Though electronic cigarettes have yet to achieve a use in the hospital setting, 19% of our respondents reported receiving requests from hospitalized patients to use these devices. With increasing patient demand for electronic cigarettes, hospitals will need to update their tobacco policies to include these novel devices as well as target educational efforts toward front‐line providers, such as nurses, who receive the majority of requests.

Participants perceived traditional cigarettes to be significantly more harmful than electronic cigarettes, while established forms of NRT were felt to be less harmful than electronic cigarettes (data not shown). Concern about the health effects of electronic cigarettes is further reflected in providers' hesitancy to view these devices as an NRT option in the hospital, reluctance to consider sharing a room with an electronic cigarette user, and near majority opinion that electronic cigarettes should be banned from healthcare settings altogether. Current regulation by the US Department of Transportation bans electronic cigarette use on airplanes, whereas a host of states currently ban electronic cigarette use in similarly enclosed spaces such as correctional facilities and commuter trains.[14] More knowledge is needed on the health effects of electronic cigarettes on the primary user, secondhand exposure range, and their potential to aid in short‐ and long‐term nicotine cessation before providers and hospitals can make an informed risk‐benefit analysis for appropriate inpatient use. As current or past tobacco users were more accepting of the use of electronic cigarettes in hospital settings, these providers' opinions should be sought for a unique understanding of the interplay between electronic cigarettes and the healthcare environment.

Concern over the unknown safety effects can also be seen in the overwhelming provider support for FDA regulation. Healthcare advocacy groups, such as the American Heart Association, the American Lung Association, and the Legacy Foundation already support federal regulation.[15, 16, 17] FDA regulation may lead to the ability to standardize device content, regulate purchasing and marketing requirements, and ensure that claims to health effects are supported by scientific evidence, though agency involvement may also slow the process of integration into hospital use. Perhaps reflective of the immediacy of the problem, nurses who receive the majority of requests for electronic cigarettes from patients are least likely to want FDA regulation. Until more is known, patients and staff may benefit from pairing vaporizing patients in shared rooms or providing users with designated inhaling spaces.

Nicotine addiction is a strong driving force and, due to a strict no‐smoking policy at our institution, we have witnessed patients making unsafe decisions to leave the hospital (in some cases against medical advice) in an effort to continue smoking. Patients may be starting to look toward electronic cigarettes as an NRT option that more closely satisfies nicotine cravings as well as the ritualistic and tactile components of cigarette use. Electronic cigarettes could have the potential to act as a harm reduction method for nicotine‐dependent inpatients by decreasing the nicotine‐withdrawal related impetus for unsafe hospital discharges. Institutions should take this into account when formulating new policy.

Our study has several limitations. First, it was a single‐center study that may not be representative of provider perspectives at other institutions. Second, the survey was a cross‐sectional sample, missing providers who did not receive the e‐mail during the enrollment period. Third, responses may not accurately reflect perspectives of smaller responding groups such as social workers. Fourth, the survey did not include all types of physicians who deal with smoking cessation, though internal and family medicine physicians provide the majority of care for hospitalized patients at our institution. Fifth, we recorded self‐reported familiarity with electronic cigarettes and did not formally test providers' knowledge of the subject.

Our study provides new perspectives and data on electronic cigarettes to inform future research as well as hospital and healthcare policy. Hospitals should educate patients and front‐line providers around the paucity of health information on these novel devices, while formulating policy that acknowledges patient demand for electronic cigarettes and their potential for cessation therapy and harm reduction. Further research should focus on the effects of nicotine vapor inhalation on patients, the consequences of secondhand nicotine vapor, and the potential for electronic nicotine delivery systems to act as a novel NRT for hospital use.

Electronic cigarettes are increasingly prevalent battery‐operated devices that heat a solution to generate an inhalable nicotine‐containing aerosol.[1, 2] Despite a diverse array of devices on the market, the US Food and Drug Administration (FDA) has only recently proposed expanding its regulatory ability to include electronic cigarettes.[3] States, municipalities, and institutions have enacted variable regulations on electronic nicotine delivery systems.[4, 5] Advocates of electronic cigarettes propose that they are a less‐toxic alternative to tobacco cigarettes, with potential for use as a nicotine replacement therapy (NRT).[6, 7, 8] Opponents argue that electronic cigarettes may undermine tobacco cessation goals and potentially expose nonusers to secondhand nicotine vapor.[9, 10]

Hospital providers frequently care for nicotine‐dependent patients.[11] We investigated inpatient healthcare providers' knowledge, perceptions, and experience with electronic cigarettes, with the goals of informing educational efforts and guiding policy decisions around hospital‐based use of electronic nicotine delivery systems.

METHODS

The study was conducted at a 183‐bed urban safety‐net medical center affiliated with a residency training program using a cross‐sectional survey to query a diverse array of inpatient providers (Table 1). Respondents who had not cared for an inpatient in the past 5 years were excluded. Surveys were designed based on prior literature, personal experience, and expert suggestions.[12] Surveys were disseminated in March 2014 via e‐mail, with embedded informed consent and a link that connected anonymously to the online survey (Qualtrics, Provo, UT). We did not collect unique identifiers and offered no incentive for participation. Data were downloaded to a secure database and analyzed using Microsoft Excel 2010 (Microsoft Corp., Redmond, WA) and GraphPad Prism version 6.04 (GraphPad Software, Inc., La Jolla, CA). The study was approved by the institutional review board.

RESULTS

DISCUSSION

Our study is the first to provide hospital‐based providers' experience and perspectives surrounding electronic cigarette use. The vast majority of participants reported familiarity with electronic cigarettes, consistent with prior findings.[13] Though electronic cigarettes have yet to achieve a use in the hospital setting, 19% of our respondents reported receiving requests from hospitalized patients to use these devices. With increasing patient demand for electronic cigarettes, hospitals will need to update their tobacco policies to include these novel devices as well as target educational efforts toward front‐line providers, such as nurses, who receive the majority of requests.

Participants perceived traditional cigarettes to be significantly more harmful than electronic cigarettes, while established forms of NRT were felt to be less harmful than electronic cigarettes (data not shown). Concern about the health effects of electronic cigarettes is further reflected in providers' hesitancy to view these devices as an NRT option in the hospital, reluctance to consider sharing a room with an electronic cigarette user, and near majority opinion that electronic cigarettes should be banned from healthcare settings altogether. Current regulation by the US Department of Transportation bans electronic cigarette use on airplanes, whereas a host of states currently ban electronic cigarette use in similarly enclosed spaces such as correctional facilities and commuter trains.[14] More knowledge is needed on the health effects of electronic cigarettes on the primary user, secondhand exposure range, and their potential to aid in short‐ and long‐term nicotine cessation before providers and hospitals can make an informed risk‐benefit analysis for appropriate inpatient use. As current or past tobacco users were more accepting of the use of electronic cigarettes in hospital settings, these providers' opinions should be sought for a unique understanding of the interplay between electronic cigarettes and the healthcare environment.

Concern over the unknown safety effects can also be seen in the overwhelming provider support for FDA regulation. Healthcare advocacy groups, such as the American Heart Association, the American Lung Association, and the Legacy Foundation already support federal regulation.[15, 16, 17] FDA regulation may lead to the ability to standardize device content, regulate purchasing and marketing requirements, and ensure that claims to health effects are supported by scientific evidence, though agency involvement may also slow the process of integration into hospital use. Perhaps reflective of the immediacy of the problem, nurses who receive the majority of requests for electronic cigarettes from patients are least likely to want FDA regulation. Until more is known, patients and staff may benefit from pairing vaporizing patients in shared rooms or providing users with designated inhaling spaces.

Nicotine addiction is a strong driving force and, due to a strict no‐smoking policy at our institution, we have witnessed patients making unsafe decisions to leave the hospital (in some cases against medical advice) in an effort to continue smoking. Patients may be starting to look toward electronic cigarettes as an NRT option that more closely satisfies nicotine cravings as well as the ritualistic and tactile components of cigarette use. Electronic cigarettes could have the potential to act as a harm reduction method for nicotine‐dependent inpatients by decreasing the nicotine‐withdrawal related impetus for unsafe hospital discharges. Institutions should take this into account when formulating new policy.

Our study has several limitations. First, it was a single‐center study that may not be representative of provider perspectives at other institutions. Second, the survey was a cross‐sectional sample, missing providers who did not receive the e‐mail during the enrollment period. Third, responses may not accurately reflect perspectives of smaller responding groups such as social workers. Fourth, the survey did not include all types of physicians who deal with smoking cessation, though internal and family medicine physicians provide the majority of care for hospitalized patients at our institution. Fifth, we recorded self‐reported familiarity with electronic cigarettes and did not formally test providers' knowledge of the subject.

Our study provides new perspectives and data on electronic cigarettes to inform future research as well as hospital and healthcare policy. Hospitals should educate patients and front‐line providers around the paucity of health information on these novel devices, while formulating policy that acknowledges patient demand for electronic cigarettes and their potential for cessation therapy and harm reduction. Further research should focus on the effects of nicotine vapor inhalation on patients, the consequences of secondhand nicotine vapor, and the potential for electronic nicotine delivery systems to act as a novel NRT for hospital use.

Electronic cigarettes are increasingly prevalent battery‐operated devices that heat a solution to generate an inhalable nicotine‐containing aerosol.[1, 2] Despite a diverse array of devices on the market, the US Food and Drug Administration (FDA) has only recently proposed expanding its regulatory ability to include electronic cigarettes.[3] States, municipalities, and institutions have enacted variable regulations on electronic nicotine delivery systems.[4, 5] Advocates of electronic cigarettes propose that they are a less‐toxic alternative to tobacco cigarettes, with potential for use as a nicotine replacement therapy (NRT).[6, 7, 8] Opponents argue that electronic cigarettes may undermine tobacco cessation goals and potentially expose nonusers to secondhand nicotine vapor.[9, 10]

Hospital providers frequently care for nicotine‐dependent patients.[11] We investigated inpatient healthcare providers' knowledge, perceptions, and experience with electronic cigarettes, with the goals of informing educational efforts and guiding policy decisions around hospital‐based use of electronic nicotine delivery systems.

METHODS

The study was conducted at a 183‐bed urban safety‐net medical center affiliated with a residency training program using a cross‐sectional survey to query a diverse array of inpatient providers (Table 1). Respondents who had not cared for an inpatient in the past 5 years were excluded. Surveys were designed based on prior literature, personal experience, and expert suggestions.[12] Surveys were disseminated in March 2014 via e‐mail, with embedded informed consent and a link that connected anonymously to the online survey (Qualtrics, Provo, UT). We did not collect unique identifiers and offered no incentive for participation. Data were downloaded to a secure database and analyzed using Microsoft Excel 2010 (Microsoft Corp., Redmond, WA) and GraphPad Prism version 6.04 (GraphPad Software, Inc., La Jolla, CA). The study was approved by the institutional review board.

RESULTS

DISCUSSION

Our study is the first to provide hospital‐based providers' experience and perspectives surrounding electronic cigarette use. The vast majority of participants reported familiarity with electronic cigarettes, consistent with prior findings.[13] Though electronic cigarettes have yet to achieve a use in the hospital setting, 19% of our respondents reported receiving requests from hospitalized patients to use these devices. With increasing patient demand for electronic cigarettes, hospitals will need to update their tobacco policies to include these novel devices as well as target educational efforts toward front‐line providers, such as nurses, who receive the majority of requests.

Participants perceived traditional cigarettes to be significantly more harmful than electronic cigarettes, while established forms of NRT were felt to be less harmful than electronic cigarettes (data not shown). Concern about the health effects of electronic cigarettes is further reflected in providers' hesitancy to view these devices as an NRT option in the hospital, reluctance to consider sharing a room with an electronic cigarette user, and near majority opinion that electronic cigarettes should be banned from healthcare settings altogether. Current regulation by the US Department of Transportation bans electronic cigarette use on airplanes, whereas a host of states currently ban electronic cigarette use in similarly enclosed spaces such as correctional facilities and commuter trains.[14] More knowledge is needed on the health effects of electronic cigarettes on the primary user, secondhand exposure range, and their potential to aid in short‐ and long‐term nicotine cessation before providers and hospitals can make an informed risk‐benefit analysis for appropriate inpatient use. As current or past tobacco users were more accepting of the use of electronic cigarettes in hospital settings, these providers' opinions should be sought for a unique understanding of the interplay between electronic cigarettes and the healthcare environment.

Concern over the unknown safety effects can also be seen in the overwhelming provider support for FDA regulation. Healthcare advocacy groups, such as the American Heart Association, the American Lung Association, and the Legacy Foundation already support federal regulation.[15, 16, 17] FDA regulation may lead to the ability to standardize device content, regulate purchasing and marketing requirements, and ensure that claims to health effects are supported by scientific evidence, though agency involvement may also slow the process of integration into hospital use. Perhaps reflective of the immediacy of the problem, nurses who receive the majority of requests for electronic cigarettes from patients are least likely to want FDA regulation. Until more is known, patients and staff may benefit from pairing vaporizing patients in shared rooms or providing users with designated inhaling spaces.

Nicotine addiction is a strong driving force and, due to a strict no‐smoking policy at our institution, we have witnessed patients making unsafe decisions to leave the hospital (in some cases against medical advice) in an effort to continue smoking. Patients may be starting to look toward electronic cigarettes as an NRT option that more closely satisfies nicotine cravings as well as the ritualistic and tactile components of cigarette use. Electronic cigarettes could have the potential to act as a harm reduction method for nicotine‐dependent inpatients by decreasing the nicotine‐withdrawal related impetus for unsafe hospital discharges. Institutions should take this into account when formulating new policy.

Our study has several limitations. First, it was a single‐center study that may not be representative of provider perspectives at other institutions. Second, the survey was a cross‐sectional sample, missing providers who did not receive the e‐mail during the enrollment period. Third, responses may not accurately reflect perspectives of smaller responding groups such as social workers. Fourth, the survey did not include all types of physicians who deal with smoking cessation, though internal and family medicine physicians provide the majority of care for hospitalized patients at our institution. Fifth, we recorded self‐reported familiarity with electronic cigarettes and did not formally test providers' knowledge of the subject.

Our study provides new perspectives and data on electronic cigarettes to inform future research as well as hospital and healthcare policy. Hospitals should educate patients and front‐line providers around the paucity of health information on these novel devices, while formulating policy that acknowledges patient demand for electronic cigarettes and their potential for cessation therapy and harm reduction. Further research should focus on the effects of nicotine vapor inhalation on patients, the consequences of secondhand nicotine vapor, and the potential for electronic nicotine delivery systems to act as a novel NRT for hospital use.

Ascites is the most common complication of cirrhosis leading to hospital admission.[1] Approximately 12% of hospitalized patients who present with decompensated cirrhosis and ascites have spontaneous bacterial peritonitis (SBP); half of these patients do not present with abdominal pain, fever, nausea, or vomiting.[2] Guidelines published by the American Association for the Study of Liver Diseases (AASLD) recommend paracentesis for all hospitalized patients with cirrhosis and ascites and also recommend long‐term antibiotic prophylaxis for survivors of an SBP episode.[3] Despite evidence that in‐hospital mortality is reduced in those patients who receive paracentesis in a timely manner,[4, 5] only 40% to 60% of eligible patients receive paracentesis.[4, 6, 7] We aimed to describe clinical predictors of paracentesis and use of antibiotics following an episode of SBP in patients with decompensated cirrhosis and ascites.

METHODS

We conducted a retrospective cohort study of adults admitted to a single tertiary care center between January 1, 2009 and December 31, 2009.⁷ We included patients with an International Classification of Diseases, Ninth Revision discharge code consistent with decompensated cirrhosis who met clinical criteria for decompensated cirrhosis (see Supporting Figure 1 in the online version of this article) [7] and had enough ascitic fluid to be sampled under imaging guidance. We collected presenting vital signs, laboratory data (within 24 hours of admission), evidence of infection other than SBP (eg, urinary infection, pneumonia), results of peritoneal fluid analysis (defining SBP as 250 polymorphonuclear leukocytes), and use of antibiotic therapy. Our statistical analysis calculated summary statistics as means, medians, and proportions. Furthermore, we used multiple logistic regression to examine the association between predictors and receipt of paracentesis, including age, sex, and clinical measures associated with paracentesis at P0.20 using the Fisher exact test. Alpha was set at 0.05 (2‐sided) for all comparisons.

RESULTS

We identified 193 admissions for 103 patients with decompensated cirrhosis and ascites (Table 1). Of these, 41% (80/193) received diagnostic paracentesis. Mean/standard deviation for age was 53.6/12.4 years; 71% of patients were male and 63% were English speaking. Common comorbidities included diabetes mellitus (33%), psychiatric diagnosis (29%), substance abuse (18%), and renal failure (17%). Excluding SBP, 31% of patients had another documented infection. Gastroenterology was consulted in 50% of the admissions. Fever was present in 27% of patients, elevated white blood cell (WBC) count (ie, WBC >11 k/mm³) was present in 27% of patients, International Normalized Ratio (INR) was elevated (>1.1) in 92% of patients, and 16% of patients had a platelet count of <50,000/mm³. Patients who received paracentesis were less likely to have a fever on presentation (19% vs 32%, P=0.06), low (ie, <50,000/mm³) platelet count (11% vs 19%, P=0.14), or concurrent gastrointestinal (GI) bleed (6% vs 16%, P=0.05). In a multiple logistic regression model including characteristics associated at P0.2 with paracentesis, fever, low platelet count, and concurrent GI bleeding were associated with decreased odds of receiving paracentesis (Appendix 1).

Of the patients who received paracentesis (n=80), 14% were diagnosed with SBP. Of these, 55% received prophylaxis on discharge. Among the patients who did not receive paracentesis (n=113), 38 (34%) received antibiotics for another documented infection (eg, pneumonia), and 25 patients (22%) received antibiotics with no other documented infection or evidence of variceal bleeding. Of these 25 patients who were presumed to be empirically treated for SBP (Figure 1), only 20% were prescribed prophylactic antibiotics on discharge.

Figure 1

CONCLUSION

We found that many patients with decompensated cirrhosis and ascites did not receive paracentesis when hospitalized, which is similar to previously published data.[4, 6, 7] Clinical evidence of infection, such as fever or elevated WBC count, did not increase the odds of receiving paracentesis. Many patients treated for SBP were not discharged on prophylaxis.

This study is limited by its small single‐center design. We could only use data from 1 year (2009), because study data collection was part of a quality‐improvement project that took place for that year only. We did not adjust for the number of red blood cells in the ascitic fluid samples. We were also unable to determine the timing of gastroenterology consultation (whether it was done prior to paracentesis), admission venue (floor vs intensive care), or patient history of SBP.

Despite these limitations, there are important implications. First, the decision to perform paracentesis was not associated with symptoms of infection, although some clinical factors (eg, low platelets or GI bleeding) were associated with reduced odds of receiving paracentesis. Second, a majority of patients treated for SBP did not receive prophylactic antibiotics at discharge. These findings suggest a clear opportunity to increase awareness and acceptance of AASLD guidelines among hospital medicine practitioners. Quality‐improvement efforts should focus on the education of providers, and future research should identify barriers to paracentesis at both the practitioner and system levels (eg, availability of interventional radiology). Checklists or decision support within electronic order entry systems may also help reduce the low rates of paracentesis seen in our and prior studies.[4, 6, 7]

Disclosures: Dr. Lagu is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL114745. Drs. Lagu, Ghaoui, and Brooling had full access to all of the data in the study. They take responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Lagu, Ghaoui, and Brooling conceived of the study. Dr. Ghaoui acquired the data. Ms. Friderici carried out the statistical analyses. Drs. Lagu, Ghaoui, Brooling, Lindenauer, and Ms. Friderici analyzed and interpreted the data, drafted the manuscript, and critically reviewed the manuscript for important intellectual content. The authors report no conflicts of interest.

Ascites is the most common complication of cirrhosis leading to hospital admission.[1] Approximately 12% of hospitalized patients who present with decompensated cirrhosis and ascites have spontaneous bacterial peritonitis (SBP); half of these patients do not present with abdominal pain, fever, nausea, or vomiting.[2] Guidelines published by the American Association for the Study of Liver Diseases (AASLD) recommend paracentesis for all hospitalized patients with cirrhosis and ascites and also recommend long‐term antibiotic prophylaxis for survivors of an SBP episode.[3] Despite evidence that in‐hospital mortality is reduced in those patients who receive paracentesis in a timely manner,[4, 5] only 40% to 60% of eligible patients receive paracentesis.[4, 6, 7] We aimed to describe clinical predictors of paracentesis and use of antibiotics following an episode of SBP in patients with decompensated cirrhosis and ascites.

METHODS

We conducted a retrospective cohort study of adults admitted to a single tertiary care center between January 1, 2009 and December 31, 2009.⁷ We included patients with an International Classification of Diseases, Ninth Revision discharge code consistent with decompensated cirrhosis who met clinical criteria for decompensated cirrhosis (see Supporting Figure 1 in the online version of this article) [7] and had enough ascitic fluid to be sampled under imaging guidance. We collected presenting vital signs, laboratory data (within 24 hours of admission), evidence of infection other than SBP (eg, urinary infection, pneumonia), results of peritoneal fluid analysis (defining SBP as 250 polymorphonuclear leukocytes), and use of antibiotic therapy. Our statistical analysis calculated summary statistics as means, medians, and proportions. Furthermore, we used multiple logistic regression to examine the association between predictors and receipt of paracentesis, including age, sex, and clinical measures associated with paracentesis at P0.20 using the Fisher exact test. Alpha was set at 0.05 (2‐sided) for all comparisons.

RESULTS

We identified 193 admissions for 103 patients with decompensated cirrhosis and ascites (Table 1). Of these, 41% (80/193) received diagnostic paracentesis. Mean/standard deviation for age was 53.6/12.4 years; 71% of patients were male and 63% were English speaking. Common comorbidities included diabetes mellitus (33%), psychiatric diagnosis (29%), substance abuse (18%), and renal failure (17%). Excluding SBP, 31% of patients had another documented infection. Gastroenterology was consulted in 50% of the admissions. Fever was present in 27% of patients, elevated white blood cell (WBC) count (ie, WBC >11 k/mm³) was present in 27% of patients, International Normalized Ratio (INR) was elevated (>1.1) in 92% of patients, and 16% of patients had a platelet count of <50,000/mm³. Patients who received paracentesis were less likely to have a fever on presentation (19% vs 32%, P=0.06), low (ie, <50,000/mm³) platelet count (11% vs 19%, P=0.14), or concurrent gastrointestinal (GI) bleed (6% vs 16%, P=0.05). In a multiple logistic regression model including characteristics associated at P0.2 with paracentesis, fever, low platelet count, and concurrent GI bleeding were associated with decreased odds of receiving paracentesis (Appendix 1).

Of the patients who received paracentesis (n=80), 14% were diagnosed with SBP. Of these, 55% received prophylaxis on discharge. Among the patients who did not receive paracentesis (n=113), 38 (34%) received antibiotics for another documented infection (eg, pneumonia), and 25 patients (22%) received antibiotics with no other documented infection or evidence of variceal bleeding. Of these 25 patients who were presumed to be empirically treated for SBP (Figure 1), only 20% were prescribed prophylactic antibiotics on discharge.

Figure 1

CONCLUSION

We found that many patients with decompensated cirrhosis and ascites did not receive paracentesis when hospitalized, which is similar to previously published data.[4, 6, 7] Clinical evidence of infection, such as fever or elevated WBC count, did not increase the odds of receiving paracentesis. Many patients treated for SBP were not discharged on prophylaxis.

This study is limited by its small single‐center design. We could only use data from 1 year (2009), because study data collection was part of a quality‐improvement project that took place for that year only. We did not adjust for the number of red blood cells in the ascitic fluid samples. We were also unable to determine the timing of gastroenterology consultation (whether it was done prior to paracentesis), admission venue (floor vs intensive care), or patient history of SBP.

Despite these limitations, there are important implications. First, the decision to perform paracentesis was not associated with symptoms of infection, although some clinical factors (eg, low platelets or GI bleeding) were associated with reduced odds of receiving paracentesis. Second, a majority of patients treated for SBP did not receive prophylactic antibiotics at discharge. These findings suggest a clear opportunity to increase awareness and acceptance of AASLD guidelines among hospital medicine practitioners. Quality‐improvement efforts should focus on the education of providers, and future research should identify barriers to paracentesis at both the practitioner and system levels (eg, availability of interventional radiology). Checklists or decision support within electronic order entry systems may also help reduce the low rates of paracentesis seen in our and prior studies.[4, 6, 7]

Disclosures: Dr. Lagu is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL114745. Drs. Lagu, Ghaoui, and Brooling had full access to all of the data in the study. They take responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Lagu, Ghaoui, and Brooling conceived of the study. Dr. Ghaoui acquired the data. Ms. Friderici carried out the statistical analyses. Drs. Lagu, Ghaoui, Brooling, Lindenauer, and Ms. Friderici analyzed and interpreted the data, drafted the manuscript, and critically reviewed the manuscript for important intellectual content. The authors report no conflicts of interest.

Ascites is the most common complication of cirrhosis leading to hospital admission.[1] Approximately 12% of hospitalized patients who present with decompensated cirrhosis and ascites have spontaneous bacterial peritonitis (SBP); half of these patients do not present with abdominal pain, fever, nausea, or vomiting.[2] Guidelines published by the American Association for the Study of Liver Diseases (AASLD) recommend paracentesis for all hospitalized patients with cirrhosis and ascites and also recommend long‐term antibiotic prophylaxis for survivors of an SBP episode.[3] Despite evidence that in‐hospital mortality is reduced in those patients who receive paracentesis in a timely manner,[4, 5] only 40% to 60% of eligible patients receive paracentesis.[4, 6, 7] We aimed to describe clinical predictors of paracentesis and use of antibiotics following an episode of SBP in patients with decompensated cirrhosis and ascites.

METHODS

We conducted a retrospective cohort study of adults admitted to a single tertiary care center between January 1, 2009 and December 31, 2009.⁷ We included patients with an International Classification of Diseases, Ninth Revision discharge code consistent with decompensated cirrhosis who met clinical criteria for decompensated cirrhosis (see Supporting Figure 1 in the online version of this article) [7] and had enough ascitic fluid to be sampled under imaging guidance. We collected presenting vital signs, laboratory data (within 24 hours of admission), evidence of infection other than SBP (eg, urinary infection, pneumonia), results of peritoneal fluid analysis (defining SBP as 250 polymorphonuclear leukocytes), and use of antibiotic therapy. Our statistical analysis calculated summary statistics as means, medians, and proportions. Furthermore, we used multiple logistic regression to examine the association between predictors and receipt of paracentesis, including age, sex, and clinical measures associated with paracentesis at P0.20 using the Fisher exact test. Alpha was set at 0.05 (2‐sided) for all comparisons.

RESULTS

We identified 193 admissions for 103 patients with decompensated cirrhosis and ascites (Table 1). Of these, 41% (80/193) received diagnostic paracentesis. Mean/standard deviation for age was 53.6/12.4 years; 71% of patients were male and 63% were English speaking. Common comorbidities included diabetes mellitus (33%), psychiatric diagnosis (29%), substance abuse (18%), and renal failure (17%). Excluding SBP, 31% of patients had another documented infection. Gastroenterology was consulted in 50% of the admissions. Fever was present in 27% of patients, elevated white blood cell (WBC) count (ie, WBC >11 k/mm³) was present in 27% of patients, International Normalized Ratio (INR) was elevated (>1.1) in 92% of patients, and 16% of patients had a platelet count of <50,000/mm³. Patients who received paracentesis were less likely to have a fever on presentation (19% vs 32%, P=0.06), low (ie, <50,000/mm³) platelet count (11% vs 19%, P=0.14), or concurrent gastrointestinal (GI) bleed (6% vs 16%, P=0.05). In a multiple logistic regression model including characteristics associated at P0.2 with paracentesis, fever, low platelet count, and concurrent GI bleeding were associated with decreased odds of receiving paracentesis (Appendix 1).

Of the patients who received paracentesis (n=80), 14% were diagnosed with SBP. Of these, 55% received prophylaxis on discharge. Among the patients who did not receive paracentesis (n=113), 38 (34%) received antibiotics for another documented infection (eg, pneumonia), and 25 patients (22%) received antibiotics with no other documented infection or evidence of variceal bleeding. Of these 25 patients who were presumed to be empirically treated for SBP (Figure 1), only 20% were prescribed prophylactic antibiotics on discharge.

Figure 1

CONCLUSION

We found that many patients with decompensated cirrhosis and ascites did not receive paracentesis when hospitalized, which is similar to previously published data.[4, 6, 7] Clinical evidence of infection, such as fever or elevated WBC count, did not increase the odds of receiving paracentesis. Many patients treated for SBP were not discharged on prophylaxis.

This study is limited by its small single‐center design. We could only use data from 1 year (2009), because study data collection was part of a quality‐improvement project that took place for that year only. We did not adjust for the number of red blood cells in the ascitic fluid samples. We were also unable to determine the timing of gastroenterology consultation (whether it was done prior to paracentesis), admission venue (floor vs intensive care), or patient history of SBP.

Despite these limitations, there are important implications. First, the decision to perform paracentesis was not associated with symptoms of infection, although some clinical factors (eg, low platelets or GI bleeding) were associated with reduced odds of receiving paracentesis. Second, a majority of patients treated for SBP did not receive prophylactic antibiotics at discharge. These findings suggest a clear opportunity to increase awareness and acceptance of AASLD guidelines among hospital medicine practitioners. Quality‐improvement efforts should focus on the education of providers, and future research should identify barriers to paracentesis at both the practitioner and system levels (eg, availability of interventional radiology). Checklists or decision support within electronic order entry systems may also help reduce the low rates of paracentesis seen in our and prior studies.[4, 6, 7]

Disclosures: Dr. Lagu is supported by the National Heart, Lung, and Blood Institute of the National Institutes of Health under award number K01HL114745. Drs. Lagu, Ghaoui, and Brooling had full access to all of the data in the study. They take responsibility for the integrity of the data and the accuracy of the data analysis. Drs. Lagu, Ghaoui, and Brooling conceived of the study. Dr. Ghaoui acquired the data. Ms. Friderici carried out the statistical analyses. Drs. Lagu, Ghaoui, Brooling, Lindenauer, and Ms. Friderici analyzed and interpreted the data, drafted the manuscript, and critically reviewed the manuscript for important intellectual content. The authors report no conflicts of interest.

Antipsychotic (AP) medications are often used in the hospitalized geriatric population for the treatment of delirium.[1] Because of adverse events associated with APs, efforts have been made to reduce their use in hospitalized elders,[2] but it is not clear if these recommendations have been widely adopted. We studied the use of APs in a cohort of hospitalized elders to better understand why APs are started and how often they are continued on discharge.

METHODS

We conducted a retrospective cohort study of patients aged 65 years or older admitted to a tertiary care hospital between October 1, 2012 and September 31, 2013. Using Stata's (StataCorp., College Station, TX) sample command,[3] we included a subset of randomly selected inpatients who received more than 1 dose of oral APs (determined using the electronic medication administration summary). We excluded patients admitted under observation status or to the psychiatric service, those who were on APs prior to admission, and those who only received prochloperazine for nausea. Using prior literature to identify terms frequently used to describe delirium (Figure 1), we created an algorithm and a chart abstraction form (see Supporting Information, Appendix 1, in the online version of this article).[4] We tested these instruments in a preliminary chart review involving 30 patients. Disagreements were discussed with coauthors and resolved through consensus, resulting in some algorithm changes (eg, excluding a large number of patients who received only 1 dose of haloperidol postoperatively, because we hypothesized that this use could be a prophylactic measure).[5] Two investigators extracted the remaining charts independently. We used descriptive statistics and performed cross‐tabulations on the selected variables.

Figure 1

RESULTS

Of 12,817 geriatric hospitalizations during the study period, 1120 (9%) were treated with antipsychotics. We randomly selected 300 of these for extraction: 54% were male, and 67% were admitted to the medical service (Table 1). The inpatient mortality rate was 10% (30/300). The most frequent indication for AP use was delirium (83%, 249/300). Only 35% of delirious patients received a formal assessment with the Confusion Assessment Method (CAM). The most commonly used atypical antipsychotic was quetiapine (86%); 55% received more than 1 antipsychotic medication during hospitalization, and 48% (143/297) of patients were continued on APs at discharge (excluding 3 patients transferred to other acute care hospitals).

Approximately 45% (134/300) had documented or suspected dementia, and 30% (89/300) were physically restrained during the hospital stay. Consultations with geriatrics were obtained in 40% (120/300) of the cases and with psychiatry in 10% (29/300) of the cases. Neurology is rarely consulted for delirium in our institution; thus, we did not collect data on those referrals. Electrocardiography (ECG) (recommended for patients at high cardiac risk[6]) was performed in 88% (265/300) of patients prior to AP administration and 52% (157/300) after. The corrected QT interval exceeded 500 ms in 15% (41/265) of patients prior to AP administration and 25% (39/157) after. Although few patients (12%) were admitted from nursing facilities, 66% (199/300) were eventually discharged to skilled nursing facilities (SNFs) or rehabilitation facilities; most of these patients (117/199, 59%) received AP treatment, compared to 38% of patients discharged to home (26/68).

DISCUSSION

In a cohort of hospitalized elders, we found that 9% were treated with APs. Most received APs for perceived delirium; in‐hospital ECG monitoring was suboptimal. Half of the patients started on APs remained on them at discharge; those discharged to SNFs were more likely to receive ongoing AP treatment.

Our study is limited by its retrospective, single‐center design, a lack of inter‐rater reliability measurement (although our training process was designed to standardize extraction methods), and the infrequent use of formal CAM assessment. Additionally, we were unable to determine how frequently APs were initiated in the intensive care unit. Any retrospective study is limited by the difficulty of distinguishing delirium from the behavioral and psychiatric symptoms of dementia, but we identified delirium using standard terms described in previous literature.

Our study also has a number of important implications. Because of a reported association between the use of APs and risk of death in the postacute setting,[7] national provider organizations have called for a reduction in AP initiation in hospitalized elders.[2] However, this study indicates that APs continue to be prescribed for delirium, which may be attributed to the lack of behavioral modification options in most hospitals, such as acute care for elders (ACE) units and hospital elder life programs (HELP).[8, 9] Our findings suggest that this problem would be further amplified in hospitals that lack access to geriatrics expertise.

Without alternative behavioral options, patients are at risk for prolonged delirium, which is associated with significant suffering and subsequent risk of further cognitive impairment and death.[10] Although evidence for the efficacy of APs in the treatment of delirium is limited and inconclusive, no better pharmacologic options exist. Hospitals that wish to reduce use of APs should therefore consider investing in environmental interventions (eg, ACE units, HELP), which lower the incidence of delirium and could, in turn, decrease the prescription and continuation of antipsychotics.[8, 9]

Antipsychotic (AP) medications are often used in the hospitalized geriatric population for the treatment of delirium.[1] Because of adverse events associated with APs, efforts have been made to reduce their use in hospitalized elders,[2] but it is not clear if these recommendations have been widely adopted. We studied the use of APs in a cohort of hospitalized elders to better understand why APs are started and how often they are continued on discharge.

METHODS

We conducted a retrospective cohort study of patients aged 65 years or older admitted to a tertiary care hospital between October 1, 2012 and September 31, 2013. Using Stata's (StataCorp., College Station, TX) sample command,[3] we included a subset of randomly selected inpatients who received more than 1 dose of oral APs (determined using the electronic medication administration summary). We excluded patients admitted under observation status or to the psychiatric service, those who were on APs prior to admission, and those who only received prochloperazine for nausea. Using prior literature to identify terms frequently used to describe delirium (Figure 1), we created an algorithm and a chart abstraction form (see Supporting Information, Appendix 1, in the online version of this article).[4] We tested these instruments in a preliminary chart review involving 30 patients. Disagreements were discussed with coauthors and resolved through consensus, resulting in some algorithm changes (eg, excluding a large number of patients who received only 1 dose of haloperidol postoperatively, because we hypothesized that this use could be a prophylactic measure).[5] Two investigators extracted the remaining charts independently. We used descriptive statistics and performed cross‐tabulations on the selected variables.

Figure 1

RESULTS

Of 12,817 geriatric hospitalizations during the study period, 1120 (9%) were treated with antipsychotics. We randomly selected 300 of these for extraction: 54% were male, and 67% were admitted to the medical service (Table 1). The inpatient mortality rate was 10% (30/300). The most frequent indication for AP use was delirium (83%, 249/300). Only 35% of delirious patients received a formal assessment with the Confusion Assessment Method (CAM). The most commonly used atypical antipsychotic was quetiapine (86%); 55% received more than 1 antipsychotic medication during hospitalization, and 48% (143/297) of patients were continued on APs at discharge (excluding 3 patients transferred to other acute care hospitals).

Approximately 45% (134/300) had documented or suspected dementia, and 30% (89/300) were physically restrained during the hospital stay. Consultations with geriatrics were obtained in 40% (120/300) of the cases and with psychiatry in 10% (29/300) of the cases. Neurology is rarely consulted for delirium in our institution; thus, we did not collect data on those referrals. Electrocardiography (ECG) (recommended for patients at high cardiac risk[6]) was performed in 88% (265/300) of patients prior to AP administration and 52% (157/300) after. The corrected QT interval exceeded 500 ms in 15% (41/265) of patients prior to AP administration and 25% (39/157) after. Although few patients (12%) were admitted from nursing facilities, 66% (199/300) were eventually discharged to skilled nursing facilities (SNFs) or rehabilitation facilities; most of these patients (117/199, 59%) received AP treatment, compared to 38% of patients discharged to home (26/68).

DISCUSSION

In a cohort of hospitalized elders, we found that 9% were treated with APs. Most received APs for perceived delirium; in‐hospital ECG monitoring was suboptimal. Half of the patients started on APs remained on them at discharge; those discharged to SNFs were more likely to receive ongoing AP treatment.

Our study is limited by its retrospective, single‐center design, a lack of inter‐rater reliability measurement (although our training process was designed to standardize extraction methods), and the infrequent use of formal CAM assessment. Additionally, we were unable to determine how frequently APs were initiated in the intensive care unit. Any retrospective study is limited by the difficulty of distinguishing delirium from the behavioral and psychiatric symptoms of dementia, but we identified delirium using standard terms described in previous literature.

Our study also has a number of important implications. Because of a reported association between the use of APs and risk of death in the postacute setting,[7] national provider organizations have called for a reduction in AP initiation in hospitalized elders.[2] However, this study indicates that APs continue to be prescribed for delirium, which may be attributed to the lack of behavioral modification options in most hospitals, such as acute care for elders (ACE) units and hospital elder life programs (HELP).[8, 9] Our findings suggest that this problem would be further amplified in hospitals that lack access to geriatrics expertise.

Without alternative behavioral options, patients are at risk for prolonged delirium, which is associated with significant suffering and subsequent risk of further cognitive impairment and death.[10] Although evidence for the efficacy of APs in the treatment of delirium is limited and inconclusive, no better pharmacologic options exist. Hospitals that wish to reduce use of APs should therefore consider investing in environmental interventions (eg, ACE units, HELP), which lower the incidence of delirium and could, in turn, decrease the prescription and continuation of antipsychotics.[8, 9]

Antipsychotic (AP) medications are often used in the hospitalized geriatric population for the treatment of delirium.[1] Because of adverse events associated with APs, efforts have been made to reduce their use in hospitalized elders,[2] but it is not clear if these recommendations have been widely adopted. We studied the use of APs in a cohort of hospitalized elders to better understand why APs are started and how often they are continued on discharge.

METHODS

We conducted a retrospective cohort study of patients aged 65 years or older admitted to a tertiary care hospital between October 1, 2012 and September 31, 2013. Using Stata's (StataCorp., College Station, TX) sample command,[3] we included a subset of randomly selected inpatients who received more than 1 dose of oral APs (determined using the electronic medication administration summary). We excluded patients admitted under observation status or to the psychiatric service, those who were on APs prior to admission, and those who only received prochloperazine for nausea. Using prior literature to identify terms frequently used to describe delirium (Figure 1), we created an algorithm and a chart abstraction form (see Supporting Information, Appendix 1, in the online version of this article).[4] We tested these instruments in a preliminary chart review involving 30 patients. Disagreements were discussed with coauthors and resolved through consensus, resulting in some algorithm changes (eg, excluding a large number of patients who received only 1 dose of haloperidol postoperatively, because we hypothesized that this use could be a prophylactic measure).[5] Two investigators extracted the remaining charts independently. We used descriptive statistics and performed cross‐tabulations on the selected variables.

Figure 1

RESULTS

Of 12,817 geriatric hospitalizations during the study period, 1120 (9%) were treated with antipsychotics. We randomly selected 300 of these for extraction: 54% were male, and 67% were admitted to the medical service (Table 1). The inpatient mortality rate was 10% (30/300). The most frequent indication for AP use was delirium (83%, 249/300). Only 35% of delirious patients received a formal assessment with the Confusion Assessment Method (CAM). The most commonly used atypical antipsychotic was quetiapine (86%); 55% received more than 1 antipsychotic medication during hospitalization, and 48% (143/297) of patients were continued on APs at discharge (excluding 3 patients transferred to other acute care hospitals).

Approximately 45% (134/300) had documented or suspected dementia, and 30% (89/300) were physically restrained during the hospital stay. Consultations with geriatrics were obtained in 40% (120/300) of the cases and with psychiatry in 10% (29/300) of the cases. Neurology is rarely consulted for delirium in our institution; thus, we did not collect data on those referrals. Electrocardiography (ECG) (recommended for patients at high cardiac risk[6]) was performed in 88% (265/300) of patients prior to AP administration and 52% (157/300) after. The corrected QT interval exceeded 500 ms in 15% (41/265) of patients prior to AP administration and 25% (39/157) after. Although few patients (12%) were admitted from nursing facilities, 66% (199/300) were eventually discharged to skilled nursing facilities (SNFs) or rehabilitation facilities; most of these patients (117/199, 59%) received AP treatment, compared to 38% of patients discharged to home (26/68).

DISCUSSION

In a cohort of hospitalized elders, we found that 9% were treated with APs. Most received APs for perceived delirium; in‐hospital ECG monitoring was suboptimal. Half of the patients started on APs remained on them at discharge; those discharged to SNFs were more likely to receive ongoing AP treatment.

Our study is limited by its retrospective, single‐center design, a lack of inter‐rater reliability measurement (although our training process was designed to standardize extraction methods), and the infrequent use of formal CAM assessment. Additionally, we were unable to determine how frequently APs were initiated in the intensive care unit. Any retrospective study is limited by the difficulty of distinguishing delirium from the behavioral and psychiatric symptoms of dementia, but we identified delirium using standard terms described in previous literature.

Our study also has a number of important implications. Because of a reported association between the use of APs and risk of death in the postacute setting,[7] national provider organizations have called for a reduction in AP initiation in hospitalized elders.[2] However, this study indicates that APs continue to be prescribed for delirium, which may be attributed to the lack of behavioral modification options in most hospitals, such as acute care for elders (ACE) units and hospital elder life programs (HELP).[8, 9] Our findings suggest that this problem would be further amplified in hospitals that lack access to geriatrics expertise.

Without alternative behavioral options, patients are at risk for prolonged delirium, which is associated with significant suffering and subsequent risk of further cognitive impairment and death.[10] Although evidence for the efficacy of APs in the treatment of delirium is limited and inconclusive, no better pharmacologic options exist. Hospitals that wish to reduce use of APs should therefore consider investing in environmental interventions (eg, ACE units, HELP), which lower the incidence of delirium and could, in turn, decrease the prescription and continuation of antipsychotics.[8, 9]

The Society of Hospital Medicine's Adult Choosing Wisely measures include not ordering continuous telemetry monitoring outside of the ICU [intensive care unit] without using a protocol that governs continuation.[1] Current guidelines for cardiac monitoring use recommend minimum durations for all adult class I and most class II indications.[2] However, telemetry ordering often fails to include timing or criteria for discontinuation. We determined the impact of a reduction in telemetry order duration within our hospital, hypothesizing this reduction would lead to earlier reassessment of telemetry need and therefore decrease overall utilization.

METHODS

RESULTS

Following the intervention, overall order duration decreased by 33% from 66.68.3 hours to 44.52.3 hours per order (P<0.01), mirroring the reduction in the maximum telemetry order duration from 72 to 48 hours (Table 1). However, an increase in telemetry order frequency after the intervention resulted in no significant change in telemetry duration per episode or the proportion of the hospitalization on telemetry (59.3 vs 56.3 hours per patient, P=0.43; and 66.4% vs 66.2% of hospitalization, P=0.58). Rapid response and code blue events did not differ significantly relative to the intervention (2.8 events per week before and 3.1 events per week after, P=0.63).

DISCUSSION

Overall, telemetry utilization was unchanged in spite of an intervention successfully reducing telemetry order duration. Providers responded to this decreased order duration by increasing renewal orders, leaving the amount of time patients spent on telemetry unchanged.

Little primary evidence underlies the American Heart Association recommendations for duration of telemetry in general ward patients.[2] The existing literature documents the timing in which arrhythmias occur after cardiac surgery or myocardial infarction, and therefore is limited in guiding patient care outside intensive care unit settings.[3, 4] As such, hospitalists and inpatient providers have little data directing additional telemetry decisions for these patients, and none for patients requiring telemetry for other indications.

As interventions focusing solely on telemetry duration may not lead to changes in usage patterns, reducing telemetry utilization may require active stewardship. For example, explicit justification may be needed for renewal of telemetry orders. Similarly, education on appropriate telemetry indications in tandem with electronic ordering changes may be more likely to change behavior. Alternatively, incorporating data identifying chest pain patients at very low risk of developing arrhythmias or cardiac complications, based on published risk scores at the time of ordering, may lead to better decision making in initiating telemetry.[5, 6]

This QI project had several limitations. First, the intervention occurred in a facility with a previous telemetry order duration limit. In hospitals without a current duration limitation, some reduction in overall telemetry utilization may be possible. Second, this project was a nonrandom before/after study and potentially subject to bias due to confounding. However, our limited number of telemetry resources, the relatively low number of inpatient teams at our facility, and the inability to target geographic locations for team admissions would have made a cluster‐randomized trial impractical. Third, rationales for telemetry ordering were unknown, as well as drivers for increased orders after the intervention. Better understanding these factors could lead to targeted interventions in some settings.

CONCLUSION

In conclusion, a QI initiative reducing telemetry order duration did not reduce overall telemetry utilization but increased the number of telemetry orders written. Interventions incorporating appropriate telemetry indications or event risks may be required to change ordering behaviors.

Disclosure: Nothing to report.

The Society of Hospital Medicine's Adult Choosing Wisely measures include not ordering continuous telemetry monitoring outside of the ICU [intensive care unit] without using a protocol that governs continuation.[1] Current guidelines for cardiac monitoring use recommend minimum durations for all adult class I and most class II indications.[2] However, telemetry ordering often fails to include timing or criteria for discontinuation. We determined the impact of a reduction in telemetry order duration within our hospital, hypothesizing this reduction would lead to earlier reassessment of telemetry need and therefore decrease overall utilization.

METHODS

RESULTS

Following the intervention, overall order duration decreased by 33% from 66.68.3 hours to 44.52.3 hours per order (P<0.01), mirroring the reduction in the maximum telemetry order duration from 72 to 48 hours (Table 1). However, an increase in telemetry order frequency after the intervention resulted in no significant change in telemetry duration per episode or the proportion of the hospitalization on telemetry (59.3 vs 56.3 hours per patient, P=0.43; and 66.4% vs 66.2% of hospitalization, P=0.58). Rapid response and code blue events did not differ significantly relative to the intervention (2.8 events per week before and 3.1 events per week after, P=0.63).

DISCUSSION

Overall, telemetry utilization was unchanged in spite of an intervention successfully reducing telemetry order duration. Providers responded to this decreased order duration by increasing renewal orders, leaving the amount of time patients spent on telemetry unchanged.

Little primary evidence underlies the American Heart Association recommendations for duration of telemetry in general ward patients.[2] The existing literature documents the timing in which arrhythmias occur after cardiac surgery or myocardial infarction, and therefore is limited in guiding patient care outside intensive care unit settings.[3, 4] As such, hospitalists and inpatient providers have little data directing additional telemetry decisions for these patients, and none for patients requiring telemetry for other indications.

As interventions focusing solely on telemetry duration may not lead to changes in usage patterns, reducing telemetry utilization may require active stewardship. For example, explicit justification may be needed for renewal of telemetry orders. Similarly, education on appropriate telemetry indications in tandem with electronic ordering changes may be more likely to change behavior. Alternatively, incorporating data identifying chest pain patients at very low risk of developing arrhythmias or cardiac complications, based on published risk scores at the time of ordering, may lead to better decision making in initiating telemetry.[5, 6]

This QI project had several limitations. First, the intervention occurred in a facility with a previous telemetry order duration limit. In hospitals without a current duration limitation, some reduction in overall telemetry utilization may be possible. Second, this project was a nonrandom before/after study and potentially subject to bias due to confounding. However, our limited number of telemetry resources, the relatively low number of inpatient teams at our facility, and the inability to target geographic locations for team admissions would have made a cluster‐randomized trial impractical. Third, rationales for telemetry ordering were unknown, as well as drivers for increased orders after the intervention. Better understanding these factors could lead to targeted interventions in some settings.

CONCLUSION

In conclusion, a QI initiative reducing telemetry order duration did not reduce overall telemetry utilization but increased the number of telemetry orders written. Interventions incorporating appropriate telemetry indications or event risks may be required to change ordering behaviors.

Disclosure: Nothing to report.

The Society of Hospital Medicine's Adult Choosing Wisely measures include not ordering continuous telemetry monitoring outside of the ICU [intensive care unit] without using a protocol that governs continuation.[1] Current guidelines for cardiac monitoring use recommend minimum durations for all adult class I and most class II indications.[2] However, telemetry ordering often fails to include timing or criteria for discontinuation. We determined the impact of a reduction in telemetry order duration within our hospital, hypothesizing this reduction would lead to earlier reassessment of telemetry need and therefore decrease overall utilization.

METHODS

RESULTS

Following the intervention, overall order duration decreased by 33% from 66.68.3 hours to 44.52.3 hours per order (P<0.01), mirroring the reduction in the maximum telemetry order duration from 72 to 48 hours (Table 1). However, an increase in telemetry order frequency after the intervention resulted in no significant change in telemetry duration per episode or the proportion of the hospitalization on telemetry (59.3 vs 56.3 hours per patient, P=0.43; and 66.4% vs 66.2% of hospitalization, P=0.58). Rapid response and code blue events did not differ significantly relative to the intervention (2.8 events per week before and 3.1 events per week after, P=0.63).

DISCUSSION

Overall, telemetry utilization was unchanged in spite of an intervention successfully reducing telemetry order duration. Providers responded to this decreased order duration by increasing renewal orders, leaving the amount of time patients spent on telemetry unchanged.

Little primary evidence underlies the American Heart Association recommendations for duration of telemetry in general ward patients.[2] The existing literature documents the timing in which arrhythmias occur after cardiac surgery or myocardial infarction, and therefore is limited in guiding patient care outside intensive care unit settings.[3, 4] As such, hospitalists and inpatient providers have little data directing additional telemetry decisions for these patients, and none for patients requiring telemetry for other indications.

As interventions focusing solely on telemetry duration may not lead to changes in usage patterns, reducing telemetry utilization may require active stewardship. For example, explicit justification may be needed for renewal of telemetry orders. Similarly, education on appropriate telemetry indications in tandem with electronic ordering changes may be more likely to change behavior. Alternatively, incorporating data identifying chest pain patients at very low risk of developing arrhythmias or cardiac complications, based on published risk scores at the time of ordering, may lead to better decision making in initiating telemetry.[5, 6]

This QI project had several limitations. First, the intervention occurred in a facility with a previous telemetry order duration limit. In hospitals without a current duration limitation, some reduction in overall telemetry utilization may be possible. Second, this project was a nonrandom before/after study and potentially subject to bias due to confounding. However, our limited number of telemetry resources, the relatively low number of inpatient teams at our facility, and the inability to target geographic locations for team admissions would have made a cluster‐randomized trial impractical. Third, rationales for telemetry ordering were unknown, as well as drivers for increased orders after the intervention. Better understanding these factors could lead to targeted interventions in some settings.

CONCLUSION

In conclusion, a QI initiative reducing telemetry order duration did not reduce overall telemetry utilization but increased the number of telemetry orders written. Interventions incorporating appropriate telemetry indications or event risks may be required to change ordering behaviors.

Disclosure: Nothing to report.

We have traditionally viewed continuity of care with a particular intern as important for high‐quality inpatient care, but this continuity is difficult to achieve. As we move to a model of team rather than individual continuity, information transfers between team members become critical.

When discontinuity between the primary team and a cross‐covering team occurs, this informational continuity is managed through formal handoffs.[1] Accordingly, there has been ample research on handoffs between different teams,[2, 3, 4, 5] but there has been little published literature to date to describe handoffs between members of the same team. Therefore, we set out (1) to learn how interns view intrateam handoffs and (2) to identify intern‐perceived problems with intrateam handoffs.

MATERIALS AND METHODS

This was a cross‐sectional survey study done at a 500‐bed academic medical center affiliated with a large internal medicine residency program. The survey was developed by the study team and reviewed for content and clarity by our chief residents and by 2 nationally known medical educators outside our institution. Study participants were internal medicine interns. Interns in this program rotate through 3 hospitals and do 7 to 8 ward months. The call schedules are different at each site (see Supporting Information, Appendix A, in the online version of this article). Opportunities for intrateam coverage of 1 intern by another include clinics (1/week), days off (1/week), some overnight periods, and occasional educational conferences. When possible, daily attending rounds include the entire team, but due to clinics, conferences, and days off, it is rare that the entire team is present. Bedside rounds are done at the discretion of the attending. The survey (see Supporting Information, Appendix B, in the online version of this article) included questions regarding situations when the respondent was covering his or her cointern's patients (cointern was defined as another intern on the respondent's same inpatient ward team). We also asked about situations when a cointern was covering the respondent's patients. For those questions, we considered answers of >60% to be a majority. We distributed this anonymous survey on 2 dates (January 2012 and March 2012) during regularly scheduled conferences. We mainly report descriptive findings. We also compared the percentage of study participants reporting problems when covering cointerns' patients to the percentage of study participants reporting problems when cointerns covered their (study participants') patients using ², with significance set at P<0.05. This study was designated as exempt by the institutional review board.

RESULTS

Thirty‐four interns completed the survey out of a total of 44 interns present at the conferences (response rate=77%). There were 46 interns in the program, including categorical, medicine‐pediatrics, and preliminary interns. The mean age was 28 (standard deviation 2.8). Two‐thirds of respondents were female, and 65% were categorical.

DISCUSSION

In our program, interns commonly cover for each other. This intrateam coverage frequently occurs without a formal handoff, and interns do not always know key information about their cointern's patients. Interns reported frequent problems with intrateam coverage such as missed lab results, consult recommendations, and changes in the physical exam. These missed items could result in delayed diagnoses and delayed treatment. These problems have been identified in interteam handoffs as well.[6, 7] Even in optimized interteam handoffs, receivers fail to identify the most important piece of information about 60% of the patients,[8] and our results mirror this finding.

The finding that fewer than a quarter of the respondents have ever seen the majority of their cointerns' patients is certainly of concern. This likely arises from several inter‐related factors: reduced hours for housestaff, schedules built to accommodate the reduced hours (eg, overlapping rather than simultaneous shifts), and the choice of some attendings to not take the entire team around to see every patient. In institutions where bedside rounds as a team are the norm, this finding will be less applicable, but others across the country have noticed this trend[9, 10] and have tried to counteract it.[11] This situation has both patient care and educational implications. The main patient care implication is that the other team members may be less able to seamlessly assume care when the primary intern is away or busy. Therefore, intrateam coverage becomes much more like traditional cross‐coverage of another team's patients, during which there is no expectation that the covering person will have ever seen the patients for whom they are assuming care. The main educational implication of not seeing the cointerns' patients is that the interns are seeing only half the patients that they could otherwise see. Learning medicine is experiential, and limiting opportunities for seeing and examining patients is unwise in this era of reduced time spent in the hospital.

Limitations of this study include being conducted in a single program. It will be important for other sites to assess their own practices with respect to intrateam handoffs. Another limitation is that it was a cross‐sectional survey subject to recall bias. We may have obtained more detailed information if we had conducted interviews. We also did not quantify the frequency of missed labs, consult recommendations, and physical examination changes that occurred during intrateam coverage. Finally, we did not independently verify the problems identified by the interns.

Some possible strategies to address this issue include (1) treating intrateam handoffs like interteam handoffs by implementing a formal system, (2) better utilizing senior residents/faculty when interns are covering for each other, (3) using bedside attending rounds to increase the exposure of all team members to the team's patients, (4) block scheduling to avoid absences due to clinics,[12] and (5) better communication and teamwork training to increase team awareness of all patients.[13]

We have traditionally viewed continuity of care with a particular intern as important for high‐quality inpatient care, but this continuity is difficult to achieve. As we move to a model of team rather than individual continuity, information transfers between team members become critical.

When discontinuity between the primary team and a cross‐covering team occurs, this informational continuity is managed through formal handoffs.[1] Accordingly, there has been ample research on handoffs between different teams,[2, 3, 4, 5] but there has been little published literature to date to describe handoffs between members of the same team. Therefore, we set out (1) to learn how interns view intrateam handoffs and (2) to identify intern‐perceived problems with intrateam handoffs.

MATERIALS AND METHODS

This was a cross‐sectional survey study done at a 500‐bed academic medical center affiliated with a large internal medicine residency program. The survey was developed by the study team and reviewed for content and clarity by our chief residents and by 2 nationally known medical educators outside our institution. Study participants were internal medicine interns. Interns in this program rotate through 3 hospitals and do 7 to 8 ward months. The call schedules are different at each site (see Supporting Information, Appendix A, in the online version of this article). Opportunities for intrateam coverage of 1 intern by another include clinics (1/week), days off (1/week), some overnight periods, and occasional educational conferences. When possible, daily attending rounds include the entire team, but due to clinics, conferences, and days off, it is rare that the entire team is present. Bedside rounds are done at the discretion of the attending. The survey (see Supporting Information, Appendix B, in the online version of this article) included questions regarding situations when the respondent was covering his or her cointern's patients (cointern was defined as another intern on the respondent's same inpatient ward team). We also asked about situations when a cointern was covering the respondent's patients. For those questions, we considered answers of >60% to be a majority. We distributed this anonymous survey on 2 dates (January 2012 and March 2012) during regularly scheduled conferences. We mainly report descriptive findings. We also compared the percentage of study participants reporting problems when covering cointerns' patients to the percentage of study participants reporting problems when cointerns covered their (study participants') patients using ², with significance set at P<0.05. This study was designated as exempt by the institutional review board.

RESULTS

Thirty‐four interns completed the survey out of a total of 44 interns present at the conferences (response rate=77%). There were 46 interns in the program, including categorical, medicine‐pediatrics, and preliminary interns. The mean age was 28 (standard deviation 2.8). Two‐thirds of respondents were female, and 65% were categorical.

DISCUSSION

In our program, interns commonly cover for each other. This intrateam coverage frequently occurs without a formal handoff, and interns do not always know key information about their cointern's patients. Interns reported frequent problems with intrateam coverage such as missed lab results, consult recommendations, and changes in the physical exam. These missed items could result in delayed diagnoses and delayed treatment. These problems have been identified in interteam handoffs as well.[6, 7] Even in optimized interteam handoffs, receivers fail to identify the most important piece of information about 60% of the patients,[8] and our results mirror this finding.

The finding that fewer than a quarter of the respondents have ever seen the majority of their cointerns' patients is certainly of concern. This likely arises from several inter‐related factors: reduced hours for housestaff, schedules built to accommodate the reduced hours (eg, overlapping rather than simultaneous shifts), and the choice of some attendings to not take the entire team around to see every patient. In institutions where bedside rounds as a team are the norm, this finding will be less applicable, but others across the country have noticed this trend[9, 10] and have tried to counteract it.[11] This situation has both patient care and educational implications. The main patient care implication is that the other team members may be less able to seamlessly assume care when the primary intern is away or busy. Therefore, intrateam coverage becomes much more like traditional cross‐coverage of another team's patients, during which there is no expectation that the covering person will have ever seen the patients for whom they are assuming care. The main educational implication of not seeing the cointerns' patients is that the interns are seeing only half the patients that they could otherwise see. Learning medicine is experiential, and limiting opportunities for seeing and examining patients is unwise in this era of reduced time spent in the hospital.

Limitations of this study include being conducted in a single program. It will be important for other sites to assess their own practices with respect to intrateam handoffs. Another limitation is that it was a cross‐sectional survey subject to recall bias. We may have obtained more detailed information if we had conducted interviews. We also did not quantify the frequency of missed labs, consult recommendations, and physical examination changes that occurred during intrateam coverage. Finally, we did not independently verify the problems identified by the interns.

Some possible strategies to address this issue include (1) treating intrateam handoffs like interteam handoffs by implementing a formal system, (2) better utilizing senior residents/faculty when interns are covering for each other, (3) using bedside attending rounds to increase the exposure of all team members to the team's patients, (4) block scheduling to avoid absences due to clinics,[12] and (5) better communication and teamwork training to increase team awareness of all patients.[13]

We have traditionally viewed continuity of care with a particular intern as important for high‐quality inpatient care, but this continuity is difficult to achieve. As we move to a model of team rather than individual continuity, information transfers between team members become critical.

When discontinuity between the primary team and a cross‐covering team occurs, this informational continuity is managed through formal handoffs.[1] Accordingly, there has been ample research on handoffs between different teams,[2, 3, 4, 5] but there has been little published literature to date to describe handoffs between members of the same team. Therefore, we set out (1) to learn how interns view intrateam handoffs and (2) to identify intern‐perceived problems with intrateam handoffs.

MATERIALS AND METHODS

This was a cross‐sectional survey study done at a 500‐bed academic medical center affiliated with a large internal medicine residency program. The survey was developed by the study team and reviewed for content and clarity by our chief residents and by 2 nationally known medical educators outside our institution. Study participants were internal medicine interns. Interns in this program rotate through 3 hospitals and do 7 to 8 ward months. The call schedules are different at each site (see Supporting Information, Appendix A, in the online version of this article). Opportunities for intrateam coverage of 1 intern by another include clinics (1/week), days off (1/week), some overnight periods, and occasional educational conferences. When possible, daily attending rounds include the entire team, but due to clinics, conferences, and days off, it is rare that the entire team is present. Bedside rounds are done at the discretion of the attending. The survey (see Supporting Information, Appendix B, in the online version of this article) included questions regarding situations when the respondent was covering his or her cointern's patients (cointern was defined as another intern on the respondent's same inpatient ward team). We also asked about situations when a cointern was covering the respondent's patients. For those questions, we considered answers of >60% to be a majority. We distributed this anonymous survey on 2 dates (January 2012 and March 2012) during regularly scheduled conferences. We mainly report descriptive findings. We also compared the percentage of study participants reporting problems when covering cointerns' patients to the percentage of study participants reporting problems when cointerns covered their (study participants') patients using ², with significance set at P<0.05. This study was designated as exempt by the institutional review board.

RESULTS

Thirty‐four interns completed the survey out of a total of 44 interns present at the conferences (response rate=77%). There were 46 interns in the program, including categorical, medicine‐pediatrics, and preliminary interns. The mean age was 28 (standard deviation 2.8). Two‐thirds of respondents were female, and 65% were categorical.

DISCUSSION

In our program, interns commonly cover for each other. This intrateam coverage frequently occurs without a formal handoff, and interns do not always know key information about their cointern's patients. Interns reported frequent problems with intrateam coverage such as missed lab results, consult recommendations, and changes in the physical exam. These missed items could result in delayed diagnoses and delayed treatment. These problems have been identified in interteam handoffs as well.[6, 7] Even in optimized interteam handoffs, receivers fail to identify the most important piece of information about 60% of the patients,[8] and our results mirror this finding.

The finding that fewer than a quarter of the respondents have ever seen the majority of their cointerns' patients is certainly of concern. This likely arises from several inter‐related factors: reduced hours for housestaff, schedules built to accommodate the reduced hours (eg, overlapping rather than simultaneous shifts), and the choice of some attendings to not take the entire team around to see every patient. In institutions where bedside rounds as a team are the norm, this finding will be less applicable, but others across the country have noticed this trend[9, 10] and have tried to counteract it.[11] This situation has both patient care and educational implications. The main patient care implication is that the other team members may be less able to seamlessly assume care when the primary intern is away or busy. Therefore, intrateam coverage becomes much more like traditional cross‐coverage of another team's patients, during which there is no expectation that the covering person will have ever seen the patients for whom they are assuming care. The main educational implication of not seeing the cointerns' patients is that the interns are seeing only half the patients that they could otherwise see. Learning medicine is experiential, and limiting opportunities for seeing and examining patients is unwise in this era of reduced time spent in the hospital.

Limitations of this study include being conducted in a single program. It will be important for other sites to assess their own practices with respect to intrateam handoffs. Another limitation is that it was a cross‐sectional survey subject to recall bias. We may have obtained more detailed information if we had conducted interviews. We also did not quantify the frequency of missed labs, consult recommendations, and physical examination changes that occurred during intrateam coverage. Finally, we did not independently verify the problems identified by the interns.

Some possible strategies to address this issue include (1) treating intrateam handoffs like interteam handoffs by implementing a formal system, (2) better utilizing senior residents/faculty when interns are covering for each other, (3) using bedside attending rounds to increase the exposure of all team members to the team's patients, (4) block scheduling to avoid absences due to clinics,[12] and (5) better communication and teamwork training to increase team awareness of all patients.[13]

Proton pump inhibitors (PPIs) are commonly used to treat acid‐related disorders but are associated with an increased risk of pneumonia and Clostridium difficile‐associated diarrhea.[1, 2] Initiation of PPIs in hospitalized patients should therefore be limited to specific clinical situations, such as upper gastrointestinal bleeding or stress ulcer prophylaxis in the critically ill.[3] Prior studies suggest significant overuse of PPIs in hospitalized patients exists,[4, 5, 6, 7] but these were published before the widespread implementation of local and national quality improvement efforts targeted at reducing PPI use in medical inpatients (eg, Society of Hospital Medicine's Choosing Wisely list[8]). We aimed to determine the frequency of inappropriate use of PPIs in a contemporary cohort of hospitalized patients in a tertiary care academic medical center.

METHODS

We conducted a retrospective cohort study of 297 patients admitted to a tertiary care center hospitalist service comprised of teaching and nonteaching medical patients who were not critically ill, were admitted between January 1, 2012 and March 31, 2012, and received a PPI during their hospital stay. Three internists used American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy and prior studies to develop criteria to identify appropriate and inappropriate PPI use (Table 1).[4, 5, 6, 7] Appropriate indications included gastrointestinal (GI) bleeding, esophagitis, gastritis, gastroesophageal reflux (GERD), and continuation of home PPI (abrupt discontinuation can trigger reflux symptoms).[9] We extracted the medical records of included patients, applying our prespecified criteria to determine whether use was appropriate. In patients in whom PPI was a continued home medication, we also extracted 2 years of data prior to the index date to determine if the medication was started during a prior hospital admission and, if so, whether this initiation was appropriate. We used descriptive statistics and [2] tests to compare patient characteristics and indications for PPI use.

RESULTS

Of 297 patients, the mean age was 64.4 years (standard deviation 16.3 years), most were white (69%), and 56% were women (Table 2). PPI use was appropriate in 231 (78%, 95% confidence interval: 72.6%‐82.4%) patients. Of these, a majority (172, 75%) of patients received a PPI because it was a continued home medication. Only 40 of the 172 patients had the medication started during a recent hospitalization, and in half of those cases (20) the PPI use was appropriate.

The second most common appropriate diagnosis was GERD (31%), followed by history of GI bleeding (19%) and treatment for esophagitis or gastritis (18%). Among the 66 patients receiving a PPI inappropriately, the majority of patients (56%) had no documented reason for PPI use, and only 11 patients (17%) were receiving PPI for stress ulcer prophylaxis (Figure 1). Five patients (8%) were treated prophylactically because of steroid or anticoagulant use. We observed no differences in age, gender, race, or reason for admission between the patients treated appropriately versus inappropriately.

Figure 1

DISCUSSION

In a contemporary cohort, chronic PPI use prior to admission was the most common reason PPIs were prescribed in the hospital. About 20% of hospitalized patients were started on a PPI for an inappropriate indication, the majority of whom lacked documentation concerning the reason for use. Among patients treated inappropriately, 36% were discharged on acid‐suppressive therapy.

The prior literature has reported a much higher percentages of unnecessary PPI use in hospitalized patients.[4, 5, 6, 7] Gupta et al. found that 70% of patients admitted to an internal medicine service received acid‐suppressive therapy, 73% of whom were treated unnecessarily.[5] Similarly, Nardino et al. found that 65% of acid‐suppressive therapy in hospitalized medical patients was not indicated.[4] If we had excluded patients on home PPIs from our study cohort, we would have found a higher rate of inappropriate use due to a smaller overall patient population. However, we chose to include these patients because they represented the vast majority of hospitalist‐prescribed PPIs. Notably, most of these prior prescriptions were not written during a recent hospital stay, indicating that the majority were initiated by outpatient physicians.

Our study is limited by its small sample size, single‐center design, and inability to determine the indications for outpatient PPI use. Still, it has important implications. Prior work has suggested that focusing efforts on PPI overuse may be premature in the absence of valid risk‐prediction models defining the patient populations that most benefit from PPI therapy.[10] Our work additionally suggests that hospital rates of inappropriate initiation may be relatively low, perhaps because hospitalist culture and practice have been affected by both local and national quality improvement efforts and by evidence dissemination.[8] Quality improvement efforts focused on reducing inpatient PPI use are likely to reveal diminishing returns, as admitting hospitalists are unlikely to abruptly discontinue PPIs prescribed in the outpatient setting.[9] Hospitalists should be encouraged to assess and document the need for PPIs during admission, hospitalization, and discharge processes. However, future efforts to reduce PPI overuse among hospitalized patients should predominately be focused on reducing inappropriate chronic PPI use in the outpatient setting.

Proton pump inhibitors (PPIs) are commonly used to treat acid‐related disorders but are associated with an increased risk of pneumonia and Clostridium difficile‐associated diarrhea.[1, 2] Initiation of PPIs in hospitalized patients should therefore be limited to specific clinical situations, such as upper gastrointestinal bleeding or stress ulcer prophylaxis in the critically ill.[3] Prior studies suggest significant overuse of PPIs in hospitalized patients exists,[4, 5, 6, 7] but these were published before the widespread implementation of local and national quality improvement efforts targeted at reducing PPI use in medical inpatients (eg, Society of Hospital Medicine's Choosing Wisely list[8]). We aimed to determine the frequency of inappropriate use of PPIs in a contemporary cohort of hospitalized patients in a tertiary care academic medical center.

METHODS

We conducted a retrospective cohort study of 297 patients admitted to a tertiary care center hospitalist service comprised of teaching and nonteaching medical patients who were not critically ill, were admitted between January 1, 2012 and March 31, 2012, and received a PPI during their hospital stay. Three internists used American College of Gastroenterology and the American Society for Gastrointestinal Endoscopy and prior studies to develop criteria to identify appropriate and inappropriate PPI use (Table 1).[4, 5, 6, 7] Appropriate indications included gastrointestinal (GI) bleeding, esophagitis, gastritis, gastroesophageal reflux (GERD), and continuation of home PPI (abrupt discontinuation can trigger reflux symptoms).[9] We extracted the medical records of included patients, applying our prespecified criteria to determine whether use was appropriate. In patients in whom PPI was a continued home medication, we also extracted 2 years of data prior to the index date to determine if the medication was started during a prior hospital admission and, if so, whether this initiation was appropriate. We used descriptive statistics and [2] tests to compare patient characteristics and indications for PPI use.

RESULTS

Of 297 patients, the mean age was 64.4 years (standard deviation 16.3 years), most were white (69%), and 56% were women (Table 2). PPI use was appropriate in 231 (78%, 95% confidence interval: 72.6%‐82.4%) patients. Of these, a majority (172, 75%) of patients received a PPI because it was a continued home medication. Only 40 of the 172 patients had the medication started during a recent hospitalization, and in half of those cases (20) the PPI use was appropriate.