Transforming Healthcare

Medical emergency teams (METs) were introduced more than a decade ago in Australia and the United Kingdom to rapidly identify and manage seriously ill patients at risk of cardiopulmonary arrest and other high‐risk conditions.1 METs, known in the United States as rapid response teams (RRTs), have been slow to be adopted thus far but are quickly gaining ground. Despite numerous studies indicating long‐term patient outcomes are poor following cardiac resuscitation in the hospital, the benefits of early intervention have sometimes been overlooked.25 Several observational studies and a retrospective analysis that included the Medical Emergency Response Improvement Team (MERIT) in Pittsburgh showed that introduction of a MET apparently has the potential to decrease the incidence of unanticipated intensive care unit (ICU) admissions and in‐hospital morbidity and mortality from unexpected cardiopulmonary arrest.69 Furthermore, the use of a MET as a quality improvement tool to detect medical errors and effect systemwide interventions is promising.10 Most recently, the Institute for Healthcare Improvement (IHI) and the American Hospital Association challenged health care organizations to redesign patient safety systems to prevent avoidable deaths in its 100K Lives Campaign. One of the 6 proposed core interventions was the deployment of rapid response teams at the first sign of patient decline.11

Despite these reports of success, a recent large cluster‐randomized controlled trial did not yield the same positive results. In this well‐designed study of 23 Australian hospitals, the Medical Early Response, Intervention and Therapy (MERIT) study investigators found the incidence of cardiac arrest, unplanned ICU admissions, and unexpected death essentially unchanged despite large increases in how often the emergency team was called.12 One possible explanation why these findings conflicted with previous favorable results is that the ultimate impact of a MET may depend on the effectiveness of implementation strategies. To derive the benefits of a MET/RRT, hospitals must increasingly focus on identifying barriers to implementation and address practical issues that may undermine their long‐term effectiveness.

In this article we describe in detail the process of establishing an RRT at our urban, academic hospital and the modifications that became necessary as we rolled out the intervention and encountered obstacles. This analysis was undertaken as a quality improvement (QI) activity. To our knowledge, this is one of the few recent published descriptions of the experiences of implementing an RRT in the United States since earlier work in Pittsburgh.9, 13

METHODS

Temple University Hospital is a tertiary care academic hospital in urban Philadelphia, Pennsylvania. Our RRT was first implemented July 1, 2004, and in the first 12 months of initiation, it was activated 307 times. The RRT at Temple University Hospital was designed to be accessible 24 hours a day, 7 days a week. The daytime team (8 am‐5 pm) is composed of an attending physician (a hospitalist trained as a general internist), a senior internal medicine resident, a critical care nurse, a nurse manager, a pharmacist, and a respiratory therapist. In addition, both a transporter and a member of the admissions office respond to all rapid response team calls but do not get clinically involved in patient care. For nighttime (5 pm‐8 am) and weekend coverage the hospitalist is replaced by an on‐site pulmonary critical care physician, but the remainder of the team is unchanged. All RRT members carry beepers synchronized to provide the location of an RRT activation. In addition, all RRT calls are simultaneously announced on the overhead paging system. No changes were made to the existing cardiac arrest team (code team) at the hospital, which remained a 24‐hour response team for patients found to be in true cardiopulmonary arrest and was comprised of on‐call internal medicine house staff (but no hospitalist attending physician), a respiratory therapist, a pharmacist, a critical care nurse, a nurse manager, and, most notably, an anesthesiologist for emergent intubation and airway management.

The RRT was intended for use within the physical confines of Temple University Hospital and its immediately adjacent grounds. Within the hospital the main locations defined were: inpatient areas, including patient rooms and hallways of the medical‐surgical units of the inpatient tower, as well as the burn, coronary, medical, neurological, neurosurgical, and surgical intensive care units; off‐unit/procedural areas, including diagnostic/emnterventional radiology, the gastroenterology endoscopy suite, the pulmonary procedure suite and pulmonary function lab, the cardiac catheterization/ECHO/stress Lab, the inpatient dialysis unit, and the physical therapy gym, all areas where inpatients are routinely transported during their hospital admission for workup/treatment and where outpatients go for scheduled procedures and therapies; and outpatient/common areas, including all the general medical and subspecialty outpatient clinics in 2 separate outpatient towers (Outpatient Building and Parkinson Pavilion) with direct access from the main hospital building, the outpatient pharmacy, the elevators, the hallways in the outpatient sections of the hospital, all lobbies, and the immediately adjacent outside grounds.

Prior to the launch date of the RRT, clinical criteria were established to help guide staff about when an RRT might be called (Fig. 1). These were based in part on early literature on the clinical markers that most often precede clinical deterioration.14, 15 In addition, 2 much broader categories for RRT activation were added (Inability to reach the patient's primary team of treating physicians for any of the above and Any potentially serious medical errors or adverse events) in order to minimize the need for a very specific physiologic definition to be met in order to activate the team. Physicians, nurses, and other staff with significant daily contact with inpatients and outpatients were in‐serviced about the purpose of the RRT and how to activate the system via the hospital paging operator. Laminated cards with RRT criteria were distributed to all hospital personnel, and educational posters were displayed prominently throughout the hospital.

Figure 1

Each RRT event was to be assessed by team members using a standardized evaluation form (Fig. 2), with primary responsibility going to the physician team leader. In the initial phases of implementation, these forms were kept in the offices of the Section of Hospital Medicine for the use of hospitalist attending physician team leaders. Later on in the year they were kept in the pharmacist's RRT medication bag. These forms were collected at the completion of each RRT event or faxed to a central location and then entered into a database maintained by the hospital's Department of Patient Safety Operations. Weekly debriefing meetings to review all RRT events from the preceding week were attended by representatives from patient safety, respiratory, nursing, hospital medicine, and the pharmacy. Attempts were made to identify the issues that led to selected RRT activations, to obtain patient follow‐up from the clinical event, and to evaluate the performance of the team. Throughout these weekly meetings, QI strategies for improving the effectiveness of the RRT were identified and implemented.

Figure 2

The core outcome measures that were used to assess RRT performance were: appropriateness of the RRT activation, percentage of patients who were stabilized, percentage of patients who were transferred to a higher level of care, and overall team performance.

In the weekly meeting of the RRT evaluation committee, at which each RRT was reviewed by the clinical team, each scenario and details of the event were reviewed to determine whether the RRT activation was appropriate, whether the intervention was successful, and whether there were any issues with the team performance. After a thorough discussion of each case and review of additional data from the chart if necessary, the RRT evaluation committee reached a consensus about each of these measures.

We also tracked the number of code team activations from the year preceding establishment of the RRT (2003‐2004) through the year during which the RRT was established (2004‐2005). Because all calls for both the RRT and the code team go first to the hospital operator, we reviewed the hospital paging operators' logs for the entire 12‐month period to track the rate of code team events to RRT events on a monthly basis.

RESULTS

In a 12‐month period, the RRT was activated 307 times, as recorded in the hospital operator logs. In the year preceding inception of the RRT, there were 272 code team activations. In the first 12 months concurrent with RRT implementation, the code team was activated 258 times. Overall, at their discretion the team leaders converted 13% of the 307 RRT activations to traditional code team activations.

There were 11 RRT activations in July, the first month of implementation, and 14 activations in the second month. At that point, the internal hospital newsletter released a feature on the new RRT, and our patient safety officer/director of patient safety operations made a concerted effort to educate hospital administration and the Graduate Medical Education Committee (GMEC); as a result, utilization picked up. From September onward through the remainder of the academic year, an average of 28 RRT activations occurred each month (range 20‐37), whereas an average of 22 codes took place each month (range 12‐27). The numbers of RRT versus code team activations are plotted in Figure 3. A trend line for the number of code team activations per month in 2003, the year prior to implementation of the RRT, was added for comparison; it conveys the slight overall decrease in the number of codes as the RRT took effect (average of 23 codes per month, range 15‐31).

Figure 3

Physician evaluation forms were returned for 170 of the 307 RRT events (55%). The main inpatient tower was the site of 42% of these RRT activations, followed by the outpatient/common areas, where 19% of the activations occurred, and off‐unit/procedural areas, the site of 18%. Table 2 provides information on specific location, reason for call, and disposition of a sample of the RRT activations in the non‐inpatient areas. Time of day was noted in 76.8% of events. Of these, 82.9% occurred during the traditional day shift (7 am‐7 pm) and 17.1% on night shift (7 pm‐7 am). Most RRT activations occurred between 8 am and 4 pm. Daytime events heavily outnumbered nighttime events regardless of location.

Physician team leaders largely believed a specific underlying clinical diagnosis was responsible for 59% of the RRT activations, followed by adverse drug reactions (3.5%), physician error (1.8%), and nursing error (0.6%). When an underlying clinical diagnosis or organ system was suspected, it was most frequently pulmonary (32%), followed by neurological (14%) and cardiac (11%). It was believed that 32% of events were for other reason not listed. Table 1 provides the breakdown of other underlying diagnoses in RRT events.

In the judgment of evaluators, the system was utilized appropriately in 98% of the evaluated events. Eighty‐five percent of RRT activations were believed to have prevented further clinical deterioration, though it was also thought that 3% of patients deteriorated despite the efforts of the team. Disposition of the patient following an RRT event was noted 87% of the time, and it was believed that 88% of the patients were stabilized. Of the formally evaluated RRT events, team members were largely satisfied with the response and the functioning of the team, stating for 68% of the events that the team performed without a problem.

DISCUSSION

We have found the RRT to be an effective but challenging‐to‐implement QI intervention to increase patient safety at our academic institution. The Australian MERIT investigators recently suggested that despite growing evidence of the benefits of MET/RRT systems, long‐term success may depend most on effective implementation strategies.12 We experienced firsthand these challenges in the first year of our new RRT system.

Large system changes in a hospital are especially fraught with danger because of the unique aspects of health care delivery systems. As Reid commented in an editorial about the emerging use of the MET system in the United Kingdom, Despite potential advantages to patients, ensuring appropriate utilization was difficult because of cultural barriers. Traditional hierarchical behaviors that dictate how doctors and nurses react and work got in the way of people calling these life saving teams.17

Our weekly multidisciplinary RRT debriefings were the most crucial component of our implementation strategy. Many latent systems issues were uncovered, as well as more subtle problems such as lack of coordination of care, communication errors, gaps in patient handoffs or sign‐out. Previous studies by the Pittsburgh MERIT team have validated such retrospective categorization of errors uncovered by MET responses.10

However, neither that group nor the Australian MERIT study investigators specifically addressed the importance of the feedback process in RRT implementation. A strength of our system is that modifications to the RRT are made prospectively and in real time based on feedback from active RRT members during debriefing. In fact, the success of our RRT underscores the importance of open communication among hospitalists, house staff, nurses, pharmacists, and ancillary staff in multidisciplinary patient safety and QI endeavors. Everything from the responsibilities of team members to equipment evolved over the 12‐month period in order to improve the function and effectiveness of the team and was almost entirely based on feedback from the RRT doctors and nurses on the front lines. Suggestions from the evaluation forms were given serious consideration at every RRT evaluation committee debriefing. By optimizing the efficient operation of the RRT, we hope to continue to improve outcomes.

We believe a key to the success of our debriefing process was the constant attendance of our patient safety officer/chief medical officer and director of patient safety operations, who both encouraged active participation. Early on in the process, comments were made principally by physician and critical care nurse RRT members, and the dynamic was a bit one‐sided. However, we quickly saw a noticeable and sustained increase in participation by pharmacists and respiratory therapists, and by year's end, they had offered some of the most valuable practical suggestions, which resulted in a more efficient response. As the year went on and real changes were made quickly, all groups were much more vocal and willing to bounce ideas around the room, and the team dynamic and spirit of the group effort improved substantially.

Previous studies have focused on the impact of METs/RRTs on the rate of inpatient cardiac arrests. However, we found that nearly as many RRT events occurred off the inpatient units, for instance, when admitted patients were transported to other areas such as radiology, procedural suites, physical therapy, or dialysis and when scheduled outpatients arrived for their appointments. In addition, a large number of RRT calls came from outpatient departments and common areas of the hospital such as lobbies, hallways, and waiting rooms, mostly involving outpatients and visitors, but not infrequently hospital employees were involved as well. This unexpected and, to our knowledge, previously unreported finding is mirrored in the distribution of RRT activations throughout the course of the day. Most events occurred during the traditional day shift of 7 am‐7 pm, and were heavily clustered between 8 am and 4 pm. In most American hospitals, these are the hours during which outpatients and visitors make up a significant proportion of the hospital population and during which most elective procedures on inpatients occur. Prior to the introduction of our RRT, no specific system was in place for emergent triage, assessment, and expedited treatment of off‐unit patients, outpatients, and visitors. Most often, the code team was mobilized, sometimes taking them to remote locations and making them unavailable for true inpatient cardiopulmonary arrests. Our RRT seems to have the potential to fill a much‐needed gap in patient safety, offering off‐unit patients, outpatients, and visitors a safety net while in our hospital. No prior descriptions of RRT or MET implementation have touched on this area. It would be interesting to see if other hospitals with RRTs have had a similar experience in order to determine whether having an RRT dedicated specifically to the outpatient and common areas of the hospital might provide even more targeted efforts and efficient response times. Thus, the benefits of our RRT seemed to extend beyond a simple reduction in the number of in‐hospital cardiopulmonary arrests and into an unanticipated patient safety black hole.

Implementation of the RRT specifically in academic medical centers has been limited to date. In our opinion, the academic environment is an ideal area for RRTs (because the most critically ill patients often are cared for on teaching services by junior house officers), but it is also a challenging arena in which to make change (because of the complex hierarchy of teaching hospitals). We chose to have an attending physician lead our RRT efforts for the most part. However, residents always participated, and not infrequently led, as key team members. As a commentator on the Australian RRT system pointed out, it is important that junior medical staff [feel empowered] to call for immediate assistance when they are concerned about their patient, but may not have the experience, knowledge, confidence or skills necessary to manage them appropriately.18 We believe that the RRT serves as a valuable educational forum for resident education. Academic centers that develop RRTs must work to integrate the teams into an educational context while simultaneously providing patients with the most experienced and knowledgeable clinical team to address their needs at a time when appropriate clinical decision making is critical. Therefore, the residents who participate in our RRT are formally evaluated by the hospitalists using a standard program evaluation form that encompasses the Accreditation Council for Graduate Medical Education (ACGME) core competencies.19

Through the first year of our RRT system and beyond, activation of the code team and RRT shifted as more RRT activations were recorded and fewer codes were called. Concerted educational efforts and reinforcement of the criteria for calling the RRT had a definite sustained impact of helping staff to become comfortable with using the system. At our institution, it has been difficult to definitively conclude whether RRT calls prevented codes or merely substituted for them at times, especially because 13% of all RRT activations were subsequently converted to code team calls. The Australian MERIT study investigators, despite an excellent study design of a large multicenter trial, also were unable to demonstrate a true decrease in the cardiac arrest rate.12 Much more significant to us, especially in the first year of implementation, was learning that the vast majority of physician RRT leaders perceived activation of the team to occur appropriately and to play a role in preventing clinical deterioration of patients. None of the other RRT or MET implementation studies that we reviewed commented specifically on these areas. It will be interesting to continue to follow these trends, as we expect the use of RRTs to become even more defined. Over time, we will no doubt be better able to determine whether RRTs have a true, sustained impact on preventing patient deterioration and inpatient cardiopulmonary arrests while maintaining a high rate of physician satisfaction that the team is being activated for legitimate reasons.

Our descriptive study had some limitations. The number of RRT evaluations received, while adequate for preliminary analysis, may not accurately represent the 307 activations of the system that occurred in the first 12 months. We suspect that this underreporting, especially in the first half of the year, was in large part a result of relying on team leaders to voluntarily return data forms at the conclusion of each RRT event. RRT evaluations in the second half of the year were more actively distributed at the point of care to the team leader directly by the pharmacist and were more diligently followed up on. Forms are now readily available in the team pharmacist's fanny pack, which was done because of quality improvement feedback from physicians at a debriefing meeting. Since those interventions, there has been a dramatic improvement in the capture of event data and the timely submission of forms. We expect and have demanded close to a 100% return of the forms in the second year of our RRT system, which will vastly improve our analysis. We were also surprised that despite the comprehensiveness of our RRT activation criteria, 32% of physicians were unable to find a match with a clinical indication on the list, indicating unanticipated reasons for calling an RRT. We will continually strive to improve the specificity of future data for planning purposes and training initiatives. However, in some way this confirms our belief that RRTs occur for such a wide variety of reasons that they cannot always be limited to the major clinical categories. On a similar note, we regret not adding a specific category under Outcomes on the evaluation form to include the possibility that RRT members might have offered palliative care or changes in code/do not resuscitate (DNR) status to patients or families. Given that our hospital has both a code team and an RRT begs the question of whether mortality rates might be affected if patients who prior to the RRT might have had a full resuscitation effort were made DNR. In the future, this would be an interesting issue to consider in analysis. Carefully categorizing RRT events is critical to continued success. Further work involving formal team skills training for RRT members, including use of the medical school's clinical simulators for mock RRT scenarios, is planned. These sessions are planned to review performance and clinical decision making for the most common scenarios that we have found to be involved in RRT activations. The 307 activations of the RRT in our first year have clearly set us on the path toward defining predictive rules and directed skills training for earlier identification of patient problems. Further outcome analyses of these efforts will be crucial.

CONCLUSIONS

An RRT was successfully introduced into an academic medical center. The team was heavily utilized in the first 12 months after the program was initiated, especially for off‐unit inpatients and those in outpatient/common areas, perhaps filling a gap in hospital patient safety. The keys to the early success of implementation of our RRT were multidisciplinary input and improvements made in real time. The long‐term effects of the RRT on the culture of patient safety in our institution and throughout the United States remain to be seen but are promising.

Medical emergency teams (METs) were introduced more than a decade ago in Australia and the United Kingdom to rapidly identify and manage seriously ill patients at risk of cardiopulmonary arrest and other high‐risk conditions.1 METs, known in the United States as rapid response teams (RRTs), have been slow to be adopted thus far but are quickly gaining ground. Despite numerous studies indicating long‐term patient outcomes are poor following cardiac resuscitation in the hospital, the benefits of early intervention have sometimes been overlooked.25 Several observational studies and a retrospective analysis that included the Medical Emergency Response Improvement Team (MERIT) in Pittsburgh showed that introduction of a MET apparently has the potential to decrease the incidence of unanticipated intensive care unit (ICU) admissions and in‐hospital morbidity and mortality from unexpected cardiopulmonary arrest.69 Furthermore, the use of a MET as a quality improvement tool to detect medical errors and effect systemwide interventions is promising.10 Most recently, the Institute for Healthcare Improvement (IHI) and the American Hospital Association challenged health care organizations to redesign patient safety systems to prevent avoidable deaths in its 100K Lives Campaign. One of the 6 proposed core interventions was the deployment of rapid response teams at the first sign of patient decline.11

Despite these reports of success, a recent large cluster‐randomized controlled trial did not yield the same positive results. In this well‐designed study of 23 Australian hospitals, the Medical Early Response, Intervention and Therapy (MERIT) study investigators found the incidence of cardiac arrest, unplanned ICU admissions, and unexpected death essentially unchanged despite large increases in how often the emergency team was called.12 One possible explanation why these findings conflicted with previous favorable results is that the ultimate impact of a MET may depend on the effectiveness of implementation strategies. To derive the benefits of a MET/RRT, hospitals must increasingly focus on identifying barriers to implementation and address practical issues that may undermine their long‐term effectiveness.

In this article we describe in detail the process of establishing an RRT at our urban, academic hospital and the modifications that became necessary as we rolled out the intervention and encountered obstacles. This analysis was undertaken as a quality improvement (QI) activity. To our knowledge, this is one of the few recent published descriptions of the experiences of implementing an RRT in the United States since earlier work in Pittsburgh.9, 13

METHODS

Temple University Hospital is a tertiary care academic hospital in urban Philadelphia, Pennsylvania. Our RRT was first implemented July 1, 2004, and in the first 12 months of initiation, it was activated 307 times. The RRT at Temple University Hospital was designed to be accessible 24 hours a day, 7 days a week. The daytime team (8 am‐5 pm) is composed of an attending physician (a hospitalist trained as a general internist), a senior internal medicine resident, a critical care nurse, a nurse manager, a pharmacist, and a respiratory therapist. In addition, both a transporter and a member of the admissions office respond to all rapid response team calls but do not get clinically involved in patient care. For nighttime (5 pm‐8 am) and weekend coverage the hospitalist is replaced by an on‐site pulmonary critical care physician, but the remainder of the team is unchanged. All RRT members carry beepers synchronized to provide the location of an RRT activation. In addition, all RRT calls are simultaneously announced on the overhead paging system. No changes were made to the existing cardiac arrest team (code team) at the hospital, which remained a 24‐hour response team for patients found to be in true cardiopulmonary arrest and was comprised of on‐call internal medicine house staff (but no hospitalist attending physician), a respiratory therapist, a pharmacist, a critical care nurse, a nurse manager, and, most notably, an anesthesiologist for emergent intubation and airway management.

The RRT was intended for use within the physical confines of Temple University Hospital and its immediately adjacent grounds. Within the hospital the main locations defined were: inpatient areas, including patient rooms and hallways of the medical‐surgical units of the inpatient tower, as well as the burn, coronary, medical, neurological, neurosurgical, and surgical intensive care units; off‐unit/procedural areas, including diagnostic/emnterventional radiology, the gastroenterology endoscopy suite, the pulmonary procedure suite and pulmonary function lab, the cardiac catheterization/ECHO/stress Lab, the inpatient dialysis unit, and the physical therapy gym, all areas where inpatients are routinely transported during their hospital admission for workup/treatment and where outpatients go for scheduled procedures and therapies; and outpatient/common areas, including all the general medical and subspecialty outpatient clinics in 2 separate outpatient towers (Outpatient Building and Parkinson Pavilion) with direct access from the main hospital building, the outpatient pharmacy, the elevators, the hallways in the outpatient sections of the hospital, all lobbies, and the immediately adjacent outside grounds.

Prior to the launch date of the RRT, clinical criteria were established to help guide staff about when an RRT might be called (Fig. 1). These were based in part on early literature on the clinical markers that most often precede clinical deterioration.14, 15 In addition, 2 much broader categories for RRT activation were added (Inability to reach the patient's primary team of treating physicians for any of the above and Any potentially serious medical errors or adverse events) in order to minimize the need for a very specific physiologic definition to be met in order to activate the team. Physicians, nurses, and other staff with significant daily contact with inpatients and outpatients were in‐serviced about the purpose of the RRT and how to activate the system via the hospital paging operator. Laminated cards with RRT criteria were distributed to all hospital personnel, and educational posters were displayed prominently throughout the hospital.

Figure 1

Each RRT event was to be assessed by team members using a standardized evaluation form (Fig. 2), with primary responsibility going to the physician team leader. In the initial phases of implementation, these forms were kept in the offices of the Section of Hospital Medicine for the use of hospitalist attending physician team leaders. Later on in the year they were kept in the pharmacist's RRT medication bag. These forms were collected at the completion of each RRT event or faxed to a central location and then entered into a database maintained by the hospital's Department of Patient Safety Operations. Weekly debriefing meetings to review all RRT events from the preceding week were attended by representatives from patient safety, respiratory, nursing, hospital medicine, and the pharmacy. Attempts were made to identify the issues that led to selected RRT activations, to obtain patient follow‐up from the clinical event, and to evaluate the performance of the team. Throughout these weekly meetings, QI strategies for improving the effectiveness of the RRT were identified and implemented.

Figure 2

The core outcome measures that were used to assess RRT performance were: appropriateness of the RRT activation, percentage of patients who were stabilized, percentage of patients who were transferred to a higher level of care, and overall team performance.

In the weekly meeting of the RRT evaluation committee, at which each RRT was reviewed by the clinical team, each scenario and details of the event were reviewed to determine whether the RRT activation was appropriate, whether the intervention was successful, and whether there were any issues with the team performance. After a thorough discussion of each case and review of additional data from the chart if necessary, the RRT evaluation committee reached a consensus about each of these measures.

We also tracked the number of code team activations from the year preceding establishment of the RRT (2003‐2004) through the year during which the RRT was established (2004‐2005). Because all calls for both the RRT and the code team go first to the hospital operator, we reviewed the hospital paging operators' logs for the entire 12‐month period to track the rate of code team events to RRT events on a monthly basis.

RESULTS

In a 12‐month period, the RRT was activated 307 times, as recorded in the hospital operator logs. In the year preceding inception of the RRT, there were 272 code team activations. In the first 12 months concurrent with RRT implementation, the code team was activated 258 times. Overall, at their discretion the team leaders converted 13% of the 307 RRT activations to traditional code team activations.

There were 11 RRT activations in July, the first month of implementation, and 14 activations in the second month. At that point, the internal hospital newsletter released a feature on the new RRT, and our patient safety officer/director of patient safety operations made a concerted effort to educate hospital administration and the Graduate Medical Education Committee (GMEC); as a result, utilization picked up. From September onward through the remainder of the academic year, an average of 28 RRT activations occurred each month (range 20‐37), whereas an average of 22 codes took place each month (range 12‐27). The numbers of RRT versus code team activations are plotted in Figure 3. A trend line for the number of code team activations per month in 2003, the year prior to implementation of the RRT, was added for comparison; it conveys the slight overall decrease in the number of codes as the RRT took effect (average of 23 codes per month, range 15‐31).

Figure 3

Physician evaluation forms were returned for 170 of the 307 RRT events (55%). The main inpatient tower was the site of 42% of these RRT activations, followed by the outpatient/common areas, where 19% of the activations occurred, and off‐unit/procedural areas, the site of 18%. Table 2 provides information on specific location, reason for call, and disposition of a sample of the RRT activations in the non‐inpatient areas. Time of day was noted in 76.8% of events. Of these, 82.9% occurred during the traditional day shift (7 am‐7 pm) and 17.1% on night shift (7 pm‐7 am). Most RRT activations occurred between 8 am and 4 pm. Daytime events heavily outnumbered nighttime events regardless of location.

Physician team leaders largely believed a specific underlying clinical diagnosis was responsible for 59% of the RRT activations, followed by adverse drug reactions (3.5%), physician error (1.8%), and nursing error (0.6%). When an underlying clinical diagnosis or organ system was suspected, it was most frequently pulmonary (32%), followed by neurological (14%) and cardiac (11%). It was believed that 32% of events were for other reason not listed. Table 1 provides the breakdown of other underlying diagnoses in RRT events.

In the judgment of evaluators, the system was utilized appropriately in 98% of the evaluated events. Eighty‐five percent of RRT activations were believed to have prevented further clinical deterioration, though it was also thought that 3% of patients deteriorated despite the efforts of the team. Disposition of the patient following an RRT event was noted 87% of the time, and it was believed that 88% of the patients were stabilized. Of the formally evaluated RRT events, team members were largely satisfied with the response and the functioning of the team, stating for 68% of the events that the team performed without a problem.

DISCUSSION

We have found the RRT to be an effective but challenging‐to‐implement QI intervention to increase patient safety at our academic institution. The Australian MERIT investigators recently suggested that despite growing evidence of the benefits of MET/RRT systems, long‐term success may depend most on effective implementation strategies.12 We experienced firsthand these challenges in the first year of our new RRT system.

Large system changes in a hospital are especially fraught with danger because of the unique aspects of health care delivery systems. As Reid commented in an editorial about the emerging use of the MET system in the United Kingdom, Despite potential advantages to patients, ensuring appropriate utilization was difficult because of cultural barriers. Traditional hierarchical behaviors that dictate how doctors and nurses react and work got in the way of people calling these life saving teams.17

Our weekly multidisciplinary RRT debriefings were the most crucial component of our implementation strategy. Many latent systems issues were uncovered, as well as more subtle problems such as lack of coordination of care, communication errors, gaps in patient handoffs or sign‐out. Previous studies by the Pittsburgh MERIT team have validated such retrospective categorization of errors uncovered by MET responses.10

However, neither that group nor the Australian MERIT study investigators specifically addressed the importance of the feedback process in RRT implementation. A strength of our system is that modifications to the RRT are made prospectively and in real time based on feedback from active RRT members during debriefing. In fact, the success of our RRT underscores the importance of open communication among hospitalists, house staff, nurses, pharmacists, and ancillary staff in multidisciplinary patient safety and QI endeavors. Everything from the responsibilities of team members to equipment evolved over the 12‐month period in order to improve the function and effectiveness of the team and was almost entirely based on feedback from the RRT doctors and nurses on the front lines. Suggestions from the evaluation forms were given serious consideration at every RRT evaluation committee debriefing. By optimizing the efficient operation of the RRT, we hope to continue to improve outcomes.

We believe a key to the success of our debriefing process was the constant attendance of our patient safety officer/chief medical officer and director of patient safety operations, who both encouraged active participation. Early on in the process, comments were made principally by physician and critical care nurse RRT members, and the dynamic was a bit one‐sided. However, we quickly saw a noticeable and sustained increase in participation by pharmacists and respiratory therapists, and by year's end, they had offered some of the most valuable practical suggestions, which resulted in a more efficient response. As the year went on and real changes were made quickly, all groups were much more vocal and willing to bounce ideas around the room, and the team dynamic and spirit of the group effort improved substantially.

Previous studies have focused on the impact of METs/RRTs on the rate of inpatient cardiac arrests. However, we found that nearly as many RRT events occurred off the inpatient units, for instance, when admitted patients were transported to other areas such as radiology, procedural suites, physical therapy, or dialysis and when scheduled outpatients arrived for their appointments. In addition, a large number of RRT calls came from outpatient departments and common areas of the hospital such as lobbies, hallways, and waiting rooms, mostly involving outpatients and visitors, but not infrequently hospital employees were involved as well. This unexpected and, to our knowledge, previously unreported finding is mirrored in the distribution of RRT activations throughout the course of the day. Most events occurred during the traditional day shift of 7 am‐7 pm, and were heavily clustered between 8 am and 4 pm. In most American hospitals, these are the hours during which outpatients and visitors make up a significant proportion of the hospital population and during which most elective procedures on inpatients occur. Prior to the introduction of our RRT, no specific system was in place for emergent triage, assessment, and expedited treatment of off‐unit patients, outpatients, and visitors. Most often, the code team was mobilized, sometimes taking them to remote locations and making them unavailable for true inpatient cardiopulmonary arrests. Our RRT seems to have the potential to fill a much‐needed gap in patient safety, offering off‐unit patients, outpatients, and visitors a safety net while in our hospital. No prior descriptions of RRT or MET implementation have touched on this area. It would be interesting to see if other hospitals with RRTs have had a similar experience in order to determine whether having an RRT dedicated specifically to the outpatient and common areas of the hospital might provide even more targeted efforts and efficient response times. Thus, the benefits of our RRT seemed to extend beyond a simple reduction in the number of in‐hospital cardiopulmonary arrests and into an unanticipated patient safety black hole.

Implementation of the RRT specifically in academic medical centers has been limited to date. In our opinion, the academic environment is an ideal area for RRTs (because the most critically ill patients often are cared for on teaching services by junior house officers), but it is also a challenging arena in which to make change (because of the complex hierarchy of teaching hospitals). We chose to have an attending physician lead our RRT efforts for the most part. However, residents always participated, and not infrequently led, as key team members. As a commentator on the Australian RRT system pointed out, it is important that junior medical staff [feel empowered] to call for immediate assistance when they are concerned about their patient, but may not have the experience, knowledge, confidence or skills necessary to manage them appropriately.18 We believe that the RRT serves as a valuable educational forum for resident education. Academic centers that develop RRTs must work to integrate the teams into an educational context while simultaneously providing patients with the most experienced and knowledgeable clinical team to address their needs at a time when appropriate clinical decision making is critical. Therefore, the residents who participate in our RRT are formally evaluated by the hospitalists using a standard program evaluation form that encompasses the Accreditation Council for Graduate Medical Education (ACGME) core competencies.19

Through the first year of our RRT system and beyond, activation of the code team and RRT shifted as more RRT activations were recorded and fewer codes were called. Concerted educational efforts and reinforcement of the criteria for calling the RRT had a definite sustained impact of helping staff to become comfortable with using the system. At our institution, it has been difficult to definitively conclude whether RRT calls prevented codes or merely substituted for them at times, especially because 13% of all RRT activations were subsequently converted to code team calls. The Australian MERIT study investigators, despite an excellent study design of a large multicenter trial, also were unable to demonstrate a true decrease in the cardiac arrest rate.12 Much more significant to us, especially in the first year of implementation, was learning that the vast majority of physician RRT leaders perceived activation of the team to occur appropriately and to play a role in preventing clinical deterioration of patients. None of the other RRT or MET implementation studies that we reviewed commented specifically on these areas. It will be interesting to continue to follow these trends, as we expect the use of RRTs to become even more defined. Over time, we will no doubt be better able to determine whether RRTs have a true, sustained impact on preventing patient deterioration and inpatient cardiopulmonary arrests while maintaining a high rate of physician satisfaction that the team is being activated for legitimate reasons.

Our descriptive study had some limitations. The number of RRT evaluations received, while adequate for preliminary analysis, may not accurately represent the 307 activations of the system that occurred in the first 12 months. We suspect that this underreporting, especially in the first half of the year, was in large part a result of relying on team leaders to voluntarily return data forms at the conclusion of each RRT event. RRT evaluations in the second half of the year were more actively distributed at the point of care to the team leader directly by the pharmacist and were more diligently followed up on. Forms are now readily available in the team pharmacist's fanny pack, which was done because of quality improvement feedback from physicians at a debriefing meeting. Since those interventions, there has been a dramatic improvement in the capture of event data and the timely submission of forms. We expect and have demanded close to a 100% return of the forms in the second year of our RRT system, which will vastly improve our analysis. We were also surprised that despite the comprehensiveness of our RRT activation criteria, 32% of physicians were unable to find a match with a clinical indication on the list, indicating unanticipated reasons for calling an RRT. We will continually strive to improve the specificity of future data for planning purposes and training initiatives. However, in some way this confirms our belief that RRTs occur for such a wide variety of reasons that they cannot always be limited to the major clinical categories. On a similar note, we regret not adding a specific category under Outcomes on the evaluation form to include the possibility that RRT members might have offered palliative care or changes in code/do not resuscitate (DNR) status to patients or families. Given that our hospital has both a code team and an RRT begs the question of whether mortality rates might be affected if patients who prior to the RRT might have had a full resuscitation effort were made DNR. In the future, this would be an interesting issue to consider in analysis. Carefully categorizing RRT events is critical to continued success. Further work involving formal team skills training for RRT members, including use of the medical school's clinical simulators for mock RRT scenarios, is planned. These sessions are planned to review performance and clinical decision making for the most common scenarios that we have found to be involved in RRT activations. The 307 activations of the RRT in our first year have clearly set us on the path toward defining predictive rules and directed skills training for earlier identification of patient problems. Further outcome analyses of these efforts will be crucial.

CONCLUSIONS

An RRT was successfully introduced into an academic medical center. The team was heavily utilized in the first 12 months after the program was initiated, especially for off‐unit inpatients and those in outpatient/common areas, perhaps filling a gap in hospital patient safety. The keys to the early success of implementation of our RRT were multidisciplinary input and improvements made in real time. The long‐term effects of the RRT on the culture of patient safety in our institution and throughout the United States remain to be seen but are promising.

Medical emergency teams (METs) were introduced more than a decade ago in Australia and the United Kingdom to rapidly identify and manage seriously ill patients at risk of cardiopulmonary arrest and other high‐risk conditions.1 METs, known in the United States as rapid response teams (RRTs), have been slow to be adopted thus far but are quickly gaining ground. Despite numerous studies indicating long‐term patient outcomes are poor following cardiac resuscitation in the hospital, the benefits of early intervention have sometimes been overlooked.25 Several observational studies and a retrospective analysis that included the Medical Emergency Response Improvement Team (MERIT) in Pittsburgh showed that introduction of a MET apparently has the potential to decrease the incidence of unanticipated intensive care unit (ICU) admissions and in‐hospital morbidity and mortality from unexpected cardiopulmonary arrest.69 Furthermore, the use of a MET as a quality improvement tool to detect medical errors and effect systemwide interventions is promising.10 Most recently, the Institute for Healthcare Improvement (IHI) and the American Hospital Association challenged health care organizations to redesign patient safety systems to prevent avoidable deaths in its 100K Lives Campaign. One of the 6 proposed core interventions was the deployment of rapid response teams at the first sign of patient decline.11

Despite these reports of success, a recent large cluster‐randomized controlled trial did not yield the same positive results. In this well‐designed study of 23 Australian hospitals, the Medical Early Response, Intervention and Therapy (MERIT) study investigators found the incidence of cardiac arrest, unplanned ICU admissions, and unexpected death essentially unchanged despite large increases in how often the emergency team was called.12 One possible explanation why these findings conflicted with previous favorable results is that the ultimate impact of a MET may depend on the effectiveness of implementation strategies. To derive the benefits of a MET/RRT, hospitals must increasingly focus on identifying barriers to implementation and address practical issues that may undermine their long‐term effectiveness.

In this article we describe in detail the process of establishing an RRT at our urban, academic hospital and the modifications that became necessary as we rolled out the intervention and encountered obstacles. This analysis was undertaken as a quality improvement (QI) activity. To our knowledge, this is one of the few recent published descriptions of the experiences of implementing an RRT in the United States since earlier work in Pittsburgh.9, 13

METHODS

Temple University Hospital is a tertiary care academic hospital in urban Philadelphia, Pennsylvania. Our RRT was first implemented July 1, 2004, and in the first 12 months of initiation, it was activated 307 times. The RRT at Temple University Hospital was designed to be accessible 24 hours a day, 7 days a week. The daytime team (8 am‐5 pm) is composed of an attending physician (a hospitalist trained as a general internist), a senior internal medicine resident, a critical care nurse, a nurse manager, a pharmacist, and a respiratory therapist. In addition, both a transporter and a member of the admissions office respond to all rapid response team calls but do not get clinically involved in patient care. For nighttime (5 pm‐8 am) and weekend coverage the hospitalist is replaced by an on‐site pulmonary critical care physician, but the remainder of the team is unchanged. All RRT members carry beepers synchronized to provide the location of an RRT activation. In addition, all RRT calls are simultaneously announced on the overhead paging system. No changes were made to the existing cardiac arrest team (code team) at the hospital, which remained a 24‐hour response team for patients found to be in true cardiopulmonary arrest and was comprised of on‐call internal medicine house staff (but no hospitalist attending physician), a respiratory therapist, a pharmacist, a critical care nurse, a nurse manager, and, most notably, an anesthesiologist for emergent intubation and airway management.

The RRT was intended for use within the physical confines of Temple University Hospital and its immediately adjacent grounds. Within the hospital the main locations defined were: inpatient areas, including patient rooms and hallways of the medical‐surgical units of the inpatient tower, as well as the burn, coronary, medical, neurological, neurosurgical, and surgical intensive care units; off‐unit/procedural areas, including diagnostic/emnterventional radiology, the gastroenterology endoscopy suite, the pulmonary procedure suite and pulmonary function lab, the cardiac catheterization/ECHO/stress Lab, the inpatient dialysis unit, and the physical therapy gym, all areas where inpatients are routinely transported during their hospital admission for workup/treatment and where outpatients go for scheduled procedures and therapies; and outpatient/common areas, including all the general medical and subspecialty outpatient clinics in 2 separate outpatient towers (Outpatient Building and Parkinson Pavilion) with direct access from the main hospital building, the outpatient pharmacy, the elevators, the hallways in the outpatient sections of the hospital, all lobbies, and the immediately adjacent outside grounds.

Prior to the launch date of the RRT, clinical criteria were established to help guide staff about when an RRT might be called (Fig. 1). These were based in part on early literature on the clinical markers that most often precede clinical deterioration.14, 15 In addition, 2 much broader categories for RRT activation were added (Inability to reach the patient's primary team of treating physicians for any of the above and Any potentially serious medical errors or adverse events) in order to minimize the need for a very specific physiologic definition to be met in order to activate the team. Physicians, nurses, and other staff with significant daily contact with inpatients and outpatients were in‐serviced about the purpose of the RRT and how to activate the system via the hospital paging operator. Laminated cards with RRT criteria were distributed to all hospital personnel, and educational posters were displayed prominently throughout the hospital.

Figure 1

Each RRT event was to be assessed by team members using a standardized evaluation form (Fig. 2), with primary responsibility going to the physician team leader. In the initial phases of implementation, these forms were kept in the offices of the Section of Hospital Medicine for the use of hospitalist attending physician team leaders. Later on in the year they were kept in the pharmacist's RRT medication bag. These forms were collected at the completion of each RRT event or faxed to a central location and then entered into a database maintained by the hospital's Department of Patient Safety Operations. Weekly debriefing meetings to review all RRT events from the preceding week were attended by representatives from patient safety, respiratory, nursing, hospital medicine, and the pharmacy. Attempts were made to identify the issues that led to selected RRT activations, to obtain patient follow‐up from the clinical event, and to evaluate the performance of the team. Throughout these weekly meetings, QI strategies for improving the effectiveness of the RRT were identified and implemented.

Figure 2

The core outcome measures that were used to assess RRT performance were: appropriateness of the RRT activation, percentage of patients who were stabilized, percentage of patients who were transferred to a higher level of care, and overall team performance.

In the weekly meeting of the RRT evaluation committee, at which each RRT was reviewed by the clinical team, each scenario and details of the event were reviewed to determine whether the RRT activation was appropriate, whether the intervention was successful, and whether there were any issues with the team performance. After a thorough discussion of each case and review of additional data from the chart if necessary, the RRT evaluation committee reached a consensus about each of these measures.

We also tracked the number of code team activations from the year preceding establishment of the RRT (2003‐2004) through the year during which the RRT was established (2004‐2005). Because all calls for both the RRT and the code team go first to the hospital operator, we reviewed the hospital paging operators' logs for the entire 12‐month period to track the rate of code team events to RRT events on a monthly basis.

RESULTS

In a 12‐month period, the RRT was activated 307 times, as recorded in the hospital operator logs. In the year preceding inception of the RRT, there were 272 code team activations. In the first 12 months concurrent with RRT implementation, the code team was activated 258 times. Overall, at their discretion the team leaders converted 13% of the 307 RRT activations to traditional code team activations.

There were 11 RRT activations in July, the first month of implementation, and 14 activations in the second month. At that point, the internal hospital newsletter released a feature on the new RRT, and our patient safety officer/director of patient safety operations made a concerted effort to educate hospital administration and the Graduate Medical Education Committee (GMEC); as a result, utilization picked up. From September onward through the remainder of the academic year, an average of 28 RRT activations occurred each month (range 20‐37), whereas an average of 22 codes took place each month (range 12‐27). The numbers of RRT versus code team activations are plotted in Figure 3. A trend line for the number of code team activations per month in 2003, the year prior to implementation of the RRT, was added for comparison; it conveys the slight overall decrease in the number of codes as the RRT took effect (average of 23 codes per month, range 15‐31).

Figure 3

Physician evaluation forms were returned for 170 of the 307 RRT events (55%). The main inpatient tower was the site of 42% of these RRT activations, followed by the outpatient/common areas, where 19% of the activations occurred, and off‐unit/procedural areas, the site of 18%. Table 2 provides information on specific location, reason for call, and disposition of a sample of the RRT activations in the non‐inpatient areas. Time of day was noted in 76.8% of events. Of these, 82.9% occurred during the traditional day shift (7 am‐7 pm) and 17.1% on night shift (7 pm‐7 am). Most RRT activations occurred between 8 am and 4 pm. Daytime events heavily outnumbered nighttime events regardless of location.

Physician team leaders largely believed a specific underlying clinical diagnosis was responsible for 59% of the RRT activations, followed by adverse drug reactions (3.5%), physician error (1.8%), and nursing error (0.6%). When an underlying clinical diagnosis or organ system was suspected, it was most frequently pulmonary (32%), followed by neurological (14%) and cardiac (11%). It was believed that 32% of events were for other reason not listed. Table 1 provides the breakdown of other underlying diagnoses in RRT events.

In the judgment of evaluators, the system was utilized appropriately in 98% of the evaluated events. Eighty‐five percent of RRT activations were believed to have prevented further clinical deterioration, though it was also thought that 3% of patients deteriorated despite the efforts of the team. Disposition of the patient following an RRT event was noted 87% of the time, and it was believed that 88% of the patients were stabilized. Of the formally evaluated RRT events, team members were largely satisfied with the response and the functioning of the team, stating for 68% of the events that the team performed without a problem.

DISCUSSION

We have found the RRT to be an effective but challenging‐to‐implement QI intervention to increase patient safety at our academic institution. The Australian MERIT investigators recently suggested that despite growing evidence of the benefits of MET/RRT systems, long‐term success may depend most on effective implementation strategies.12 We experienced firsthand these challenges in the first year of our new RRT system.

Large system changes in a hospital are especially fraught with danger because of the unique aspects of health care delivery systems. As Reid commented in an editorial about the emerging use of the MET system in the United Kingdom, Despite potential advantages to patients, ensuring appropriate utilization was difficult because of cultural barriers. Traditional hierarchical behaviors that dictate how doctors and nurses react and work got in the way of people calling these life saving teams.17

Our weekly multidisciplinary RRT debriefings were the most crucial component of our implementation strategy. Many latent systems issues were uncovered, as well as more subtle problems such as lack of coordination of care, communication errors, gaps in patient handoffs or sign‐out. Previous studies by the Pittsburgh MERIT team have validated such retrospective categorization of errors uncovered by MET responses.10

However, neither that group nor the Australian MERIT study investigators specifically addressed the importance of the feedback process in RRT implementation. A strength of our system is that modifications to the RRT are made prospectively and in real time based on feedback from active RRT members during debriefing. In fact, the success of our RRT underscores the importance of open communication among hospitalists, house staff, nurses, pharmacists, and ancillary staff in multidisciplinary patient safety and QI endeavors. Everything from the responsibilities of team members to equipment evolved over the 12‐month period in order to improve the function and effectiveness of the team and was almost entirely based on feedback from the RRT doctors and nurses on the front lines. Suggestions from the evaluation forms were given serious consideration at every RRT evaluation committee debriefing. By optimizing the efficient operation of the RRT, we hope to continue to improve outcomes.

We believe a key to the success of our debriefing process was the constant attendance of our patient safety officer/chief medical officer and director of patient safety operations, who both encouraged active participation. Early on in the process, comments were made principally by physician and critical care nurse RRT members, and the dynamic was a bit one‐sided. However, we quickly saw a noticeable and sustained increase in participation by pharmacists and respiratory therapists, and by year's end, they had offered some of the most valuable practical suggestions, which resulted in a more efficient response. As the year went on and real changes were made quickly, all groups were much more vocal and willing to bounce ideas around the room, and the team dynamic and spirit of the group effort improved substantially.

Previous studies have focused on the impact of METs/RRTs on the rate of inpatient cardiac arrests. However, we found that nearly as many RRT events occurred off the inpatient units, for instance, when admitted patients were transported to other areas such as radiology, procedural suites, physical therapy, or dialysis and when scheduled outpatients arrived for their appointments. In addition, a large number of RRT calls came from outpatient departments and common areas of the hospital such as lobbies, hallways, and waiting rooms, mostly involving outpatients and visitors, but not infrequently hospital employees were involved as well. This unexpected and, to our knowledge, previously unreported finding is mirrored in the distribution of RRT activations throughout the course of the day. Most events occurred during the traditional day shift of 7 am‐7 pm, and were heavily clustered between 8 am and 4 pm. In most American hospitals, these are the hours during which outpatients and visitors make up a significant proportion of the hospital population and during which most elective procedures on inpatients occur. Prior to the introduction of our RRT, no specific system was in place for emergent triage, assessment, and expedited treatment of off‐unit patients, outpatients, and visitors. Most often, the code team was mobilized, sometimes taking them to remote locations and making them unavailable for true inpatient cardiopulmonary arrests. Our RRT seems to have the potential to fill a much‐needed gap in patient safety, offering off‐unit patients, outpatients, and visitors a safety net while in our hospital. No prior descriptions of RRT or MET implementation have touched on this area. It would be interesting to see if other hospitals with RRTs have had a similar experience in order to determine whether having an RRT dedicated specifically to the outpatient and common areas of the hospital might provide even more targeted efforts and efficient response times. Thus, the benefits of our RRT seemed to extend beyond a simple reduction in the number of in‐hospital cardiopulmonary arrests and into an unanticipated patient safety black hole.

Implementation of the RRT specifically in academic medical centers has been limited to date. In our opinion, the academic environment is an ideal area for RRTs (because the most critically ill patients often are cared for on teaching services by junior house officers), but it is also a challenging arena in which to make change (because of the complex hierarchy of teaching hospitals). We chose to have an attending physician lead our RRT efforts for the most part. However, residents always participated, and not infrequently led, as key team members. As a commentator on the Australian RRT system pointed out, it is important that junior medical staff [feel empowered] to call for immediate assistance when they are concerned about their patient, but may not have the experience, knowledge, confidence or skills necessary to manage them appropriately.18 We believe that the RRT serves as a valuable educational forum for resident education. Academic centers that develop RRTs must work to integrate the teams into an educational context while simultaneously providing patients with the most experienced and knowledgeable clinical team to address their needs at a time when appropriate clinical decision making is critical. Therefore, the residents who participate in our RRT are formally evaluated by the hospitalists using a standard program evaluation form that encompasses the Accreditation Council for Graduate Medical Education (ACGME) core competencies.19

Through the first year of our RRT system and beyond, activation of the code team and RRT shifted as more RRT activations were recorded and fewer codes were called. Concerted educational efforts and reinforcement of the criteria for calling the RRT had a definite sustained impact of helping staff to become comfortable with using the system. At our institution, it has been difficult to definitively conclude whether RRT calls prevented codes or merely substituted for them at times, especially because 13% of all RRT activations were subsequently converted to code team calls. The Australian MERIT study investigators, despite an excellent study design of a large multicenter trial, also were unable to demonstrate a true decrease in the cardiac arrest rate.12 Much more significant to us, especially in the first year of implementation, was learning that the vast majority of physician RRT leaders perceived activation of the team to occur appropriately and to play a role in preventing clinical deterioration of patients. None of the other RRT or MET implementation studies that we reviewed commented specifically on these areas. It will be interesting to continue to follow these trends, as we expect the use of RRTs to become even more defined. Over time, we will no doubt be better able to determine whether RRTs have a true, sustained impact on preventing patient deterioration and inpatient cardiopulmonary arrests while maintaining a high rate of physician satisfaction that the team is being activated for legitimate reasons.

Our descriptive study had some limitations. The number of RRT evaluations received, while adequate for preliminary analysis, may not accurately represent the 307 activations of the system that occurred in the first 12 months. We suspect that this underreporting, especially in the first half of the year, was in large part a result of relying on team leaders to voluntarily return data forms at the conclusion of each RRT event. RRT evaluations in the second half of the year were more actively distributed at the point of care to the team leader directly by the pharmacist and were more diligently followed up on. Forms are now readily available in the team pharmacist's fanny pack, which was done because of quality improvement feedback from physicians at a debriefing meeting. Since those interventions, there has been a dramatic improvement in the capture of event data and the timely submission of forms. We expect and have demanded close to a 100% return of the forms in the second year of our RRT system, which will vastly improve our analysis. We were also surprised that despite the comprehensiveness of our RRT activation criteria, 32% of physicians were unable to find a match with a clinical indication on the list, indicating unanticipated reasons for calling an RRT. We will continually strive to improve the specificity of future data for planning purposes and training initiatives. However, in some way this confirms our belief that RRTs occur for such a wide variety of reasons that they cannot always be limited to the major clinical categories. On a similar note, we regret not adding a specific category under Outcomes on the evaluation form to include the possibility that RRT members might have offered palliative care or changes in code/do not resuscitate (DNR) status to patients or families. Given that our hospital has both a code team and an RRT begs the question of whether mortality rates might be affected if patients who prior to the RRT might have had a full resuscitation effort were made DNR. In the future, this would be an interesting issue to consider in analysis. Carefully categorizing RRT events is critical to continued success. Further work involving formal team skills training for RRT members, including use of the medical school's clinical simulators for mock RRT scenarios, is planned. These sessions are planned to review performance and clinical decision making for the most common scenarios that we have found to be involved in RRT activations. The 307 activations of the RRT in our first year have clearly set us on the path toward defining predictive rules and directed skills training for earlier identification of patient problems. Further outcome analyses of these efforts will be crucial.

CONCLUSIONS

An RRT was successfully introduced into an academic medical center. The team was heavily utilized in the first 12 months after the program was initiated, especially for off‐unit inpatients and those in outpatient/common areas, perhaps filling a gap in hospital patient safety. The keys to the early success of implementation of our RRT were multidisciplinary input and improvements made in real time. The long‐term effects of the RRT on the culture of patient safety in our institution and throughout the United States remain to be seen but are promising.

Modern‐day continuity of patient care in teaching hospitals, once remarkably high because of a cadre of sleep‐deprived residents, is now peppered with breaks, each accompanied by the transfer of patient care responsibility from one resident to another; a process often referred to as a handoff. Such transitions have long been a part of medical practice but have recently received increased attention because of restrictions in the duty hours of house staff. In July 2003 the Accreditation Council for Graduate Medical Education (ACGME) mandated reduced duty hours for all trainees in hopes of improving resident education and well‐being and patient safety.1 In fact, some studies have shown improved resident well‐being2 and fewer medical errors with reductions in duty hours,3, 4 but the growing consensus about the negative consequences of resident fatigue on patient safety has been accompanied by parallel concerns about the potential for information loss with each break in the continuity of care.5, 6

Although the tradeoff of increased discontinuity of care for fewer hours worked is sometimes characterized as an unintended consequence of duty hour regulations, it is in fact predictable and essential. As individuals work fewer hours, discontinuity must necessarily increase (assuming 24‐hour coverage).7 The extent to which this occurs may vary, but the link is consistent. At the University of California, San Francisco (UCSF), for example, we found that compliance with new duty hour requirements for internal medicine resulted in an average of 15 handoffs per patient during a 5‐day hospitalization. Each individual intern was involved in more than 300 handoffs in an average month‐long rotation, an increase of 40% since system changes were introduced to decrease duty hours. We found similar increases at Brigham and Women's Hospital (BWH) and the University of Chicago. Because U.S. teaching hospitals care for more than 6 million patients each year,8 the impact of these handoffs on the quality and efficiency of care is tremendous.

Discontinuity of care is currently managed by sign‐out, or the transfer of patient information from one physician to another. Recognizing the importance of information transfer at these vulnerable transition times for patients, the Joint Commission on Accreditation of Hospital Organizations (JCAHO) issued the 2006 National Patient Safety Goal 2E: Implement a standardized approach to hand off communications, including an opportunity to ask and respond to questions.9 Hospitals have little data to draw on to determine how to comply with this mandate and even less data to guide them in how to achieve its intended goals of improving communication and thus patient safety.

In an effort to better understand sign‐outs and ways to improve this process for house staff on in‐patient services, we reviewed data from the fields of aviation, communications, systems engineering, and human factors research, and we also searched the medical literature using key words pass‐off, handoff, sign‐out, duty hours, work hours, and discontinuity of care and MeSH headings Continuity of Patient Care Internship and Residency/*organization & administration, Personnel Staffing and Scheduling/*organization & administration, and Quality of Health Care. We also searched the websites of the Agency of Healthcare Quality and Research and the National Patient Safety Foundation. On the basis of these reviews, our experiences as hospitalist medical educators organizing resident sign‐out efforts at the University of California, San Francisco, the University of Chicago, and Brigham and Women's Hospital, and our efforts leading national training sessions on sign‐outs at the Society of General Internal Medicine (2004 and 2005), the Society of Hospital Medicine (2004), and the Association of Program Directors in Internal Medicine (2005, 2006), we propose a set of best practices regarding the content and process of sign‐out in an effort to improve communication between residents caring for hospitalized patients, assist programs in building safe and effective sign‐out systems, and improve the quality of patient care.

Effects of Discontinuity on Patient Safety

Research on the effects of discontinuity of care, although limited, suggests it has a negative impact on patient safety. In a study that investigated the institution of code 405 (the regulation that reduced duty hours in New York State), researchers found that the presumed increase in discontinuity with decreased duty hours resulted in delayed test ordering and an increased number of hospital complications.10 Another study found that the number of potentially preventable adverse events doubled when patients were under the care of a physician from a nonprimary team (eg, the cross‐covering intern).11 Studies have also linked resident discontinuity with longer length of stay, increased laboratory testing, and increased medication errors.12, 13

Managing Discontinuity: Sign‐Out as the Means of Information Transfer

In theory, more effective sign‐out systems should mitigate the potential for patient harm, but there is little in the literature describing current effective sign‐out practices or the best ways to design and implement such systems in the health care field. Examining information transfer mechanisms used in fields outside health care can assist in developing these systems.

The Current Practice of Sign‐Out

In examining sign‐outs at our 3 institutions, we found them to be unstructured and unstandardized. From discussion with faculty participating in national workshops on sign‐out, we found that most sign‐outs are conducted by interns, usually with little or no formal training. Templates, checklists, or other methods to standardize the content of the information transferred were rarely used.

We also noted that the vehicle for written sign‐out is highly variable. At UCSF, different residency training programs used a variety of modalities for written sign‐outs, including index cards, Excel spreadsheets, Word documents, and loose sheets of paper. Recently, the UCSF Department of Medicine designed a simple database (on Filemaker Pro) that allows members of the house staff to update their sign‐out information, share it with other house staff and nurses, and access it at locations throughout the hospital (Fig. 1). Although this database is not yet linked to the hospital information system (planned for 2006), anecdotally resident satisfaction with sign‐out has vastly improved since its implementation. The cost of design and implementation was approximately $10,000. At the University of Chicago, interns used Microsoft Word to create sign‐out sheets containing patient summaries to transfer information. However, during structured interviews, 95% of the interns reported that these sheets were frequently lost or misplaced.7 Although medicine residents at BWH use a computerized system to produce sign‐out sheets, this system did not guarantee complete and structured information. For example, a survey at BWH found that 56% of cross‐covering residents said that when paged about a patient overnight, the relevant information needed to care for that patient was present less than half the time; and 27% of residents reported being paged more than 3 times in the previous 2 weeks about a test result or consultant recommendation that they did not know was pending.36

Figure 1

The process of sign‐out also varied across disciplines and institutions. From our experiences at our sites and at the sites of faculty nationally, we found limited standardization about whether sign‐out was verbal, the data transmitted, and the setting in which it was transmitted. In fact, at UCSF most residents signed out verbally on the fly, wherever and whenever they could find the cross‐coverage intern. At BWH, only 37% of residents said that sign‐out occurred in a quiet place most of the time, and only 52% signed out on every patient both orally and in writing.36 At the University of Chicago, the sign‐out process was characterized by outright failures in communication because of omission of needed information (ie, medications, active or anticipated medical problems, etc.) or by failure‐prone communication (ie, lack of face‐to‐face communication, illegible writing). These failures often led to uncertainty in making patient care decisions, potentially resulting in inefficient or suboptimal care.35

Strategies for Safe and Effective Sign‐Out

Given the current landscape of variability in sign‐outs, the recognition that information lost during sign‐out may result in harm to patients, and evidence of improvements in information transfer in areas outside health care, we aimed to develop mechanisms to improve the sign‐out process for residents working in a hospital setting. These strategies are based on our review of the existing literature supplemented by our experiences at our 3 institutions.

Content of Sign‐Out

The elements of content necessary for safe and effective sign‐out can be divided into 5 broad categories (Table 1), contained in the mnemonic ANTICipate: Administrative information, New clinical information, specific Tasks to be performed, assessment of severity of Illness, and Contingency plans or anticipated problems (Table 1, Fig. 2).

Table 1.Checklist for Elements of a Safe and Effective Written Sign‐outANTICipate

✓ Administrative data
□ Patient name, age, sex
□ Medical record number
□ Room number
□ Admission date
□ Primary inpatient medical team, primary care physician
□ Family contact information
✓ New information (clinical update)
□ Chief complaint, brief HPI, and diagnosis (or differential diagnosis)
□ Updated list of medications with doses, updated allergies
□ Updated, brief assessment by system/problem, with dates
□ Current baseline status (eg, mental status, cardiopulmonary, vital signs, especially if abnormal but stable)
□ Recent procedures and significant events
✓ Tasks (what needs to be done)
□ Specific, using if‐then statements
□ Prepare cross‐coverage (eg, patient consent for blood transfusion)
□ Alert to incoming information (eg, study results, consultant recommendations), and what action, if any, needs to be taken during the cross‐coverage
✓ Illness
□ Is the patient sick?
✓ Contingency planning/Code status
□ What may go wrong and what to do about it
□ What has or has not worked before (eg, responds to 40 mg IV furosemide)
□ Difficult family or psychosocial situations
□ Code status, especially recent changes or family discussions

Figure 2

Several general points about this list should be noted. First, the sign‐out content is not meant to replace the chart. The information included reflects the goal of a sign‐out, namely, to provide enough information to allow for a safe transition in patient care. Information we believe is not essential to the sign‐out includes: a complete history and physical exam from the day of admission, a list of tasks already completed, and data necessary only to complete a discharge summary.

Sign‐out must be also be a closed loopthe process of signing in is as important as the process of signing out. This usually entails members of the primary team obtaining information from the cross‐covering physician when they resume care of the patient. The information conveyed in this case is different and includes details on events during cross‐coverage such as: 1) time called to assess patient; 2) reason for call; 3) a brief assessment of the patient, including vital signs; 4) actions taken, for example, medications given and tests ordered; and 5) rationale for those actions. Some of this information may also be included in the chart as an event note (see Fig. 3).

Figure 3

CONCLUSIONS

Sign‐outs are a part of the current landscape of academic medical centers as well as hospitals at large. Interns, residents, and consulting fellows, not to mention nurses, physical therapists, and nutritionists, transfer patient care information at each transition point. There are few resources that can assist these caregivers in identifying and implementing the most effective ways to transfer patient care information. Hospitals and other care facilities are now mandated to develop standards and systems to improve sign‐out. On the basis of the limited literature to date and our own experiences, we have proposed standards and best practices to assist hospitals, training programs, and institutional leaders in designing safe and usable sign‐out systems. Effective implementation of the standards must include appropriate allocation of resources, individualization to meet specific needs of each program or institution, intensive training, and ongoing evaluation. Future research should focus on developing valid surrogate measures of continuity of care, conducting rigorous trials to determine the elements of sign‐out that lead to the best patient outcomes, and studying the most effective ways of implementing these improvements. By improving the content and process of sign‐out, we can meet the challenges of the new health care landscape while putting patient safety at the forefront.

Modern‐day continuity of patient care in teaching hospitals, once remarkably high because of a cadre of sleep‐deprived residents, is now peppered with breaks, each accompanied by the transfer of patient care responsibility from one resident to another; a process often referred to as a handoff. Such transitions have long been a part of medical practice but have recently received increased attention because of restrictions in the duty hours of house staff. In July 2003 the Accreditation Council for Graduate Medical Education (ACGME) mandated reduced duty hours for all trainees in hopes of improving resident education and well‐being and patient safety.1 In fact, some studies have shown improved resident well‐being2 and fewer medical errors with reductions in duty hours,3, 4 but the growing consensus about the negative consequences of resident fatigue on patient safety has been accompanied by parallel concerns about the potential for information loss with each break in the continuity of care.5, 6

Although the tradeoff of increased discontinuity of care for fewer hours worked is sometimes characterized as an unintended consequence of duty hour regulations, it is in fact predictable and essential. As individuals work fewer hours, discontinuity must necessarily increase (assuming 24‐hour coverage).7 The extent to which this occurs may vary, but the link is consistent. At the University of California, San Francisco (UCSF), for example, we found that compliance with new duty hour requirements for internal medicine resulted in an average of 15 handoffs per patient during a 5‐day hospitalization. Each individual intern was involved in more than 300 handoffs in an average month‐long rotation, an increase of 40% since system changes were introduced to decrease duty hours. We found similar increases at Brigham and Women's Hospital (BWH) and the University of Chicago. Because U.S. teaching hospitals care for more than 6 million patients each year,8 the impact of these handoffs on the quality and efficiency of care is tremendous.

Discontinuity of care is currently managed by sign‐out, or the transfer of patient information from one physician to another. Recognizing the importance of information transfer at these vulnerable transition times for patients, the Joint Commission on Accreditation of Hospital Organizations (JCAHO) issued the 2006 National Patient Safety Goal 2E: Implement a standardized approach to hand off communications, including an opportunity to ask and respond to questions.9 Hospitals have little data to draw on to determine how to comply with this mandate and even less data to guide them in how to achieve its intended goals of improving communication and thus patient safety.

In an effort to better understand sign‐outs and ways to improve this process for house staff on in‐patient services, we reviewed data from the fields of aviation, communications, systems engineering, and human factors research, and we also searched the medical literature using key words pass‐off, handoff, sign‐out, duty hours, work hours, and discontinuity of care and MeSH headings Continuity of Patient Care Internship and Residency/*organization & administration, Personnel Staffing and Scheduling/*organization & administration, and Quality of Health Care. We also searched the websites of the Agency of Healthcare Quality and Research and the National Patient Safety Foundation. On the basis of these reviews, our experiences as hospitalist medical educators organizing resident sign‐out efforts at the University of California, San Francisco, the University of Chicago, and Brigham and Women's Hospital, and our efforts leading national training sessions on sign‐outs at the Society of General Internal Medicine (2004 and 2005), the Society of Hospital Medicine (2004), and the Association of Program Directors in Internal Medicine (2005, 2006), we propose a set of best practices regarding the content and process of sign‐out in an effort to improve communication between residents caring for hospitalized patients, assist programs in building safe and effective sign‐out systems, and improve the quality of patient care.

Effects of Discontinuity on Patient Safety

Research on the effects of discontinuity of care, although limited, suggests it has a negative impact on patient safety. In a study that investigated the institution of code 405 (the regulation that reduced duty hours in New York State), researchers found that the presumed increase in discontinuity with decreased duty hours resulted in delayed test ordering and an increased number of hospital complications.10 Another study found that the number of potentially preventable adverse events doubled when patients were under the care of a physician from a nonprimary team (eg, the cross‐covering intern).11 Studies have also linked resident discontinuity with longer length of stay, increased laboratory testing, and increased medication errors.12, 13

Managing Discontinuity: Sign‐Out as the Means of Information Transfer

In theory, more effective sign‐out systems should mitigate the potential for patient harm, but there is little in the literature describing current effective sign‐out practices or the best ways to design and implement such systems in the health care field. Examining information transfer mechanisms used in fields outside health care can assist in developing these systems.

The Current Practice of Sign‐Out

In examining sign‐outs at our 3 institutions, we found them to be unstructured and unstandardized. From discussion with faculty participating in national workshops on sign‐out, we found that most sign‐outs are conducted by interns, usually with little or no formal training. Templates, checklists, or other methods to standardize the content of the information transferred were rarely used.

We also noted that the vehicle for written sign‐out is highly variable. At UCSF, different residency training programs used a variety of modalities for written sign‐outs, including index cards, Excel spreadsheets, Word documents, and loose sheets of paper. Recently, the UCSF Department of Medicine designed a simple database (on Filemaker Pro) that allows members of the house staff to update their sign‐out information, share it with other house staff and nurses, and access it at locations throughout the hospital (Fig. 1). Although this database is not yet linked to the hospital information system (planned for 2006), anecdotally resident satisfaction with sign‐out has vastly improved since its implementation. The cost of design and implementation was approximately $10,000. At the University of Chicago, interns used Microsoft Word to create sign‐out sheets containing patient summaries to transfer information. However, during structured interviews, 95% of the interns reported that these sheets were frequently lost or misplaced.7 Although medicine residents at BWH use a computerized system to produce sign‐out sheets, this system did not guarantee complete and structured information. For example, a survey at BWH found that 56% of cross‐covering residents said that when paged about a patient overnight, the relevant information needed to care for that patient was present less than half the time; and 27% of residents reported being paged more than 3 times in the previous 2 weeks about a test result or consultant recommendation that they did not know was pending.36

Figure 1

The process of sign‐out also varied across disciplines and institutions. From our experiences at our sites and at the sites of faculty nationally, we found limited standardization about whether sign‐out was verbal, the data transmitted, and the setting in which it was transmitted. In fact, at UCSF most residents signed out verbally on the fly, wherever and whenever they could find the cross‐coverage intern. At BWH, only 37% of residents said that sign‐out occurred in a quiet place most of the time, and only 52% signed out on every patient both orally and in writing.36 At the University of Chicago, the sign‐out process was characterized by outright failures in communication because of omission of needed information (ie, medications, active or anticipated medical problems, etc.) or by failure‐prone communication (ie, lack of face‐to‐face communication, illegible writing). These failures often led to uncertainty in making patient care decisions, potentially resulting in inefficient or suboptimal care.35

Strategies for Safe and Effective Sign‐Out

Given the current landscape of variability in sign‐outs, the recognition that information lost during sign‐out may result in harm to patients, and evidence of improvements in information transfer in areas outside health care, we aimed to develop mechanisms to improve the sign‐out process for residents working in a hospital setting. These strategies are based on our review of the existing literature supplemented by our experiences at our 3 institutions.

Content of Sign‐Out

The elements of content necessary for safe and effective sign‐out can be divided into 5 broad categories (Table 1), contained in the mnemonic ANTICipate: Administrative information, New clinical information, specific Tasks to be performed, assessment of severity of Illness, and Contingency plans or anticipated problems (Table 1, Fig. 2).

Table 1.Checklist for Elements of a Safe and Effective Written Sign‐outANTICipate

✓ Administrative data
□ Patient name, age, sex
□ Medical record number
□ Room number
□ Admission date
□ Primary inpatient medical team, primary care physician
□ Family contact information
✓ New information (clinical update)
□ Chief complaint, brief HPI, and diagnosis (or differential diagnosis)
□ Updated list of medications with doses, updated allergies
□ Updated, brief assessment by system/problem, with dates
□ Current baseline status (eg, mental status, cardiopulmonary, vital signs, especially if abnormal but stable)
□ Recent procedures and significant events
✓ Tasks (what needs to be done)
□ Specific, using if‐then statements
□ Prepare cross‐coverage (eg, patient consent for blood transfusion)
□ Alert to incoming information (eg, study results, consultant recommendations), and what action, if any, needs to be taken during the cross‐coverage
✓ Illness
□ Is the patient sick?
✓ Contingency planning/Code status
□ What may go wrong and what to do about it
□ What has or has not worked before (eg, responds to 40 mg IV furosemide)
□ Difficult family or psychosocial situations
□ Code status, especially recent changes or family discussions

Figure 2

Several general points about this list should be noted. First, the sign‐out content is not meant to replace the chart. The information included reflects the goal of a sign‐out, namely, to provide enough information to allow for a safe transition in patient care. Information we believe is not essential to the sign‐out includes: a complete history and physical exam from the day of admission, a list of tasks already completed, and data necessary only to complete a discharge summary.

Sign‐out must be also be a closed loopthe process of signing in is as important as the process of signing out. This usually entails members of the primary team obtaining information from the cross‐covering physician when they resume care of the patient. The information conveyed in this case is different and includes details on events during cross‐coverage such as: 1) time called to assess patient; 2) reason for call; 3) a brief assessment of the patient, including vital signs; 4) actions taken, for example, medications given and tests ordered; and 5) rationale for those actions. Some of this information may also be included in the chart as an event note (see Fig. 3).

Figure 3

CONCLUSIONS

Sign‐outs are a part of the current landscape of academic medical centers as well as hospitals at large. Interns, residents, and consulting fellows, not to mention nurses, physical therapists, and nutritionists, transfer patient care information at each transition point. There are few resources that can assist these caregivers in identifying and implementing the most effective ways to transfer patient care information. Hospitals and other care facilities are now mandated to develop standards and systems to improve sign‐out. On the basis of the limited literature to date and our own experiences, we have proposed standards and best practices to assist hospitals, training programs, and institutional leaders in designing safe and usable sign‐out systems. Effective implementation of the standards must include appropriate allocation of resources, individualization to meet specific needs of each program or institution, intensive training, and ongoing evaluation. Future research should focus on developing valid surrogate measures of continuity of care, conducting rigorous trials to determine the elements of sign‐out that lead to the best patient outcomes, and studying the most effective ways of implementing these improvements. By improving the content and process of sign‐out, we can meet the challenges of the new health care landscape while putting patient safety at the forefront.

Modern‐day continuity of patient care in teaching hospitals, once remarkably high because of a cadre of sleep‐deprived residents, is now peppered with breaks, each accompanied by the transfer of patient care responsibility from one resident to another; a process often referred to as a handoff. Such transitions have long been a part of medical practice but have recently received increased attention because of restrictions in the duty hours of house staff. In July 2003 the Accreditation Council for Graduate Medical Education (ACGME) mandated reduced duty hours for all trainees in hopes of improving resident education and well‐being and patient safety.1 In fact, some studies have shown improved resident well‐being2 and fewer medical errors with reductions in duty hours,3, 4 but the growing consensus about the negative consequences of resident fatigue on patient safety has been accompanied by parallel concerns about the potential for information loss with each break in the continuity of care.5, 6

Although the tradeoff of increased discontinuity of care for fewer hours worked is sometimes characterized as an unintended consequence of duty hour regulations, it is in fact predictable and essential. As individuals work fewer hours, discontinuity must necessarily increase (assuming 24‐hour coverage).7 The extent to which this occurs may vary, but the link is consistent. At the University of California, San Francisco (UCSF), for example, we found that compliance with new duty hour requirements for internal medicine resulted in an average of 15 handoffs per patient during a 5‐day hospitalization. Each individual intern was involved in more than 300 handoffs in an average month‐long rotation, an increase of 40% since system changes were introduced to decrease duty hours. We found similar increases at Brigham and Women's Hospital (BWH) and the University of Chicago. Because U.S. teaching hospitals care for more than 6 million patients each year,8 the impact of these handoffs on the quality and efficiency of care is tremendous.

Discontinuity of care is currently managed by sign‐out, or the transfer of patient information from one physician to another. Recognizing the importance of information transfer at these vulnerable transition times for patients, the Joint Commission on Accreditation of Hospital Organizations (JCAHO) issued the 2006 National Patient Safety Goal 2E: Implement a standardized approach to hand off communications, including an opportunity to ask and respond to questions.9 Hospitals have little data to draw on to determine how to comply with this mandate and even less data to guide them in how to achieve its intended goals of improving communication and thus patient safety.

In an effort to better understand sign‐outs and ways to improve this process for house staff on in‐patient services, we reviewed data from the fields of aviation, communications, systems engineering, and human factors research, and we also searched the medical literature using key words pass‐off, handoff, sign‐out, duty hours, work hours, and discontinuity of care and MeSH headings Continuity of Patient Care Internship and Residency/*organization & administration, Personnel Staffing and Scheduling/*organization & administration, and Quality of Health Care. We also searched the websites of the Agency of Healthcare Quality and Research and the National Patient Safety Foundation. On the basis of these reviews, our experiences as hospitalist medical educators organizing resident sign‐out efforts at the University of California, San Francisco, the University of Chicago, and Brigham and Women's Hospital, and our efforts leading national training sessions on sign‐outs at the Society of General Internal Medicine (2004 and 2005), the Society of Hospital Medicine (2004), and the Association of Program Directors in Internal Medicine (2005, 2006), we propose a set of best practices regarding the content and process of sign‐out in an effort to improve communication between residents caring for hospitalized patients, assist programs in building safe and effective sign‐out systems, and improve the quality of patient care.

Effects of Discontinuity on Patient Safety

Research on the effects of discontinuity of care, although limited, suggests it has a negative impact on patient safety. In a study that investigated the institution of code 405 (the regulation that reduced duty hours in New York State), researchers found that the presumed increase in discontinuity with decreased duty hours resulted in delayed test ordering and an increased number of hospital complications.10 Another study found that the number of potentially preventable adverse events doubled when patients were under the care of a physician from a nonprimary team (eg, the cross‐covering intern).11 Studies have also linked resident discontinuity with longer length of stay, increased laboratory testing, and increased medication errors.12, 13

Managing Discontinuity: Sign‐Out as the Means of Information Transfer

In theory, more effective sign‐out systems should mitigate the potential for patient harm, but there is little in the literature describing current effective sign‐out practices or the best ways to design and implement such systems in the health care field. Examining information transfer mechanisms used in fields outside health care can assist in developing these systems.

The Current Practice of Sign‐Out

In examining sign‐outs at our 3 institutions, we found them to be unstructured and unstandardized. From discussion with faculty participating in national workshops on sign‐out, we found that most sign‐outs are conducted by interns, usually with little or no formal training. Templates, checklists, or other methods to standardize the content of the information transferred were rarely used.

We also noted that the vehicle for written sign‐out is highly variable. At UCSF, different residency training programs used a variety of modalities for written sign‐outs, including index cards, Excel spreadsheets, Word documents, and loose sheets of paper. Recently, the UCSF Department of Medicine designed a simple database (on Filemaker Pro) that allows members of the house staff to update their sign‐out information, share it with other house staff and nurses, and access it at locations throughout the hospital (Fig. 1). Although this database is not yet linked to the hospital information system (planned for 2006), anecdotally resident satisfaction with sign‐out has vastly improved since its implementation. The cost of design and implementation was approximately $10,000. At the University of Chicago, interns used Microsoft Word to create sign‐out sheets containing patient summaries to transfer information. However, during structured interviews, 95% of the interns reported that these sheets were frequently lost or misplaced.7 Although medicine residents at BWH use a computerized system to produce sign‐out sheets, this system did not guarantee complete and structured information. For example, a survey at BWH found that 56% of cross‐covering residents said that when paged about a patient overnight, the relevant information needed to care for that patient was present less than half the time; and 27% of residents reported being paged more than 3 times in the previous 2 weeks about a test result or consultant recommendation that they did not know was pending.36

Figure 1

The process of sign‐out also varied across disciplines and institutions. From our experiences at our sites and at the sites of faculty nationally, we found limited standardization about whether sign‐out was verbal, the data transmitted, and the setting in which it was transmitted. In fact, at UCSF most residents signed out verbally on the fly, wherever and whenever they could find the cross‐coverage intern. At BWH, only 37% of residents said that sign‐out occurred in a quiet place most of the time, and only 52% signed out on every patient both orally and in writing.36 At the University of Chicago, the sign‐out process was characterized by outright failures in communication because of omission of needed information (ie, medications, active or anticipated medical problems, etc.) or by failure‐prone communication (ie, lack of face‐to‐face communication, illegible writing). These failures often led to uncertainty in making patient care decisions, potentially resulting in inefficient or suboptimal care.35

Strategies for Safe and Effective Sign‐Out

Given the current landscape of variability in sign‐outs, the recognition that information lost during sign‐out may result in harm to patients, and evidence of improvements in information transfer in areas outside health care, we aimed to develop mechanisms to improve the sign‐out process for residents working in a hospital setting. These strategies are based on our review of the existing literature supplemented by our experiences at our 3 institutions.

Content of Sign‐Out

The elements of content necessary for safe and effective sign‐out can be divided into 5 broad categories (Table 1), contained in the mnemonic ANTICipate: Administrative information, New clinical information, specific Tasks to be performed, assessment of severity of Illness, and Contingency plans or anticipated problems (Table 1, Fig. 2).

Table 1.Checklist for Elements of a Safe and Effective Written Sign‐outANTICipate

✓ Administrative data
□ Patient name, age, sex
□ Medical record number
□ Room number
□ Admission date
□ Primary inpatient medical team, primary care physician
□ Family contact information
✓ New information (clinical update)
□ Chief complaint, brief HPI, and diagnosis (or differential diagnosis)
□ Updated list of medications with doses, updated allergies
□ Updated, brief assessment by system/problem, with dates
□ Current baseline status (eg, mental status, cardiopulmonary, vital signs, especially if abnormal but stable)
□ Recent procedures and significant events
✓ Tasks (what needs to be done)
□ Specific, using if‐then statements
□ Prepare cross‐coverage (eg, patient consent for blood transfusion)
□ Alert to incoming information (eg, study results, consultant recommendations), and what action, if any, needs to be taken during the cross‐coverage
✓ Illness
□ Is the patient sick?
✓ Contingency planning/Code status
□ What may go wrong and what to do about it
□ What has or has not worked before (eg, responds to 40 mg IV furosemide)
□ Difficult family or psychosocial situations
□ Code status, especially recent changes or family discussions

Figure 2

Several general points about this list should be noted. First, the sign‐out content is not meant to replace the chart. The information included reflects the goal of a sign‐out, namely, to provide enough information to allow for a safe transition in patient care. Information we believe is not essential to the sign‐out includes: a complete history and physical exam from the day of admission, a list of tasks already completed, and data necessary only to complete a discharge summary.

Sign‐out must be also be a closed loopthe process of signing in is as important as the process of signing out. This usually entails members of the primary team obtaining information from the cross‐covering physician when they resume care of the patient. The information conveyed in this case is different and includes details on events during cross‐coverage such as: 1) time called to assess patient; 2) reason for call; 3) a brief assessment of the patient, including vital signs; 4) actions taken, for example, medications given and tests ordered; and 5) rationale for those actions. Some of this information may also be included in the chart as an event note (see Fig. 3).

Figure 3

CONCLUSIONS

Sign‐outs are a part of the current landscape of academic medical centers as well as hospitals at large. Interns, residents, and consulting fellows, not to mention nurses, physical therapists, and nutritionists, transfer patient care information at each transition point. There are few resources that can assist these caregivers in identifying and implementing the most effective ways to transfer patient care information. Hospitals and other care facilities are now mandated to develop standards and systems to improve sign‐out. On the basis of the limited literature to date and our own experiences, we have proposed standards and best practices to assist hospitals, training programs, and institutional leaders in designing safe and usable sign‐out systems. Effective implementation of the standards must include appropriate allocation of resources, individualization to meet specific needs of each program or institution, intensive training, and ongoing evaluation. Future research should focus on developing valid surrogate measures of continuity of care, conducting rigorous trials to determine the elements of sign‐out that lead to the best patient outcomes, and studying the most effective ways of implementing these improvements. By improving the content and process of sign‐out, we can meet the challenges of the new health care landscape while putting patient safety at the forefront.

In the nearly 10 years since Bob Wachter and Lee Goldman coined the word hospitalist,1 it has been inspiring to see the dramatic growth of this specialty and with it, the growth in membership of the Society of Hospital Medicine.

Over the same period, the health care system has made progress toward ensuring that it provides the safest, highest‐quality health care possible.

In my mind, the two phenomena are related. The Society of Hospital Medicine, along with the hospitalist field more generally, has played a critical role in promoting the use of evidence‐based care, improved teamwork, and health information technology, which can make a significant difference in the care patients receive in the hospital. Similarly, the mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. So, both of our organizations are working to create positive change that will improve the health and health care of all patients.

As a research agency, we support studies, systematic reviews, and evaluations that help to build the foundation of evidence for health care. However, our work goes beyond simply conducting, supporting, and disseminating health services research. At its heart, our mission is helping the health care system translate research into improved practice and policy. We do not see research as an end in itself but rather a vehicle to improve health care and health. We achieve our goals by working with our public‐ and private‐sector partners to translate the research we support and conduct into knowledge and information that can be used immediately to improve health care for all Americans.

Health Information Technology

This commentary features AHRQ's quality‐related initiatives, including promoting the use of health information technology to improve quality and safety, providing the tools to assess health care quality, and expanding training to promote quality improvement in local communities. Many of these tools are ideal for hospitalists to use in their mission to ensure high‐quality care and an efficient and thorough handoff at discharge.

AHRQ is at the leading edge of President Bush's vision of a health care system that harnesses the power of health information technology (IT) to improve quality. AHRQ has invested more than $166 million in more than 100 projects to promote the use of health IT, with a special focus on rural hospitals and communities. These projects will enable providers to improve patient safety and reduce medication errors by eliminating handwritten prescriptions, help to ensure that important information follows patients as they move among health care settings, and reduce duplicative and unnecessary testing.

As part of this investment, AHRQ has awarded multiyear contracts totaling nearly $30 million to Colorado, Delaware, Indiana, Rhode Island, Tennessee, and Utah to help in the development of statewide networks that are secure, ensure privacy, and make information more accessible. Participants in the networks include major purchasers of health care, public and private payers, hospitals, ambulatory care facilities, home health care providers, and long‐term care providers.

In addition, AHRQ created the AHRQ National Resource Center for Health Information Technology (http://healthit.ahrq.gov) as a focus for technical assistance, information sharing, and collaboration. The resource center site provides emerging lessons from the field, a knowledge library with links to more than 5000 health IT information resources, an evaluation toolkit to help those implementing health IT projects, a summary of key topics, plus other resources pointing to current health IT activities, funding opportunities, and other information.

Effective Health Care Program

However, as we all know, health IT is not a magic bullet or the sole answer to the quality and safety problems facing the American health care system. It is a means to an end. Although health IT has the great potential to deliver evidence to clinicians, patients, and other health care decision makers when they need it, one challenge is to ensure the evidence base is readily available.

To that end, AHRQ's new Effective Health Care Program, authorized under Section 1013 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, is conducting research with a focus on outcomes, comparative clinical effectiveness, and appropriateness of pharmaceuticals, devices, and health care services. At press time, AHRQ had released two effectiveness reports, Comparative Effectiveness of Management Strategies for Gastroesophageal Reflux Disease2 and Effectiveness of Noninvasive Diagnostic Tests for Breast Abnormalities.3

The AHRQ Effective Health Care Program takes three approaches to research on the comparative effectiveness of different treatments and clinical practices:

• Review and synthesize knowledge. AHRQ's Evidence‐Based Practice Centers systematically review published and unpublished scientific evidence to develop evidence reports.

• Promote and generate knowledge. A new AHRQ‐supported research network called DEcIDE (Developing Evidence to Inform Decisions about Effectiveness) conducts accelerated practical studies of new scientific evidence and analytic tools.

• Compile the findings and translate knowledge. The John M. Eisenberg Clinical Decisions and Communications Science Center compiles the research results into a variety of useful formats for stakeholders.

Interested readers should go to the Effective Health Care Web site, www.effectivehealthcare.ahrq.gov, to read more about AHRQ's Effective Health Care Program and to see work in progress, suggest topics for research, or comment on research questions and draft reports.

Patient Safety and Quality

Since 2001, AHRQ has been the leading funder of patient safety research, and I am proud that our $165 million patient safety research program is bearing fruit.

For example, Bob Wachterin his spare timeand his team at the University of California, San Francisco, under contract to AHRQ, developed AHRQ's Patient Safety Network, which can be found at http://www.psnet.ahrq.gov. AHRQ PSNet is a national Web‐based portal featuring the latest news and essential resources on patient safety. Included in the Patient Safety Network is AHRQ's Web M&M site (http://www.webmm.ahrq.gov/), an anonymous forum where clinicians post new cases of medical errors for discussion. The site also includes expert commentaries on how to think through such cases, identifying problem areas and potential solutions. Together, PSNet and Web M&M receive more than 100,000 visits each month.

Readers of JHM also will be interested in AHRQ's Hospital Survey on Patient Safety Culture, which we released in partnership with Premier, Inc., the Department of Defense (DoD), and the American Hospital Association. The survey can be used to evaluate employees' attitudes about patient safety in their facilities or within specific units. It addresses a critical aspect of patient safety improvement: measuring organizational conditions that can lead to adverse events and patient harm. The survey, which is being used in the DoD's medical facilities, is available at http://www.ahrq.gov/qual/hospculture. Premier and the AHA are strongly encouraging their members to adopt the Hospital Survey on Patient Safety Culture if they are not already using a survey as part of their safety improvement efforts.

In another quality initiative, AHRQ also has developed a series of software tools that can help hospitals gauge the quality of care they provide. AHRQ's Prevention Quality Indicators allow hospitals to detect potentially avoidable hospital admissions for illnesses that can be effectively treated with high‐quality, community‐based primary care.

Another tool is the Inpatient Quality Indicators, 29 measures that can be used to help hospitals identify potential problem areas and to provide a proxy measure of hospital quality of care. The Patient Safety Indicators can help hospitals enhance their performance by quickly detecting potential medical errors in patients who have undergone medical or surgical care. Staff can then investigate to determine whether the problems detected by the indicators were caused by potentially preventable medical errors or have some other explanation.

Building on its long track record of developing surveys to gauge consumers' experiences in the health care system, AHRQ has developed H‐CAHPS, a survey tool that hospitals, employers, states, and others can use to assess the perceptions of hospital patients about the quality of the care they receive. This information is designed to help patients, their employers, and other purchasers make informed decisions and give hospitals feedback they can use to improve care. The Centers for Medicare & Medicaid Services, in partnership with the nation's major hospital trade groups, is using H‐CAHPS as part of their collaborative Hospital Quality Alliance to develop comparative information about hospitals.

In the future, AHRQ plans to create other surveys, including Ambulatory CAHPS, In‐Center Hemodialysis CAHPS, and Nursing Home CAHPS.

AHRQ also is now working in partnership with the Department of Veterans Affairs to train the third class of state and hospital teams participating in the Patient Safety Improvement Corps. The program was created because states asked us for help in areas such as conducting effective investigations of reports of medical errors and developing interventions and changes in standard clinical practice. When trained, the teams return to their local communities armed with the knowledge to improve patient safety.

National Health Care Quality and Disparities Reports

Finally, in January 2006, AHRQ released the third annual National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report. These reports provide data on the quality of health care and disparities in the use of health care services associated with patient characteristics, including race, ethnicity, income, education, and area of residence.45 In March 2006, AHRQ released a Web‐based tool called State Snapshots for states to use in measuring health care quality. The State Snapshots provides quick and easy access to the many measures and tables of the 2005 NHQR and also provides trend data that can help in the understanding of the quality of health care in individual states, including strengths, weaknesses, and opportunities for improvement. The reports and the State Snapshots are available on AHRQ's QualityTools Web site at http://www.qualitytools.ahrq.gov/.

I hope this article has provided a glimpse into the quality improvement initiatives and activities supported by AHRQ. For ongoing information on these activities, I urge readers to go to AHRQ's Web site and sign up for our electronic newsletter (http://www.ahrq.gov/news/ahrqlist.htm) and our patient safety newsletter (http://www.ahrq.gov/qual/ptsflist.htm).

AHRQ's aim is to make doing the right thing the easy thing to do for the health care system. We look forward to working with readers of the Journal of Hospital Medicine to achieve that goal.

In the nearly 10 years since Bob Wachter and Lee Goldman coined the word hospitalist,1 it has been inspiring to see the dramatic growth of this specialty and with it, the growth in membership of the Society of Hospital Medicine.

Over the same period, the health care system has made progress toward ensuring that it provides the safest, highest‐quality health care possible.

In my mind, the two phenomena are related. The Society of Hospital Medicine, along with the hospitalist field more generally, has played a critical role in promoting the use of evidence‐based care, improved teamwork, and health information technology, which can make a significant difference in the care patients receive in the hospital. Similarly, the mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. So, both of our organizations are working to create positive change that will improve the health and health care of all patients.

As a research agency, we support studies, systematic reviews, and evaluations that help to build the foundation of evidence for health care. However, our work goes beyond simply conducting, supporting, and disseminating health services research. At its heart, our mission is helping the health care system translate research into improved practice and policy. We do not see research as an end in itself but rather a vehicle to improve health care and health. We achieve our goals by working with our public‐ and private‐sector partners to translate the research we support and conduct into knowledge and information that can be used immediately to improve health care for all Americans.

Health Information Technology

This commentary features AHRQ's quality‐related initiatives, including promoting the use of health information technology to improve quality and safety, providing the tools to assess health care quality, and expanding training to promote quality improvement in local communities. Many of these tools are ideal for hospitalists to use in their mission to ensure high‐quality care and an efficient and thorough handoff at discharge.

AHRQ is at the leading edge of President Bush's vision of a health care system that harnesses the power of health information technology (IT) to improve quality. AHRQ has invested more than $166 million in more than 100 projects to promote the use of health IT, with a special focus on rural hospitals and communities. These projects will enable providers to improve patient safety and reduce medication errors by eliminating handwritten prescriptions, help to ensure that important information follows patients as they move among health care settings, and reduce duplicative and unnecessary testing.

As part of this investment, AHRQ has awarded multiyear contracts totaling nearly $30 million to Colorado, Delaware, Indiana, Rhode Island, Tennessee, and Utah to help in the development of statewide networks that are secure, ensure privacy, and make information more accessible. Participants in the networks include major purchasers of health care, public and private payers, hospitals, ambulatory care facilities, home health care providers, and long‐term care providers.

In addition, AHRQ created the AHRQ National Resource Center for Health Information Technology (http://healthit.ahrq.gov) as a focus for technical assistance, information sharing, and collaboration. The resource center site provides emerging lessons from the field, a knowledge library with links to more than 5000 health IT information resources, an evaluation toolkit to help those implementing health IT projects, a summary of key topics, plus other resources pointing to current health IT activities, funding opportunities, and other information.

Effective Health Care Program

However, as we all know, health IT is not a magic bullet or the sole answer to the quality and safety problems facing the American health care system. It is a means to an end. Although health IT has the great potential to deliver evidence to clinicians, patients, and other health care decision makers when they need it, one challenge is to ensure the evidence base is readily available.

To that end, AHRQ's new Effective Health Care Program, authorized under Section 1013 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, is conducting research with a focus on outcomes, comparative clinical effectiveness, and appropriateness of pharmaceuticals, devices, and health care services. At press time, AHRQ had released two effectiveness reports, Comparative Effectiveness of Management Strategies for Gastroesophageal Reflux Disease2 and Effectiveness of Noninvasive Diagnostic Tests for Breast Abnormalities.3

The AHRQ Effective Health Care Program takes three approaches to research on the comparative effectiveness of different treatments and clinical practices:

• Review and synthesize knowledge. AHRQ's Evidence‐Based Practice Centers systematically review published and unpublished scientific evidence to develop evidence reports.

• Promote and generate knowledge. A new AHRQ‐supported research network called DEcIDE (Developing Evidence to Inform Decisions about Effectiveness) conducts accelerated practical studies of new scientific evidence and analytic tools.

• Compile the findings and translate knowledge. The John M. Eisenberg Clinical Decisions and Communications Science Center compiles the research results into a variety of useful formats for stakeholders.

Interested readers should go to the Effective Health Care Web site, www.effectivehealthcare.ahrq.gov, to read more about AHRQ's Effective Health Care Program and to see work in progress, suggest topics for research, or comment on research questions and draft reports.

Patient Safety and Quality

Since 2001, AHRQ has been the leading funder of patient safety research, and I am proud that our $165 million patient safety research program is bearing fruit.

For example, Bob Wachterin his spare timeand his team at the University of California, San Francisco, under contract to AHRQ, developed AHRQ's Patient Safety Network, which can be found at http://www.psnet.ahrq.gov. AHRQ PSNet is a national Web‐based portal featuring the latest news and essential resources on patient safety. Included in the Patient Safety Network is AHRQ's Web M&M site (http://www.webmm.ahrq.gov/), an anonymous forum where clinicians post new cases of medical errors for discussion. The site also includes expert commentaries on how to think through such cases, identifying problem areas and potential solutions. Together, PSNet and Web M&M receive more than 100,000 visits each month.

Readers of JHM also will be interested in AHRQ's Hospital Survey on Patient Safety Culture, which we released in partnership with Premier, Inc., the Department of Defense (DoD), and the American Hospital Association. The survey can be used to evaluate employees' attitudes about patient safety in their facilities or within specific units. It addresses a critical aspect of patient safety improvement: measuring organizational conditions that can lead to adverse events and patient harm. The survey, which is being used in the DoD's medical facilities, is available at http://www.ahrq.gov/qual/hospculture. Premier and the AHA are strongly encouraging their members to adopt the Hospital Survey on Patient Safety Culture if they are not already using a survey as part of their safety improvement efforts.

In another quality initiative, AHRQ also has developed a series of software tools that can help hospitals gauge the quality of care they provide. AHRQ's Prevention Quality Indicators allow hospitals to detect potentially avoidable hospital admissions for illnesses that can be effectively treated with high‐quality, community‐based primary care.

Another tool is the Inpatient Quality Indicators, 29 measures that can be used to help hospitals identify potential problem areas and to provide a proxy measure of hospital quality of care. The Patient Safety Indicators can help hospitals enhance their performance by quickly detecting potential medical errors in patients who have undergone medical or surgical care. Staff can then investigate to determine whether the problems detected by the indicators were caused by potentially preventable medical errors or have some other explanation.

Building on its long track record of developing surveys to gauge consumers' experiences in the health care system, AHRQ has developed H‐CAHPS, a survey tool that hospitals, employers, states, and others can use to assess the perceptions of hospital patients about the quality of the care they receive. This information is designed to help patients, their employers, and other purchasers make informed decisions and give hospitals feedback they can use to improve care. The Centers for Medicare & Medicaid Services, in partnership with the nation's major hospital trade groups, is using H‐CAHPS as part of their collaborative Hospital Quality Alliance to develop comparative information about hospitals.

In the future, AHRQ plans to create other surveys, including Ambulatory CAHPS, In‐Center Hemodialysis CAHPS, and Nursing Home CAHPS.

AHRQ also is now working in partnership with the Department of Veterans Affairs to train the third class of state and hospital teams participating in the Patient Safety Improvement Corps. The program was created because states asked us for help in areas such as conducting effective investigations of reports of medical errors and developing interventions and changes in standard clinical practice. When trained, the teams return to their local communities armed with the knowledge to improve patient safety.

National Health Care Quality and Disparities Reports

Finally, in January 2006, AHRQ released the third annual National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report. These reports provide data on the quality of health care and disparities in the use of health care services associated with patient characteristics, including race, ethnicity, income, education, and area of residence.45 In March 2006, AHRQ released a Web‐based tool called State Snapshots for states to use in measuring health care quality. The State Snapshots provides quick and easy access to the many measures and tables of the 2005 NHQR and also provides trend data that can help in the understanding of the quality of health care in individual states, including strengths, weaknesses, and opportunities for improvement. The reports and the State Snapshots are available on AHRQ's QualityTools Web site at http://www.qualitytools.ahrq.gov/.

I hope this article has provided a glimpse into the quality improvement initiatives and activities supported by AHRQ. For ongoing information on these activities, I urge readers to go to AHRQ's Web site and sign up for our electronic newsletter (http://www.ahrq.gov/news/ahrqlist.htm) and our patient safety newsletter (http://www.ahrq.gov/qual/ptsflist.htm).

AHRQ's aim is to make doing the right thing the easy thing to do for the health care system. We look forward to working with readers of the Journal of Hospital Medicine to achieve that goal.

In the nearly 10 years since Bob Wachter and Lee Goldman coined the word hospitalist,1 it has been inspiring to see the dramatic growth of this specialty and with it, the growth in membership of the Society of Hospital Medicine.

Over the same period, the health care system has made progress toward ensuring that it provides the safest, highest‐quality health care possible.

In my mind, the two phenomena are related. The Society of Hospital Medicine, along with the hospitalist field more generally, has played a critical role in promoting the use of evidence‐based care, improved teamwork, and health information technology, which can make a significant difference in the care patients receive in the hospital. Similarly, the mission of the Agency for Healthcare Research and Quality (AHRQ) is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. So, both of our organizations are working to create positive change that will improve the health and health care of all patients.

As a research agency, we support studies, systematic reviews, and evaluations that help to build the foundation of evidence for health care. However, our work goes beyond simply conducting, supporting, and disseminating health services research. At its heart, our mission is helping the health care system translate research into improved practice and policy. We do not see research as an end in itself but rather a vehicle to improve health care and health. We achieve our goals by working with our public‐ and private‐sector partners to translate the research we support and conduct into knowledge and information that can be used immediately to improve health care for all Americans.

Health Information Technology

This commentary features AHRQ's quality‐related initiatives, including promoting the use of health information technology to improve quality and safety, providing the tools to assess health care quality, and expanding training to promote quality improvement in local communities. Many of these tools are ideal for hospitalists to use in their mission to ensure high‐quality care and an efficient and thorough handoff at discharge.

AHRQ is at the leading edge of President Bush's vision of a health care system that harnesses the power of health information technology (IT) to improve quality. AHRQ has invested more than $166 million in more than 100 projects to promote the use of health IT, with a special focus on rural hospitals and communities. These projects will enable providers to improve patient safety and reduce medication errors by eliminating handwritten prescriptions, help to ensure that important information follows patients as they move among health care settings, and reduce duplicative and unnecessary testing.

As part of this investment, AHRQ has awarded multiyear contracts totaling nearly $30 million to Colorado, Delaware, Indiana, Rhode Island, Tennessee, and Utah to help in the development of statewide networks that are secure, ensure privacy, and make information more accessible. Participants in the networks include major purchasers of health care, public and private payers, hospitals, ambulatory care facilities, home health care providers, and long‐term care providers.

In addition, AHRQ created the AHRQ National Resource Center for Health Information Technology (http://healthit.ahrq.gov) as a focus for technical assistance, information sharing, and collaboration. The resource center site provides emerging lessons from the field, a knowledge library with links to more than 5000 health IT information resources, an evaluation toolkit to help those implementing health IT projects, a summary of key topics, plus other resources pointing to current health IT activities, funding opportunities, and other information.

Effective Health Care Program

However, as we all know, health IT is not a magic bullet or the sole answer to the quality and safety problems facing the American health care system. It is a means to an end. Although health IT has the great potential to deliver evidence to clinicians, patients, and other health care decision makers when they need it, one challenge is to ensure the evidence base is readily available.

To that end, AHRQ's new Effective Health Care Program, authorized under Section 1013 of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003, is conducting research with a focus on outcomes, comparative clinical effectiveness, and appropriateness of pharmaceuticals, devices, and health care services. At press time, AHRQ had released two effectiveness reports, Comparative Effectiveness of Management Strategies for Gastroesophageal Reflux Disease2 and Effectiveness of Noninvasive Diagnostic Tests for Breast Abnormalities.3

The AHRQ Effective Health Care Program takes three approaches to research on the comparative effectiveness of different treatments and clinical practices:

• Review and synthesize knowledge. AHRQ's Evidence‐Based Practice Centers systematically review published and unpublished scientific evidence to develop evidence reports.

• Promote and generate knowledge. A new AHRQ‐supported research network called DEcIDE (Developing Evidence to Inform Decisions about Effectiveness) conducts accelerated practical studies of new scientific evidence and analytic tools.

• Compile the findings and translate knowledge. The John M. Eisenberg Clinical Decisions and Communications Science Center compiles the research results into a variety of useful formats for stakeholders.

Interested readers should go to the Effective Health Care Web site, www.effectivehealthcare.ahrq.gov, to read more about AHRQ's Effective Health Care Program and to see work in progress, suggest topics for research, or comment on research questions and draft reports.

Patient Safety and Quality

Since 2001, AHRQ has been the leading funder of patient safety research, and I am proud that our $165 million patient safety research program is bearing fruit.

For example, Bob Wachterin his spare timeand his team at the University of California, San Francisco, under contract to AHRQ, developed AHRQ's Patient Safety Network, which can be found at http://www.psnet.ahrq.gov. AHRQ PSNet is a national Web‐based portal featuring the latest news and essential resources on patient safety. Included in the Patient Safety Network is AHRQ's Web M&M site (http://www.webmm.ahrq.gov/), an anonymous forum where clinicians post new cases of medical errors for discussion. The site also includes expert commentaries on how to think through such cases, identifying problem areas and potential solutions. Together, PSNet and Web M&M receive more than 100,000 visits each month.

Readers of JHM also will be interested in AHRQ's Hospital Survey on Patient Safety Culture, which we released in partnership with Premier, Inc., the Department of Defense (DoD), and the American Hospital Association. The survey can be used to evaluate employees' attitudes about patient safety in their facilities or within specific units. It addresses a critical aspect of patient safety improvement: measuring organizational conditions that can lead to adverse events and patient harm. The survey, which is being used in the DoD's medical facilities, is available at http://www.ahrq.gov/qual/hospculture. Premier and the AHA are strongly encouraging their members to adopt the Hospital Survey on Patient Safety Culture if they are not already using a survey as part of their safety improvement efforts.

In another quality initiative, AHRQ also has developed a series of software tools that can help hospitals gauge the quality of care they provide. AHRQ's Prevention Quality Indicators allow hospitals to detect potentially avoidable hospital admissions for illnesses that can be effectively treated with high‐quality, community‐based primary care.

Another tool is the Inpatient Quality Indicators, 29 measures that can be used to help hospitals identify potential problem areas and to provide a proxy measure of hospital quality of care. The Patient Safety Indicators can help hospitals enhance their performance by quickly detecting potential medical errors in patients who have undergone medical or surgical care. Staff can then investigate to determine whether the problems detected by the indicators were caused by potentially preventable medical errors or have some other explanation.

Building on its long track record of developing surveys to gauge consumers' experiences in the health care system, AHRQ has developed H‐CAHPS, a survey tool that hospitals, employers, states, and others can use to assess the perceptions of hospital patients about the quality of the care they receive. This information is designed to help patients, their employers, and other purchasers make informed decisions and give hospitals feedback they can use to improve care. The Centers for Medicare & Medicaid Services, in partnership with the nation's major hospital trade groups, is using H‐CAHPS as part of their collaborative Hospital Quality Alliance to develop comparative information about hospitals.

In the future, AHRQ plans to create other surveys, including Ambulatory CAHPS, In‐Center Hemodialysis CAHPS, and Nursing Home CAHPS.

AHRQ also is now working in partnership with the Department of Veterans Affairs to train the third class of state and hospital teams participating in the Patient Safety Improvement Corps. The program was created because states asked us for help in areas such as conducting effective investigations of reports of medical errors and developing interventions and changes in standard clinical practice. When trained, the teams return to their local communities armed with the knowledge to improve patient safety.

National Health Care Quality and Disparities Reports

Finally, in January 2006, AHRQ released the third annual National Healthcare Quality Report (NHQR) and the National Healthcare Disparities Report. These reports provide data on the quality of health care and disparities in the use of health care services associated with patient characteristics, including race, ethnicity, income, education, and area of residence.45 In March 2006, AHRQ released a Web‐based tool called State Snapshots for states to use in measuring health care quality. The State Snapshots provides quick and easy access to the many measures and tables of the 2005 NHQR and also provides trend data that can help in the understanding of the quality of health care in individual states, including strengths, weaknesses, and opportunities for improvement. The reports and the State Snapshots are available on AHRQ's QualityTools Web site at http://www.qualitytools.ahrq.gov/.

I hope this article has provided a glimpse into the quality improvement initiatives and activities supported by AHRQ. For ongoing information on these activities, I urge readers to go to AHRQ's Web site and sign up for our electronic newsletter (http://www.ahrq.gov/news/ahrqlist.htm) and our patient safety newsletter (http://www.ahrq.gov/qual/ptsflist.htm).

AHRQ's aim is to make doing the right thing the easy thing to do for the health care system. We look forward to working with readers of the Journal of Hospital Medicine to achieve that goal.

Toyota is widely recognized as one of the most successful companies in the world. Its automobiles have consistently placed at or near the top of the quality and customer satisfaction rankings published by J.D. Power and Associates and Consumer Reports. Toyota constantly focuses on the safety and well‐being of its employees and the quality of its cars through its relentless dedication to continuous improvement in everything it does. Toyota has recently become the world's number two auto manufacturer, and the company's net profit margin was more than 8 times that of the industry average. 1

How has Toyota been able to achieve such remarkable results in product quality, market share, and profit margins? Jeffrey Liker, in his book The Toyota Way, described the world‐renowned Toyota production system as supported by 2 pillars: continuous improvement and respect for people. The end result is a learning organization that values employee contributions and continuously strives to produce products of higher quality at lower cost. 1, 2 Lean production is the generic term used to describe the principles and methods of the Toyota Production System. Lean production has been implemented to improve performance in a broad array of industries, from aerospace and aluminum refining to financial services and insurance. The philosophy of lean thinking, which is derived from the Toyota Production System, is rapidly gaining a following among health care leaders, with a number of hospitals and medical groups around the country adopting a version of lean production as their systematic approach to improving quality and efficiency. In the coming years, the application of lean principles and methods could have a transformational effect on how health care is delivered, with the potential for dramatic gains in quality, safety, efficiency, and appropriateness.

LEAN CONCEPTS

To understand how lean production can be applied to improve the delivery of health care, some of the fundamental concepts and practice of lean must first be explained. 3, 4 The first step in a lean improvement initiative is to understand value as defined by our customers. 5 In clinical care delivery, external customers include patients, families, payers, and regulators. Internal customers include physicians, nurses, clerks, and others involved in the care process. What customers value usually includes care that is of high quality, safe, efficient and appropriate. The second step typically is to go to the workplace and observe firsthand how the process now operates. 6 As the flow of the process from beginning to end is seen, the observer learns to see and to understand the multiple areas of delay, inefficiency, and waste that may exist. 7, 8 A representational flowchart called a current‐state value stream map (CS VSM) is created to make the work visible and to depict graphically all the individual steps necessary to complete the process from beginning to end. It is important that the CS VSM be a factual depiction of how an entire process flows created by those who actually work in that process. The CS VSM does not state any exceptions to or provide any explanations for why certain steps are taken. It does include key measures such as process time (the actual time it takes to complete a particular step of the process), lead time (the total time it takes to complete the entire process, including waiting time), and first‐time quality (the percentage of time in which that step of the process is completed without defect); (see Figure 1).

Figure 1

In the hands of an improvement team, the current state map becomes a powerful tool that allows participants to systematically recognize and categorize waste. The CS VSM also allows workers to visualize how much opportunity there is for improving the existing process. Working from the CS VSM, the team members can identify specific areas of waste, delay, causes of error, and inefficiency. The team then brainstorms ideas for improvement, proposing how steps of the process might be combined, eliminated, error‐proofed, or otherwise improved to transform waste into value from the customer's perspective. In the third step, the team seeks to achieve the flow state in which the steps of the process follow one another without stopping. All ideas are welcomed at this stage and are placed on the current state map itself or arrayed elsewhere for consideration. Using the ideas generated by the team, a new and better process is designed and depicted on a flow map called the future‐state value stream map (FS VSM). 9, 10 The FS VSM represents an improved and streamlined or ideal way in which the process could be accomplished, as best the team was able to envision at this point (see Figure 2). Ideally, the process described in the FS VSM also allows customers to pull value when they need goods or services provided by the organization, rather than having to do the usual requesting and waiting seen in health care and other service industries. Creating processes from which customers pull what they need is the fourth step in lean design.

Figure 2

Once a future state map is devised and approved, the critical work of rapid deployment of an implementation plan for reaching the future state begins. An implementation plan explicitly identifies who is responsible for what aspect of implementation. Usually a senior leader or leadership group sponsoring the project is responsible for encouraging team members to think beyond their historical (and often political) limits and to support the team in overcoming barriers outside its control. As the individuals return to work and attempt to implement the new solutions, however, they will likely encounter areas of resistance and ambiguity that require creative solutions. The implementation phase focuses on and encourages the individual worker to experiment and work toward a solution that can be broadly adopted and disseminated for use as a standardized solution by all workers facing similar situations. 11, 12 Through this experimental development and dissemination of solutions, the agreed‐to future‐state map is revised. In this way the old future‐state map plays the role of the new current‐state map. There is an ongoing, continuous loop between the current‐ and future‐state maps through implementation and testing to develop the ideal way in which the process should flow toward the final product or service (see Figure 3). The fifth step, pursuing perfection, requires this continuous loop of all workers improving everything they do, every day. The hardest of all the steps, pursuing perfection requires an organization to commit to process improvement and the elimination of defects and waste on a daily and permanent basis. 5

Figure 3

The steps outlined above provide only the basic foundations of lean concepts, of course. A detailed description of learning about and applying lean within one's own organization requires further study and help. Readers interested in learning more about value stream mapping are referred to a workbook by Mike Rother and John Shook called Learning to See, Value Stream Mapping to Create Value and Eliminate Muda. 4 Further, there are consultants with lean expertise who are available to help hospitals get started on the lean journey.

The management philosophy of lean production methods has ties to other operational and quality‐improvement models such as total quality management (TQM)/continuous quality improvement (CQI), developed by W. E. Deming, and Six Sigma, developed by Motorola and General Electric. Although there are several overlapping points of philosophy and techniques, a feature distinguishing lean from these other models is in its value stream approach to driving change and eliminating waste within the process of providing a product for the customer. Lean is unique in its focus on the specification of value from the customer's perspective and on the identification and categorization of waste and its transformation to value using specific tools. The lean approach encourages individuals within the organization (from top to bottom) to learn to see the flow of their product's process and thus to help to identify areas of waste, with the ultimate goal of creating a product with built‐in quality with the least amount of waste. Both Six Sigma and TQM/CQI focus on the delivery of a high‐quality product. Once a system has been studied and standardized, Six Sigma utilizes rigorous statistical and data measurements to drive quality improvements in product delivery. 13 Total quality management/continuous quality improvement engages the entire organization in delivering a high‐quality product from the customer's standpoint by getting everyone in the organization involved in the continuous improvement effort. 14 Lean thinking builds directly on the plandocheckact cycle of CQI but adds tools to identify and transform waste, supplies metrics of timing and resources, and, most important, focuses intently on the creation of value as defined by the customer. A more detailed comparison of lean philosophy with these other quality‐improvement management philosophies is beyond the scope of this article on the introduction of lean methods for hospitals.

DOES HEALTH CARE NEED LEAN THINKERS?

So, should health care try to emulate the successes of an automobile manufacturing company? Before answering this question, consider the following about the health care system as we know it and the significant challenges it faces.

• A key take‐home message of the Institute of Medicine's 1999 report, To Err Is Human: Building a Safer Health System, was that errors are caused by poorly designed systems. 15

• The Centers for Medicare and Medicaid Services (CMS) reported that the cost of health care is rising rapidly and that the rate of growth is not sustainable. 16

• Studies by the RAND Corporation demonstrated considerable variability in the practice of medicine, raising important questions about the appropriateness and necessity of some medical care and procedures. 17, 18

• In Crossing the Quality Chasm: a New Health System for the 21st Century, the Institute of Medicine concluded that today's health care system functions at far lower levels than it can and should and recommended 6 aims for improving the health care system: health care should be safe, effective, patient centered, timely, efficient, and equitable. 19 This report is rich in detail about what the ideal health care system should look like and how application of lean philosophy and tools can help hospitals and physicians achieve that vision.

Although these challenges reflect a view of the health care system at a very macro level, the mechanism and process of driving change will need to be initiated at the more local and organizational level. Lean production focuses on the goal of continuously transforming waste into value from the customer's perspective. It provides a rigorous and systematic approach to process improvement, error proofing, and waste reduction. Manufacturing companies such as Toyota and Alcoa and financial service organizations such as Vanguard have enjoyed tremendous success in implementing lean production, reporting gains in both quality and efficiency. 11 It is time for health care leaders and practitioners to evaluate how lean techniques can be adapted and applied to addressing the pressing challenges of safety, quality, efficiency, and appropriateness in order to improve system reliability and timeliness. As hospitalists, we are at the forefront of these challenges and therefore are in a prime position to lead the change in how health care delivery is improved continuously using a rigorous system such as the Toyota production system.

LEAN IN HEALTH CARE: EXAMPLES OF SOME EARLY RESULTS

Lean health care is still a very novel concept to most health care institutions; however, there have been some early adopters of lean health care, and some of their experiences are described here:

• At Virginia Mason Medical Center (VMMC) in Seattle, Washington, changes implemented using lean production methods have resulted in decreased incidence of ventilator‐associated pneumoniafrom 34 cases with 5 deaths in 2002 to 4 cases with 1 death in 2004. This led to a cost reduction of nearly a half‐million dollars. VMMC has also reported increased profit margins and improvement in space utilization at its cancer center, enabling 57% more patients to be seen in the same allotted space; and it is now taking measures to decrease the number of medication errors by standardizing and mistake‐proofing the process of ordering, delivering, and administering medications, all using lean techniques. 12, 20

• At Park Nicollet Health Services (PNHS) in Minneapolis, Minnesota, implementation of lean production has enabled improved patient access through flow improvements. Results include increasing the number of CT and MRI scans performed per day by 2 and 1, respectively; creating a capacity for 10 additional chemotherapy and antibiotic infusion patients per day in the cancer center; reducing the waiting time of patients from 122 to 52 minutes at the urgent care clinic; standardizing surgical instrument use by the general surgery group, which resulted in processing more than 40,000 fewer instruments each month. These improvements achieved through applying lean concepts have resulted in Park Nicollet being recognized by the American Medical Group Association (AMGA) with its top‐rated Acclaim Award. 21 In addition, PNHS has been able to achieve a record 3.9% operating margin, which equates to a $7.5 million profit in 2004.

• In Pittsburgh, Pennsylvania, a group of hospitals participating in the Pittsburgh Regional Healthcare Initiative (PRHI) have implemented lean concepts to minimize the risk of developing central catheterrelated bloodstream infections. Several hospitals have been able to cut the incidence of central line infections by 50%‐90% through implementation of lean production methods. 12

• At Community Medical Center in Missoula, Montana, a series of pilot projects have been initiated to test lean methods. Some of the early results have demonstrated a reduction in turnaround time for pathology reports from the anatomical pathology lab from 5 to 2 days, a reduction in the number of steps and therefore the time from medication order to treatment initiation from 4 hours to 12 minutes, and a reduction in time for unit clerks to process new physician orders from an average of 43 minutes to 10 minutes during the hospital's busiest hours. 22

THE MICHIGAN LEAN EXPERIENCE

In the past year, the University of Michigan has begun to use lean production methods to improve the care of patients across various venues of hospitalization and flow toward discharge. Delays in placement of peripherally inserted central catheters (PICC) were associated with delays in appropriate and timely administration of intravenous medication, as well as in delays in discharges home or to extended‐care facilities (ECF) for continuation of medical care post‐hospitalization. Since the initiation of the lean PICC initiative, when adjusted for increased volume of demand, for 3 consecutive months 90%95% of the PICC lines have been inserted within 24 hours of request. This is a remarkable achievement, given that in the previous 12 months only 50%70% of PICC lines were placed within 24 hours of request. Even without adjusting for volume of demand, the lean PICC initiative has resulted in a 36% decrease in the average time to line placement and in a 50% decrease in the number of PICC referrals to interventional radiology (IR), thus decreasing the workload of a constrained resource.

As with all lean improvement projects, the entire value stream map was assessed in order to identify areas of intervention that would enhance the final product of the process for the patient (in this case, placing a PICC line as timely as possible). As we evaluated this value stream, one step in the process, occurring prior to placement of the line, appeared to be significantly wasteful: when the PICC nurse needed to search for data (such as locating a patient's chart for the order and reviewing labs and medication records) and to ensure that the patient was in his/her room and prepared for line placement. This step appeared to be inefficient use of the time of technically skilled individuals. The future state map of this process implemented the addition of an assisting individual who would ensure that these prework issues were prepared and completed in advance for the PICC nurses, thus making maximum use of the time of these skilled individuals in placing PICC lines, not in performing unskilled work. Another area where an intervention was believed beneficial was streamlining the process of chest x‐ray (CXR) ordering and reading in order to obtain PICC line confirmation. Performance of the previous process was not standardized and led to delays. The future state proposed a standard method of writing an order for a CXR, a standard method for getting that order to the radiology department, and a standard method for reading the films for dictation. This prevented the confusion and rework that had previously occurred. A last example of an intervention is that the PICC nurses began to internally defer to more experienced nurses if a less experienced nurse could not successfully place a PICC line in a patient. Previously, an unsuccessful attempt at bedside PICC placement warranted an IR referral, thus increasing the demand on an already constrained resource. This intervention by the PICC nurses drove down referrals to the IR suite by 50%. Although this may have led to a small increase in rework early in the process, it has led to a significant reduction in work downstream in the process. Thus, we believe that the overall work flow process has been served well by this intervention. As depicted in Figure 3, the lean process improvement method seeks to have continuous improvement, with the old future‐state map taking on the role of the new current‐state map. Since the initial development of these value stream maps, we have been working toward developing and implementing new areas of intervention, which will lead to new future‐state maps and to further improvement of this process, as the demand for PICC lines continues to rise.

Another critical segment in the care of hospitalized patients is the discharge process, including coordination of care to an outpatient or extended care facility (ECF) setting, which has several potential areas of disconnect that could result inpatients having untoward complications requiring rehospitalization, higher morbidity, or prolongation of suffering from their illnesses. The University of Michigan sees a tremendous opportunity to make a significant impact on patient care in this realm and has just initiated a lean project on the coordination of care. Team members on this project will be relevant process stakeholders, including those representing hospitalists, discharge planning, nursing, social work, a related home nursing company, a home infusion service, an ECF, ambulatory care, pharmacy, case management, nutrition, utilization review, patients and their families, and clinic physicians. The overall goal of the project is to optimize patient care from hospitalization to discharge and transfer of care to the outpatient setting.

CONCLUSION

The health care industry should learn about and consider adoption of lean techniques in order to improve its processes. More specifically, hospitals are prime locales for reaping the benefits of implementation of lean production, which can significantly affect how health care is delivered to patients. Toyota and other lean exemplars in the manufacturing industry have achieved a high level of success by utilizing the practice of lean. Early results from health care organizations suggest that utilizing lean production methods can lead to substantial improvements in the quality and efficiency of health care. To determine if the magnitude of success experienced by Toyota and other lean exemplars can also be achieved in the health care sector, it will be necessary to continuously test and evaluate the impact lean health care can have. In the hospital setting, where hospitalists are at the forefront of delivering care, it is incumbent on the hospitalist community to evaluate whether these techniques can make a difference in the quality, efficiency, and safety of the care provided to patients.

Lean thinking is still a novel idea to those in the health care sector, and as early adopters of this promising management model, we are very optimistic about the benefits of applying lean concepts in our hospital. Some of the first published reports and results presented on the benefits of lean in individual organizations are encouraging; however, as health care is a scientific community, we believe that future work should undergo rigorous evaluation on the benefits of lean and that such future works should be shared among the health care community through peer‐reviewed and published works.

Toyota is widely recognized as one of the most successful companies in the world. Its automobiles have consistently placed at or near the top of the quality and customer satisfaction rankings published by J.D. Power and Associates and Consumer Reports. Toyota constantly focuses on the safety and well‐being of its employees and the quality of its cars through its relentless dedication to continuous improvement in everything it does. Toyota has recently become the world's number two auto manufacturer, and the company's net profit margin was more than 8 times that of the industry average. 1

How has Toyota been able to achieve such remarkable results in product quality, market share, and profit margins? Jeffrey Liker, in his book The Toyota Way, described the world‐renowned Toyota production system as supported by 2 pillars: continuous improvement and respect for people. The end result is a learning organization that values employee contributions and continuously strives to produce products of higher quality at lower cost. 1, 2 Lean production is the generic term used to describe the principles and methods of the Toyota Production System. Lean production has been implemented to improve performance in a broad array of industries, from aerospace and aluminum refining to financial services and insurance. The philosophy of lean thinking, which is derived from the Toyota Production System, is rapidly gaining a following among health care leaders, with a number of hospitals and medical groups around the country adopting a version of lean production as their systematic approach to improving quality and efficiency. In the coming years, the application of lean principles and methods could have a transformational effect on how health care is delivered, with the potential for dramatic gains in quality, safety, efficiency, and appropriateness.

LEAN CONCEPTS

To understand how lean production can be applied to improve the delivery of health care, some of the fundamental concepts and practice of lean must first be explained. 3, 4 The first step in a lean improvement initiative is to understand value as defined by our customers. 5 In clinical care delivery, external customers include patients, families, payers, and regulators. Internal customers include physicians, nurses, clerks, and others involved in the care process. What customers value usually includes care that is of high quality, safe, efficient and appropriate. The second step typically is to go to the workplace and observe firsthand how the process now operates. 6 As the flow of the process from beginning to end is seen, the observer learns to see and to understand the multiple areas of delay, inefficiency, and waste that may exist. 7, 8 A representational flowchart called a current‐state value stream map (CS VSM) is created to make the work visible and to depict graphically all the individual steps necessary to complete the process from beginning to end. It is important that the CS VSM be a factual depiction of how an entire process flows created by those who actually work in that process. The CS VSM does not state any exceptions to or provide any explanations for why certain steps are taken. It does include key measures such as process time (the actual time it takes to complete a particular step of the process), lead time (the total time it takes to complete the entire process, including waiting time), and first‐time quality (the percentage of time in which that step of the process is completed without defect); (see Figure 1).

Figure 1

In the hands of an improvement team, the current state map becomes a powerful tool that allows participants to systematically recognize and categorize waste. The CS VSM also allows workers to visualize how much opportunity there is for improving the existing process. Working from the CS VSM, the team members can identify specific areas of waste, delay, causes of error, and inefficiency. The team then brainstorms ideas for improvement, proposing how steps of the process might be combined, eliminated, error‐proofed, or otherwise improved to transform waste into value from the customer's perspective. In the third step, the team seeks to achieve the flow state in which the steps of the process follow one another without stopping. All ideas are welcomed at this stage and are placed on the current state map itself or arrayed elsewhere for consideration. Using the ideas generated by the team, a new and better process is designed and depicted on a flow map called the future‐state value stream map (FS VSM). 9, 10 The FS VSM represents an improved and streamlined or ideal way in which the process could be accomplished, as best the team was able to envision at this point (see Figure 2). Ideally, the process described in the FS VSM also allows customers to pull value when they need goods or services provided by the organization, rather than having to do the usual requesting and waiting seen in health care and other service industries. Creating processes from which customers pull what they need is the fourth step in lean design.

Figure 2

Once a future state map is devised and approved, the critical work of rapid deployment of an implementation plan for reaching the future state begins. An implementation plan explicitly identifies who is responsible for what aspect of implementation. Usually a senior leader or leadership group sponsoring the project is responsible for encouraging team members to think beyond their historical (and often political) limits and to support the team in overcoming barriers outside its control. As the individuals return to work and attempt to implement the new solutions, however, they will likely encounter areas of resistance and ambiguity that require creative solutions. The implementation phase focuses on and encourages the individual worker to experiment and work toward a solution that can be broadly adopted and disseminated for use as a standardized solution by all workers facing similar situations. 11, 12 Through this experimental development and dissemination of solutions, the agreed‐to future‐state map is revised. In this way the old future‐state map plays the role of the new current‐state map. There is an ongoing, continuous loop between the current‐ and future‐state maps through implementation and testing to develop the ideal way in which the process should flow toward the final product or service (see Figure 3). The fifth step, pursuing perfection, requires this continuous loop of all workers improving everything they do, every day. The hardest of all the steps, pursuing perfection requires an organization to commit to process improvement and the elimination of defects and waste on a daily and permanent basis. 5

Figure 3

The steps outlined above provide only the basic foundations of lean concepts, of course. A detailed description of learning about and applying lean within one's own organization requires further study and help. Readers interested in learning more about value stream mapping are referred to a workbook by Mike Rother and John Shook called Learning to See, Value Stream Mapping to Create Value and Eliminate Muda. 4 Further, there are consultants with lean expertise who are available to help hospitals get started on the lean journey.

The management philosophy of lean production methods has ties to other operational and quality‐improvement models such as total quality management (TQM)/continuous quality improvement (CQI), developed by W. E. Deming, and Six Sigma, developed by Motorola and General Electric. Although there are several overlapping points of philosophy and techniques, a feature distinguishing lean from these other models is in its value stream approach to driving change and eliminating waste within the process of providing a product for the customer. Lean is unique in its focus on the specification of value from the customer's perspective and on the identification and categorization of waste and its transformation to value using specific tools. The lean approach encourages individuals within the organization (from top to bottom) to learn to see the flow of their product's process and thus to help to identify areas of waste, with the ultimate goal of creating a product with built‐in quality with the least amount of waste. Both Six Sigma and TQM/CQI focus on the delivery of a high‐quality product. Once a system has been studied and standardized, Six Sigma utilizes rigorous statistical and data measurements to drive quality improvements in product delivery. 13 Total quality management/continuous quality improvement engages the entire organization in delivering a high‐quality product from the customer's standpoint by getting everyone in the organization involved in the continuous improvement effort. 14 Lean thinking builds directly on the plandocheckact cycle of CQI but adds tools to identify and transform waste, supplies metrics of timing and resources, and, most important, focuses intently on the creation of value as defined by the customer. A more detailed comparison of lean philosophy with these other quality‐improvement management philosophies is beyond the scope of this article on the introduction of lean methods for hospitals.

DOES HEALTH CARE NEED LEAN THINKERS?

So, should health care try to emulate the successes of an automobile manufacturing company? Before answering this question, consider the following about the health care system as we know it and the significant challenges it faces.

• A key take‐home message of the Institute of Medicine's 1999 report, To Err Is Human: Building a Safer Health System, was that errors are caused by poorly designed systems. 15

• The Centers for Medicare and Medicaid Services (CMS) reported that the cost of health care is rising rapidly and that the rate of growth is not sustainable. 16

• Studies by the RAND Corporation demonstrated considerable variability in the practice of medicine, raising important questions about the appropriateness and necessity of some medical care and procedures. 17, 18

• In Crossing the Quality Chasm: a New Health System for the 21st Century, the Institute of Medicine concluded that today's health care system functions at far lower levels than it can and should and recommended 6 aims for improving the health care system: health care should be safe, effective, patient centered, timely, efficient, and equitable. 19 This report is rich in detail about what the ideal health care system should look like and how application of lean philosophy and tools can help hospitals and physicians achieve that vision.

Although these challenges reflect a view of the health care system at a very macro level, the mechanism and process of driving change will need to be initiated at the more local and organizational level. Lean production focuses on the goal of continuously transforming waste into value from the customer's perspective. It provides a rigorous and systematic approach to process improvement, error proofing, and waste reduction. Manufacturing companies such as Toyota and Alcoa and financial service organizations such as Vanguard have enjoyed tremendous success in implementing lean production, reporting gains in both quality and efficiency. 11 It is time for health care leaders and practitioners to evaluate how lean techniques can be adapted and applied to addressing the pressing challenges of safety, quality, efficiency, and appropriateness in order to improve system reliability and timeliness. As hospitalists, we are at the forefront of these challenges and therefore are in a prime position to lead the change in how health care delivery is improved continuously using a rigorous system such as the Toyota production system.

LEAN IN HEALTH CARE: EXAMPLES OF SOME EARLY RESULTS

Lean health care is still a very novel concept to most health care institutions; however, there have been some early adopters of lean health care, and some of their experiences are described here:

• At Virginia Mason Medical Center (VMMC) in Seattle, Washington, changes implemented using lean production methods have resulted in decreased incidence of ventilator‐associated pneumoniafrom 34 cases with 5 deaths in 2002 to 4 cases with 1 death in 2004. This led to a cost reduction of nearly a half‐million dollars. VMMC has also reported increased profit margins and improvement in space utilization at its cancer center, enabling 57% more patients to be seen in the same allotted space; and it is now taking measures to decrease the number of medication errors by standardizing and mistake‐proofing the process of ordering, delivering, and administering medications, all using lean techniques. 12, 20

• At Park Nicollet Health Services (PNHS) in Minneapolis, Minnesota, implementation of lean production has enabled improved patient access through flow improvements. Results include increasing the number of CT and MRI scans performed per day by 2 and 1, respectively; creating a capacity for 10 additional chemotherapy and antibiotic infusion patients per day in the cancer center; reducing the waiting time of patients from 122 to 52 minutes at the urgent care clinic; standardizing surgical instrument use by the general surgery group, which resulted in processing more than 40,000 fewer instruments each month. These improvements achieved through applying lean concepts have resulted in Park Nicollet being recognized by the American Medical Group Association (AMGA) with its top‐rated Acclaim Award. 21 In addition, PNHS has been able to achieve a record 3.9% operating margin, which equates to a $7.5 million profit in 2004.

• In Pittsburgh, Pennsylvania, a group of hospitals participating in the Pittsburgh Regional Healthcare Initiative (PRHI) have implemented lean concepts to minimize the risk of developing central catheterrelated bloodstream infections. Several hospitals have been able to cut the incidence of central line infections by 50%‐90% through implementation of lean production methods. 12

• At Community Medical Center in Missoula, Montana, a series of pilot projects have been initiated to test lean methods. Some of the early results have demonstrated a reduction in turnaround time for pathology reports from the anatomical pathology lab from 5 to 2 days, a reduction in the number of steps and therefore the time from medication order to treatment initiation from 4 hours to 12 minutes, and a reduction in time for unit clerks to process new physician orders from an average of 43 minutes to 10 minutes during the hospital's busiest hours. 22

THE MICHIGAN LEAN EXPERIENCE

In the past year, the University of Michigan has begun to use lean production methods to improve the care of patients across various venues of hospitalization and flow toward discharge. Delays in placement of peripherally inserted central catheters (PICC) were associated with delays in appropriate and timely administration of intravenous medication, as well as in delays in discharges home or to extended‐care facilities (ECF) for continuation of medical care post‐hospitalization. Since the initiation of the lean PICC initiative, when adjusted for increased volume of demand, for 3 consecutive months 90%95% of the PICC lines have been inserted within 24 hours of request. This is a remarkable achievement, given that in the previous 12 months only 50%70% of PICC lines were placed within 24 hours of request. Even without adjusting for volume of demand, the lean PICC initiative has resulted in a 36% decrease in the average time to line placement and in a 50% decrease in the number of PICC referrals to interventional radiology (IR), thus decreasing the workload of a constrained resource.

As with all lean improvement projects, the entire value stream map was assessed in order to identify areas of intervention that would enhance the final product of the process for the patient (in this case, placing a PICC line as timely as possible). As we evaluated this value stream, one step in the process, occurring prior to placement of the line, appeared to be significantly wasteful: when the PICC nurse needed to search for data (such as locating a patient's chart for the order and reviewing labs and medication records) and to ensure that the patient was in his/her room and prepared for line placement. This step appeared to be inefficient use of the time of technically skilled individuals. The future state map of this process implemented the addition of an assisting individual who would ensure that these prework issues were prepared and completed in advance for the PICC nurses, thus making maximum use of the time of these skilled individuals in placing PICC lines, not in performing unskilled work. Another area where an intervention was believed beneficial was streamlining the process of chest x‐ray (CXR) ordering and reading in order to obtain PICC line confirmation. Performance of the previous process was not standardized and led to delays. The future state proposed a standard method of writing an order for a CXR, a standard method for getting that order to the radiology department, and a standard method for reading the films for dictation. This prevented the confusion and rework that had previously occurred. A last example of an intervention is that the PICC nurses began to internally defer to more experienced nurses if a less experienced nurse could not successfully place a PICC line in a patient. Previously, an unsuccessful attempt at bedside PICC placement warranted an IR referral, thus increasing the demand on an already constrained resource. This intervention by the PICC nurses drove down referrals to the IR suite by 50%. Although this may have led to a small increase in rework early in the process, it has led to a significant reduction in work downstream in the process. Thus, we believe that the overall work flow process has been served well by this intervention. As depicted in Figure 3, the lean process improvement method seeks to have continuous improvement, with the old future‐state map taking on the role of the new current‐state map. Since the initial development of these value stream maps, we have been working toward developing and implementing new areas of intervention, which will lead to new future‐state maps and to further improvement of this process, as the demand for PICC lines continues to rise.

Another critical segment in the care of hospitalized patients is the discharge process, including coordination of care to an outpatient or extended care facility (ECF) setting, which has several potential areas of disconnect that could result inpatients having untoward complications requiring rehospitalization, higher morbidity, or prolongation of suffering from their illnesses. The University of Michigan sees a tremendous opportunity to make a significant impact on patient care in this realm and has just initiated a lean project on the coordination of care. Team members on this project will be relevant process stakeholders, including those representing hospitalists, discharge planning, nursing, social work, a related home nursing company, a home infusion service, an ECF, ambulatory care, pharmacy, case management, nutrition, utilization review, patients and their families, and clinic physicians. The overall goal of the project is to optimize patient care from hospitalization to discharge and transfer of care to the outpatient setting.

CONCLUSION

The health care industry should learn about and consider adoption of lean techniques in order to improve its processes. More specifically, hospitals are prime locales for reaping the benefits of implementation of lean production, which can significantly affect how health care is delivered to patients. Toyota and other lean exemplars in the manufacturing industry have achieved a high level of success by utilizing the practice of lean. Early results from health care organizations suggest that utilizing lean production methods can lead to substantial improvements in the quality and efficiency of health care. To determine if the magnitude of success experienced by Toyota and other lean exemplars can also be achieved in the health care sector, it will be necessary to continuously test and evaluate the impact lean health care can have. In the hospital setting, where hospitalists are at the forefront of delivering care, it is incumbent on the hospitalist community to evaluate whether these techniques can make a difference in the quality, efficiency, and safety of the care provided to patients.

Lean thinking is still a novel idea to those in the health care sector, and as early adopters of this promising management model, we are very optimistic about the benefits of applying lean concepts in our hospital. Some of the first published reports and results presented on the benefits of lean in individual organizations are encouraging; however, as health care is a scientific community, we believe that future work should undergo rigorous evaluation on the benefits of lean and that such future works should be shared among the health care community through peer‐reviewed and published works.

Toyota is widely recognized as one of the most successful companies in the world. Its automobiles have consistently placed at or near the top of the quality and customer satisfaction rankings published by J.D. Power and Associates and Consumer Reports. Toyota constantly focuses on the safety and well‐being of its employees and the quality of its cars through its relentless dedication to continuous improvement in everything it does. Toyota has recently become the world's number two auto manufacturer, and the company's net profit margin was more than 8 times that of the industry average. 1

How has Toyota been able to achieve such remarkable results in product quality, market share, and profit margins? Jeffrey Liker, in his book The Toyota Way, described the world‐renowned Toyota production system as supported by 2 pillars: continuous improvement and respect for people. The end result is a learning organization that values employee contributions and continuously strives to produce products of higher quality at lower cost. 1, 2 Lean production is the generic term used to describe the principles and methods of the Toyota Production System. Lean production has been implemented to improve performance in a broad array of industries, from aerospace and aluminum refining to financial services and insurance. The philosophy of lean thinking, which is derived from the Toyota Production System, is rapidly gaining a following among health care leaders, with a number of hospitals and medical groups around the country adopting a version of lean production as their systematic approach to improving quality and efficiency. In the coming years, the application of lean principles and methods could have a transformational effect on how health care is delivered, with the potential for dramatic gains in quality, safety, efficiency, and appropriateness.

LEAN CONCEPTS

To understand how lean production can be applied to improve the delivery of health care, some of the fundamental concepts and practice of lean must first be explained. 3, 4 The first step in a lean improvement initiative is to understand value as defined by our customers. 5 In clinical care delivery, external customers include patients, families, payers, and regulators. Internal customers include physicians, nurses, clerks, and others involved in the care process. What customers value usually includes care that is of high quality, safe, efficient and appropriate. The second step typically is to go to the workplace and observe firsthand how the process now operates. 6 As the flow of the process from beginning to end is seen, the observer learns to see and to understand the multiple areas of delay, inefficiency, and waste that may exist. 7, 8 A representational flowchart called a current‐state value stream map (CS VSM) is created to make the work visible and to depict graphically all the individual steps necessary to complete the process from beginning to end. It is important that the CS VSM be a factual depiction of how an entire process flows created by those who actually work in that process. The CS VSM does not state any exceptions to or provide any explanations for why certain steps are taken. It does include key measures such as process time (the actual time it takes to complete a particular step of the process), lead time (the total time it takes to complete the entire process, including waiting time), and first‐time quality (the percentage of time in which that step of the process is completed without defect); (see Figure 1).

Figure 1

In the hands of an improvement team, the current state map becomes a powerful tool that allows participants to systematically recognize and categorize waste. The CS VSM also allows workers to visualize how much opportunity there is for improving the existing process. Working from the CS VSM, the team members can identify specific areas of waste, delay, causes of error, and inefficiency. The team then brainstorms ideas for improvement, proposing how steps of the process might be combined, eliminated, error‐proofed, or otherwise improved to transform waste into value from the customer's perspective. In the third step, the team seeks to achieve the flow state in which the steps of the process follow one another without stopping. All ideas are welcomed at this stage and are placed on the current state map itself or arrayed elsewhere for consideration. Using the ideas generated by the team, a new and better process is designed and depicted on a flow map called the future‐state value stream map (FS VSM). 9, 10 The FS VSM represents an improved and streamlined or ideal way in which the process could be accomplished, as best the team was able to envision at this point (see Figure 2). Ideally, the process described in the FS VSM also allows customers to pull value when they need goods or services provided by the organization, rather than having to do the usual requesting and waiting seen in health care and other service industries. Creating processes from which customers pull what they need is the fourth step in lean design.

Figure 2

Once a future state map is devised and approved, the critical work of rapid deployment of an implementation plan for reaching the future state begins. An implementation plan explicitly identifies who is responsible for what aspect of implementation. Usually a senior leader or leadership group sponsoring the project is responsible for encouraging team members to think beyond their historical (and often political) limits and to support the team in overcoming barriers outside its control. As the individuals return to work and attempt to implement the new solutions, however, they will likely encounter areas of resistance and ambiguity that require creative solutions. The implementation phase focuses on and encourages the individual worker to experiment and work toward a solution that can be broadly adopted and disseminated for use as a standardized solution by all workers facing similar situations. 11, 12 Through this experimental development and dissemination of solutions, the agreed‐to future‐state map is revised. In this way the old future‐state map plays the role of the new current‐state map. There is an ongoing, continuous loop between the current‐ and future‐state maps through implementation and testing to develop the ideal way in which the process should flow toward the final product or service (see Figure 3). The fifth step, pursuing perfection, requires this continuous loop of all workers improving everything they do, every day. The hardest of all the steps, pursuing perfection requires an organization to commit to process improvement and the elimination of defects and waste on a daily and permanent basis. 5

Figure 3

The steps outlined above provide only the basic foundations of lean concepts, of course. A detailed description of learning about and applying lean within one's own organization requires further study and help. Readers interested in learning more about value stream mapping are referred to a workbook by Mike Rother and John Shook called Learning to See, Value Stream Mapping to Create Value and Eliminate Muda. 4 Further, there are consultants with lean expertise who are available to help hospitals get started on the lean journey.

The management philosophy of lean production methods has ties to other operational and quality‐improvement models such as total quality management (TQM)/continuous quality improvement (CQI), developed by W. E. Deming, and Six Sigma, developed by Motorola and General Electric. Although there are several overlapping points of philosophy and techniques, a feature distinguishing lean from these other models is in its value stream approach to driving change and eliminating waste within the process of providing a product for the customer. Lean is unique in its focus on the specification of value from the customer's perspective and on the identification and categorization of waste and its transformation to value using specific tools. The lean approach encourages individuals within the organization (from top to bottom) to learn to see the flow of their product's process and thus to help to identify areas of waste, with the ultimate goal of creating a product with built‐in quality with the least amount of waste. Both Six Sigma and TQM/CQI focus on the delivery of a high‐quality product. Once a system has been studied and standardized, Six Sigma utilizes rigorous statistical and data measurements to drive quality improvements in product delivery. 13 Total quality management/continuous quality improvement engages the entire organization in delivering a high‐quality product from the customer's standpoint by getting everyone in the organization involved in the continuous improvement effort. 14 Lean thinking builds directly on the plandocheckact cycle of CQI but adds tools to identify and transform waste, supplies metrics of timing and resources, and, most important, focuses intently on the creation of value as defined by the customer. A more detailed comparison of lean philosophy with these other quality‐improvement management philosophies is beyond the scope of this article on the introduction of lean methods for hospitals.

DOES HEALTH CARE NEED LEAN THINKERS?

So, should health care try to emulate the successes of an automobile manufacturing company? Before answering this question, consider the following about the health care system as we know it and the significant challenges it faces.

• A key take‐home message of the Institute of Medicine's 1999 report, To Err Is Human: Building a Safer Health System, was that errors are caused by poorly designed systems. 15

• The Centers for Medicare and Medicaid Services (CMS) reported that the cost of health care is rising rapidly and that the rate of growth is not sustainable. 16

• Studies by the RAND Corporation demonstrated considerable variability in the practice of medicine, raising important questions about the appropriateness and necessity of some medical care and procedures. 17, 18

• In Crossing the Quality Chasm: a New Health System for the 21st Century, the Institute of Medicine concluded that today's health care system functions at far lower levels than it can and should and recommended 6 aims for improving the health care system: health care should be safe, effective, patient centered, timely, efficient, and equitable. 19 This report is rich in detail about what the ideal health care system should look like and how application of lean philosophy and tools can help hospitals and physicians achieve that vision.

Although these challenges reflect a view of the health care system at a very macro level, the mechanism and process of driving change will need to be initiated at the more local and organizational level. Lean production focuses on the goal of continuously transforming waste into value from the customer's perspective. It provides a rigorous and systematic approach to process improvement, error proofing, and waste reduction. Manufacturing companies such as Toyota and Alcoa and financial service organizations such as Vanguard have enjoyed tremendous success in implementing lean production, reporting gains in both quality and efficiency. 11 It is time for health care leaders and practitioners to evaluate how lean techniques can be adapted and applied to addressing the pressing challenges of safety, quality, efficiency, and appropriateness in order to improve system reliability and timeliness. As hospitalists, we are at the forefront of these challenges and therefore are in a prime position to lead the change in how health care delivery is improved continuously using a rigorous system such as the Toyota production system.

LEAN IN HEALTH CARE: EXAMPLES OF SOME EARLY RESULTS

Lean health care is still a very novel concept to most health care institutions; however, there have been some early adopters of lean health care, and some of their experiences are described here:

• At Virginia Mason Medical Center (VMMC) in Seattle, Washington, changes implemented using lean production methods have resulted in decreased incidence of ventilator‐associated pneumoniafrom 34 cases with 5 deaths in 2002 to 4 cases with 1 death in 2004. This led to a cost reduction of nearly a half‐million dollars. VMMC has also reported increased profit margins and improvement in space utilization at its cancer center, enabling 57% more patients to be seen in the same allotted space; and it is now taking measures to decrease the number of medication errors by standardizing and mistake‐proofing the process of ordering, delivering, and administering medications, all using lean techniques. 12, 20

• At Park Nicollet Health Services (PNHS) in Minneapolis, Minnesota, implementation of lean production has enabled improved patient access through flow improvements. Results include increasing the number of CT and MRI scans performed per day by 2 and 1, respectively; creating a capacity for 10 additional chemotherapy and antibiotic infusion patients per day in the cancer center; reducing the waiting time of patients from 122 to 52 minutes at the urgent care clinic; standardizing surgical instrument use by the general surgery group, which resulted in processing more than 40,000 fewer instruments each month. These improvements achieved through applying lean concepts have resulted in Park Nicollet being recognized by the American Medical Group Association (AMGA) with its top‐rated Acclaim Award. 21 In addition, PNHS has been able to achieve a record 3.9% operating margin, which equates to a $7.5 million profit in 2004.

• In Pittsburgh, Pennsylvania, a group of hospitals participating in the Pittsburgh Regional Healthcare Initiative (PRHI) have implemented lean concepts to minimize the risk of developing central catheterrelated bloodstream infections. Several hospitals have been able to cut the incidence of central line infections by 50%‐90% through implementation of lean production methods. 12

• At Community Medical Center in Missoula, Montana, a series of pilot projects have been initiated to test lean methods. Some of the early results have demonstrated a reduction in turnaround time for pathology reports from the anatomical pathology lab from 5 to 2 days, a reduction in the number of steps and therefore the time from medication order to treatment initiation from 4 hours to 12 minutes, and a reduction in time for unit clerks to process new physician orders from an average of 43 minutes to 10 minutes during the hospital's busiest hours. 22

THE MICHIGAN LEAN EXPERIENCE

In the past year, the University of Michigan has begun to use lean production methods to improve the care of patients across various venues of hospitalization and flow toward discharge. Delays in placement of peripherally inserted central catheters (PICC) were associated with delays in appropriate and timely administration of intravenous medication, as well as in delays in discharges home or to extended‐care facilities (ECF) for continuation of medical care post‐hospitalization. Since the initiation of the lean PICC initiative, when adjusted for increased volume of demand, for 3 consecutive months 90%95% of the PICC lines have been inserted within 24 hours of request. This is a remarkable achievement, given that in the previous 12 months only 50%70% of PICC lines were placed within 24 hours of request. Even without adjusting for volume of demand, the lean PICC initiative has resulted in a 36% decrease in the average time to line placement and in a 50% decrease in the number of PICC referrals to interventional radiology (IR), thus decreasing the workload of a constrained resource.

As with all lean improvement projects, the entire value stream map was assessed in order to identify areas of intervention that would enhance the final product of the process for the patient (in this case, placing a PICC line as timely as possible). As we evaluated this value stream, one step in the process, occurring prior to placement of the line, appeared to be significantly wasteful: when the PICC nurse needed to search for data (such as locating a patient's chart for the order and reviewing labs and medication records) and to ensure that the patient was in his/her room and prepared for line placement. This step appeared to be inefficient use of the time of technically skilled individuals. The future state map of this process implemented the addition of an assisting individual who would ensure that these prework issues were prepared and completed in advance for the PICC nurses, thus making maximum use of the time of these skilled individuals in placing PICC lines, not in performing unskilled work. Another area where an intervention was believed beneficial was streamlining the process of chest x‐ray (CXR) ordering and reading in order to obtain PICC line confirmation. Performance of the previous process was not standardized and led to delays. The future state proposed a standard method of writing an order for a CXR, a standard method for getting that order to the radiology department, and a standard method for reading the films for dictation. This prevented the confusion and rework that had previously occurred. A last example of an intervention is that the PICC nurses began to internally defer to more experienced nurses if a less experienced nurse could not successfully place a PICC line in a patient. Previously, an unsuccessful attempt at bedside PICC placement warranted an IR referral, thus increasing the demand on an already constrained resource. This intervention by the PICC nurses drove down referrals to the IR suite by 50%. Although this may have led to a small increase in rework early in the process, it has led to a significant reduction in work downstream in the process. Thus, we believe that the overall work flow process has been served well by this intervention. As depicted in Figure 3, the lean process improvement method seeks to have continuous improvement, with the old future‐state map taking on the role of the new current‐state map. Since the initial development of these value stream maps, we have been working toward developing and implementing new areas of intervention, which will lead to new future‐state maps and to further improvement of this process, as the demand for PICC lines continues to rise.

Another critical segment in the care of hospitalized patients is the discharge process, including coordination of care to an outpatient or extended care facility (ECF) setting, which has several potential areas of disconnect that could result inpatients having untoward complications requiring rehospitalization, higher morbidity, or prolongation of suffering from their illnesses. The University of Michigan sees a tremendous opportunity to make a significant impact on patient care in this realm and has just initiated a lean project on the coordination of care. Team members on this project will be relevant process stakeholders, including those representing hospitalists, discharge planning, nursing, social work, a related home nursing company, a home infusion service, an ECF, ambulatory care, pharmacy, case management, nutrition, utilization review, patients and their families, and clinic physicians. The overall goal of the project is to optimize patient care from hospitalization to discharge and transfer of care to the outpatient setting.

CONCLUSION

The health care industry should learn about and consider adoption of lean techniques in order to improve its processes. More specifically, hospitals are prime locales for reaping the benefits of implementation of lean production, which can significantly affect how health care is delivered to patients. Toyota and other lean exemplars in the manufacturing industry have achieved a high level of success by utilizing the practice of lean. Early results from health care organizations suggest that utilizing lean production methods can lead to substantial improvements in the quality and efficiency of health care. To determine if the magnitude of success experienced by Toyota and other lean exemplars can also be achieved in the health care sector, it will be necessary to continuously test and evaluate the impact lean health care can have. In the hospital setting, where hospitalists are at the forefront of delivering care, it is incumbent on the hospitalist community to evaluate whether these techniques can make a difference in the quality, efficiency, and safety of the care provided to patients.

Lean thinking is still a novel idea to those in the health care sector, and as early adopters of this promising management model, we are very optimistic about the benefits of applying lean concepts in our hospital. Some of the first published reports and results presented on the benefits of lean in individual organizations are encouraging; however, as health care is a scientific community, we believe that future work should undergo rigorous evaluation on the benefits of lean and that such future works should be shared among the health care community through peer‐reviewed and published works.

Despite more than 2 decades of significant advances in human immunodeficiency virus (HIV) testing and treatment and major HIV‐oriented public health initiatives, the Centers for Disease Control and Prevention (CDC) reports that the incidence of new HIV cases in the United States has remained stable at about 40 000 cases annually.1 CDC estimates indicate that 252 000312 000 of the 1 039 0001 185 000 people in the United States with HIV infection do not know their serostatus,2 and it appears that these unaware individuals may play a significant role in HIV transmission to others.3, 4 In an effort to promote testing for HIV, the CDC initiated a program called Advancing HIV Prevention: New Strategies for a Changing Epidemic in 2003.1 This program recommends incorporating HIV testing into routine medical care.

A decade before Advancing HIV Prevention was published, the CDC directly addressed the issue of HIV testing of hospitalized patients by recommending that hospitals with an HIV seroprevalence rate of at least 1% or an AIDS diagnosis rate 1.0 per 1000 discharges should strongly consider adopting a policy of offering HIV counseling and testing routinely to patients ages 1554 years.5 Despite the information on discharge diagnosis rates often being easily available from hospital databases, even if seroprevalence rates may not, routine HIV testing of hospitalized patients has not occurred.

In 2005 the United States Preventive Services Taskforce (USPSTF) recommendations stated that there was fair evidence that screening adolescents and adults not known to be at increased risk for HIV can detect additional individuals with HIV.6 Their statement reflects data from Chen et al., who identified that self‐reported risk factordirected testing strategies would have missed nearly three quarters of the HIV infections in their clinic setting,7 and from Peterman et al., who demonstrated that 2026% of HIV‐positive patients acknowledged no HIV‐associated risk factors.8

Despite the prior CDC recommendations,1, 5 Chen and Peterman's data,7, 8 and acknowledgment of the high accuracy of the new HIV antibody tests, making false‐positive test results quite rare, the published recommendations of the USPSTF do not support routinely testing individuals who are not at increased risk for acquiring the infection because of the relatively low yield and concern about anxiety and related consequences of HIV testing.

Hospitalists are poised to offer inpatient HIV testing to all inpatients at hospitals that meet the CDC guidelines in an effort to reduce the numbers of patients who have undiagnosed HIV infection. This article examines inpatient HIV testing including barriers that may exist to routine testing and reviews the available rapid HIV tests, which may assist in overcoming some of these barriers.

HIV Testing in the Hospital

Patients diagnosed with HIV infection often have had multiple contacts with the medical community, both inpatient and outpatient, prior to their HIV diagnosis, during which HIV testing had not been offered, thus delaying diagnosis.9 Though clinicians often identify and document triggers that should prompt HIV testing, patients with HIV infection are still not diagnosed in a timely manner. In addition, according to previously published data on inpatient testing from urban institutions, the targeted testing of patients based on traditional risk factors also misses a large proportion of HIV‐infected patients.10 Thus, routine nontargeted inpatient testing, as the CDC suggests, is the preferred strategy.

More than a quarter of patients with HIV in the United States are diagnosed in hospital settings, often in conjunction with an illness that prompts specific testing.11 An important recent study by Brady evaluated the HIV seroprevalence on the medicine and trauma medicine services of 2 hospitals during 2 seasons. The study was blinded and used leftover blood samples taken for other reasons. It found seroprevalence rates varying between 1.4% and 3.7%.12 Two points are noteworthy about this study. First, having excluded those from patients with known HIV disease, a significant proportion of the samples identified as seropositive likely represented unidentified HIV cases. Second, although the seroprevalence varied depending on the season during which testing was done and the service from which blood was obtained, even the lower percentage (1.4%) is higher than the CDC's threshold for offering routine HIV testing.5

With the average length of a hospital stay declining to less than 5 days,13 many patients who undergo nonrapid HIV testing while hospitalized will not receive their results prior to discharge. Though no data specifying the rates of HIV test result follow‐up after hospital discharge have been published, the experience in the outpatient setting suggests a significant number of patients never receive their test results. The CDC estimates that 31% of patients who tested positive for HIV did not return to receive their test results.14 State‐funded, community‐based programs also have highly variable rates of return, with published reports of 2548% of patients never receiving their results.1517 Fortunately, new and highly accurate rapid HIV tests are now available in the United States, almost eliminating the problem of loss to follow‐up18 (see Rapid HIV Antibody Tests, below).

Barriers to Implementing HIV Testing

There are numerous potential barriers to instituting broad‐based screening of hospitalized patients for HIV in addition to the follow‐up issues with standard HIV tests illustrated above. These include the cost and cost effectiveness of the program; the logistics of test performance and counseling on the ward; the risk of offending patients; and the culture changes required of inpatient caregivers and hospital administrators. Each of these is addressed briefly.

Cost

Two cost effectiveness analyses examining routine HIV testing have been published recently. The first, by Sanders,20 assumed a 1% seroprevalence of undiagnosed HIV infection in accordance with CDC recommendations5 and found a one‐time testing cost of $15 078 (2004 dollars) per quality‐adjusted life‐year (QALY) including the benefit accrued to sexual partners of the tested patient. This cost/QALY rose to nearly $40 000/QALY with a seroprevalence of only 0.1%. The second study, by Paltiel,21 demonstrated that the cost/QALY of one‐time testing of patients with a 1% seroprevalence to be $38 000.

A few points must be noted about these studies. First, they are not based on inpatient testing specifically. Nonetheless, the Brady study, above,12 as well as our own experience with routine inpatient testing (unpublished data), suggests that the prevalence may be similar in many inpatient populations. Second, the cost/QALY is very consistent with other routine screening efforts broadly accepted.22 Finally, although both analyses cited moderately to significantly higher costs/QALY for recurrent (eg, every 35 years) routine testing, the relevance of this to routine inpatient testing is less clear.

Another study compared hospitalized patients newly testing HIV positive with a rapid HIV test kit, performed in an emergency department, with those testing HIV positive with conventional HIV tests performed on an inpatient unit.23 Though it was not designed as a cost analysis, the length of stay of the group that received the rapid test was 7 days shorter than that of the group that received the conventional test (6 vs. 13 days; P < .001), with type of HIV testing used identified as an independent effect on length of stay in multivariate regression analysis.

Despite what these analyses reported, start‐up costs for HIV testing services can be substantial, and, at present, insurance reimbursement for HIV counseling does not exist. If physicians offer HIV counseling, they may bill for their time as an extended service, when appropriate. Laboratory fees can be billed, which may help to cover materials and processing costs. Grants through the CDC or the Department of Public Health may be available to support programs that operationalize routine HIV testing.

Logistics of Routine Testing on the Ward

An inpatient unit is a difficult place to do HIV counseling. Issues of patient privacy are substantial, especially in shared rooms or when family or friends are present. Physicians and counselors must be cognizant of these issues and be flexible in the timing and structure of the counseling offered to maximize patient comfort and minimize interruptions. Educating inpatient staff about HIV counseling may help to avoid embarrassing situations and interruptions.

In addition, the time required to do HIV testing properly could significantly slow a busy physician's work flow if offered to every patient. Dedicated HIV counseling and testing staff members can be of great assistance in the process and can remove the time barrier from the physician by performing the tests themselves. Such staff members require training in HIV testing procedures if they are to perform point‐of‐care tests at the bedside. This type of program, coordinated with the leadership of the inpatient service, is ideal for providing routine screening of all admissions as recommended by the CDC.5 In addition, considerations about minimizing or eliminating pretest counseling are ongoing, with counseling only offered during the posttest phase.1, 24 This plan would also reduce the impact of this process on work flow.

An advantage of using an inpatient service as a site for HIV testing is the ability to mobilize a hospital's resources should a patient be diagnosed as HIV positive. Addressing the medical, psychological, and psychosocial needs of newly diagnosed (or previously diagnosed but medically disconnected) patient requires using a multidisciplinary team approach, including inpatient caregivers, social workers, case managers, mental health providers, and HIV specialists.

Avoiding Offending Patients and Changing Hospital Culture

An inpatient unit is an unusual place for routine screening, which usually is relegated to the ambulatory setting. Moreover, with the stigma of HIV still present, despite efforts to quell it,25 inpatient caregivers and hospital administrators may be uncomfortable in approaching or having a trained counselor approach all patients on an inpatient service to discuss HIV counseling and testing.

No studies have been published on inpatient attitudes toward routinely being offered HIV testing. Our HIV testing service faced this question when we wanted to expand our inpatient testing from risk‐factor‐directed and physician‐referral‐based testing to routine testing. To assess patient responses, we asked 72 medical inpatients how they would feel about an unsolicited offer to be tested for HIV while they were inpatients. The results, displayed in Figure 1, demonstrated that only 11% of the patients had an unfavorable response. Of note, the study did not permit further explanations to be given to dispel the concerns of those whose response was unfavorable. With this information, our administration permitted expanded testing to commence.

Figure 1

From the experiences of our testing program, with several thousand patients having been approached, we have found that patients are very rarely offended or upset by being offered HIV testing.

Rapid HIV Antibody Tests in the United States

As noted, a substantial proportion of patients fail to return to obtain results.1517 As with other posthospitalization test follow‐ups,26 significant complications may occur if follow‐up of HIV test results is inadequate. Rapid HIV antibody tests may offer programs a way to ensure that the vast majority of patients learn their test results.

There are currently 4 rapid HIV tests that have been approved for use in the United States by the Food and Drug Administration (FDA). Two of these, the OraQuick ADVANCE Rapid HIV‐1/2 Antibody Test (OraSure Technologies, Inc., Bethlehem, PA)27 and the Uni‐Gold Recombigen HIV Test (Trinity Biotech, Bray, County Wicklow, Ireland),28 have received a waiver from the Clinical Laboratories Improvement Amendment (CLIA), which means they may be used outside a laboratory setting.29 Such a waiver means these tests may be used at the bedside of a patient in a point‐of‐care (POC) fashion similar to that of blood sugar monitoring.

It must be noted, however, that extensive quality assurance and quality control are involved with the use of these POC tests.30 Despite the CLIA waiver, a relationship with the hospital laboratory is required, as the test kits may only be used by an agent of the laboratory. An agent is an individual who the laboratory deems capable and qualified to perform the test competently.

Two additional rapid HIV tests are FDA approved but not CLIA waived. These tests, the Reveal G2 Rapid HIV‐1 Antibody Test (MedMira, Bayers Lake Park, Halifax, Nova Scotia)31 and the Multispot HIV‐1/HIV‐2 Rapid Test (Bio‐Rad Laboratories, Redmond, Washington),32 must be performed in a laboratory (see Table 1).

All 4 tests have sensitivities and specificities similar to those of commercially available standard HIV enzyme immunosorbent assays (EIA) for HIV. As the tests are extremely sensitive, no confirmatory testing is required for nonreactive rapid test results. These tests should be considered negative. False negatives may occur if the patient has had a recent HIV exposure. Thus, as with standard EIA tests, it is important to recommend retesting in 6 weeks for all patients who test HIV negative but who have had a high‐risk exposure in the last 3 months. Also, very rarely, patients receiving antiretroviral therapy who have successfully suppressed their viral replication below detectable limits for long periods may also have false‐negative results. Therefore, with all patients, it is important to reinforce the idea that it is not appropriate to retest for HIV if a patient already knows he or she is HIV positive.

All reactive rapid HIV tests require confirmation. This process is most commonly done with a Western Blot assay and must be completed before a patient is told that he or she has confirmed HIV infection. Although uncommon, false‐positive rapid tests do occur, reinforcing the need for confirmatory testing before a formal diagnosis of HIV infection can be made. Currently, no FDA‐approved rapid confirmatory HIV test is available, so standard laboratory delays may be unavoidable for these patients. It is therefore critical that hospitals providing rapid HIV testing have access to medical and social support systems that may be rapidly mobilized for patients with reactive and confirmed positive tests.

Hospitalists at the Helm of Routine Inpatient HIV Testing

Putting a hospitalist in charge of implementing inpatient HIV testing has several advantages. First, as experts in the hospital systems in which they work, hospitalists are prime candidates to organize a multidisciplinary team involving those from nursing, laboratory medicine, mental health, and social work, as well as HIV specialists. If dedicated HIV counselors are available to participate, they, too, should be included. A hospitalist with an interest in HIV makes an ideal director of such a multidisciplinary program.

Second, hospitalists are on the front line of clinical care and see patients during the earliest hours of their clinical evaluation. By making HIV testing a routine part of all admissions, the hospitalist may act as a role model in the process and will also be able to explain to patients that they are not being singled out, as all patients are encouraged to undergo testing.

Finally, with the demonstrated added value of hospitalist programs33 and the recent literature demonstrating the cost effectiveness of routine HIV testing,20, 21 hospitalists are well suited to demonstrate leadership in the acquisition of the resources required to make routine inpatient HIV testing possible.

Future Directions

To make routine testing a broadly accepted reality, several developments must begin to take place. These include: increasing education about HIV disease as a chronic disease rather than a rapidly terminal illness;34 reducing the stigma of HIV disease (a stigma that has impaired testing rates),25 which should include discussions of eliminating the need for separate HIV test consent forms, not required for testing for other sexually transmitted diseases (eg, syphilis) or life‐threatening diseases (eg, hepatitis C);1 examining the experience and impact of the universal HIV testing recommendations for pregnant women;35, 36 reducing1, 24 or entirely eliminating37 the requirements for extensive pretest counselingwhich may be a low‐yield38 time barrierwith a greater focus on case‐specific post‐test risk reduction;1 and broadening the realization that targeted testing based on traditional HIV risk factors fails to identify a significant number of HIV cases.10, 39

CONCLUSIONS

Though it has been more than a decade since the original CDC recommendations on inpatient HIV testing were released,5 it remains quite clear that routine inpatient HIV testing can and should be a reality in many hospitals in the United States. As the literature12 and our institution's experience suggest, those in an inpatient service may be a population with a higher prevalence of HIV disease, and as such, an inpatient service should be a venue where routine HIV testing is offered. The U.S. Preventive Services Taskforce's conclusion that the benefit of screening adolescents and adults without risk factors for HIV is too small relative to potential harms to justify a general recommendation6 may not apply to the inpatient services where HIV disease may be more common than in the general population. However, because of time constraints, busy clinicians may require the assistance of an HIV counseling and testing service to make this kind of program a reality.

Clearly, using targeted testing strategies based on traditional HIV risk factors fails to identify a significant proportion of undiagnosed HIV cases.7, 8 New, FDA‐approved rapid HIV antibody tests can help to reduce the issue of loss to follow‐up as a barrier to having successful testing programs, and the cost effectiveness of such HIV testing programs has been suggested in recent literature. Although studies are needed to elucidate the differences between routinely tested inpatients and those tested in more traditional ambulatory sites, hospitalists have the opportunity to take the lead in dramatically increasing testing and in substantially decreasing the number of patients unaware of their HIV status.

Despite more than 2 decades of significant advances in human immunodeficiency virus (HIV) testing and treatment and major HIV‐oriented public health initiatives, the Centers for Disease Control and Prevention (CDC) reports that the incidence of new HIV cases in the United States has remained stable at about 40 000 cases annually.1 CDC estimates indicate that 252 000312 000 of the 1 039 0001 185 000 people in the United States with HIV infection do not know their serostatus,2 and it appears that these unaware individuals may play a significant role in HIV transmission to others.3, 4 In an effort to promote testing for HIV, the CDC initiated a program called Advancing HIV Prevention: New Strategies for a Changing Epidemic in 2003.1 This program recommends incorporating HIV testing into routine medical care.

A decade before Advancing HIV Prevention was published, the CDC directly addressed the issue of HIV testing of hospitalized patients by recommending that hospitals with an HIV seroprevalence rate of at least 1% or an AIDS diagnosis rate 1.0 per 1000 discharges should strongly consider adopting a policy of offering HIV counseling and testing routinely to patients ages 1554 years.5 Despite the information on discharge diagnosis rates often being easily available from hospital databases, even if seroprevalence rates may not, routine HIV testing of hospitalized patients has not occurred.

In 2005 the United States Preventive Services Taskforce (USPSTF) recommendations stated that there was fair evidence that screening adolescents and adults not known to be at increased risk for HIV can detect additional individuals with HIV.6 Their statement reflects data from Chen et al., who identified that self‐reported risk factordirected testing strategies would have missed nearly three quarters of the HIV infections in their clinic setting,7 and from Peterman et al., who demonstrated that 2026% of HIV‐positive patients acknowledged no HIV‐associated risk factors.8

Despite the prior CDC recommendations,1, 5 Chen and Peterman's data,7, 8 and acknowledgment of the high accuracy of the new HIV antibody tests, making false‐positive test results quite rare, the published recommendations of the USPSTF do not support routinely testing individuals who are not at increased risk for acquiring the infection because of the relatively low yield and concern about anxiety and related consequences of HIV testing.

Hospitalists are poised to offer inpatient HIV testing to all inpatients at hospitals that meet the CDC guidelines in an effort to reduce the numbers of patients who have undiagnosed HIV infection. This article examines inpatient HIV testing including barriers that may exist to routine testing and reviews the available rapid HIV tests, which may assist in overcoming some of these barriers.

HIV Testing in the Hospital

Patients diagnosed with HIV infection often have had multiple contacts with the medical community, both inpatient and outpatient, prior to their HIV diagnosis, during which HIV testing had not been offered, thus delaying diagnosis.9 Though clinicians often identify and document triggers that should prompt HIV testing, patients with HIV infection are still not diagnosed in a timely manner. In addition, according to previously published data on inpatient testing from urban institutions, the targeted testing of patients based on traditional risk factors also misses a large proportion of HIV‐infected patients.10 Thus, routine nontargeted inpatient testing, as the CDC suggests, is the preferred strategy.

More than a quarter of patients with HIV in the United States are diagnosed in hospital settings, often in conjunction with an illness that prompts specific testing.11 An important recent study by Brady evaluated the HIV seroprevalence on the medicine and trauma medicine services of 2 hospitals during 2 seasons. The study was blinded and used leftover blood samples taken for other reasons. It found seroprevalence rates varying between 1.4% and 3.7%.12 Two points are noteworthy about this study. First, having excluded those from patients with known HIV disease, a significant proportion of the samples identified as seropositive likely represented unidentified HIV cases. Second, although the seroprevalence varied depending on the season during which testing was done and the service from which blood was obtained, even the lower percentage (1.4%) is higher than the CDC's threshold for offering routine HIV testing.5

With the average length of a hospital stay declining to less than 5 days,13 many patients who undergo nonrapid HIV testing while hospitalized will not receive their results prior to discharge. Though no data specifying the rates of HIV test result follow‐up after hospital discharge have been published, the experience in the outpatient setting suggests a significant number of patients never receive their test results. The CDC estimates that 31% of patients who tested positive for HIV did not return to receive their test results.14 State‐funded, community‐based programs also have highly variable rates of return, with published reports of 2548% of patients never receiving their results.1517 Fortunately, new and highly accurate rapid HIV tests are now available in the United States, almost eliminating the problem of loss to follow‐up18 (see Rapid HIV Antibody Tests, below).

Barriers to Implementing HIV Testing

There are numerous potential barriers to instituting broad‐based screening of hospitalized patients for HIV in addition to the follow‐up issues with standard HIV tests illustrated above. These include the cost and cost effectiveness of the program; the logistics of test performance and counseling on the ward; the risk of offending patients; and the culture changes required of inpatient caregivers and hospital administrators. Each of these is addressed briefly.

Cost

Two cost effectiveness analyses examining routine HIV testing have been published recently. The first, by Sanders,20 assumed a 1% seroprevalence of undiagnosed HIV infection in accordance with CDC recommendations5 and found a one‐time testing cost of $15 078 (2004 dollars) per quality‐adjusted life‐year (QALY) including the benefit accrued to sexual partners of the tested patient. This cost/QALY rose to nearly $40 000/QALY with a seroprevalence of only 0.1%. The second study, by Paltiel,21 demonstrated that the cost/QALY of one‐time testing of patients with a 1% seroprevalence to be $38 000.

A few points must be noted about these studies. First, they are not based on inpatient testing specifically. Nonetheless, the Brady study, above,12 as well as our own experience with routine inpatient testing (unpublished data), suggests that the prevalence may be similar in many inpatient populations. Second, the cost/QALY is very consistent with other routine screening efforts broadly accepted.22 Finally, although both analyses cited moderately to significantly higher costs/QALY for recurrent (eg, every 35 years) routine testing, the relevance of this to routine inpatient testing is less clear.

Another study compared hospitalized patients newly testing HIV positive with a rapid HIV test kit, performed in an emergency department, with those testing HIV positive with conventional HIV tests performed on an inpatient unit.23 Though it was not designed as a cost analysis, the length of stay of the group that received the rapid test was 7 days shorter than that of the group that received the conventional test (6 vs. 13 days; P < .001), with type of HIV testing used identified as an independent effect on length of stay in multivariate regression analysis.

Despite what these analyses reported, start‐up costs for HIV testing services can be substantial, and, at present, insurance reimbursement for HIV counseling does not exist. If physicians offer HIV counseling, they may bill for their time as an extended service, when appropriate. Laboratory fees can be billed, which may help to cover materials and processing costs. Grants through the CDC or the Department of Public Health may be available to support programs that operationalize routine HIV testing.

Logistics of Routine Testing on the Ward

An inpatient unit is a difficult place to do HIV counseling. Issues of patient privacy are substantial, especially in shared rooms or when family or friends are present. Physicians and counselors must be cognizant of these issues and be flexible in the timing and structure of the counseling offered to maximize patient comfort and minimize interruptions. Educating inpatient staff about HIV counseling may help to avoid embarrassing situations and interruptions.

In addition, the time required to do HIV testing properly could significantly slow a busy physician's work flow if offered to every patient. Dedicated HIV counseling and testing staff members can be of great assistance in the process and can remove the time barrier from the physician by performing the tests themselves. Such staff members require training in HIV testing procedures if they are to perform point‐of‐care tests at the bedside. This type of program, coordinated with the leadership of the inpatient service, is ideal for providing routine screening of all admissions as recommended by the CDC.5 In addition, considerations about minimizing or eliminating pretest counseling are ongoing, with counseling only offered during the posttest phase.1, 24 This plan would also reduce the impact of this process on work flow.

An advantage of using an inpatient service as a site for HIV testing is the ability to mobilize a hospital's resources should a patient be diagnosed as HIV positive. Addressing the medical, psychological, and psychosocial needs of newly diagnosed (or previously diagnosed but medically disconnected) patient requires using a multidisciplinary team approach, including inpatient caregivers, social workers, case managers, mental health providers, and HIV specialists.

Avoiding Offending Patients and Changing Hospital Culture

An inpatient unit is an unusual place for routine screening, which usually is relegated to the ambulatory setting. Moreover, with the stigma of HIV still present, despite efforts to quell it,25 inpatient caregivers and hospital administrators may be uncomfortable in approaching or having a trained counselor approach all patients on an inpatient service to discuss HIV counseling and testing.

No studies have been published on inpatient attitudes toward routinely being offered HIV testing. Our HIV testing service faced this question when we wanted to expand our inpatient testing from risk‐factor‐directed and physician‐referral‐based testing to routine testing. To assess patient responses, we asked 72 medical inpatients how they would feel about an unsolicited offer to be tested for HIV while they were inpatients. The results, displayed in Figure 1, demonstrated that only 11% of the patients had an unfavorable response. Of note, the study did not permit further explanations to be given to dispel the concerns of those whose response was unfavorable. With this information, our administration permitted expanded testing to commence.

Figure 1

From the experiences of our testing program, with several thousand patients having been approached, we have found that patients are very rarely offended or upset by being offered HIV testing.

Rapid HIV Antibody Tests in the United States

As noted, a substantial proportion of patients fail to return to obtain results.1517 As with other posthospitalization test follow‐ups,26 significant complications may occur if follow‐up of HIV test results is inadequate. Rapid HIV antibody tests may offer programs a way to ensure that the vast majority of patients learn their test results.

There are currently 4 rapid HIV tests that have been approved for use in the United States by the Food and Drug Administration (FDA). Two of these, the OraQuick ADVANCE Rapid HIV‐1/2 Antibody Test (OraSure Technologies, Inc., Bethlehem, PA)27 and the Uni‐Gold Recombigen HIV Test (Trinity Biotech, Bray, County Wicklow, Ireland),28 have received a waiver from the Clinical Laboratories Improvement Amendment (CLIA), which means they may be used outside a laboratory setting.29 Such a waiver means these tests may be used at the bedside of a patient in a point‐of‐care (POC) fashion similar to that of blood sugar monitoring.

It must be noted, however, that extensive quality assurance and quality control are involved with the use of these POC tests.30 Despite the CLIA waiver, a relationship with the hospital laboratory is required, as the test kits may only be used by an agent of the laboratory. An agent is an individual who the laboratory deems capable and qualified to perform the test competently.

Two additional rapid HIV tests are FDA approved but not CLIA waived. These tests, the Reveal G2 Rapid HIV‐1 Antibody Test (MedMira, Bayers Lake Park, Halifax, Nova Scotia)31 and the Multispot HIV‐1/HIV‐2 Rapid Test (Bio‐Rad Laboratories, Redmond, Washington),32 must be performed in a laboratory (see Table 1).

All 4 tests have sensitivities and specificities similar to those of commercially available standard HIV enzyme immunosorbent assays (EIA) for HIV. As the tests are extremely sensitive, no confirmatory testing is required for nonreactive rapid test results. These tests should be considered negative. False negatives may occur if the patient has had a recent HIV exposure. Thus, as with standard EIA tests, it is important to recommend retesting in 6 weeks for all patients who test HIV negative but who have had a high‐risk exposure in the last 3 months. Also, very rarely, patients receiving antiretroviral therapy who have successfully suppressed their viral replication below detectable limits for long periods may also have false‐negative results. Therefore, with all patients, it is important to reinforce the idea that it is not appropriate to retest for HIV if a patient already knows he or she is HIV positive.

All reactive rapid HIV tests require confirmation. This process is most commonly done with a Western Blot assay and must be completed before a patient is told that he or she has confirmed HIV infection. Although uncommon, false‐positive rapid tests do occur, reinforcing the need for confirmatory testing before a formal diagnosis of HIV infection can be made. Currently, no FDA‐approved rapid confirmatory HIV test is available, so standard laboratory delays may be unavoidable for these patients. It is therefore critical that hospitals providing rapid HIV testing have access to medical and social support systems that may be rapidly mobilized for patients with reactive and confirmed positive tests.

Hospitalists at the Helm of Routine Inpatient HIV Testing

Putting a hospitalist in charge of implementing inpatient HIV testing has several advantages. First, as experts in the hospital systems in which they work, hospitalists are prime candidates to organize a multidisciplinary team involving those from nursing, laboratory medicine, mental health, and social work, as well as HIV specialists. If dedicated HIV counselors are available to participate, they, too, should be included. A hospitalist with an interest in HIV makes an ideal director of such a multidisciplinary program.

Second, hospitalists are on the front line of clinical care and see patients during the earliest hours of their clinical evaluation. By making HIV testing a routine part of all admissions, the hospitalist may act as a role model in the process and will also be able to explain to patients that they are not being singled out, as all patients are encouraged to undergo testing.

Finally, with the demonstrated added value of hospitalist programs33 and the recent literature demonstrating the cost effectiveness of routine HIV testing,20, 21 hospitalists are well suited to demonstrate leadership in the acquisition of the resources required to make routine inpatient HIV testing possible.

Future Directions

To make routine testing a broadly accepted reality, several developments must begin to take place. These include: increasing education about HIV disease as a chronic disease rather than a rapidly terminal illness;34 reducing the stigma of HIV disease (a stigma that has impaired testing rates),25 which should include discussions of eliminating the need for separate HIV test consent forms, not required for testing for other sexually transmitted diseases (eg, syphilis) or life‐threatening diseases (eg, hepatitis C);1 examining the experience and impact of the universal HIV testing recommendations for pregnant women;35, 36 reducing1, 24 or entirely eliminating37 the requirements for extensive pretest counselingwhich may be a low‐yield38 time barrierwith a greater focus on case‐specific post‐test risk reduction;1 and broadening the realization that targeted testing based on traditional HIV risk factors fails to identify a significant number of HIV cases.10, 39

CONCLUSIONS

Though it has been more than a decade since the original CDC recommendations on inpatient HIV testing were released,5 it remains quite clear that routine inpatient HIV testing can and should be a reality in many hospitals in the United States. As the literature12 and our institution's experience suggest, those in an inpatient service may be a population with a higher prevalence of HIV disease, and as such, an inpatient service should be a venue where routine HIV testing is offered. The U.S. Preventive Services Taskforce's conclusion that the benefit of screening adolescents and adults without risk factors for HIV is too small relative to potential harms to justify a general recommendation6 may not apply to the inpatient services where HIV disease may be more common than in the general population. However, because of time constraints, busy clinicians may require the assistance of an HIV counseling and testing service to make this kind of program a reality.

Clearly, using targeted testing strategies based on traditional HIV risk factors fails to identify a significant proportion of undiagnosed HIV cases.7, 8 New, FDA‐approved rapid HIV antibody tests can help to reduce the issue of loss to follow‐up as a barrier to having successful testing programs, and the cost effectiveness of such HIV testing programs has been suggested in recent literature. Although studies are needed to elucidate the differences between routinely tested inpatients and those tested in more traditional ambulatory sites, hospitalists have the opportunity to take the lead in dramatically increasing testing and in substantially decreasing the number of patients unaware of their HIV status.

Despite more than 2 decades of significant advances in human immunodeficiency virus (HIV) testing and treatment and major HIV‐oriented public health initiatives, the Centers for Disease Control and Prevention (CDC) reports that the incidence of new HIV cases in the United States has remained stable at about 40 000 cases annually.1 CDC estimates indicate that 252 000312 000 of the 1 039 0001 185 000 people in the United States with HIV infection do not know their serostatus,2 and it appears that these unaware individuals may play a significant role in HIV transmission to others.3, 4 In an effort to promote testing for HIV, the CDC initiated a program called Advancing HIV Prevention: New Strategies for a Changing Epidemic in 2003.1 This program recommends incorporating HIV testing into routine medical care.

A decade before Advancing HIV Prevention was published, the CDC directly addressed the issue of HIV testing of hospitalized patients by recommending that hospitals with an HIV seroprevalence rate of at least 1% or an AIDS diagnosis rate 1.0 per 1000 discharges should strongly consider adopting a policy of offering HIV counseling and testing routinely to patients ages 1554 years.5 Despite the information on discharge diagnosis rates often being easily available from hospital databases, even if seroprevalence rates may not, routine HIV testing of hospitalized patients has not occurred.

In 2005 the United States Preventive Services Taskforce (USPSTF) recommendations stated that there was fair evidence that screening adolescents and adults not known to be at increased risk for HIV can detect additional individuals with HIV.6 Their statement reflects data from Chen et al., who identified that self‐reported risk factordirected testing strategies would have missed nearly three quarters of the HIV infections in their clinic setting,7 and from Peterman et al., who demonstrated that 2026% of HIV‐positive patients acknowledged no HIV‐associated risk factors.8

Despite the prior CDC recommendations,1, 5 Chen and Peterman's data,7, 8 and acknowledgment of the high accuracy of the new HIV antibody tests, making false‐positive test results quite rare, the published recommendations of the USPSTF do not support routinely testing individuals who are not at increased risk for acquiring the infection because of the relatively low yield and concern about anxiety and related consequences of HIV testing.

Hospitalists are poised to offer inpatient HIV testing to all inpatients at hospitals that meet the CDC guidelines in an effort to reduce the numbers of patients who have undiagnosed HIV infection. This article examines inpatient HIV testing including barriers that may exist to routine testing and reviews the available rapid HIV tests, which may assist in overcoming some of these barriers.

HIV Testing in the Hospital

Patients diagnosed with HIV infection often have had multiple contacts with the medical community, both inpatient and outpatient, prior to their HIV diagnosis, during which HIV testing had not been offered, thus delaying diagnosis.9 Though clinicians often identify and document triggers that should prompt HIV testing, patients with HIV infection are still not diagnosed in a timely manner. In addition, according to previously published data on inpatient testing from urban institutions, the targeted testing of patients based on traditional risk factors also misses a large proportion of HIV‐infected patients.10 Thus, routine nontargeted inpatient testing, as the CDC suggests, is the preferred strategy.

More than a quarter of patients with HIV in the United States are diagnosed in hospital settings, often in conjunction with an illness that prompts specific testing.11 An important recent study by Brady evaluated the HIV seroprevalence on the medicine and trauma medicine services of 2 hospitals during 2 seasons. The study was blinded and used leftover blood samples taken for other reasons. It found seroprevalence rates varying between 1.4% and 3.7%.12 Two points are noteworthy about this study. First, having excluded those from patients with known HIV disease, a significant proportion of the samples identified as seropositive likely represented unidentified HIV cases. Second, although the seroprevalence varied depending on the season during which testing was done and the service from which blood was obtained, even the lower percentage (1.4%) is higher than the CDC's threshold for offering routine HIV testing.5

With the average length of a hospital stay declining to less than 5 days,13 many patients who undergo nonrapid HIV testing while hospitalized will not receive their results prior to discharge. Though no data specifying the rates of HIV test result follow‐up after hospital discharge have been published, the experience in the outpatient setting suggests a significant number of patients never receive their test results. The CDC estimates that 31% of patients who tested positive for HIV did not return to receive their test results.14 State‐funded, community‐based programs also have highly variable rates of return, with published reports of 2548% of patients never receiving their results.1517 Fortunately, new and highly accurate rapid HIV tests are now available in the United States, almost eliminating the problem of loss to follow‐up18 (see Rapid HIV Antibody Tests, below).

Barriers to Implementing HIV Testing

There are numerous potential barriers to instituting broad‐based screening of hospitalized patients for HIV in addition to the follow‐up issues with standard HIV tests illustrated above. These include the cost and cost effectiveness of the program; the logistics of test performance and counseling on the ward; the risk of offending patients; and the culture changes required of inpatient caregivers and hospital administrators. Each of these is addressed briefly.

Cost

Two cost effectiveness analyses examining routine HIV testing have been published recently. The first, by Sanders,20 assumed a 1% seroprevalence of undiagnosed HIV infection in accordance with CDC recommendations5 and found a one‐time testing cost of $15 078 (2004 dollars) per quality‐adjusted life‐year (QALY) including the benefit accrued to sexual partners of the tested patient. This cost/QALY rose to nearly $40 000/QALY with a seroprevalence of only 0.1%. The second study, by Paltiel,21 demonstrated that the cost/QALY of one‐time testing of patients with a 1% seroprevalence to be $38 000.

A few points must be noted about these studies. First, they are not based on inpatient testing specifically. Nonetheless, the Brady study, above,12 as well as our own experience with routine inpatient testing (unpublished data), suggests that the prevalence may be similar in many inpatient populations. Second, the cost/QALY is very consistent with other routine screening efforts broadly accepted.22 Finally, although both analyses cited moderately to significantly higher costs/QALY for recurrent (eg, every 35 years) routine testing, the relevance of this to routine inpatient testing is less clear.

Another study compared hospitalized patients newly testing HIV positive with a rapid HIV test kit, performed in an emergency department, with those testing HIV positive with conventional HIV tests performed on an inpatient unit.23 Though it was not designed as a cost analysis, the length of stay of the group that received the rapid test was 7 days shorter than that of the group that received the conventional test (6 vs. 13 days; P < .001), with type of HIV testing used identified as an independent effect on length of stay in multivariate regression analysis.

Despite what these analyses reported, start‐up costs for HIV testing services can be substantial, and, at present, insurance reimbursement for HIV counseling does not exist. If physicians offer HIV counseling, they may bill for their time as an extended service, when appropriate. Laboratory fees can be billed, which may help to cover materials and processing costs. Grants through the CDC or the Department of Public Health may be available to support programs that operationalize routine HIV testing.

Logistics of Routine Testing on the Ward

An inpatient unit is a difficult place to do HIV counseling. Issues of patient privacy are substantial, especially in shared rooms or when family or friends are present. Physicians and counselors must be cognizant of these issues and be flexible in the timing and structure of the counseling offered to maximize patient comfort and minimize interruptions. Educating inpatient staff about HIV counseling may help to avoid embarrassing situations and interruptions.

In addition, the time required to do HIV testing properly could significantly slow a busy physician's work flow if offered to every patient. Dedicated HIV counseling and testing staff members can be of great assistance in the process and can remove the time barrier from the physician by performing the tests themselves. Such staff members require training in HIV testing procedures if they are to perform point‐of‐care tests at the bedside. This type of program, coordinated with the leadership of the inpatient service, is ideal for providing routine screening of all admissions as recommended by the CDC.5 In addition, considerations about minimizing or eliminating pretest counseling are ongoing, with counseling only offered during the posttest phase.1, 24 This plan would also reduce the impact of this process on work flow.

An advantage of using an inpatient service as a site for HIV testing is the ability to mobilize a hospital's resources should a patient be diagnosed as HIV positive. Addressing the medical, psychological, and psychosocial needs of newly diagnosed (or previously diagnosed but medically disconnected) patient requires using a multidisciplinary team approach, including inpatient caregivers, social workers, case managers, mental health providers, and HIV specialists.

Avoiding Offending Patients and Changing Hospital Culture

An inpatient unit is an unusual place for routine screening, which usually is relegated to the ambulatory setting. Moreover, with the stigma of HIV still present, despite efforts to quell it,25 inpatient caregivers and hospital administrators may be uncomfortable in approaching or having a trained counselor approach all patients on an inpatient service to discuss HIV counseling and testing.

No studies have been published on inpatient attitudes toward routinely being offered HIV testing. Our HIV testing service faced this question when we wanted to expand our inpatient testing from risk‐factor‐directed and physician‐referral‐based testing to routine testing. To assess patient responses, we asked 72 medical inpatients how they would feel about an unsolicited offer to be tested for HIV while they were inpatients. The results, displayed in Figure 1, demonstrated that only 11% of the patients had an unfavorable response. Of note, the study did not permit further explanations to be given to dispel the concerns of those whose response was unfavorable. With this information, our administration permitted expanded testing to commence.

Figure 1

From the experiences of our testing program, with several thousand patients having been approached, we have found that patients are very rarely offended or upset by being offered HIV testing.

Rapid HIV Antibody Tests in the United States

As noted, a substantial proportion of patients fail to return to obtain results.1517 As with other posthospitalization test follow‐ups,26 significant complications may occur if follow‐up of HIV test results is inadequate. Rapid HIV antibody tests may offer programs a way to ensure that the vast majority of patients learn their test results.

There are currently 4 rapid HIV tests that have been approved for use in the United States by the Food and Drug Administration (FDA). Two of these, the OraQuick ADVANCE Rapid HIV‐1/2 Antibody Test (OraSure Technologies, Inc., Bethlehem, PA)27 and the Uni‐Gold Recombigen HIV Test (Trinity Biotech, Bray, County Wicklow, Ireland),28 have received a waiver from the Clinical Laboratories Improvement Amendment (CLIA), which means they may be used outside a laboratory setting.29 Such a waiver means these tests may be used at the bedside of a patient in a point‐of‐care (POC) fashion similar to that of blood sugar monitoring.

It must be noted, however, that extensive quality assurance and quality control are involved with the use of these POC tests.30 Despite the CLIA waiver, a relationship with the hospital laboratory is required, as the test kits may only be used by an agent of the laboratory. An agent is an individual who the laboratory deems capable and qualified to perform the test competently.

Two additional rapid HIV tests are FDA approved but not CLIA waived. These tests, the Reveal G2 Rapid HIV‐1 Antibody Test (MedMira, Bayers Lake Park, Halifax, Nova Scotia)31 and the Multispot HIV‐1/HIV‐2 Rapid Test (Bio‐Rad Laboratories, Redmond, Washington),32 must be performed in a laboratory (see Table 1).

All 4 tests have sensitivities and specificities similar to those of commercially available standard HIV enzyme immunosorbent assays (EIA) for HIV. As the tests are extremely sensitive, no confirmatory testing is required for nonreactive rapid test results. These tests should be considered negative. False negatives may occur if the patient has had a recent HIV exposure. Thus, as with standard EIA tests, it is important to recommend retesting in 6 weeks for all patients who test HIV negative but who have had a high‐risk exposure in the last 3 months. Also, very rarely, patients receiving antiretroviral therapy who have successfully suppressed their viral replication below detectable limits for long periods may also have false‐negative results. Therefore, with all patients, it is important to reinforce the idea that it is not appropriate to retest for HIV if a patient already knows he or she is HIV positive.

All reactive rapid HIV tests require confirmation. This process is most commonly done with a Western Blot assay and must be completed before a patient is told that he or she has confirmed HIV infection. Although uncommon, false‐positive rapid tests do occur, reinforcing the need for confirmatory testing before a formal diagnosis of HIV infection can be made. Currently, no FDA‐approved rapid confirmatory HIV test is available, so standard laboratory delays may be unavoidable for these patients. It is therefore critical that hospitals providing rapid HIV testing have access to medical and social support systems that may be rapidly mobilized for patients with reactive and confirmed positive tests.

Hospitalists at the Helm of Routine Inpatient HIV Testing

Putting a hospitalist in charge of implementing inpatient HIV testing has several advantages. First, as experts in the hospital systems in which they work, hospitalists are prime candidates to organize a multidisciplinary team involving those from nursing, laboratory medicine, mental health, and social work, as well as HIV specialists. If dedicated HIV counselors are available to participate, they, too, should be included. A hospitalist with an interest in HIV makes an ideal director of such a multidisciplinary program.

Second, hospitalists are on the front line of clinical care and see patients during the earliest hours of their clinical evaluation. By making HIV testing a routine part of all admissions, the hospitalist may act as a role model in the process and will also be able to explain to patients that they are not being singled out, as all patients are encouraged to undergo testing.

Finally, with the demonstrated added value of hospitalist programs33 and the recent literature demonstrating the cost effectiveness of routine HIV testing,20, 21 hospitalists are well suited to demonstrate leadership in the acquisition of the resources required to make routine inpatient HIV testing possible.

Future Directions

To make routine testing a broadly accepted reality, several developments must begin to take place. These include: increasing education about HIV disease as a chronic disease rather than a rapidly terminal illness;34 reducing the stigma of HIV disease (a stigma that has impaired testing rates),25 which should include discussions of eliminating the need for separate HIV test consent forms, not required for testing for other sexually transmitted diseases (eg, syphilis) or life‐threatening diseases (eg, hepatitis C);1 examining the experience and impact of the universal HIV testing recommendations for pregnant women;35, 36 reducing1, 24 or entirely eliminating37 the requirements for extensive pretest counselingwhich may be a low‐yield38 time barrierwith a greater focus on case‐specific post‐test risk reduction;1 and broadening the realization that targeted testing based on traditional HIV risk factors fails to identify a significant number of HIV cases.10, 39

CONCLUSIONS

Though it has been more than a decade since the original CDC recommendations on inpatient HIV testing were released,5 it remains quite clear that routine inpatient HIV testing can and should be a reality in many hospitals in the United States. As the literature12 and our institution's experience suggest, those in an inpatient service may be a population with a higher prevalence of HIV disease, and as such, an inpatient service should be a venue where routine HIV testing is offered. The U.S. Preventive Services Taskforce's conclusion that the benefit of screening adolescents and adults without risk factors for HIV is too small relative to potential harms to justify a general recommendation6 may not apply to the inpatient services where HIV disease may be more common than in the general population. However, because of time constraints, busy clinicians may require the assistance of an HIV counseling and testing service to make this kind of program a reality.

Clearly, using targeted testing strategies based on traditional HIV risk factors fails to identify a significant proportion of undiagnosed HIV cases.7, 8 New, FDA‐approved rapid HIV antibody tests can help to reduce the issue of loss to follow‐up as a barrier to having successful testing programs, and the cost effectiveness of such HIV testing programs has been suggested in recent literature. Although studies are needed to elucidate the differences between routinely tested inpatients and those tested in more traditional ambulatory sites, hospitalists have the opportunity to take the lead in dramatically increasing testing and in substantially decreasing the number of patients unaware of their HIV status.

Between 1996with the first appearance of hospitalists in the medical literatureand the present, the hospitalist workforce has grown to nearly 10,000.1, 2 More remarkable is the estimate that the number of hospitalists will double in the next 5 years.2 The rapid growth of hospital medicine raises significant issues for the care of older patients, who are hospitalized at high rates3 and suffer numerous complications from hospitalization including functional decline,4 delirium,5 and a disproportionate share of adverse events.6 Conversely, the needs of patients older than 65 years of age, whose hospital stays make up nearly 50% of acute‐care bed days, will shape the future of hospital medicine.3

To date, the hospital medicine literature has failed to address the particular challenges of treating older patients, focusing primarily on opportunities for reductions in costs and length of stay for hospitalists' Medicare patients (of about $1000 per admission and 0.5 days, respectively7, 8) when compared with those cared for by other physicians. This focus on economic efficiency reflects the early orientation of the hospitalist movement. More recently, leaders of the hospitalist professional organization, the Society of Hospital Medicine (SHM), have increasingly recognized that caring for the older population will require additional knowledge and clinical skills beyond that taught in internal medicine residencies.9 Beyond educational initiatives, however, hospitalists must reconsider the paradigms of hospital care that make the hospital setting so dangerous for the older patient.

Given the aging population and the predicted growth of hospital medicine, it is essential to develop an understanding of the impact of hospitalists on the care of older patients and to encourage clinical innovation at the intersection of hospital medicine and geriatrics. Consequently, this article 1) identifies and summarizes geriatric care approaches in hospitalist programs, 2) presents a case study of geriatric hospital care by a hospitalist group, and 3) highlights opportunities for innovation and further research.

METHODS

RESULTS

In 2003 the annual survey of the American Hospital Association identified 1415 hospitalist groups in the United States (Joe Miller, SHM senior vice‐president, personal communication). Remarkably, our query identified only 11 hospitalist groups with clinical innovations aimed at the older population. These innovations ranged from single individuals involved in targeted quality‐improvement projects to highly developed programs addressing an array of clinical needs for the hospitalized older patient. These 11 programs are summarized in Table 1 and described below.

DISCUSSION

Although SHM increasingly recognizes the challenges inherent in caring for older patients, few hospitalists are adapting their care for this vulnerable population. We identified only 11 innovations in geriatric care despite there being more than 1000 hospitalist groups. This apparent paucity of innovation in geriatrics might be explained by the relatively recent introduction of hospital medicine. As no hospitalist program is more than 10 years old, most programs are still focused on building core clinical activities or on other competing demands. In addition to time, funding may limit the typical program's ability to innovate without directly increasing revenue. Although the geriatrics literature supports that specialized inpatient care for older patients can result in increased physical functioning and quality of life at no additional cost, it may be that geriatricians have yet to make this case effectively to the hospitalist community.14, 15

The findings of this study were limited by our survey methodology. Specifically, our sample was limited to professional contacts and those using SHM listservs. In addition, some innovative hospitalists may not consider their programs to be geriatric programs and so may not have responded to our queries. Therefore, the reported innovations are not representative of geriatric care among all hospitalist groups, and we are unable to provide a comprehensive picture of geriatric care in hospitalist programs. In addition, we cannot comment on the effectiveness of the care approaches at participating institutions. For example, interdisciplinary care is an important tenet of geriatric medicine. Although six of our programs reported interdisciplinary rounds, it is unclear if these rounds are models of effective collaborative practice. Nonetheless, the information obtained from the structured interviews allowed the identification of several instructive themes discussed below.

CONCLUSIONS

The rapid growth of the hospitalist movement will significantly affect clinical care in American hospitals. As most hospital patients are older, the impact on acute care geriatrics cannot be overlooked. In our study, we identified only a small number of hospitalist groups that have made geriatric medicine a priority. These programs prioritize geriatric medicine through the employment of geriatrics‐trained staff, adaptation of geriatric care models such as ACE units, and commitment to clinical quality improvement and patient safety. They also focus on common clinical challenges for older patients, including postoperative and postdischarge care. Although much can be learned from these examples, programs at other institutions will need to be individualized to meet the specific needs of each hospital and community. The common goal of clinical excellence shared by hospitalists and geriatricians should motivate cooperation, collaborative approaches, and a joint clinical research agenda at all levels, as the current paradigm of hospital care remains inadequate to meet the needs of the acutely ill older patient.