Patient Safety

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Maynard says.

For example:

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

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

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

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

Karen Appold is a freelance medical writer in Pennsylvania.

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Maynard says.

For example:

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

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

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

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

Karen Appold is a freelance medical writer in Pennsylvania.

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

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

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

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

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

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

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

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

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

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

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

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

Dr. Maynard says.

For example:

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

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

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

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

Karen Appold is a freelance medical writer in Pennsylvania.

In 2015, reimbursement for physicians in large groups is subject to a value modifier that takes into account the cost and quality of services performed under the Medicare Physician Fee Schedule. By 2017, the modifier will apply to all physicians participating in fee-for-service Medicare.

It’s one more way the Centers for Medicare and Medicaid Services (CMS) and the federal government are attempting to tip the scales on skyrocketing healthcare costs. Their end goal is a focus on better efficiency and less waste in the healthcare system.

But in an environment of top-down measures, hospitalists on the front lines are leading the charge to reduce overuse and overtreatment, slow cost growth, and improve both the quality of care and outcomes for their patients.

“I think the hospitalist movement has prided itself on quality improvement and patient safety in the hospital,” says Chris Moriates, MD, assistant clinical professor in the division of hospital medicine at the University of California San Francisco (UCSF) and co-creator of the cost awareness curriculum for UCSF’s internal medicine residents. “Over the last few years…they are more focused and enthusiastic about looking at value.”

Dr. Moriates leads the UCSF hospitalist division’s High Value Care Committee and is director of implementation initiatives at Costs of Care. He’s also part of a UCSF program that invites all employees to submit ideas for cutting waste in the hospital while maintaining or improving patient care quality. Last year, the winning project tackled unnecessary blood transfusions and at the same time realized $1 million in savings due to lower transfusion rates. This year, the hospital will focus on decreasing money spent on surgical supplies, potentially saving millions of dollars, he says.

A 2012 article in the Journal of the American Medical Association (JAMA) estimates wasteful spending costs the U.S. healthcare system at least $600 billion and potentially more than a trillion dollars annually due to such issues as care coordination and care delivery failures and overtreatment.¹ Numerous studies also indicate overtreatment can lead to patient harm.²

“Say a patient gets a prophylactic scan for abdominal pain,” says Vineet Arora, MD, MAPP, a hospitalist on faculty in the University of Chicago’s department of medicine and director of education initiatives for Costs of Care. “The patient gets better, but an incidental finding of the scan is a renal mass. Now, there is a work-up of that mass, the patient gets a biopsy, and they have a bleed. A lot of testing leads to more testing, and more testing can lead to harm.”

Doing less is often better, says John Bulger, DO, MBA, SFHM, chief quality officer for the Geisinger Health System in Danville, Pa. Dr. Bulger, who has led SHM’s participation in the Choosing Wisely campaign, cites a September 2014 study in JAMA Internal Medicine, in which Christiana Care Health System—an 1,100-bed tertiary care center in northern Delaware—built best practice telemetry guidelines into its electronic ordering system to help physicians determine when monitoring was appropriate.³ The health system also assembled multidisciplinary teams, which identified when medications warranted telemetry, and equipped nurses with tools to determine when telemetry should be stopped.

Appropriate use of telemetry is one of SHM’s five Choosing Wisely recommendations for adult patient care.

In addition to an overall 70% reduction in telemetry use without negative impact to patient safety, Christiana Care saved $4.8 million. Throughout its inpatient units, Christiana Care utilizes a multidisciplinary team approach to coordinate patient care. Daily rounds are attended by hospitalists, nurses, pharmacists, case managers, social workers, and others to ensure timely and appropriate patient care. The health system’s Value Institute evaluates hospital efforts and assesses process design to improve efficiency and, ultimately, outcomes.

“This is preparing for war in a time of peace, essentially,” says LeRoi S. Hicks, MD, MPH, a hospitalist, researcher, and educator at Christiana Care. “The goal will be, as we move to bundled payment and population health approaches, to minimize the time patients spend in the hospitals and limit the growth curve in spending on the hospital side. We are doing this and not taking on financial risk.”

Dr. Hicks adds that in its most simple form the project “reduces variation in the care we deliver” while improving efficiency and outcomes.

For many physicians, the best way to start is to begin a dialogue with patients who might also be at risk of financial harm due to unnecessary care, Dr. Arora says. “Patients are willing to change their minds and go with the more affordable and more evidence-based treatment and forgo expensive ones if they have that conversation,” she says.

Many resources exist for physicians interested in driving the frontline charge to improve healthcare quality and value. The Costs of Care curriculum provides training and tools for physicians at teachingvalue.org, as do SHM’s Center for Quality Innovation and the Institute for Healthcare Improvement. Dr. Moriates and Dr. Arora also have co-authored a book, along with Neel Shah, MD, founder and executive director of Costs of Care, called “Understanding Value Based Healthcare.” The book will be available this spring.

“We shouldn’t sit by the side of the road waiting for things to pass by,” Dr. Arora says. “I think the key is, we know the needle is shifting in Washington, we know system innovation models are being tested. It would be silly for us to say we’re going to continue the status quo and not look at ways to contribute as physicians.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513-1516.
2. Morgan DJ, Wright SM, Dhruva S. Update on medical overuse. JAMA Intern Med. 2015;175(1):120-124.
3. Dressler R, Dryer MM, Coletti C, Mahoney D, Doorey AJ. Altering overuse of cardiac telemetry in non-intensive care unit settings by hardwiring the use of American Heart Association guidelines. JAMA Intern Med. 2014;174(11):1852-1854.

In 2015, reimbursement for physicians in large groups is subject to a value modifier that takes into account the cost and quality of services performed under the Medicare Physician Fee Schedule. By 2017, the modifier will apply to all physicians participating in fee-for-service Medicare.

It’s one more way the Centers for Medicare and Medicaid Services (CMS) and the federal government are attempting to tip the scales on skyrocketing healthcare costs. Their end goal is a focus on better efficiency and less waste in the healthcare system.

But in an environment of top-down measures, hospitalists on the front lines are leading the charge to reduce overuse and overtreatment, slow cost growth, and improve both the quality of care and outcomes for their patients.

“I think the hospitalist movement has prided itself on quality improvement and patient safety in the hospital,” says Chris Moriates, MD, assistant clinical professor in the division of hospital medicine at the University of California San Francisco (UCSF) and co-creator of the cost awareness curriculum for UCSF’s internal medicine residents. “Over the last few years…they are more focused and enthusiastic about looking at value.”

Dr. Moriates leads the UCSF hospitalist division’s High Value Care Committee and is director of implementation initiatives at Costs of Care. He’s also part of a UCSF program that invites all employees to submit ideas for cutting waste in the hospital while maintaining or improving patient care quality. Last year, the winning project tackled unnecessary blood transfusions and at the same time realized $1 million in savings due to lower transfusion rates. This year, the hospital will focus on decreasing money spent on surgical supplies, potentially saving millions of dollars, he says.

A 2012 article in the Journal of the American Medical Association (JAMA) estimates wasteful spending costs the U.S. healthcare system at least $600 billion and potentially more than a trillion dollars annually due to such issues as care coordination and care delivery failures and overtreatment.¹ Numerous studies also indicate overtreatment can lead to patient harm.²

“Say a patient gets a prophylactic scan for abdominal pain,” says Vineet Arora, MD, MAPP, a hospitalist on faculty in the University of Chicago’s department of medicine and director of education initiatives for Costs of Care. “The patient gets better, but an incidental finding of the scan is a renal mass. Now, there is a work-up of that mass, the patient gets a biopsy, and they have a bleed. A lot of testing leads to more testing, and more testing can lead to harm.”

Doing less is often better, says John Bulger, DO, MBA, SFHM, chief quality officer for the Geisinger Health System in Danville, Pa. Dr. Bulger, who has led SHM’s participation in the Choosing Wisely campaign, cites a September 2014 study in JAMA Internal Medicine, in which Christiana Care Health System—an 1,100-bed tertiary care center in northern Delaware—built best practice telemetry guidelines into its electronic ordering system to help physicians determine when monitoring was appropriate.³ The health system also assembled multidisciplinary teams, which identified when medications warranted telemetry, and equipped nurses with tools to determine when telemetry should be stopped.

Appropriate use of telemetry is one of SHM’s five Choosing Wisely recommendations for adult patient care.

In addition to an overall 70% reduction in telemetry use without negative impact to patient safety, Christiana Care saved $4.8 million. Throughout its inpatient units, Christiana Care utilizes a multidisciplinary team approach to coordinate patient care. Daily rounds are attended by hospitalists, nurses, pharmacists, case managers, social workers, and others to ensure timely and appropriate patient care. The health system’s Value Institute evaluates hospital efforts and assesses process design to improve efficiency and, ultimately, outcomes.

“This is preparing for war in a time of peace, essentially,” says LeRoi S. Hicks, MD, MPH, a hospitalist, researcher, and educator at Christiana Care. “The goal will be, as we move to bundled payment and population health approaches, to minimize the time patients spend in the hospitals and limit the growth curve in spending on the hospital side. We are doing this and not taking on financial risk.”

Dr. Hicks adds that in its most simple form the project “reduces variation in the care we deliver” while improving efficiency and outcomes.

For many physicians, the best way to start is to begin a dialogue with patients who might also be at risk of financial harm due to unnecessary care, Dr. Arora says. “Patients are willing to change their minds and go with the more affordable and more evidence-based treatment and forgo expensive ones if they have that conversation,” she says.

Many resources exist for physicians interested in driving the frontline charge to improve healthcare quality and value. The Costs of Care curriculum provides training and tools for physicians at teachingvalue.org, as do SHM’s Center for Quality Innovation and the Institute for Healthcare Improvement. Dr. Moriates and Dr. Arora also have co-authored a book, along with Neel Shah, MD, founder and executive director of Costs of Care, called “Understanding Value Based Healthcare.” The book will be available this spring.

“We shouldn’t sit by the side of the road waiting for things to pass by,” Dr. Arora says. “I think the key is, we know the needle is shifting in Washington, we know system innovation models are being tested. It would be silly for us to say we’re going to continue the status quo and not look at ways to contribute as physicians.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513-1516.
2. Morgan DJ, Wright SM, Dhruva S. Update on medical overuse. JAMA Intern Med. 2015;175(1):120-124.
3. Dressler R, Dryer MM, Coletti C, Mahoney D, Doorey AJ. Altering overuse of cardiac telemetry in non-intensive care unit settings by hardwiring the use of American Heart Association guidelines. JAMA Intern Med. 2014;174(11):1852-1854.

In 2015, reimbursement for physicians in large groups is subject to a value modifier that takes into account the cost and quality of services performed under the Medicare Physician Fee Schedule. By 2017, the modifier will apply to all physicians participating in fee-for-service Medicare.

It’s one more way the Centers for Medicare and Medicaid Services (CMS) and the federal government are attempting to tip the scales on skyrocketing healthcare costs. Their end goal is a focus on better efficiency and less waste in the healthcare system.

But in an environment of top-down measures, hospitalists on the front lines are leading the charge to reduce overuse and overtreatment, slow cost growth, and improve both the quality of care and outcomes for their patients.

“I think the hospitalist movement has prided itself on quality improvement and patient safety in the hospital,” says Chris Moriates, MD, assistant clinical professor in the division of hospital medicine at the University of California San Francisco (UCSF) and co-creator of the cost awareness curriculum for UCSF’s internal medicine residents. “Over the last few years…they are more focused and enthusiastic about looking at value.”

Dr. Moriates leads the UCSF hospitalist division’s High Value Care Committee and is director of implementation initiatives at Costs of Care. He’s also part of a UCSF program that invites all employees to submit ideas for cutting waste in the hospital while maintaining or improving patient care quality. Last year, the winning project tackled unnecessary blood transfusions and at the same time realized $1 million in savings due to lower transfusion rates. This year, the hospital will focus on decreasing money spent on surgical supplies, potentially saving millions of dollars, he says.

A 2012 article in the Journal of the American Medical Association (JAMA) estimates wasteful spending costs the U.S. healthcare system at least $600 billion and potentially more than a trillion dollars annually due to such issues as care coordination and care delivery failures and overtreatment.¹ Numerous studies also indicate overtreatment can lead to patient harm.²

“Say a patient gets a prophylactic scan for abdominal pain,” says Vineet Arora, MD, MAPP, a hospitalist on faculty in the University of Chicago’s department of medicine and director of education initiatives for Costs of Care. “The patient gets better, but an incidental finding of the scan is a renal mass. Now, there is a work-up of that mass, the patient gets a biopsy, and they have a bleed. A lot of testing leads to more testing, and more testing can lead to harm.”

Doing less is often better, says John Bulger, DO, MBA, SFHM, chief quality officer for the Geisinger Health System in Danville, Pa. Dr. Bulger, who has led SHM’s participation in the Choosing Wisely campaign, cites a September 2014 study in JAMA Internal Medicine, in which Christiana Care Health System—an 1,100-bed tertiary care center in northern Delaware—built best practice telemetry guidelines into its electronic ordering system to help physicians determine when monitoring was appropriate.³ The health system also assembled multidisciplinary teams, which identified when medications warranted telemetry, and equipped nurses with tools to determine when telemetry should be stopped.

Appropriate use of telemetry is one of SHM’s five Choosing Wisely recommendations for adult patient care.

In addition to an overall 70% reduction in telemetry use without negative impact to patient safety, Christiana Care saved $4.8 million. Throughout its inpatient units, Christiana Care utilizes a multidisciplinary team approach to coordinate patient care. Daily rounds are attended by hospitalists, nurses, pharmacists, case managers, social workers, and others to ensure timely and appropriate patient care. The health system’s Value Institute evaluates hospital efforts and assesses process design to improve efficiency and, ultimately, outcomes.

“This is preparing for war in a time of peace, essentially,” says LeRoi S. Hicks, MD, MPH, a hospitalist, researcher, and educator at Christiana Care. “The goal will be, as we move to bundled payment and population health approaches, to minimize the time patients spend in the hospitals and limit the growth curve in spending on the hospital side. We are doing this and not taking on financial risk.”

Dr. Hicks adds that in its most simple form the project “reduces variation in the care we deliver” while improving efficiency and outcomes.

For many physicians, the best way to start is to begin a dialogue with patients who might also be at risk of financial harm due to unnecessary care, Dr. Arora says. “Patients are willing to change their minds and go with the more affordable and more evidence-based treatment and forgo expensive ones if they have that conversation,” she says.

Many resources exist for physicians interested in driving the frontline charge to improve healthcare quality and value. The Costs of Care curriculum provides training and tools for physicians at teachingvalue.org, as do SHM’s Center for Quality Innovation and the Institute for Healthcare Improvement. Dr. Moriates and Dr. Arora also have co-authored a book, along with Neel Shah, MD, founder and executive director of Costs of Care, called “Understanding Value Based Healthcare.” The book will be available this spring.

“We shouldn’t sit by the side of the road waiting for things to pass by,” Dr. Arora says. “I think the key is, we know the needle is shifting in Washington, we know system innovation models are being tested. It would be silly for us to say we’re going to continue the status quo and not look at ways to contribute as physicians.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

References

1. Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513-1516.
2. Morgan DJ, Wright SM, Dhruva S. Update on medical overuse. JAMA Intern Med. 2015;175(1):120-124.
3. Dressler R, Dryer MM, Coletti C, Mahoney D, Doorey AJ. Altering overuse of cardiac telemetry in non-intensive care unit settings by hardwiring the use of American Heart Association guidelines. JAMA Intern Med. 2014;174(11):1852-1854.

When the outbreak first started, and in the months that followed, Ebola virus dominated American headlines. The disease made its way from West Africa, infecting nurses in Spain and the U.S., and questions arose over how to keep healthcare providers and the public safe.

The answers to these questions are not limited to Ebola. Hospitalists and other providers work in the face of infectious disease on a routine basis, particularly in an era of widespread antibiotic resistance and emerging infections caused by such viruses as chikungunya, enterovirus D68, and MERS (Middle East Respiratory Syndrome) coronavirus.

The key to adequate preparation, says Joshua Lenchus, DO, RPh, FACP, SFHM, associate director of the Center for Patient Safety at the University of Miami-Jackson Memorial Hospital, is “information, the ability to implement relevant protocols and procedures when necessary, and, when possible, simulated exercises.”

Hospitalists can play a key role in ensuring their hospitals are prepared.

“I am constantly being reminded by my Society of Hospital Medicine colleagues that many facilities may not have an infectious disease specialist or an infectious disease program,” says Abbigail Tumpey, MPH, CHES, associate director for communications science in the CDC’s Division of Healthcare Quality Promotion.

It starts at the front door of the hospital, Tumpey and Dr. Lenchus say, with appropriate triage, screening, and isolation of potentially infectious patients.

“We diligently draft screening procedures for our frontline staff, clinic personnel, and appointment line phone operators to adequately and quickly evaluate patients so that those affected are provided the appropriate level of care,” says Dr. Lenchus, also a hospitalist and associate professor of clinical medicine and anesthesiology at the University of Miami Miller School of Medicine.

“We diligently draft screening procedures for our frontline staff, clinic personnel, and appointment line phone operators to adequately and quickly evaluate patients so that those affected are provided the appropriate level of care.”–Dr. Lenchus

These screening and management procedures originate with the CDC and state health departments and are often informed by outbreaks occurring in other locales.

“When an outbreak occurs elsewhere in the world, it is simply a matter of time before we may be faced with it in the United States,” Dr. Lenchus says, “so it behooves us to begin the research process and work with our hospital, local, and state personnel.”

The second line of defense, says Tumpey, is having in place the proper administrative controls to ensure that providers have time to don the appropriate personal protective equipment, or PPE. This means not just having access to PPE, but also the ability to put it on and take it off appropriately.

According to The New York Times, European officials investigated whether the Spanish nurse became infected with Ebola by accidentally touching her face while removing her PPE, and officials in the U.S. investigated whether the Dallas nurse who contracted Ebola while treating an infected Liberian patient also breached protocol. In Spain, investigators determined the layout of the hospital’s cramped Ebola ward could lead to accidents. In Dallas, rapidly changing conditions and poor preparation may have played a role, according to some reports. For just these kinds of reasons, Tumpey and Dr. Lenchus suggest hospitals engage in simulations and drills of outbreak events whenever possible.

“The facilities we’ve seen do this have found information they didn’t realize or a way of handling things that was surprising to them,” Tumpey says. “Certainly, there are some things that come up in those drills that highlight potential flaws and show opportunities where you can improve.”

For instance, simulations might reveal problems with the storage or disposal of PPE, lead to changes in hand hygiene locations, or highlight the need for better communication among healthcare workers.

Calm, Cool, Collected

Proper infection control procedures—hand hygiene, injection safety, appropriate cleanup, and careful waste handling—are a third line of defense in preventing the spread of infectious disease, Tumpey says.

Dr. Lenchus says that, particularly in light of diseases like Ebola, hospitalists should present concerned patients with valid information in a “calm, cool, and collected manner” that “helps allay the fear, misconception, and hysteria from generalizations, emotional responses, and anecdotal hearsay.”

These conversations present hospitalists with an opportunity to highlight the protocols, procedures, and patient safety programs in place at their institutions. They also provide a forum to discuss common cold and influenza viruses, which spread more easily than Ebola.

Of course, in the face of new rules for admissions, packed EDs, mounting metrics, and sometimes nonintuitive electronic health records, staying abreast of the latest information and catching every patient with symptoms that may or may not be related to an infectious disease may be easier said than done.

The CDC is redoubling its outreach efforts, Tumpey says, and will offer webinars and trainings for health providers.

“Our hope is that increased awareness can improve triage, early recognition, and appropriate infection control and could help for other things like MRSA, the endemic threats we face every day in U.S. healthcare facilities, even emerging diseases like MERS and carbapenem-resistant Enterobacteriaceae,” says Tumpey. “Awareness of proper infection control could help with many disease threats.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

When the outbreak first started, and in the months that followed, Ebola virus dominated American headlines. The disease made its way from West Africa, infecting nurses in Spain and the U.S., and questions arose over how to keep healthcare providers and the public safe.

The answers to these questions are not limited to Ebola. Hospitalists and other providers work in the face of infectious disease on a routine basis, particularly in an era of widespread antibiotic resistance and emerging infections caused by such viruses as chikungunya, enterovirus D68, and MERS (Middle East Respiratory Syndrome) coronavirus.

The key to adequate preparation, says Joshua Lenchus, DO, RPh, FACP, SFHM, associate director of the Center for Patient Safety at the University of Miami-Jackson Memorial Hospital, is “information, the ability to implement relevant protocols and procedures when necessary, and, when possible, simulated exercises.”

Hospitalists can play a key role in ensuring their hospitals are prepared.

“I am constantly being reminded by my Society of Hospital Medicine colleagues that many facilities may not have an infectious disease specialist or an infectious disease program,” says Abbigail Tumpey, MPH, CHES, associate director for communications science in the CDC’s Division of Healthcare Quality Promotion.

It starts at the front door of the hospital, Tumpey and Dr. Lenchus say, with appropriate triage, screening, and isolation of potentially infectious patients.

“We diligently draft screening procedures for our frontline staff, clinic personnel, and appointment line phone operators to adequately and quickly evaluate patients so that those affected are provided the appropriate level of care,” says Dr. Lenchus, also a hospitalist and associate professor of clinical medicine and anesthesiology at the University of Miami Miller School of Medicine.

“We diligently draft screening procedures for our frontline staff, clinic personnel, and appointment line phone operators to adequately and quickly evaluate patients so that those affected are provided the appropriate level of care.”–Dr. Lenchus

These screening and management procedures originate with the CDC and state health departments and are often informed by outbreaks occurring in other locales.

“When an outbreak occurs elsewhere in the world, it is simply a matter of time before we may be faced with it in the United States,” Dr. Lenchus says, “so it behooves us to begin the research process and work with our hospital, local, and state personnel.”

The second line of defense, says Tumpey, is having in place the proper administrative controls to ensure that providers have time to don the appropriate personal protective equipment, or PPE. This means not just having access to PPE, but also the ability to put it on and take it off appropriately.

According to The New York Times, European officials investigated whether the Spanish nurse became infected with Ebola by accidentally touching her face while removing her PPE, and officials in the U.S. investigated whether the Dallas nurse who contracted Ebola while treating an infected Liberian patient also breached protocol. In Spain, investigators determined the layout of the hospital’s cramped Ebola ward could lead to accidents. In Dallas, rapidly changing conditions and poor preparation may have played a role, according to some reports. For just these kinds of reasons, Tumpey and Dr. Lenchus suggest hospitals engage in simulations and drills of outbreak events whenever possible.

“The facilities we’ve seen do this have found information they didn’t realize or a way of handling things that was surprising to them,” Tumpey says. “Certainly, there are some things that come up in those drills that highlight potential flaws and show opportunities where you can improve.”

For instance, simulations might reveal problems with the storage or disposal of PPE, lead to changes in hand hygiene locations, or highlight the need for better communication among healthcare workers.

Calm, Cool, Collected

Proper infection control procedures—hand hygiene, injection safety, appropriate cleanup, and careful waste handling—are a third line of defense in preventing the spread of infectious disease, Tumpey says.

Dr. Lenchus says that, particularly in light of diseases like Ebola, hospitalists should present concerned patients with valid information in a “calm, cool, and collected manner” that “helps allay the fear, misconception, and hysteria from generalizations, emotional responses, and anecdotal hearsay.”

These conversations present hospitalists with an opportunity to highlight the protocols, procedures, and patient safety programs in place at their institutions. They also provide a forum to discuss common cold and influenza viruses, which spread more easily than Ebola.

Of course, in the face of new rules for admissions, packed EDs, mounting metrics, and sometimes nonintuitive electronic health records, staying abreast of the latest information and catching every patient with symptoms that may or may not be related to an infectious disease may be easier said than done.

The CDC is redoubling its outreach efforts, Tumpey says, and will offer webinars and trainings for health providers.

“Our hope is that increased awareness can improve triage, early recognition, and appropriate infection control and could help for other things like MRSA, the endemic threats we face every day in U.S. healthcare facilities, even emerging diseases like MERS and carbapenem-resistant Enterobacteriaceae,” says Tumpey. “Awareness of proper infection control could help with many disease threats.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

When the outbreak first started, and in the months that followed, Ebola virus dominated American headlines. The disease made its way from West Africa, infecting nurses in Spain and the U.S., and questions arose over how to keep healthcare providers and the public safe.

The answers to these questions are not limited to Ebola. Hospitalists and other providers work in the face of infectious disease on a routine basis, particularly in an era of widespread antibiotic resistance and emerging infections caused by such viruses as chikungunya, enterovirus D68, and MERS (Middle East Respiratory Syndrome) coronavirus.

The key to adequate preparation, says Joshua Lenchus, DO, RPh, FACP, SFHM, associate director of the Center for Patient Safety at the University of Miami-Jackson Memorial Hospital, is “information, the ability to implement relevant protocols and procedures when necessary, and, when possible, simulated exercises.”

Hospitalists can play a key role in ensuring their hospitals are prepared.

“I am constantly being reminded by my Society of Hospital Medicine colleagues that many facilities may not have an infectious disease specialist or an infectious disease program,” says Abbigail Tumpey, MPH, CHES, associate director for communications science in the CDC’s Division of Healthcare Quality Promotion.

It starts at the front door of the hospital, Tumpey and Dr. Lenchus say, with appropriate triage, screening, and isolation of potentially infectious patients.

“We diligently draft screening procedures for our frontline staff, clinic personnel, and appointment line phone operators to adequately and quickly evaluate patients so that those affected are provided the appropriate level of care,” says Dr. Lenchus, also a hospitalist and associate professor of clinical medicine and anesthesiology at the University of Miami Miller School of Medicine.

“We diligently draft screening procedures for our frontline staff, clinic personnel, and appointment line phone operators to adequately and quickly evaluate patients so that those affected are provided the appropriate level of care.”–Dr. Lenchus

These screening and management procedures originate with the CDC and state health departments and are often informed by outbreaks occurring in other locales.

“When an outbreak occurs elsewhere in the world, it is simply a matter of time before we may be faced with it in the United States,” Dr. Lenchus says, “so it behooves us to begin the research process and work with our hospital, local, and state personnel.”

The second line of defense, says Tumpey, is having in place the proper administrative controls to ensure that providers have time to don the appropriate personal protective equipment, or PPE. This means not just having access to PPE, but also the ability to put it on and take it off appropriately.

According to The New York Times, European officials investigated whether the Spanish nurse became infected with Ebola by accidentally touching her face while removing her PPE, and officials in the U.S. investigated whether the Dallas nurse who contracted Ebola while treating an infected Liberian patient also breached protocol. In Spain, investigators determined the layout of the hospital’s cramped Ebola ward could lead to accidents. In Dallas, rapidly changing conditions and poor preparation may have played a role, according to some reports. For just these kinds of reasons, Tumpey and Dr. Lenchus suggest hospitals engage in simulations and drills of outbreak events whenever possible.

“The facilities we’ve seen do this have found information they didn’t realize or a way of handling things that was surprising to them,” Tumpey says. “Certainly, there are some things that come up in those drills that highlight potential flaws and show opportunities where you can improve.”

For instance, simulations might reveal problems with the storage or disposal of PPE, lead to changes in hand hygiene locations, or highlight the need for better communication among healthcare workers.

Calm, Cool, Collected

Proper infection control procedures—hand hygiene, injection safety, appropriate cleanup, and careful waste handling—are a third line of defense in preventing the spread of infectious disease, Tumpey says.

Dr. Lenchus says that, particularly in light of diseases like Ebola, hospitalists should present concerned patients with valid information in a “calm, cool, and collected manner” that “helps allay the fear, misconception, and hysteria from generalizations, emotional responses, and anecdotal hearsay.”

These conversations present hospitalists with an opportunity to highlight the protocols, procedures, and patient safety programs in place at their institutions. They also provide a forum to discuss common cold and influenza viruses, which spread more easily than Ebola.

Of course, in the face of new rules for admissions, packed EDs, mounting metrics, and sometimes nonintuitive electronic health records, staying abreast of the latest information and catching every patient with symptoms that may or may not be related to an infectious disease may be easier said than done.

The CDC is redoubling its outreach efforts, Tumpey says, and will offer webinars and trainings for health providers.

“Our hope is that increased awareness can improve triage, early recognition, and appropriate infection control and could help for other things like MRSA, the endemic threats we face every day in U.S. healthcare facilities, even emerging diseases like MERS and carbapenem-resistant Enterobacteriaceae,” says Tumpey. “Awareness of proper infection control could help with many disease threats.”

Kelly April Tyrrell is a freelance writer in Madison, Wis.

A recent study published in the Journal of Hospital Medicine reports on an early warning and response system (EWRS) for sepsis used in all three hospitals within the Philadelphia-based University of Pennsylvania Health System (UPHS) for three-month spans in 2012 and 2013. The system integrates laboratory values and vital signs into patients EHRs and establishes a threshold for triggering the alert.

After implementing the EWRS, at-risk patients received faster care for sepsis and/or were transferred to the ICU more quickly, says lead author Craig A. Umscheid, MD, MSCE, director of the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Study authors also note that quicker care suggested reduced mortality from sepsis as well.

"Whenever a patient triggered the alert, their probability of mortality was much higher than patients who didn't trigger the alert," Dr. Umscheid says. "I think what makes our study unique compared to other studies that have tried to predict sepsis is that beyond just creating a prediction rule for sepsis, we actually implemented it into a clinical care setting, alerted providers in real time, and then those providers changed their care based on the prediction."

More than 90% of care teams arrived at the bedside when they received an alert. "Meaning that they saw some value in the alert, and the infrastructure that we put in place was able to mobilize the team and get them to the bedside within 30 minutes," Dr. Umscheid adds. "We saw an increase in sepsis antibiotics used, and we saw an increase in fluid boluses within six hours.”

As many as 3 million cases of severe sepsis occur in the U.S. annually, and 750,000 result in deaths, according to the study. The high number of cases has led to several efforts to create better clinical practices for sepsis patients.

"Sepsis is arguably one of the most, if not the most important, causes of preventable mortality in the inpatient setting," Dr. Umscheid says. "One thing that we thought we could do better was identify sepsis cases earlier so that we could provide early antibiotics and fluids."

Visit our website for more information on identifying and treating sepsis.

A recent study published in the Journal of Hospital Medicine reports on an early warning and response system (EWRS) for sepsis used in all three hospitals within the Philadelphia-based University of Pennsylvania Health System (UPHS) for three-month spans in 2012 and 2013. The system integrates laboratory values and vital signs into patients EHRs and establishes a threshold for triggering the alert.

After implementing the EWRS, at-risk patients received faster care for sepsis and/or were transferred to the ICU more quickly, says lead author Craig A. Umscheid, MD, MSCE, director of the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Study authors also note that quicker care suggested reduced mortality from sepsis as well.

"Whenever a patient triggered the alert, their probability of mortality was much higher than patients who didn't trigger the alert," Dr. Umscheid says. "I think what makes our study unique compared to other studies that have tried to predict sepsis is that beyond just creating a prediction rule for sepsis, we actually implemented it into a clinical care setting, alerted providers in real time, and then those providers changed their care based on the prediction."

More than 90% of care teams arrived at the bedside when they received an alert. "Meaning that they saw some value in the alert, and the infrastructure that we put in place was able to mobilize the team and get them to the bedside within 30 minutes," Dr. Umscheid adds. "We saw an increase in sepsis antibiotics used, and we saw an increase in fluid boluses within six hours.”

As many as 3 million cases of severe sepsis occur in the U.S. annually, and 750,000 result in deaths, according to the study. The high number of cases has led to several efforts to create better clinical practices for sepsis patients.

"Sepsis is arguably one of the most, if not the most important, causes of preventable mortality in the inpatient setting," Dr. Umscheid says. "One thing that we thought we could do better was identify sepsis cases earlier so that we could provide early antibiotics and fluids."

Visit our website for more information on identifying and treating sepsis.

A recent study published in the Journal of Hospital Medicine reports on an early warning and response system (EWRS) for sepsis used in all three hospitals within the Philadelphia-based University of Pennsylvania Health System (UPHS) for three-month spans in 2012 and 2013. The system integrates laboratory values and vital signs into patients EHRs and establishes a threshold for triggering the alert.

After implementing the EWRS, at-risk patients received faster care for sepsis and/or were transferred to the ICU more quickly, says lead author Craig A. Umscheid, MD, MSCE, director of the Center for Evidence-Based Practice at the University of Pennsylvania in Philadelphia. Study authors also note that quicker care suggested reduced mortality from sepsis as well.

"Whenever a patient triggered the alert, their probability of mortality was much higher than patients who didn't trigger the alert," Dr. Umscheid says. "I think what makes our study unique compared to other studies that have tried to predict sepsis is that beyond just creating a prediction rule for sepsis, we actually implemented it into a clinical care setting, alerted providers in real time, and then those providers changed their care based on the prediction."

More than 90% of care teams arrived at the bedside when they received an alert. "Meaning that they saw some value in the alert, and the infrastructure that we put in place was able to mobilize the team and get them to the bedside within 30 minutes," Dr. Umscheid adds. "We saw an increase in sepsis antibiotics used, and we saw an increase in fluid boluses within six hours.”

As many as 3 million cases of severe sepsis occur in the U.S. annually, and 750,000 result in deaths, according to the study. The high number of cases has led to several efforts to create better clinical practices for sepsis patients.

"Sepsis is arguably one of the most, if not the most important, causes of preventable mortality in the inpatient setting," Dr. Umscheid says. "One thing that we thought we could do better was identify sepsis cases earlier so that we could provide early antibiotics and fluids."

Visit our website for more information on identifying and treating sepsis.

Kristen Kulasa, MD, assistant clinical professor of medicine and director of Inpatient Glycemic Control, Division of Endocrinology, Diabetes, and Metabolism at the University of California in San Diego, provides tips on how hospitalists can work with nutritionists and dieticians for the betterment of diabetic patients. As a mentor for SHM's care coordination program on inpatient diabetes, Dr. Kulasa offers hospitalists advice in treating diabetic patients. She points to SHM’s website, which has a lot of resources to help hospitalists feel comfortable with insulin dosing.

Kristen Kulasa, MD, assistant clinical professor of medicine and director of Inpatient Glycemic Control, Division of Endocrinology, Diabetes, and Metabolism at the University of California in San Diego, provides tips on how hospitalists can work with nutritionists and dieticians for the betterment of diabetic patients. As a mentor for SHM's care coordination program on inpatient diabetes, Dr. Kulasa offers hospitalists advice in treating diabetic patients. She points to SHM’s website, which has a lot of resources to help hospitalists feel comfortable with insulin dosing.

Kristen Kulasa, MD, assistant clinical professor of medicine and director of Inpatient Glycemic Control, Division of Endocrinology, Diabetes, and Metabolism at the University of California in San Diego, provides tips on how hospitalists can work with nutritionists and dieticians for the betterment of diabetic patients. As a mentor for SHM's care coordination program on inpatient diabetes, Dr. Kulasa offers hospitalists advice in treating diabetic patients. She points to SHM’s website, which has a lot of resources to help hospitalists feel comfortable with insulin dosing.

Although new medications to manage and treat hyperglycemia and diabetes continuously appear on the market, national guidelines and position statements consistently refer to insulin as the treatment of choice in the inpatient hospital setting.

“When patients are admitted to the hospital, our standard is to switch from the outpatient regimen [wide variety of medications] to the inpatient regimen—insulin,” says Paul M. Szumita, PharmD, BCPS, clinical pharmacy practice manager director at Brigham and Women’s Hospital in Boston.

For critically ill patients in ICUs or during the peri-operative period, intravenous infusion of insulin is preferred. Most general medicine and surgery patients are managed with subcutaneous insulin.

“Using a basal bolus regimen starting at a total daily dose of 0.3-0.5 unit/kg is sufficient for most patients,” says Guillermo Umpierrez, MD, CDE, FCAE, FACP, professor of medicine at Emory University in Atlanta, Ga., and a member of the board of directors for the American Diabetes Association; however, for most general medicine and surgical patients who have low oral intake or are NPO, a recent trial reported that the administration of basal insulin alone plus correction doses with rapid-acting insulin analogs before meals is as good as a basal bolus regimen. A regimen should be tweaked throughout the inpatient’s stay with an aim to reach the goal of minimal or no hypoglycemia.¹

Planning for a discharge regimen should start early in the hospital stay, Dr. Szumita says, and should be based on several factors:

1. The patient’s Hb1c;
2. The prior regimen and how it was performing;
3. The patient’s wishes; and
4. Collaboration with outpatient providers.

At discharge, it is critical that patients be clear about what medications they should be on post-discharge and that they follow-up with outpatient providers in a timely manner. TH

Karen Appold is a freelance writer in Pennsylvania.

Reference

1. Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care. 2013;36(8):2169-2174.

Although new medications to manage and treat hyperglycemia and diabetes continuously appear on the market, national guidelines and position statements consistently refer to insulin as the treatment of choice in the inpatient hospital setting.

“When patients are admitted to the hospital, our standard is to switch from the outpatient regimen [wide variety of medications] to the inpatient regimen—insulin,” says Paul M. Szumita, PharmD, BCPS, clinical pharmacy practice manager director at Brigham and Women’s Hospital in Boston.

For critically ill patients in ICUs or during the peri-operative period, intravenous infusion of insulin is preferred. Most general medicine and surgery patients are managed with subcutaneous insulin.

“Using a basal bolus regimen starting at a total daily dose of 0.3-0.5 unit/kg is sufficient for most patients,” says Guillermo Umpierrez, MD, CDE, FCAE, FACP, professor of medicine at Emory University in Atlanta, Ga., and a member of the board of directors for the American Diabetes Association; however, for most general medicine and surgical patients who have low oral intake or are NPO, a recent trial reported that the administration of basal insulin alone plus correction doses with rapid-acting insulin analogs before meals is as good as a basal bolus regimen. A regimen should be tweaked throughout the inpatient’s stay with an aim to reach the goal of minimal or no hypoglycemia.¹

Planning for a discharge regimen should start early in the hospital stay, Dr. Szumita says, and should be based on several factors:

1. The patient’s Hb1c;
2. The prior regimen and how it was performing;
3. The patient’s wishes; and
4. Collaboration with outpatient providers.

At discharge, it is critical that patients be clear about what medications they should be on post-discharge and that they follow-up with outpatient providers in a timely manner. TH

Karen Appold is a freelance writer in Pennsylvania.

Reference

1. Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care. 2013;36(8):2169-2174.

Although new medications to manage and treat hyperglycemia and diabetes continuously appear on the market, national guidelines and position statements consistently refer to insulin as the treatment of choice in the inpatient hospital setting.

“When patients are admitted to the hospital, our standard is to switch from the outpatient regimen [wide variety of medications] to the inpatient regimen—insulin,” says Paul M. Szumita, PharmD, BCPS, clinical pharmacy practice manager director at Brigham and Women’s Hospital in Boston.

For critically ill patients in ICUs or during the peri-operative period, intravenous infusion of insulin is preferred. Most general medicine and surgery patients are managed with subcutaneous insulin.

“Using a basal bolus regimen starting at a total daily dose of 0.3-0.5 unit/kg is sufficient for most patients,” says Guillermo Umpierrez, MD, CDE, FCAE, FACP, professor of medicine at Emory University in Atlanta, Ga., and a member of the board of directors for the American Diabetes Association; however, for most general medicine and surgical patients who have low oral intake or are NPO, a recent trial reported that the administration of basal insulin alone plus correction doses with rapid-acting insulin analogs before meals is as good as a basal bolus regimen. A regimen should be tweaked throughout the inpatient’s stay with an aim to reach the goal of minimal or no hypoglycemia.¹

Planning for a discharge regimen should start early in the hospital stay, Dr. Szumita says, and should be based on several factors:

1. The patient’s Hb1c;
2. The prior regimen and how it was performing;
3. The patient’s wishes; and
4. Collaboration with outpatient providers.

At discharge, it is critical that patients be clear about what medications they should be on post-discharge and that they follow-up with outpatient providers in a timely manner. TH

Karen Appold is a freelance writer in Pennsylvania.

Reference

1. Umpierrez GE, Smiley D, Hermayer K, et al. Randomized study comparing a basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial. Diabetes Care. 2013;36(8):2169-2174.

A new study on transitions of care gives hospitalists a view from the other side.

Published recently online in the Journal of Hospital Medicine, the authors surveyed 22 primary-care physician leaders in California-based post-discharge clinics and asked them about ways to improve care transitions.

Physicians' responses focused on several areas that need work, most notably aligned financial incentives, regulations to standardize interoperability among electronic health records (EHR) and data sharing, and more opportunities for professional networking, the authors note.

Although the qualitative study takes a broad view of the healthcare system, its lead author says hospitalists should view "systems change" as a long-term goal achievable via incremental improvements that can start now.

"National policy change is needed to move the needle for the whole health system," says hospitalist Oanh Kieu Nguyen, MD, MAS, of the University of Texas Southwestern Medical Center in Dallas. "But locally, you can innovate within these domains and start to make changes to improve practice settings more immediately. National policy to align financial incentives and improve EHR interoperability will be key to helping local changes take hold and spread across systems. Otherwise, there will continue to be a lot of variability and fragmentation around care transitions on a national level."

Dr. Nguyen, who has practiced as both a hospitalist and PCP, says that because policies and studies on post-discharge care transitions primarily have focused on the hospital perspective, it is important to gain an understanding of the primary-care point of view.

"As a hospitalist, it's really easy to get caught up in just wanting to get patients teed up and sent home. Once they're out, we think they're no longer really our problem," Dr. Nguyen adds. "It's easy to forget that primary care is an important part of the other side of the equation. The way our healthcare system is designed doesn't really give physicians an incentive to look at the whole picture of a patient across all the environments they're in."

Many hospitalists are sharing their challenges and successes in care transitions through HMX. Join the conversation now.

Visit our website for more information on transitions of care.

A new study on transitions of care gives hospitalists a view from the other side.

Published recently online in the Journal of Hospital Medicine, the authors surveyed 22 primary-care physician leaders in California-based post-discharge clinics and asked them about ways to improve care transitions.

Physicians' responses focused on several areas that need work, most notably aligned financial incentives, regulations to standardize interoperability among electronic health records (EHR) and data sharing, and more opportunities for professional networking, the authors note.

Although the qualitative study takes a broad view of the healthcare system, its lead author says hospitalists should view "systems change" as a long-term goal achievable via incremental improvements that can start now.

"National policy change is needed to move the needle for the whole health system," says hospitalist Oanh Kieu Nguyen, MD, MAS, of the University of Texas Southwestern Medical Center in Dallas. "But locally, you can innovate within these domains and start to make changes to improve practice settings more immediately. National policy to align financial incentives and improve EHR interoperability will be key to helping local changes take hold and spread across systems. Otherwise, there will continue to be a lot of variability and fragmentation around care transitions on a national level."

Dr. Nguyen, who has practiced as both a hospitalist and PCP, says that because policies and studies on post-discharge care transitions primarily have focused on the hospital perspective, it is important to gain an understanding of the primary-care point of view.

"As a hospitalist, it's really easy to get caught up in just wanting to get patients teed up and sent home. Once they're out, we think they're no longer really our problem," Dr. Nguyen adds. "It's easy to forget that primary care is an important part of the other side of the equation. The way our healthcare system is designed doesn't really give physicians an incentive to look at the whole picture of a patient across all the environments they're in."

Many hospitalists are sharing their challenges and successes in care transitions through HMX. Join the conversation now.

Visit our website for more information on transitions of care.

A new study on transitions of care gives hospitalists a view from the other side.

Published recently online in the Journal of Hospital Medicine, the authors surveyed 22 primary-care physician leaders in California-based post-discharge clinics and asked them about ways to improve care transitions.

Physicians' responses focused on several areas that need work, most notably aligned financial incentives, regulations to standardize interoperability among electronic health records (EHR) and data sharing, and more opportunities for professional networking, the authors note.

Although the qualitative study takes a broad view of the healthcare system, its lead author says hospitalists should view "systems change" as a long-term goal achievable via incremental improvements that can start now.

"National policy change is needed to move the needle for the whole health system," says hospitalist Oanh Kieu Nguyen, MD, MAS, of the University of Texas Southwestern Medical Center in Dallas. "But locally, you can innovate within these domains and start to make changes to improve practice settings more immediately. National policy to align financial incentives and improve EHR interoperability will be key to helping local changes take hold and spread across systems. Otherwise, there will continue to be a lot of variability and fragmentation around care transitions on a national level."

Dr. Nguyen, who has practiced as both a hospitalist and PCP, says that because policies and studies on post-discharge care transitions primarily have focused on the hospital perspective, it is important to gain an understanding of the primary-care point of view.

"As a hospitalist, it's really easy to get caught up in just wanting to get patients teed up and sent home. Once they're out, we think they're no longer really our problem," Dr. Nguyen adds. "It's easy to forget that primary care is an important part of the other side of the equation. The way our healthcare system is designed doesn't really give physicians an incentive to look at the whole picture of a patient across all the environments they're in."

Many hospitalists are sharing their challenges and successes in care transitions through HMX. Join the conversation now.

Visit our website for more information on transitions of care.

Adverse drug events and medication errors are unfortunately all too common within hospitals, but hospitalists can now take the lead in preventing them using SHM’s MARQUIS [Multi-Center Medication Reconciliation Quality Improvement Study] toolkit.

The authors of the new toolkit outline the hospitalist’s role in reducing medication errors as:

• Take responsibility for the accuracy of the medication reconciliation process for each patient under your care;
• Lead, coordinate, or participate in medication reconciliation quality improvement (QI) efforts with other key team members on the “front lines” to inform the hospital QI team on key interventions that would lead to improved patient outcomes;
• Become trained in taking the “best possible medication history” and in using effective discharge medication counseling; and
• Identify patients who are at high risk for a medication reconciliation error and would benefit from a more intensive medication reconciliation process.

“The MARQUIS study is important because it shows the potential of a mentored implementation effort, working with local hospitalist leaders and a QI toolkit, to improve medication safety related to the medication reconciliation process,” says MARQUIS principal investigator Jeff Schnipper, MD, MPH, FHM.

“It also shows the importance of institutional commitment to the success of these efforts. Lastly, hospitalists need to realize that medication reconciliation is not just some external regulatory requirement—it’s about the safety of the medications they order—and, therefore, that they need to ensure the quality of the process for the patients they care for and to lead efforts to improve the process across their hospitals.”

For more information, visit www.hospitalmedicine.org/marquis.

Adverse drug events and medication errors are unfortunately all too common within hospitals, but hospitalists can now take the lead in preventing them using SHM’s MARQUIS [Multi-Center Medication Reconciliation Quality Improvement Study] toolkit.

The authors of the new toolkit outline the hospitalist’s role in reducing medication errors as:

• Take responsibility for the accuracy of the medication reconciliation process for each patient under your care;
• Lead, coordinate, or participate in medication reconciliation quality improvement (QI) efforts with other key team members on the “front lines” to inform the hospital QI team on key interventions that would lead to improved patient outcomes;
• Become trained in taking the “best possible medication history” and in using effective discharge medication counseling; and
• Identify patients who are at high risk for a medication reconciliation error and would benefit from a more intensive medication reconciliation process.

“The MARQUIS study is important because it shows the potential of a mentored implementation effort, working with local hospitalist leaders and a QI toolkit, to improve medication safety related to the medication reconciliation process,” says MARQUIS principal investigator Jeff Schnipper, MD, MPH, FHM.

“It also shows the importance of institutional commitment to the success of these efforts. Lastly, hospitalists need to realize that medication reconciliation is not just some external regulatory requirement—it’s about the safety of the medications they order—and, therefore, that they need to ensure the quality of the process for the patients they care for and to lead efforts to improve the process across their hospitals.”

For more information, visit www.hospitalmedicine.org/marquis.

Adverse drug events and medication errors are unfortunately all too common within hospitals, but hospitalists can now take the lead in preventing them using SHM’s MARQUIS [Multi-Center Medication Reconciliation Quality Improvement Study] toolkit.

The authors of the new toolkit outline the hospitalist’s role in reducing medication errors as:

• Take responsibility for the accuracy of the medication reconciliation process for each patient under your care;
• Lead, coordinate, or participate in medication reconciliation quality improvement (QI) efforts with other key team members on the “front lines” to inform the hospital QI team on key interventions that would lead to improved patient outcomes;
• Become trained in taking the “best possible medication history” and in using effective discharge medication counseling; and
• Identify patients who are at high risk for a medication reconciliation error and would benefit from a more intensive medication reconciliation process.

“The MARQUIS study is important because it shows the potential of a mentored implementation effort, working with local hospitalist leaders and a QI toolkit, to improve medication safety related to the medication reconciliation process,” says MARQUIS principal investigator Jeff Schnipper, MD, MPH, FHM.

“It also shows the importance of institutional commitment to the success of these efforts. Lastly, hospitalists need to realize that medication reconciliation is not just some external regulatory requirement—it’s about the safety of the medications they order—and, therefore, that they need to ensure the quality of the process for the patients they care for and to lead efforts to improve the process across their hospitals.”

For more information, visit www.hospitalmedicine.org/marquis.

Clinical question: Do signouts vary in the quality and quantity of information, and what are the various factors affecting signout quality?

Background: Miscommunication during transfers of responsibility for hospitalized patients is common and can result in harm. Recommendations for safe and effective handoffs emphasize key content, clear communication, senior staff supervision, and adequate time for questions. Still, little is known about adherence to these recommendations in clinical practice.

Study design: Prospective, observational cohort.

Setting: Medical unit of an acute-care teaching hospital.

Synopsis: Oral signouts were audiotaped among IM house staff teams and the accompanying written signouts were collected for review of content. Signout sessions (n=88) included eight IM teams at one hospital and contained 503 patient signouts.

The median signout duration was 35 seconds (IQR 19-62) per patient. Key clinical information was present in just 62% of combined written or oral signouts. Most signouts included no questions from the recipient. Factors associated with higher rate of content inclusion included: familiarity with the patient, sense of responsibility (primary team vs. covering team), only one signout per day (as compared to sequential signout), presence of a senior resident, and comprehensive, written signouts.

Study limitations include the Hawthorne effect, as several participants mentioned that the presence of audiotape led to more comprehensive signouts than are typical. Also, the signout quality assessment in this study has not been validated with patient-safety outcomes.

Bottom line: Signouts among internal-medicine residents at this one hospital showed variability in terms of quantitative and qualitative information and often missed crucial information about patient care.

Citation: Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Qual Saf Health Care. 2009;18(4):248-255.

Clinical question: Do signouts vary in the quality and quantity of information, and what are the various factors affecting signout quality?

Background: Miscommunication during transfers of responsibility for hospitalized patients is common and can result in harm. Recommendations for safe and effective handoffs emphasize key content, clear communication, senior staff supervision, and adequate time for questions. Still, little is known about adherence to these recommendations in clinical practice.

Study design: Prospective, observational cohort.

Setting: Medical unit of an acute-care teaching hospital.

Synopsis: Oral signouts were audiotaped among IM house staff teams and the accompanying written signouts were collected for review of content. Signout sessions (n=88) included eight IM teams at one hospital and contained 503 patient signouts.

The median signout duration was 35 seconds (IQR 19-62) per patient. Key clinical information was present in just 62% of combined written or oral signouts. Most signouts included no questions from the recipient. Factors associated with higher rate of content inclusion included: familiarity with the patient, sense of responsibility (primary team vs. covering team), only one signout per day (as compared to sequential signout), presence of a senior resident, and comprehensive, written signouts.

Study limitations include the Hawthorne effect, as several participants mentioned that the presence of audiotape led to more comprehensive signouts than are typical. Also, the signout quality assessment in this study has not been validated with patient-safety outcomes.

Bottom line: Signouts among internal-medicine residents at this one hospital showed variability in terms of quantitative and qualitative information and often missed crucial information about patient care.

Citation: Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Qual Saf Health Care. 2009;18(4):248-255.

Clinical question: Do signouts vary in the quality and quantity of information, and what are the various factors affecting signout quality?

Background: Miscommunication during transfers of responsibility for hospitalized patients is common and can result in harm. Recommendations for safe and effective handoffs emphasize key content, clear communication, senior staff supervision, and adequate time for questions. Still, little is known about adherence to these recommendations in clinical practice.

Study design: Prospective, observational cohort.

Setting: Medical unit of an acute-care teaching hospital.

Synopsis: Oral signouts were audiotaped among IM house staff teams and the accompanying written signouts were collected for review of content. Signout sessions (n=88) included eight IM teams at one hospital and contained 503 patient signouts.

The median signout duration was 35 seconds (IQR 19-62) per patient. Key clinical information was present in just 62% of combined written or oral signouts. Most signouts included no questions from the recipient. Factors associated with higher rate of content inclusion included: familiarity with the patient, sense of responsibility (primary team vs. covering team), only one signout per day (as compared to sequential signout), presence of a senior resident, and comprehensive, written signouts.

Study limitations include the Hawthorne effect, as several participants mentioned that the presence of audiotape led to more comprehensive signouts than are typical. Also, the signout quality assessment in this study has not been validated with patient-safety outcomes.

Bottom line: Signouts among internal-medicine residents at this one hospital showed variability in terms of quantitative and qualitative information and often missed crucial information about patient care.

Citation: Horwitz LI, Moin T, Krumholz HM, Wang L, Bradley EH. What are covering doctors told about their patients? Analysis of sign-out among internal medicine house staff. Qual Saf Health Care. 2009;18(4):248-255.