Patient Safety

Are you helping your hospital choose wisely? You could receive thousands of dollars in return for your good work in providing high-value care to hospitalized patients through SHM’s Choosing Wisely case study competition.

SHM will be awarding a total of $20,000 to hospitalists who submit winning case studies illustrating their implementation of the Choosing Wisely principles published by SHM in 2013. Grand prize winners for both adult and pediatric HM will receive $4,000 each, and three honorable mention winners in both categories will each receive $2,000.

But don’t wait long. The deadline for submissions is September 9. For information and submission forms, visit www.hospitalmedicine.org/choosingwisely.

Are you helping your hospital choose wisely? You could receive thousands of dollars in return for your good work in providing high-value care to hospitalized patients through SHM’s Choosing Wisely case study competition.

SHM will be awarding a total of $20,000 to hospitalists who submit winning case studies illustrating their implementation of the Choosing Wisely principles published by SHM in 2013. Grand prize winners for both adult and pediatric HM will receive $4,000 each, and three honorable mention winners in both categories will each receive $2,000.

But don’t wait long. The deadline for submissions is September 9. For information and submission forms, visit www.hospitalmedicine.org/choosingwisely.

Are you helping your hospital choose wisely? You could receive thousands of dollars in return for your good work in providing high-value care to hospitalized patients through SHM’s Choosing Wisely case study competition.

SHM will be awarding a total of $20,000 to hospitalists who submit winning case studies illustrating their implementation of the Choosing Wisely principles published by SHM in 2013. Grand prize winners for both adult and pediatric HM will receive $4,000 each, and three honorable mention winners in both categories will each receive $2,000.

But don’t wait long. The deadline for submissions is September 9. For information and submission forms, visit www.hospitalmedicine.org/choosingwisely.

Maybe you just returned from HM14 in Las Vegas and are ready to head back. Or maybe you missed out on SHM’s annual meeting but would like to meet up with an important part of the hospitalist team: hospital and health system pharmacists.

Regardless of your motivation, the American Society of Health-System Pharmacist’s (ASHP’s) combination of three meetings in one brings a wealth of information to hospitalists—physicians and pharmacists alike—and now SHM members can register for the Medication Safety Collaborative at the applicable ASHP member rates.

SHM members receive the ASHP member rate at ASHP’s meeting within a meeting for hospital and health system pharmacists, to be held May 31-June 4 in Las Vegas.

Many hospitalists will be especially interested in the Medication Safety Collaborative, which brings the entire hospital team together to share best practices in medication and patient safety.

The Medication Safety Collaborative consists of three meetings:

• ASHP Informatics Institute: An event for informaticists to innovate, interact, and improve the use of information technology in healthcare;
• The Medication Safety Collaborative: For inter-professional teams of health system-based clinicians, coordinators, managers, and administrators who focus on patient safety and quality; and
• Pharmacy Practice Policy: The most relevant issues affecting health system pharmacy practice today at ASHP’s first Pharmacy Practice and Policy Meeting.

Maybe you just returned from HM14 in Las Vegas and are ready to head back. Or maybe you missed out on SHM’s annual meeting but would like to meet up with an important part of the hospitalist team: hospital and health system pharmacists.

Regardless of your motivation, the American Society of Health-System Pharmacist’s (ASHP’s) combination of three meetings in one brings a wealth of information to hospitalists—physicians and pharmacists alike—and now SHM members can register for the Medication Safety Collaborative at the applicable ASHP member rates.

SHM members receive the ASHP member rate at ASHP’s meeting within a meeting for hospital and health system pharmacists, to be held May 31-June 4 in Las Vegas.

Many hospitalists will be especially interested in the Medication Safety Collaborative, which brings the entire hospital team together to share best practices in medication and patient safety.

The Medication Safety Collaborative consists of three meetings:

• ASHP Informatics Institute: An event for informaticists to innovate, interact, and improve the use of information technology in healthcare;
• The Medication Safety Collaborative: For inter-professional teams of health system-based clinicians, coordinators, managers, and administrators who focus on patient safety and quality; and
• Pharmacy Practice Policy: The most relevant issues affecting health system pharmacy practice today at ASHP’s first Pharmacy Practice and Policy Meeting.

Maybe you just returned from HM14 in Las Vegas and are ready to head back. Or maybe you missed out on SHM’s annual meeting but would like to meet up with an important part of the hospitalist team: hospital and health system pharmacists.

Regardless of your motivation, the American Society of Health-System Pharmacist’s (ASHP’s) combination of three meetings in one brings a wealth of information to hospitalists—physicians and pharmacists alike—and now SHM members can register for the Medication Safety Collaborative at the applicable ASHP member rates.

SHM members receive the ASHP member rate at ASHP’s meeting within a meeting for hospital and health system pharmacists, to be held May 31-June 4 in Las Vegas.

Many hospitalists will be especially interested in the Medication Safety Collaborative, which brings the entire hospital team together to share best practices in medication and patient safety.

The Medication Safety Collaborative consists of three meetings:

• ASHP Informatics Institute: An event for informaticists to innovate, interact, and improve the use of information technology in healthcare;
• The Medication Safety Collaborative: For inter-professional teams of health system-based clinicians, coordinators, managers, and administrators who focus on patient safety and quality; and
• Pharmacy Practice Policy: The most relevant issues affecting health system pharmacy practice today at ASHP’s first Pharmacy Practice and Policy Meeting.

LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.

Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.

“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”

Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.

Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”

After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”

John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”

“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”

Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.

“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.

He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.

“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”

In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.

An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.

“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”

Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.

“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”

One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.

“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”

The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.

And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.

“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”

LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.

Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.

“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”

Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.

Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”

After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”

John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”

“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”

Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.

“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.

He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.

“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”

In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.

An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.

“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”

Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.

“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”

One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.

“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”

The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.

And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.

“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”

LAS VEGAS—Hospitalist Ijeoma “Carol” Nwelue, MD, has been more focused on patient readmissions over the past year at her practice in Lansing, Mich. So when the directors at Sparrow Hospitalists told her she had a meeting a few weeks after HM14 to discuss different risk assessment tools that might be used to pre-identify patients at high risk for readmission, she wasn’t nervous.

Instead, she prepped at SHM’s annual meeting at Mandalay Bay Resort and Casino—a veritable three-day crash course in the latest and greatest approaches to preventing readmissions.

“It’s very helpful,” she says. “It helps to see things that I haven’t thought about in our practice that other people are looking into.”

Quality improvement (QI) and patient safety are at the core of what hospitalists do, and the HM14 organizers understand that. From multiple pre-courses on the topics trending today to a dedicated educational track of breakout sessions and expert speakers to hundreds of posters identifying HM-specific QI projects, SHM’s annual meeting is a veritable QI opportunity of its own.

Take the annual pre-course, “ABIM Maintenance of Certification Facilitated Modules.” One attendee told presenter Read Pierce, MD, director of quality improvement and clinical innovation for the hospitalist group at the University of Colorado Denver, that before the session in Las Vegas he had always had “the sense that quality and safety is soft science or fuzzy stuff around the edges, and if you were a smart clinician, that was good enough.”

After some time in the session, Dr. Pierce recounts, the man “realized it’s not just enough to have great intellectual horsepower. You have to have some approach for dealing with these complex systems. And I think that’s the really fun thing....It’s not just about the discreet concepts; it’s about understanding the environment in which we practice, the importance of engaging systems and of using the tools of quality and safety to augment what physicians have always been good at doing.”

John Coppes, MD, FHM, a hospitalist at Mount Nittany Medical Center in State College, Pa., says quality and patient safety are the “most important things that we do.”

“It’s our responsibility to our patients to do the best job we can,” he notes. “It’s our responsibility to society to do it as efficiently as we can.”

Veteran meeting faculty John Bulger, DO, MBA, FACP, SFHM, hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, agrees completely and is one of HM’s biggest proponents of the American Board of Internal Medicine (ABIM) Foundation’s Choosing Wisely (www.hospitalmedicine.org/choosingwisely) campaign. The national initiative, aimed at educating physicians—and patients—about wasteful medical tests, procedures, and treatments, launched in 2012, but SHM joined the chorus as a strategic partner last year.

“Choosing Wisely is about bending the cost curve,” Dr. Bulger says.

He added that although standardization of care is necessary for Choosing Wisely to work, homogeneity doesn’t mean everybody does everything exactly the same way. It means ensuring that hospitalists adopt “agreed upon best practices” before local variations are added. He compared it to a cookbook of apple pie recipes. All apple pies contain apples and crust, but the tasty treats are tailored differently from there.

“When you come up with guidelines in your hospital, that’s what you’re doing,” Dr. Bulger says. “You’re writing the cookbook and coming up with what works at your hospital. It might not work at [my hospital] at all, but I can look at it and learn.”

In the long-term, SHM hopes to create resources beyond the recommendations themselves—perhaps including a mentored implementation program akin to Project BOOST or pre-packaged order sets and checklists. Whatever the society does, it needs to engage the younger generation of physicians to ensure that quality and safety stay a priority for them, says Darlene Tad-y, MD, chair of SHM’s Physicians in Training Committee.

An assistant professor of medicine and a hospitalist at the University of Colorado Denver, Dr. Tad-y says that getting residents and students involved in quality and safety measures is critical for HM’s future.

“Especially since we want to have hospital medicine be at the forefront,” she explains. “It’s vital for us to have our students and residents taking the lead.”

Younger physicians already see the role quality and safety take in day-to-day practice. So, for them, according to Dr. Tad-y, a focus on making sure patient care is delivered better and more safely isn’t a renewed effort—it’s what they’re taught from the beginning.

“They haven’t been trained in the old way yet,” she says. “They still have an open mind. They see that things can change and things can be better. We don’t have to change old habits. We are just evolving good new habits for them.”

One new perspective was a first-time pre-course, “Cardiology: What Hospitalists Need to Know as Front-Line Providers.” The eight-hour seminar was led by cardiologist Matthews Chacko, MD, of Johns Hopkins Hospital in Baltimore, who says the time is right for quality-focused hospitalists to devote a full-day pre-course to cardiology.

“Cardiovascular disease is the most common reason we die,” he says. “It’s something hospital-based practitioners see often. Providing a comprehensive, yet simplified, overview of the way to manage some of these diseases with talks given by some of the leading experts in the field seemed very appropriate for this meeting.”

The sheer scale of QI initiatives can be daunting, says Michelle Mourad, MD, director of quality and safety at the University of California at San Francisco (UCSF) School of Medicine. She urges her peers to take the proverbial step back, identify a single issue—sepsis mortality or hand hygiene, for example—and then focus on understanding that issue intimately. That way, a hospitalist or HM group can convince other physicians that there is a problem and that it’s worth the work to fix it. Once that’s done, a hospitalist can launch a QI project that devises a measurement strategy to see if change is occurring.

And, while sustaining that change beyond the initial start-up can be difficult, Dr. Mourad believes success breeds success.

“When you work hard at a quality gap that’s in your organization, [when you] actually see the care you provide get better—not just for the patient in front of you, but for all the patients in your organization—it’s extremely powerful and motivating,” she says. “It changes the culture in your institution and convinces other people that they can do the same.”

Dr. Danella

10 Things: At A Glance

1. Take out urinary catheters as soon as possible.
2. But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.
3. Beware certain types of medications in vulnerable patients.
4. Don’t discharge patients who are having difficulty voiding.
5. Broach sensitive topics, but do so gently.
6. Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.
7. Diabetic patients require extra attention.
8. Practice good antibiotic stewardship.
9. Determine whether the patient can be seen as an outpatient.
10. Embrace your role as eyes and ears.

1: Intravenous Haloperidol Does Not Prevent ICU Delirium

Urology is an area in which hospitalists might not have much formal training, but because many of these patients undergo highly complicated surgical procedures with great potential for complications, hospitalists can be vital for good outcomes, urologists say.

The use of urinary catheters is a prime area of concern when it comes to quality and safety, making hospitalists’ role in the care of urological patients even more crucial.

The Hospitalist spoke with a half dozen urologists and well-versed HM clinicians about caring for patients with urological disorders. Here are the best nuggets of guidance for hospitalists.

Take out urinary catheters as soon as possible.

John Bulger, DO, FACOI, FACP, SFHM, a hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, says that, all too often, urinary catheters are left in too long. “There’s pretty good data to suggest that there’s a very direct relationship with the length of time the catheter’s in and the chance of it getting infected,” he says. “Upwards to half of the urinary catheters that are in in hospitals right now wouldn’t meet the guidelines of having a urinary catheter in.”

Dr. Bulger is chair of SHM’s Choosing Wisely subcommittee. One of SHM’s Choosing Wisely recommendations warns physicians not to place, or leave in place, catheters for incontinence, convenience, or monitoring of non-critically ill patients.¹

2: But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.

William Steers, MD, chair of urology at the University of Virginia and editor of the Journal of Urology, says there are risks associated with taking catheters out when it’s not appropriate, especially in patients who’ve undergone surgery.

“We’ve seen situations where we’re called into the operating room by another team,” Dr. Steers says. “Let’s say there was a bladder injury of another service. We’ve repaired the bladder with a catheter in for seven to 10 days. It’s taken out day one; the bladder fills and has the potential of causing harm.”

Early removal before the bladder wall heals can cause bladder rupture, requiring emergency surgery.

“So the devil’s in the details,” he says.

Mark Austenfeld, MD, FACS, president of the American Association of Clinical Urologists, which is dedicated to political action, advocacy, and best practice parameters, says catheters should remain in place for patients with mental status changes, or those who are debilitated in some way and can’t get out of bed or don’t have the wherewithal to ask for help from a nurse.

He says he realizes hospitalists are following pay-for-performance protocols, but he adds a caveat.

“Many times these protocols cannot take into account all of these specialized situations,” says Dr. Austenfeld, a urologist with Kansas City Urology Care. He stresses, though, that the hospitalists he’s worked with do high-quality work.

Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor, says that even with these issues, early removal should remain a priority when appropriate.

“There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while,” Dr. Saint explains. “But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.”²

Dr. Steers says most agree that urinary catheters are often “overutilized.”

“You do want to get them out as soon as possible,” he says. “But if it’s ever in doubt, there should be communication with the urology team.”

3: Beware certain types of medications in vulnerable patients.

Hospitalists should tread carefully with medications that might be difficult to handle for patients with kidney issues, like stones or obstructive disease, Dr. Bulger says.

“If they only have one kidney that works well, you have to pay particular attention to drugs that are toxic to the kidneys,” he says. He notes that the nature of the patient’s health “will change the doses of some drugs, as well, depending on what the function of their kidney is.”

Dr. Austenfeld says that drugs with anticholinergic side effects, including some cold remedies such as Benadryl, should possibly be avoided in patients who are having trouble emptying their bladders, because they might make it more difficult for a patient to urinate. Some sedatives, such as amitriptyline, have similar effects and should be used cautiously in these patients, Dr. Austenfeld points out.

“That class of drugs—sometimes I see patients on them for a long time, or placed on them, and they do have a little trouble emptying their bladders,” he says.

4: Don’t discharge patients who are having difficulty voiding.

“If patients are in the hospital and they’ve been taking narcotics post-surgically, or they’re a diabetic patient and they’ve had urinary catheter infections, we should be very careful that these patients are emptying their bladders,” says Dennis Pessis, professor of urology at Rush University Medical Center in Chicago and immediate past president of the American Urological Association. “You can do a very simple ultrasound of the bladder to be sure that they’re emptying. Because if they’re not emptying well, and if they’re going to go home, they may not empty their bladders well and may colonize bacteria.”

Dr. Pessis says it’s not common, but it does happen.

“It’s something that’s of concern,” he says. “It happens often enough that we should be very alert to watching for those problems.”

5: Broach sensitive topics, but do so gently.

“Sexual dysfunction is a significant issue,” Dr. Bulger says. “I think that it’s in the best interest of the patient to address that up front. Generally, urologists are pretty good at that as well. Because you’re co-managing with them, they’re going to help out with that. But it’s important to always remember what’s going to concern the patient.”

Incontinence can be similarly sensitive but important to discuss.

“I think it helps sometimes if the physician brings it up in an appropriate way and kind of opens the door to be able to have the discussion,” Dr. Bulger said.

[Diabetic patients] may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders. They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.

—Dennis Pessis, professor of urology, Rush University Medical Center, Chicago, immediate past president, American Urological Association

6: Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.

One rule of thumb is, if you try twice to put in a urinary catheter without success, call in someone else to do it.

“You don’t want what we call ‘false passages,’” Dr. Pessis says. “If you are having difficulty inserting the catheter, if it’s not moving down the channel well, then you should back off and either consult someone that has more experience in catheterizing or contact the urologist.”

Two reasons the placement might be difficult: strictures like old scar formations, within the urethra, or an enlarged prostate.

Dr. Danella

John Danella, MD, FACS, head of urology for the Geisinger Health System, says a coudé catheter, with a curved tip to help it navigate around the prostate, should be tried on male patients over 50.

“If that’s not successful, then I think you need to call the urologist,” he says. “It’s better to call them before there’s been trauma to the urethra than afterwards.”

Dr. Danella says he understands that attempts by hospitalists in the face of difficulty are made with “best intentions” to save the urologist the time. But when injuries happen, “often times you’re forced to take that patient to the operating room for cystoscopy.”

7: Diabetic patients require extra attention.

“They may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders,” Dr. Pessis explains. “They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.”

8: Practice good antibiotic stewardship.

After 72 hours, almost all urine cultures from a catheterized patient are positive. That doesn’t mean they all need antibiotics, Dr. Steers says.

“Unless the patient’s symptomatic, we don’t treat until a catheter comes out,” he says. “The constant use of antibiotics in somebody with an in-dwelling catheter is creating tremendous problems with resistance and biofilms, etc.”

Dr. Steers says hospitalists can be an educational resource for care teams, using the latest infectious disease literature to say, “Hey, this antibiotic should be stopped. You don’t need to continue this many days.”

“One of the problems we’re having with guidelines is every specialty has their own antibiotic prophylaxis guidelines,” he adds. “So it can be very confusing for the hospitalist.”

9: Determine whether the patient can be seen as an outpatient.

Dr. Danella says that determination often is not made carefully enough. After initial treatment, follow-up with the urologist often can be done on an outpatient basis.

“Sometimes, they’re waiting around all day before we’re free and we can come see them. So I think in many cases, at least in our system, it would be helpful if folks could just place a phone call or just send a message and say, ‘Do you need to see this patient or can we send them home?’” Dr. Danella says. “I think it’s better for everybody if we can do that.”

One common example is an elderly patient who comes to the hospital, is put into a bed, and can’t void. Often, the patient would respond to a catheter and an alpha-blocker (if no contraindication), he says. But, that day, there’s nothing the urologist will be able to do to help make them void immediately, he says.

Another example is a patient with a small kidney stone, less than 5 mm, who probably would respond to medical therapy and won’t need an intervention, Dr. Danella says.

There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while. But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.

—Sanjay Saint, MD, MPH, FHM, hospitalist, professor of internal medicine, University of Michigan, Ann Arbor

10: Embrace your role as eyes and ears.

If a surgical patient’s note isn’t changed in three or four days, the hospitalist needs to ask the surgical team about what has changed in the case, Dr. Steers says.

“At the end of the day, it’s communication with urologists and surgeons,” he says. “And most would appreciate that. I think the [attitude from the] old days of ‘untold command of my patient, I want no other input,’ is really short-sighted.”

Hospitalist vigilance is especially important for complicated patients, such as those who’ve undergone radical cystectomy for bladder cancer. That’s the procedure with the highest mortality rate in urology, as patients are generally older, smoke, and often are obese. And they have high readmission rates—nearly 30 percent.³

Dr. Steers says hospitalists are needed to look for early warning signs in these patients.

“We look for that sort of input, especially when it comes to being the early eyes and ears of potential problems or somebody helping in discharge planning,” he says. “It might be a little too early to go home, and being readmitted is not very good for the hospital as a whole, but, more importantly, the patient.”

Tom Collins is a freelance writer in South Florida.

References

1. Society of Hospital Medicine. Five things physicians and patients should question. SHM website. Available at: http://www.hospitalmedicine.org/AM/pdf/SHM-Adult_5things_List_Web.pdf. Accessed October 24, 2013.
2. Loeb M, Hunt D, O’Halloran K, Carusone SC, Dafoe N, Walter SD. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. J Gen Intern Med. 2008;23(6):816-820.
3. Stimson CJ, Chang SS, Barocas DA, et al. Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series. J Urol. 2010;184(4):1296-1300.
4. Saint S, Lipsky BA, Goold SD. Indwelling urinary catheters: a one-point restraint? Ann Intern Med. 2002;137(2):125-127.

Dr. Danella

10 Things: At A Glance

1. Take out urinary catheters as soon as possible.
2. But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.
3. Beware certain types of medications in vulnerable patients.
4. Don’t discharge patients who are having difficulty voiding.
5. Broach sensitive topics, but do so gently.
6. Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.
7. Diabetic patients require extra attention.
8. Practice good antibiotic stewardship.
9. Determine whether the patient can be seen as an outpatient.
10. Embrace your role as eyes and ears.

1: Intravenous Haloperidol Does Not Prevent ICU Delirium

Urology is an area in which hospitalists might not have much formal training, but because many of these patients undergo highly complicated surgical procedures with great potential for complications, hospitalists can be vital for good outcomes, urologists say.

The use of urinary catheters is a prime area of concern when it comes to quality and safety, making hospitalists’ role in the care of urological patients even more crucial.

The Hospitalist spoke with a half dozen urologists and well-versed HM clinicians about caring for patients with urological disorders. Here are the best nuggets of guidance for hospitalists.

Take out urinary catheters as soon as possible.

John Bulger, DO, FACOI, FACP, SFHM, a hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, says that, all too often, urinary catheters are left in too long. “There’s pretty good data to suggest that there’s a very direct relationship with the length of time the catheter’s in and the chance of it getting infected,” he says. “Upwards to half of the urinary catheters that are in in hospitals right now wouldn’t meet the guidelines of having a urinary catheter in.”

Dr. Bulger is chair of SHM’s Choosing Wisely subcommittee. One of SHM’s Choosing Wisely recommendations warns physicians not to place, or leave in place, catheters for incontinence, convenience, or monitoring of non-critically ill patients.¹

2: But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.

William Steers, MD, chair of urology at the University of Virginia and editor of the Journal of Urology, says there are risks associated with taking catheters out when it’s not appropriate, especially in patients who’ve undergone surgery.

“We’ve seen situations where we’re called into the operating room by another team,” Dr. Steers says. “Let’s say there was a bladder injury of another service. We’ve repaired the bladder with a catheter in for seven to 10 days. It’s taken out day one; the bladder fills and has the potential of causing harm.”

Early removal before the bladder wall heals can cause bladder rupture, requiring emergency surgery.

“So the devil’s in the details,” he says.

Mark Austenfeld, MD, FACS, president of the American Association of Clinical Urologists, which is dedicated to political action, advocacy, and best practice parameters, says catheters should remain in place for patients with mental status changes, or those who are debilitated in some way and can’t get out of bed or don’t have the wherewithal to ask for help from a nurse.

He says he realizes hospitalists are following pay-for-performance protocols, but he adds a caveat.

“Many times these protocols cannot take into account all of these specialized situations,” says Dr. Austenfeld, a urologist with Kansas City Urology Care. He stresses, though, that the hospitalists he’s worked with do high-quality work.

Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor, says that even with these issues, early removal should remain a priority when appropriate.

“There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while,” Dr. Saint explains. “But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.”²

Dr. Steers says most agree that urinary catheters are often “overutilized.”

“You do want to get them out as soon as possible,” he says. “But if it’s ever in doubt, there should be communication with the urology team.”

3: Beware certain types of medications in vulnerable patients.

Hospitalists should tread carefully with medications that might be difficult to handle for patients with kidney issues, like stones or obstructive disease, Dr. Bulger says.

“If they only have one kidney that works well, you have to pay particular attention to drugs that are toxic to the kidneys,” he says. He notes that the nature of the patient’s health “will change the doses of some drugs, as well, depending on what the function of their kidney is.”

Dr. Austenfeld says that drugs with anticholinergic side effects, including some cold remedies such as Benadryl, should possibly be avoided in patients who are having trouble emptying their bladders, because they might make it more difficult for a patient to urinate. Some sedatives, such as amitriptyline, have similar effects and should be used cautiously in these patients, Dr. Austenfeld points out.

“That class of drugs—sometimes I see patients on them for a long time, or placed on them, and they do have a little trouble emptying their bladders,” he says.

4: Don’t discharge patients who are having difficulty voiding.

“If patients are in the hospital and they’ve been taking narcotics post-surgically, or they’re a diabetic patient and they’ve had urinary catheter infections, we should be very careful that these patients are emptying their bladders,” says Dennis Pessis, professor of urology at Rush University Medical Center in Chicago and immediate past president of the American Urological Association. “You can do a very simple ultrasound of the bladder to be sure that they’re emptying. Because if they’re not emptying well, and if they’re going to go home, they may not empty their bladders well and may colonize bacteria.”

Dr. Pessis says it’s not common, but it does happen.

“It’s something that’s of concern,” he says. “It happens often enough that we should be very alert to watching for those problems.”

5: Broach sensitive topics, but do so gently.

“Sexual dysfunction is a significant issue,” Dr. Bulger says. “I think that it’s in the best interest of the patient to address that up front. Generally, urologists are pretty good at that as well. Because you’re co-managing with them, they’re going to help out with that. But it’s important to always remember what’s going to concern the patient.”

Incontinence can be similarly sensitive but important to discuss.

“I think it helps sometimes if the physician brings it up in an appropriate way and kind of opens the door to be able to have the discussion,” Dr. Bulger said.

[Diabetic patients] may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders. They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.

—Dennis Pessis, professor of urology, Rush University Medical Center, Chicago, immediate past president, American Urological Association

6: Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.

One rule of thumb is, if you try twice to put in a urinary catheter without success, call in someone else to do it.

“You don’t want what we call ‘false passages,’” Dr. Pessis says. “If you are having difficulty inserting the catheter, if it’s not moving down the channel well, then you should back off and either consult someone that has more experience in catheterizing or contact the urologist.”

Two reasons the placement might be difficult: strictures like old scar formations, within the urethra, or an enlarged prostate.

Dr. Danella

John Danella, MD, FACS, head of urology for the Geisinger Health System, says a coudé catheter, with a curved tip to help it navigate around the prostate, should be tried on male patients over 50.

“If that’s not successful, then I think you need to call the urologist,” he says. “It’s better to call them before there’s been trauma to the urethra than afterwards.”

Dr. Danella says he understands that attempts by hospitalists in the face of difficulty are made with “best intentions” to save the urologist the time. But when injuries happen, “often times you’re forced to take that patient to the operating room for cystoscopy.”

7: Diabetic patients require extra attention.

“They may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders,” Dr. Pessis explains. “They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.”

8: Practice good antibiotic stewardship.

After 72 hours, almost all urine cultures from a catheterized patient are positive. That doesn’t mean they all need antibiotics, Dr. Steers says.

“Unless the patient’s symptomatic, we don’t treat until a catheter comes out,” he says. “The constant use of antibiotics in somebody with an in-dwelling catheter is creating tremendous problems with resistance and biofilms, etc.”

Dr. Steers says hospitalists can be an educational resource for care teams, using the latest infectious disease literature to say, “Hey, this antibiotic should be stopped. You don’t need to continue this many days.”

“One of the problems we’re having with guidelines is every specialty has their own antibiotic prophylaxis guidelines,” he adds. “So it can be very confusing for the hospitalist.”

9: Determine whether the patient can be seen as an outpatient.

Dr. Danella says that determination often is not made carefully enough. After initial treatment, follow-up with the urologist often can be done on an outpatient basis.

“Sometimes, they’re waiting around all day before we’re free and we can come see them. So I think in many cases, at least in our system, it would be helpful if folks could just place a phone call or just send a message and say, ‘Do you need to see this patient or can we send them home?’” Dr. Danella says. “I think it’s better for everybody if we can do that.”

One common example is an elderly patient who comes to the hospital, is put into a bed, and can’t void. Often, the patient would respond to a catheter and an alpha-blocker (if no contraindication), he says. But, that day, there’s nothing the urologist will be able to do to help make them void immediately, he says.

Another example is a patient with a small kidney stone, less than 5 mm, who probably would respond to medical therapy and won’t need an intervention, Dr. Danella says.

There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while. But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.

—Sanjay Saint, MD, MPH, FHM, hospitalist, professor of internal medicine, University of Michigan, Ann Arbor

10: Embrace your role as eyes and ears.

If a surgical patient’s note isn’t changed in three or four days, the hospitalist needs to ask the surgical team about what has changed in the case, Dr. Steers says.

“At the end of the day, it’s communication with urologists and surgeons,” he says. “And most would appreciate that. I think the [attitude from the] old days of ‘untold command of my patient, I want no other input,’ is really short-sighted.”

Hospitalist vigilance is especially important for complicated patients, such as those who’ve undergone radical cystectomy for bladder cancer. That’s the procedure with the highest mortality rate in urology, as patients are generally older, smoke, and often are obese. And they have high readmission rates—nearly 30 percent.³

Dr. Steers says hospitalists are needed to look for early warning signs in these patients.

“We look for that sort of input, especially when it comes to being the early eyes and ears of potential problems or somebody helping in discharge planning,” he says. “It might be a little too early to go home, and being readmitted is not very good for the hospital as a whole, but, more importantly, the patient.”

Tom Collins is a freelance writer in South Florida.

References

1. Society of Hospital Medicine. Five things physicians and patients should question. SHM website. Available at: http://www.hospitalmedicine.org/AM/pdf/SHM-Adult_5things_List_Web.pdf. Accessed October 24, 2013.
2. Loeb M, Hunt D, O’Halloran K, Carusone SC, Dafoe N, Walter SD. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. J Gen Intern Med. 2008;23(6):816-820.
3. Stimson CJ, Chang SS, Barocas DA, et al. Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series. J Urol. 2010;184(4):1296-1300.
4. Saint S, Lipsky BA, Goold SD. Indwelling urinary catheters: a one-point restraint? Ann Intern Med. 2002;137(2):125-127.

Dr. Danella

10 Things: At A Glance

1. Take out urinary catheters as soon as possible.
2. But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.
3. Beware certain types of medications in vulnerable patients.
4. Don’t discharge patients who are having difficulty voiding.
5. Broach sensitive topics, but do so gently.
6. Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.
7. Diabetic patients require extra attention.
8. Practice good antibiotic stewardship.
9. Determine whether the patient can be seen as an outpatient.
10. Embrace your role as eyes and ears.

1: Intravenous Haloperidol Does Not Prevent ICU Delirium

Urology is an area in which hospitalists might not have much formal training, but because many of these patients undergo highly complicated surgical procedures with great potential for complications, hospitalists can be vital for good outcomes, urologists say.

The use of urinary catheters is a prime area of concern when it comes to quality and safety, making hospitalists’ role in the care of urological patients even more crucial.

The Hospitalist spoke with a half dozen urologists and well-versed HM clinicians about caring for patients with urological disorders. Here are the best nuggets of guidance for hospitalists.

Take out urinary catheters as soon as possible.

John Bulger, DO, FACOI, FACP, SFHM, a hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, says that, all too often, urinary catheters are left in too long. “There’s pretty good data to suggest that there’s a very direct relationship with the length of time the catheter’s in and the chance of it getting infected,” he says. “Upwards to half of the urinary catheters that are in in hospitals right now wouldn’t meet the guidelines of having a urinary catheter in.”

Dr. Bulger is chair of SHM’s Choosing Wisely subcommittee. One of SHM’s Choosing Wisely recommendations warns physicians not to place, or leave in place, catheters for incontinence, convenience, or monitoring of non-critically ill patients.¹

2: But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.

William Steers, MD, chair of urology at the University of Virginia and editor of the Journal of Urology, says there are risks associated with taking catheters out when it’s not appropriate, especially in patients who’ve undergone surgery.

“We’ve seen situations where we’re called into the operating room by another team,” Dr. Steers says. “Let’s say there was a bladder injury of another service. We’ve repaired the bladder with a catheter in for seven to 10 days. It’s taken out day one; the bladder fills and has the potential of causing harm.”

Early removal before the bladder wall heals can cause bladder rupture, requiring emergency surgery.

“So the devil’s in the details,” he says.

Mark Austenfeld, MD, FACS, president of the American Association of Clinical Urologists, which is dedicated to political action, advocacy, and best practice parameters, says catheters should remain in place for patients with mental status changes, or those who are debilitated in some way and can’t get out of bed or don’t have the wherewithal to ask for help from a nurse.

He says he realizes hospitalists are following pay-for-performance protocols, but he adds a caveat.

“Many times these protocols cannot take into account all of these specialized situations,” says Dr. Austenfeld, a urologist with Kansas City Urology Care. He stresses, though, that the hospitalists he’s worked with do high-quality work.

Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor, says that even with these issues, early removal should remain a priority when appropriate.

“There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while,” Dr. Saint explains. “But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.”²

Dr. Steers says most agree that urinary catheters are often “overutilized.”

“You do want to get them out as soon as possible,” he says. “But if it’s ever in doubt, there should be communication with the urology team.”

3: Beware certain types of medications in vulnerable patients.

Hospitalists should tread carefully with medications that might be difficult to handle for patients with kidney issues, like stones or obstructive disease, Dr. Bulger says.

“If they only have one kidney that works well, you have to pay particular attention to drugs that are toxic to the kidneys,” he says. He notes that the nature of the patient’s health “will change the doses of some drugs, as well, depending on what the function of their kidney is.”

Dr. Austenfeld says that drugs with anticholinergic side effects, including some cold remedies such as Benadryl, should possibly be avoided in patients who are having trouble emptying their bladders, because they might make it more difficult for a patient to urinate. Some sedatives, such as amitriptyline, have similar effects and should be used cautiously in these patients, Dr. Austenfeld points out.

“That class of drugs—sometimes I see patients on them for a long time, or placed on them, and they do have a little trouble emptying their bladders,” he says.

4: Don’t discharge patients who are having difficulty voiding.

“If patients are in the hospital and they’ve been taking narcotics post-surgically, or they’re a diabetic patient and they’ve had urinary catheter infections, we should be very careful that these patients are emptying their bladders,” says Dennis Pessis, professor of urology at Rush University Medical Center in Chicago and immediate past president of the American Urological Association. “You can do a very simple ultrasound of the bladder to be sure that they’re emptying. Because if they’re not emptying well, and if they’re going to go home, they may not empty their bladders well and may colonize bacteria.”

Dr. Pessis says it’s not common, but it does happen.

“It’s something that’s of concern,” he says. “It happens often enough that we should be very alert to watching for those problems.”

5: Broach sensitive topics, but do so gently.

“Sexual dysfunction is a significant issue,” Dr. Bulger says. “I think that it’s in the best interest of the patient to address that up front. Generally, urologists are pretty good at that as well. Because you’re co-managing with them, they’re going to help out with that. But it’s important to always remember what’s going to concern the patient.”

Incontinence can be similarly sensitive but important to discuss.

“I think it helps sometimes if the physician brings it up in an appropriate way and kind of opens the door to be able to have the discussion,” Dr. Bulger said.

[Diabetic patients] may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders. They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.

—Dennis Pessis, professor of urology, Rush University Medical Center, Chicago, immediate past president, American Urological Association

6: Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.

One rule of thumb is, if you try twice to put in a urinary catheter without success, call in someone else to do it.

“You don’t want what we call ‘false passages,’” Dr. Pessis says. “If you are having difficulty inserting the catheter, if it’s not moving down the channel well, then you should back off and either consult someone that has more experience in catheterizing or contact the urologist.”

Two reasons the placement might be difficult: strictures like old scar formations, within the urethra, or an enlarged prostate.

Dr. Danella

John Danella, MD, FACS, head of urology for the Geisinger Health System, says a coudé catheter, with a curved tip to help it navigate around the prostate, should be tried on male patients over 50.

“If that’s not successful, then I think you need to call the urologist,” he says. “It’s better to call them before there’s been trauma to the urethra than afterwards.”

Dr. Danella says he understands that attempts by hospitalists in the face of difficulty are made with “best intentions” to save the urologist the time. But when injuries happen, “often times you’re forced to take that patient to the operating room for cystoscopy.”

7: Diabetic patients require extra attention.

“They may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders,” Dr. Pessis explains. “They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.”

8: Practice good antibiotic stewardship.

After 72 hours, almost all urine cultures from a catheterized patient are positive. That doesn’t mean they all need antibiotics, Dr. Steers says.

“Unless the patient’s symptomatic, we don’t treat until a catheter comes out,” he says. “The constant use of antibiotics in somebody with an in-dwelling catheter is creating tremendous problems with resistance and biofilms, etc.”

Dr. Steers says hospitalists can be an educational resource for care teams, using the latest infectious disease literature to say, “Hey, this antibiotic should be stopped. You don’t need to continue this many days.”

“One of the problems we’re having with guidelines is every specialty has their own antibiotic prophylaxis guidelines,” he adds. “So it can be very confusing for the hospitalist.”

9: Determine whether the patient can be seen as an outpatient.

Dr. Danella says that determination often is not made carefully enough. After initial treatment, follow-up with the urologist often can be done on an outpatient basis.

“Sometimes, they’re waiting around all day before we’re free and we can come see them. So I think in many cases, at least in our system, it would be helpful if folks could just place a phone call or just send a message and say, ‘Do you need to see this patient or can we send them home?’” Dr. Danella says. “I think it’s better for everybody if we can do that.”

One common example is an elderly patient who comes to the hospital, is put into a bed, and can’t void. Often, the patient would respond to a catheter and an alpha-blocker (if no contraindication), he says. But, that day, there’s nothing the urologist will be able to do to help make them void immediately, he says.

Another example is a patient with a small kidney stone, less than 5 mm, who probably would respond to medical therapy and won’t need an intervention, Dr. Danella says.

There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while. But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.

—Sanjay Saint, MD, MPH, FHM, hospitalist, professor of internal medicine, University of Michigan, Ann Arbor

10: Embrace your role as eyes and ears.

If a surgical patient’s note isn’t changed in three or four days, the hospitalist needs to ask the surgical team about what has changed in the case, Dr. Steers says.

“At the end of the day, it’s communication with urologists and surgeons,” he says. “And most would appreciate that. I think the [attitude from the] old days of ‘untold command of my patient, I want no other input,’ is really short-sighted.”

Hospitalist vigilance is especially important for complicated patients, such as those who’ve undergone radical cystectomy for bladder cancer. That’s the procedure with the highest mortality rate in urology, as patients are generally older, smoke, and often are obese. And they have high readmission rates—nearly 30 percent.³

Dr. Steers says hospitalists are needed to look for early warning signs in these patients.

“We look for that sort of input, especially when it comes to being the early eyes and ears of potential problems or somebody helping in discharge planning,” he says. “It might be a little too early to go home, and being readmitted is not very good for the hospital as a whole, but, more importantly, the patient.”

Tom Collins is a freelance writer in South Florida.

References

1. Society of Hospital Medicine. Five things physicians and patients should question. SHM website. Available at: http://www.hospitalmedicine.org/AM/pdf/SHM-Adult_5things_List_Web.pdf. Accessed October 24, 2013.
2. Loeb M, Hunt D, O’Halloran K, Carusone SC, Dafoe N, Walter SD. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. J Gen Intern Med. 2008;23(6):816-820.
3. Stimson CJ, Chang SS, Barocas DA, et al. Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series. J Urol. 2010;184(4):1296-1300.
4. Saint S, Lipsky BA, Goold SD. Indwelling urinary catheters: a one-point restraint? Ann Intern Med. 2002;137(2):125-127.

Don Berwick, MD, former president and CEO of the Institute for Healthcare Improvement (IHI) and former administrator for the Centers for Medicare and Medicaid Services (CMS), recently consulted with the National Health Service (NHS) on how to devise and implement a safer and better healthcare system for England. His services were solicited due to a number of high-profile scandals involving neglect in hospitals. His team’s work resulted in a report entitled “A Promise to Learn – A Commitment to Act: Improving the Safety of Patients in England.”¹ The purpose of the consultative visit and resulting series of recommendations was to identify and recommend solutions to ailments and limitations in the current NHS.

Many of the “current state” ailments outlined in Dr. Berwick’s report would not sound terribly novel or unfamiliar to most U.S. healthcare systems. The report listed problems with:

• Systems-procedures-conditions-environments-constraints that lead people to make bad or incorrect decisions;
• Incorrect priorities;
• Not heeding warning signals about patient safety;
• Diffusion of responsibility;
• Lack of support for continuous improvement; and
• Fear, which is “toxic to both safety and improvement.”

Dr. Berwick and his team made a number of recommendations to reshape priorities and resources, enhance the safety of the system, and rebuild the confidence of its customers (e.g., patients and caregivers).

The consultant group’s core message was simple and inspiring:

“The NHS in England can become the safest healthcare system in the world. It will require unified will, optimism, investment, and change. Everyone can and should help. And, it will require a culture firmly rooted in continual improvement. Rules, standards, regulations, and enforcement have a place in the pursuit of quality, but they pale in potential compared to the power of pervasive and constant learning.”

To achieve improvement, Dr. Berwick’s team recommended 10 guiding principles. Similar to The 10 Commandments, they offer a way of thinking, acting, and living—to make the healthcare industry a better place. These healthcare 10 commandments include the following:

1. “The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning.” While we should all aspire to zero harm, the reality is that getting there will be a long and difficult goal, more than likely a goal of continual reduction. Defining harm is also more difficult than looking just at what meets the eye; because the qualitative “you know it when you see it” will likely never be embraced widely, we are left with quantitative and imperfect measures, such as hospital-acquired conditions (HACs) and patient safety indicators (PSIs). Despite the imperfection of current measures, the goal for continual reduction is laudable and necessary.
2. “All leaders concerned with NHS healthcare—political, regulatory, governance, executive, clinical, and advocacy—should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement, and support.” As with anything, leadership sets the vision, mission, and values of an organization or system. Leadership will have to commit to placing patient safety at the top of the priority list, without sacrificing other priorities.

1. “Patients and their caregivers should be present, powerful, and involved at all levels of healthcare organizations, from the wards to the boards of trusts.” This directive is certainly ideal, but, realistically, it will take a while to develop a level of comfort from both the patients and the providers, because both are much more used to operating in parallel, with intermittent intersections. Involving patients in all organizational decision-making, and including the boards of trustees, will be prerequisite to true patient-caregiver-centered care.
2. “Government, Health Education England, and NHS England should assure that sufficient staff are available to meet the NHS’ needs now and in the future. Healthcare organizations should ensure staff are present in appropriate numbers to provide safe care at all times and are well-supported." All healthcare organizations should be on a relentless pursuit to match workload and intensity to staffing, pursue work standardization and efficiency, and match work to human intellect. These are the founding tenets of Lean and Six Sigma and should be pursued for all disciplines, both clinical and non-clinical.
3. “Mastery of quality and patient-safety sciences and practices should be part of initial preparation and lifelong education of all healthcare professionals, including managers and executives.” The U.S. has made great strides in incorporating at least a basic curriculum of quality and safety for most healthcare professionals, but we need to move the current level of understanding to the next level. We need to ensure that all healthcare professionals have at least a basic understanding of the fundamental principles.
4. “The NHS should become a learning organization. Its leaders should create and support the capability for learning, and therefore change, at scale within the NHS.” Healthcare organizations should not just be willing to learn from individual and system opportunities; they should be eager to learn. Quality and safety missions should uniformly extend into educational and research missions in all organizations, to enhance learning opportunities and create best practice.
5. “Transparency should be complete, timely, and unequivocal. All data on quality and safety, whether assembled by government, organizations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.” Many healthcare organizations equate transparency with marketing, where they tout their fanciest technology or latest innovation. And many also subscribe to the theory “if you’re gonna go bare, you better be buff” and only widely disseminate those metrics that make them appear superior. We all need to be more transparent across the board, because going “bare” can actually stimulate improvements more quickly and reliably than they would otherwise occur. Organizational metrics really should not belong to the organization; they should belong to the patients who created the metrics. As such, full transparency of organizational performance (on all the domains of quality) should be an organizational and patient expectation.
6. “All organizations should seek out the patient and caregiver voice as an essential asset in monitoring the safety and quality of care.” Organizations should seek out patient-caregiver feedback and should be eager to learn from their words. Most other industries regularly and routinely seek out customer feedback to improve upon their products and services; some even pay customers for a chance to hear what they have to say. Too often, the theme from disgruntled patients is that no one is listening to them.
7. “Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.”
8. U.S. regulatory agencies have an incredible amount of simplification to accomplish, along with a need to align incentives for the betterment of the patient. “We support responsive regulation of organizations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.”

This commandment acknowledges the rarity of willful misconduct, by organizations and providers, and calls for a simplification of the governance needed for such rare events and situations.

In Sum As with The 10 Commandments, these guiding principles can help transform the way we in the healthcare industry think, act, and live—and put us on the road to making it a better place.

Reference

1. National Advisory Group on the Safety of Patients in England. A promise to learn a commitment to act: improving the safety of patients in England. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf. Accessed September 21, 2013.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

Don Berwick, MD, former president and CEO of the Institute for Healthcare Improvement (IHI) and former administrator for the Centers for Medicare and Medicaid Services (CMS), recently consulted with the National Health Service (NHS) on how to devise and implement a safer and better healthcare system for England. His services were solicited due to a number of high-profile scandals involving neglect in hospitals. His team’s work resulted in a report entitled “A Promise to Learn – A Commitment to Act: Improving the Safety of Patients in England.”¹ The purpose of the consultative visit and resulting series of recommendations was to identify and recommend solutions to ailments and limitations in the current NHS.

Many of the “current state” ailments outlined in Dr. Berwick’s report would not sound terribly novel or unfamiliar to most U.S. healthcare systems. The report listed problems with:

• Systems-procedures-conditions-environments-constraints that lead people to make bad or incorrect decisions;
• Incorrect priorities;
• Not heeding warning signals about patient safety;
• Diffusion of responsibility;
• Lack of support for continuous improvement; and
• Fear, which is “toxic to both safety and improvement.”

Dr. Berwick and his team made a number of recommendations to reshape priorities and resources, enhance the safety of the system, and rebuild the confidence of its customers (e.g., patients and caregivers).

The consultant group’s core message was simple and inspiring:

“The NHS in England can become the safest healthcare system in the world. It will require unified will, optimism, investment, and change. Everyone can and should help. And, it will require a culture firmly rooted in continual improvement. Rules, standards, regulations, and enforcement have a place in the pursuit of quality, but they pale in potential compared to the power of pervasive and constant learning.”

To achieve improvement, Dr. Berwick’s team recommended 10 guiding principles. Similar to The 10 Commandments, they offer a way of thinking, acting, and living—to make the healthcare industry a better place. These healthcare 10 commandments include the following:

1. “The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning.” While we should all aspire to zero harm, the reality is that getting there will be a long and difficult goal, more than likely a goal of continual reduction. Defining harm is also more difficult than looking just at what meets the eye; because the qualitative “you know it when you see it” will likely never be embraced widely, we are left with quantitative and imperfect measures, such as hospital-acquired conditions (HACs) and patient safety indicators (PSIs). Despite the imperfection of current measures, the goal for continual reduction is laudable and necessary.
2. “All leaders concerned with NHS healthcare—political, regulatory, governance, executive, clinical, and advocacy—should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement, and support.” As with anything, leadership sets the vision, mission, and values of an organization or system. Leadership will have to commit to placing patient safety at the top of the priority list, without sacrificing other priorities.

1. “Patients and their caregivers should be present, powerful, and involved at all levels of healthcare organizations, from the wards to the boards of trusts.” This directive is certainly ideal, but, realistically, it will take a while to develop a level of comfort from both the patients and the providers, because both are much more used to operating in parallel, with intermittent intersections. Involving patients in all organizational decision-making, and including the boards of trustees, will be prerequisite to true patient-caregiver-centered care.
2. “Government, Health Education England, and NHS England should assure that sufficient staff are available to meet the NHS’ needs now and in the future. Healthcare organizations should ensure staff are present in appropriate numbers to provide safe care at all times and are well-supported." All healthcare organizations should be on a relentless pursuit to match workload and intensity to staffing, pursue work standardization and efficiency, and match work to human intellect. These are the founding tenets of Lean and Six Sigma and should be pursued for all disciplines, both clinical and non-clinical.
3. “Mastery of quality and patient-safety sciences and practices should be part of initial preparation and lifelong education of all healthcare professionals, including managers and executives.” The U.S. has made great strides in incorporating at least a basic curriculum of quality and safety for most healthcare professionals, but we need to move the current level of understanding to the next level. We need to ensure that all healthcare professionals have at least a basic understanding of the fundamental principles.
4. “The NHS should become a learning organization. Its leaders should create and support the capability for learning, and therefore change, at scale within the NHS.” Healthcare organizations should not just be willing to learn from individual and system opportunities; they should be eager to learn. Quality and safety missions should uniformly extend into educational and research missions in all organizations, to enhance learning opportunities and create best practice.
5. “Transparency should be complete, timely, and unequivocal. All data on quality and safety, whether assembled by government, organizations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.” Many healthcare organizations equate transparency with marketing, where they tout their fanciest technology or latest innovation. And many also subscribe to the theory “if you’re gonna go bare, you better be buff” and only widely disseminate those metrics that make them appear superior. We all need to be more transparent across the board, because going “bare” can actually stimulate improvements more quickly and reliably than they would otherwise occur. Organizational metrics really should not belong to the organization; they should belong to the patients who created the metrics. As such, full transparency of organizational performance (on all the domains of quality) should be an organizational and patient expectation.
6. “All organizations should seek out the patient and caregiver voice as an essential asset in monitoring the safety and quality of care.” Organizations should seek out patient-caregiver feedback and should be eager to learn from their words. Most other industries regularly and routinely seek out customer feedback to improve upon their products and services; some even pay customers for a chance to hear what they have to say. Too often, the theme from disgruntled patients is that no one is listening to them.
7. “Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.”
8. U.S. regulatory agencies have an incredible amount of simplification to accomplish, along with a need to align incentives for the betterment of the patient. “We support responsive regulation of organizations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.”

This commandment acknowledges the rarity of willful misconduct, by organizations and providers, and calls for a simplification of the governance needed for such rare events and situations.

In Sum As with The 10 Commandments, these guiding principles can help transform the way we in the healthcare industry think, act, and live—and put us on the road to making it a better place.

Reference

1. National Advisory Group on the Safety of Patients in England. A promise to learn a commitment to act: improving the safety of patients in England. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf. Accessed September 21, 2013.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

Don Berwick, MD, former president and CEO of the Institute for Healthcare Improvement (IHI) and former administrator for the Centers for Medicare and Medicaid Services (CMS), recently consulted with the National Health Service (NHS) on how to devise and implement a safer and better healthcare system for England. His services were solicited due to a number of high-profile scandals involving neglect in hospitals. His team’s work resulted in a report entitled “A Promise to Learn – A Commitment to Act: Improving the Safety of Patients in England.”¹ The purpose of the consultative visit and resulting series of recommendations was to identify and recommend solutions to ailments and limitations in the current NHS.

Many of the “current state” ailments outlined in Dr. Berwick’s report would not sound terribly novel or unfamiliar to most U.S. healthcare systems. The report listed problems with:

• Systems-procedures-conditions-environments-constraints that lead people to make bad or incorrect decisions;
• Incorrect priorities;
• Not heeding warning signals about patient safety;
• Diffusion of responsibility;
• Lack of support for continuous improvement; and
• Fear, which is “toxic to both safety and improvement.”

Dr. Berwick and his team made a number of recommendations to reshape priorities and resources, enhance the safety of the system, and rebuild the confidence of its customers (e.g., patients and caregivers).

The consultant group’s core message was simple and inspiring:

“The NHS in England can become the safest healthcare system in the world. It will require unified will, optimism, investment, and change. Everyone can and should help. And, it will require a culture firmly rooted in continual improvement. Rules, standards, regulations, and enforcement have a place in the pursuit of quality, but they pale in potential compared to the power of pervasive and constant learning.”

To achieve improvement, Dr. Berwick’s team recommended 10 guiding principles. Similar to The 10 Commandments, they offer a way of thinking, acting, and living—to make the healthcare industry a better place. These healthcare 10 commandments include the following:

1. “The NHS should continually and forever reduce patient harm by embracing wholeheartedly an ethic of learning.” While we should all aspire to zero harm, the reality is that getting there will be a long and difficult goal, more than likely a goal of continual reduction. Defining harm is also more difficult than looking just at what meets the eye; because the qualitative “you know it when you see it” will likely never be embraced widely, we are left with quantitative and imperfect measures, such as hospital-acquired conditions (HACs) and patient safety indicators (PSIs). Despite the imperfection of current measures, the goal for continual reduction is laudable and necessary.
2. “All leaders concerned with NHS healthcare—political, regulatory, governance, executive, clinical, and advocacy—should place quality of care in general, and patient safety in particular, at the top of their priorities for investment, inquiry, improvement, regular reporting, encouragement, and support.” As with anything, leadership sets the vision, mission, and values of an organization or system. Leadership will have to commit to placing patient safety at the top of the priority list, without sacrificing other priorities.

1. “Patients and their caregivers should be present, powerful, and involved at all levels of healthcare organizations, from the wards to the boards of trusts.” This directive is certainly ideal, but, realistically, it will take a while to develop a level of comfort from both the patients and the providers, because both are much more used to operating in parallel, with intermittent intersections. Involving patients in all organizational decision-making, and including the boards of trustees, will be prerequisite to true patient-caregiver-centered care.
2. “Government, Health Education England, and NHS England should assure that sufficient staff are available to meet the NHS’ needs now and in the future. Healthcare organizations should ensure staff are present in appropriate numbers to provide safe care at all times and are well-supported." All healthcare organizations should be on a relentless pursuit to match workload and intensity to staffing, pursue work standardization and efficiency, and match work to human intellect. These are the founding tenets of Lean and Six Sigma and should be pursued for all disciplines, both clinical and non-clinical.
3. “Mastery of quality and patient-safety sciences and practices should be part of initial preparation and lifelong education of all healthcare professionals, including managers and executives.” The U.S. has made great strides in incorporating at least a basic curriculum of quality and safety for most healthcare professionals, but we need to move the current level of understanding to the next level. We need to ensure that all healthcare professionals have at least a basic understanding of the fundamental principles.
4. “The NHS should become a learning organization. Its leaders should create and support the capability for learning, and therefore change, at scale within the NHS.” Healthcare organizations should not just be willing to learn from individual and system opportunities; they should be eager to learn. Quality and safety missions should uniformly extend into educational and research missions in all organizations, to enhance learning opportunities and create best practice.
5. “Transparency should be complete, timely, and unequivocal. All data on quality and safety, whether assembled by government, organizations, or professional societies, should be shared in a timely fashion with all parties who want it, including, in accessible form, with the public.” Many healthcare organizations equate transparency with marketing, where they tout their fanciest technology or latest innovation. And many also subscribe to the theory “if you’re gonna go bare, you better be buff” and only widely disseminate those metrics that make them appear superior. We all need to be more transparent across the board, because going “bare” can actually stimulate improvements more quickly and reliably than they would otherwise occur. Organizational metrics really should not belong to the organization; they should belong to the patients who created the metrics. As such, full transparency of organizational performance (on all the domains of quality) should be an organizational and patient expectation.
6. “All organizations should seek out the patient and caregiver voice as an essential asset in monitoring the safety and quality of care.” Organizations should seek out patient-caregiver feedback and should be eager to learn from their words. Most other industries regularly and routinely seek out customer feedback to improve upon their products and services; some even pay customers for a chance to hear what they have to say. Too often, the theme from disgruntled patients is that no one is listening to them.
7. “Supervisory and regulatory systems should be simple and clear. They should avoid diffusion of responsibility. They should be respectful of the goodwill and sound intention of the vast majority of staff. All incentives should point in the same direction.”
8. U.S. regulatory agencies have an incredible amount of simplification to accomplish, along with a need to align incentives for the betterment of the patient. “We support responsive regulation of organizations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.”

This commandment acknowledges the rarity of willful misconduct, by organizations and providers, and calls for a simplification of the governance needed for such rare events and situations.

In Sum As with The 10 Commandments, these guiding principles can help transform the way we in the healthcare industry think, act, and live—and put us on the road to making it a better place.

Reference

1. National Advisory Group on the Safety of Patients in England. A promise to learn a commitment to act: improving the safety of patients in England. Available at: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/226703/Berwick_Report.pdf. Accessed September 21, 2013.

Dr. Scheurer is a hospitalist and chief quality officer at the Medical University of South Carolina in Charleston. She is physician editor of The Hospitalist. Email her at scheured@musc.edu.

Click here to listen to more of our interview with Dr. Patel

Click here to listen to more of our interview with Dr. Patel

Click here to listen to more of our interview with Dr. Patel

Prevent infections. This might be the most obvious way to fight antibiotic-resistance—if there’s no infection, there is no need to worry about one that can’t be treated. Hospitalists can help prevent infection by quickly and effectively treating those who are infected to prevent the spread, washing hands, and promoting effective cleaning habits.

Tracking. The CDC has programs to gather information on antibiotic-resistant infections, causes of infections, and risk factors for infections. With this information, hospitalists can stay aware of the threats. They can also help by remaining vigilant about signs of new resistance and helping to get that information to the CDC.

The CDC is now working on a new module that will collect antimicrobial-susceptibility data that’s generated in hospital labs, Dr. Patel says.

“This will be compiled in a national database and then made available to state and local public health departments that could track antimicrobial resistance trends in their own state,” she says. “We hope those data will then be used to identify new trends in anti-microbial resistance and used to strategize how to prevent resistance from being transmitted locally.”

Antibiotic stewardship. The CDC says prescribing antibiotics only when necessary and tailoring treatment as narrowly as possible might be the most important step in fighting antimicrobial resistance. The CDC estimates that up to half of antibiotic use in humans is unnecessary.

The CDC is working to capture data on antibiotic use in healthcare settings, which will be used for benchmarking antibiotic use among different institutions and regions.

“I think this additional information will really help healthcare institutions measure how well antibiotics are being used in their institutions and make appropriate adjustments,” Dr. Patel says.

New drugs and diagnostic tests. New antibiotics will be needed because, while resistance can be slowed, it cannot be stopped. However, the number of New Drug Application approvals for antibiotics has fallen drastically—nearly 20 from 1980 to 1984, but fewer than five from 2005 to 2012, according to the CDC report.

Prevent infections. This might be the most obvious way to fight antibiotic-resistance—if there’s no infection, there is no need to worry about one that can’t be treated. Hospitalists can help prevent infection by quickly and effectively treating those who are infected to prevent the spread, washing hands, and promoting effective cleaning habits.

Tracking. The CDC has programs to gather information on antibiotic-resistant infections, causes of infections, and risk factors for infections. With this information, hospitalists can stay aware of the threats. They can also help by remaining vigilant about signs of new resistance and helping to get that information to the CDC.

The CDC is now working on a new module that will collect antimicrobial-susceptibility data that’s generated in hospital labs, Dr. Patel says.

“This will be compiled in a national database and then made available to state and local public health departments that could track antimicrobial resistance trends in their own state,” she says. “We hope those data will then be used to identify new trends in anti-microbial resistance and used to strategize how to prevent resistance from being transmitted locally.”

Antibiotic stewardship. The CDC says prescribing antibiotics only when necessary and tailoring treatment as narrowly as possible might be the most important step in fighting antimicrobial resistance. The CDC estimates that up to half of antibiotic use in humans is unnecessary.

The CDC is working to capture data on antibiotic use in healthcare settings, which will be used for benchmarking antibiotic use among different institutions and regions.

“I think this additional information will really help healthcare institutions measure how well antibiotics are being used in their institutions and make appropriate adjustments,” Dr. Patel says.

New drugs and diagnostic tests. New antibiotics will be needed because, while resistance can be slowed, it cannot be stopped. However, the number of New Drug Application approvals for antibiotics has fallen drastically—nearly 20 from 1980 to 1984, but fewer than five from 2005 to 2012, according to the CDC report.

Prevent infections. This might be the most obvious way to fight antibiotic-resistance—if there’s no infection, there is no need to worry about one that can’t be treated. Hospitalists can help prevent infection by quickly and effectively treating those who are infected to prevent the spread, washing hands, and promoting effective cleaning habits.

Tracking. The CDC has programs to gather information on antibiotic-resistant infections, causes of infections, and risk factors for infections. With this information, hospitalists can stay aware of the threats. They can also help by remaining vigilant about signs of new resistance and helping to get that information to the CDC.

The CDC is now working on a new module that will collect antimicrobial-susceptibility data that’s generated in hospital labs, Dr. Patel says.

“This will be compiled in a national database and then made available to state and local public health departments that could track antimicrobial resistance trends in their own state,” she says. “We hope those data will then be used to identify new trends in anti-microbial resistance and used to strategize how to prevent resistance from being transmitted locally.”

Antibiotic stewardship. The CDC says prescribing antibiotics only when necessary and tailoring treatment as narrowly as possible might be the most important step in fighting antimicrobial resistance. The CDC estimates that up to half of antibiotic use in humans is unnecessary.

The CDC is working to capture data on antibiotic use in healthcare settings, which will be used for benchmarking antibiotic use among different institutions and regions.

“I think this additional information will really help healthcare institutions measure how well antibiotics are being used in their institutions and make appropriate adjustments,” Dr. Patel says.

New drugs and diagnostic tests. New antibiotics will be needed because, while resistance can be slowed, it cannot be stopped. However, the number of New Drug Application approvals for antibiotics has fallen drastically—nearly 20 from 1980 to 1984, but fewer than five from 2005 to 2012, according to the CDC report.

What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?

Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.

“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.

“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.

Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.

An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.¹

“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.

The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.

Listen to more of our interview with MARQUIS principal investigator Jeffrey Schnipper, MD, MPH, FHM.

Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.

Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.

The MARQUIS toolkit is available on the SHM website. TH

Larry Beresford is a freelance writer in San Francisco.

Reference

1. Schnipper JL, Mueller SK, Salanitro AH, Stein J. Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). PowerPoint presentation at Society of Hospital Medicine annual meeting, May 16-19, 2013, National Harbor, Md.

What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?

Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.

“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.

“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.

Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.

An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.¹

“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.

The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.

Listen to more of our interview with MARQUIS principal investigator Jeffrey Schnipper, MD, MPH, FHM.

Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.

Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.

The MARQUIS toolkit is available on the SHM website. TH

Larry Beresford is a freelance writer in San Francisco.

Reference

1. Schnipper JL, Mueller SK, Salanitro AH, Stein J. Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). PowerPoint presentation at Society of Hospital Medicine annual meeting, May 16-19, 2013, National Harbor, Md.

What is the best possible medication history? How is it done? Who should do it? When should it be done during a patient’s journey in and out of the hospital? What medication discrepancies—and potential adverse drug events—are most likely?

Those are questions veteran hospitalist Jason Stein, MD, tried to answer during an HM13 breakout session on medication reconciliation at the Gaylord National Resort and Conference Center in National Harbor, Md.

“How do you know as the discharging provider if the medication list you’re looking at is gold or garbage?” said Dr. Stein, associate director for quality improvement (QI) at Emory University in Atlanta and a mentor for SHM’s Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS) quality-research initiative.

“Sometimes it’s impossible to know what the patient was or wasn’t taking, but it doesn’t mean you don’t do your best,” he said, adding that hospitalists should attempt to get at least one reliable, corroborating source of information for a patient’s medical history.

Sometimes it is necessary to speak to family members or the community pharmacy, Dr. Schnipper said, because many patients can’t remember all of the drugs they are taking. Trying to do medication reconciliation at the time of discharge when BPMH has not been done can lead to more work for the provider, medication errors, or rehospitalizations. Ideally, knowledge of what the patient was taking before admission, as well as the patient’s health literacy and adherence history, should be gathered and documented once, early, and well during the hospitalization by a trained provider, according to Dr. Schnipper.

An SHM survey, however, showed 50% to 70% percent of front-line providers have never received BPMH training, and 60% say they are not given the time.¹

“Not knowing means a diligent provider would need to take a BPMH at discharge, which is a waste,” Dr. Stein said. It would be nice to tell from the electronic health record whether a true BPMH had been taken for every hospitalized patient—or at least every high-risk patient—but this goal is not well-supported by current information technology, MARQUIS investigators said they have learned.

The MARQUIS program was launched in 2011 with a grant from the federal Agency for Healthcare Research and Quality. It began with a thorough review of the literature on medication reconciliation and the development of a toolkit of best practices. In 2012, six pilot sites were offered a menu of 11 MARQUIS medication-reconciliation interventions to choose from and help in implementing them from an SHM mentor, with expertise in both QI and medication safety.

Listen to more of our interview with MARQUIS principal investigator Jeffrey Schnipper, MD, MPH, FHM.

Participating sites have mobilized high-level hospital leadership and utilize a local champion, usually a hospitalist, tools for assessing high-risk patients, medication-reconciliation assistants or counselors, and pharmacist involvement. Different sites have employed different professional staff to take medication histories.

Dr. Schnipper said he expects another round of MARQUIS-mentored implementation, probably in 2014, after data from the first round have been analyzed. The program is tracking such outcomes as the number of potentially harmful, unintentional medication discrepancies per patient at participating sites.

The MARQUIS toolkit is available on the SHM website. TH

Larry Beresford is a freelance writer in San Francisco.

Reference

1. Schnipper JL, Mueller SK, Salanitro AH, Stein J. Got Med Wreck? Targeted Repairs from the Multi-Center Medication Reconciliation Quality Improvement Study (MARQUIS). PowerPoint presentation at Society of Hospital Medicine annual meeting, May 16-19, 2013, National Harbor, Md.

In July, four U.S. hospitals were recognized for their leadership and innovation in quality improvement (QI) and safety—as defined by the Institute of Medicine (IOM)—through the American Hospital Association’s McKesson Quest for Quality Prize.² Beth Israel Deaconess Medical Center (BIDMC) in Boston was awarded the overall prize for its sustainable approach and hospitalwide commitment to pursuing IOM’s quality aims for safe, effective, efficient, timely, patient-centered, and equitable health care.

The award, presented since 2002, is supported by healthcare-services company McKesson Corp., based in San Francisco.

Key to BIDMC’s success is the clear message of its top leadership’s commitment to quality and a strong partnership with the medical community, says Kenneth Sands, MD, MPH, BIDMC’s senior vice president for healthcare quality. “That includes an official vote by the hospital’s board to adopt IOM’s definition of quality. And everyone here participates in the quality process,” he says.

Each year, the hospital holds a quality symposium featuring QI projects solicited from across the organization. This year’s poster contest recognized three winners, one from the finance department, one from an ICU, and a third from the hospital cafeteria (it tracked the percentage of days that fresh fish is offered as a healthy menu choice).

“To see these three winners standing together on the podium sends a powerful message,” Dr. Sands says. “These are not quality-improvement experts, but front-line staff.”

Another quality initiative involves a hospitalist leader trying to promote “conversation readiness” for a hospital staff’s ability to respond to patients’ expressed desires to complete advance directives, then make sure these documents get captured in the medical record.

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

In July, four U.S. hospitals were recognized for their leadership and innovation in quality improvement (QI) and safety—as defined by the Institute of Medicine (IOM)—through the American Hospital Association’s McKesson Quest for Quality Prize.² Beth Israel Deaconess Medical Center (BIDMC) in Boston was awarded the overall prize for its sustainable approach and hospitalwide commitment to pursuing IOM’s quality aims for safe, effective, efficient, timely, patient-centered, and equitable health care.

The award, presented since 2002, is supported by healthcare-services company McKesson Corp., based in San Francisco.

Key to BIDMC’s success is the clear message of its top leadership’s commitment to quality and a strong partnership with the medical community, says Kenneth Sands, MD, MPH, BIDMC’s senior vice president for healthcare quality. “That includes an official vote by the hospital’s board to adopt IOM’s definition of quality. And everyone here participates in the quality process,” he says.

Each year, the hospital holds a quality symposium featuring QI projects solicited from across the organization. This year’s poster contest recognized three winners, one from the finance department, one from an ICU, and a third from the hospital cafeteria (it tracked the percentage of days that fresh fish is offered as a healthy menu choice).

“To see these three winners standing together on the podium sends a powerful message,” Dr. Sands says. “These are not quality-improvement experts, but front-line staff.”

Another quality initiative involves a hospitalist leader trying to promote “conversation readiness” for a hospital staff’s ability to respond to patients’ expressed desires to complete advance directives, then make sure these documents get captured in the medical record.

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

In July, four U.S. hospitals were recognized for their leadership and innovation in quality improvement (QI) and safety—as defined by the Institute of Medicine (IOM)—through the American Hospital Association’s McKesson Quest for Quality Prize.² Beth Israel Deaconess Medical Center (BIDMC) in Boston was awarded the overall prize for its sustainable approach and hospitalwide commitment to pursuing IOM’s quality aims for safe, effective, efficient, timely, patient-centered, and equitable health care.

The award, presented since 2002, is supported by healthcare-services company McKesson Corp., based in San Francisco.

Key to BIDMC’s success is the clear message of its top leadership’s commitment to quality and a strong partnership with the medical community, says Kenneth Sands, MD, MPH, BIDMC’s senior vice president for healthcare quality. “That includes an official vote by the hospital’s board to adopt IOM’s definition of quality. And everyone here participates in the quality process,” he says.

Each year, the hospital holds a quality symposium featuring QI projects solicited from across the organization. This year’s poster contest recognized three winners, one from the finance department, one from an ICU, and a third from the hospital cafeteria (it tracked the percentage of days that fresh fish is offered as a healthy menu choice).

“To see these three winners standing together on the podium sends a powerful message,” Dr. Sands says. “These are not quality-improvement experts, but front-line staff.”

Another quality initiative involves a hospitalist leader trying to promote “conversation readiness” for a hospital staff’s ability to respond to patients’ expressed desires to complete advance directives, then make sure these documents get captured in the medical record.

Larry Beresford is a freelance writer in San Francisco.

References

1. Harrison J, Quinn K, Mourad M. Is anyone home? The association between being reached for a post-discharge telephone call and 30-day hospital readmission. Harrison J, Quinn K, Mourad M. Any questions? The relationship between responses to post-discharge call questions and 30-day hospital readmissions [abstracts]. Journal of Hospital Medicine, 2013, 8 Suppl 1.
2. Institute of Medicine. Crossing the quality chasm: a new health system for the 21st century. Institute of Medicine website. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2001/Crossing-the-Quality-Chasm/Quality%20Chasm%202001%20%20report%20brief.pdf. Accessed Sept. 9, 2013.
3. Shlaes DM, Sahm D, Opiela C, Spellberg B. Commentary: the FDA reboot of antibiotic development. Antimicrob Agents Chemother. 29 Jul 2013 [Epub ahead of print].
4. Alliance for Aging Research. HAIs growing problem, group says. Alliance for Aging Research website. Available at: http://www.agingresearch.org/content/article/detail/33504. Accessed Sept. 9, 2013.
5. Huang SS, Septimus E, Kleinman K, et al. Targeted versus universal decolonization to prevent ICU infection. N Engl J Med. 2013;368:2255-2265.
6. Hospitals in Pursuit of Excellence. Eliminating catheter-associated urinary tract infections. Hospitals in Pursuit of Excellence website. Available at: http://www.hpoe.org/Reports-HPOE/eliminating_catheter_associated_urinary_tract_infection.pdf. Accessed Sept. 9, 2013.
7. Center to Advance Palliative Care. Growth of palliative care in U.S. hospitals 2013 snapshot. Center to Advance Palliative Care website. Available at: http://www.capc.org/capc-growth-analysis-snapshot-2013.pdf. Accessed Sept. 9, 2013.

click for large version

A shift in governmental regulations regarding reimbursement for hospital-acquired infections (HAIs) is forcing hospitals to take a closer look at how to reduce them. A recent study in Infection Control and Hospital Epidemiology shows that copper-alloy surfaces may be one such solution.³ According to the study, although only 9% of the touch surfaces in each ICU were replaced with copper components, there were 58% fewer HAI cases.¹

“Before these regulations, hospitals didn’t necessarily want technology to decrease HAI rates, because the more infections and complications, the longer the length of patient stay, the greater the reimbursement, and the better the bottom line,” says Archelle Georgiou, MD, president of Georgiou Consulting LLC in Minneapolis and an advisor to the Copper Development Association.

Three regulations that have resulted in reimbursements to hospitals getting cut include:

1. The Deficit Reduction Act of 2005, which was implemented on Oct. 1, 2008, which states that Medicare will not reimburse for certain types of HAIs;
2. Section 3025 of the Affordable Care Act (signed into law in 2010), which incentivizes hospitals to decrease their readmission rates, which frequently are caused by HAIs. Beginning this fall, hospitals are getting reduced reimbursement when their readmission rates exceed a certain threshold. The maximum penalty in 2013 is 1% and will increase to 3% by 2015; and
3. Section 1886 of the Affordable Care Act, which describes value-based purchasing and makes hospitals eligible to receive incentive payments for achieving better care on certain quality metrics. Funding for the program comes from withholding payment from poor-performing hospitals. The financial impact to hospitals started this year. In 2014, urinary tract infections and vascular-catheter-associated infections will be among the targeted conditions measured by CMS to calculate incentives and penalties.

“Hospitals are now feeling a direct impact from all of this,” Dr. Georgiou says. “Back in 2008, hospitals were noticing, but it was hard to get their attention since only one program was impacting their bottom line. But, pretty soon, hospitals risk losing upwards of 5% of their Medicare reimbursement for decreased quality.

“Reducing HAIs is clearly on the priority list of chief operating officers. They are very aware of the impact to their bottom line. They are looking to their vendors and suppliers to develop strategies to work with their hospitals to improve performance around these metrics.”

Karen Appold is a freelance writer in Pennsylvania.

click for large version

A shift in governmental regulations regarding reimbursement for hospital-acquired infections (HAIs) is forcing hospitals to take a closer look at how to reduce them. A recent study in Infection Control and Hospital Epidemiology shows that copper-alloy surfaces may be one such solution.³ According to the study, although only 9% of the touch surfaces in each ICU were replaced with copper components, there were 58% fewer HAI cases.¹

“Before these regulations, hospitals didn’t necessarily want technology to decrease HAI rates, because the more infections and complications, the longer the length of patient stay, the greater the reimbursement, and the better the bottom line,” says Archelle Georgiou, MD, president of Georgiou Consulting LLC in Minneapolis and an advisor to the Copper Development Association.

Three regulations that have resulted in reimbursements to hospitals getting cut include:

1. The Deficit Reduction Act of 2005, which was implemented on Oct. 1, 2008, which states that Medicare will not reimburse for certain types of HAIs;
2. Section 3025 of the Affordable Care Act (signed into law in 2010), which incentivizes hospitals to decrease their readmission rates, which frequently are caused by HAIs. Beginning this fall, hospitals are getting reduced reimbursement when their readmission rates exceed a certain threshold. The maximum penalty in 2013 is 1% and will increase to 3% by 2015; and
3. Section 1886 of the Affordable Care Act, which describes value-based purchasing and makes hospitals eligible to receive incentive payments for achieving better care on certain quality metrics. Funding for the program comes from withholding payment from poor-performing hospitals. The financial impact to hospitals started this year. In 2014, urinary tract infections and vascular-catheter-associated infections will be among the targeted conditions measured by CMS to calculate incentives and penalties.

“Hospitals are now feeling a direct impact from all of this,” Dr. Georgiou says. “Back in 2008, hospitals were noticing, but it was hard to get their attention since only one program was impacting their bottom line. But, pretty soon, hospitals risk losing upwards of 5% of their Medicare reimbursement for decreased quality.

“Reducing HAIs is clearly on the priority list of chief operating officers. They are very aware of the impact to their bottom line. They are looking to their vendors and suppliers to develop strategies to work with their hospitals to improve performance around these metrics.”

Karen Appold is a freelance writer in Pennsylvania.

click for large version

A shift in governmental regulations regarding reimbursement for hospital-acquired infections (HAIs) is forcing hospitals to take a closer look at how to reduce them. A recent study in Infection Control and Hospital Epidemiology shows that copper-alloy surfaces may be one such solution.³ According to the study, although only 9% of the touch surfaces in each ICU were replaced with copper components, there were 58% fewer HAI cases.¹

“Before these regulations, hospitals didn’t necessarily want technology to decrease HAI rates, because the more infections and complications, the longer the length of patient stay, the greater the reimbursement, and the better the bottom line,” says Archelle Georgiou, MD, president of Georgiou Consulting LLC in Minneapolis and an advisor to the Copper Development Association.

Three regulations that have resulted in reimbursements to hospitals getting cut include:

1. The Deficit Reduction Act of 2005, which was implemented on Oct. 1, 2008, which states that Medicare will not reimburse for certain types of HAIs;
2. Section 3025 of the Affordable Care Act (signed into law in 2010), which incentivizes hospitals to decrease their readmission rates, which frequently are caused by HAIs. Beginning this fall, hospitals are getting reduced reimbursement when their readmission rates exceed a certain threshold. The maximum penalty in 2013 is 1% and will increase to 3% by 2015; and
3. Section 1886 of the Affordable Care Act, which describes value-based purchasing and makes hospitals eligible to receive incentive payments for achieving better care on certain quality metrics. Funding for the program comes from withholding payment from poor-performing hospitals. The financial impact to hospitals started this year. In 2014, urinary tract infections and vascular-catheter-associated infections will be among the targeted conditions measured by CMS to calculate incentives and penalties.

“Hospitals are now feeling a direct impact from all of this,” Dr. Georgiou says. “Back in 2008, hospitals were noticing, but it was hard to get their attention since only one program was impacting their bottom line. But, pretty soon, hospitals risk losing upwards of 5% of their Medicare reimbursement for decreased quality.

“Reducing HAIs is clearly on the priority list of chief operating officers. They are very aware of the impact to their bottom line. They are looking to their vendors and suppliers to develop strategies to work with their hospitals to improve performance around these metrics.”

Karen Appold is a freelance writer in Pennsylvania.