By Anna Maria Muñoa

Clinical question: What roles, training, and support do hospitalists have and perceive in the intensive care unit?

Background: There is a well-documented shortage of intensivists in the United States, which has left hospitalists to help fill the gap of care. Hospitalists, however, have varied levels of critical care knowledge and skills. In some regions, more than 80% of hospitalists deliver care in the ICU. It is unknown how much support hospitalized patients receive from board-certified critical care physicians.

Study design: Multistage cross-section survey.

Setting: Web-based survey initially sent through the Critical Care Task Force professional networks and later sent to 4,000 hospitalists randomly selected from Society of Hospital Medicine’s national electronic mailing list of 12,000 hospitalists.

Synopsis: This study includes 425 responses, approximately 10% of those solicited. Compared with the annual SHM survey, this included more hospitalists from academic hospitals (24% vs. 14.8%) and fewer from nonteaching hospitals (41% vs. 58.7%). A total of 77% of responders provide care in the ICU, with 66% serving as the attending physician.

Rural and nonacademic hospitalists are more prevalent in the ICU (96% rural vs. 73% nonrural; 90% nonacademic vs. 67% academic), are more likely to serve as the primary physician for all or most ICU patients (85% rural vs. 62% nonrural; 81% nonacademic vs. 44% academic), and provide all critical care services (55% rural vs. 10% nonrural; 64% nonacademic vs. 25% academic).

Many rural (43%) and nonacademic (42%) hospitalists feel that they are expected to practice beyond their perceived scope of expertise at least some of the time, which was correlated with perceived difficulty in transferring patients to higher levels of care. About 90% of rural hospitalists report at least insufficient support from board-certified intensivists. Of all responders in the study, 85% indicated interest in additional critical care training in some form, short of fellowship training.

Bottom line: Most hospitalists provide care in the ICU, however hospitalists provide critical care at significantly higher rates in rural and nonacademic hospital settings. This care is being provided with a perceived lack of intensivist support and training.

Citation: Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Clinical question: What roles, training, and support do hospitalists have and perceive in the intensive care unit?

Background: There is a well-documented shortage of intensivists in the United States, which has left hospitalists to help fill the gap of care. Hospitalists, however, have varied levels of critical care knowledge and skills. In some regions, more than 80% of hospitalists deliver care in the ICU. It is unknown how much support hospitalized patients receive from board-certified critical care physicians.

Study design: Multistage cross-section survey.

Setting: Web-based survey initially sent through the Critical Care Task Force professional networks and later sent to 4,000 hospitalists randomly selected from Society of Hospital Medicine’s national electronic mailing list of 12,000 hospitalists.

Synopsis: This study includes 425 responses, approximately 10% of those solicited. Compared with the annual SHM survey, this included more hospitalists from academic hospitals (24% vs. 14.8%) and fewer from nonteaching hospitals (41% vs. 58.7%). A total of 77% of responders provide care in the ICU, with 66% serving as the attending physician.

Rural and nonacademic hospitalists are more prevalent in the ICU (96% rural vs. 73% nonrural; 90% nonacademic vs. 67% academic), are more likely to serve as the primary physician for all or most ICU patients (85% rural vs. 62% nonrural; 81% nonacademic vs. 44% academic), and provide all critical care services (55% rural vs. 10% nonrural; 64% nonacademic vs. 25% academic).

Many rural (43%) and nonacademic (42%) hospitalists feel that they are expected to practice beyond their perceived scope of expertise at least some of the time, which was correlated with perceived difficulty in transferring patients to higher levels of care. About 90% of rural hospitalists report at least insufficient support from board-certified intensivists. Of all responders in the study, 85% indicated interest in additional critical care training in some form, short of fellowship training.

Bottom line: Most hospitalists provide care in the ICU, however hospitalists provide critical care at significantly higher rates in rural and nonacademic hospital settings. This care is being provided with a perceived lack of intensivist support and training.

Citation: Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Clinical question: What roles, training, and support do hospitalists have and perceive in the intensive care unit?

Background: There is a well-documented shortage of intensivists in the United States, which has left hospitalists to help fill the gap of care. Hospitalists, however, have varied levels of critical care knowledge and skills. In some regions, more than 80% of hospitalists deliver care in the ICU. It is unknown how much support hospitalized patients receive from board-certified critical care physicians.

Study design: Multistage cross-section survey.

Setting: Web-based survey initially sent through the Critical Care Task Force professional networks and later sent to 4,000 hospitalists randomly selected from Society of Hospital Medicine’s national electronic mailing list of 12,000 hospitalists.

Synopsis: This study includes 425 responses, approximately 10% of those solicited. Compared with the annual SHM survey, this included more hospitalists from academic hospitals (24% vs. 14.8%) and fewer from nonteaching hospitals (41% vs. 58.7%). A total of 77% of responders provide care in the ICU, with 66% serving as the attending physician.

Rural and nonacademic hospitalists are more prevalent in the ICU (96% rural vs. 73% nonrural; 90% nonacademic vs. 67% academic), are more likely to serve as the primary physician for all or most ICU patients (85% rural vs. 62% nonrural; 81% nonacademic vs. 44% academic), and provide all critical care services (55% rural vs. 10% nonrural; 64% nonacademic vs. 25% academic).

Many rural (43%) and nonacademic (42%) hospitalists feel that they are expected to practice beyond their perceived scope of expertise at least some of the time, which was correlated with perceived difficulty in transferring patients to higher levels of care. About 90% of rural hospitalists report at least insufficient support from board-certified intensivists. Of all responders in the study, 85% indicated interest in additional critical care training in some form, short of fellowship training.

Bottom line: Most hospitalists provide care in the ICU, however hospitalists provide critical care at significantly higher rates in rural and nonacademic hospital settings. This care is being provided with a perceived lack of intensivist support and training.

Citation: Sweigart JR et al. Characterizing hospitalist practice and perceptions of critical care delivery. J Hosp Med. 2018 Jan 1;13(1):6-12.

Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Clinical question: What guidance is there for clinical care of complex heart failure patients?

Background: The prevalence of heart failure (HF)is escalating and consumes significant health care resources, inflicts significant morbidity and mortality, and greatly affects quality of life. There is a plethora of research, multiple medical therapies, devices, and care strategies that have been shown to improve outcomes in heart failure patients. Previous publications have reviewed evidence-based literature but left a gap in knowledge for those more-complex areas or lacked practical clinical guidance. This policy document was created to guide physicians in informed decision making in a directed decision pathway form.

Study design: Expert consensus guidelines.

Setting: American College of Cardiology Task Force on Expert Consensus Decision Pathways.

Synopsis: A multidisciplinary group of specialties including physicians, nurses, pharmacists, epidemiologists, and patient advocacy groups addressed 10 pivotal issues in heart failure through literature review, expert consensus, and round table discussion.

Ten principles were identified and addressed:

• Initiating, adding, or switching to new evidenced-based guideline-directed therapy.
• Achieving optimal therapy using multiple HF drugs and therapies.
• Knowing when to refer a patient to an HF specialist.
• Addressing the challenges of care coordination for team-based HF treatment.
• Improving patient adherence.
• Managing specific patient cohorts, such as African Americans, older adults, and the frail.
• Managing your patients’ cost of care for HF.
• Reducing costs and managing the increased complexity of HF.
• Managing the most common cardiac and noncardiac comorbidities.
• Integrating palliative care and transitioning patients to hospice care

Bottom line: Structured guidelines to provide practical and actionable recommendations to improve heart failure outcomes, integrate evidence-based medicine when available, and utilize expert conscious when evidence-based medicine is not available.

Citation: Yancy CW et al. 2017 ACC expert consensus on decision pathway for optimizing of heart failure treatment: Answers to 10 pivotal issues about heart failure with reduced ejection fraction. J Am Coll Cardiol. 2018 Jan 16;71(2):201-30.

Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Clinical question: What guidance is there for clinical care of complex heart failure patients?

Background: The prevalence of heart failure (HF)is escalating and consumes significant health care resources, inflicts significant morbidity and mortality, and greatly affects quality of life. There is a plethora of research, multiple medical therapies, devices, and care strategies that have been shown to improve outcomes in heart failure patients. Previous publications have reviewed evidence-based literature but left a gap in knowledge for those more-complex areas or lacked practical clinical guidance. This policy document was created to guide physicians in informed decision making in a directed decision pathway form.

Study design: Expert consensus guidelines.

Setting: American College of Cardiology Task Force on Expert Consensus Decision Pathways.

Synopsis: A multidisciplinary group of specialties including physicians, nurses, pharmacists, epidemiologists, and patient advocacy groups addressed 10 pivotal issues in heart failure through literature review, expert consensus, and round table discussion.

Ten principles were identified and addressed:

• Initiating, adding, or switching to new evidenced-based guideline-directed therapy.
• Achieving optimal therapy using multiple HF drugs and therapies.
• Knowing when to refer a patient to an HF specialist.
• Addressing the challenges of care coordination for team-based HF treatment.
• Improving patient adherence.
• Managing specific patient cohorts, such as African Americans, older adults, and the frail.
• Managing your patients’ cost of care for HF.
• Reducing costs and managing the increased complexity of HF.
• Managing the most common cardiac and noncardiac comorbidities.
• Integrating palliative care and transitioning patients to hospice care

Bottom line: Structured guidelines to provide practical and actionable recommendations to improve heart failure outcomes, integrate evidence-based medicine when available, and utilize expert conscious when evidence-based medicine is not available.

Citation: Yancy CW et al. 2017 ACC expert consensus on decision pathway for optimizing of heart failure treatment: Answers to 10 pivotal issues about heart failure with reduced ejection fraction. J Am Coll Cardiol. 2018 Jan 16;71(2):201-30.

Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.

Clinical question: What guidance is there for clinical care of complex heart failure patients?

Background: The prevalence of heart failure (HF)is escalating and consumes significant health care resources, inflicts significant morbidity and mortality, and greatly affects quality of life. There is a plethora of research, multiple medical therapies, devices, and care strategies that have been shown to improve outcomes in heart failure patients. Previous publications have reviewed evidence-based literature but left a gap in knowledge for those more-complex areas or lacked practical clinical guidance. This policy document was created to guide physicians in informed decision making in a directed decision pathway form.

Study design: Expert consensus guidelines.

Setting: American College of Cardiology Task Force on Expert Consensus Decision Pathways.

Synopsis: A multidisciplinary group of specialties including physicians, nurses, pharmacists, epidemiologists, and patient advocacy groups addressed 10 pivotal issues in heart failure through literature review, expert consensus, and round table discussion.

Ten principles were identified and addressed:

• Initiating, adding, or switching to new evidenced-based guideline-directed therapy.
• Achieving optimal therapy using multiple HF drugs and therapies.
• Knowing when to refer a patient to an HF specialist.
• Addressing the challenges of care coordination for team-based HF treatment.
• Improving patient adherence.
• Managing specific patient cohorts, such as African Americans, older adults, and the frail.
• Managing your patients’ cost of care for HF.
• Reducing costs and managing the increased complexity of HF.
• Managing the most common cardiac and noncardiac comorbidities.
• Integrating palliative care and transitioning patients to hospice care

Bottom line: Structured guidelines to provide practical and actionable recommendations to improve heart failure outcomes, integrate evidence-based medicine when available, and utilize expert conscious when evidence-based medicine is not available.

Citation: Yancy CW et al. 2017 ACC expert consensus on decision pathway for optimizing of heart failure treatment: Answers to 10 pivotal issues about heart failure with reduced ejection fraction. J Am Coll Cardiol. 2018 Jan 16;71(2):201-30.

Dr. Muñoa is a hospitalist at Denver Health Medical Center and an assistant professor of medicine at the University of Colorado at Denver, Aurora.