Diana Mancini, MD

Hospitalists are physicians whose primary focus is the general medical care of hospitalized patients. Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency.1 With emergency department (ED) diversion reaching rates upward of 70%, lack of access to inpatient beds leads to delayed care with worsened outcomes.25

To improve access to hospital beds, hospitals may increase capacity by either adding beds or by more efficiently using existing beds. Operations management principles have been applied to healthcare to ensure efficient use of beds. These include: reducing variability of scheduled admissions, remeasuring length of stay (LOS) and bed demand after implementing strategies to reduce practice variation, and employing queuing theory to generate predictions of optimal beds needed.6 The Joint Commission implemented a leadership standard (LD 04.03.11) that hospitals develop and implement plans to identify and mitigate impediments to efficient patient flow through the hospital.

To improve access, hospital leaders expect hospitalists to staff in inpatient medicine programs, surgical comanagement, short stay and chest pain units, and active bed management.7 In the following review, we define hospitalists' roles in the aforementioned programs and their effect on patient flow. We also touch on preoperative clinics, palliative care, geographic rounding, and flexible staffing models.

ACUTE INPATIENT CARE

Hospitalists are one of the fastest growing physician groups in the United States.810 Hospitalists improve efficiency and quality of care across a variety of demographic, geographic, and healthcare settings.11, 12 A 2002 retrospective cohort study in a community‐based urban teaching hospital showed that hospitalists decreased LOS by 0.61 days and lowered risk for death in the hospital (adjusted relative hazard, 0.71; 95% confidence interval [CI], 0.540.93).13 A 2004 prospective quasi‐experimental observational study done at an academic teaching hospital showed an adjusted LOS that was 16.2% lower, and adjusted cost 9.7% lower, for patients on the hospitalists' service.14 In 2007, Lindenauer and colleagues found that a national sample of hospitalists decreased LOS by 0.4 days and lowered cost by $286 per patient.15 The findings of these individual studies were supported in a 2009 systematic review of 33 studies by Peterson which showed that hospitalists decrease LOS.16 In a recent study, Kuo and Goodwin showed that while hospitalists decrease LOS and cost, the patients they care for have higher Medicare costs after discharge by $322 per patient, and are more likely to be readmitted (odds ratio, 1.08; CI, 1.041.14).17

The hospitalist model of care continues to grow, and hospitalists will soon number as many as 30,000.18 For acute medical inpatients, the evidence suggests that hospitalists improve patient flow by decreasing LOS while improving other aspects of quality of care. However, Kuo and Goodwin's findings suggest that the transition of care from inpatient to outpatient settings still requires attention.17

SURGICAL COMANAGEMENT

The Society of Hospital Medicine (SHM) core competencies include perioperative medicine.19, 20 In the 2006 SHM national survey, 85% of hospital medicine groups indicated that they participated in surgical comanagement.21

Hospitalists have improved patient flow and outcomes for orthopedic patients. Hospitalist management of hip fracture patients decreases time to surgery and LOS compared to standard care.2224 Phy and colleagues studied 466 patients for 2 years after the inception of hospital medicine comanagement of surgical patients, and found that care by hospitalists decreased LOS by 2.2 days.22 In a retrospective study of 118 patients, Roy and colleagues found that hospitalist‐managed patients had shorter time to consultation and surgery, decreased LOS, and lower costs.23 In a retrospective cohort study, Batsis looked at mortality in 466 patients with hip fracture, and found no difference between hospitalist management and standard care.24 In patients undergoing elective hip and knee arthroplasty, Huddleston and colleagues reported that patients managed by hospitalists had fewer complications and shorter LOS. The nurses and orthopedic surgeons preferred the hospitalistorthopedist comanagement model.25

The benefits of hospitalist comanagement are not limited to adult patients undergoing orthopedic surgery. For high‐risk patients undergoing lower extremity reconstruction surgery, Pinzur and colleagues noted that LOS was shorter for a cohort of patients managed by hospitalists than for a group of historical controls not treated by hospitalists.26 Simon and colleagues studied comanagement for pediatric spinal fusion patients, and found a decrease in LOS from 6.5 to 4.8 days.27

Several factors should be considered in developing and implementing a successful comanagement program. Since comanagement duties may fall upon hospitalists in order to protect surgeons' time,28 hospital medicine groups should ensure adequate staffing prior to taking on additional services. Clear guidelines to delineate roles and responsibilities of the comanaging groups also need to be developed and implemented.29, 30

Comanaging may also involve additional training. Hospitalists who manage neurologic, neurosurgical, trauma, and psychiatric patients report being undertrained for such conditions.31, 32 Hospital medicine groups need to ensure training needs are met and supported. Given the successes of comanagement and the increasing complexity of surgical patients,33 this practice will likely expand to a greater variety of non‐medical patients.

SHORT STAY UNITS

In 2003, short stay units (SSU) were present in approximately 20% of US hospitals, with 11% of hospitals planning on opening one in the next year.34 SSU are designed to manage acute, self‐limited medical conditions that require brief staysusually less than 72 hours. Approximately 80% of SSU patients are discharged home, avoiding hospitalization.35 Historically, SSU have been under the domain of the ED; however, there is an emerging role for hospitalist‐run SSU.36

Despite demand for SSU, little research has been performed on hospitalist‐led SSU. In 2000, Abenhaim and colleagues showed that a hospitalist‐run SSU at a university‐affiliated teaching hospital had a shorter LOS and lower rates of complications and readmissions when compared to medicine teaching services.37 In 2008, Northwestern Memorial Hospital opened a 30‐bed hospitalist‐run SSU; for those patients, LOS decreased by 2 days.38 In 2010, Leykum and colleagues showed that a hospitalist‐run observation unit can decrease LOS from 2.4 days to 2.2 days.39 Careful selection of SSU patients is needed to obtain these results. Lucas and colleagues found that whether or not SSU patients required assistance of specialists was the strongest predictor of unsuccessful stays (>72 hours or inpatient conversion) in SSU.36

Whether SSU are run by hospital medicine or emergency medicine is decided at an institutional level. Location of SSU in a specifically designated area is crucial, as it allows physicians to round efficiently on patients and to work with staff trained in observation services. Development of admission criteria that include specific diagnoses which match hospitalists' scope of practice is also important (Table 1).32

The protocol‐based and diagnosis‐specific nature of SSU may enhance quality of care through standardization. Future research may delineate the utility of SSU.

CHEST PAIN UNITS

In the United States, in 2004, approximately 6 million patients present annually to EDs with chest pain.40 Cost of care of patients unnecessarily admitted to coronary care units has been estimated to be nearly $3 billion annually.41 Still, as many as 3% of patients with acute myocardial infarction are discharged home.42 Chest pain units (CPU) were developed to facilitate evaluation of patients with chest pain, at low risk for acute coronary syndrome, without requiring inpatient admission. A number of studies have suggested that admission to a CPU is a safe and cost‐effective alternative to hospital admission.4348

CPU have traditionally been staffed by ED physicians and/or cardiologists. In a prepost study, Krantz and colleagues found that a CPU model, incorporating hospitalists at an academic public safety‐net hospital, decreased ED LOS with no difference in 30‐day cardiac event rate.49 Myers and colleagues created a hospitalist‐directed nonteaching service in an academic medical center to admit low‐risk chest pain patients. Patients admitted to the hospitalist service had a statistically significant lower median LOS (23 hours vs 33 hours) and approximately half the median hospital charges than those admitted to teaching services.50 At the same academic medical center, Bayley and colleagues showed that 91% of patients admitted for chest pain waited more than 3 hours for a bed. This adversely affected ED revenue by tying up beds, resulting in an estimated annual loss of $168,300 of hospital revenue. Creation of a hospitalist‐managed service for low‐acuity chest pain patients reduced hospital LOS by 7 hours.51 Somekh and colleagues demonstrated that a protocol‐driven, cardiologist‐run CPU results in a decreased LOS and readmission rate compared to usual care.52 In a non‐peer reviewed case study, Cox Health opened an 8‐bed, hospitalist‐led CPU in 2003. They decreased LOS from 72 to 18 hours, while increasing revenue by $2.5 million a year.53 These studies suggest that hospitalist‐run CPU can decrease LOS, increase revenue, and relieve ED overcrowding.

Development of a successful CPU depends upon clear inclusion/exclusion criteria; close collaboration among ED physicians, hospitalists, and cardiologists; the development of evidence‐based protocols, and the availability of stress testing.

ACTIVE BED MANAGEMENT

As of 2007, 90% of EDs were crowded beyond their capacity.2 ED crowding leads to ambulance diversion,54 which can delay care and increase mortality rates.55 One of the main causes of ED crowding is the boarding of admitted patients.56 Boarded, admitted patients have been shown to have decreased quality of care and patient satisfaction.35

Active bed management (ABM) by hospitalists can decrease ED diversion. Howell and colleagues instituted ABM where hospitalists, as active bed managers, facilitate placement of patients to their inpatient destinations to assist ED flow.57 This 24‐hour, hospitalist‐led, active bed management service decreased both ED LOS and ambulance diversion. The bed manager collaborated real‐time with medicine and ED attending physicians, nursing supervisors, and charge nurses to change patient care status, and assign and facilitate transfer of patients to appropriate units. These hospitalist bed managers were also empowered to activate additional resources when pre‐diversion rounds identified resource limitations and impending ED divert. They found overall ED LOS for admitted patients decreased by 98 minutes, while LOS for non‐admitted patients stayed the same. AMB decreased diversion due to critically ill and telemetry patients by 28% (786 hours), and diversion due to lower acuity patients by 6% (182 hours). This intervention proved cost‐effective. Three full‐time equivalent (FTE) hospitalists' salaries staff 1 active bed manager working 24/7. Nearly 1000 hours of diversion were avoided at an annual savings of $1086 per hour of diversion decreased.

ABM is a new frontier for hospitals in general, and hospitalists in particular. Chadaga and colleagues found that a hospital medicine‐ED team participating in active bed management, while caring for admitted patients boarded in the ED, can decrease ED diversion and improve patient flow. The percentage of patients transferred to a medicine floor and discharged within 8 hours was reduced by 67% (P < 0.01), while the number of discharges from the ED of admitted medicine patients increased by 61% (P < 0.001).58

To decrease initial investment, components of ABM (ED triage, bed assignment, discharge facilitation) can be instituted in parts. Hospital medicine groups with limited resources may only provide a triage service by phone for difficult ED cases. Bedside evaluations and collaboration with nursing staff to improve bed placement may be a next step, with floor and/or intensive care unit (ICU) rounds to facilitate early discharges as a final component.

OTHER AREAS

CONCLUSION

While many hospital medicine groups were started to provide acute inpatient medical care, most have found that their value to hospitals reaches beyond bedside care. With an epidemic of ED diversion and lack of access to hospital beds and services, optimizing throughput has become imperative for hospital systems. While hospital access can be improved with addition of new beds, improving throughput by decreasing LOS maximizes utilization of existing resources.

We have reviewed how hospitalists improve patient flow in acute inpatient medicine, surgical comanagement, short stay units, chest pain units, and active bed management. In each instance, the literature supports measures for decreasing LOS while maintaining or improving quality of care. Hinami and colleagues showed physician satisfaction with hospitalist‐provided patient care.75 Most studies have been limited by tracking upstream effects of improved efficiency. As there is now some evidence that decreasing LOS may increase readmissions,17 future studies should incorporate this metric into their outcomes. The effect of formal operations management principles on patient flow and bed efficiency is not well known and should be further examined.

In addition, we have touched on other areas (perioperative clinics, palliative care, geographic rounding, and flexible staffing models) where hospitalists may impact patient throughput. These areas represent excellent opportunities for future research.

Hospitalist participation in many of these areas is in its infancy. Hospital medicine programs interested in expanding their services, beyond acute inpatient care, have the opportunity to develop standards and continue research on the effect of hospital medicine‐led services on patient care and flow.

Hospitalists are physicians whose primary focus is the general medical care of hospitalized patients. Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency.1 With emergency department (ED) diversion reaching rates upward of 70%, lack of access to inpatient beds leads to delayed care with worsened outcomes.25

To improve access to hospital beds, hospitals may increase capacity by either adding beds or by more efficiently using existing beds. Operations management principles have been applied to healthcare to ensure efficient use of beds. These include: reducing variability of scheduled admissions, remeasuring length of stay (LOS) and bed demand after implementing strategies to reduce practice variation, and employing queuing theory to generate predictions of optimal beds needed.6 The Joint Commission implemented a leadership standard (LD 04.03.11) that hospitals develop and implement plans to identify and mitigate impediments to efficient patient flow through the hospital.

To improve access, hospital leaders expect hospitalists to staff in inpatient medicine programs, surgical comanagement, short stay and chest pain units, and active bed management.7 In the following review, we define hospitalists' roles in the aforementioned programs and their effect on patient flow. We also touch on preoperative clinics, palliative care, geographic rounding, and flexible staffing models.

ACUTE INPATIENT CARE

Hospitalists are one of the fastest growing physician groups in the United States.810 Hospitalists improve efficiency and quality of care across a variety of demographic, geographic, and healthcare settings.11, 12 A 2002 retrospective cohort study in a community‐based urban teaching hospital showed that hospitalists decreased LOS by 0.61 days and lowered risk for death in the hospital (adjusted relative hazard, 0.71; 95% confidence interval [CI], 0.540.93).13 A 2004 prospective quasi‐experimental observational study done at an academic teaching hospital showed an adjusted LOS that was 16.2% lower, and adjusted cost 9.7% lower, for patients on the hospitalists' service.14 In 2007, Lindenauer and colleagues found that a national sample of hospitalists decreased LOS by 0.4 days and lowered cost by $286 per patient.15 The findings of these individual studies were supported in a 2009 systematic review of 33 studies by Peterson which showed that hospitalists decrease LOS.16 In a recent study, Kuo and Goodwin showed that while hospitalists decrease LOS and cost, the patients they care for have higher Medicare costs after discharge by $322 per patient, and are more likely to be readmitted (odds ratio, 1.08; CI, 1.041.14).17

The hospitalist model of care continues to grow, and hospitalists will soon number as many as 30,000.18 For acute medical inpatients, the evidence suggests that hospitalists improve patient flow by decreasing LOS while improving other aspects of quality of care. However, Kuo and Goodwin's findings suggest that the transition of care from inpatient to outpatient settings still requires attention.17

SURGICAL COMANAGEMENT

The Society of Hospital Medicine (SHM) core competencies include perioperative medicine.19, 20 In the 2006 SHM national survey, 85% of hospital medicine groups indicated that they participated in surgical comanagement.21

Hospitalists have improved patient flow and outcomes for orthopedic patients. Hospitalist management of hip fracture patients decreases time to surgery and LOS compared to standard care.2224 Phy and colleagues studied 466 patients for 2 years after the inception of hospital medicine comanagement of surgical patients, and found that care by hospitalists decreased LOS by 2.2 days.22 In a retrospective study of 118 patients, Roy and colleagues found that hospitalist‐managed patients had shorter time to consultation and surgery, decreased LOS, and lower costs.23 In a retrospective cohort study, Batsis looked at mortality in 466 patients with hip fracture, and found no difference between hospitalist management and standard care.24 In patients undergoing elective hip and knee arthroplasty, Huddleston and colleagues reported that patients managed by hospitalists had fewer complications and shorter LOS. The nurses and orthopedic surgeons preferred the hospitalistorthopedist comanagement model.25

The benefits of hospitalist comanagement are not limited to adult patients undergoing orthopedic surgery. For high‐risk patients undergoing lower extremity reconstruction surgery, Pinzur and colleagues noted that LOS was shorter for a cohort of patients managed by hospitalists than for a group of historical controls not treated by hospitalists.26 Simon and colleagues studied comanagement for pediatric spinal fusion patients, and found a decrease in LOS from 6.5 to 4.8 days.27

Several factors should be considered in developing and implementing a successful comanagement program. Since comanagement duties may fall upon hospitalists in order to protect surgeons' time,28 hospital medicine groups should ensure adequate staffing prior to taking on additional services. Clear guidelines to delineate roles and responsibilities of the comanaging groups also need to be developed and implemented.29, 30

Comanaging may also involve additional training. Hospitalists who manage neurologic, neurosurgical, trauma, and psychiatric patients report being undertrained for such conditions.31, 32 Hospital medicine groups need to ensure training needs are met and supported. Given the successes of comanagement and the increasing complexity of surgical patients,33 this practice will likely expand to a greater variety of non‐medical patients.

SHORT STAY UNITS

In 2003, short stay units (SSU) were present in approximately 20% of US hospitals, with 11% of hospitals planning on opening one in the next year.34 SSU are designed to manage acute, self‐limited medical conditions that require brief staysusually less than 72 hours. Approximately 80% of SSU patients are discharged home, avoiding hospitalization.35 Historically, SSU have been under the domain of the ED; however, there is an emerging role for hospitalist‐run SSU.36

Despite demand for SSU, little research has been performed on hospitalist‐led SSU. In 2000, Abenhaim and colleagues showed that a hospitalist‐run SSU at a university‐affiliated teaching hospital had a shorter LOS and lower rates of complications and readmissions when compared to medicine teaching services.37 In 2008, Northwestern Memorial Hospital opened a 30‐bed hospitalist‐run SSU; for those patients, LOS decreased by 2 days.38 In 2010, Leykum and colleagues showed that a hospitalist‐run observation unit can decrease LOS from 2.4 days to 2.2 days.39 Careful selection of SSU patients is needed to obtain these results. Lucas and colleagues found that whether or not SSU patients required assistance of specialists was the strongest predictor of unsuccessful stays (>72 hours or inpatient conversion) in SSU.36

Whether SSU are run by hospital medicine or emergency medicine is decided at an institutional level. Location of SSU in a specifically designated area is crucial, as it allows physicians to round efficiently on patients and to work with staff trained in observation services. Development of admission criteria that include specific diagnoses which match hospitalists' scope of practice is also important (Table 1).32

The protocol‐based and diagnosis‐specific nature of SSU may enhance quality of care through standardization. Future research may delineate the utility of SSU.

CHEST PAIN UNITS

In the United States, in 2004, approximately 6 million patients present annually to EDs with chest pain.40 Cost of care of patients unnecessarily admitted to coronary care units has been estimated to be nearly $3 billion annually.41 Still, as many as 3% of patients with acute myocardial infarction are discharged home.42 Chest pain units (CPU) were developed to facilitate evaluation of patients with chest pain, at low risk for acute coronary syndrome, without requiring inpatient admission. A number of studies have suggested that admission to a CPU is a safe and cost‐effective alternative to hospital admission.4348

CPU have traditionally been staffed by ED physicians and/or cardiologists. In a prepost study, Krantz and colleagues found that a CPU model, incorporating hospitalists at an academic public safety‐net hospital, decreased ED LOS with no difference in 30‐day cardiac event rate.49 Myers and colleagues created a hospitalist‐directed nonteaching service in an academic medical center to admit low‐risk chest pain patients. Patients admitted to the hospitalist service had a statistically significant lower median LOS (23 hours vs 33 hours) and approximately half the median hospital charges than those admitted to teaching services.50 At the same academic medical center, Bayley and colleagues showed that 91% of patients admitted for chest pain waited more than 3 hours for a bed. This adversely affected ED revenue by tying up beds, resulting in an estimated annual loss of $168,300 of hospital revenue. Creation of a hospitalist‐managed service for low‐acuity chest pain patients reduced hospital LOS by 7 hours.51 Somekh and colleagues demonstrated that a protocol‐driven, cardiologist‐run CPU results in a decreased LOS and readmission rate compared to usual care.52 In a non‐peer reviewed case study, Cox Health opened an 8‐bed, hospitalist‐led CPU in 2003. They decreased LOS from 72 to 18 hours, while increasing revenue by $2.5 million a year.53 These studies suggest that hospitalist‐run CPU can decrease LOS, increase revenue, and relieve ED overcrowding.

Development of a successful CPU depends upon clear inclusion/exclusion criteria; close collaboration among ED physicians, hospitalists, and cardiologists; the development of evidence‐based protocols, and the availability of stress testing.

ACTIVE BED MANAGEMENT

As of 2007, 90% of EDs were crowded beyond their capacity.2 ED crowding leads to ambulance diversion,54 which can delay care and increase mortality rates.55 One of the main causes of ED crowding is the boarding of admitted patients.56 Boarded, admitted patients have been shown to have decreased quality of care and patient satisfaction.35

Active bed management (ABM) by hospitalists can decrease ED diversion. Howell and colleagues instituted ABM where hospitalists, as active bed managers, facilitate placement of patients to their inpatient destinations to assist ED flow.57 This 24‐hour, hospitalist‐led, active bed management service decreased both ED LOS and ambulance diversion. The bed manager collaborated real‐time with medicine and ED attending physicians, nursing supervisors, and charge nurses to change patient care status, and assign and facilitate transfer of patients to appropriate units. These hospitalist bed managers were also empowered to activate additional resources when pre‐diversion rounds identified resource limitations and impending ED divert. They found overall ED LOS for admitted patients decreased by 98 minutes, while LOS for non‐admitted patients stayed the same. AMB decreased diversion due to critically ill and telemetry patients by 28% (786 hours), and diversion due to lower acuity patients by 6% (182 hours). This intervention proved cost‐effective. Three full‐time equivalent (FTE) hospitalists' salaries staff 1 active bed manager working 24/7. Nearly 1000 hours of diversion were avoided at an annual savings of $1086 per hour of diversion decreased.

ABM is a new frontier for hospitals in general, and hospitalists in particular. Chadaga and colleagues found that a hospital medicine‐ED team participating in active bed management, while caring for admitted patients boarded in the ED, can decrease ED diversion and improve patient flow. The percentage of patients transferred to a medicine floor and discharged within 8 hours was reduced by 67% (P < 0.01), while the number of discharges from the ED of admitted medicine patients increased by 61% (P < 0.001).58

To decrease initial investment, components of ABM (ED triage, bed assignment, discharge facilitation) can be instituted in parts. Hospital medicine groups with limited resources may only provide a triage service by phone for difficult ED cases. Bedside evaluations and collaboration with nursing staff to improve bed placement may be a next step, with floor and/or intensive care unit (ICU) rounds to facilitate early discharges as a final component.

OTHER AREAS

CONCLUSION

While many hospital medicine groups were started to provide acute inpatient medical care, most have found that their value to hospitals reaches beyond bedside care. With an epidemic of ED diversion and lack of access to hospital beds and services, optimizing throughput has become imperative for hospital systems. While hospital access can be improved with addition of new beds, improving throughput by decreasing LOS maximizes utilization of existing resources.

We have reviewed how hospitalists improve patient flow in acute inpatient medicine, surgical comanagement, short stay units, chest pain units, and active bed management. In each instance, the literature supports measures for decreasing LOS while maintaining or improving quality of care. Hinami and colleagues showed physician satisfaction with hospitalist‐provided patient care.75 Most studies have been limited by tracking upstream effects of improved efficiency. As there is now some evidence that decreasing LOS may increase readmissions,17 future studies should incorporate this metric into their outcomes. The effect of formal operations management principles on patient flow and bed efficiency is not well known and should be further examined.

In addition, we have touched on other areas (perioperative clinics, palliative care, geographic rounding, and flexible staffing models) where hospitalists may impact patient throughput. These areas represent excellent opportunities for future research.

Hospitalist participation in many of these areas is in its infancy. Hospital medicine programs interested in expanding their services, beyond acute inpatient care, have the opportunity to develop standards and continue research on the effect of hospital medicine‐led services on patient care and flow.

Hospitalists are physicians whose primary focus is the general medical care of hospitalized patients. Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency.1 With emergency department (ED) diversion reaching rates upward of 70%, lack of access to inpatient beds leads to delayed care with worsened outcomes.25

To improve access to hospital beds, hospitals may increase capacity by either adding beds or by more efficiently using existing beds. Operations management principles have been applied to healthcare to ensure efficient use of beds. These include: reducing variability of scheduled admissions, remeasuring length of stay (LOS) and bed demand after implementing strategies to reduce practice variation, and employing queuing theory to generate predictions of optimal beds needed.6 The Joint Commission implemented a leadership standard (LD 04.03.11) that hospitals develop and implement plans to identify and mitigate impediments to efficient patient flow through the hospital.

To improve access, hospital leaders expect hospitalists to staff in inpatient medicine programs, surgical comanagement, short stay and chest pain units, and active bed management.7 In the following review, we define hospitalists' roles in the aforementioned programs and their effect on patient flow. We also touch on preoperative clinics, palliative care, geographic rounding, and flexible staffing models.

ACUTE INPATIENT CARE

Hospitalists are one of the fastest growing physician groups in the United States.810 Hospitalists improve efficiency and quality of care across a variety of demographic, geographic, and healthcare settings.11, 12 A 2002 retrospective cohort study in a community‐based urban teaching hospital showed that hospitalists decreased LOS by 0.61 days and lowered risk for death in the hospital (adjusted relative hazard, 0.71; 95% confidence interval [CI], 0.540.93).13 A 2004 prospective quasi‐experimental observational study done at an academic teaching hospital showed an adjusted LOS that was 16.2% lower, and adjusted cost 9.7% lower, for patients on the hospitalists' service.14 In 2007, Lindenauer and colleagues found that a national sample of hospitalists decreased LOS by 0.4 days and lowered cost by $286 per patient.15 The findings of these individual studies were supported in a 2009 systematic review of 33 studies by Peterson which showed that hospitalists decrease LOS.16 In a recent study, Kuo and Goodwin showed that while hospitalists decrease LOS and cost, the patients they care for have higher Medicare costs after discharge by $322 per patient, and are more likely to be readmitted (odds ratio, 1.08; CI, 1.041.14).17

The hospitalist model of care continues to grow, and hospitalists will soon number as many as 30,000.18 For acute medical inpatients, the evidence suggests that hospitalists improve patient flow by decreasing LOS while improving other aspects of quality of care. However, Kuo and Goodwin's findings suggest that the transition of care from inpatient to outpatient settings still requires attention.17

SURGICAL COMANAGEMENT

The Society of Hospital Medicine (SHM) core competencies include perioperative medicine.19, 20 In the 2006 SHM national survey, 85% of hospital medicine groups indicated that they participated in surgical comanagement.21

Hospitalists have improved patient flow and outcomes for orthopedic patients. Hospitalist management of hip fracture patients decreases time to surgery and LOS compared to standard care.2224 Phy and colleagues studied 466 patients for 2 years after the inception of hospital medicine comanagement of surgical patients, and found that care by hospitalists decreased LOS by 2.2 days.22 In a retrospective study of 118 patients, Roy and colleagues found that hospitalist‐managed patients had shorter time to consultation and surgery, decreased LOS, and lower costs.23 In a retrospective cohort study, Batsis looked at mortality in 466 patients with hip fracture, and found no difference between hospitalist management and standard care.24 In patients undergoing elective hip and knee arthroplasty, Huddleston and colleagues reported that patients managed by hospitalists had fewer complications and shorter LOS. The nurses and orthopedic surgeons preferred the hospitalistorthopedist comanagement model.25

The benefits of hospitalist comanagement are not limited to adult patients undergoing orthopedic surgery. For high‐risk patients undergoing lower extremity reconstruction surgery, Pinzur and colleagues noted that LOS was shorter for a cohort of patients managed by hospitalists than for a group of historical controls not treated by hospitalists.26 Simon and colleagues studied comanagement for pediatric spinal fusion patients, and found a decrease in LOS from 6.5 to 4.8 days.27

Several factors should be considered in developing and implementing a successful comanagement program. Since comanagement duties may fall upon hospitalists in order to protect surgeons' time,28 hospital medicine groups should ensure adequate staffing prior to taking on additional services. Clear guidelines to delineate roles and responsibilities of the comanaging groups also need to be developed and implemented.29, 30

Comanaging may also involve additional training. Hospitalists who manage neurologic, neurosurgical, trauma, and psychiatric patients report being undertrained for such conditions.31, 32 Hospital medicine groups need to ensure training needs are met and supported. Given the successes of comanagement and the increasing complexity of surgical patients,33 this practice will likely expand to a greater variety of non‐medical patients.

SHORT STAY UNITS

In 2003, short stay units (SSU) were present in approximately 20% of US hospitals, with 11% of hospitals planning on opening one in the next year.34 SSU are designed to manage acute, self‐limited medical conditions that require brief staysusually less than 72 hours. Approximately 80% of SSU patients are discharged home, avoiding hospitalization.35 Historically, SSU have been under the domain of the ED; however, there is an emerging role for hospitalist‐run SSU.36

Despite demand for SSU, little research has been performed on hospitalist‐led SSU. In 2000, Abenhaim and colleagues showed that a hospitalist‐run SSU at a university‐affiliated teaching hospital had a shorter LOS and lower rates of complications and readmissions when compared to medicine teaching services.37 In 2008, Northwestern Memorial Hospital opened a 30‐bed hospitalist‐run SSU; for those patients, LOS decreased by 2 days.38 In 2010, Leykum and colleagues showed that a hospitalist‐run observation unit can decrease LOS from 2.4 days to 2.2 days.39 Careful selection of SSU patients is needed to obtain these results. Lucas and colleagues found that whether or not SSU patients required assistance of specialists was the strongest predictor of unsuccessful stays (>72 hours or inpatient conversion) in SSU.36

Whether SSU are run by hospital medicine or emergency medicine is decided at an institutional level. Location of SSU in a specifically designated area is crucial, as it allows physicians to round efficiently on patients and to work with staff trained in observation services. Development of admission criteria that include specific diagnoses which match hospitalists' scope of practice is also important (Table 1).32

The protocol‐based and diagnosis‐specific nature of SSU may enhance quality of care through standardization. Future research may delineate the utility of SSU.

CHEST PAIN UNITS

In the United States, in 2004, approximately 6 million patients present annually to EDs with chest pain.40 Cost of care of patients unnecessarily admitted to coronary care units has been estimated to be nearly $3 billion annually.41 Still, as many as 3% of patients with acute myocardial infarction are discharged home.42 Chest pain units (CPU) were developed to facilitate evaluation of patients with chest pain, at low risk for acute coronary syndrome, without requiring inpatient admission. A number of studies have suggested that admission to a CPU is a safe and cost‐effective alternative to hospital admission.4348

CPU have traditionally been staffed by ED physicians and/or cardiologists. In a prepost study, Krantz and colleagues found that a CPU model, incorporating hospitalists at an academic public safety‐net hospital, decreased ED LOS with no difference in 30‐day cardiac event rate.49 Myers and colleagues created a hospitalist‐directed nonteaching service in an academic medical center to admit low‐risk chest pain patients. Patients admitted to the hospitalist service had a statistically significant lower median LOS (23 hours vs 33 hours) and approximately half the median hospital charges than those admitted to teaching services.50 At the same academic medical center, Bayley and colleagues showed that 91% of patients admitted for chest pain waited more than 3 hours for a bed. This adversely affected ED revenue by tying up beds, resulting in an estimated annual loss of $168,300 of hospital revenue. Creation of a hospitalist‐managed service for low‐acuity chest pain patients reduced hospital LOS by 7 hours.51 Somekh and colleagues demonstrated that a protocol‐driven, cardiologist‐run CPU results in a decreased LOS and readmission rate compared to usual care.52 In a non‐peer reviewed case study, Cox Health opened an 8‐bed, hospitalist‐led CPU in 2003. They decreased LOS from 72 to 18 hours, while increasing revenue by $2.5 million a year.53 These studies suggest that hospitalist‐run CPU can decrease LOS, increase revenue, and relieve ED overcrowding.

Development of a successful CPU depends upon clear inclusion/exclusion criteria; close collaboration among ED physicians, hospitalists, and cardiologists; the development of evidence‐based protocols, and the availability of stress testing.

ACTIVE BED MANAGEMENT

As of 2007, 90% of EDs were crowded beyond their capacity.2 ED crowding leads to ambulance diversion,54 which can delay care and increase mortality rates.55 One of the main causes of ED crowding is the boarding of admitted patients.56 Boarded, admitted patients have been shown to have decreased quality of care and patient satisfaction.35

Active bed management (ABM) by hospitalists can decrease ED diversion. Howell and colleagues instituted ABM where hospitalists, as active bed managers, facilitate placement of patients to their inpatient destinations to assist ED flow.57 This 24‐hour, hospitalist‐led, active bed management service decreased both ED LOS and ambulance diversion. The bed manager collaborated real‐time with medicine and ED attending physicians, nursing supervisors, and charge nurses to change patient care status, and assign and facilitate transfer of patients to appropriate units. These hospitalist bed managers were also empowered to activate additional resources when pre‐diversion rounds identified resource limitations and impending ED divert. They found overall ED LOS for admitted patients decreased by 98 minutes, while LOS for non‐admitted patients stayed the same. AMB decreased diversion due to critically ill and telemetry patients by 28% (786 hours), and diversion due to lower acuity patients by 6% (182 hours). This intervention proved cost‐effective. Three full‐time equivalent (FTE) hospitalists' salaries staff 1 active bed manager working 24/7. Nearly 1000 hours of diversion were avoided at an annual savings of $1086 per hour of diversion decreased.

ABM is a new frontier for hospitals in general, and hospitalists in particular. Chadaga and colleagues found that a hospital medicine‐ED team participating in active bed management, while caring for admitted patients boarded in the ED, can decrease ED diversion and improve patient flow. The percentage of patients transferred to a medicine floor and discharged within 8 hours was reduced by 67% (P < 0.01), while the number of discharges from the ED of admitted medicine patients increased by 61% (P < 0.001).58

To decrease initial investment, components of ABM (ED triage, bed assignment, discharge facilitation) can be instituted in parts. Hospital medicine groups with limited resources may only provide a triage service by phone for difficult ED cases. Bedside evaluations and collaboration with nursing staff to improve bed placement may be a next step, with floor and/or intensive care unit (ICU) rounds to facilitate early discharges as a final component.

OTHER AREAS

CONCLUSION

While many hospital medicine groups were started to provide acute inpatient medical care, most have found that their value to hospitals reaches beyond bedside care. With an epidemic of ED diversion and lack of access to hospital beds and services, optimizing throughput has become imperative for hospital systems. While hospital access can be improved with addition of new beds, improving throughput by decreasing LOS maximizes utilization of existing resources.

We have reviewed how hospitalists improve patient flow in acute inpatient medicine, surgical comanagement, short stay units, chest pain units, and active bed management. In each instance, the literature supports measures for decreasing LOS while maintaining or improving quality of care. Hinami and colleagues showed physician satisfaction with hospitalist‐provided patient care.75 Most studies have been limited by tracking upstream effects of improved efficiency. As there is now some evidence that decreasing LOS may increase readmissions,17 future studies should incorporate this metric into their outcomes. The effect of formal operations management principles on patient flow and bed efficiency is not well known and should be further examined.

In addition, we have touched on other areas (perioperative clinics, palliative care, geographic rounding, and flexible staffing models) where hospitalists may impact patient throughput. These areas represent excellent opportunities for future research.

Hospitalist participation in many of these areas is in its infancy. Hospital medicine programs interested in expanding their services, beyond acute inpatient care, have the opportunity to develop standards and continue research on the effect of hospital medicine‐led services on patient care and flow.

Communication failures are well‐recognized as causes of medical errors.1, 2 Specifically, handoffs of patient care responsibilities, which are increasingly prevalent in academic medical centers,3 have been cited as the most frequent cause of teamwork breakdown resulting in the harmful medical errors found in malpractice claims.1 The Institute of Medicine has recently identified patient handoffs as the moment where patient care errors are most likely to occur.4 A survey of 125 U.S. medical schools, however, found that only 8% specifically taught students how to hand off patient care.3

In July 2003, the American Council of Graduate Medical Education (ACGME) mandated that residency programs decrease resident work hours to improve patient care and safety by reducing fatigue,5 and a recent Institute of Medicine report suggests that they be decreased even further.4 Studies examining outcomes during the first 2 years after reducing duty hours did not find reductions in risk‐adjusted mortality.68 One proposed explanation for this lack of improvement is that the reduction in fatigue‐related medical errors is being offset by discontinuity of care with due to the increased number of patient handoffs resulting from shortened duty hours,911 one recent study found that omission of key information during patient sign outs frequently resulted in adverse patient care outcomes.12

In 2007, the Joint Commission developed a new National Patient Safety Goal that requires organizations to improve communication between caregivers.13 We recently developed an approach by which Internal Medicine residents hand off patient care using a structured process, written and verbal templates, formal training about handoffs, and direct attending supervision.14 Because fourth‐year medical students perform the duties of interns when working as subinterns, we recognized that education about handoffs should occur prior to the time students became interns. Accordingly, we developed a course designed to teach patient handoffs to medical students at the transition between their third and fourth years of training.

Setting

The Handoff Selective was developed by faculty of Denver Health and the University of Colorado Denver School of Medicine.

Program Description

The Selective was first offered in April 2007 as part of an Integrated Clinician's Course (ICC), a 2‐week course for students beginning their fourth year, which starts in April at the University of Colorado. The ICC includes both mandatory and selective sessions that are focused on developing clinical skills and preparing them for their subinternships. The Handoff Selective was conducted in a computerized teaching laboratory, lasted a total of 2 hours and consisted of 2 parts. Each of the 5 Denver Health Hospital Medicine faculty members versed in handoff education taught 2 sessions of 6 to 8 students.

Part 1: Didactic

During the first hour of class, the faculty presented a lecture that summarized the relevant literature on handoffs and explained the importance of the topic. The objectives of the didactic were to: (1) understand the importance of handoffs; (2) explore different communication elements and structures; (3) gain exposure to handoffs outside of healthcare; and (4) learn a structure for handoffs of patient care in hospitalized patients.

We used 3 video clips of handoffs from 2 football games to demonstrate the importance of practice, training, and 2‐way communications in handoffs. The first video clip showed a runner trying to make a spontaneous handoff while being tackled. The receiver was not expecting the handoff and was preoccupied with blocking another player. This attempted handoff resulted in a fumble, which we related to an adverse patient event.

The next 2 video clips showed 2 complex, seldom used, but well‐known football handoffsthe hook and lateral and the Statue of Liberty. Both handoffs were successfully executed presumably as a result of education, practice and the active participation of both players (handing off and receiving) in the process. We then related the teaching and practicing of complex communication to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO; now simply the Joint Commission) data suggesting that most sentinel events have their root cause in communication and training failures.2

Basic communication elements and process structures were then explored using scenarios from everyday life and evidence from fields outside of medicine. We emphasized that structures for communication (modes, vehicles, and settings) must be chosen according to the occasion and that handoffs are common and important in all occupations. In discussing modes (verbal, written, or nonverbal), vehicles (paper, telephone, or e‐mail), and settings (face‐to face, virtual, or disconnected), we emphasized that the most effective structures for communication (verbal, face‐to face meetings, with written materials and other visual aids at the patient's bedside) were also the most time‐consuming (Figure 1). While our standard for resident handoffs is a face‐to‐face verbal interaction with preprinted written materials as an aid, we also emphasized that for complex patients (eg, mental status changes, concern for an acute abdomen) more robust communication is often needed. Accordingly, a more time‐consuming bedside handoff with simultaneous, focused physical exam and history‐taking by both oncoming and off‐going providers may be most appropriate.

Figure 1

As real‐life examples, we asked our students to communicate a happy birthday wish to their mother, who lives in another state. Almost uniformly, in addition to a written aid (birthday card), they choose the telephone as a vehicle for their verbal mode in a virtual setting with 2‐way communication possible. In contrast, when asked to propose marriage to a significant other in another state, students felt that a face‐to‐face meeting with verbal and nonverbal (ie, ring) modes was appropriate. This time‐consuming mode of communication was felt to be necessary to create a sentiment of importance and avert any possible miscommunication.

The didactic session concluded by demonstrating how to use standardized written and verbal templates for handoffs of the care of a hospitalized patient. We explore the differentiation between written and verbal handoffs in our discussion below.

Program Evaluation

We developed a 2‐part survey to evaluate the effectiveness of the Selective and to solicit feedback about the didactic and practicum portions of the course. The first part of the survey (Table 2) contained 16 items to assess the students' knowledge of, and attitudes toward handing off patient care, along with their comfort with the handoff process. Responses to this section were scored using a 5‐point Likert scale with 1 indicating strongly disagree and 5 indicating strongly agree. This part of the survey was administered both prior to and after the Selective.

The second part (Table 3) contained 12 items and was designed to evaluate the perceived usefulness of the different components of the class. This section was only administered at the end of the Selective. It utilized a 4‐point Likert scale with 1 indicating that the component was not useful at all, and 4 indicating that it was extremely useful. The first 6 items of the second section allowed students to evaluate the didactic portion of the handoff. The second 6 items allowed students to evaluate the practicum. Responses to all 12 items were then combined to determine an overall composite usefulness for the Selective.

The Selective was also evaluated qualitatively through the use of open‐ended, written comments that were solicited at the end of the survey. All surveys were administered anonymously.

Results

More students chose the Selective than we had capacity to accommodate (60 of a class of 150). The pre‐ and postcourse survey response rate was 56 of 60 (93%) and 58 of 60 (97%), respectively. After the Selective, the mean score in response to whether handoffs are well taught in medical school increased from 1.6 to 3.5 (P < 0.003). Our students' self‐perceived skills and knowledge about handoffs improved after the Selective (Table 2). The greatest changes in perceived knowledge occurred in questions regarding the what, how, and when of read‐backs, and the knowledge of standard verbal and written handoff structures. The responses to the survey elements which assessed our students' attitudes regarding the importance of standardization and whether they felt handoffs were safer with faculty supervision did not change after the Selective (Table 2).

A total of 92% of the students felt that the course was extremely useful or useful. The role‐playing activity was thought to be more helpful than the didactic, but 84% of the students still rated the didactic portion as useful or extremely useful (Table 3). The element which was the least well received in the didactic portion was the use of video clips to demonstrate successful and unsuccessful (fumbled) college football handoffs, although the majority (64%) of students still found it useful.

The major theme generated from the comments section of the survey was that the Selective should be a required course.

Discussion

We know of no previously published literature that has addressed teaching handoffs to medical students. Horwitz et al.15 developed a sign‐out curriculum for Internal Medicine residents and found that none of their house‐staff had any previous training in handoffs during medical school, consistent with the finding that only 8% of U.S. medical schools provided formal instruction on handoffs.3 Prior to taking the Selective, our students had no knowledge of verbal or written templates for patient handoffs, although both before and after the course they felt that standardization was an important component of the process.

A number of verbal structures for handing off patient care have been described in the literature and there is not a consensus as to which functions best. Perhaps the most cited verbal communication format is SBAR (ie, situation, background, assessment and recommendation).16, 17 This tool was developed by Leonard et al.18 specifically for use by nurses to provide 1‐way communication to physicians pertaining to a change in patient status. We considered teaching the SBAR approach to the students but felt that it did not provide a suitable structure for handoffs because the transfer of care is not generally an event‐based situation and the literature on handoffs indicates that an optimal verbal system includes 2‐way communication.

Additional mnemonics for handoffs found in the literature include SIGNOUT (ie, Sick or DNR, Identifying information, General hospital course, New events of the day, Overall health status, Upcoming possibilities with plan, and Tasks to complete),14 I PASS the BATON (ie, Introduction, Patient, Assessment, Situation, Safety, Background, Actions, Timing, Ownership, Next)19 and the SAIF‐IR system (see boxed text).14

We developed the SAIF‐IR mnemonic to maximize efficiency and effectiveness while differentiating the verbal portion of the handoff from the written and incorporating 2‐way communication into its structure. In the Summary statement, we emphasize that this is not a history of present illness. We ask our students to summarize, in 1 to 3 sentences, the patient's presentation and working diagnosis. When discussing patient issues, we ask our students to only verbalize Active issues, although the written template has inactive, chronic issues listed. Here, we also ask our students to express their level of concern for the active issues and patient in general. If‐then's and Follow‐ups are usually verbalized together. Based on the offgoing provider's knowledge of the patient, we encourage the offgoing provider to anticipate potential problems and advise the oncoming provider on potential responses. Much of this advice is difficult to express in the written format and thus may not be found on the written handoff when the verbal handoff occurs. We encourage oncoming providers to take notes on the preprinted handoff sheet as part of the handoff process.

Through Interactive questioning and Read‐backs, we train our students and house‐staff to use the active listening techniques used outside of healthcare, in settings such as nuclear power plants and National Aeronautics and Space Administration mission control, where poor handoff communication may also result in safety concerns and adverse events.20 Interactive questioning allows the oncoming provider to correct or clarify any information given by the off‐going provider. Read‐backs are a method of confirming follow‐up activity or contingency plans. Together, the SAIF‐IR mnemonic builds a 2‐way communication structure into the patient handoff with both offgoing and oncoming providers having predefined roles.

Much of the information on our written handoff (patient identifying information, medications, language preference, code status, admission date) is not verbalized unless it is part of the active issues or the if‐then, follow‐ups (ie, medication titration for a patient admitted with an acute coronary syndrome or cor status in a patient newly made comfort care). By not reading extraneous information, we seek to emphasize the Active issues as well as the If‐then, Follow‐ups. We feel this emphasis maximizes the effectiveness of the handoff, while the purposeful nonverbalization of written materials such as identifying information maximizes its efficiency. Future work may examine which verbal and written structures for patient handoffs most benefit patient care and workflow through standard communication.

While our students found the Handoff Selective to be useful and to improve their self‐perceived ability to perform handoffs, we were not able to determine whether our program affected downstream outcomes such as adverse events relating to failures in handoff communication. Additionally, since we only taught and evaluated our Selective at the University of Colorado Denver School of Medicine, the response of our students may not generalize to other medical schools. Multicentered, prospective, randomized controlled trials may determine whether handoff education programs are successful in reducing patient adverse events related to transfers of care.

While handoffs occur frequently and are increasingly recognized as a vulnerable time in patient care, little is known about how to effectively teach handoffs to medical students during their clinical years. We developed a formal course to teach the importance of handoffs and how the process should be conducted. Our students reported that the Handoff Selective we developed improved their knowledge about the process and their perception of their ability to perform handoffs in a time‐appropriate and effective manner. In response to the feedback we received from our students, the Handoff Selective is the only course in the ICC that has been made mandatory for all students.

Communication failures are well‐recognized as causes of medical errors.1, 2 Specifically, handoffs of patient care responsibilities, which are increasingly prevalent in academic medical centers,3 have been cited as the most frequent cause of teamwork breakdown resulting in the harmful medical errors found in malpractice claims.1 The Institute of Medicine has recently identified patient handoffs as the moment where patient care errors are most likely to occur.4 A survey of 125 U.S. medical schools, however, found that only 8% specifically taught students how to hand off patient care.3

In July 2003, the American Council of Graduate Medical Education (ACGME) mandated that residency programs decrease resident work hours to improve patient care and safety by reducing fatigue,5 and a recent Institute of Medicine report suggests that they be decreased even further.4 Studies examining outcomes during the first 2 years after reducing duty hours did not find reductions in risk‐adjusted mortality.68 One proposed explanation for this lack of improvement is that the reduction in fatigue‐related medical errors is being offset by discontinuity of care with due to the increased number of patient handoffs resulting from shortened duty hours,911 one recent study found that omission of key information during patient sign outs frequently resulted in adverse patient care outcomes.12

In 2007, the Joint Commission developed a new National Patient Safety Goal that requires organizations to improve communication between caregivers.13 We recently developed an approach by which Internal Medicine residents hand off patient care using a structured process, written and verbal templates, formal training about handoffs, and direct attending supervision.14 Because fourth‐year medical students perform the duties of interns when working as subinterns, we recognized that education about handoffs should occur prior to the time students became interns. Accordingly, we developed a course designed to teach patient handoffs to medical students at the transition between their third and fourth years of training.

Setting

The Handoff Selective was developed by faculty of Denver Health and the University of Colorado Denver School of Medicine.

Program Description

The Selective was first offered in April 2007 as part of an Integrated Clinician's Course (ICC), a 2‐week course for students beginning their fourth year, which starts in April at the University of Colorado. The ICC includes both mandatory and selective sessions that are focused on developing clinical skills and preparing them for their subinternships. The Handoff Selective was conducted in a computerized teaching laboratory, lasted a total of 2 hours and consisted of 2 parts. Each of the 5 Denver Health Hospital Medicine faculty members versed in handoff education taught 2 sessions of 6 to 8 students.

Part 1: Didactic

During the first hour of class, the faculty presented a lecture that summarized the relevant literature on handoffs and explained the importance of the topic. The objectives of the didactic were to: (1) understand the importance of handoffs; (2) explore different communication elements and structures; (3) gain exposure to handoffs outside of healthcare; and (4) learn a structure for handoffs of patient care in hospitalized patients.

We used 3 video clips of handoffs from 2 football games to demonstrate the importance of practice, training, and 2‐way communications in handoffs. The first video clip showed a runner trying to make a spontaneous handoff while being tackled. The receiver was not expecting the handoff and was preoccupied with blocking another player. This attempted handoff resulted in a fumble, which we related to an adverse patient event.

The next 2 video clips showed 2 complex, seldom used, but well‐known football handoffsthe hook and lateral and the Statue of Liberty. Both handoffs were successfully executed presumably as a result of education, practice and the active participation of both players (handing off and receiving) in the process. We then related the teaching and practicing of complex communication to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO; now simply the Joint Commission) data suggesting that most sentinel events have their root cause in communication and training failures.2

Basic communication elements and process structures were then explored using scenarios from everyday life and evidence from fields outside of medicine. We emphasized that structures for communication (modes, vehicles, and settings) must be chosen according to the occasion and that handoffs are common and important in all occupations. In discussing modes (verbal, written, or nonverbal), vehicles (paper, telephone, or e‐mail), and settings (face‐to face, virtual, or disconnected), we emphasized that the most effective structures for communication (verbal, face‐to face meetings, with written materials and other visual aids at the patient's bedside) were also the most time‐consuming (Figure 1). While our standard for resident handoffs is a face‐to‐face verbal interaction with preprinted written materials as an aid, we also emphasized that for complex patients (eg, mental status changes, concern for an acute abdomen) more robust communication is often needed. Accordingly, a more time‐consuming bedside handoff with simultaneous, focused physical exam and history‐taking by both oncoming and off‐going providers may be most appropriate.

Figure 1

As real‐life examples, we asked our students to communicate a happy birthday wish to their mother, who lives in another state. Almost uniformly, in addition to a written aid (birthday card), they choose the telephone as a vehicle for their verbal mode in a virtual setting with 2‐way communication possible. In contrast, when asked to propose marriage to a significant other in another state, students felt that a face‐to‐face meeting with verbal and nonverbal (ie, ring) modes was appropriate. This time‐consuming mode of communication was felt to be necessary to create a sentiment of importance and avert any possible miscommunication.

The didactic session concluded by demonstrating how to use standardized written and verbal templates for handoffs of the care of a hospitalized patient. We explore the differentiation between written and verbal handoffs in our discussion below.

Program Evaluation

We developed a 2‐part survey to evaluate the effectiveness of the Selective and to solicit feedback about the didactic and practicum portions of the course. The first part of the survey (Table 2) contained 16 items to assess the students' knowledge of, and attitudes toward handing off patient care, along with their comfort with the handoff process. Responses to this section were scored using a 5‐point Likert scale with 1 indicating strongly disagree and 5 indicating strongly agree. This part of the survey was administered both prior to and after the Selective.

The second part (Table 3) contained 12 items and was designed to evaluate the perceived usefulness of the different components of the class. This section was only administered at the end of the Selective. It utilized a 4‐point Likert scale with 1 indicating that the component was not useful at all, and 4 indicating that it was extremely useful. The first 6 items of the second section allowed students to evaluate the didactic portion of the handoff. The second 6 items allowed students to evaluate the practicum. Responses to all 12 items were then combined to determine an overall composite usefulness for the Selective.

The Selective was also evaluated qualitatively through the use of open‐ended, written comments that were solicited at the end of the survey. All surveys were administered anonymously.

Results

More students chose the Selective than we had capacity to accommodate (60 of a class of 150). The pre‐ and postcourse survey response rate was 56 of 60 (93%) and 58 of 60 (97%), respectively. After the Selective, the mean score in response to whether handoffs are well taught in medical school increased from 1.6 to 3.5 (P < 0.003). Our students' self‐perceived skills and knowledge about handoffs improved after the Selective (Table 2). The greatest changes in perceived knowledge occurred in questions regarding the what, how, and when of read‐backs, and the knowledge of standard verbal and written handoff structures. The responses to the survey elements which assessed our students' attitudes regarding the importance of standardization and whether they felt handoffs were safer with faculty supervision did not change after the Selective (Table 2).

A total of 92% of the students felt that the course was extremely useful or useful. The role‐playing activity was thought to be more helpful than the didactic, but 84% of the students still rated the didactic portion as useful or extremely useful (Table 3). The element which was the least well received in the didactic portion was the use of video clips to demonstrate successful and unsuccessful (fumbled) college football handoffs, although the majority (64%) of students still found it useful.

The major theme generated from the comments section of the survey was that the Selective should be a required course.

Discussion

We know of no previously published literature that has addressed teaching handoffs to medical students. Horwitz et al.15 developed a sign‐out curriculum for Internal Medicine residents and found that none of their house‐staff had any previous training in handoffs during medical school, consistent with the finding that only 8% of U.S. medical schools provided formal instruction on handoffs.3 Prior to taking the Selective, our students had no knowledge of verbal or written templates for patient handoffs, although both before and after the course they felt that standardization was an important component of the process.

A number of verbal structures for handing off patient care have been described in the literature and there is not a consensus as to which functions best. Perhaps the most cited verbal communication format is SBAR (ie, situation, background, assessment and recommendation).16, 17 This tool was developed by Leonard et al.18 specifically for use by nurses to provide 1‐way communication to physicians pertaining to a change in patient status. We considered teaching the SBAR approach to the students but felt that it did not provide a suitable structure for handoffs because the transfer of care is not generally an event‐based situation and the literature on handoffs indicates that an optimal verbal system includes 2‐way communication.

Additional mnemonics for handoffs found in the literature include SIGNOUT (ie, Sick or DNR, Identifying information, General hospital course, New events of the day, Overall health status, Upcoming possibilities with plan, and Tasks to complete),14 I PASS the BATON (ie, Introduction, Patient, Assessment, Situation, Safety, Background, Actions, Timing, Ownership, Next)19 and the SAIF‐IR system (see boxed text).14

We developed the SAIF‐IR mnemonic to maximize efficiency and effectiveness while differentiating the verbal portion of the handoff from the written and incorporating 2‐way communication into its structure. In the Summary statement, we emphasize that this is not a history of present illness. We ask our students to summarize, in 1 to 3 sentences, the patient's presentation and working diagnosis. When discussing patient issues, we ask our students to only verbalize Active issues, although the written template has inactive, chronic issues listed. Here, we also ask our students to express their level of concern for the active issues and patient in general. If‐then's and Follow‐ups are usually verbalized together. Based on the offgoing provider's knowledge of the patient, we encourage the offgoing provider to anticipate potential problems and advise the oncoming provider on potential responses. Much of this advice is difficult to express in the written format and thus may not be found on the written handoff when the verbal handoff occurs. We encourage oncoming providers to take notes on the preprinted handoff sheet as part of the handoff process.

Through Interactive questioning and Read‐backs, we train our students and house‐staff to use the active listening techniques used outside of healthcare, in settings such as nuclear power plants and National Aeronautics and Space Administration mission control, where poor handoff communication may also result in safety concerns and adverse events.20 Interactive questioning allows the oncoming provider to correct or clarify any information given by the off‐going provider. Read‐backs are a method of confirming follow‐up activity or contingency plans. Together, the SAIF‐IR mnemonic builds a 2‐way communication structure into the patient handoff with both offgoing and oncoming providers having predefined roles.

Much of the information on our written handoff (patient identifying information, medications, language preference, code status, admission date) is not verbalized unless it is part of the active issues or the if‐then, follow‐ups (ie, medication titration for a patient admitted with an acute coronary syndrome or cor status in a patient newly made comfort care). By not reading extraneous information, we seek to emphasize the Active issues as well as the If‐then, Follow‐ups. We feel this emphasis maximizes the effectiveness of the handoff, while the purposeful nonverbalization of written materials such as identifying information maximizes its efficiency. Future work may examine which verbal and written structures for patient handoffs most benefit patient care and workflow through standard communication.

While our students found the Handoff Selective to be useful and to improve their self‐perceived ability to perform handoffs, we were not able to determine whether our program affected downstream outcomes such as adverse events relating to failures in handoff communication. Additionally, since we only taught and evaluated our Selective at the University of Colorado Denver School of Medicine, the response of our students may not generalize to other medical schools. Multicentered, prospective, randomized controlled trials may determine whether handoff education programs are successful in reducing patient adverse events related to transfers of care.

While handoffs occur frequently and are increasingly recognized as a vulnerable time in patient care, little is known about how to effectively teach handoffs to medical students during their clinical years. We developed a formal course to teach the importance of handoffs and how the process should be conducted. Our students reported that the Handoff Selective we developed improved their knowledge about the process and their perception of their ability to perform handoffs in a time‐appropriate and effective manner. In response to the feedback we received from our students, the Handoff Selective is the only course in the ICC that has been made mandatory for all students.

Communication failures are well‐recognized as causes of medical errors.1, 2 Specifically, handoffs of patient care responsibilities, which are increasingly prevalent in academic medical centers,3 have been cited as the most frequent cause of teamwork breakdown resulting in the harmful medical errors found in malpractice claims.1 The Institute of Medicine has recently identified patient handoffs as the moment where patient care errors are most likely to occur.4 A survey of 125 U.S. medical schools, however, found that only 8% specifically taught students how to hand off patient care.3

In July 2003, the American Council of Graduate Medical Education (ACGME) mandated that residency programs decrease resident work hours to improve patient care and safety by reducing fatigue,5 and a recent Institute of Medicine report suggests that they be decreased even further.4 Studies examining outcomes during the first 2 years after reducing duty hours did not find reductions in risk‐adjusted mortality.68 One proposed explanation for this lack of improvement is that the reduction in fatigue‐related medical errors is being offset by discontinuity of care with due to the increased number of patient handoffs resulting from shortened duty hours,911 one recent study found that omission of key information during patient sign outs frequently resulted in adverse patient care outcomes.12

In 2007, the Joint Commission developed a new National Patient Safety Goal that requires organizations to improve communication between caregivers.13 We recently developed an approach by which Internal Medicine residents hand off patient care using a structured process, written and verbal templates, formal training about handoffs, and direct attending supervision.14 Because fourth‐year medical students perform the duties of interns when working as subinterns, we recognized that education about handoffs should occur prior to the time students became interns. Accordingly, we developed a course designed to teach patient handoffs to medical students at the transition between their third and fourth years of training.

Setting

The Handoff Selective was developed by faculty of Denver Health and the University of Colorado Denver School of Medicine.

Program Description

The Selective was first offered in April 2007 as part of an Integrated Clinician's Course (ICC), a 2‐week course for students beginning their fourth year, which starts in April at the University of Colorado. The ICC includes both mandatory and selective sessions that are focused on developing clinical skills and preparing them for their subinternships. The Handoff Selective was conducted in a computerized teaching laboratory, lasted a total of 2 hours and consisted of 2 parts. Each of the 5 Denver Health Hospital Medicine faculty members versed in handoff education taught 2 sessions of 6 to 8 students.

Part 1: Didactic

During the first hour of class, the faculty presented a lecture that summarized the relevant literature on handoffs and explained the importance of the topic. The objectives of the didactic were to: (1) understand the importance of handoffs; (2) explore different communication elements and structures; (3) gain exposure to handoffs outside of healthcare; and (4) learn a structure for handoffs of patient care in hospitalized patients.

We used 3 video clips of handoffs from 2 football games to demonstrate the importance of practice, training, and 2‐way communications in handoffs. The first video clip showed a runner trying to make a spontaneous handoff while being tackled. The receiver was not expecting the handoff and was preoccupied with blocking another player. This attempted handoff resulted in a fumble, which we related to an adverse patient event.

The next 2 video clips showed 2 complex, seldom used, but well‐known football handoffsthe hook and lateral and the Statue of Liberty. Both handoffs were successfully executed presumably as a result of education, practice and the active participation of both players (handing off and receiving) in the process. We then related the teaching and practicing of complex communication to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO; now simply the Joint Commission) data suggesting that most sentinel events have their root cause in communication and training failures.2

Basic communication elements and process structures were then explored using scenarios from everyday life and evidence from fields outside of medicine. We emphasized that structures for communication (modes, vehicles, and settings) must be chosen according to the occasion and that handoffs are common and important in all occupations. In discussing modes (verbal, written, or nonverbal), vehicles (paper, telephone, or e‐mail), and settings (face‐to face, virtual, or disconnected), we emphasized that the most effective structures for communication (verbal, face‐to face meetings, with written materials and other visual aids at the patient's bedside) were also the most time‐consuming (Figure 1). While our standard for resident handoffs is a face‐to‐face verbal interaction with preprinted written materials as an aid, we also emphasized that for complex patients (eg, mental status changes, concern for an acute abdomen) more robust communication is often needed. Accordingly, a more time‐consuming bedside handoff with simultaneous, focused physical exam and history‐taking by both oncoming and off‐going providers may be most appropriate.

Figure 1

As real‐life examples, we asked our students to communicate a happy birthday wish to their mother, who lives in another state. Almost uniformly, in addition to a written aid (birthday card), they choose the telephone as a vehicle for their verbal mode in a virtual setting with 2‐way communication possible. In contrast, when asked to propose marriage to a significant other in another state, students felt that a face‐to‐face meeting with verbal and nonverbal (ie, ring) modes was appropriate. This time‐consuming mode of communication was felt to be necessary to create a sentiment of importance and avert any possible miscommunication.

The didactic session concluded by demonstrating how to use standardized written and verbal templates for handoffs of the care of a hospitalized patient. We explore the differentiation between written and verbal handoffs in our discussion below.

Program Evaluation

We developed a 2‐part survey to evaluate the effectiveness of the Selective and to solicit feedback about the didactic and practicum portions of the course. The first part of the survey (Table 2) contained 16 items to assess the students' knowledge of, and attitudes toward handing off patient care, along with their comfort with the handoff process. Responses to this section were scored using a 5‐point Likert scale with 1 indicating strongly disagree and 5 indicating strongly agree. This part of the survey was administered both prior to and after the Selective.

The second part (Table 3) contained 12 items and was designed to evaluate the perceived usefulness of the different components of the class. This section was only administered at the end of the Selective. It utilized a 4‐point Likert scale with 1 indicating that the component was not useful at all, and 4 indicating that it was extremely useful. The first 6 items of the second section allowed students to evaluate the didactic portion of the handoff. The second 6 items allowed students to evaluate the practicum. Responses to all 12 items were then combined to determine an overall composite usefulness for the Selective.

The Selective was also evaluated qualitatively through the use of open‐ended, written comments that were solicited at the end of the survey. All surveys were administered anonymously.

Results

More students chose the Selective than we had capacity to accommodate (60 of a class of 150). The pre‐ and postcourse survey response rate was 56 of 60 (93%) and 58 of 60 (97%), respectively. After the Selective, the mean score in response to whether handoffs are well taught in medical school increased from 1.6 to 3.5 (P < 0.003). Our students' self‐perceived skills and knowledge about handoffs improved after the Selective (Table 2). The greatest changes in perceived knowledge occurred in questions regarding the what, how, and when of read‐backs, and the knowledge of standard verbal and written handoff structures. The responses to the survey elements which assessed our students' attitudes regarding the importance of standardization and whether they felt handoffs were safer with faculty supervision did not change after the Selective (Table 2).

A total of 92% of the students felt that the course was extremely useful or useful. The role‐playing activity was thought to be more helpful than the didactic, but 84% of the students still rated the didactic portion as useful or extremely useful (Table 3). The element which was the least well received in the didactic portion was the use of video clips to demonstrate successful and unsuccessful (fumbled) college football handoffs, although the majority (64%) of students still found it useful.

The major theme generated from the comments section of the survey was that the Selective should be a required course.

Discussion

We know of no previously published literature that has addressed teaching handoffs to medical students. Horwitz et al.15 developed a sign‐out curriculum for Internal Medicine residents and found that none of their house‐staff had any previous training in handoffs during medical school, consistent with the finding that only 8% of U.S. medical schools provided formal instruction on handoffs.3 Prior to taking the Selective, our students had no knowledge of verbal or written templates for patient handoffs, although both before and after the course they felt that standardization was an important component of the process.

A number of verbal structures for handing off patient care have been described in the literature and there is not a consensus as to which functions best. Perhaps the most cited verbal communication format is SBAR (ie, situation, background, assessment and recommendation).16, 17 This tool was developed by Leonard et al.18 specifically for use by nurses to provide 1‐way communication to physicians pertaining to a change in patient status. We considered teaching the SBAR approach to the students but felt that it did not provide a suitable structure for handoffs because the transfer of care is not generally an event‐based situation and the literature on handoffs indicates that an optimal verbal system includes 2‐way communication.

Additional mnemonics for handoffs found in the literature include SIGNOUT (ie, Sick or DNR, Identifying information, General hospital course, New events of the day, Overall health status, Upcoming possibilities with plan, and Tasks to complete),14 I PASS the BATON (ie, Introduction, Patient, Assessment, Situation, Safety, Background, Actions, Timing, Ownership, Next)19 and the SAIF‐IR system (see boxed text).14

We developed the SAIF‐IR mnemonic to maximize efficiency and effectiveness while differentiating the verbal portion of the handoff from the written and incorporating 2‐way communication into its structure. In the Summary statement, we emphasize that this is not a history of present illness. We ask our students to summarize, in 1 to 3 sentences, the patient's presentation and working diagnosis. When discussing patient issues, we ask our students to only verbalize Active issues, although the written template has inactive, chronic issues listed. Here, we also ask our students to express their level of concern for the active issues and patient in general. If‐then's and Follow‐ups are usually verbalized together. Based on the offgoing provider's knowledge of the patient, we encourage the offgoing provider to anticipate potential problems and advise the oncoming provider on potential responses. Much of this advice is difficult to express in the written format and thus may not be found on the written handoff when the verbal handoff occurs. We encourage oncoming providers to take notes on the preprinted handoff sheet as part of the handoff process.

Through Interactive questioning and Read‐backs, we train our students and house‐staff to use the active listening techniques used outside of healthcare, in settings such as nuclear power plants and National Aeronautics and Space Administration mission control, where poor handoff communication may also result in safety concerns and adverse events.20 Interactive questioning allows the oncoming provider to correct or clarify any information given by the off‐going provider. Read‐backs are a method of confirming follow‐up activity or contingency plans. Together, the SAIF‐IR mnemonic builds a 2‐way communication structure into the patient handoff with both offgoing and oncoming providers having predefined roles.

Much of the information on our written handoff (patient identifying information, medications, language preference, code status, admission date) is not verbalized unless it is part of the active issues or the if‐then, follow‐ups (ie, medication titration for a patient admitted with an acute coronary syndrome or cor status in a patient newly made comfort care). By not reading extraneous information, we seek to emphasize the Active issues as well as the If‐then, Follow‐ups. We feel this emphasis maximizes the effectiveness of the handoff, while the purposeful nonverbalization of written materials such as identifying information maximizes its efficiency. Future work may examine which verbal and written structures for patient handoffs most benefit patient care and workflow through standard communication.

While our students found the Handoff Selective to be useful and to improve their self‐perceived ability to perform handoffs, we were not able to determine whether our program affected downstream outcomes such as adverse events relating to failures in handoff communication. Additionally, since we only taught and evaluated our Selective at the University of Colorado Denver School of Medicine, the response of our students may not generalize to other medical schools. Multicentered, prospective, randomized controlled trials may determine whether handoff education programs are successful in reducing patient adverse events related to transfers of care.

While handoffs occur frequently and are increasingly recognized as a vulnerable time in patient care, little is known about how to effectively teach handoffs to medical students during their clinical years. We developed a formal course to teach the importance of handoffs and how the process should be conducted. Our students reported that the Handoff Selective we developed improved their knowledge about the process and their perception of their ability to perform handoffs in a time‐appropriate and effective manner. In response to the feedback we received from our students, the Handoff Selective is the only course in the ICC that has been made mandatory for all students.