Tracy Cardin, ACNP-BC

I attended the HM13 breakout session “Success Stories: How to Integrate NPs and PAs into a Hospitalist Practice,” which featured Timothy Capstack, MD, a hospitalist at Maryland Inpatient Care Specialists, James Levy, a physician assistant/hospitalist at Hospitalists of Northern Michigan, Kaine Brown, MD, a hospitalist at Tift Regional Medical Center, and Justin Psaila, MD, a hospitalist at St. Luke’s University Hospital and Health Network. Judging from the attendance, this is a very relevant topic. It seems every group is looking to hire NP/PAs, and most want to learn how to successfully incorporate them into a hospitalist practice.

Dr. Psaila explained the first key to success is hiring “beyond the basics,” meaning that it is not enough to be a good clinician, you must also hire a good fit to your practice culture. Additionally, NPs/PAs need to be part of a team they can rely on. He said critical-thinking skills are a much better asset for an NP/PA than technical procedural skills.

Levy agreed, and noted successful integration starts with getting the “right people on the bus.” HM groups should develop a thoughtful, consistent hiring process—and be willing to cut loose a provider if they are not a good fit. He also thinks it is important to have a lead NP/PA, so new hires know where to turn.

Dr. Brown found successful integration when his group turned to NP/PAs to run the post-discharge transition clinic. His group’s NP/PAs are helping reduce readmissions, improve patient/provider communication, and supporting the social and emotional needs of patients.

Watch a 2-minute video clip of Bob Wachter's HM13 keynote address

Dr. Capstack agreed that HM groups have to “hire right.” Hospitalist NP/PAs need to communicate well and be a team player, but also “know what they don’t know.” If the skill set is right, and you create a culture of collaboration, he said success is guaranteed.

All of the presenters agreed NP/PAs in hospital medicine are here to stay, and that they can be an asset to any HM group. TH

Tracy Cardin is a nurse practitioner in the Section of Hospital Medicine at the University of Chicago.

I attended the HM13 breakout session “Success Stories: How to Integrate NPs and PAs into a Hospitalist Practice,” which featured Timothy Capstack, MD, a hospitalist at Maryland Inpatient Care Specialists, James Levy, a physician assistant/hospitalist at Hospitalists of Northern Michigan, Kaine Brown, MD, a hospitalist at Tift Regional Medical Center, and Justin Psaila, MD, a hospitalist at St. Luke’s University Hospital and Health Network. Judging from the attendance, this is a very relevant topic. It seems every group is looking to hire NP/PAs, and most want to learn how to successfully incorporate them into a hospitalist practice.

Dr. Psaila explained the first key to success is hiring “beyond the basics,” meaning that it is not enough to be a good clinician, you must also hire a good fit to your practice culture. Additionally, NPs/PAs need to be part of a team they can rely on. He said critical-thinking skills are a much better asset for an NP/PA than technical procedural skills.

Levy agreed, and noted successful integration starts with getting the “right people on the bus.” HM groups should develop a thoughtful, consistent hiring process—and be willing to cut loose a provider if they are not a good fit. He also thinks it is important to have a lead NP/PA, so new hires know where to turn.

Dr. Brown found successful integration when his group turned to NP/PAs to run the post-discharge transition clinic. His group’s NP/PAs are helping reduce readmissions, improve patient/provider communication, and supporting the social and emotional needs of patients.

Watch a 2-minute video clip of Bob Wachter's HM13 keynote address

Dr. Capstack agreed that HM groups have to “hire right.” Hospitalist NP/PAs need to communicate well and be a team player, but also “know what they don’t know.” If the skill set is right, and you create a culture of collaboration, he said success is guaranteed.

All of the presenters agreed NP/PAs in hospital medicine are here to stay, and that they can be an asset to any HM group. TH

Tracy Cardin is a nurse practitioner in the Section of Hospital Medicine at the University of Chicago.

I attended the HM13 breakout session “Success Stories: How to Integrate NPs and PAs into a Hospitalist Practice,” which featured Timothy Capstack, MD, a hospitalist at Maryland Inpatient Care Specialists, James Levy, a physician assistant/hospitalist at Hospitalists of Northern Michigan, Kaine Brown, MD, a hospitalist at Tift Regional Medical Center, and Justin Psaila, MD, a hospitalist at St. Luke’s University Hospital and Health Network. Judging from the attendance, this is a very relevant topic. It seems every group is looking to hire NP/PAs, and most want to learn how to successfully incorporate them into a hospitalist practice.

Dr. Psaila explained the first key to success is hiring “beyond the basics,” meaning that it is not enough to be a good clinician, you must also hire a good fit to your practice culture. Additionally, NPs/PAs need to be part of a team they can rely on. He said critical-thinking skills are a much better asset for an NP/PA than technical procedural skills.

Levy agreed, and noted successful integration starts with getting the “right people on the bus.” HM groups should develop a thoughtful, consistent hiring process—and be willing to cut loose a provider if they are not a good fit. He also thinks it is important to have a lead NP/PA, so new hires know where to turn.

Dr. Brown found successful integration when his group turned to NP/PAs to run the post-discharge transition clinic. His group’s NP/PAs are helping reduce readmissions, improve patient/provider communication, and supporting the social and emotional needs of patients.

Watch a 2-minute video clip of Bob Wachter's HM13 keynote address

Dr. Capstack agreed that HM groups have to “hire right.” Hospitalist NP/PAs need to communicate well and be a team player, but also “know what they don’t know.” If the skill set is right, and you create a culture of collaboration, he said success is guaranteed.

All of the presenters agreed NP/PAs in hospital medicine are here to stay, and that they can be an asset to any HM group. TH

Tracy Cardin is a nurse practitioner in the Section of Hospital Medicine at the University of Chicago.

Scott Flanders, MD, SFHM, director of the hospitalist program at the University of Michigan in Ann Arbor set out to answer three key questions in “rapid-fire” format during the “Pneumonia Update” at HM13.

1. Is procalcitonin ready for “prime time” in determining community-acquired pneumonia (CAP) treatment duration?
2. What is the utility of diagnostic testing in CAP patients?
3. How do you decide which pneumonia patients need broad-spectrum antibiotic coverage?

It turns out that lots of other countries follow procalcitonin levels as a marker of inflammation during CAP treatment. A 2012 Archives of Internal Medicine article notes that U.S. compliance with measuring procalcitonin levels is less than 40%, and monitoring these levels can help diagnosis and guide treatment and the duration of treatment. Procalcitonin is released in the blood in response to bacterial infection. It rises within four hours of infection (earlier than other markers such as CRP and ESR.) The degree and rate of rise is associated with severity; the rate of decline is associated with resolution. Numerous studies show that when providers correlate CAP treatment with procalcitonin levels there is a safe reduction in antibiotic days.

Dr. Flanders also examined the utility of diagnostic tests. In general, CAP outcomes are unchanged and management rarely is impacted by sputum collection. Within the ICU setting it is recommended to get sputum cultures, as it may have a role in healthcare-associated pneumonia, especially if a patient has a history of drug-resistant organisms.

With regard to blood culture analysis, only 4% to 7% of blood cultures are positive in CAP, with many of them being false positives. False positive cultures lead to a 50% increase in charges, and increase length of stay by 65%. A 2004 American Journal of Respiratory and Critical Care Medicine article recommends targeted blood culture screen that correctly detect 90% of bacteremia with 40% fewer cultures. It recommends that patients who are at risk for bacteremia (those with prior antibiotics, WBC count greater than 20, systolic BP less than 90, history of liver disease, temperature greater than 40 degrees or less than 35 degrees celsius, elevated BUN greater than 30, sodium less than 130, pulse greater than 125) be given a point for each risk factor. Those with no risk and no prior antibiotics were deemed safe to forgo cultures. Those with one risk factor, with prior antibiotics were recommended to get one set of cultures. Those with more than one risk factor were recommended to receive two sets of cultures.

Pneumococcal urinary antigen was evaluated. It is noted to have great specificity, but lousy sensitivity. Patients with bacteremia might have false negative results. In general, the antigen might be appropriate in non-severe cases if it will help you narrow therapy. But it shouldn’t be ordered if it is not going to change therapy.

Dr. Flanders also noted that urinary legionella antigen is 80% sensitive for legionella.

Answering the question about the need for broad-spectrum antibiotics, it was thought that any patient receiving home care or home wound care, goes to a dialysis center, lives in a NH or LTC facility would need broad-spectrum antibiotics for HCAP. But Dr. Flanders states it may be a case of doing too much too fast. He recommends patients that reside in nursing homes or who receive home care be treated as a CAP, as the risk of drug-resistant organisms isn’t actually that high in that group. But if a patient had previous admission to the hospital, he recommends treatment for HCAP.

Strong risk factors for resistant organisms include prior hospitalization in past 90 days, LTAC/SNF patients if they have had prior antibiotics and have poor functional status, critically-ill patients, or those with prior MRSA/pseudomonal infections. The data for nursing home patients, home health or home wound care or dialysis patients is less clear. TH

Tracy Cardin is a nurse practitioner in the section of hospital medicine at University of Chicago.

Scott Flanders, MD, SFHM, director of the hospitalist program at the University of Michigan in Ann Arbor set out to answer three key questions in “rapid-fire” format during the “Pneumonia Update” at HM13.

1. Is procalcitonin ready for “prime time” in determining community-acquired pneumonia (CAP) treatment duration?
2. What is the utility of diagnostic testing in CAP patients?
3. How do you decide which pneumonia patients need broad-spectrum antibiotic coverage?

It turns out that lots of other countries follow procalcitonin levels as a marker of inflammation during CAP treatment. A 2012 Archives of Internal Medicine article notes that U.S. compliance with measuring procalcitonin levels is less than 40%, and monitoring these levels can help diagnosis and guide treatment and the duration of treatment. Procalcitonin is released in the blood in response to bacterial infection. It rises within four hours of infection (earlier than other markers such as CRP and ESR.) The degree and rate of rise is associated with severity; the rate of decline is associated with resolution. Numerous studies show that when providers correlate CAP treatment with procalcitonin levels there is a safe reduction in antibiotic days.

Dr. Flanders also examined the utility of diagnostic tests. In general, CAP outcomes are unchanged and management rarely is impacted by sputum collection. Within the ICU setting it is recommended to get sputum cultures, as it may have a role in healthcare-associated pneumonia, especially if a patient has a history of drug-resistant organisms.

With regard to blood culture analysis, only 4% to 7% of blood cultures are positive in CAP, with many of them being false positives. False positive cultures lead to a 50% increase in charges, and increase length of stay by 65%. A 2004 American Journal of Respiratory and Critical Care Medicine article recommends targeted blood culture screen that correctly detect 90% of bacteremia with 40% fewer cultures. It recommends that patients who are at risk for bacteremia (those with prior antibiotics, WBC count greater than 20, systolic BP less than 90, history of liver disease, temperature greater than 40 degrees or less than 35 degrees celsius, elevated BUN greater than 30, sodium less than 130, pulse greater than 125) be given a point for each risk factor. Those with no risk and no prior antibiotics were deemed safe to forgo cultures. Those with one risk factor, with prior antibiotics were recommended to get one set of cultures. Those with more than one risk factor were recommended to receive two sets of cultures.

Pneumococcal urinary antigen was evaluated. It is noted to have great specificity, but lousy sensitivity. Patients with bacteremia might have false negative results. In general, the antigen might be appropriate in non-severe cases if it will help you narrow therapy. But it shouldn’t be ordered if it is not going to change therapy.

Dr. Flanders also noted that urinary legionella antigen is 80% sensitive for legionella.

Answering the question about the need for broad-spectrum antibiotics, it was thought that any patient receiving home care or home wound care, goes to a dialysis center, lives in a NH or LTC facility would need broad-spectrum antibiotics for HCAP. But Dr. Flanders states it may be a case of doing too much too fast. He recommends patients that reside in nursing homes or who receive home care be treated as a CAP, as the risk of drug-resistant organisms isn’t actually that high in that group. But if a patient had previous admission to the hospital, he recommends treatment for HCAP.

Strong risk factors for resistant organisms include prior hospitalization in past 90 days, LTAC/SNF patients if they have had prior antibiotics and have poor functional status, critically-ill patients, or those with prior MRSA/pseudomonal infections. The data for nursing home patients, home health or home wound care or dialysis patients is less clear. TH

Tracy Cardin is a nurse practitioner in the section of hospital medicine at University of Chicago.

Scott Flanders, MD, SFHM, director of the hospitalist program at the University of Michigan in Ann Arbor set out to answer three key questions in “rapid-fire” format during the “Pneumonia Update” at HM13.

1. Is procalcitonin ready for “prime time” in determining community-acquired pneumonia (CAP) treatment duration?
2. What is the utility of diagnostic testing in CAP patients?
3. How do you decide which pneumonia patients need broad-spectrum antibiotic coverage?

It turns out that lots of other countries follow procalcitonin levels as a marker of inflammation during CAP treatment. A 2012 Archives of Internal Medicine article notes that U.S. compliance with measuring procalcitonin levels is less than 40%, and monitoring these levels can help diagnosis and guide treatment and the duration of treatment. Procalcitonin is released in the blood in response to bacterial infection. It rises within four hours of infection (earlier than other markers such as CRP and ESR.) The degree and rate of rise is associated with severity; the rate of decline is associated with resolution. Numerous studies show that when providers correlate CAP treatment with procalcitonin levels there is a safe reduction in antibiotic days.

Dr. Flanders also examined the utility of diagnostic tests. In general, CAP outcomes are unchanged and management rarely is impacted by sputum collection. Within the ICU setting it is recommended to get sputum cultures, as it may have a role in healthcare-associated pneumonia, especially if a patient has a history of drug-resistant organisms.

With regard to blood culture analysis, only 4% to 7% of blood cultures are positive in CAP, with many of them being false positives. False positive cultures lead to a 50% increase in charges, and increase length of stay by 65%. A 2004 American Journal of Respiratory and Critical Care Medicine article recommends targeted blood culture screen that correctly detect 90% of bacteremia with 40% fewer cultures. It recommends that patients who are at risk for bacteremia (those with prior antibiotics, WBC count greater than 20, systolic BP less than 90, history of liver disease, temperature greater than 40 degrees or less than 35 degrees celsius, elevated BUN greater than 30, sodium less than 130, pulse greater than 125) be given a point for each risk factor. Those with no risk and no prior antibiotics were deemed safe to forgo cultures. Those with one risk factor, with prior antibiotics were recommended to get one set of cultures. Those with more than one risk factor were recommended to receive two sets of cultures.

Pneumococcal urinary antigen was evaluated. It is noted to have great specificity, but lousy sensitivity. Patients with bacteremia might have false negative results. In general, the antigen might be appropriate in non-severe cases if it will help you narrow therapy. But it shouldn’t be ordered if it is not going to change therapy.

Dr. Flanders also noted that urinary legionella antigen is 80% sensitive for legionella.

Answering the question about the need for broad-spectrum antibiotics, it was thought that any patient receiving home care or home wound care, goes to a dialysis center, lives in a NH or LTC facility would need broad-spectrum antibiotics for HCAP. But Dr. Flanders states it may be a case of doing too much too fast. He recommends patients that reside in nursing homes or who receive home care be treated as a CAP, as the risk of drug-resistant organisms isn’t actually that high in that group. But if a patient had previous admission to the hospital, he recommends treatment for HCAP.

Strong risk factors for resistant organisms include prior hospitalization in past 90 days, LTAC/SNF patients if they have had prior antibiotics and have poor functional status, critically-ill patients, or those with prior MRSA/pseudomonal infections. The data for nursing home patients, home health or home wound care or dialysis patients is less clear. TH

Tracy Cardin is a nurse practitioner in the section of hospital medicine at University of Chicago.

I attended the practice-management session with an intriguing title, “Hospitalist Workload: Is 15 the Right Number?” My own group, as I am sure many are, is struggling with this very question.

Henry Michtalik, assistant professor and hospitalist from Johns Hopkins and associate faculty at the Armstrong Institute for Patient Safety and Quality talked about physician perceptions of workload and the impact of that perception on patient safety. He noted that 40% of physicans report that their typical census exceeds “safe” levels at least monthly. Multiple factors impact that perception, including the physicians’ years of experience and the presence of housestaff, as well as the total amount of clinical time yearly. Other factors that can influence this perception include the type of hospital, the ancillary team make-up, and the patient’s payer mix and acuity. Twenty percent of physicians reported that workload negatively impacted the hospitalist’s ability to discuss the plan of care or delayed discharge.

The JAMA Internal Medicine article from April 2013 that he wrote also noted, most interestingly, that fixed census caps decreased the odds of reporting an unsafe census by 34%. Bring ’em on!

Daniel Elliott presented data from his role as acting associate chair for research and co-director of ambulatory research and Clinical Outcomes at Chistiana Care Department of Medicine in Wilmington, Del. He undertook a study designed to answer the question: What is the impact of increased workload on clinical outcomes? He looked at key variables of length of stay, continuity, 24-hour average occupancy, and turn-around time (i.e., time between ordering a test until the time completed on five most commonly ordered tests by hospitalists).

What he learned is that a higher physician workload is associated with increasing LOS, but notably this association decreases as hospital occupancy increases, meaning that a less-busy hospital means that LOS is a hospitalist dependent variable and MORE sensitive to workload. Conversely, a more busy hospital’s LOS is hospital dependent and LESS sensitive to physician workload. This reveals the importance in collaboration between hospitals and hospitalists, as they both contribute to outcomes that impact LOS.

Jill Menzel program manager for the hospitalist program business unit for Thedacare, said her group utilizes a balanced approach to evaluate workload, looking at safety/quality by evaluating 30-day readmission rates, financial stewardship by evaluating productivity (which she defines as units of service divided by the number of hours worked), and by evaluating people’s perception of the manageability of their workload, all surrounding the central tenet of the customer. They don’t look at a RVU metric, but instead focus on tracking the average amount of time to do work by provider. This tracking method allows them to accurately see where more help was needed and get it there.

And finally John Nelson, a hospitalist in suburban Seattle and practice management consultant summed up the session with the information that there is no clear correlation between a specific workload and burnout or stress, but there definitely IS a correlation between perceived workload and burnout. The take-home message? If you feel as if you are working too hard, then you are. A specific number is not clear.

Basically, there is no right number. But there is some data noting that higher workload leads to increased LOS, and that if you feel like you are working at an unsafe level your patients may be at risk of a longer hospitalization with less communication and more unnecessary tests, and you may personally be at risk for burnout. TH

Tracy Cardin is a nurse practitioner in the section of hospital medicine at the University of Chicago Hospital.

I attended the practice-management session with an intriguing title, “Hospitalist Workload: Is 15 the Right Number?” My own group, as I am sure many are, is struggling with this very question.

Henry Michtalik, assistant professor and hospitalist from Johns Hopkins and associate faculty at the Armstrong Institute for Patient Safety and Quality talked about physician perceptions of workload and the impact of that perception on patient safety. He noted that 40% of physicans report that their typical census exceeds “safe” levels at least monthly. Multiple factors impact that perception, including the physicians’ years of experience and the presence of housestaff, as well as the total amount of clinical time yearly. Other factors that can influence this perception include the type of hospital, the ancillary team make-up, and the patient’s payer mix and acuity. Twenty percent of physicians reported that workload negatively impacted the hospitalist’s ability to discuss the plan of care or delayed discharge.

The JAMA Internal Medicine article from April 2013 that he wrote also noted, most interestingly, that fixed census caps decreased the odds of reporting an unsafe census by 34%. Bring ’em on!

Daniel Elliott presented data from his role as acting associate chair for research and co-director of ambulatory research and Clinical Outcomes at Chistiana Care Department of Medicine in Wilmington, Del. He undertook a study designed to answer the question: What is the impact of increased workload on clinical outcomes? He looked at key variables of length of stay, continuity, 24-hour average occupancy, and turn-around time (i.e., time between ordering a test until the time completed on five most commonly ordered tests by hospitalists).

What he learned is that a higher physician workload is associated with increasing LOS, but notably this association decreases as hospital occupancy increases, meaning that a less-busy hospital means that LOS is a hospitalist dependent variable and MORE sensitive to workload. Conversely, a more busy hospital’s LOS is hospital dependent and LESS sensitive to physician workload. This reveals the importance in collaboration between hospitals and hospitalists, as they both contribute to outcomes that impact LOS.

Jill Menzel program manager for the hospitalist program business unit for Thedacare, said her group utilizes a balanced approach to evaluate workload, looking at safety/quality by evaluating 30-day readmission rates, financial stewardship by evaluating productivity (which she defines as units of service divided by the number of hours worked), and by evaluating people’s perception of the manageability of their workload, all surrounding the central tenet of the customer. They don’t look at a RVU metric, but instead focus on tracking the average amount of time to do work by provider. This tracking method allows them to accurately see where more help was needed and get it there.

And finally John Nelson, a hospitalist in suburban Seattle and practice management consultant summed up the session with the information that there is no clear correlation between a specific workload and burnout or stress, but there definitely IS a correlation between perceived workload and burnout. The take-home message? If you feel as if you are working too hard, then you are. A specific number is not clear.

Basically, there is no right number. But there is some data noting that higher workload leads to increased LOS, and that if you feel like you are working at an unsafe level your patients may be at risk of a longer hospitalization with less communication and more unnecessary tests, and you may personally be at risk for burnout. TH

Tracy Cardin is a nurse practitioner in the section of hospital medicine at the University of Chicago Hospital.

I attended the practice-management session with an intriguing title, “Hospitalist Workload: Is 15 the Right Number?” My own group, as I am sure many are, is struggling with this very question.

Henry Michtalik, assistant professor and hospitalist from Johns Hopkins and associate faculty at the Armstrong Institute for Patient Safety and Quality talked about physician perceptions of workload and the impact of that perception on patient safety. He noted that 40% of physicans report that their typical census exceeds “safe” levels at least monthly. Multiple factors impact that perception, including the physicians’ years of experience and the presence of housestaff, as well as the total amount of clinical time yearly. Other factors that can influence this perception include the type of hospital, the ancillary team make-up, and the patient’s payer mix and acuity. Twenty percent of physicians reported that workload negatively impacted the hospitalist’s ability to discuss the plan of care or delayed discharge.

The JAMA Internal Medicine article from April 2013 that he wrote also noted, most interestingly, that fixed census caps decreased the odds of reporting an unsafe census by 34%. Bring ’em on!

Daniel Elliott presented data from his role as acting associate chair for research and co-director of ambulatory research and Clinical Outcomes at Chistiana Care Department of Medicine in Wilmington, Del. He undertook a study designed to answer the question: What is the impact of increased workload on clinical outcomes? He looked at key variables of length of stay, continuity, 24-hour average occupancy, and turn-around time (i.e., time between ordering a test until the time completed on five most commonly ordered tests by hospitalists).

What he learned is that a higher physician workload is associated with increasing LOS, but notably this association decreases as hospital occupancy increases, meaning that a less-busy hospital means that LOS is a hospitalist dependent variable and MORE sensitive to workload. Conversely, a more busy hospital’s LOS is hospital dependent and LESS sensitive to physician workload. This reveals the importance in collaboration between hospitals and hospitalists, as they both contribute to outcomes that impact LOS.

Jill Menzel program manager for the hospitalist program business unit for Thedacare, said her group utilizes a balanced approach to evaluate workload, looking at safety/quality by evaluating 30-day readmission rates, financial stewardship by evaluating productivity (which she defines as units of service divided by the number of hours worked), and by evaluating people’s perception of the manageability of their workload, all surrounding the central tenet of the customer. They don’t look at a RVU metric, but instead focus on tracking the average amount of time to do work by provider. This tracking method allows them to accurately see where more help was needed and get it there.

And finally John Nelson, a hospitalist in suburban Seattle and practice management consultant summed up the session with the information that there is no clear correlation between a specific workload and burnout or stress, but there definitely IS a correlation between perceived workload and burnout. The take-home message? If you feel as if you are working too hard, then you are. A specific number is not clear.

Basically, there is no right number. But there is some data noting that higher workload leads to increased LOS, and that if you feel like you are working at an unsafe level your patients may be at risk of a longer hospitalization with less communication and more unnecessary tests, and you may personally be at risk for burnout. TH

Tracy Cardin is a nurse practitioner in the section of hospital medicine at the University of Chicago Hospital.