The current state of our profession is that the US population is aging rapidly, requiring ever more healthcare, and there is a stagnant number of physicians to care for them. The question of who will care for our aging population has been raised over and over in the past decade but the question is worth repeating. As our country continues to deliver state‐of‐the‐art medical care, it is slow to embrace the notion that in order for it to continue, it will need to incorporate the professions of advanced practice nurses and physician assistants. Without these nonphysician providers our medical community will not be able to reach the patients we have sworn to treat.

The percent of the US population age >65 years is projected to increase from 12.4% in 2000 to 19.6% in 2030. The number of persons age >65 years is expected to increase from approximately 35 million in 2000 to an estimated 71 million in 2030, and the number of persons age >80 years is expected to increase from 9.3 million in 2000 to 19.5 million in 2030.1 Our aging America is also coupled with a growing physician shortage. In its report entitled Physician Workforce Policy Guidelines for the United States, 2000‐2020, the Council on Graduate Medical Education recommended increasing the number of medical school graduates by 3000 per year by the year 2015 to meet the increasing need.2 Given the current trend of decreasing physician reimbursement coupled with the average medical school debt of $139,517,3 it is doubtful that the extra 3000 physicians needed to graduate in 2015 will actually ever do so. Despite this possible additional physician workforce, there still stands to be enormous need for the nonphysician provider with our rapidly expanding senior population.

Our nation's hospitals are by no means spared from our aging population or physician shortage. In fact, they are likely to be the hardest hit. Hospitalists are already feeling the pressure of an overstressed workforce coupled with increasing patient volume.4 There is a growing body of evidence supporting the successful collaboration between hospitalists and nurse practitioners (NPs)/physician assistants (PAs) (collectively, nonphysician providers [NPPs]). No longer are NPPs only working in outpatient practices or in the operating room, but they are actively involved with inpatient medical units improving our Hospital Medicine (HM) specialty. According to Myers et al.,5 the hospitalist NP model improved program finances and increased physician and resident satisfaction. In order for Hospital Medicine to create increasing value for its parent hospital or to the community it serves, NPPs will need increased integration into our care model for improved overall efficiency. We focus herein on the advantages and potential benefits of NPPs relating to their varied roles within HM.

Scope of Practice

The scope of practice of NPPs is regulated by each individual state board of registration. However, differences from state to state are usually minor and general statements on the practice scope of PAs and NPs can be made.

Potential Benefits of NPPs

Models of Care

There are many models for NPP roles in hospital medicine groups. Some groups use NPPs in the same role as physicians. They perform admissions, rounding, and discharges with varying degrees of oversight by physicians. Other groups use NPPs for a more limited role, such as exclusively performing histories and physicals in the emergency department or handling discharges on the wards. It is important to take into account the preferences and expectations of NPPs when designing job descriptions. While some NPPs may like the fast pace and quick turnover of admissions and discharges, others may prefer to follow patients throughout their hospital stay. The quality of handoffs is crucial if the former model is used, just as it is with physicians in this more truncated role. An NPP who works in a nonacademic model will likely have more autonomy and control over patient care decisions. An NPP role in the teaching service of an academic hospital is likely to be more collaborative and focus more on quality initiatives, patient teaching, and communication. It is crucial to design an NPP model that is sustainable with very strong support of management once the NPP is hired and orientated.

Registered Nurses And Hospital Medicine

Patient handoffs and communication are one of the most challenging aspects of an HMG. There is an increasing movement, throughout the country, to incorporate registered nurses (RNs) into daily workflow. The RN on the HM team can serve to augment the communication and workflow process. A highly motivated and organized registered nurse can help to improve overall provider's workflow efficiency. Communication to primary care physician and collecting ancillary medical information can allow the provider to treat more patients in a given shift and decrease the liability risk from lack of information. As HM organizations and hospitals become more financially bound, HMGs will need to become more efficient at time management and a dedicated RN can help smooth that process.

Potential Unintended Side Effects

Obviously, integration of NPPs can be a disaster for an HMG if not handled properly. Most hospitalists have heard of an integration of NPP into a group that was an unqualified failure. NPPs can feel unsupported, poorly oriented to the job, or thrown into a situation that is over their heads. Before an NPP is hired into an HMG, there needs to be a thorough examination of the rationale behind the decision and assessment of the hospital culture that will be the host of the new NPP. What does the HMG need for support? Are they looking for a short‐term fix for increased volume or a long‐term strategy to build a multidisciplinary team? Does the hospital culture see NPPs as poorly qualified to act as hospitalists or uniquely qualified to address shortcomings of the program? A clear job description should be the first step in determining what the NPP is expected to do. This can then be shared with the hospital leadership in advance to promote buy‐in. The second step is finding an NPP that fits the goals of the program. A new NPP, by virtue of the fact that they have less clinical hours in training than a physician hospitalist, will need more support and a longer orientation. NPPs who have experience in hospital medicine will have a much shorter orientation. A stepwise approach to orientation can be helpful in assessing skill level of new hires. These NPPs can be initially paired with an enthusiastic physician to provide support and assessment of existing skills. A gradual increase in independence can provide assurance that the NPP is qualified to provide care and gives many opportunities for reevaluation of the NPP. Clear expectations and constructive feedback should ultimately lead to a degree of comfort within the HMG, hospital, and the NPPs themselves.

Conclusions

It is clear that our healthcare system will need a very different approach to the economic problems it is facing. Standardization of care, integrated medical records, and expanded and universal resource utilization will drive the next generation of healthcare providers. The model of a private physician working alone under the direction of only his or her own medical knowledge is a thing of the past. Just as the HM specialty has grown from 300 in 1996 to more than 20,000 in 2008, so shall the integration of NPPs grow into our healthcare fabric.

The current state of our profession is that the US population is aging rapidly, requiring ever more healthcare, and there is a stagnant number of physicians to care for them. The question of who will care for our aging population has been raised over and over in the past decade but the question is worth repeating. As our country continues to deliver state‐of‐the‐art medical care, it is slow to embrace the notion that in order for it to continue, it will need to incorporate the professions of advanced practice nurses and physician assistants. Without these nonphysician providers our medical community will not be able to reach the patients we have sworn to treat.

The percent of the US population age >65 years is projected to increase from 12.4% in 2000 to 19.6% in 2030. The number of persons age >65 years is expected to increase from approximately 35 million in 2000 to an estimated 71 million in 2030, and the number of persons age >80 years is expected to increase from 9.3 million in 2000 to 19.5 million in 2030.1 Our aging America is also coupled with a growing physician shortage. In its report entitled Physician Workforce Policy Guidelines for the United States, 2000‐2020, the Council on Graduate Medical Education recommended increasing the number of medical school graduates by 3000 per year by the year 2015 to meet the increasing need.2 Given the current trend of decreasing physician reimbursement coupled with the average medical school debt of $139,517,3 it is doubtful that the extra 3000 physicians needed to graduate in 2015 will actually ever do so. Despite this possible additional physician workforce, there still stands to be enormous need for the nonphysician provider with our rapidly expanding senior population.

Our nation's hospitals are by no means spared from our aging population or physician shortage. In fact, they are likely to be the hardest hit. Hospitalists are already feeling the pressure of an overstressed workforce coupled with increasing patient volume.4 There is a growing body of evidence supporting the successful collaboration between hospitalists and nurse practitioners (NPs)/physician assistants (PAs) (collectively, nonphysician providers [NPPs]). No longer are NPPs only working in outpatient practices or in the operating room, but they are actively involved with inpatient medical units improving our Hospital Medicine (HM) specialty. According to Myers et al.,5 the hospitalist NP model improved program finances and increased physician and resident satisfaction. In order for Hospital Medicine to create increasing value for its parent hospital or to the community it serves, NPPs will need increased integration into our care model for improved overall efficiency. We focus herein on the advantages and potential benefits of NPPs relating to their varied roles within HM.

Scope of Practice

The scope of practice of NPPs is regulated by each individual state board of registration. However, differences from state to state are usually minor and general statements on the practice scope of PAs and NPs can be made.

Potential Benefits of NPPs

Models of Care

There are many models for NPP roles in hospital medicine groups. Some groups use NPPs in the same role as physicians. They perform admissions, rounding, and discharges with varying degrees of oversight by physicians. Other groups use NPPs for a more limited role, such as exclusively performing histories and physicals in the emergency department or handling discharges on the wards. It is important to take into account the preferences and expectations of NPPs when designing job descriptions. While some NPPs may like the fast pace and quick turnover of admissions and discharges, others may prefer to follow patients throughout their hospital stay. The quality of handoffs is crucial if the former model is used, just as it is with physicians in this more truncated role. An NPP who works in a nonacademic model will likely have more autonomy and control over patient care decisions. An NPP role in the teaching service of an academic hospital is likely to be more collaborative and focus more on quality initiatives, patient teaching, and communication. It is crucial to design an NPP model that is sustainable with very strong support of management once the NPP is hired and orientated.

Registered Nurses And Hospital Medicine

Patient handoffs and communication are one of the most challenging aspects of an HMG. There is an increasing movement, throughout the country, to incorporate registered nurses (RNs) into daily workflow. The RN on the HM team can serve to augment the communication and workflow process. A highly motivated and organized registered nurse can help to improve overall provider's workflow efficiency. Communication to primary care physician and collecting ancillary medical information can allow the provider to treat more patients in a given shift and decrease the liability risk from lack of information. As HM organizations and hospitals become more financially bound, HMGs will need to become more efficient at time management and a dedicated RN can help smooth that process.

Potential Unintended Side Effects

Obviously, integration of NPPs can be a disaster for an HMG if not handled properly. Most hospitalists have heard of an integration of NPP into a group that was an unqualified failure. NPPs can feel unsupported, poorly oriented to the job, or thrown into a situation that is over their heads. Before an NPP is hired into an HMG, there needs to be a thorough examination of the rationale behind the decision and assessment of the hospital culture that will be the host of the new NPP. What does the HMG need for support? Are they looking for a short‐term fix for increased volume or a long‐term strategy to build a multidisciplinary team? Does the hospital culture see NPPs as poorly qualified to act as hospitalists or uniquely qualified to address shortcomings of the program? A clear job description should be the first step in determining what the NPP is expected to do. This can then be shared with the hospital leadership in advance to promote buy‐in. The second step is finding an NPP that fits the goals of the program. A new NPP, by virtue of the fact that they have less clinical hours in training than a physician hospitalist, will need more support and a longer orientation. NPPs who have experience in hospital medicine will have a much shorter orientation. A stepwise approach to orientation can be helpful in assessing skill level of new hires. These NPPs can be initially paired with an enthusiastic physician to provide support and assessment of existing skills. A gradual increase in independence can provide assurance that the NPP is qualified to provide care and gives many opportunities for reevaluation of the NPP. Clear expectations and constructive feedback should ultimately lead to a degree of comfort within the HMG, hospital, and the NPPs themselves.

Conclusions

It is clear that our healthcare system will need a very different approach to the economic problems it is facing. Standardization of care, integrated medical records, and expanded and universal resource utilization will drive the next generation of healthcare providers. The model of a private physician working alone under the direction of only his or her own medical knowledge is a thing of the past. Just as the HM specialty has grown from 300 in 1996 to more than 20,000 in 2008, so shall the integration of NPPs grow into our healthcare fabric.

The current state of our profession is that the US population is aging rapidly, requiring ever more healthcare, and there is a stagnant number of physicians to care for them. The question of who will care for our aging population has been raised over and over in the past decade but the question is worth repeating. As our country continues to deliver state‐of‐the‐art medical care, it is slow to embrace the notion that in order for it to continue, it will need to incorporate the professions of advanced practice nurses and physician assistants. Without these nonphysician providers our medical community will not be able to reach the patients we have sworn to treat.

The percent of the US population age >65 years is projected to increase from 12.4% in 2000 to 19.6% in 2030. The number of persons age >65 years is expected to increase from approximately 35 million in 2000 to an estimated 71 million in 2030, and the number of persons age >80 years is expected to increase from 9.3 million in 2000 to 19.5 million in 2030.1 Our aging America is also coupled with a growing physician shortage. In its report entitled Physician Workforce Policy Guidelines for the United States, 2000‐2020, the Council on Graduate Medical Education recommended increasing the number of medical school graduates by 3000 per year by the year 2015 to meet the increasing need.2 Given the current trend of decreasing physician reimbursement coupled with the average medical school debt of $139,517,3 it is doubtful that the extra 3000 physicians needed to graduate in 2015 will actually ever do so. Despite this possible additional physician workforce, there still stands to be enormous need for the nonphysician provider with our rapidly expanding senior population.

Our nation's hospitals are by no means spared from our aging population or physician shortage. In fact, they are likely to be the hardest hit. Hospitalists are already feeling the pressure of an overstressed workforce coupled with increasing patient volume.4 There is a growing body of evidence supporting the successful collaboration between hospitalists and nurse practitioners (NPs)/physician assistants (PAs) (collectively, nonphysician providers [NPPs]). No longer are NPPs only working in outpatient practices or in the operating room, but they are actively involved with inpatient medical units improving our Hospital Medicine (HM) specialty. According to Myers et al.,5 the hospitalist NP model improved program finances and increased physician and resident satisfaction. In order for Hospital Medicine to create increasing value for its parent hospital or to the community it serves, NPPs will need increased integration into our care model for improved overall efficiency. We focus herein on the advantages and potential benefits of NPPs relating to their varied roles within HM.

Scope of Practice

The scope of practice of NPPs is regulated by each individual state board of registration. However, differences from state to state are usually minor and general statements on the practice scope of PAs and NPs can be made.

Potential Benefits of NPPs

Models of Care

There are many models for NPP roles in hospital medicine groups. Some groups use NPPs in the same role as physicians. They perform admissions, rounding, and discharges with varying degrees of oversight by physicians. Other groups use NPPs for a more limited role, such as exclusively performing histories and physicals in the emergency department or handling discharges on the wards. It is important to take into account the preferences and expectations of NPPs when designing job descriptions. While some NPPs may like the fast pace and quick turnover of admissions and discharges, others may prefer to follow patients throughout their hospital stay. The quality of handoffs is crucial if the former model is used, just as it is with physicians in this more truncated role. An NPP who works in a nonacademic model will likely have more autonomy and control over patient care decisions. An NPP role in the teaching service of an academic hospital is likely to be more collaborative and focus more on quality initiatives, patient teaching, and communication. It is crucial to design an NPP model that is sustainable with very strong support of management once the NPP is hired and orientated.

Registered Nurses And Hospital Medicine

Patient handoffs and communication are one of the most challenging aspects of an HMG. There is an increasing movement, throughout the country, to incorporate registered nurses (RNs) into daily workflow. The RN on the HM team can serve to augment the communication and workflow process. A highly motivated and organized registered nurse can help to improve overall provider's workflow efficiency. Communication to primary care physician and collecting ancillary medical information can allow the provider to treat more patients in a given shift and decrease the liability risk from lack of information. As HM organizations and hospitals become more financially bound, HMGs will need to become more efficient at time management and a dedicated RN can help smooth that process.

Potential Unintended Side Effects

Obviously, integration of NPPs can be a disaster for an HMG if not handled properly. Most hospitalists have heard of an integration of NPP into a group that was an unqualified failure. NPPs can feel unsupported, poorly oriented to the job, or thrown into a situation that is over their heads. Before an NPP is hired into an HMG, there needs to be a thorough examination of the rationale behind the decision and assessment of the hospital culture that will be the host of the new NPP. What does the HMG need for support? Are they looking for a short‐term fix for increased volume or a long‐term strategy to build a multidisciplinary team? Does the hospital culture see NPPs as poorly qualified to act as hospitalists or uniquely qualified to address shortcomings of the program? A clear job description should be the first step in determining what the NPP is expected to do. This can then be shared with the hospital leadership in advance to promote buy‐in. The second step is finding an NPP that fits the goals of the program. A new NPP, by virtue of the fact that they have less clinical hours in training than a physician hospitalist, will need more support and a longer orientation. NPPs who have experience in hospital medicine will have a much shorter orientation. A stepwise approach to orientation can be helpful in assessing skill level of new hires. These NPPs can be initially paired with an enthusiastic physician to provide support and assessment of existing skills. A gradual increase in independence can provide assurance that the NPP is qualified to provide care and gives many opportunities for reevaluation of the NPP. Clear expectations and constructive feedback should ultimately lead to a degree of comfort within the HMG, hospital, and the NPPs themselves.

Conclusions

It is clear that our healthcare system will need a very different approach to the economic problems it is facing. Standardization of care, integrated medical records, and expanded and universal resource utilization will drive the next generation of healthcare providers. The model of a private physician working alone under the direction of only his or her own medical knowledge is a thing of the past. Just as the HM specialty has grown from 300 in 1996 to more than 20,000 in 2008, so shall the integration of NPPs grow into our healthcare fabric.

An association between hypertension and operative risk has been reported in small studies since the early 1970s. In two studies, Prys‐Roberts et al.1, 2 found that subjects with uncontrolled hypertension were more likely to have myocardial ischemic changes on electrocardiography with episodes of hypotension during induction of anesthesia. Subjects without hypertension or with hypertension controlled by medication were less likely to have episodes of hypotension, regardless of the type of anesthetic.

Hypertension increases the risk of developing perioperative heart failure (HF), renal failure, myocardial ischemia, or stroke. The level of risk is dependent upon the blood pressure (BP) level. It has been shown that a BP of 180/110 mm Hg without target‐organ damage (TOD) is not an independent risk factor for perioperative cardiovascular (CV) complications, suggesting this level of BP does not need to be reduced rapidly to normal.3, 4

The Joint National Committee defines hypertensive emergency as severe elevations in BP (usually >180/120 mm Hg) that produce evidence of TOD.5 Patients with this level of BP who are asymptomatic and have no signs of TOD are considered to have hypertensive urgency. As patients with this level of BP are at higher risk perioperatively, pharmacotherapy is indicated. When oral medications cannot be administered, hypertensive urgency can be managed with a parenteral medication. The agent should be easily and predictably titrated, safe, and convenient (Table 1). This article reviews the management of perioperative hypertensive urgency with parenteral medications. The management of hypertensive emergencies, aortic dissection, and hypertension of pregnancy is outside the scope of this review.

Preoperative Considerations

In normotensive patients the induction of anesthesia can cause an acute elevation in BP (2030 mm Hg) and heart rate (HR) (1520 bpm).6 In patients with preexisting hypertension these changes are often greater, with elevations up to 90 mm Hg and 40 bpm. As anesthesia progresses systolic BP starts to fall (30 mm Hg), as a direct effect of both the anesthetic and the inhibition of the sympathetic nervous system (SNS). Patients with uncontrolled hypertension can have more severe reductions (60 mm Hg).6 This can result in intraoperative hypotension and shock. In a study of over 650 patients, marked intraoperative hypotension (50% of preoperative BP or a 33% reduction for more than 10 minutes) was an independent risk factor for perioperative CV complications (cardiac arrhythmia, ischemia, HF, or renal failure).7

Therefore, when BP is mildly elevated at the time of surgery (180/110 mm Hg), rapid reduction in BP is not necessary, and studies have been unable to demonstrate a benefit to delaying surgery.8 However, when BP is 180/110 mm Hg preoperatively, antihypertensive medications should be administered and intraoperative blood pressure monitored closely. There is a lack of data to support delay of surgery.9

Postoperative Considerations

The postoperative period is also associated with elevations in BP. In the immediate recovery phase from anesthesia, there is a mild elevation in BP within 10 to 15 mm Hg, but there are larger fluctuations in patients with preexisting hypertension.6 Otherwise postoperative hypertension can be seen from a variety of causes such as pain, excitement on emergence from anesthesia, and hypercarbia.10 Less common causes include agitation, hypoxemia, and hypervolemia. These secondary causes should be identified and treated before any antihypertensive medications are administered.

Discussion

Nitroprusside, nitroglycerin, nicardipine, and fenoldopam are all effective antihypertensive medications. However, their availability only as continuous infusions requires ICU monitoring and an intraarterial catheter, and they are therefore unnecessary in the management of hypertensive urgency. The parenteral medications that do not require a continuous infusion are diltiazem, verapamil, metoprolol, labetalol, enalaprilat, hydralazine, and transdermal clonidine.

As stated, the intravenous formulations of diltiazem and verapamil are indicated only for certain arrhythmias. Because the onset of action of transdermal clonidine is about 2 days and the offset is 8 hours, it has limited usefulness in the treatment of perioperative hypertension. Therefore, only metoprolol, labetalol, enalaprilat, and hydralazine have a major role in the treatment of hypertensive urgency when oral medications cannot be used.

When given intravenously, enalaprilat and hydralazine are safe, effective, widely available, and inexpensive. When deciding between these 2 agents, a few other considerations may be of importance. Even though ACE inhibitors have well‐recognized benefits in the management of HF50 and diabetic nephropathy,51 these characteristics are not relevant in the short‐term use of enalaprilat to treat perioperative hypertension. However, enalaprilat may be preferred over hydralazine when activation of the SNS and reflex tachycardia is to be avoided (cardiac ischemia, aortic dissection, increased intracranial pressure). Hydralazine may be preferred in the setting of hyperkalemia and acute renal failure. It must be preferred in pregnancy or bilateral renal artery stenosis.

Although the weight of the evidence of perioperative ‐blocker use to reduce CV events in noncardiac surgery suggests a benefit, there are significant limitations. Few studies have compared different ‐blockers. Studies to determine the ideal target population, duration of therapy, and route of administration are lacking. Additionally, using perioperative ‐blockers may cause harm in low‐risk patients.52 Care should be taken when using labetalol and metoprolol in combination as they can induce a dangerous reduction in HR. The role of acute administration of intravenous ‐blockers in the setting of myocardial ischemia is debatable, and probably dangerous in the setting of hypotension, bradycardia, HB, pulmonary edema, or bronchospasm.53

Therefore, generalizing the perioperative ‐blocker data to all patients with perioperative hypertension seems unlikely to have significant benefit, and may possibly pose harm.29 However, it seems reasonable to use ‐blockers in those in whom it would be indicated otherwise, and to continue parenteral therapy in those already taking a ‐blocker preoperatively in order to avoid withdrawal.54

When deciding between metoprolol and labetalol, a few considerations may be of importance. First, there is much more evidence documenting the safety and efficacy of labetalol in perioperative hypertension. Second, even though metoprolol has proven benefit in patients with chronic HF, coronary artery disease (CAD), and MI, these long‐term studies investigated oral metoprolol, not the intravenous formulation.55 Most importantly, labetalol is more effective at lowering BP due to its additional blockade of alpha₁ adrenoreceptors. Neither drug should be used in acute HF, bradycardia or greater than first‐degree HB, or bronchospasm. In conclusion, intravenous labetalol should be preferred over intravenous metoprolol for the management of perioperative hypertension.

Conclusions

Perioperative hypertension ideally should be evaluated well before the operative time period, when there is adequate time to initiate medications. Secondary causes such as pain, agitation, hypercarbia, hypoxemia, and hypervolemia should be treated directly prior to the administration of antihypertensive medications. It is uncertain whether patients with a BP of 180/110 mm Hg benefit from any specific parenteral medication, as there is little evidence from several studies that this level of BP without TOD leads to an increase in perioperative morbidity or mortality.3, 4, 7, 56 However, patients with hypertensive urgency are at higher risk for perioperative complications; therefore, their BP should be managed gradually to 160/110 mm Hg with the outlined recommended parenteral regimen (Figure 1).

Figure 1

When selecting a parenteral medication, we suggest first to exclude any contraindications, or see if an indication exists for a specific agent. Hydralazine, enalaprilat, metoprolol, or labetalol can be used as first‐line agents. Due to the scarcity of comparative trials looking at clinically significant outcomes (length of hospital stay, morbidity, mortality), decisions for the management of perioperative hypertension should be made based on comorbidity, efficacy, toxicity, and cost (Table 1).

An association between hypertension and operative risk has been reported in small studies since the early 1970s. In two studies, Prys‐Roberts et al.1, 2 found that subjects with uncontrolled hypertension were more likely to have myocardial ischemic changes on electrocardiography with episodes of hypotension during induction of anesthesia. Subjects without hypertension or with hypertension controlled by medication were less likely to have episodes of hypotension, regardless of the type of anesthetic.

Hypertension increases the risk of developing perioperative heart failure (HF), renal failure, myocardial ischemia, or stroke. The level of risk is dependent upon the blood pressure (BP) level. It has been shown that a BP of 180/110 mm Hg without target‐organ damage (TOD) is not an independent risk factor for perioperative cardiovascular (CV) complications, suggesting this level of BP does not need to be reduced rapidly to normal.3, 4

The Joint National Committee defines hypertensive emergency as severe elevations in BP (usually >180/120 mm Hg) that produce evidence of TOD.5 Patients with this level of BP who are asymptomatic and have no signs of TOD are considered to have hypertensive urgency. As patients with this level of BP are at higher risk perioperatively, pharmacotherapy is indicated. When oral medications cannot be administered, hypertensive urgency can be managed with a parenteral medication. The agent should be easily and predictably titrated, safe, and convenient (Table 1). This article reviews the management of perioperative hypertensive urgency with parenteral medications. The management of hypertensive emergencies, aortic dissection, and hypertension of pregnancy is outside the scope of this review.

Preoperative Considerations

In normotensive patients the induction of anesthesia can cause an acute elevation in BP (2030 mm Hg) and heart rate (HR) (1520 bpm).6 In patients with preexisting hypertension these changes are often greater, with elevations up to 90 mm Hg and 40 bpm. As anesthesia progresses systolic BP starts to fall (30 mm Hg), as a direct effect of both the anesthetic and the inhibition of the sympathetic nervous system (SNS). Patients with uncontrolled hypertension can have more severe reductions (60 mm Hg).6 This can result in intraoperative hypotension and shock. In a study of over 650 patients, marked intraoperative hypotension (50% of preoperative BP or a 33% reduction for more than 10 minutes) was an independent risk factor for perioperative CV complications (cardiac arrhythmia, ischemia, HF, or renal failure).7

Therefore, when BP is mildly elevated at the time of surgery (180/110 mm Hg), rapid reduction in BP is not necessary, and studies have been unable to demonstrate a benefit to delaying surgery.8 However, when BP is 180/110 mm Hg preoperatively, antihypertensive medications should be administered and intraoperative blood pressure monitored closely. There is a lack of data to support delay of surgery.9

Postoperative Considerations

The postoperative period is also associated with elevations in BP. In the immediate recovery phase from anesthesia, there is a mild elevation in BP within 10 to 15 mm Hg, but there are larger fluctuations in patients with preexisting hypertension.6 Otherwise postoperative hypertension can be seen from a variety of causes such as pain, excitement on emergence from anesthesia, and hypercarbia.10 Less common causes include agitation, hypoxemia, and hypervolemia. These secondary causes should be identified and treated before any antihypertensive medications are administered.

Discussion

Nitroprusside, nitroglycerin, nicardipine, and fenoldopam are all effective antihypertensive medications. However, their availability only as continuous infusions requires ICU monitoring and an intraarterial catheter, and they are therefore unnecessary in the management of hypertensive urgency. The parenteral medications that do not require a continuous infusion are diltiazem, verapamil, metoprolol, labetalol, enalaprilat, hydralazine, and transdermal clonidine.

As stated, the intravenous formulations of diltiazem and verapamil are indicated only for certain arrhythmias. Because the onset of action of transdermal clonidine is about 2 days and the offset is 8 hours, it has limited usefulness in the treatment of perioperative hypertension. Therefore, only metoprolol, labetalol, enalaprilat, and hydralazine have a major role in the treatment of hypertensive urgency when oral medications cannot be used.

When given intravenously, enalaprilat and hydralazine are safe, effective, widely available, and inexpensive. When deciding between these 2 agents, a few other considerations may be of importance. Even though ACE inhibitors have well‐recognized benefits in the management of HF50 and diabetic nephropathy,51 these characteristics are not relevant in the short‐term use of enalaprilat to treat perioperative hypertension. However, enalaprilat may be preferred over hydralazine when activation of the SNS and reflex tachycardia is to be avoided (cardiac ischemia, aortic dissection, increased intracranial pressure). Hydralazine may be preferred in the setting of hyperkalemia and acute renal failure. It must be preferred in pregnancy or bilateral renal artery stenosis.

Although the weight of the evidence of perioperative ‐blocker use to reduce CV events in noncardiac surgery suggests a benefit, there are significant limitations. Few studies have compared different ‐blockers. Studies to determine the ideal target population, duration of therapy, and route of administration are lacking. Additionally, using perioperative ‐blockers may cause harm in low‐risk patients.52 Care should be taken when using labetalol and metoprolol in combination as they can induce a dangerous reduction in HR. The role of acute administration of intravenous ‐blockers in the setting of myocardial ischemia is debatable, and probably dangerous in the setting of hypotension, bradycardia, HB, pulmonary edema, or bronchospasm.53

Therefore, generalizing the perioperative ‐blocker data to all patients with perioperative hypertension seems unlikely to have significant benefit, and may possibly pose harm.29 However, it seems reasonable to use ‐blockers in those in whom it would be indicated otherwise, and to continue parenteral therapy in those already taking a ‐blocker preoperatively in order to avoid withdrawal.54

When deciding between metoprolol and labetalol, a few considerations may be of importance. First, there is much more evidence documenting the safety and efficacy of labetalol in perioperative hypertension. Second, even though metoprolol has proven benefit in patients with chronic HF, coronary artery disease (CAD), and MI, these long‐term studies investigated oral metoprolol, not the intravenous formulation.55 Most importantly, labetalol is more effective at lowering BP due to its additional blockade of alpha₁ adrenoreceptors. Neither drug should be used in acute HF, bradycardia or greater than first‐degree HB, or bronchospasm. In conclusion, intravenous labetalol should be preferred over intravenous metoprolol for the management of perioperative hypertension.

Conclusions

Perioperative hypertension ideally should be evaluated well before the operative time period, when there is adequate time to initiate medications. Secondary causes such as pain, agitation, hypercarbia, hypoxemia, and hypervolemia should be treated directly prior to the administration of antihypertensive medications. It is uncertain whether patients with a BP of 180/110 mm Hg benefit from any specific parenteral medication, as there is little evidence from several studies that this level of BP without TOD leads to an increase in perioperative morbidity or mortality.3, 4, 7, 56 However, patients with hypertensive urgency are at higher risk for perioperative complications; therefore, their BP should be managed gradually to 160/110 mm Hg with the outlined recommended parenteral regimen (Figure 1).

Figure 1

When selecting a parenteral medication, we suggest first to exclude any contraindications, or see if an indication exists for a specific agent. Hydralazine, enalaprilat, metoprolol, or labetalol can be used as first‐line agents. Due to the scarcity of comparative trials looking at clinically significant outcomes (length of hospital stay, morbidity, mortality), decisions for the management of perioperative hypertension should be made based on comorbidity, efficacy, toxicity, and cost (Table 1).

An association between hypertension and operative risk has been reported in small studies since the early 1970s. In two studies, Prys‐Roberts et al.1, 2 found that subjects with uncontrolled hypertension were more likely to have myocardial ischemic changes on electrocardiography with episodes of hypotension during induction of anesthesia. Subjects without hypertension or with hypertension controlled by medication were less likely to have episodes of hypotension, regardless of the type of anesthetic.

Hypertension increases the risk of developing perioperative heart failure (HF), renal failure, myocardial ischemia, or stroke. The level of risk is dependent upon the blood pressure (BP) level. It has been shown that a BP of 180/110 mm Hg without target‐organ damage (TOD) is not an independent risk factor for perioperative cardiovascular (CV) complications, suggesting this level of BP does not need to be reduced rapidly to normal.3, 4

The Joint National Committee defines hypertensive emergency as severe elevations in BP (usually >180/120 mm Hg) that produce evidence of TOD.5 Patients with this level of BP who are asymptomatic and have no signs of TOD are considered to have hypertensive urgency. As patients with this level of BP are at higher risk perioperatively, pharmacotherapy is indicated. When oral medications cannot be administered, hypertensive urgency can be managed with a parenteral medication. The agent should be easily and predictably titrated, safe, and convenient (Table 1). This article reviews the management of perioperative hypertensive urgency with parenteral medications. The management of hypertensive emergencies, aortic dissection, and hypertension of pregnancy is outside the scope of this review.

Preoperative Considerations

In normotensive patients the induction of anesthesia can cause an acute elevation in BP (2030 mm Hg) and heart rate (HR) (1520 bpm).6 In patients with preexisting hypertension these changes are often greater, with elevations up to 90 mm Hg and 40 bpm. As anesthesia progresses systolic BP starts to fall (30 mm Hg), as a direct effect of both the anesthetic and the inhibition of the sympathetic nervous system (SNS). Patients with uncontrolled hypertension can have more severe reductions (60 mm Hg).6 This can result in intraoperative hypotension and shock. In a study of over 650 patients, marked intraoperative hypotension (50% of preoperative BP or a 33% reduction for more than 10 minutes) was an independent risk factor for perioperative CV complications (cardiac arrhythmia, ischemia, HF, or renal failure).7

Therefore, when BP is mildly elevated at the time of surgery (180/110 mm Hg), rapid reduction in BP is not necessary, and studies have been unable to demonstrate a benefit to delaying surgery.8 However, when BP is 180/110 mm Hg preoperatively, antihypertensive medications should be administered and intraoperative blood pressure monitored closely. There is a lack of data to support delay of surgery.9

Postoperative Considerations

The postoperative period is also associated with elevations in BP. In the immediate recovery phase from anesthesia, there is a mild elevation in BP within 10 to 15 mm Hg, but there are larger fluctuations in patients with preexisting hypertension.6 Otherwise postoperative hypertension can be seen from a variety of causes such as pain, excitement on emergence from anesthesia, and hypercarbia.10 Less common causes include agitation, hypoxemia, and hypervolemia. These secondary causes should be identified and treated before any antihypertensive medications are administered.

Discussion

Nitroprusside, nitroglycerin, nicardipine, and fenoldopam are all effective antihypertensive medications. However, their availability only as continuous infusions requires ICU monitoring and an intraarterial catheter, and they are therefore unnecessary in the management of hypertensive urgency. The parenteral medications that do not require a continuous infusion are diltiazem, verapamil, metoprolol, labetalol, enalaprilat, hydralazine, and transdermal clonidine.

As stated, the intravenous formulations of diltiazem and verapamil are indicated only for certain arrhythmias. Because the onset of action of transdermal clonidine is about 2 days and the offset is 8 hours, it has limited usefulness in the treatment of perioperative hypertension. Therefore, only metoprolol, labetalol, enalaprilat, and hydralazine have a major role in the treatment of hypertensive urgency when oral medications cannot be used.

When given intravenously, enalaprilat and hydralazine are safe, effective, widely available, and inexpensive. When deciding between these 2 agents, a few other considerations may be of importance. Even though ACE inhibitors have well‐recognized benefits in the management of HF50 and diabetic nephropathy,51 these characteristics are not relevant in the short‐term use of enalaprilat to treat perioperative hypertension. However, enalaprilat may be preferred over hydralazine when activation of the SNS and reflex tachycardia is to be avoided (cardiac ischemia, aortic dissection, increased intracranial pressure). Hydralazine may be preferred in the setting of hyperkalemia and acute renal failure. It must be preferred in pregnancy or bilateral renal artery stenosis.

Although the weight of the evidence of perioperative ‐blocker use to reduce CV events in noncardiac surgery suggests a benefit, there are significant limitations. Few studies have compared different ‐blockers. Studies to determine the ideal target population, duration of therapy, and route of administration are lacking. Additionally, using perioperative ‐blockers may cause harm in low‐risk patients.52 Care should be taken when using labetalol and metoprolol in combination as they can induce a dangerous reduction in HR. The role of acute administration of intravenous ‐blockers in the setting of myocardial ischemia is debatable, and probably dangerous in the setting of hypotension, bradycardia, HB, pulmonary edema, or bronchospasm.53

Therefore, generalizing the perioperative ‐blocker data to all patients with perioperative hypertension seems unlikely to have significant benefit, and may possibly pose harm.29 However, it seems reasonable to use ‐blockers in those in whom it would be indicated otherwise, and to continue parenteral therapy in those already taking a ‐blocker preoperatively in order to avoid withdrawal.54

When deciding between metoprolol and labetalol, a few considerations may be of importance. First, there is much more evidence documenting the safety and efficacy of labetalol in perioperative hypertension. Second, even though metoprolol has proven benefit in patients with chronic HF, coronary artery disease (CAD), and MI, these long‐term studies investigated oral metoprolol, not the intravenous formulation.55 Most importantly, labetalol is more effective at lowering BP due to its additional blockade of alpha₁ adrenoreceptors. Neither drug should be used in acute HF, bradycardia or greater than first‐degree HB, or bronchospasm. In conclusion, intravenous labetalol should be preferred over intravenous metoprolol for the management of perioperative hypertension.

Conclusions

Perioperative hypertension ideally should be evaluated well before the operative time period, when there is adequate time to initiate medications. Secondary causes such as pain, agitation, hypercarbia, hypoxemia, and hypervolemia should be treated directly prior to the administration of antihypertensive medications. It is uncertain whether patients with a BP of 180/110 mm Hg benefit from any specific parenteral medication, as there is little evidence from several studies that this level of BP without TOD leads to an increase in perioperative morbidity or mortality.3, 4, 7, 56 However, patients with hypertensive urgency are at higher risk for perioperative complications; therefore, their BP should be managed gradually to 160/110 mm Hg with the outlined recommended parenteral regimen (Figure 1).

Figure 1

When selecting a parenteral medication, we suggest first to exclude any contraindications, or see if an indication exists for a specific agent. Hydralazine, enalaprilat, metoprolol, or labetalol can be used as first‐line agents. Due to the scarcity of comparative trials looking at clinically significant outcomes (length of hospital stay, morbidity, mortality), decisions for the management of perioperative hypertension should be made based on comorbidity, efficacy, toxicity, and cost (Table 1).

In recent years, the demand for hospitalists has outstripped the supply, creating a national shortage.1, 2 A recent Society of Hospital Medicine (SHM) survey found that in the last 2 years there has been a 31% mean growth increase in the number of hospitalist groups.3 As hospitalists are becoming more difficult to recruit, many practices are utilizing physician assistants (PAs) and nurse practitioners (NPs), collectively referred to as nonphysician providers (NPPs) to help offset the workload.4 The SHM survey also noted that the number of hospitalist groups utilizing NPPs increased from 29% to 38%.3 The exact number of NPPs working for hospitalist groups is unknown.

Hospitalist NPPs are in demand for reasons other than just physician shortages. NPPs have been utilized to fill the gap in many institutions where the workforce was impacted by the 2002 Accreditation Council for Graduate Medical Education (ACGME) ruling to restrict resident work hours. Several studies have documented NPPs' ability to assist with the compliance of ACCGME resident work‐hour restrictions while maintaining patient continuity of care, improving length of stays, and reducing health care costs on various hospital services.59 Dresselhaus et al.10 found that 56% of medical resident's time on service was delegated to tasks not related to direct patient care. They proposed that these tasks can be delegated to the NPPs, leaving more time for the residents to focus on direct patient care. In a recent study performed at a Pennsylvania hospital, patients presenting to the emergency department with low‐risk chest pain (based upon thrombolysis in myocardial infarction [TIMI] risk score) were admitted to a nonteaching service staffed with NPPs and attending physicians. Simultaneously, a similar group of low‐risk chest pain patients were admitted to a traditional internal medicine resident service. The results demonstrated lower median length of stay and hospital charges on the nonteaching service. This study suggested that NPPs can offset the workload volume for medical residents, allowing them to focus on patients with higher acuity and greater learning value.11

Barriers to Finding Experienced NPPs in Hospital Medicine

Although many hospitalist groups are interested in hiring NPPs, there can be significant obstacles to recruitment. For example, most experienced PAs and NPs have clinical backgrounds in either surgical or medical subspecialties and therefore typically need extensive on‐the‐job training in hospital medicine, which can often take at least 6 to 12 months to acquire the basic skill set.12 Hiring new graduates may require even longer training periods.

The inexperience of new graduates has become an even more pertinent issue due to recent changes in PA education. Traditionally, PA programs attracted older students with prior healthcare experience, who wished to return to school for additional training. However, in 2005 a major shift occurred in PA education: programs began transitioning from graduating trainees with a bachelor's degree to now requiring a master's level degree for completion of the PA program.13 The acquisition of more advanced degrees has changed the demographics of the students matriculating into PA programs, attracting younger students, straight from undergraduate institutions, with less prior healthcare experience.14 As a result, not only are new PA graduates less experienced overall, but they are particularly lacking in exposure to hospital medicine. After PA students complete their first 12 months of PA school in the basic sciences and didactic coursework, they embark on 12 to 15 months of clinical rotations, which are largely rooted in primary care. In fact, many PA programs find it difficult to offer hospital‐based rotations while fulfilling the required rotations in primary care. These factors have resulted in the need for more extensive on‐the‐job training particularly for those new graduates interested in hospital medicine. In light of these challenges, our institution created a 12‐month postgraduate PA fellowship program in Hospital Medicine.

Postgraduate PA Training Programs

Postgraduate PA fellowships, interchangeably called residencies, are voluntary 1‐year training programs that provide both didactic instruction and clinical experience in a medical or surgical subspecialty, thereby lessening the need for on‐the‐job training. These programs are recognized by the Association of Postgraduate Physician Assistant Programs.15 Currently, there are 44 postgraduate training programs in the United States, in a wide range of medical and surgical specialties. At the end of these 1‐year postgraduate PA programs, most graduates receive a certificate of completion. Until now, the only postgraduate education option for PAs interested in Hospital Medicine was a master's completion program only available to PAs who were already employed by a hospitalist group.15 This work reviews the first reported postgraduate hospitalist training program for PAs. Specifically, the program's background, curriculum, anticipated program outcomes, and future plans are discussed.

Background for A Hospitalist Postgraduate PA Fellowship

Mayo Clinic Arizona is a multispecialty private group comprised of both outpatient services and a tertiary care hospital medical center, located in the metropolitan Phoenix, AZ, area. The Mayo Clinic Hospital is a 7‐story facility with 244 licensed beds, 18 operating rooms, and a Level II emergency department. The Mayo Hospitalist group is composed of 15 full time hospitalists and 6 part‐time hospitalists, all of whom are salaried Mayo employees. The group provides 24‐hour in‐house staffing, covering both resident services (teams composed of interns and residents supervised by a staff hospitalist) and nonresident services (staff hospitalists). Over the years there has been steady growth in the number of nonresident services, in part due to resident work‐hour restrictions. To support the physicians working on these nonresident services, the first PA was hired in 2001. Since then, the number of NPPs in our Hospitalist group has increased to 9.35 full‐time equivalents (FTEs), including 1 nurse practitioner. However, one of the greatest challenges in expanding the NPP service was the difficulty finding candidates with experience in hospital internal medicine. This need inspired the creation of a PA fellowship in Hospital Medicine. At the time, there were 2 other postgraduate PA training programs at the Mayo Clinic Arizona in Hepatology and Otolaryngology/Ear, Nose, and Throat (ENT) Surgery.

Program Description

The Mayo Clinic Arizona PA fellowship in Hospital Medicine began in October 2007 and currently accepts 1 fellow per year. Applicants must be graduates of an Accreditation Review Commission in Education for the Physician Assistant (ARC‐PA)‐accredited PA program and be certified through the National Commission on Certification of Physician Assistants (NCCPA). Furthermore, they must be licensed to work as a PA in the state of Arizona. The program is 12 months in duration, and is comprised of both didactic and clinical components. Upon graduation, the fellow earns a certificate of completion from the Mayo Clinic College of Medicine. The program has received recognition with the Association of Postgraduate Physician Assistant Programs (APPAP).

Two physician assistants act as co‐program directors of the PA fellowship in hospital medicine. They are given 0.10 full‐time equivalent (FTE) for management of the program, which includes day‐to‐day operations, curriculum development, and candidate selection. The program also has 2 volunteer physician medical directors, both of whom have previous medical residency experience. The physicians and NPPs in our hospitalist group volunteer their time to serve as faculty for the program, assisting with much of the didactic and clinical education. The program receives a budget of $99,500 per year, which is funded by the organization's foundation through the department of education. This includes the fellow stipend of $44,000 per 12 months and institutional malpractice insurance coverage. The fellow also receives health and dental insurance, 2 weeks of paid vacation, and $500 stipend toward attendance of a continuing medical education (CME) conference.

CURRICULUM

The PA fellowship curriculum is designed in a diverse unique format that strives to accommodate all types of learners. It includes clinical rotations in various medicine/surgical subspecialties, didactic instruction, and teaching modules (Figure 1). The curriculum is based upon the SHM Core Competencies.15

Figure 1

Clinical Rotations

The PA fellow completes 12 to 14 general hospital medicine and medical specialty rotations, each 2 to 4 weeks in duration. The rotation calendar for the current fellow is given in Figure 2. These rotations are all inpatient‐based and are supervised by either the hospitalist or the respective inpatient subspecialists. The PA fellow's specific clinical responsibilities vary from rotation to rotation, and are designed to maximize the fellow's exposure to that particular specialty. Each rotation has specific written objectives created by the program directors and reviewed by the rotation's preceptor(s) (Figure 2). During the clinical rotations, complementary didactic lectures, coursework, and readings are provided to ensure the PA fellow receives a strong foundation. Didactic instruction is designed by the program directors, physician preceptors and staff NPPs, and is coordinated with the clinical rotation specialty. At the end of each rotation the fellow is evaluated by the preceptor and given direct feedback on their performance.

Figure 2

Teaching Modules

One component of the Hospital Medicine PA fellowship curriculum that may be unique is the concept of teaching modules. While receiving regular didactic instruction and completing their clinical rotations, the PA is also expected to complete self‐directed teaching module assignments. These modules serve to educate the PA fellow on the hospital as a systemthe true essence of hospital medicine. The modules cover a variety of topics not directly addressed during their rotations. These topics are outlined in Figure 3. Each teaching module consists of a didactic component, clinical application, and assessment (Figure 4) and has its own specific objectives and goals. Teaching modules are often taught by the local expert in the hospital in that particular area. For example, for the infectious control teaching module, the PA fellow will rotate with the infection control nursing staff learning about the isolation and infection control policies of the institution.

Figure 3

Figure 4

Assessment Tools

There are several tools utilized to assess both the PA fellow and the fellowship program itself (Figure 5). The assessment tools used include both ongoing and summative assessments. To fulfill the ongoing assessment, each rotation and teaching module contains assessment tools provided by the preceptor, which are reviewed by the program directors. Additionally, during the clinical rotations, skills are assessed using competency checklists that require the preceptor to directly observe the PA fellow perform a specific task or skill‐set and sign off on its successful completion (Supplementary Figures 6, 7).

Figure 5

There are 2 forms of summative assessment for the PA fellow. First, to assess the PA fellow's knowledge, comprehensive mid‐year and end‐year examinations are utilized. These multiple‐choice examinations are comprised of questions which align with the didactic lectures/objectives provided by the Hospital Medicine faculty throughout the year. The second form of summative evaluation of the fellow is project‐based and divided into 2 parts. First, the fellow is expected to write a publication‐quality manuscript on a hospital medicine topic by the end of the year. Second, the PA fellow is expected to create a professional portfolio, which is comprised of a collection of all of the rotation/module assessments, the formal program assessments, and documentation of all of the skills obtained by the fellow throughout year (competency checklists). This portfolio can be used by the graduate to demonstrate to future employers what skills they possess and provide documentation of knowledge gained during the fellowship.

The program itself is evaluated by several measures. First, the fellow provides formal feedback during the mid‐year and end‐of‐the‐year assessments, which are used to enhance the experience of future fellows. Second, there is ongoing review by both the division of Hospital Medicine and the institution's Allied Health Education Committee, which ensures that the program maintains the appropriate standards and goals.

Future Goals for the PA Fellowship

The program graduated its first fellow at the end of October 2008 and has enjoyed early success. Integrating the PA fellow onto the hospitalist services augmented the present mid‐level and physician teams. There has been excellent institutional support for the program with extremely positive feedback from the rotation preceptors. There are several futures plans for the program. Our first goal is to seek accreditation from the Accreditation Review Commission for Physician Assistants (ARC‐PA), the organization that accredits entry level PA programs and which began formal, voluntary accreditation of postgraduate programs in early 2008. We plan to begin this process within the next academic year.

Our second long‐term goal for the program is to include NPs in the training program. Because of the desire to seek accreditation, the program directors felt temporarily limiting the fellowship to PAs would aide in the rigorous accreditation process, which can take approximately 1 year to complete. There is an NP on our faculty and the program has received interest from NPs. Once we obtain accreditation, expand the program enrollment, and develop an NP curriculum, we plan to open the fellowship to either PA or NP applicants.

Our third goal is to substantiate our PA Fellowship validity with outcome measures and ultimately publishable data. Thus far, the success of the PA fellowship is qualitative, and with small numbers of graduates it is difficult to quantify. After graduation of many subsequent PA fellows, our goal is to obtain quantifiable data that can be used to improve the quality of the PA fellowship and demonstrate the value of postgraduate training for physician assistants.

Perhaps the most important goal of the program is to eventually accept additional PA/NP fellows per year. While 1 program does not meet the demands of a national shortage of hospitalist providers, it may serve as a model that other institutions can adapt to their own needs. Since the program is based upon the SHM Core Competencies, the curriculum can be applied to a variety of hospitalist programs, and its relatively low operating cost makes it feasible for both academic‐based and community‐based institutions. Importantly, since recruitment and retention of employees is such a challenge for most hospitalist groups, this PA fellowship program may serve as a vehicle for recruitment and long‐term retention of well‐trained employees. This precedent has been set, as our division has hired our first PA fellow, whose transition from PA fellow to PA staff was seamless.

In conclusion, our PA fellowship in Hospital Medicine represents the first reported postgraduate PA program of this kind in the United States offering a certificate of completion. As the need for hospitalists increase so will the need for NPPs, particularly those with additional training in hospital medicine. This program serves as an example of 1 type of training tool for physician assistants looking to work in hospital medicine.

In recent years, the demand for hospitalists has outstripped the supply, creating a national shortage.1, 2 A recent Society of Hospital Medicine (SHM) survey found that in the last 2 years there has been a 31% mean growth increase in the number of hospitalist groups.3 As hospitalists are becoming more difficult to recruit, many practices are utilizing physician assistants (PAs) and nurse practitioners (NPs), collectively referred to as nonphysician providers (NPPs) to help offset the workload.4 The SHM survey also noted that the number of hospitalist groups utilizing NPPs increased from 29% to 38%.3 The exact number of NPPs working for hospitalist groups is unknown.

Hospitalist NPPs are in demand for reasons other than just physician shortages. NPPs have been utilized to fill the gap in many institutions where the workforce was impacted by the 2002 Accreditation Council for Graduate Medical Education (ACGME) ruling to restrict resident work hours. Several studies have documented NPPs' ability to assist with the compliance of ACCGME resident work‐hour restrictions while maintaining patient continuity of care, improving length of stays, and reducing health care costs on various hospital services.59 Dresselhaus et al.10 found that 56% of medical resident's time on service was delegated to tasks not related to direct patient care. They proposed that these tasks can be delegated to the NPPs, leaving more time for the residents to focus on direct patient care. In a recent study performed at a Pennsylvania hospital, patients presenting to the emergency department with low‐risk chest pain (based upon thrombolysis in myocardial infarction [TIMI] risk score) were admitted to a nonteaching service staffed with NPPs and attending physicians. Simultaneously, a similar group of low‐risk chest pain patients were admitted to a traditional internal medicine resident service. The results demonstrated lower median length of stay and hospital charges on the nonteaching service. This study suggested that NPPs can offset the workload volume for medical residents, allowing them to focus on patients with higher acuity and greater learning value.11

Barriers to Finding Experienced NPPs in Hospital Medicine

Although many hospitalist groups are interested in hiring NPPs, there can be significant obstacles to recruitment. For example, most experienced PAs and NPs have clinical backgrounds in either surgical or medical subspecialties and therefore typically need extensive on‐the‐job training in hospital medicine, which can often take at least 6 to 12 months to acquire the basic skill set.12 Hiring new graduates may require even longer training periods.

The inexperience of new graduates has become an even more pertinent issue due to recent changes in PA education. Traditionally, PA programs attracted older students with prior healthcare experience, who wished to return to school for additional training. However, in 2005 a major shift occurred in PA education: programs began transitioning from graduating trainees with a bachelor's degree to now requiring a master's level degree for completion of the PA program.13 The acquisition of more advanced degrees has changed the demographics of the students matriculating into PA programs, attracting younger students, straight from undergraduate institutions, with less prior healthcare experience.14 As a result, not only are new PA graduates less experienced overall, but they are particularly lacking in exposure to hospital medicine. After PA students complete their first 12 months of PA school in the basic sciences and didactic coursework, they embark on 12 to 15 months of clinical rotations, which are largely rooted in primary care. In fact, many PA programs find it difficult to offer hospital‐based rotations while fulfilling the required rotations in primary care. These factors have resulted in the need for more extensive on‐the‐job training particularly for those new graduates interested in hospital medicine. In light of these challenges, our institution created a 12‐month postgraduate PA fellowship program in Hospital Medicine.

Postgraduate PA Training Programs

Postgraduate PA fellowships, interchangeably called residencies, are voluntary 1‐year training programs that provide both didactic instruction and clinical experience in a medical or surgical subspecialty, thereby lessening the need for on‐the‐job training. These programs are recognized by the Association of Postgraduate Physician Assistant Programs.15 Currently, there are 44 postgraduate training programs in the United States, in a wide range of medical and surgical specialties. At the end of these 1‐year postgraduate PA programs, most graduates receive a certificate of completion. Until now, the only postgraduate education option for PAs interested in Hospital Medicine was a master's completion program only available to PAs who were already employed by a hospitalist group.15 This work reviews the first reported postgraduate hospitalist training program for PAs. Specifically, the program's background, curriculum, anticipated program outcomes, and future plans are discussed.

Background for A Hospitalist Postgraduate PA Fellowship

Mayo Clinic Arizona is a multispecialty private group comprised of both outpatient services and a tertiary care hospital medical center, located in the metropolitan Phoenix, AZ, area. The Mayo Clinic Hospital is a 7‐story facility with 244 licensed beds, 18 operating rooms, and a Level II emergency department. The Mayo Hospitalist group is composed of 15 full time hospitalists and 6 part‐time hospitalists, all of whom are salaried Mayo employees. The group provides 24‐hour in‐house staffing, covering both resident services (teams composed of interns and residents supervised by a staff hospitalist) and nonresident services (staff hospitalists). Over the years there has been steady growth in the number of nonresident services, in part due to resident work‐hour restrictions. To support the physicians working on these nonresident services, the first PA was hired in 2001. Since then, the number of NPPs in our Hospitalist group has increased to 9.35 full‐time equivalents (FTEs), including 1 nurse practitioner. However, one of the greatest challenges in expanding the NPP service was the difficulty finding candidates with experience in hospital internal medicine. This need inspired the creation of a PA fellowship in Hospital Medicine. At the time, there were 2 other postgraduate PA training programs at the Mayo Clinic Arizona in Hepatology and Otolaryngology/Ear, Nose, and Throat (ENT) Surgery.

Program Description

The Mayo Clinic Arizona PA fellowship in Hospital Medicine began in October 2007 and currently accepts 1 fellow per year. Applicants must be graduates of an Accreditation Review Commission in Education for the Physician Assistant (ARC‐PA)‐accredited PA program and be certified through the National Commission on Certification of Physician Assistants (NCCPA). Furthermore, they must be licensed to work as a PA in the state of Arizona. The program is 12 months in duration, and is comprised of both didactic and clinical components. Upon graduation, the fellow earns a certificate of completion from the Mayo Clinic College of Medicine. The program has received recognition with the Association of Postgraduate Physician Assistant Programs (APPAP).

Two physician assistants act as co‐program directors of the PA fellowship in hospital medicine. They are given 0.10 full‐time equivalent (FTE) for management of the program, which includes day‐to‐day operations, curriculum development, and candidate selection. The program also has 2 volunteer physician medical directors, both of whom have previous medical residency experience. The physicians and NPPs in our hospitalist group volunteer their time to serve as faculty for the program, assisting with much of the didactic and clinical education. The program receives a budget of $99,500 per year, which is funded by the organization's foundation through the department of education. This includes the fellow stipend of $44,000 per 12 months and institutional malpractice insurance coverage. The fellow also receives health and dental insurance, 2 weeks of paid vacation, and $500 stipend toward attendance of a continuing medical education (CME) conference.

CURRICULUM

The PA fellowship curriculum is designed in a diverse unique format that strives to accommodate all types of learners. It includes clinical rotations in various medicine/surgical subspecialties, didactic instruction, and teaching modules (Figure 1). The curriculum is based upon the SHM Core Competencies.15

Figure 1

Clinical Rotations

The PA fellow completes 12 to 14 general hospital medicine and medical specialty rotations, each 2 to 4 weeks in duration. The rotation calendar for the current fellow is given in Figure 2. These rotations are all inpatient‐based and are supervised by either the hospitalist or the respective inpatient subspecialists. The PA fellow's specific clinical responsibilities vary from rotation to rotation, and are designed to maximize the fellow's exposure to that particular specialty. Each rotation has specific written objectives created by the program directors and reviewed by the rotation's preceptor(s) (Figure 2). During the clinical rotations, complementary didactic lectures, coursework, and readings are provided to ensure the PA fellow receives a strong foundation. Didactic instruction is designed by the program directors, physician preceptors and staff NPPs, and is coordinated with the clinical rotation specialty. At the end of each rotation the fellow is evaluated by the preceptor and given direct feedback on their performance.

Figure 2

Teaching Modules

One component of the Hospital Medicine PA fellowship curriculum that may be unique is the concept of teaching modules. While receiving regular didactic instruction and completing their clinical rotations, the PA is also expected to complete self‐directed teaching module assignments. These modules serve to educate the PA fellow on the hospital as a systemthe true essence of hospital medicine. The modules cover a variety of topics not directly addressed during their rotations. These topics are outlined in Figure 3. Each teaching module consists of a didactic component, clinical application, and assessment (Figure 4) and has its own specific objectives and goals. Teaching modules are often taught by the local expert in the hospital in that particular area. For example, for the infectious control teaching module, the PA fellow will rotate with the infection control nursing staff learning about the isolation and infection control policies of the institution.

Figure 3

Figure 4

Assessment Tools

There are several tools utilized to assess both the PA fellow and the fellowship program itself (Figure 5). The assessment tools used include both ongoing and summative assessments. To fulfill the ongoing assessment, each rotation and teaching module contains assessment tools provided by the preceptor, which are reviewed by the program directors. Additionally, during the clinical rotations, skills are assessed using competency checklists that require the preceptor to directly observe the PA fellow perform a specific task or skill‐set and sign off on its successful completion (Supplementary Figures 6, 7).

Figure 5

There are 2 forms of summative assessment for the PA fellow. First, to assess the PA fellow's knowledge, comprehensive mid‐year and end‐year examinations are utilized. These multiple‐choice examinations are comprised of questions which align with the didactic lectures/objectives provided by the Hospital Medicine faculty throughout the year. The second form of summative evaluation of the fellow is project‐based and divided into 2 parts. First, the fellow is expected to write a publication‐quality manuscript on a hospital medicine topic by the end of the year. Second, the PA fellow is expected to create a professional portfolio, which is comprised of a collection of all of the rotation/module assessments, the formal program assessments, and documentation of all of the skills obtained by the fellow throughout year (competency checklists). This portfolio can be used by the graduate to demonstrate to future employers what skills they possess and provide documentation of knowledge gained during the fellowship.

The program itself is evaluated by several measures. First, the fellow provides formal feedback during the mid‐year and end‐of‐the‐year assessments, which are used to enhance the experience of future fellows. Second, there is ongoing review by both the division of Hospital Medicine and the institution's Allied Health Education Committee, which ensures that the program maintains the appropriate standards and goals.

Future Goals for the PA Fellowship

The program graduated its first fellow at the end of October 2008 and has enjoyed early success. Integrating the PA fellow onto the hospitalist services augmented the present mid‐level and physician teams. There has been excellent institutional support for the program with extremely positive feedback from the rotation preceptors. There are several futures plans for the program. Our first goal is to seek accreditation from the Accreditation Review Commission for Physician Assistants (ARC‐PA), the organization that accredits entry level PA programs and which began formal, voluntary accreditation of postgraduate programs in early 2008. We plan to begin this process within the next academic year.

Our second long‐term goal for the program is to include NPs in the training program. Because of the desire to seek accreditation, the program directors felt temporarily limiting the fellowship to PAs would aide in the rigorous accreditation process, which can take approximately 1 year to complete. There is an NP on our faculty and the program has received interest from NPs. Once we obtain accreditation, expand the program enrollment, and develop an NP curriculum, we plan to open the fellowship to either PA or NP applicants.

Our third goal is to substantiate our PA Fellowship validity with outcome measures and ultimately publishable data. Thus far, the success of the PA fellowship is qualitative, and with small numbers of graduates it is difficult to quantify. After graduation of many subsequent PA fellows, our goal is to obtain quantifiable data that can be used to improve the quality of the PA fellowship and demonstrate the value of postgraduate training for physician assistants.

Perhaps the most important goal of the program is to eventually accept additional PA/NP fellows per year. While 1 program does not meet the demands of a national shortage of hospitalist providers, it may serve as a model that other institutions can adapt to their own needs. Since the program is based upon the SHM Core Competencies, the curriculum can be applied to a variety of hospitalist programs, and its relatively low operating cost makes it feasible for both academic‐based and community‐based institutions. Importantly, since recruitment and retention of employees is such a challenge for most hospitalist groups, this PA fellowship program may serve as a vehicle for recruitment and long‐term retention of well‐trained employees. This precedent has been set, as our division has hired our first PA fellow, whose transition from PA fellow to PA staff was seamless.

In conclusion, our PA fellowship in Hospital Medicine represents the first reported postgraduate PA program of this kind in the United States offering a certificate of completion. As the need for hospitalists increase so will the need for NPPs, particularly those with additional training in hospital medicine. This program serves as an example of 1 type of training tool for physician assistants looking to work in hospital medicine.

In recent years, the demand for hospitalists has outstripped the supply, creating a national shortage.1, 2 A recent Society of Hospital Medicine (SHM) survey found that in the last 2 years there has been a 31% mean growth increase in the number of hospitalist groups.3 As hospitalists are becoming more difficult to recruit, many practices are utilizing physician assistants (PAs) and nurse practitioners (NPs), collectively referred to as nonphysician providers (NPPs) to help offset the workload.4 The SHM survey also noted that the number of hospitalist groups utilizing NPPs increased from 29% to 38%.3 The exact number of NPPs working for hospitalist groups is unknown.

Hospitalist NPPs are in demand for reasons other than just physician shortages. NPPs have been utilized to fill the gap in many institutions where the workforce was impacted by the 2002 Accreditation Council for Graduate Medical Education (ACGME) ruling to restrict resident work hours. Several studies have documented NPPs' ability to assist with the compliance of ACCGME resident work‐hour restrictions while maintaining patient continuity of care, improving length of stays, and reducing health care costs on various hospital services.59 Dresselhaus et al.10 found that 56% of medical resident's time on service was delegated to tasks not related to direct patient care. They proposed that these tasks can be delegated to the NPPs, leaving more time for the residents to focus on direct patient care. In a recent study performed at a Pennsylvania hospital, patients presenting to the emergency department with low‐risk chest pain (based upon thrombolysis in myocardial infarction [TIMI] risk score) were admitted to a nonteaching service staffed with NPPs and attending physicians. Simultaneously, a similar group of low‐risk chest pain patients were admitted to a traditional internal medicine resident service. The results demonstrated lower median length of stay and hospital charges on the nonteaching service. This study suggested that NPPs can offset the workload volume for medical residents, allowing them to focus on patients with higher acuity and greater learning value.11

Barriers to Finding Experienced NPPs in Hospital Medicine

Although many hospitalist groups are interested in hiring NPPs, there can be significant obstacles to recruitment. For example, most experienced PAs and NPs have clinical backgrounds in either surgical or medical subspecialties and therefore typically need extensive on‐the‐job training in hospital medicine, which can often take at least 6 to 12 months to acquire the basic skill set.12 Hiring new graduates may require even longer training periods.

The inexperience of new graduates has become an even more pertinent issue due to recent changes in PA education. Traditionally, PA programs attracted older students with prior healthcare experience, who wished to return to school for additional training. However, in 2005 a major shift occurred in PA education: programs began transitioning from graduating trainees with a bachelor's degree to now requiring a master's level degree for completion of the PA program.13 The acquisition of more advanced degrees has changed the demographics of the students matriculating into PA programs, attracting younger students, straight from undergraduate institutions, with less prior healthcare experience.14 As a result, not only are new PA graduates less experienced overall, but they are particularly lacking in exposure to hospital medicine. After PA students complete their first 12 months of PA school in the basic sciences and didactic coursework, they embark on 12 to 15 months of clinical rotations, which are largely rooted in primary care. In fact, many PA programs find it difficult to offer hospital‐based rotations while fulfilling the required rotations in primary care. These factors have resulted in the need for more extensive on‐the‐job training particularly for those new graduates interested in hospital medicine. In light of these challenges, our institution created a 12‐month postgraduate PA fellowship program in Hospital Medicine.

Postgraduate PA Training Programs

Postgraduate PA fellowships, interchangeably called residencies, are voluntary 1‐year training programs that provide both didactic instruction and clinical experience in a medical or surgical subspecialty, thereby lessening the need for on‐the‐job training. These programs are recognized by the Association of Postgraduate Physician Assistant Programs.15 Currently, there are 44 postgraduate training programs in the United States, in a wide range of medical and surgical specialties. At the end of these 1‐year postgraduate PA programs, most graduates receive a certificate of completion. Until now, the only postgraduate education option for PAs interested in Hospital Medicine was a master's completion program only available to PAs who were already employed by a hospitalist group.15 This work reviews the first reported postgraduate hospitalist training program for PAs. Specifically, the program's background, curriculum, anticipated program outcomes, and future plans are discussed.

Background for A Hospitalist Postgraduate PA Fellowship

Mayo Clinic Arizona is a multispecialty private group comprised of both outpatient services and a tertiary care hospital medical center, located in the metropolitan Phoenix, AZ, area. The Mayo Clinic Hospital is a 7‐story facility with 244 licensed beds, 18 operating rooms, and a Level II emergency department. The Mayo Hospitalist group is composed of 15 full time hospitalists and 6 part‐time hospitalists, all of whom are salaried Mayo employees. The group provides 24‐hour in‐house staffing, covering both resident services (teams composed of interns and residents supervised by a staff hospitalist) and nonresident services (staff hospitalists). Over the years there has been steady growth in the number of nonresident services, in part due to resident work‐hour restrictions. To support the physicians working on these nonresident services, the first PA was hired in 2001. Since then, the number of NPPs in our Hospitalist group has increased to 9.35 full‐time equivalents (FTEs), including 1 nurse practitioner. However, one of the greatest challenges in expanding the NPP service was the difficulty finding candidates with experience in hospital internal medicine. This need inspired the creation of a PA fellowship in Hospital Medicine. At the time, there were 2 other postgraduate PA training programs at the Mayo Clinic Arizona in Hepatology and Otolaryngology/Ear, Nose, and Throat (ENT) Surgery.

Program Description

The Mayo Clinic Arizona PA fellowship in Hospital Medicine began in October 2007 and currently accepts 1 fellow per year. Applicants must be graduates of an Accreditation Review Commission in Education for the Physician Assistant (ARC‐PA)‐accredited PA program and be certified through the National Commission on Certification of Physician Assistants (NCCPA). Furthermore, they must be licensed to work as a PA in the state of Arizona. The program is 12 months in duration, and is comprised of both didactic and clinical components. Upon graduation, the fellow earns a certificate of completion from the Mayo Clinic College of Medicine. The program has received recognition with the Association of Postgraduate Physician Assistant Programs (APPAP).

Two physician assistants act as co‐program directors of the PA fellowship in hospital medicine. They are given 0.10 full‐time equivalent (FTE) for management of the program, which includes day‐to‐day operations, curriculum development, and candidate selection. The program also has 2 volunteer physician medical directors, both of whom have previous medical residency experience. The physicians and NPPs in our hospitalist group volunteer their time to serve as faculty for the program, assisting with much of the didactic and clinical education. The program receives a budget of $99,500 per year, which is funded by the organization's foundation through the department of education. This includes the fellow stipend of $44,000 per 12 months and institutional malpractice insurance coverage. The fellow also receives health and dental insurance, 2 weeks of paid vacation, and $500 stipend toward attendance of a continuing medical education (CME) conference.

CURRICULUM

The PA fellowship curriculum is designed in a diverse unique format that strives to accommodate all types of learners. It includes clinical rotations in various medicine/surgical subspecialties, didactic instruction, and teaching modules (Figure 1). The curriculum is based upon the SHM Core Competencies.15

Figure 1

Clinical Rotations

The PA fellow completes 12 to 14 general hospital medicine and medical specialty rotations, each 2 to 4 weeks in duration. The rotation calendar for the current fellow is given in Figure 2. These rotations are all inpatient‐based and are supervised by either the hospitalist or the respective inpatient subspecialists. The PA fellow's specific clinical responsibilities vary from rotation to rotation, and are designed to maximize the fellow's exposure to that particular specialty. Each rotation has specific written objectives created by the program directors and reviewed by the rotation's preceptor(s) (Figure 2). During the clinical rotations, complementary didactic lectures, coursework, and readings are provided to ensure the PA fellow receives a strong foundation. Didactic instruction is designed by the program directors, physician preceptors and staff NPPs, and is coordinated with the clinical rotation specialty. At the end of each rotation the fellow is evaluated by the preceptor and given direct feedback on their performance.

Figure 2

Teaching Modules

One component of the Hospital Medicine PA fellowship curriculum that may be unique is the concept of teaching modules. While receiving regular didactic instruction and completing their clinical rotations, the PA is also expected to complete self‐directed teaching module assignments. These modules serve to educate the PA fellow on the hospital as a systemthe true essence of hospital medicine. The modules cover a variety of topics not directly addressed during their rotations. These topics are outlined in Figure 3. Each teaching module consists of a didactic component, clinical application, and assessment (Figure 4) and has its own specific objectives and goals. Teaching modules are often taught by the local expert in the hospital in that particular area. For example, for the infectious control teaching module, the PA fellow will rotate with the infection control nursing staff learning about the isolation and infection control policies of the institution.

Figure 3

Figure 4

Assessment Tools

There are several tools utilized to assess both the PA fellow and the fellowship program itself (Figure 5). The assessment tools used include both ongoing and summative assessments. To fulfill the ongoing assessment, each rotation and teaching module contains assessment tools provided by the preceptor, which are reviewed by the program directors. Additionally, during the clinical rotations, skills are assessed using competency checklists that require the preceptor to directly observe the PA fellow perform a specific task or skill‐set and sign off on its successful completion (Supplementary Figures 6, 7).

Figure 5

There are 2 forms of summative assessment for the PA fellow. First, to assess the PA fellow's knowledge, comprehensive mid‐year and end‐year examinations are utilized. These multiple‐choice examinations are comprised of questions which align with the didactic lectures/objectives provided by the Hospital Medicine faculty throughout the year. The second form of summative evaluation of the fellow is project‐based and divided into 2 parts. First, the fellow is expected to write a publication‐quality manuscript on a hospital medicine topic by the end of the year. Second, the PA fellow is expected to create a professional portfolio, which is comprised of a collection of all of the rotation/module assessments, the formal program assessments, and documentation of all of the skills obtained by the fellow throughout year (competency checklists). This portfolio can be used by the graduate to demonstrate to future employers what skills they possess and provide documentation of knowledge gained during the fellowship.

The program itself is evaluated by several measures. First, the fellow provides formal feedback during the mid‐year and end‐of‐the‐year assessments, which are used to enhance the experience of future fellows. Second, there is ongoing review by both the division of Hospital Medicine and the institution's Allied Health Education Committee, which ensures that the program maintains the appropriate standards and goals.

Future Goals for the PA Fellowship

The program graduated its first fellow at the end of October 2008 and has enjoyed early success. Integrating the PA fellow onto the hospitalist services augmented the present mid‐level and physician teams. There has been excellent institutional support for the program with extremely positive feedback from the rotation preceptors. There are several futures plans for the program. Our first goal is to seek accreditation from the Accreditation Review Commission for Physician Assistants (ARC‐PA), the organization that accredits entry level PA programs and which began formal, voluntary accreditation of postgraduate programs in early 2008. We plan to begin this process within the next academic year.

Our second long‐term goal for the program is to include NPs in the training program. Because of the desire to seek accreditation, the program directors felt temporarily limiting the fellowship to PAs would aide in the rigorous accreditation process, which can take approximately 1 year to complete. There is an NP on our faculty and the program has received interest from NPs. Once we obtain accreditation, expand the program enrollment, and develop an NP curriculum, we plan to open the fellowship to either PA or NP applicants.

Our third goal is to substantiate our PA Fellowship validity with outcome measures and ultimately publishable data. Thus far, the success of the PA fellowship is qualitative, and with small numbers of graduates it is difficult to quantify. After graduation of many subsequent PA fellows, our goal is to obtain quantifiable data that can be used to improve the quality of the PA fellowship and demonstrate the value of postgraduate training for physician assistants.

Perhaps the most important goal of the program is to eventually accept additional PA/NP fellows per year. While 1 program does not meet the demands of a national shortage of hospitalist providers, it may serve as a model that other institutions can adapt to their own needs. Since the program is based upon the SHM Core Competencies, the curriculum can be applied to a variety of hospitalist programs, and its relatively low operating cost makes it feasible for both academic‐based and community‐based institutions. Importantly, since recruitment and retention of employees is such a challenge for most hospitalist groups, this PA fellowship program may serve as a vehicle for recruitment and long‐term retention of well‐trained employees. This precedent has been set, as our division has hired our first PA fellow, whose transition from PA fellow to PA staff was seamless.

In conclusion, our PA fellowship in Hospital Medicine represents the first reported postgraduate PA program of this kind in the United States offering a certificate of completion. As the need for hospitalists increase so will the need for NPPs, particularly those with additional training in hospital medicine. This program serves as an example of 1 type of training tool for physician assistants looking to work in hospital medicine.

In 2001, approximately 12.6 million individuals age 65 and older were discharged from American hospitals with an average length of stay of 5.8 days1 and up to 66% of them suffered from cognitive impairment (CI).220 CI in hospitalized older adults includes a variety of disorders ranging from mild cognitive deficit, delirium, to full‐blown dementia. Dementia is a syndrome of decline in memory plus at least 1 other cognitive domain, such as language, visuospatial, or executive function sufficient to interfere with social or occupational functioning in an alert person.21 Delirium is a disturbance of consciousness with reduced ability to focus, sustain, or shift attention that occurs over a short period of time and tends to fluctuate over the course of the day.22 Mild CI without dementia is defined as the presence of a cognitive deficit in the absence of delirium that does not affect functional performance.23

Hospitalized older adults with CI are vulnerable to hospital complications, including delirium, physical restraints, urinary catheters, and tethers.2, 3, 2435 The management of their medical or surgical illnesses requires avoiding certain medications with anticholinergic activities that might worsen cognition.36 Furthermore, CI may delay diagnostic and therapeutic procedures, demand more time for informed consentrelated issues, and result in difficulty in adherence to medical recommendations.37, 38 The special needs of hospitalized older adults with delirium and dementia has been shown to increase demands on nursing staff, risk of postdischarge institutionalization, length of stay, and health care costs.310, 27, 3948 We wanted to look specifically at CI because it often goes undetected4951 and can have a great impact on the hospital course of elders.

Screening for CI among hospitalized older adults has been considered to have potential benefit in hospital care of older adults.52 Screening may lead to early detection by uncovering subtle symptoms not yet apparent to families or other caregivers who know the patient well but do not notice small declines or changes in day‐to‐day functioning. Early recognition of CI may lead to early treatment and subsequently may delay progression of cognitive decline and improve health outcomes. Screening may enhance physician prescribing practices and reduce exposure to harmful medications among these vulnerable patients. Finally, delirium is an important prognostic indicator, and screening patients could provide invaluable information toward the overall clinical picture. Despite all of this, the current literature does not provide sufficient information to support the use of routine screening on admission.220, 41, 5254 Most of the published studies were conducted among elders who stayed in the hospital for more than 48 hours, missing data on the crucial first 48 hours of the hospital course.220, 41, 5254 These studies did not evaluate the impact of unrecognized CI on the hospital course and the majority of these studies were not conducted in the urban and lower socioeconomic status populations of elders that are the most vulnerable to bad health outcomes.220, 41, 5254 Finally, few studies evaluated the impact of delirium superimposed on CI on the hospital course and mortality of elders.220, 41, 5254

With these details in mind, we wanted to explore the impact of CI recognition among patients age 65 years and older admitted to the medical services of an urban, public hospital in Indianapolis to determine the prevalence and the impact of recognized and unrecognized CI on the hospital course of these elders. Furthermore, we examined the role of delirium superimposed on these hospitalized elders with CI.

Patients and Methods

The study was approved by the Indiana University Purdue University at Indianapolis Institutional Review Board (IRB).

Results

Discussion

Our study found that in an urban, public hospital, acute or preexisting CI affects more than one‐third of hospitalized elders admitted to general medical services. Unfortunately, our hospital system does not currently recognize the majority of these vulnerable patients. Our study also found that delirium affects more than one‐third of hospitalized elders with CI during their hospital course. Delirium complicates hospital care by prolonging length of stay and decreasing the probability of surviving and getting discharged home. It leads to high use of Foley catheterization, physical restraints, and tethers.

The high prevalence of CI with and without delirium in our cohort is within the rates reported previously in the literature. It is estimated that the prevalence of CI in hospitalized older adults ranges from 14% to 66%, depending on the method used to measure cognition, the definition of CI, and the type of hospital ward (surgical, medical, and geriatric units).220 One particular study that used a similar cognitive assessment method reported higher prevalence rates for both CI and delirium.11 The study randomly evaluated a sample of 201 patients age 65 and over who were hospitalized for a medical illness and found that 56% of the cohort suffered from CI and among those with CI, 47% had delirium.11 The difference between this finding and our study is most likely due to our sampling technique; more than 70% of our cognitive screening occurred in the first 48 hours of hospital admission whereas the Australian study, in similar enrollment criteria to all of the published studies in this area, excluded patients who were discharged within 48 hours of admission. We believe, however, that by including the first 48 hours of admission in our design, our study provides a more generalizable reflection of the actual acute care experience.

The impact of delirium on the course of hospital care found in our study supports some of the findings from previous studies conducted in the past 2 decades.5, 6, 11 Despite 2 decades of clinical research, delirium continues to increase mortality, hospital stays, and posthospital institutionalization.

We were surprised to find that patients suffering from delirium continue to receive at least 1 definite anticholinergic medication. Such medications are considered inappropriate among patients with any form of cognitive impairment.36, 62 Although the impact of anticholinergic medications on hospitalized outcomes is less well‐described, their use has been suspected to negatively impact long‐term outcomes of cognitive impairment.61, 63 Our study found no difference in the use of anticholinergic medications between those with CI who experienced delirium and those who did not; however, the total burden of anticholinergic medication was not assessed in a quantitative manner. It is still unknown if certain anticholinergic medications or a cumulative effect of anticholinergic medications may impact cognitive or health‐related outcomes in a vulnerable older population with CI.

Although our study reported for the first time in a systematic way the rate of undocumented CI among hospitalized elders found to have CI on admission, we found no impact of such underrecognition on the length of hospital stay, mortality, discharge location, and delirium occurrence. Although the use of anticholinergic medications is not recommended for patients with any form of CI, our results indicate that a significant number of patients with cognitive impairment continue to receive inappropriate medications. CI recognition in the elderly was not shown to have a statistically significant affect on length of stay, cost, or mortality.

Our study has some limitations. First of all, we did not determine the underlying types of CI such as Alzheimer disease, vascular dementia, mild cognitive impairment, or reversible etiology other than delirium. Such a categorization requires posthospital assessment, which was not included in our study design. Second, our delirium incidence rate and delirium impact on hospital outcomes might be very conservative and may underestimate its true prevalence and correlation due to our data collection methods. Despite the fluctuating nature of delirium, our study was not designed to assess the presence of delirium every shift and tried to assess cognitive function on a daily basis throughout the patient's hospitalization. Therefore, the severity and duration of delirium could not be accurately assessed. Our reported rates of use of Foley catheterization, physical restraints, and tethers are also very conservative and we could not determine the appropriateness of these procedures. Our study was conducted in 1 public hospital in an urban city with a higher percentage of African Americans. Thus, our sample is not a true representative sample. However, studies with significant representation of minority groups are not common in the research literature, especially in CI research; we hope to fulfill some of the gaps in the literature regarding the most vulnerable older American population. Finally, we were limited in our use of ICD‐9 coding to determine if patients had previously been recognized by other providers as having CI. ICD‐9 coding, while useful, is not perfect in identifying all if a patient's medical problems. Use of coding to determine whether a patient had been recognized as impaired also does not allow us to determine when the diagnosis was made.

In conclusion, our study evaluated cognitive impairment in hospitalized elders and found that in our cohort of 997 patients, 43% were cognitively impaired on admission. Of those with CI, 61% were not documented or recognized as impaired. We found no statistically significant difference between those with documented CI and those with undocumented CI in terms of length of stay, mortality, home discharge, readmission rates, incidence of delirium, or potential to receive anticholinergics or restraints. Among those with CI, 38% had delirium. Those with delirium experienced increased length of stay, decreased discharge to home, and increased use of Foley catheters and restraints.

In 2001, approximately 12.6 million individuals age 65 and older were discharged from American hospitals with an average length of stay of 5.8 days1 and up to 66% of them suffered from cognitive impairment (CI).220 CI in hospitalized older adults includes a variety of disorders ranging from mild cognitive deficit, delirium, to full‐blown dementia. Dementia is a syndrome of decline in memory plus at least 1 other cognitive domain, such as language, visuospatial, or executive function sufficient to interfere with social or occupational functioning in an alert person.21 Delirium is a disturbance of consciousness with reduced ability to focus, sustain, or shift attention that occurs over a short period of time and tends to fluctuate over the course of the day.22 Mild CI without dementia is defined as the presence of a cognitive deficit in the absence of delirium that does not affect functional performance.23

Hospitalized older adults with CI are vulnerable to hospital complications, including delirium, physical restraints, urinary catheters, and tethers.2, 3, 2435 The management of their medical or surgical illnesses requires avoiding certain medications with anticholinergic activities that might worsen cognition.36 Furthermore, CI may delay diagnostic and therapeutic procedures, demand more time for informed consentrelated issues, and result in difficulty in adherence to medical recommendations.37, 38 The special needs of hospitalized older adults with delirium and dementia has been shown to increase demands on nursing staff, risk of postdischarge institutionalization, length of stay, and health care costs.310, 27, 3948 We wanted to look specifically at CI because it often goes undetected4951 and can have a great impact on the hospital course of elders.

Screening for CI among hospitalized older adults has been considered to have potential benefit in hospital care of older adults.52 Screening may lead to early detection by uncovering subtle symptoms not yet apparent to families or other caregivers who know the patient well but do not notice small declines or changes in day‐to‐day functioning. Early recognition of CI may lead to early treatment and subsequently may delay progression of cognitive decline and improve health outcomes. Screening may enhance physician prescribing practices and reduce exposure to harmful medications among these vulnerable patients. Finally, delirium is an important prognostic indicator, and screening patients could provide invaluable information toward the overall clinical picture. Despite all of this, the current literature does not provide sufficient information to support the use of routine screening on admission.220, 41, 5254 Most of the published studies were conducted among elders who stayed in the hospital for more than 48 hours, missing data on the crucial first 48 hours of the hospital course.220, 41, 5254 These studies did not evaluate the impact of unrecognized CI on the hospital course and the majority of these studies were not conducted in the urban and lower socioeconomic status populations of elders that are the most vulnerable to bad health outcomes.220, 41, 5254 Finally, few studies evaluated the impact of delirium superimposed on CI on the hospital course and mortality of elders.220, 41, 5254

With these details in mind, we wanted to explore the impact of CI recognition among patients age 65 years and older admitted to the medical services of an urban, public hospital in Indianapolis to determine the prevalence and the impact of recognized and unrecognized CI on the hospital course of these elders. Furthermore, we examined the role of delirium superimposed on these hospitalized elders with CI.

Patients and Methods

The study was approved by the Indiana University Purdue University at Indianapolis Institutional Review Board (IRB).

Results

Discussion

Our study found that in an urban, public hospital, acute or preexisting CI affects more than one‐third of hospitalized elders admitted to general medical services. Unfortunately, our hospital system does not currently recognize the majority of these vulnerable patients. Our study also found that delirium affects more than one‐third of hospitalized elders with CI during their hospital course. Delirium complicates hospital care by prolonging length of stay and decreasing the probability of surviving and getting discharged home. It leads to high use of Foley catheterization, physical restraints, and tethers.

The high prevalence of CI with and without delirium in our cohort is within the rates reported previously in the literature. It is estimated that the prevalence of CI in hospitalized older adults ranges from 14% to 66%, depending on the method used to measure cognition, the definition of CI, and the type of hospital ward (surgical, medical, and geriatric units).220 One particular study that used a similar cognitive assessment method reported higher prevalence rates for both CI and delirium.11 The study randomly evaluated a sample of 201 patients age 65 and over who were hospitalized for a medical illness and found that 56% of the cohort suffered from CI and among those with CI, 47% had delirium.11 The difference between this finding and our study is most likely due to our sampling technique; more than 70% of our cognitive screening occurred in the first 48 hours of hospital admission whereas the Australian study, in similar enrollment criteria to all of the published studies in this area, excluded patients who were discharged within 48 hours of admission. We believe, however, that by including the first 48 hours of admission in our design, our study provides a more generalizable reflection of the actual acute care experience.

The impact of delirium on the course of hospital care found in our study supports some of the findings from previous studies conducted in the past 2 decades.5, 6, 11 Despite 2 decades of clinical research, delirium continues to increase mortality, hospital stays, and posthospital institutionalization.

We were surprised to find that patients suffering from delirium continue to receive at least 1 definite anticholinergic medication. Such medications are considered inappropriate among patients with any form of cognitive impairment.36, 62 Although the impact of anticholinergic medications on hospitalized outcomes is less well‐described, their use has been suspected to negatively impact long‐term outcomes of cognitive impairment.61, 63 Our study found no difference in the use of anticholinergic medications between those with CI who experienced delirium and those who did not; however, the total burden of anticholinergic medication was not assessed in a quantitative manner. It is still unknown if certain anticholinergic medications or a cumulative effect of anticholinergic medications may impact cognitive or health‐related outcomes in a vulnerable older population with CI.

Although our study reported for the first time in a systematic way the rate of undocumented CI among hospitalized elders found to have CI on admission, we found no impact of such underrecognition on the length of hospital stay, mortality, discharge location, and delirium occurrence. Although the use of anticholinergic medications is not recommended for patients with any form of CI, our results indicate that a significant number of patients with cognitive impairment continue to receive inappropriate medications. CI recognition in the elderly was not shown to have a statistically significant affect on length of stay, cost, or mortality.

Our study has some limitations. First of all, we did not determine the underlying types of CI such as Alzheimer disease, vascular dementia, mild cognitive impairment, or reversible etiology other than delirium. Such a categorization requires posthospital assessment, which was not included in our study design. Second, our delirium incidence rate and delirium impact on hospital outcomes might be very conservative and may underestimate its true prevalence and correlation due to our data collection methods. Despite the fluctuating nature of delirium, our study was not designed to assess the presence of delirium every shift and tried to assess cognitive function on a daily basis throughout the patient's hospitalization. Therefore, the severity and duration of delirium could not be accurately assessed. Our reported rates of use of Foley catheterization, physical restraints, and tethers are also very conservative and we could not determine the appropriateness of these procedures. Our study was conducted in 1 public hospital in an urban city with a higher percentage of African Americans. Thus, our sample is not a true representative sample. However, studies with significant representation of minority groups are not common in the research literature, especially in CI research; we hope to fulfill some of the gaps in the literature regarding the most vulnerable older American population. Finally, we were limited in our use of ICD‐9 coding to determine if patients had previously been recognized by other providers as having CI. ICD‐9 coding, while useful, is not perfect in identifying all if a patient's medical problems. Use of coding to determine whether a patient had been recognized as impaired also does not allow us to determine when the diagnosis was made.

In conclusion, our study evaluated cognitive impairment in hospitalized elders and found that in our cohort of 997 patients, 43% were cognitively impaired on admission. Of those with CI, 61% were not documented or recognized as impaired. We found no statistically significant difference between those with documented CI and those with undocumented CI in terms of length of stay, mortality, home discharge, readmission rates, incidence of delirium, or potential to receive anticholinergics or restraints. Among those with CI, 38% had delirium. Those with delirium experienced increased length of stay, decreased discharge to home, and increased use of Foley catheters and restraints.

In 2001, approximately 12.6 million individuals age 65 and older were discharged from American hospitals with an average length of stay of 5.8 days1 and up to 66% of them suffered from cognitive impairment (CI).220 CI in hospitalized older adults includes a variety of disorders ranging from mild cognitive deficit, delirium, to full‐blown dementia. Dementia is a syndrome of decline in memory plus at least 1 other cognitive domain, such as language, visuospatial, or executive function sufficient to interfere with social or occupational functioning in an alert person.21 Delirium is a disturbance of consciousness with reduced ability to focus, sustain, or shift attention that occurs over a short period of time and tends to fluctuate over the course of the day.22 Mild CI without dementia is defined as the presence of a cognitive deficit in the absence of delirium that does not affect functional performance.23

Hospitalized older adults with CI are vulnerable to hospital complications, including delirium, physical restraints, urinary catheters, and tethers.2, 3, 2435 The management of their medical or surgical illnesses requires avoiding certain medications with anticholinergic activities that might worsen cognition.36 Furthermore, CI may delay diagnostic and therapeutic procedures, demand more time for informed consentrelated issues, and result in difficulty in adherence to medical recommendations.37, 38 The special needs of hospitalized older adults with delirium and dementia has been shown to increase demands on nursing staff, risk of postdischarge institutionalization, length of stay, and health care costs.310, 27, 3948 We wanted to look specifically at CI because it often goes undetected4951 and can have a great impact on the hospital course of elders.

Screening for CI among hospitalized older adults has been considered to have potential benefit in hospital care of older adults.52 Screening may lead to early detection by uncovering subtle symptoms not yet apparent to families or other caregivers who know the patient well but do not notice small declines or changes in day‐to‐day functioning. Early recognition of CI may lead to early treatment and subsequently may delay progression of cognitive decline and improve health outcomes. Screening may enhance physician prescribing practices and reduce exposure to harmful medications among these vulnerable patients. Finally, delirium is an important prognostic indicator, and screening patients could provide invaluable information toward the overall clinical picture. Despite all of this, the current literature does not provide sufficient information to support the use of routine screening on admission.220, 41, 5254 Most of the published studies were conducted among elders who stayed in the hospital for more than 48 hours, missing data on the crucial first 48 hours of the hospital course.220, 41, 5254 These studies did not evaluate the impact of unrecognized CI on the hospital course and the majority of these studies were not conducted in the urban and lower socioeconomic status populations of elders that are the most vulnerable to bad health outcomes.220, 41, 5254 Finally, few studies evaluated the impact of delirium superimposed on CI on the hospital course and mortality of elders.220, 41, 5254

With these details in mind, we wanted to explore the impact of CI recognition among patients age 65 years and older admitted to the medical services of an urban, public hospital in Indianapolis to determine the prevalence and the impact of recognized and unrecognized CI on the hospital course of these elders. Furthermore, we examined the role of delirium superimposed on these hospitalized elders with CI.

Patients and Methods

The study was approved by the Indiana University Purdue University at Indianapolis Institutional Review Board (IRB).

Results

Discussion

Our study found that in an urban, public hospital, acute or preexisting CI affects more than one‐third of hospitalized elders admitted to general medical services. Unfortunately, our hospital system does not currently recognize the majority of these vulnerable patients. Our study also found that delirium affects more than one‐third of hospitalized elders with CI during their hospital course. Delirium complicates hospital care by prolonging length of stay and decreasing the probability of surviving and getting discharged home. It leads to high use of Foley catheterization, physical restraints, and tethers.

The high prevalence of CI with and without delirium in our cohort is within the rates reported previously in the literature. It is estimated that the prevalence of CI in hospitalized older adults ranges from 14% to 66%, depending on the method used to measure cognition, the definition of CI, and the type of hospital ward (surgical, medical, and geriatric units).220 One particular study that used a similar cognitive assessment method reported higher prevalence rates for both CI and delirium.11 The study randomly evaluated a sample of 201 patients age 65 and over who were hospitalized for a medical illness and found that 56% of the cohort suffered from CI and among those with CI, 47% had delirium.11 The difference between this finding and our study is most likely due to our sampling technique; more than 70% of our cognitive screening occurred in the first 48 hours of hospital admission whereas the Australian study, in similar enrollment criteria to all of the published studies in this area, excluded patients who were discharged within 48 hours of admission. We believe, however, that by including the first 48 hours of admission in our design, our study provides a more generalizable reflection of the actual acute care experience.

The impact of delirium on the course of hospital care found in our study supports some of the findings from previous studies conducted in the past 2 decades.5, 6, 11 Despite 2 decades of clinical research, delirium continues to increase mortality, hospital stays, and posthospital institutionalization.

We were surprised to find that patients suffering from delirium continue to receive at least 1 definite anticholinergic medication. Such medications are considered inappropriate among patients with any form of cognitive impairment.36, 62 Although the impact of anticholinergic medications on hospitalized outcomes is less well‐described, their use has been suspected to negatively impact long‐term outcomes of cognitive impairment.61, 63 Our study found no difference in the use of anticholinergic medications between those with CI who experienced delirium and those who did not; however, the total burden of anticholinergic medication was not assessed in a quantitative manner. It is still unknown if certain anticholinergic medications or a cumulative effect of anticholinergic medications may impact cognitive or health‐related outcomes in a vulnerable older population with CI.

Although our study reported for the first time in a systematic way the rate of undocumented CI among hospitalized elders found to have CI on admission, we found no impact of such underrecognition on the length of hospital stay, mortality, discharge location, and delirium occurrence. Although the use of anticholinergic medications is not recommended for patients with any form of CI, our results indicate that a significant number of patients with cognitive impairment continue to receive inappropriate medications. CI recognition in the elderly was not shown to have a statistically significant affect on length of stay, cost, or mortality.

Our study has some limitations. First of all, we did not determine the underlying types of CI such as Alzheimer disease, vascular dementia, mild cognitive impairment, or reversible etiology other than delirium. Such a categorization requires posthospital assessment, which was not included in our study design. Second, our delirium incidence rate and delirium impact on hospital outcomes might be very conservative and may underestimate its true prevalence and correlation due to our data collection methods. Despite the fluctuating nature of delirium, our study was not designed to assess the presence of delirium every shift and tried to assess cognitive function on a daily basis throughout the patient's hospitalization. Therefore, the severity and duration of delirium could not be accurately assessed. Our reported rates of use of Foley catheterization, physical restraints, and tethers are also very conservative and we could not determine the appropriateness of these procedures. Our study was conducted in 1 public hospital in an urban city with a higher percentage of African Americans. Thus, our sample is not a true representative sample. However, studies with significant representation of minority groups are not common in the research literature, especially in CI research; we hope to fulfill some of the gaps in the literature regarding the most vulnerable older American population. Finally, we were limited in our use of ICD‐9 coding to determine if patients had previously been recognized by other providers as having CI. ICD‐9 coding, while useful, is not perfect in identifying all if a patient's medical problems. Use of coding to determine whether a patient had been recognized as impaired also does not allow us to determine when the diagnosis was made.

In conclusion, our study evaluated cognitive impairment in hospitalized elders and found that in our cohort of 997 patients, 43% were cognitively impaired on admission. Of those with CI, 61% were not documented or recognized as impaired. We found no statistically significant difference between those with documented CI and those with undocumented CI in terms of length of stay, mortality, home discharge, readmission rates, incidence of delirium, or potential to receive anticholinergics or restraints. Among those with CI, 38% had delirium. Those with delirium experienced increased length of stay, decreased discharge to home, and increased use of Foley catheters and restraints.