Practice Management

Editors’ note: “Alliances” is a series written about the relationships that hospitalists have with members of the clinical care team—from the team members’ points of view. Each installment of “Alliances” provides valuable, revealing feedback that hospitalists can use to continually improve their intrateam relationships and, ultimately, patient care.

Several months ago, a patient with decompensated end-stage liver disease was admitted to the Internal Medicine Hospitalist Service at the University of Texas Medical Branch in Galveston and required a paracentesis. One of the new hospitalist faculty members was taken aback when the physician assistant (PA) on the service volunteered to do the procedure. “He was surprised,” says Karen Kislingbury, PA-C, a member of SHM’s Non-Physician Provider Task Force and a PA with the Internal Medicine Hospitalist Service, “that the scope of practice for the physician assistant included [performing] procedures.”

PAs are not new to the hospital setting, and their inclusion as physician extenders to increase patient access to care will likely increase in the current regulatory environment—especially state-mandated staff/patient ratios and resident work hour limitations. The efficacy of utilizing physician extenders to improve patient care and outcomes has been validated in studies over the past two decades. A recent Journal of Trauma study found statistically significant reductions in floor, ICU, and overall hospital lengths of stay after incorporating physician extenders into their trauma service.1

However, hospitalists unfamiliar with PAs may not understand their colleagues’ roles and scope of practice. As her anecdote illustrated, Kislingbury notes that “although PAs aren’t new to the healthcare delivery system, and physicians have been utilizing us for a long time, our partnership in the unique setting of hospital medicine is kind of new.”

Kislingbury’s colleague Ryan Genzink, PA-C, who works with Hospitalists of West Michigan, a private hospitalists-only group that subcontracts hospitalist services to Spectrum Health of Grand Rapids, Mich., agrees with her assessment.

“There are more and more PAs and [nurse practitioners] working in hospital medicine, and I think there is a lot of curiosity and some apprehension on the part of people who have not worked with these non-physician providers,” says Genzink.

Genzink, also a member of SHM’s Non-Physician Provider Task Force, speculates that the apprehension of physicians who have not worked with PAs may be due to a misunderstanding of the PA’s role. “They’re either underestimating or overestimating exactly what a PA can do or what they are getting when they hire a PA,” he says.

A Short History of the Profession

PA programs officially began in the mid-1960s at Duke University Medical School (Durham, N.C.). Eugene Stead, MD, is credited with developing the concept of the physician assistant as a health professional who would work with physician supervision to extend patient access to care, according to the American Academy of Physician Assistants.

For the first class of PAs in 1965, Dr. Stead selected Navy corpsmen who had received medical training and experience during their service in Vietnam. The curriculum was based on Dr. Stead’s knowledge of fast-track training of physicians during World War II. From this early program, the profession has evolved to more than 130 programs that now adhere to rigorous national accreditation standards set forth by the independent Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). The ARC-PA is sponsored by the American Medical Association and the American College of Surgeons, among many other professional medical organizations (www.aapa.org/geninfo1.html).

Scope of Practice

Prerequisites to PA programs include two years of college courses in basic and behavioral science, as well as prior experience in healthcare. According to a report generated by the Association of Physician Assistant Programs, most PA students have earned a bachelor’s degree and have an average of 38 months of healthcare experience before being admitted to a PA program.2

The first year of PA education comprises a didactic curriculum with coursework in anatomy, physiology, biochemistry, pharmacology, physical diagnosis, pathophysiology, microbiology, clinical laboratory sciences, behavioral sciences, and medical ethics. In the second year, students receive hands-on clinical training through a series of rotations—typically in family and internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine, and psychiatry. By the time they graduate (typical PA programs last an average of 26 months), PAs will have completed more than 2,000 hours of supervised clinical practice.

PAs work in all areas of medicine. Although hospital bylaws and state regulations often stipulate the PA’s scope of practice, the major determinant of duties is the supervising physician. The relationship between supervising physician and PA, says Kislingbury, is a collaborative one. Duties are “defined on an individual basis, and they are determined based on our [PAs’] experience, the physicians’ experience with us, and then the nuances of the system and the hospital itself.

“The PA who is hired should know what his or her scope of practice is,” she continues. “By the time they have graduated and obtained their license, they should know what their state allows them to do.”

For instance, according to the American Academy of Physician Assistants, 48 of the 50 states, plus the District of Columbia and [the U.S. Territory of] Guam, authorize PAs to prescribe medications. In California, PA prescriptions are referred to as “written prescription transmittal orders.”

“For the most part,” says Genzink, “the supervising physician determines what the PA is capable of doing, within the guidelines of state law.”

Within Genzink’s hospital medicine group (with which he has been affiliated for five years) the physician and PA roles are very similar.

“We see the same type of patients in a team approach. For instance, it’s not uncommon for one of us to order a test early in the day, and then, when results come back, the other person may be discharging that patient or prescribing other treatments, if necessary,” he explains. “In general, the physicians take care of the more complicated patients, while PAs take care of more routine patients.”

Genzink’s group experience aligns with findings of a 1998 University of Pittsburgh School of Nursing Study, which evaluated provider roles and patient outcomes in an acute care setting.3 Compared with acute care nurse practitioners and PAs, residents in that study tended to care for patients who were older and sicker.

Genzink reports that in his group initial histories and physicals, as well as the consultations, are performed exclusively by the PAs and then the physician takes over for treatment. “Based on the acuity of the patient,” says Genzink, “the physician may be right down there to see the patient immediately.”

Areas for Improvement?

Although the two PAs interviewed for this article report positive experiences working with hospitalists, they admit that some physicians continue to hold misperceptions about the PA’s role in caring for patients.

Kislingbury says that hospitalists could improve their delegation of duties to the PAs and recognize their scope of practice. She admits that delegation duties can be improved through gaining experience. “Although the PA profession has been around for a while, there are a surprising number of institutions that do not utilize physician assistants on the wards in routine rounds and bedside-type care,” says Kislingbury.

“I think some of the problems develop when they [physicians] hire a PA and expect to get a physician—and they [don’t],” says Genzink. “The easiest way for me to explain the role is to compare it to a teaching model. All physicians have been through residency programs. They understand the hierarchy that involves training and teaching residents. PAs come out of school ‘green,’ with the assumption that training will go on at the workplace. So, if a physician takes the same stance toward a new PA as they would toward an intern, that is a pretty close comparison.

“You begin by letting PAs or interns do a few simple things, and as they master those, you teach them more,” he continues. “And then, hopefully, over time they’ve been able to master everything that the physician is able to master. [Employing a PA] is a significant investment. And, it takes time. Sometimes, that process can be very easy, depending on the person. Sometimes it can be very slow, and I think that’s sometimes where some of the frustration may come in.”

Genzink adds that in his hospital medicine group, the physicians are familiar with the idea that part of their job as supervising physicians is to train new PAs.

Kislingbury points that out that PAs can also play a role in informing the physician team members about the range of cases they are allowed to treat, thus furthering the collaboration between PAs and hospitalists: “It is merely a matter of educating the team members about what we can and cannot do.”

Accordingly, the SHM Non-Physician Provider Task Force was formed to provide a resource to hospitalists who work with PAs and have questions about scope of practice, reimbursement, and other issues as they pertain to PAs and nurse practitioners. (Visit www.hospitalmedicine.org for more information.) The Task Force is a resource for non-physicians providers, too, offering educational opportunities at SHM meetings, more visibility with the specialty, and a voice for advocacy.

The Positives of the Collaboration

While the PAs report that hospitalists could improve in communicating about their practice roles with PAs, “There are so many things that hospitalists do right!” says Kislingbury. Calling the experience of working with hospitalists a privilege, she says that “where it is a true partnership, we are treated as equals, we are given the responsibility that our experience will allow, and we are truly team members.

“Hospitalists are geared into the efficiencies of the system and the nuances of the hospital. These are subtleties that come with practicing in an area for a long period of time, not just coming in for a month and then leaving and returning,” she says. “Hospitalists know the daily ins and outs, and it is really a pleasure to learn from them.”

Prior to his affiliation with Hospitalists of West Michigan, Genzink was employed directly by a hospital in Grand Rapids. The physicians with whom he now works have been hospitalists almost exclusively throughout their medical careers. “One of the main benefits they offer is availability, simply because we [the group’s practice members] are in the hospital 24/7,” he says. “They also have more experience in dealing with more complex issues, just as do the PAs that are working in our system.”

What about the notion that PAs and nurse practitioners are more skilled or practiced with patient and family communications? One study by Rudy, et al. found that nurse practitioners and PAs were more likely than residents to discuss patients with bedside nurses and to interact with patients’ families.3 Genzink does not find this to be the case in his group’s practice.

“That presumption [that PAs are more communicative with families and patients] may have come about simply because as the demands on hospitalists continue to grow and the workload increases, adding the PA to the team means there are more people to do things like that [handle family communications],” he says. “Certainly, in our group, the PAs do lots of patient education, and we talk to patients about end-of-life issues and other difficult matters as well. But that is not delegated to them; in our group, both the PAs and the physicians participate equally in patient and family communication.”

Daily Learning

Hospitalists and PAs also complement each other in the interdisciplinary care team because, “as a general rule, hospitalists love to teach,” says Kislingbury. “They don’t forget that just because you have your PA degree your learning does not stop there. The PA profession is almost like on-the-job training. You are allowed to choose the specialty that you want, and you gain your experience when you enter that [arena], as opposed to an internship or residency, where you first gain experience and then enter the specialty. We so appreciate the ability of the hospitalist to teach because we are learning while doing, on a day-to-day basis. It’s invaluable to have their teaching.” TH

Gretchen Henkel also writes about dealing with difficult families in this issue.

Resources

1. Christmas AB, Reynolds J, Hodges S, et al. Physician extenders impact trauma systems. J Trauma. 2005 May;58(5):917-920.
2. Nineteenth Annual Report on Physician Assistant Educational Programs in the United States, 2002-2203. Alexandria, Va. Association of Physician Assistant Programs.
3. Rudy EB, Davidson LJ, Daly B, et al. Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: a comparison. Am J Crit Care. 1998 Jul;7(4):267-281.

Editors’ note: “Alliances” is a series written about the relationships that hospitalists have with members of the clinical care team—from the team members’ points of view. Each installment of “Alliances” provides valuable, revealing feedback that hospitalists can use to continually improve their intrateam relationships and, ultimately, patient care.

Several months ago, a patient with decompensated end-stage liver disease was admitted to the Internal Medicine Hospitalist Service at the University of Texas Medical Branch in Galveston and required a paracentesis. One of the new hospitalist faculty members was taken aback when the physician assistant (PA) on the service volunteered to do the procedure. “He was surprised,” says Karen Kislingbury, PA-C, a member of SHM’s Non-Physician Provider Task Force and a PA with the Internal Medicine Hospitalist Service, “that the scope of practice for the physician assistant included [performing] procedures.”

PAs are not new to the hospital setting, and their inclusion as physician extenders to increase patient access to care will likely increase in the current regulatory environment—especially state-mandated staff/patient ratios and resident work hour limitations. The efficacy of utilizing physician extenders to improve patient care and outcomes has been validated in studies over the past two decades. A recent Journal of Trauma study found statistically significant reductions in floor, ICU, and overall hospital lengths of stay after incorporating physician extenders into their trauma service.1

However, hospitalists unfamiliar with PAs may not understand their colleagues’ roles and scope of practice. As her anecdote illustrated, Kislingbury notes that “although PAs aren’t new to the healthcare delivery system, and physicians have been utilizing us for a long time, our partnership in the unique setting of hospital medicine is kind of new.”

Kislingbury’s colleague Ryan Genzink, PA-C, who works with Hospitalists of West Michigan, a private hospitalists-only group that subcontracts hospitalist services to Spectrum Health of Grand Rapids, Mich., agrees with her assessment.

“There are more and more PAs and [nurse practitioners] working in hospital medicine, and I think there is a lot of curiosity and some apprehension on the part of people who have not worked with these non-physician providers,” says Genzink.

Genzink, also a member of SHM’s Non-Physician Provider Task Force, speculates that the apprehension of physicians who have not worked with PAs may be due to a misunderstanding of the PA’s role. “They’re either underestimating or overestimating exactly what a PA can do or what they are getting when they hire a PA,” he says.

A Short History of the Profession

PA programs officially began in the mid-1960s at Duke University Medical School (Durham, N.C.). Eugene Stead, MD, is credited with developing the concept of the physician assistant as a health professional who would work with physician supervision to extend patient access to care, according to the American Academy of Physician Assistants.

For the first class of PAs in 1965, Dr. Stead selected Navy corpsmen who had received medical training and experience during their service in Vietnam. The curriculum was based on Dr. Stead’s knowledge of fast-track training of physicians during World War II. From this early program, the profession has evolved to more than 130 programs that now adhere to rigorous national accreditation standards set forth by the independent Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). The ARC-PA is sponsored by the American Medical Association and the American College of Surgeons, among many other professional medical organizations (www.aapa.org/geninfo1.html).

Scope of Practice

Prerequisites to PA programs include two years of college courses in basic and behavioral science, as well as prior experience in healthcare. According to a report generated by the Association of Physician Assistant Programs, most PA students have earned a bachelor’s degree and have an average of 38 months of healthcare experience before being admitted to a PA program.2

The first year of PA education comprises a didactic curriculum with coursework in anatomy, physiology, biochemistry, pharmacology, physical diagnosis, pathophysiology, microbiology, clinical laboratory sciences, behavioral sciences, and medical ethics. In the second year, students receive hands-on clinical training through a series of rotations—typically in family and internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine, and psychiatry. By the time they graduate (typical PA programs last an average of 26 months), PAs will have completed more than 2,000 hours of supervised clinical practice.

PAs work in all areas of medicine. Although hospital bylaws and state regulations often stipulate the PA’s scope of practice, the major determinant of duties is the supervising physician. The relationship between supervising physician and PA, says Kislingbury, is a collaborative one. Duties are “defined on an individual basis, and they are determined based on our [PAs’] experience, the physicians’ experience with us, and then the nuances of the system and the hospital itself.

“The PA who is hired should know what his or her scope of practice is,” she continues. “By the time they have graduated and obtained their license, they should know what their state allows them to do.”

For instance, according to the American Academy of Physician Assistants, 48 of the 50 states, plus the District of Columbia and [the U.S. Territory of] Guam, authorize PAs to prescribe medications. In California, PA prescriptions are referred to as “written prescription transmittal orders.”

“For the most part,” says Genzink, “the supervising physician determines what the PA is capable of doing, within the guidelines of state law.”

Within Genzink’s hospital medicine group (with which he has been affiliated for five years) the physician and PA roles are very similar.

“We see the same type of patients in a team approach. For instance, it’s not uncommon for one of us to order a test early in the day, and then, when results come back, the other person may be discharging that patient or prescribing other treatments, if necessary,” he explains. “In general, the physicians take care of the more complicated patients, while PAs take care of more routine patients.”

Genzink’s group experience aligns with findings of a 1998 University of Pittsburgh School of Nursing Study, which evaluated provider roles and patient outcomes in an acute care setting.3 Compared with acute care nurse practitioners and PAs, residents in that study tended to care for patients who were older and sicker.

Genzink reports that in his group initial histories and physicals, as well as the consultations, are performed exclusively by the PAs and then the physician takes over for treatment. “Based on the acuity of the patient,” says Genzink, “the physician may be right down there to see the patient immediately.”

Areas for Improvement?

Although the two PAs interviewed for this article report positive experiences working with hospitalists, they admit that some physicians continue to hold misperceptions about the PA’s role in caring for patients.

Kislingbury says that hospitalists could improve their delegation of duties to the PAs and recognize their scope of practice. She admits that delegation duties can be improved through gaining experience. “Although the PA profession has been around for a while, there are a surprising number of institutions that do not utilize physician assistants on the wards in routine rounds and bedside-type care,” says Kislingbury.

“I think some of the problems develop when they [physicians] hire a PA and expect to get a physician—and they [don’t],” says Genzink. “The easiest way for me to explain the role is to compare it to a teaching model. All physicians have been through residency programs. They understand the hierarchy that involves training and teaching residents. PAs come out of school ‘green,’ with the assumption that training will go on at the workplace. So, if a physician takes the same stance toward a new PA as they would toward an intern, that is a pretty close comparison.

“You begin by letting PAs or interns do a few simple things, and as they master those, you teach them more,” he continues. “And then, hopefully, over time they’ve been able to master everything that the physician is able to master. [Employing a PA] is a significant investment. And, it takes time. Sometimes, that process can be very easy, depending on the person. Sometimes it can be very slow, and I think that’s sometimes where some of the frustration may come in.”

Genzink adds that in his hospital medicine group, the physicians are familiar with the idea that part of their job as supervising physicians is to train new PAs.

Kislingbury points that out that PAs can also play a role in informing the physician team members about the range of cases they are allowed to treat, thus furthering the collaboration between PAs and hospitalists: “It is merely a matter of educating the team members about what we can and cannot do.”

Accordingly, the SHM Non-Physician Provider Task Force was formed to provide a resource to hospitalists who work with PAs and have questions about scope of practice, reimbursement, and other issues as they pertain to PAs and nurse practitioners. (Visit www.hospitalmedicine.org for more information.) The Task Force is a resource for non-physicians providers, too, offering educational opportunities at SHM meetings, more visibility with the specialty, and a voice for advocacy.

The Positives of the Collaboration

While the PAs report that hospitalists could improve in communicating about their practice roles with PAs, “There are so many things that hospitalists do right!” says Kislingbury. Calling the experience of working with hospitalists a privilege, she says that “where it is a true partnership, we are treated as equals, we are given the responsibility that our experience will allow, and we are truly team members.

“Hospitalists are geared into the efficiencies of the system and the nuances of the hospital. These are subtleties that come with practicing in an area for a long period of time, not just coming in for a month and then leaving and returning,” she says. “Hospitalists know the daily ins and outs, and it is really a pleasure to learn from them.”

Prior to his affiliation with Hospitalists of West Michigan, Genzink was employed directly by a hospital in Grand Rapids. The physicians with whom he now works have been hospitalists almost exclusively throughout their medical careers. “One of the main benefits they offer is availability, simply because we [the group’s practice members] are in the hospital 24/7,” he says. “They also have more experience in dealing with more complex issues, just as do the PAs that are working in our system.”

What about the notion that PAs and nurse practitioners are more skilled or practiced with patient and family communications? One study by Rudy, et al. found that nurse practitioners and PAs were more likely than residents to discuss patients with bedside nurses and to interact with patients’ families.3 Genzink does not find this to be the case in his group’s practice.

“That presumption [that PAs are more communicative with families and patients] may have come about simply because as the demands on hospitalists continue to grow and the workload increases, adding the PA to the team means there are more people to do things like that [handle family communications],” he says. “Certainly, in our group, the PAs do lots of patient education, and we talk to patients about end-of-life issues and other difficult matters as well. But that is not delegated to them; in our group, both the PAs and the physicians participate equally in patient and family communication.”

Daily Learning

Hospitalists and PAs also complement each other in the interdisciplinary care team because, “as a general rule, hospitalists love to teach,” says Kislingbury. “They don’t forget that just because you have your PA degree your learning does not stop there. The PA profession is almost like on-the-job training. You are allowed to choose the specialty that you want, and you gain your experience when you enter that [arena], as opposed to an internship or residency, where you first gain experience and then enter the specialty. We so appreciate the ability of the hospitalist to teach because we are learning while doing, on a day-to-day basis. It’s invaluable to have their teaching.” TH

Gretchen Henkel also writes about dealing with difficult families in this issue.

Resources

1. Christmas AB, Reynolds J, Hodges S, et al. Physician extenders impact trauma systems. J Trauma. 2005 May;58(5):917-920.
2. Nineteenth Annual Report on Physician Assistant Educational Programs in the United States, 2002-2203. Alexandria, Va. Association of Physician Assistant Programs.
3. Rudy EB, Davidson LJ, Daly B, et al. Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: a comparison. Am J Crit Care. 1998 Jul;7(4):267-281.

Editors’ note: “Alliances” is a series written about the relationships that hospitalists have with members of the clinical care team—from the team members’ points of view. Each installment of “Alliances” provides valuable, revealing feedback that hospitalists can use to continually improve their intrateam relationships and, ultimately, patient care.

Several months ago, a patient with decompensated end-stage liver disease was admitted to the Internal Medicine Hospitalist Service at the University of Texas Medical Branch in Galveston and required a paracentesis. One of the new hospitalist faculty members was taken aback when the physician assistant (PA) on the service volunteered to do the procedure. “He was surprised,” says Karen Kislingbury, PA-C, a member of SHM’s Non-Physician Provider Task Force and a PA with the Internal Medicine Hospitalist Service, “that the scope of practice for the physician assistant included [performing] procedures.”

PAs are not new to the hospital setting, and their inclusion as physician extenders to increase patient access to care will likely increase in the current regulatory environment—especially state-mandated staff/patient ratios and resident work hour limitations. The efficacy of utilizing physician extenders to improve patient care and outcomes has been validated in studies over the past two decades. A recent Journal of Trauma study found statistically significant reductions in floor, ICU, and overall hospital lengths of stay after incorporating physician extenders into their trauma service.1

However, hospitalists unfamiliar with PAs may not understand their colleagues’ roles and scope of practice. As her anecdote illustrated, Kislingbury notes that “although PAs aren’t new to the healthcare delivery system, and physicians have been utilizing us for a long time, our partnership in the unique setting of hospital medicine is kind of new.”

Kislingbury’s colleague Ryan Genzink, PA-C, who works with Hospitalists of West Michigan, a private hospitalists-only group that subcontracts hospitalist services to Spectrum Health of Grand Rapids, Mich., agrees with her assessment.

“There are more and more PAs and [nurse practitioners] working in hospital medicine, and I think there is a lot of curiosity and some apprehension on the part of people who have not worked with these non-physician providers,” says Genzink.

Genzink, also a member of SHM’s Non-Physician Provider Task Force, speculates that the apprehension of physicians who have not worked with PAs may be due to a misunderstanding of the PA’s role. “They’re either underestimating or overestimating exactly what a PA can do or what they are getting when they hire a PA,” he says.

A Short History of the Profession

PA programs officially began in the mid-1960s at Duke University Medical School (Durham, N.C.). Eugene Stead, MD, is credited with developing the concept of the physician assistant as a health professional who would work with physician supervision to extend patient access to care, according to the American Academy of Physician Assistants.

For the first class of PAs in 1965, Dr. Stead selected Navy corpsmen who had received medical training and experience during their service in Vietnam. The curriculum was based on Dr. Stead’s knowledge of fast-track training of physicians during World War II. From this early program, the profession has evolved to more than 130 programs that now adhere to rigorous national accreditation standards set forth by the independent Accreditation Review Commission on Education for the Physician Assistant (ARC-PA). The ARC-PA is sponsored by the American Medical Association and the American College of Surgeons, among many other professional medical organizations (www.aapa.org/geninfo1.html).

Scope of Practice

Prerequisites to PA programs include two years of college courses in basic and behavioral science, as well as prior experience in healthcare. According to a report generated by the Association of Physician Assistant Programs, most PA students have earned a bachelor’s degree and have an average of 38 months of healthcare experience before being admitted to a PA program.2

The first year of PA education comprises a didactic curriculum with coursework in anatomy, physiology, biochemistry, pharmacology, physical diagnosis, pathophysiology, microbiology, clinical laboratory sciences, behavioral sciences, and medical ethics. In the second year, students receive hands-on clinical training through a series of rotations—typically in family and internal medicine, obstetrics and gynecology, pediatrics, general surgery, emergency medicine, and psychiatry. By the time they graduate (typical PA programs last an average of 26 months), PAs will have completed more than 2,000 hours of supervised clinical practice.

PAs work in all areas of medicine. Although hospital bylaws and state regulations often stipulate the PA’s scope of practice, the major determinant of duties is the supervising physician. The relationship between supervising physician and PA, says Kislingbury, is a collaborative one. Duties are “defined on an individual basis, and they are determined based on our [PAs’] experience, the physicians’ experience with us, and then the nuances of the system and the hospital itself.

“The PA who is hired should know what his or her scope of practice is,” she continues. “By the time they have graduated and obtained their license, they should know what their state allows them to do.”

For instance, according to the American Academy of Physician Assistants, 48 of the 50 states, plus the District of Columbia and [the U.S. Territory of] Guam, authorize PAs to prescribe medications. In California, PA prescriptions are referred to as “written prescription transmittal orders.”

“For the most part,” says Genzink, “the supervising physician determines what the PA is capable of doing, within the guidelines of state law.”

Within Genzink’s hospital medicine group (with which he has been affiliated for five years) the physician and PA roles are very similar.

“We see the same type of patients in a team approach. For instance, it’s not uncommon for one of us to order a test early in the day, and then, when results come back, the other person may be discharging that patient or prescribing other treatments, if necessary,” he explains. “In general, the physicians take care of the more complicated patients, while PAs take care of more routine patients.”

Genzink’s group experience aligns with findings of a 1998 University of Pittsburgh School of Nursing Study, which evaluated provider roles and patient outcomes in an acute care setting.3 Compared with acute care nurse practitioners and PAs, residents in that study tended to care for patients who were older and sicker.

Genzink reports that in his group initial histories and physicals, as well as the consultations, are performed exclusively by the PAs and then the physician takes over for treatment. “Based on the acuity of the patient,” says Genzink, “the physician may be right down there to see the patient immediately.”

Areas for Improvement?

Although the two PAs interviewed for this article report positive experiences working with hospitalists, they admit that some physicians continue to hold misperceptions about the PA’s role in caring for patients.

Kislingbury says that hospitalists could improve their delegation of duties to the PAs and recognize their scope of practice. She admits that delegation duties can be improved through gaining experience. “Although the PA profession has been around for a while, there are a surprising number of institutions that do not utilize physician assistants on the wards in routine rounds and bedside-type care,” says Kislingbury.

“I think some of the problems develop when they [physicians] hire a PA and expect to get a physician—and they [don’t],” says Genzink. “The easiest way for me to explain the role is to compare it to a teaching model. All physicians have been through residency programs. They understand the hierarchy that involves training and teaching residents. PAs come out of school ‘green,’ with the assumption that training will go on at the workplace. So, if a physician takes the same stance toward a new PA as they would toward an intern, that is a pretty close comparison.

“You begin by letting PAs or interns do a few simple things, and as they master those, you teach them more,” he continues. “And then, hopefully, over time they’ve been able to master everything that the physician is able to master. [Employing a PA] is a significant investment. And, it takes time. Sometimes, that process can be very easy, depending on the person. Sometimes it can be very slow, and I think that’s sometimes where some of the frustration may come in.”

Genzink adds that in his hospital medicine group, the physicians are familiar with the idea that part of their job as supervising physicians is to train new PAs.

Kislingbury points that out that PAs can also play a role in informing the physician team members about the range of cases they are allowed to treat, thus furthering the collaboration between PAs and hospitalists: “It is merely a matter of educating the team members about what we can and cannot do.”

Accordingly, the SHM Non-Physician Provider Task Force was formed to provide a resource to hospitalists who work with PAs and have questions about scope of practice, reimbursement, and other issues as they pertain to PAs and nurse practitioners. (Visit www.hospitalmedicine.org for more information.) The Task Force is a resource for non-physicians providers, too, offering educational opportunities at SHM meetings, more visibility with the specialty, and a voice for advocacy.

The Positives of the Collaboration

While the PAs report that hospitalists could improve in communicating about their practice roles with PAs, “There are so many things that hospitalists do right!” says Kislingbury. Calling the experience of working with hospitalists a privilege, she says that “where it is a true partnership, we are treated as equals, we are given the responsibility that our experience will allow, and we are truly team members.

“Hospitalists are geared into the efficiencies of the system and the nuances of the hospital. These are subtleties that come with practicing in an area for a long period of time, not just coming in for a month and then leaving and returning,” she says. “Hospitalists know the daily ins and outs, and it is really a pleasure to learn from them.”

Prior to his affiliation with Hospitalists of West Michigan, Genzink was employed directly by a hospital in Grand Rapids. The physicians with whom he now works have been hospitalists almost exclusively throughout their medical careers. “One of the main benefits they offer is availability, simply because we [the group’s practice members] are in the hospital 24/7,” he says. “They also have more experience in dealing with more complex issues, just as do the PAs that are working in our system.”

What about the notion that PAs and nurse practitioners are more skilled or practiced with patient and family communications? One study by Rudy, et al. found that nurse practitioners and PAs were more likely than residents to discuss patients with bedside nurses and to interact with patients’ families.3 Genzink does not find this to be the case in his group’s practice.

“That presumption [that PAs are more communicative with families and patients] may have come about simply because as the demands on hospitalists continue to grow and the workload increases, adding the PA to the team means there are more people to do things like that [handle family communications],” he says. “Certainly, in our group, the PAs do lots of patient education, and we talk to patients about end-of-life issues and other difficult matters as well. But that is not delegated to them; in our group, both the PAs and the physicians participate equally in patient and family communication.”

Daily Learning

Hospitalists and PAs also complement each other in the interdisciplinary care team because, “as a general rule, hospitalists love to teach,” says Kislingbury. “They don’t forget that just because you have your PA degree your learning does not stop there. The PA profession is almost like on-the-job training. You are allowed to choose the specialty that you want, and you gain your experience when you enter that [arena], as opposed to an internship or residency, where you first gain experience and then enter the specialty. We so appreciate the ability of the hospitalist to teach because we are learning while doing, on a day-to-day basis. It’s invaluable to have their teaching.” TH

Gretchen Henkel also writes about dealing with difficult families in this issue.

Resources

1. Christmas AB, Reynolds J, Hodges S, et al. Physician extenders impact trauma systems. J Trauma. 2005 May;58(5):917-920.
2. Nineteenth Annual Report on Physician Assistant Educational Programs in the United States, 2002-2203. Alexandria, Va. Association of Physician Assistant Programs.
3. Rudy EB, Davidson LJ, Daly B, et al. Care activities and outcomes of patients cared for by acute care nurse practitioners, physician assistants, and resident physicians: a comparison. Am J Crit Care. 1998 Jul;7(4):267-281.

Rothschild JM, Landrigan CP, Cronin JW, et al. The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33:1694-1700.

Background: Critically ill patients require complex, immediate, high-intensity care, potentially placing them at increased risk of iatrogenic injury. The frequency and nature of adverse events and errors in the modern ICU have not been clearly defined.

Methods: Harvard researchers conducted a prospective, one-year, observational study of a MICU and a CCU at a tertiary care medical center. Adverse events and medical errors were identified by a four-pronged approach: direct 24-hour observation of interns, voluntary incident reporting, a computerized adverse drug event monitoring system, and chart abstraction. Two physicians independently assessed the type, severity, and preventability of the incidents.

Results: A total of 391 patients comprising 1,490 patient-days were observed and included. Twenty percent of all patients suffered an adverse event, 45% of which were preventable and 13% of which were felt to be life-threatening. There were 223 serious errors (those that caused harm or had the potential to cause harm) observed of which 11% were life threatening. Medication adverse events and medication errors accounted for a large proportion of the incidents during the study. Slips and lapses in care were much more common than rule-based (such as using the wrong protocol) or knowledge-based mistakes.

Discussion: Since the Institute of Medicine report in 1999, there has been an increasing focus on patient safety in the inpatient setting. Based on the results of this study and others, it appears the high-intensity, fast-paced nature of critical care places patients at substantial risk for iatrogenic injury. Up to 20% of patients admitted to the ICU in this study suffered an adverse event or a medical error, which translates into 0.8 adverse events and 1.5 serious medical errors per day in a 10-bed ICU.

Because failure to carry out intended plans (usually secondary to slips and lapses on the part of healthcare providers) was the most common cause of adverse events and errors, the authors address possible solutions. They propose employing computerized-order entry, clinical pharmacists in the ICU, closed ICU staffing, “smart” intravenous pumps, and improved teamwork and communication among healthcare providers. Hospitalists often manage critically ill patients and should be aware of the high risk of medical errors and should consider implementing specific systems changes to mitigate the risk.

The Value of Obtaining Blood Cultures in Pneumonia Pts

Kennedy M, Bates DW, Wright SB, et al. Do emergency department blood cultures change practice in patients with pneumonia? Ann Emerg Med. 2005 Nov;46(5):393-400.

Background: Previous observational studies in patients hospitalized with community-acquired pneumonia (CAP) have shown obtaining blood cultures may have a mortality benefit. This practice has become expert guideline-recommended, the standard of care, as well as a quality marker in the management of CAP. Several recent studies have questioned the utility and cost-effectiveness of this practice.

Methods: Harvard researchers performed a prospective, observational, cohort study of adults admitted to an urban university medical center. Researchers identified patients who had all of the following: clinical CAP, radiographic CAP, and blood cultures at admission. Blood cultures were classified as positive, negative, or contaminated based on previously established criteria. Data were collected on antimicrobial sensitivities, empiric antibiotic choices, and antibiotic changes.

Results: In one year, 414 patients with clinical and radiographic CAP had blood cultures at the time of admission. Twenty-nine of 414 (7%) of patients had true bacteremia while 25 of 414 (6%) had contaminants. Antibiotic therapy was altered in response to blood culture results in 15 of 414 patients (3.6%), of which 11 (2.7%) had therapy narrowed and four (1.0%) had therapy broadened. Of the 11 patients with bacteremia whose therapy was not changed, culture results supported narrowing therapy in eight cases but this was not done.

Discussion: This well done prospective observational study adds to a growing body of evidence questioning the utility of routine blood cultures on all patients hospitalized with CAP. The argument traditionally has been made that blood cultures allow clinicians to narrow or broaden antibiotics based on sensitivities. Yet, empiric therapy was broadened in response to bacteremia in only a small fraction of patients (1%) and in only 11 of 19 patients was therapy appropriately narrowed based on the blood cultures. The study did not measure the impact of blood cultures on clinical outcomes, but these striking results reveal that routine blood cultures rarely alter our management of hospitalized patients with CAP.

Further, many have argued obtaining routine blood cultures in CAP can have negative consequences. Blood cultures are relatively costly and time intensive, contaminated blood cultures can lead to repeated testing and increased length of stay, and delays in obtaining blood cultures can delay antibiotic administration, another important quality marker in CAP. For now, it remains the standard of care to obtain blood cultures in these patients, but hospitalists should be aware of the limitations of this practice and consider focusing on other clinical interventions and quality measures in CAP.

A Review Study: A Dyspneic Emergency Patient

Wang CS, FitzGerald JM, Schulzer M, et al. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005 Oct 19;294:944-1956.

Background: Distinguishing CHF from non-cardiac causes of dyspnea is a major challenge for hospitalists and emergency physicians, particularly in patients with a prior history of cardiac disease. Traditionally, clinicians have relied on the history, physical examination, and basic tests (chest X-ray and electrocardiogram) to diagnose CHF, but rapid B-type natriuretic peptide (BNP) testing is now widely incorporated as well.

A previous article in the Rational Clinical Examination series (Can the clinical examination diagnose left-sided heart failure in adults? JAMA. 1997;277(21):1712-1719) found that systolic dysfunction was moderately well predicted by an abnormal apical impulse on physical examination, radiographic cardiomegaly or venous redistribution, or electrocardiographic q waves or left bundle branch block.

Methods: In this review, the authors update and extend previous findings by also assessing the utility of serum BNP testing. The authors identified articles evaluating the diagnostic accuracy of the clinical exam and laboratory testing in diagnosing CHF in patients presenting to the emergency department with undifferentiated dyspnea. The “gold standard” was a clinical diagnosis of CHF made by the treating clinicians after an appropriate diagnostic workup. Summary likelihood ratios (LRs) were calculated using meta-analytic methodology.

Results/discussion: The authors determined that several findings increase the probability of CHF. A prior history of CHF (LR 5.8, CI 4.1-8.0) or myocardial infarction (LR 3.1, 95% CI 2.0-4.9), symptoms of paroxysmal nocturnal dyspnea (LR 2.6, 95% CI 1.5-4.5) and orthopnea (LR 2.2, 95% CI 1.2-3.9) were the most predictive historical factors. On physical examination, the presence of an S3 (LR 11, 95% CI 4.9-25), jugular venous distension (5.1, 95% CI 3.2-7.9), lung rales (LR 2.8, 95% CI 1.9-4.1), and peripheral edema (2.3, 95% CI 1.5-3.7) increased the probability of CHF. In interpreting these results, it is helpful to remember that a likelihood ratio of 2 increases the post-test probability by about 15%, and an LR of 5 increases the post-test probability by about 30%. Thus, a prior history of CHF and presence of an S3 or jugular venous distension are the most useful findings. Interestingly, clinician’s gestalt was equally predictive (LR 4.4, 95% CI 1.8-10.0.)

The most useful radiographic findings were venous congestion (LR 12.0, 95% CI 6.8-21) and the presence of cardiomegaly (LR 3.3; 95% CI 2.4-4.7). The single most predictive ECG finding was atrial fibrillation (LR 3.8; 95% CI 2.7-8.8); any abnormality on ECG had an LR of 2.2 (95% CI 1.6-3.1). Serum BNP levels were not more predictive of CHF than the history or physical examination; a BNP of >250 was associated with an LR of 4.6 (95% CI 2.6-8.0).

Few findings markedly decreased the probability of CHF. Here, it is helpful to remember that an LR of 0.5 decreases the post-test probability by about 15%, and an LR of 0.2 decreases the post-test probability by about 30%. With these in mind, the absence of cardiomegaly on CXR significantly changes the post-test probability (LR 0.33; 95% CI 0.23-0.48). A serum BNP level of less than 100pg/ml strongly argues against CHF, with an LR of 0.11 (95% CI 0.07-0.16); this finding lowers the post-test probability of CHF by about 45% compared to the pre-test probability.

In summary, the most useful findings for ruling in CHF in dyspneic emergency department patients were clinical gestalt, a prior history of CHF, findings of an S3 or jugular venous distension, and radiographic findings of venous congestion or cardiomegaly. Absence of radiographic cardiomegaly and a BNP of less than 100pg/ml argue against CHF. These must be interpreted in the context of the clinical pre-test probability of CHF, as none of the findings had likelihood ratios sufficient to be diagnostic of CHF when used individually.

What Should I Wear Today?

Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med. 2005 Nov; 118(11): 1279-1286.

Background: This study addresses the prototypical everyday clinical dilemma: What should I wear to work?

Methods: Patients and visitors to an outpatient Veterans Affairs internal medicine clinic in South Carolina were shown photographs of male and female physicians in four different styles of dress:

1. Professional (male physician wearing white coat with tie, female physician wearing white coat with tailored skirt or trousers);
2. Business (suit and tie for male, tailored trouser or skirt for female);
3. Surgical (surgical scrubs for both male and female): and
4. Casual (jeans and t-shirt or short skirt).

The study was randomized so that male and female respondents viewed photographs of either male or female physicians. Respondents were asked to report how strongly they felt about the importance of their physician’s appearance, and their preference for each style of dress; specifically, respondents were asked which physician was the most trustworthy, which physician they felt most comfortable with for routine examinations and emergencies, and which physician they felt most comfortable discussing psychological, sexual, and social problems with.

Results: Respondents overwhelmingly preferred professional attire for all questions: 76.3% felt most comfortable with a professionally dressed physician for all encounters, with surgical scrubs a distant second (10.2%), ahead of business dress (8.8%). Respondents were also significantly more willing to discuss psychological, sexual, and social problems with a professionally dressed physician. Even for care in an emergency situation, respondents still expressed a significant preference for professional attire over scrubs.

In a logistic regression model, patients who were older, African-American, and had less than a high school education were significantly more likely to prefer professional attire. Interestingly, female respondents who viewed photographs of female physicians placed significantly greater emphasis on physician’s attire than did male respondents.

Discussion: The study is clearly subject to caveats, chiefly that it was conducted at a single VA clinic and that only one aspect of the physician-patient encounter was addressed. Undoubtedly, patient’s preferences were influenced by the popular portrayal of physicians on TV shows. Nevertheless, given that hospitalists typically see older patients with whom they are not familiar, the initial clinical encounter may indeed by influenced by something as simple as wearing a white coat.

UA by Nephrologist Versus Hospital-Based Clinical Labs

Tsai JJ, Yeun JY, Kumar VA, Don BR. Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory. Am J Kidney Dis. 2005 Nov;46(5):820-829.

Background: Distinguishing the correct cause of acute renal failure is a frequent clinical dilemma for hospitalists, particularly diagnosing acute tubular necrosis (ATN), which is the most common cause of in-hospital acute renal failure. Although urinalysis with microscopy is the first test ordered on noting an abnormal serum creatinine, most hospitalists rely on the results generated by a laboratory technician. Anecdotally, many nephrologists have noted significant differences between urinalysis results performed by technicians and results found by nephrologists.

Methods: This study enrolled 26 patients hospitalized with acute renal failure on whom nephrology consultation was obtained. Urinalysis was performed both by laboratory personnel and a nephrologist (nephrologist A) who was blinded to the patient’s clinical information. Both sets of urinalysis results were independently used by nephrologist A and a second nephrologist (nephrologist B) to arrive at a clinical diagnosis for the patient, without having access to any other clinical information. These diagnoses were compared to the final diagnosis determined by the consulting nephrology service, who themselves did not have access to the diagnosis of either nephrologist A or B.

Results: The influence of having a nephrologist perform and interpret the urinalysis was striking. Nephrologist A was able to correctly diagnose 92.3% of cases based solely on his interpretation of the urinalysis. However, when given only the laboratory report of the urinalysis, both nephrologists were unable to diagnose most cases (23.1% for nephrologist A and 19.2% for nephrologist B). The major difference appeared to be in nephrologist A’s ability to find renal tubular epithelial (RTE) cells and RTE casts, which are pathognomonic of ATN. RTE cells and granular casts were frequently misinterpreted as squamous epithelial cells by laboratory personnel. This was particularly important as 81% of patients in the study had ATN as the primary cause of renal failure. Acanthocytes (dysmorphic red blood cells) were also missed by laboratory personnel in all six patients who were subsequently diagnosed with glomerulonephritis; nephrologist A correctly noted acanthocytes in five of these patients, and arrived at the correct diagnosis in all six patients.

Discussion: Microscopic evaluation of urine sediment has become a lost art among physicians, especially since passage of the Clinical Laboratory Improvement Amendments (CLIA) in 1988, which mandated that only CLIA-certified personnel could perform most laboratory tests. While it is probably unrealistic to call for training in microscopic urinalysis for all physicians, hospitalists in particular would benefit from such training, and at the very least should be mindful that laboratory urinalysis results may miss subtle findings that can be invaluable in diagnosing acute renal failure. This study points out the need for greater oversight and training of laboratory personnel, and serves as a reminder to clinicians that laboratory results should not be considered the gold standard. TH

Rothschild JM, Landrigan CP, Cronin JW, et al. The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33:1694-1700.

Background: Critically ill patients require complex, immediate, high-intensity care, potentially placing them at increased risk of iatrogenic injury. The frequency and nature of adverse events and errors in the modern ICU have not been clearly defined.

Methods: Harvard researchers conducted a prospective, one-year, observational study of a MICU and a CCU at a tertiary care medical center. Adverse events and medical errors were identified by a four-pronged approach: direct 24-hour observation of interns, voluntary incident reporting, a computerized adverse drug event monitoring system, and chart abstraction. Two physicians independently assessed the type, severity, and preventability of the incidents.

Results: A total of 391 patients comprising 1,490 patient-days were observed and included. Twenty percent of all patients suffered an adverse event, 45% of which were preventable and 13% of which were felt to be life-threatening. There were 223 serious errors (those that caused harm or had the potential to cause harm) observed of which 11% were life threatening. Medication adverse events and medication errors accounted for a large proportion of the incidents during the study. Slips and lapses in care were much more common than rule-based (such as using the wrong protocol) or knowledge-based mistakes.

Discussion: Since the Institute of Medicine report in 1999, there has been an increasing focus on patient safety in the inpatient setting. Based on the results of this study and others, it appears the high-intensity, fast-paced nature of critical care places patients at substantial risk for iatrogenic injury. Up to 20% of patients admitted to the ICU in this study suffered an adverse event or a medical error, which translates into 0.8 adverse events and 1.5 serious medical errors per day in a 10-bed ICU.

Because failure to carry out intended plans (usually secondary to slips and lapses on the part of healthcare providers) was the most common cause of adverse events and errors, the authors address possible solutions. They propose employing computerized-order entry, clinical pharmacists in the ICU, closed ICU staffing, “smart” intravenous pumps, and improved teamwork and communication among healthcare providers. Hospitalists often manage critically ill patients and should be aware of the high risk of medical errors and should consider implementing specific systems changes to mitigate the risk.

The Value of Obtaining Blood Cultures in Pneumonia Pts

Kennedy M, Bates DW, Wright SB, et al. Do emergency department blood cultures change practice in patients with pneumonia? Ann Emerg Med. 2005 Nov;46(5):393-400.

Background: Previous observational studies in patients hospitalized with community-acquired pneumonia (CAP) have shown obtaining blood cultures may have a mortality benefit. This practice has become expert guideline-recommended, the standard of care, as well as a quality marker in the management of CAP. Several recent studies have questioned the utility and cost-effectiveness of this practice.

Methods: Harvard researchers performed a prospective, observational, cohort study of adults admitted to an urban university medical center. Researchers identified patients who had all of the following: clinical CAP, radiographic CAP, and blood cultures at admission. Blood cultures were classified as positive, negative, or contaminated based on previously established criteria. Data were collected on antimicrobial sensitivities, empiric antibiotic choices, and antibiotic changes.

Results: In one year, 414 patients with clinical and radiographic CAP had blood cultures at the time of admission. Twenty-nine of 414 (7%) of patients had true bacteremia while 25 of 414 (6%) had contaminants. Antibiotic therapy was altered in response to blood culture results in 15 of 414 patients (3.6%), of which 11 (2.7%) had therapy narrowed and four (1.0%) had therapy broadened. Of the 11 patients with bacteremia whose therapy was not changed, culture results supported narrowing therapy in eight cases but this was not done.

Discussion: This well done prospective observational study adds to a growing body of evidence questioning the utility of routine blood cultures on all patients hospitalized with CAP. The argument traditionally has been made that blood cultures allow clinicians to narrow or broaden antibiotics based on sensitivities. Yet, empiric therapy was broadened in response to bacteremia in only a small fraction of patients (1%) and in only 11 of 19 patients was therapy appropriately narrowed based on the blood cultures. The study did not measure the impact of blood cultures on clinical outcomes, but these striking results reveal that routine blood cultures rarely alter our management of hospitalized patients with CAP.

Further, many have argued obtaining routine blood cultures in CAP can have negative consequences. Blood cultures are relatively costly and time intensive, contaminated blood cultures can lead to repeated testing and increased length of stay, and delays in obtaining blood cultures can delay antibiotic administration, another important quality marker in CAP. For now, it remains the standard of care to obtain blood cultures in these patients, but hospitalists should be aware of the limitations of this practice and consider focusing on other clinical interventions and quality measures in CAP.

A Review Study: A Dyspneic Emergency Patient

Wang CS, FitzGerald JM, Schulzer M, et al. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005 Oct 19;294:944-1956.

Background: Distinguishing CHF from non-cardiac causes of dyspnea is a major challenge for hospitalists and emergency physicians, particularly in patients with a prior history of cardiac disease. Traditionally, clinicians have relied on the history, physical examination, and basic tests (chest X-ray and electrocardiogram) to diagnose CHF, but rapid B-type natriuretic peptide (BNP) testing is now widely incorporated as well.

A previous article in the Rational Clinical Examination series (Can the clinical examination diagnose left-sided heart failure in adults? JAMA. 1997;277(21):1712-1719) found that systolic dysfunction was moderately well predicted by an abnormal apical impulse on physical examination, radiographic cardiomegaly or venous redistribution, or electrocardiographic q waves or left bundle branch block.

Methods: In this review, the authors update and extend previous findings by also assessing the utility of serum BNP testing. The authors identified articles evaluating the diagnostic accuracy of the clinical exam and laboratory testing in diagnosing CHF in patients presenting to the emergency department with undifferentiated dyspnea. The “gold standard” was a clinical diagnosis of CHF made by the treating clinicians after an appropriate diagnostic workup. Summary likelihood ratios (LRs) were calculated using meta-analytic methodology.

Results/discussion: The authors determined that several findings increase the probability of CHF. A prior history of CHF (LR 5.8, CI 4.1-8.0) or myocardial infarction (LR 3.1, 95% CI 2.0-4.9), symptoms of paroxysmal nocturnal dyspnea (LR 2.6, 95% CI 1.5-4.5) and orthopnea (LR 2.2, 95% CI 1.2-3.9) were the most predictive historical factors. On physical examination, the presence of an S3 (LR 11, 95% CI 4.9-25), jugular venous distension (5.1, 95% CI 3.2-7.9), lung rales (LR 2.8, 95% CI 1.9-4.1), and peripheral edema (2.3, 95% CI 1.5-3.7) increased the probability of CHF. In interpreting these results, it is helpful to remember that a likelihood ratio of 2 increases the post-test probability by about 15%, and an LR of 5 increases the post-test probability by about 30%. Thus, a prior history of CHF and presence of an S3 or jugular venous distension are the most useful findings. Interestingly, clinician’s gestalt was equally predictive (LR 4.4, 95% CI 1.8-10.0.)

The most useful radiographic findings were venous congestion (LR 12.0, 95% CI 6.8-21) and the presence of cardiomegaly (LR 3.3; 95% CI 2.4-4.7). The single most predictive ECG finding was atrial fibrillation (LR 3.8; 95% CI 2.7-8.8); any abnormality on ECG had an LR of 2.2 (95% CI 1.6-3.1). Serum BNP levels were not more predictive of CHF than the history or physical examination; a BNP of >250 was associated with an LR of 4.6 (95% CI 2.6-8.0).

Few findings markedly decreased the probability of CHF. Here, it is helpful to remember that an LR of 0.5 decreases the post-test probability by about 15%, and an LR of 0.2 decreases the post-test probability by about 30%. With these in mind, the absence of cardiomegaly on CXR significantly changes the post-test probability (LR 0.33; 95% CI 0.23-0.48). A serum BNP level of less than 100pg/ml strongly argues against CHF, with an LR of 0.11 (95% CI 0.07-0.16); this finding lowers the post-test probability of CHF by about 45% compared to the pre-test probability.

In summary, the most useful findings for ruling in CHF in dyspneic emergency department patients were clinical gestalt, a prior history of CHF, findings of an S3 or jugular venous distension, and radiographic findings of venous congestion or cardiomegaly. Absence of radiographic cardiomegaly and a BNP of less than 100pg/ml argue against CHF. These must be interpreted in the context of the clinical pre-test probability of CHF, as none of the findings had likelihood ratios sufficient to be diagnostic of CHF when used individually.

What Should I Wear Today?

Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med. 2005 Nov; 118(11): 1279-1286.

Background: This study addresses the prototypical everyday clinical dilemma: What should I wear to work?

Methods: Patients and visitors to an outpatient Veterans Affairs internal medicine clinic in South Carolina were shown photographs of male and female physicians in four different styles of dress:

1. Professional (male physician wearing white coat with tie, female physician wearing white coat with tailored skirt or trousers);
2. Business (suit and tie for male, tailored trouser or skirt for female);
3. Surgical (surgical scrubs for both male and female): and
4. Casual (jeans and t-shirt or short skirt).

The study was randomized so that male and female respondents viewed photographs of either male or female physicians. Respondents were asked to report how strongly they felt about the importance of their physician’s appearance, and their preference for each style of dress; specifically, respondents were asked which physician was the most trustworthy, which physician they felt most comfortable with for routine examinations and emergencies, and which physician they felt most comfortable discussing psychological, sexual, and social problems with.

Results: Respondents overwhelmingly preferred professional attire for all questions: 76.3% felt most comfortable with a professionally dressed physician for all encounters, with surgical scrubs a distant second (10.2%), ahead of business dress (8.8%). Respondents were also significantly more willing to discuss psychological, sexual, and social problems with a professionally dressed physician. Even for care in an emergency situation, respondents still expressed a significant preference for professional attire over scrubs.

In a logistic regression model, patients who were older, African-American, and had less than a high school education were significantly more likely to prefer professional attire. Interestingly, female respondents who viewed photographs of female physicians placed significantly greater emphasis on physician’s attire than did male respondents.

Discussion: The study is clearly subject to caveats, chiefly that it was conducted at a single VA clinic and that only one aspect of the physician-patient encounter was addressed. Undoubtedly, patient’s preferences were influenced by the popular portrayal of physicians on TV shows. Nevertheless, given that hospitalists typically see older patients with whom they are not familiar, the initial clinical encounter may indeed by influenced by something as simple as wearing a white coat.

UA by Nephrologist Versus Hospital-Based Clinical Labs

Tsai JJ, Yeun JY, Kumar VA, Don BR. Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory. Am J Kidney Dis. 2005 Nov;46(5):820-829.

Background: Distinguishing the correct cause of acute renal failure is a frequent clinical dilemma for hospitalists, particularly diagnosing acute tubular necrosis (ATN), which is the most common cause of in-hospital acute renal failure. Although urinalysis with microscopy is the first test ordered on noting an abnormal serum creatinine, most hospitalists rely on the results generated by a laboratory technician. Anecdotally, many nephrologists have noted significant differences between urinalysis results performed by technicians and results found by nephrologists.

Methods: This study enrolled 26 patients hospitalized with acute renal failure on whom nephrology consultation was obtained. Urinalysis was performed both by laboratory personnel and a nephrologist (nephrologist A) who was blinded to the patient’s clinical information. Both sets of urinalysis results were independently used by nephrologist A and a second nephrologist (nephrologist B) to arrive at a clinical diagnosis for the patient, without having access to any other clinical information. These diagnoses were compared to the final diagnosis determined by the consulting nephrology service, who themselves did not have access to the diagnosis of either nephrologist A or B.

Results: The influence of having a nephrologist perform and interpret the urinalysis was striking. Nephrologist A was able to correctly diagnose 92.3% of cases based solely on his interpretation of the urinalysis. However, when given only the laboratory report of the urinalysis, both nephrologists were unable to diagnose most cases (23.1% for nephrologist A and 19.2% for nephrologist B). The major difference appeared to be in nephrologist A’s ability to find renal tubular epithelial (RTE) cells and RTE casts, which are pathognomonic of ATN. RTE cells and granular casts were frequently misinterpreted as squamous epithelial cells by laboratory personnel. This was particularly important as 81% of patients in the study had ATN as the primary cause of renal failure. Acanthocytes (dysmorphic red blood cells) were also missed by laboratory personnel in all six patients who were subsequently diagnosed with glomerulonephritis; nephrologist A correctly noted acanthocytes in five of these patients, and arrived at the correct diagnosis in all six patients.

Discussion: Microscopic evaluation of urine sediment has become a lost art among physicians, especially since passage of the Clinical Laboratory Improvement Amendments (CLIA) in 1988, which mandated that only CLIA-certified personnel could perform most laboratory tests. While it is probably unrealistic to call for training in microscopic urinalysis for all physicians, hospitalists in particular would benefit from such training, and at the very least should be mindful that laboratory urinalysis results may miss subtle findings that can be invaluable in diagnosing acute renal failure. This study points out the need for greater oversight and training of laboratory personnel, and serves as a reminder to clinicians that laboratory results should not be considered the gold standard. TH

Rothschild JM, Landrigan CP, Cronin JW, et al. The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33:1694-1700.

Background: Critically ill patients require complex, immediate, high-intensity care, potentially placing them at increased risk of iatrogenic injury. The frequency and nature of adverse events and errors in the modern ICU have not been clearly defined.

Methods: Harvard researchers conducted a prospective, one-year, observational study of a MICU and a CCU at a tertiary care medical center. Adverse events and medical errors were identified by a four-pronged approach: direct 24-hour observation of interns, voluntary incident reporting, a computerized adverse drug event monitoring system, and chart abstraction. Two physicians independently assessed the type, severity, and preventability of the incidents.

Results: A total of 391 patients comprising 1,490 patient-days were observed and included. Twenty percent of all patients suffered an adverse event, 45% of which were preventable and 13% of which were felt to be life-threatening. There were 223 serious errors (those that caused harm or had the potential to cause harm) observed of which 11% were life threatening. Medication adverse events and medication errors accounted for a large proportion of the incidents during the study. Slips and lapses in care were much more common than rule-based (such as using the wrong protocol) or knowledge-based mistakes.

Discussion: Since the Institute of Medicine report in 1999, there has been an increasing focus on patient safety in the inpatient setting. Based on the results of this study and others, it appears the high-intensity, fast-paced nature of critical care places patients at substantial risk for iatrogenic injury. Up to 20% of patients admitted to the ICU in this study suffered an adverse event or a medical error, which translates into 0.8 adverse events and 1.5 serious medical errors per day in a 10-bed ICU.

Because failure to carry out intended plans (usually secondary to slips and lapses on the part of healthcare providers) was the most common cause of adverse events and errors, the authors address possible solutions. They propose employing computerized-order entry, clinical pharmacists in the ICU, closed ICU staffing, “smart” intravenous pumps, and improved teamwork and communication among healthcare providers. Hospitalists often manage critically ill patients and should be aware of the high risk of medical errors and should consider implementing specific systems changes to mitigate the risk.

The Value of Obtaining Blood Cultures in Pneumonia Pts

Kennedy M, Bates DW, Wright SB, et al. Do emergency department blood cultures change practice in patients with pneumonia? Ann Emerg Med. 2005 Nov;46(5):393-400.

Background: Previous observational studies in patients hospitalized with community-acquired pneumonia (CAP) have shown obtaining blood cultures may have a mortality benefit. This practice has become expert guideline-recommended, the standard of care, as well as a quality marker in the management of CAP. Several recent studies have questioned the utility and cost-effectiveness of this practice.

Methods: Harvard researchers performed a prospective, observational, cohort study of adults admitted to an urban university medical center. Researchers identified patients who had all of the following: clinical CAP, radiographic CAP, and blood cultures at admission. Blood cultures were classified as positive, negative, or contaminated based on previously established criteria. Data were collected on antimicrobial sensitivities, empiric antibiotic choices, and antibiotic changes.

Results: In one year, 414 patients with clinical and radiographic CAP had blood cultures at the time of admission. Twenty-nine of 414 (7%) of patients had true bacteremia while 25 of 414 (6%) had contaminants. Antibiotic therapy was altered in response to blood culture results in 15 of 414 patients (3.6%), of which 11 (2.7%) had therapy narrowed and four (1.0%) had therapy broadened. Of the 11 patients with bacteremia whose therapy was not changed, culture results supported narrowing therapy in eight cases but this was not done.

Discussion: This well done prospective observational study adds to a growing body of evidence questioning the utility of routine blood cultures on all patients hospitalized with CAP. The argument traditionally has been made that blood cultures allow clinicians to narrow or broaden antibiotics based on sensitivities. Yet, empiric therapy was broadened in response to bacteremia in only a small fraction of patients (1%) and in only 11 of 19 patients was therapy appropriately narrowed based on the blood cultures. The study did not measure the impact of blood cultures on clinical outcomes, but these striking results reveal that routine blood cultures rarely alter our management of hospitalized patients with CAP.

Further, many have argued obtaining routine blood cultures in CAP can have negative consequences. Blood cultures are relatively costly and time intensive, contaminated blood cultures can lead to repeated testing and increased length of stay, and delays in obtaining blood cultures can delay antibiotic administration, another important quality marker in CAP. For now, it remains the standard of care to obtain blood cultures in these patients, but hospitalists should be aware of the limitations of this practice and consider focusing on other clinical interventions and quality measures in CAP.

A Review Study: A Dyspneic Emergency Patient

Wang CS, FitzGerald JM, Schulzer M, et al. Does this dyspneic patient in the emergency department have congestive heart failure? JAMA. 2005 Oct 19;294:944-1956.

Background: Distinguishing CHF from non-cardiac causes of dyspnea is a major challenge for hospitalists and emergency physicians, particularly in patients with a prior history of cardiac disease. Traditionally, clinicians have relied on the history, physical examination, and basic tests (chest X-ray and electrocardiogram) to diagnose CHF, but rapid B-type natriuretic peptide (BNP) testing is now widely incorporated as well.

A previous article in the Rational Clinical Examination series (Can the clinical examination diagnose left-sided heart failure in adults? JAMA. 1997;277(21):1712-1719) found that systolic dysfunction was moderately well predicted by an abnormal apical impulse on physical examination, radiographic cardiomegaly or venous redistribution, or electrocardiographic q waves or left bundle branch block.

Methods: In this review, the authors update and extend previous findings by also assessing the utility of serum BNP testing. The authors identified articles evaluating the diagnostic accuracy of the clinical exam and laboratory testing in diagnosing CHF in patients presenting to the emergency department with undifferentiated dyspnea. The “gold standard” was a clinical diagnosis of CHF made by the treating clinicians after an appropriate diagnostic workup. Summary likelihood ratios (LRs) were calculated using meta-analytic methodology.

Results/discussion: The authors determined that several findings increase the probability of CHF. A prior history of CHF (LR 5.8, CI 4.1-8.0) or myocardial infarction (LR 3.1, 95% CI 2.0-4.9), symptoms of paroxysmal nocturnal dyspnea (LR 2.6, 95% CI 1.5-4.5) and orthopnea (LR 2.2, 95% CI 1.2-3.9) were the most predictive historical factors. On physical examination, the presence of an S3 (LR 11, 95% CI 4.9-25), jugular venous distension (5.1, 95% CI 3.2-7.9), lung rales (LR 2.8, 95% CI 1.9-4.1), and peripheral edema (2.3, 95% CI 1.5-3.7) increased the probability of CHF. In interpreting these results, it is helpful to remember that a likelihood ratio of 2 increases the post-test probability by about 15%, and an LR of 5 increases the post-test probability by about 30%. Thus, a prior history of CHF and presence of an S3 or jugular venous distension are the most useful findings. Interestingly, clinician’s gestalt was equally predictive (LR 4.4, 95% CI 1.8-10.0.)

The most useful radiographic findings were venous congestion (LR 12.0, 95% CI 6.8-21) and the presence of cardiomegaly (LR 3.3; 95% CI 2.4-4.7). The single most predictive ECG finding was atrial fibrillation (LR 3.8; 95% CI 2.7-8.8); any abnormality on ECG had an LR of 2.2 (95% CI 1.6-3.1). Serum BNP levels were not more predictive of CHF than the history or physical examination; a BNP of >250 was associated with an LR of 4.6 (95% CI 2.6-8.0).

Few findings markedly decreased the probability of CHF. Here, it is helpful to remember that an LR of 0.5 decreases the post-test probability by about 15%, and an LR of 0.2 decreases the post-test probability by about 30%. With these in mind, the absence of cardiomegaly on CXR significantly changes the post-test probability (LR 0.33; 95% CI 0.23-0.48). A serum BNP level of less than 100pg/ml strongly argues against CHF, with an LR of 0.11 (95% CI 0.07-0.16); this finding lowers the post-test probability of CHF by about 45% compared to the pre-test probability.

In summary, the most useful findings for ruling in CHF in dyspneic emergency department patients were clinical gestalt, a prior history of CHF, findings of an S3 or jugular venous distension, and radiographic findings of venous congestion or cardiomegaly. Absence of radiographic cardiomegaly and a BNP of less than 100pg/ml argue against CHF. These must be interpreted in the context of the clinical pre-test probability of CHF, as none of the findings had likelihood ratios sufficient to be diagnostic of CHF when used individually.

What Should I Wear Today?

Rehman SU, Nietert PJ, Cope DW, Kilpatrick AO. What to wear today? Effect of doctor’s attire on the trust and confidence of patients. Am J Med. 2005 Nov; 118(11): 1279-1286.

Background: This study addresses the prototypical everyday clinical dilemma: What should I wear to work?

Methods: Patients and visitors to an outpatient Veterans Affairs internal medicine clinic in South Carolina were shown photographs of male and female physicians in four different styles of dress:

1. Professional (male physician wearing white coat with tie, female physician wearing white coat with tailored skirt or trousers);
2. Business (suit and tie for male, tailored trouser or skirt for female);
3. Surgical (surgical scrubs for both male and female): and
4. Casual (jeans and t-shirt or short skirt).

The study was randomized so that male and female respondents viewed photographs of either male or female physicians. Respondents were asked to report how strongly they felt about the importance of their physician’s appearance, and their preference for each style of dress; specifically, respondents were asked which physician was the most trustworthy, which physician they felt most comfortable with for routine examinations and emergencies, and which physician they felt most comfortable discussing psychological, sexual, and social problems with.

Results: Respondents overwhelmingly preferred professional attire for all questions: 76.3% felt most comfortable with a professionally dressed physician for all encounters, with surgical scrubs a distant second (10.2%), ahead of business dress (8.8%). Respondents were also significantly more willing to discuss psychological, sexual, and social problems with a professionally dressed physician. Even for care in an emergency situation, respondents still expressed a significant preference for professional attire over scrubs.

In a logistic regression model, patients who were older, African-American, and had less than a high school education were significantly more likely to prefer professional attire. Interestingly, female respondents who viewed photographs of female physicians placed significantly greater emphasis on physician’s attire than did male respondents.

Discussion: The study is clearly subject to caveats, chiefly that it was conducted at a single VA clinic and that only one aspect of the physician-patient encounter was addressed. Undoubtedly, patient’s preferences were influenced by the popular portrayal of physicians on TV shows. Nevertheless, given that hospitalists typically see older patients with whom they are not familiar, the initial clinical encounter may indeed by influenced by something as simple as wearing a white coat.

UA by Nephrologist Versus Hospital-Based Clinical Labs

Tsai JJ, Yeun JY, Kumar VA, Don BR. Comparison and interpretation of urinalysis performed by a nephrologist versus a hospital-based clinical laboratory. Am J Kidney Dis. 2005 Nov;46(5):820-829.

Background: Distinguishing the correct cause of acute renal failure is a frequent clinical dilemma for hospitalists, particularly diagnosing acute tubular necrosis (ATN), which is the most common cause of in-hospital acute renal failure. Although urinalysis with microscopy is the first test ordered on noting an abnormal serum creatinine, most hospitalists rely on the results generated by a laboratory technician. Anecdotally, many nephrologists have noted significant differences between urinalysis results performed by technicians and results found by nephrologists.

Methods: This study enrolled 26 patients hospitalized with acute renal failure on whom nephrology consultation was obtained. Urinalysis was performed both by laboratory personnel and a nephrologist (nephrologist A) who was blinded to the patient’s clinical information. Both sets of urinalysis results were independently used by nephrologist A and a second nephrologist (nephrologist B) to arrive at a clinical diagnosis for the patient, without having access to any other clinical information. These diagnoses were compared to the final diagnosis determined by the consulting nephrology service, who themselves did not have access to the diagnosis of either nephrologist A or B.

Results: The influence of having a nephrologist perform and interpret the urinalysis was striking. Nephrologist A was able to correctly diagnose 92.3% of cases based solely on his interpretation of the urinalysis. However, when given only the laboratory report of the urinalysis, both nephrologists were unable to diagnose most cases (23.1% for nephrologist A and 19.2% for nephrologist B). The major difference appeared to be in nephrologist A’s ability to find renal tubular epithelial (RTE) cells and RTE casts, which are pathognomonic of ATN. RTE cells and granular casts were frequently misinterpreted as squamous epithelial cells by laboratory personnel. This was particularly important as 81% of patients in the study had ATN as the primary cause of renal failure. Acanthocytes (dysmorphic red blood cells) were also missed by laboratory personnel in all six patients who were subsequently diagnosed with glomerulonephritis; nephrologist A correctly noted acanthocytes in five of these patients, and arrived at the correct diagnosis in all six patients.

Discussion: Microscopic evaluation of urine sediment has become a lost art among physicians, especially since passage of the Clinical Laboratory Improvement Amendments (CLIA) in 1988, which mandated that only CLIA-certified personnel could perform most laboratory tests. While it is probably unrealistic to call for training in microscopic urinalysis for all physicians, hospitalists in particular would benefit from such training, and at the very least should be mindful that laboratory urinalysis results may miss subtle findings that can be invaluable in diagnosing acute renal failure. This study points out the need for greater oversight and training of laboratory personnel, and serves as a reminder to clinicians that laboratory results should not be considered the gold standard. TH

Two new insulin products were recently FDA-approved, Exubera (inhaled human insulin, Pfizer/Nektar) and Levemir (insulin detemir, Novo Nordisk). These new insulins are important to hospitalists because admitted patients may be receiving them, patients may ask about them, and other members of the healthcare team may have questions, as well.

Nektar Therapeutics has been developing noninvasive macromolecules for inhaled delivery systems for many years. To develop Exubera (their first FDA-approved product), they collaborated with Pfizer and Sanofi-Aventis. Other Nektar products are not as far along in the U.S. drug approval process.

Exubera (inhalation powder, insulin human) was FDA-approved on January 27, 2006, and is expected to be on pharmacy shelves in June or July of this year. Exubera was also recently approved in Europe but is not available there yet, either. Exubera is short-acting and was approved for use in Types 1 and 2 diabetes mellitus in conjunction with oral agents, or with a basal insulin for basal/bolus dosing.

Peak Exubera levels occur in ~49 minutes (range 30-90 minutes) compared with regular insulin with a peak in 105 minutes (range, 60-240 minutes). In an open-label, 12-week, randomized, controlled trial Exubera improved glycemic control when substituted for or added to oral combination therapy (n=309) in adult Type 2 diabetes patients. There was a small decrease in HbA1c of ~1.4% in the Exubera-treated monotherapy patients. When Exubera was combined with two oral agents (an insulin sensitizer and a secretagogue), the HbA1c decreased ~1.9%. Patients who used only oral agents had an insignificant decrease in HbA1c (0.2%).

Investigators offered Types 1 and 2 diabetics open-label use of inhaled insulin for up to four years. The patients have maintained long-term glycemic control.

The Exubera inhaler device weighs 4 ounces and is about the size of a closed eyeglass case. Carrying the device may be problematic for some because of its size. Common side effects include cough, shortness of breath, sore throat, dry mouth, and hypoglycemia. Exubera is not recommended for 1) patients who have recently quit smoking (within six months); 2) current smokers; 3) asthmatics; or 4) those with bronchitis or emphysema.

Because Exubera is a new product that has not been available in other countries, its long-term safety is unknown. Pfizer is, however, committed to long-term safety and efficacy studies. Monitoring parameters specific to Exubera include: 1) baseline pulmonary function tests (PFTs); and 2) follow-up PFTs every six-12 months until more is known about the drug’s pulmonary safety.

The Word on the Street

Exubera’s manufacturers will likely target this agent to the population that will provide them with the greatest market potential (largest profit). Likely candidates will be those with poorly controlled diabetes on >2 oral agents; these patients will likely need more than another oral agent to improve their glycemic control. Pfizer may choose to market Exubera against insulin sensitizers such as rosiglitazone or pioglitazone —especially when it comes to pharmacoeconomics because the ‘glitazones are not yet available generically and are thus higher cost items.

Ease of use for Exubera versus injected insulin may be the sole advantage for this new agent. Some say that if Exubera is used as a tool for diabetics to get insulin treatment earlier (versus injected insulin), diabetic complications may be minimized; however, medication compliance will play a large role. The medical literature is full of articles regarding non-compliance/non-adherence with asthma inhalers, including improper inhaler use and non-use of these devices. So unless inhaled insulin can significantly improve outcomes compared with the inexpensive injections and other available therapies (e.g., insulin sensitizers), its place on health-system formularies may be limited at best.

Another Inhaled Option

Novo Nordisk received initial FDA approval for its long-acting, basal insulin analog—insulin detemir—on June 17, 2005. Subsequent approval for use in the pediatric population came on October 20, 2005. Levemir is expected on U.S. pharmacy shelves any day. Levemir has been approved in 53 countries worldwide, and has been available in Europe since March 2004.

Levemir is a basal insulin, similar to Lantus (glargine, Sanofi-Aventis), and is approved for use in adults with Types 1 and 2 diabetes and in children with Type 1 diabetes.

It is recommended that Levemir be dosed once- or twice-daily subcutaneously. Pharmacokinetically Levemir has a relatively flat action profile with a mean duration of action ranging between 5.7–23.2 hours (data from clinical trials). Following subcutaneous administration, insulin detemir has a slower, more prolonged absorption over 24 hours compared with NPH insulin. Maximum serum concentrations occur within six to eight hours following administration.

A common side effect of insulin therapies is hypoglycemia. Other side effects common to human insulins include allergic reactions, injection site reactions, lipodystrophy, pruritus, and rash. A beneficial effect obtained in some of the Levemir clinical studies was weight loss (0.2 to 0.3-kg), which occurred in several Type 1 patients. Comparatively, the Type 1 patients who received NPH insulin noted weight gain (0.4 to 1.4-kg) over the six-12 month timeframe.

There are no specific monitoring parameters for insulin detemir, except for general management of the diabetic patient (e.g., fasting blood sugar, glycosylated hemoglobin, eye exam, podiatry).

At its launch, insulin detemir will be available in 10mL vials as well as in the Levemir FlexPen. The FlexPen will require the use of NovoFine 30- or 31-gauge disposable needles. TH

Michele Kaufman is based in New York City.

References—Exubera

• Hollander PA, Blonde L, Rowe R, et al. Efficacy and safety of inhaled insulin (Exubera) compared with subcutaneous insulin therapy in patients with Type 2 diabetes: Results of a 6-month, randomized, comparative trial. Diabetes Care. 2004;27:2356-2362.
• Skyler JS, Weinstock RS, Raskin P, et al. The Inhaled Insulin Phase III Type 1 Diabetes Study Group. Use of inhaled insulin in a basal/bolus insulin regimen in Type 1 diabetic subjects: a 6-month, randomized, comparative trial. Diabetes Care. 2005 Jul:28(7):1630-1635.
• Rosenstock J, Zinman B, Murphy LJ, et al. Inhaled insulin improves glycemic control when substituted for or added to oral combination therapy in Type 2 Diabetes—a randomized, controlled trial. Ann Intern Med. 2005 Oct 18;143(8):549-588.
• The Pink Sheet, February 14, 2006; Volume 68, Number 7.Available at www.fda.gov/bbs/topics/news/2006/NEW01304.html. Last accessed March 8, 2006.

References—Levemir

• Levemir (insulin detemir [rDNA origin] injection) package insert. Novo Nordisk, Inc. Princeton, NJ; October 2005.
• Goldman JD, Lee KW. Insulin detemir—a new basal insulin analog. nn Pharmacother. 2005;39:502-507.
• Home P, Bartley P, Russell-Jones D, et al. Insulin detemir offers improved glycemic control compared with NPH insulin in people with Type 1 diabetes—a randomized clinical trial. Diabetes Care. 2004;27:1081-1087. Available at http://press.novonordisk-us.com/internal.aspx?rid=318. Last accessed March 1, 2006.

Two new insulin products were recently FDA-approved, Exubera (inhaled human insulin, Pfizer/Nektar) and Levemir (insulin detemir, Novo Nordisk). These new insulins are important to hospitalists because admitted patients may be receiving them, patients may ask about them, and other members of the healthcare team may have questions, as well.

Nektar Therapeutics has been developing noninvasive macromolecules for inhaled delivery systems for many years. To develop Exubera (their first FDA-approved product), they collaborated with Pfizer and Sanofi-Aventis. Other Nektar products are not as far along in the U.S. drug approval process.

Exubera (inhalation powder, insulin human) was FDA-approved on January 27, 2006, and is expected to be on pharmacy shelves in June or July of this year. Exubera was also recently approved in Europe but is not available there yet, either. Exubera is short-acting and was approved for use in Types 1 and 2 diabetes mellitus in conjunction with oral agents, or with a basal insulin for basal/bolus dosing.

Peak Exubera levels occur in ~49 minutes (range 30-90 minutes) compared with regular insulin with a peak in 105 minutes (range, 60-240 minutes). In an open-label, 12-week, randomized, controlled trial Exubera improved glycemic control when substituted for or added to oral combination therapy (n=309) in adult Type 2 diabetes patients. There was a small decrease in HbA1c of ~1.4% in the Exubera-treated monotherapy patients. When Exubera was combined with two oral agents (an insulin sensitizer and a secretagogue), the HbA1c decreased ~1.9%. Patients who used only oral agents had an insignificant decrease in HbA1c (0.2%).

Investigators offered Types 1 and 2 diabetics open-label use of inhaled insulin for up to four years. The patients have maintained long-term glycemic control.

The Exubera inhaler device weighs 4 ounces and is about the size of a closed eyeglass case. Carrying the device may be problematic for some because of its size. Common side effects include cough, shortness of breath, sore throat, dry mouth, and hypoglycemia. Exubera is not recommended for 1) patients who have recently quit smoking (within six months); 2) current smokers; 3) asthmatics; or 4) those with bronchitis or emphysema.

Because Exubera is a new product that has not been available in other countries, its long-term safety is unknown. Pfizer is, however, committed to long-term safety and efficacy studies. Monitoring parameters specific to Exubera include: 1) baseline pulmonary function tests (PFTs); and 2) follow-up PFTs every six-12 months until more is known about the drug’s pulmonary safety.

The Word on the Street

Exubera’s manufacturers will likely target this agent to the population that will provide them with the greatest market potential (largest profit). Likely candidates will be those with poorly controlled diabetes on >2 oral agents; these patients will likely need more than another oral agent to improve their glycemic control. Pfizer may choose to market Exubera against insulin sensitizers such as rosiglitazone or pioglitazone —especially when it comes to pharmacoeconomics because the ‘glitazones are not yet available generically and are thus higher cost items.

Ease of use for Exubera versus injected insulin may be the sole advantage for this new agent. Some say that if Exubera is used as a tool for diabetics to get insulin treatment earlier (versus injected insulin), diabetic complications may be minimized; however, medication compliance will play a large role. The medical literature is full of articles regarding non-compliance/non-adherence with asthma inhalers, including improper inhaler use and non-use of these devices. So unless inhaled insulin can significantly improve outcomes compared with the inexpensive injections and other available therapies (e.g., insulin sensitizers), its place on health-system formularies may be limited at best.

Another Inhaled Option

Novo Nordisk received initial FDA approval for its long-acting, basal insulin analog—insulin detemir—on June 17, 2005. Subsequent approval for use in the pediatric population came on October 20, 2005. Levemir is expected on U.S. pharmacy shelves any day. Levemir has been approved in 53 countries worldwide, and has been available in Europe since March 2004.

Levemir is a basal insulin, similar to Lantus (glargine, Sanofi-Aventis), and is approved for use in adults with Types 1 and 2 diabetes and in children with Type 1 diabetes.

It is recommended that Levemir be dosed once- or twice-daily subcutaneously. Pharmacokinetically Levemir has a relatively flat action profile with a mean duration of action ranging between 5.7–23.2 hours (data from clinical trials). Following subcutaneous administration, insulin detemir has a slower, more prolonged absorption over 24 hours compared with NPH insulin. Maximum serum concentrations occur within six to eight hours following administration.

A common side effect of insulin therapies is hypoglycemia. Other side effects common to human insulins include allergic reactions, injection site reactions, lipodystrophy, pruritus, and rash. A beneficial effect obtained in some of the Levemir clinical studies was weight loss (0.2 to 0.3-kg), which occurred in several Type 1 patients. Comparatively, the Type 1 patients who received NPH insulin noted weight gain (0.4 to 1.4-kg) over the six-12 month timeframe.

There are no specific monitoring parameters for insulin detemir, except for general management of the diabetic patient (e.g., fasting blood sugar, glycosylated hemoglobin, eye exam, podiatry).

At its launch, insulin detemir will be available in 10mL vials as well as in the Levemir FlexPen. The FlexPen will require the use of NovoFine 30- or 31-gauge disposable needles. TH

Michele Kaufman is based in New York City.

References—Exubera

• Hollander PA, Blonde L, Rowe R, et al. Efficacy and safety of inhaled insulin (Exubera) compared with subcutaneous insulin therapy in patients with Type 2 diabetes: Results of a 6-month, randomized, comparative trial. Diabetes Care. 2004;27:2356-2362.
• Skyler JS, Weinstock RS, Raskin P, et al. The Inhaled Insulin Phase III Type 1 Diabetes Study Group. Use of inhaled insulin in a basal/bolus insulin regimen in Type 1 diabetic subjects: a 6-month, randomized, comparative trial. Diabetes Care. 2005 Jul:28(7):1630-1635.
• Rosenstock J, Zinman B, Murphy LJ, et al. Inhaled insulin improves glycemic control when substituted for or added to oral combination therapy in Type 2 Diabetes—a randomized, controlled trial. Ann Intern Med. 2005 Oct 18;143(8):549-588.
• The Pink Sheet, February 14, 2006; Volume 68, Number 7.Available at www.fda.gov/bbs/topics/news/2006/NEW01304.html. Last accessed March 8, 2006.

References—Levemir

• Levemir (insulin detemir [rDNA origin] injection) package insert. Novo Nordisk, Inc. Princeton, NJ; October 2005.
• Goldman JD, Lee KW. Insulin detemir—a new basal insulin analog. nn Pharmacother. 2005;39:502-507.
• Home P, Bartley P, Russell-Jones D, et al. Insulin detemir offers improved glycemic control compared with NPH insulin in people with Type 1 diabetes—a randomized clinical trial. Diabetes Care. 2004;27:1081-1087. Available at http://press.novonordisk-us.com/internal.aspx?rid=318. Last accessed March 1, 2006.

Two new insulin products were recently FDA-approved, Exubera (inhaled human insulin, Pfizer/Nektar) and Levemir (insulin detemir, Novo Nordisk). These new insulins are important to hospitalists because admitted patients may be receiving them, patients may ask about them, and other members of the healthcare team may have questions, as well.

Nektar Therapeutics has been developing noninvasive macromolecules for inhaled delivery systems for many years. To develop Exubera (their first FDA-approved product), they collaborated with Pfizer and Sanofi-Aventis. Other Nektar products are not as far along in the U.S. drug approval process.

Exubera (inhalation powder, insulin human) was FDA-approved on January 27, 2006, and is expected to be on pharmacy shelves in June or July of this year. Exubera was also recently approved in Europe but is not available there yet, either. Exubera is short-acting and was approved for use in Types 1 and 2 diabetes mellitus in conjunction with oral agents, or with a basal insulin for basal/bolus dosing.

Peak Exubera levels occur in ~49 minutes (range 30-90 minutes) compared with regular insulin with a peak in 105 minutes (range, 60-240 minutes). In an open-label, 12-week, randomized, controlled trial Exubera improved glycemic control when substituted for or added to oral combination therapy (n=309) in adult Type 2 diabetes patients. There was a small decrease in HbA1c of ~1.4% in the Exubera-treated monotherapy patients. When Exubera was combined with two oral agents (an insulin sensitizer and a secretagogue), the HbA1c decreased ~1.9%. Patients who used only oral agents had an insignificant decrease in HbA1c (0.2%).

Investigators offered Types 1 and 2 diabetics open-label use of inhaled insulin for up to four years. The patients have maintained long-term glycemic control.

The Exubera inhaler device weighs 4 ounces and is about the size of a closed eyeglass case. Carrying the device may be problematic for some because of its size. Common side effects include cough, shortness of breath, sore throat, dry mouth, and hypoglycemia. Exubera is not recommended for 1) patients who have recently quit smoking (within six months); 2) current smokers; 3) asthmatics; or 4) those with bronchitis or emphysema.

Because Exubera is a new product that has not been available in other countries, its long-term safety is unknown. Pfizer is, however, committed to long-term safety and efficacy studies. Monitoring parameters specific to Exubera include: 1) baseline pulmonary function tests (PFTs); and 2) follow-up PFTs every six-12 months until more is known about the drug’s pulmonary safety.

The Word on the Street

Exubera’s manufacturers will likely target this agent to the population that will provide them with the greatest market potential (largest profit). Likely candidates will be those with poorly controlled diabetes on >2 oral agents; these patients will likely need more than another oral agent to improve their glycemic control. Pfizer may choose to market Exubera against insulin sensitizers such as rosiglitazone or pioglitazone —especially when it comes to pharmacoeconomics because the ‘glitazones are not yet available generically and are thus higher cost items.

Ease of use for Exubera versus injected insulin may be the sole advantage for this new agent. Some say that if Exubera is used as a tool for diabetics to get insulin treatment earlier (versus injected insulin), diabetic complications may be minimized; however, medication compliance will play a large role. The medical literature is full of articles regarding non-compliance/non-adherence with asthma inhalers, including improper inhaler use and non-use of these devices. So unless inhaled insulin can significantly improve outcomes compared with the inexpensive injections and other available therapies (e.g., insulin sensitizers), its place on health-system formularies may be limited at best.

Another Inhaled Option

Novo Nordisk received initial FDA approval for its long-acting, basal insulin analog—insulin detemir—on June 17, 2005. Subsequent approval for use in the pediatric population came on October 20, 2005. Levemir is expected on U.S. pharmacy shelves any day. Levemir has been approved in 53 countries worldwide, and has been available in Europe since March 2004.

Levemir is a basal insulin, similar to Lantus (glargine, Sanofi-Aventis), and is approved for use in adults with Types 1 and 2 diabetes and in children with Type 1 diabetes.

It is recommended that Levemir be dosed once- or twice-daily subcutaneously. Pharmacokinetically Levemir has a relatively flat action profile with a mean duration of action ranging between 5.7–23.2 hours (data from clinical trials). Following subcutaneous administration, insulin detemir has a slower, more prolonged absorption over 24 hours compared with NPH insulin. Maximum serum concentrations occur within six to eight hours following administration.

A common side effect of insulin therapies is hypoglycemia. Other side effects common to human insulins include allergic reactions, injection site reactions, lipodystrophy, pruritus, and rash. A beneficial effect obtained in some of the Levemir clinical studies was weight loss (0.2 to 0.3-kg), which occurred in several Type 1 patients. Comparatively, the Type 1 patients who received NPH insulin noted weight gain (0.4 to 1.4-kg) over the six-12 month timeframe.

There are no specific monitoring parameters for insulin detemir, except for general management of the diabetic patient (e.g., fasting blood sugar, glycosylated hemoglobin, eye exam, podiatry).

At its launch, insulin detemir will be available in 10mL vials as well as in the Levemir FlexPen. The FlexPen will require the use of NovoFine 30- or 31-gauge disposable needles. TH

Michele Kaufman is based in New York City.

References—Exubera

• Hollander PA, Blonde L, Rowe R, et al. Efficacy and safety of inhaled insulin (Exubera) compared with subcutaneous insulin therapy in patients with Type 2 diabetes: Results of a 6-month, randomized, comparative trial. Diabetes Care. 2004;27:2356-2362.
• Skyler JS, Weinstock RS, Raskin P, et al. The Inhaled Insulin Phase III Type 1 Diabetes Study Group. Use of inhaled insulin in a basal/bolus insulin regimen in Type 1 diabetic subjects: a 6-month, randomized, comparative trial. Diabetes Care. 2005 Jul:28(7):1630-1635.
• Rosenstock J, Zinman B, Murphy LJ, et al. Inhaled insulin improves glycemic control when substituted for or added to oral combination therapy in Type 2 Diabetes—a randomized, controlled trial. Ann Intern Med. 2005 Oct 18;143(8):549-588.
• The Pink Sheet, February 14, 2006; Volume 68, Number 7.Available at www.fda.gov/bbs/topics/news/2006/NEW01304.html. Last accessed March 8, 2006.

References—Levemir

• Levemir (insulin detemir [rDNA origin] injection) package insert. Novo Nordisk, Inc. Princeton, NJ; October 2005.
• Goldman JD, Lee KW. Insulin detemir—a new basal insulin analog. nn Pharmacother. 2005;39:502-507.
• Home P, Bartley P, Russell-Jones D, et al. Insulin detemir offers improved glycemic control compared with NPH insulin in people with Type 1 diabetes—a randomized clinical trial. Diabetes Care. 2004;27:1081-1087. Available at http://press.novonordisk-us.com/internal.aspx?rid=318. Last accessed March 1, 2006.

Always searching for new ways to enhance the value of SHM membership, the SHM Membership Committee has created several task forces to work on special projects.

Designed to build upon the success of the Annual Meeting’s Mentorship Breakfast (a one-time opportunity for SHM members to meet with experienced hospitalist clinicians and leaders), the Mentorship Task Force was convened to study opportunities to expand the use of mentoring programs for SHM members. The task force has suggested mechanisms on how to assist SHM local chapter leaders, suggestions that have resulted in the creation of recurrent conference calls between members of the Midwest Region Council and local chapter leaders in the Midwest. The Task Force has also studied creating a yearlong longitudinal mentoring program on leadership skills and continues to work on this project.

The Industry Support of Local Chapters Task Force is critically looking at the role of industry sponsorship of local chapter activities. This task force (comprising participants from the SHM Ethics and Membership Committees, Regional Councils, and local chapters) is studying two issues:

1. How to assist local leaders in finding and securing sponsorship for chapter functions, and
2. How to create a process to review industry sponsored grants to support local chapter meetings.

Preliminary recommendations from this task force include additions and revisions to the SHM Local Chapter Handbook about strategies and techniques to employ when negotiating with industry representatives.

Finally, the Family Practice Task Force was recently convened to study how family practice hospitalists differ from their internal-medicine-trained colleagues. Initial efforts will focus on gathering data about family-practice-trained hospitalists, defining the unique skill set that family practice has to offer hospital medicine, and reviewing the post-graduate medical training needs of family practitioner hospital medicine physicians.

In addition to these task forces, the Membership Committee will launch a new research initiative. During 2006 SHM members will be invited to share their opinions on a variety of topics via electronic surveys. Data from each survey will be regularly shared with SHM leadership for review and use in future planning.

Your support of SHM has played a vital role in helping the society to assume the leadership position that it currently holds in the hospital medicine community. Your continued support will enable us to continue to grow and provide each member with the tools they need to best serve their patients and grow their practices in the process.

Ethics Policies Revised

Real and potential conflicts addressed in revisions

By Tom Baudendistel, MD, FACP, chair, SHM Ethics Committee

Conflicts of interest have been the major theme of the SHM Ethics Committee this past year. As SHM has grown into a major force shaping healthcare policy, the need for transparency in all of the organization’s endeavors has never been greater. Rather than being reactive to individual issues that arise, the ethics committee has adopted a proactive stance in identifying potential areas of tension. Building on the general guidelines of the 2003 SHM “Principles for Organizational Relationships,” this year’s ethics committee has refined SHM policies to address the latest real and potential conflicts of interest in several areas: the Annual Meeting Abstract competitions, the Journal of Hospital Medicine, and the SHM Board.

Prior to the 2005 Annual Meeting, chairs of the Research, Innovations, and Vignettes (RIV) Committees augmented previous disclosure policy in requiring more transparent and detailed statements of disclosure from authors submitting abstracts to the national meeting. Anjala Tess, MD, and Sunil Kripilani, MD, took the lead in this initiative, preserving the integrity of the academic process while shielding the SHM RIV competition from potential misuse by third parties.

Later in 2005, in preparation for publication of the Journal of Hospital Medicine, the ethics committee worked with the editors to develop a policy regarding potential conflicts of interest between the journal’s editors, editorial board, reviewers, and authors. Ethical dilemmas within academic journals generally arise in two main areas: academic or financial. An example of the former would include an editor or a reviewer who might benefit from affiliation with the authors or from the publication of material contained in a manuscript. Financial conflicts might arise when, for instance, an editor or author receives monetary support from an industry source and selectively publishes only manuscripts that cast the sponsoring company in a favorable light.

The SHM Ethics committee contacted editors from major journals, including Annals of Internal Medicine, Journal of the American Medical Association, The New England Journal of Medicine, and The American Journal of Medicine, and consulted the International Committee of Medical Journal Editors before crafting a policy for the Journal of Hospital Medicine’s Editorial Board. This policy directs JHM to obtain annual disclosure of potential academic and financial conflicts from its editors and editorial board members, and requests similar information from its authors and reviewers on an article-by-article basis. Thanks to Brian Harte, MD, and Don Krause, MD, for their leadership in this process.

More recently, the SHM Ethics Committee was asked to join the SHM Task Force to identify areas of potential conflict for the SHM Board. As leaders of a major organization in U.S. medical care, members of the board are obvious targets of outside interests including healthcare or pharmaceutical industry, legal associations, and other organizations to represent those outside parties’ viewpoints—either implicitly or explicitly. Should the leaders of SHM participate in malpractice litigation involving hospitalists? What restrictions should SHM place on its board members pertaining to relationships with outside academic and industry organizations? Should SHM accept funding from industry to support regional and national meetings? Should the SHM board endorse pay-for-performance initiatives? How should hospitalist scope of practice be defined?

The answers to these and similar questions will guide SHM policy in the coming years, and the SHM Ethics Committee will be there every step of the way.

The SHM Ethics Committee is now 15 members strong and continues to convene regularly via conference calls and as a group at the Annual Meeting. Check out the recent article by Erin Egan, MD, in The Hospitalist discussing the safe and ethical care of disaster victims (Jan. 2006, p. 10), or attend the “Ethical Dilemmas in the ICU” talk at the upcoming critical care precourse at the Annual Meeting on May 3 at 9 a.m. to catch other glimpses of the committee’s work. With the continued support and membership from SHM members, the committee aims to chart a clear and ethically acceptable course for SHM for years to come.

Quality of Work-Life Tools

An interim report from the SHM Career Satisfaction Task Force

By Sylvia McKean, MD, Tosha Wetterneck, MD, and Win Whitcomb, MD

A variety of career satisfaction issues threaten the evolution of hospital medicine as a specialty. These issues are analogous to the experience of other, well-established specialties essential to the smooth functioning of a hospital, including critical care and emergency medicine.

Hospitalists encounter daily disruptions in their workflow due to the unpredictability of acute medical illness, paging interruptions that require immediate attention, and an increasing variety of other demands on their time in an already stressed healthcare system. In addition, hospitalist services staffed with junior physicians may not have input into the patients triaged to their service or how the service is structured. They may encounter changing job descriptions as hospital administrators in charge of their salaries rely upon them to solve important problems.

Hospitalists face conflict as they try to control their work life. The role of the hospitalist has evolved from direct patient care, to improving throughput and related outcomes, and increasingly to one of leadership, quality improvement, and teaching. The challenges of this discipline continue to expand exponentially. In addition, community hospitals rely upon academic hospitalist programs to train and recruit physicians into the field of hospital medicine. Academic hospitalist services, therefore, need to ensure time to mentor trainees and serve as role models that hospital medicine is a satisfying, respected, and sustainable career.

In 2005 SHM’s career satisfaction task force reviewed available literature and started developing a series of chapters relating to the following “domains” related to job satisfaction:

• Control/autonomy;
• Workload/schedule;
• Reward/recognition; and
• Community/environment.

These chapters acknowledge that on-the-job challenges should be viewed from two different but related perspectives: the individual hospitalist and the hospital medicine group/service. Neither the individual nor the hospitalist service can work independently of the other because cohesiveness among hospitalist members is critical to promoting job satisfaction for the service. The task force is developing a career satisfaction tool kit consisting of individual and group self-assessment questionnaires and preventive strategies. Specific case examples from the academic and community settings will be provided to avoid pitfalls and false starts when seeking a job in hospital medicine or when responding to pressures in the hospital.

SHM has also funded additional research into career satisfaction under the leadership of Tosha Wetterneck, MD, from the University of Wisconsin Hospital and Clinic. Joe Miller, SHM senior vice president, and professional writer Phyllis Hanlon have joined the Career Satisfaction Task Force to translate our findings into a workable document for physician leaders and hospitalists. They were the editors of the supplement to The Hospitalist on “value added services” of hospitalists (vol. 9, suppl. 1, 2005).

The goals of these papers are to assist hospital administrators and hospitalist services to recruit and retain hospitalists and to help individual hospitalists to find new, more rewarding employment opportunities. The document will include practical tools for self and program analysis. As more information becomes available through survey research results and focus group analysis, the tools will be refined.

The goals of the Career Satisfaction Task Force for 2006-2007 include:

1. Complete the focused interviews;
2. Complete the first draft of the SHM Career Satisfaction Tool Kit;
3. Start the survey process at the 2006 SHM Annual Meeting;
4. Hold a workshop at the SHM Annual Meeting;
5. Utilize additional research data to modify the tool kit; and
6. Position the tool kit as a working document for structuring hospitalist programs and as a self-assessment tool for practicing hospitalists. TH

Always searching for new ways to enhance the value of SHM membership, the SHM Membership Committee has created several task forces to work on special projects.

Designed to build upon the success of the Annual Meeting’s Mentorship Breakfast (a one-time opportunity for SHM members to meet with experienced hospitalist clinicians and leaders), the Mentorship Task Force was convened to study opportunities to expand the use of mentoring programs for SHM members. The task force has suggested mechanisms on how to assist SHM local chapter leaders, suggestions that have resulted in the creation of recurrent conference calls between members of the Midwest Region Council and local chapter leaders in the Midwest. The Task Force has also studied creating a yearlong longitudinal mentoring program on leadership skills and continues to work on this project.

The Industry Support of Local Chapters Task Force is critically looking at the role of industry sponsorship of local chapter activities. This task force (comprising participants from the SHM Ethics and Membership Committees, Regional Councils, and local chapters) is studying two issues:

1. How to assist local leaders in finding and securing sponsorship for chapter functions, and
2. How to create a process to review industry sponsored grants to support local chapter meetings.

Preliminary recommendations from this task force include additions and revisions to the SHM Local Chapter Handbook about strategies and techniques to employ when negotiating with industry representatives.

Finally, the Family Practice Task Force was recently convened to study how family practice hospitalists differ from their internal-medicine-trained colleagues. Initial efforts will focus on gathering data about family-practice-trained hospitalists, defining the unique skill set that family practice has to offer hospital medicine, and reviewing the post-graduate medical training needs of family practitioner hospital medicine physicians.

In addition to these task forces, the Membership Committee will launch a new research initiative. During 2006 SHM members will be invited to share their opinions on a variety of topics via electronic surveys. Data from each survey will be regularly shared with SHM leadership for review and use in future planning.

Your support of SHM has played a vital role in helping the society to assume the leadership position that it currently holds in the hospital medicine community. Your continued support will enable us to continue to grow and provide each member with the tools they need to best serve their patients and grow their practices in the process.

Ethics Policies Revised

Real and potential conflicts addressed in revisions

By Tom Baudendistel, MD, FACP, chair, SHM Ethics Committee

Conflicts of interest have been the major theme of the SHM Ethics Committee this past year. As SHM has grown into a major force shaping healthcare policy, the need for transparency in all of the organization’s endeavors has never been greater. Rather than being reactive to individual issues that arise, the ethics committee has adopted a proactive stance in identifying potential areas of tension. Building on the general guidelines of the 2003 SHM “Principles for Organizational Relationships,” this year’s ethics committee has refined SHM policies to address the latest real and potential conflicts of interest in several areas: the Annual Meeting Abstract competitions, the Journal of Hospital Medicine, and the SHM Board.

Prior to the 2005 Annual Meeting, chairs of the Research, Innovations, and Vignettes (RIV) Committees augmented previous disclosure policy in requiring more transparent and detailed statements of disclosure from authors submitting abstracts to the national meeting. Anjala Tess, MD, and Sunil Kripilani, MD, took the lead in this initiative, preserving the integrity of the academic process while shielding the SHM RIV competition from potential misuse by third parties.

Later in 2005, in preparation for publication of the Journal of Hospital Medicine, the ethics committee worked with the editors to develop a policy regarding potential conflicts of interest between the journal’s editors, editorial board, reviewers, and authors. Ethical dilemmas within academic journals generally arise in two main areas: academic or financial. An example of the former would include an editor or a reviewer who might benefit from affiliation with the authors or from the publication of material contained in a manuscript. Financial conflicts might arise when, for instance, an editor or author receives monetary support from an industry source and selectively publishes only manuscripts that cast the sponsoring company in a favorable light.

The SHM Ethics committee contacted editors from major journals, including Annals of Internal Medicine, Journal of the American Medical Association, The New England Journal of Medicine, and The American Journal of Medicine, and consulted the International Committee of Medical Journal Editors before crafting a policy for the Journal of Hospital Medicine’s Editorial Board. This policy directs JHM to obtain annual disclosure of potential academic and financial conflicts from its editors and editorial board members, and requests similar information from its authors and reviewers on an article-by-article basis. Thanks to Brian Harte, MD, and Don Krause, MD, for their leadership in this process.

More recently, the SHM Ethics Committee was asked to join the SHM Task Force to identify areas of potential conflict for the SHM Board. As leaders of a major organization in U.S. medical care, members of the board are obvious targets of outside interests including healthcare or pharmaceutical industry, legal associations, and other organizations to represent those outside parties’ viewpoints—either implicitly or explicitly. Should the leaders of SHM participate in malpractice litigation involving hospitalists? What restrictions should SHM place on its board members pertaining to relationships with outside academic and industry organizations? Should SHM accept funding from industry to support regional and national meetings? Should the SHM board endorse pay-for-performance initiatives? How should hospitalist scope of practice be defined?

The answers to these and similar questions will guide SHM policy in the coming years, and the SHM Ethics Committee will be there every step of the way.

The SHM Ethics Committee is now 15 members strong and continues to convene regularly via conference calls and as a group at the Annual Meeting. Check out the recent article by Erin Egan, MD, in The Hospitalist discussing the safe and ethical care of disaster victims (Jan. 2006, p. 10), or attend the “Ethical Dilemmas in the ICU” talk at the upcoming critical care precourse at the Annual Meeting on May 3 at 9 a.m. to catch other glimpses of the committee’s work. With the continued support and membership from SHM members, the committee aims to chart a clear and ethically acceptable course for SHM for years to come.

Quality of Work-Life Tools

An interim report from the SHM Career Satisfaction Task Force

By Sylvia McKean, MD, Tosha Wetterneck, MD, and Win Whitcomb, MD

A variety of career satisfaction issues threaten the evolution of hospital medicine as a specialty. These issues are analogous to the experience of other, well-established specialties essential to the smooth functioning of a hospital, including critical care and emergency medicine.

Hospitalists encounter daily disruptions in their workflow due to the unpredictability of acute medical illness, paging interruptions that require immediate attention, and an increasing variety of other demands on their time in an already stressed healthcare system. In addition, hospitalist services staffed with junior physicians may not have input into the patients triaged to their service or how the service is structured. They may encounter changing job descriptions as hospital administrators in charge of their salaries rely upon them to solve important problems.

Hospitalists face conflict as they try to control their work life. The role of the hospitalist has evolved from direct patient care, to improving throughput and related outcomes, and increasingly to one of leadership, quality improvement, and teaching. The challenges of this discipline continue to expand exponentially. In addition, community hospitals rely upon academic hospitalist programs to train and recruit physicians into the field of hospital medicine. Academic hospitalist services, therefore, need to ensure time to mentor trainees and serve as role models that hospital medicine is a satisfying, respected, and sustainable career.

In 2005 SHM’s career satisfaction task force reviewed available literature and started developing a series of chapters relating to the following “domains” related to job satisfaction:

• Control/autonomy;
• Workload/schedule;
• Reward/recognition; and
• Community/environment.

These chapters acknowledge that on-the-job challenges should be viewed from two different but related perspectives: the individual hospitalist and the hospital medicine group/service. Neither the individual nor the hospitalist service can work independently of the other because cohesiveness among hospitalist members is critical to promoting job satisfaction for the service. The task force is developing a career satisfaction tool kit consisting of individual and group self-assessment questionnaires and preventive strategies. Specific case examples from the academic and community settings will be provided to avoid pitfalls and false starts when seeking a job in hospital medicine or when responding to pressures in the hospital.

SHM has also funded additional research into career satisfaction under the leadership of Tosha Wetterneck, MD, from the University of Wisconsin Hospital and Clinic. Joe Miller, SHM senior vice president, and professional writer Phyllis Hanlon have joined the Career Satisfaction Task Force to translate our findings into a workable document for physician leaders and hospitalists. They were the editors of the supplement to The Hospitalist on “value added services” of hospitalists (vol. 9, suppl. 1, 2005).

The goals of these papers are to assist hospital administrators and hospitalist services to recruit and retain hospitalists and to help individual hospitalists to find new, more rewarding employment opportunities. The document will include practical tools for self and program analysis. As more information becomes available through survey research results and focus group analysis, the tools will be refined.

The goals of the Career Satisfaction Task Force for 2006-2007 include:

1. Complete the focused interviews;
2. Complete the first draft of the SHM Career Satisfaction Tool Kit;
3. Start the survey process at the 2006 SHM Annual Meeting;
4. Hold a workshop at the SHM Annual Meeting;
5. Utilize additional research data to modify the tool kit; and
6. Position the tool kit as a working document for structuring hospitalist programs and as a self-assessment tool for practicing hospitalists. TH

Always searching for new ways to enhance the value of SHM membership, the SHM Membership Committee has created several task forces to work on special projects.

Designed to build upon the success of the Annual Meeting’s Mentorship Breakfast (a one-time opportunity for SHM members to meet with experienced hospitalist clinicians and leaders), the Mentorship Task Force was convened to study opportunities to expand the use of mentoring programs for SHM members. The task force has suggested mechanisms on how to assist SHM local chapter leaders, suggestions that have resulted in the creation of recurrent conference calls between members of the Midwest Region Council and local chapter leaders in the Midwest. The Task Force has also studied creating a yearlong longitudinal mentoring program on leadership skills and continues to work on this project.

The Industry Support of Local Chapters Task Force is critically looking at the role of industry sponsorship of local chapter activities. This task force (comprising participants from the SHM Ethics and Membership Committees, Regional Councils, and local chapters) is studying two issues:

1. How to assist local leaders in finding and securing sponsorship for chapter functions, and
2. How to create a process to review industry sponsored grants to support local chapter meetings.

Preliminary recommendations from this task force include additions and revisions to the SHM Local Chapter Handbook about strategies and techniques to employ when negotiating with industry representatives.

Finally, the Family Practice Task Force was recently convened to study how family practice hospitalists differ from their internal-medicine-trained colleagues. Initial efforts will focus on gathering data about family-practice-trained hospitalists, defining the unique skill set that family practice has to offer hospital medicine, and reviewing the post-graduate medical training needs of family practitioner hospital medicine physicians.

In addition to these task forces, the Membership Committee will launch a new research initiative. During 2006 SHM members will be invited to share their opinions on a variety of topics via electronic surveys. Data from each survey will be regularly shared with SHM leadership for review and use in future planning.

Your support of SHM has played a vital role in helping the society to assume the leadership position that it currently holds in the hospital medicine community. Your continued support will enable us to continue to grow and provide each member with the tools they need to best serve their patients and grow their practices in the process.

Ethics Policies Revised

Real and potential conflicts addressed in revisions

By Tom Baudendistel, MD, FACP, chair, SHM Ethics Committee

Conflicts of interest have been the major theme of the SHM Ethics Committee this past year. As SHM has grown into a major force shaping healthcare policy, the need for transparency in all of the organization’s endeavors has never been greater. Rather than being reactive to individual issues that arise, the ethics committee has adopted a proactive stance in identifying potential areas of tension. Building on the general guidelines of the 2003 SHM “Principles for Organizational Relationships,” this year’s ethics committee has refined SHM policies to address the latest real and potential conflicts of interest in several areas: the Annual Meeting Abstract competitions, the Journal of Hospital Medicine, and the SHM Board.

Prior to the 2005 Annual Meeting, chairs of the Research, Innovations, and Vignettes (RIV) Committees augmented previous disclosure policy in requiring more transparent and detailed statements of disclosure from authors submitting abstracts to the national meeting. Anjala Tess, MD, and Sunil Kripilani, MD, took the lead in this initiative, preserving the integrity of the academic process while shielding the SHM RIV competition from potential misuse by third parties.

Later in 2005, in preparation for publication of the Journal of Hospital Medicine, the ethics committee worked with the editors to develop a policy regarding potential conflicts of interest between the journal’s editors, editorial board, reviewers, and authors. Ethical dilemmas within academic journals generally arise in two main areas: academic or financial. An example of the former would include an editor or a reviewer who might benefit from affiliation with the authors or from the publication of material contained in a manuscript. Financial conflicts might arise when, for instance, an editor or author receives monetary support from an industry source and selectively publishes only manuscripts that cast the sponsoring company in a favorable light.

The SHM Ethics committee contacted editors from major journals, including Annals of Internal Medicine, Journal of the American Medical Association, The New England Journal of Medicine, and The American Journal of Medicine, and consulted the International Committee of Medical Journal Editors before crafting a policy for the Journal of Hospital Medicine’s Editorial Board. This policy directs JHM to obtain annual disclosure of potential academic and financial conflicts from its editors and editorial board members, and requests similar information from its authors and reviewers on an article-by-article basis. Thanks to Brian Harte, MD, and Don Krause, MD, for their leadership in this process.

More recently, the SHM Ethics Committee was asked to join the SHM Task Force to identify areas of potential conflict for the SHM Board. As leaders of a major organization in U.S. medical care, members of the board are obvious targets of outside interests including healthcare or pharmaceutical industry, legal associations, and other organizations to represent those outside parties’ viewpoints—either implicitly or explicitly. Should the leaders of SHM participate in malpractice litigation involving hospitalists? What restrictions should SHM place on its board members pertaining to relationships with outside academic and industry organizations? Should SHM accept funding from industry to support regional and national meetings? Should the SHM board endorse pay-for-performance initiatives? How should hospitalist scope of practice be defined?

The answers to these and similar questions will guide SHM policy in the coming years, and the SHM Ethics Committee will be there every step of the way.

The SHM Ethics Committee is now 15 members strong and continues to convene regularly via conference calls and as a group at the Annual Meeting. Check out the recent article by Erin Egan, MD, in The Hospitalist discussing the safe and ethical care of disaster victims (Jan. 2006, p. 10), or attend the “Ethical Dilemmas in the ICU” talk at the upcoming critical care precourse at the Annual Meeting on May 3 at 9 a.m. to catch other glimpses of the committee’s work. With the continued support and membership from SHM members, the committee aims to chart a clear and ethically acceptable course for SHM for years to come.

Quality of Work-Life Tools

An interim report from the SHM Career Satisfaction Task Force

By Sylvia McKean, MD, Tosha Wetterneck, MD, and Win Whitcomb, MD

A variety of career satisfaction issues threaten the evolution of hospital medicine as a specialty. These issues are analogous to the experience of other, well-established specialties essential to the smooth functioning of a hospital, including critical care and emergency medicine.

Hospitalists encounter daily disruptions in their workflow due to the unpredictability of acute medical illness, paging interruptions that require immediate attention, and an increasing variety of other demands on their time in an already stressed healthcare system. In addition, hospitalist services staffed with junior physicians may not have input into the patients triaged to their service or how the service is structured. They may encounter changing job descriptions as hospital administrators in charge of their salaries rely upon them to solve important problems.

Hospitalists face conflict as they try to control their work life. The role of the hospitalist has evolved from direct patient care, to improving throughput and related outcomes, and increasingly to one of leadership, quality improvement, and teaching. The challenges of this discipline continue to expand exponentially. In addition, community hospitals rely upon academic hospitalist programs to train and recruit physicians into the field of hospital medicine. Academic hospitalist services, therefore, need to ensure time to mentor trainees and serve as role models that hospital medicine is a satisfying, respected, and sustainable career.

In 2005 SHM’s career satisfaction task force reviewed available literature and started developing a series of chapters relating to the following “domains” related to job satisfaction:

• Control/autonomy;
• Workload/schedule;
• Reward/recognition; and
• Community/environment.

These chapters acknowledge that on-the-job challenges should be viewed from two different but related perspectives: the individual hospitalist and the hospital medicine group/service. Neither the individual nor the hospitalist service can work independently of the other because cohesiveness among hospitalist members is critical to promoting job satisfaction for the service. The task force is developing a career satisfaction tool kit consisting of individual and group self-assessment questionnaires and preventive strategies. Specific case examples from the academic and community settings will be provided to avoid pitfalls and false starts when seeking a job in hospital medicine or when responding to pressures in the hospital.

SHM has also funded additional research into career satisfaction under the leadership of Tosha Wetterneck, MD, from the University of Wisconsin Hospital and Clinic. Joe Miller, SHM senior vice president, and professional writer Phyllis Hanlon have joined the Career Satisfaction Task Force to translate our findings into a workable document for physician leaders and hospitalists. They were the editors of the supplement to The Hospitalist on “value added services” of hospitalists (vol. 9, suppl. 1, 2005).

The goals of these papers are to assist hospital administrators and hospitalist services to recruit and retain hospitalists and to help individual hospitalists to find new, more rewarding employment opportunities. The document will include practical tools for self and program analysis. As more information becomes available through survey research results and focus group analysis, the tools will be refined.

The goals of the Career Satisfaction Task Force for 2006-2007 include:

1. Complete the focused interviews;
2. Complete the first draft of the SHM Career Satisfaction Tool Kit;
3. Start the survey process at the 2006 SHM Annual Meeting;
4. Hold a workshop at the SHM Annual Meeting;
5. Utilize additional research data to modify the tool kit; and
6. Position the tool kit as a working document for structuring hospitalist programs and as a self-assessment tool for practicing hospitalists. TH

Benefits of Cardiac Resynchronization

By A. Rudmann, MD

Cleland J, Daubert J, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352:1539-1549.

A quarter to a third of patients with CHF have left or right bundle branch block, in which one side of the heart depolarizes and contracts before the other. Such electro-mechanical dyssynchrony is associated with decreased ejection fraction (EF), decreased cardiac output, and worse symptoms. A new pacemaker technology—called cardiac resynchronization therapy (CRT)—is a technically difficult procedure that involves placing a lead through the coronary sinus to the left side of the heart, re-establishing electro-mechanical synchrony. CRT improves EF and CHF symptoms, but its effect on mortality has been unknown.

In this unblinded trial funded and aided by Medtronic (a CRT device manufacturer) patients with class III-IV CHF despite standard medical therapy, ejection fraction <35%, and QRS >120 msec were randomized to CRT plus medical therapy or medical therapy alone. Patients with a major cardiovascular event in the preceding six weeks, conventional indication for pacemaker or defibrillator, continuous intravenous therapy for CHF, or atrial arrhythmia were excluded.

Eight-hundred-thirteen patients were followed for a mean of 2.5 years. The primary endpoint (a composite of death from any cause and first unplanned hospitalization for a major cardiovascular event) was reached by 39% of patients in the CRT arm versus 55% in the control arm. Death was also lower in the CRT group (20% versus 30%). Both outcomes were highly statistically significant. Other benefits of CRT included reduced hospitalization for worsening CHF (18% versus 33%), less severe symptoms, better quality of life, and higher left ventricular ejection fraction. Twelve percent of patients required more than one attempt to successfully insert the CRT device.

This study reports significant benefits for CRT added to medical therapy in patients with moderate-to-severe CHF, low EF, and cardiac dyssynchrony. The results are consistent with reported hemodynamic benefits of CRT. Limitations of the study include the unblinded methodology and close participation of the study sponsor in conducting the trial. Both raise questions about potential bias. Until other studies are available, clinicians should decide whether CRT is appropriate for individual patients. The cost effectiveness of CRT is not known.

Handoffs Finally Get Attention

By A. Rudmann, MD

Solet D, Norvell J, Rutan G, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80(12):1094-1099.

Handoffs involve the transfer of patient care responsibility from one clinician to another. In non-medical industries, analogous situations are known to be error-prone and have received substantial attention. However, despite the six-year-old Institute of Medicine study implicating poor communication as a major contributor to preventable deaths in U.S. hospitals, surprisingly little attention has been paid to handoffs by the medical community. A notable exception is AHRQ’s (the Agency for Healthcare Research and Quality) Web Morbidity and Mortality Rounds, which has highlighted the significance of poor communication among clinicians.

This article evaluates current handoff practices of the Indiana University School of Medicine (Indianapolis) internal medicine residency program. Major findings include significant variability in preparation, content, and method of handoffs across their four-hospital system. Barriers to effective handoff communication include lack of privacy, social hierarchy, language issues, lack of direct communication, inefficiency, and lack of formal education.

The authors propose Essential Elements for Successful Handoffs, including the following content items: complete team information, complete patient identification, brief history of present illness, active problems and past medical history, active medications, allergies, venous access status and contingencies, code status, pertinent lab data, concerns for the next 18-24 hours, long-term plans, and psychosocial concerns. Regarding process, the authors recommend both verbal and written communication routinely and bedside handoffs for high-risk patients. Additionally, they advise a formal handoff curriculum for residents, including both didactic instruction and attending role modeling.

While this may seem a tall order, the new 2006 National Patient Safety Goals now address handoff quality. As of January 1, JCAHO (Joint Commission on Accreditation of Healthcare Organizations) requires all accredited institutions to perform handoffs that are both interactive (at least offering the opportunity to interact) and appropriately informative with up-to-date clinical information about diagnoses and treatments, stability, and recent or anticipated changes. All clinicians should evaluate the quality of handoffs in their own practices and make improvements as necessary. This article offers good suggestions on where to start.

The Use of Systemic Steroids for COPD

By A. Rudmann, MD

Niewoehner D, Erbland M, Deupree R, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1999;340:1941-1947.

Systemic steroids are commonly prescribed for COPD exacerbation, despite adverse side effects including hyperglycemia, infections and osteoporosis. This randomized, double-blind, controlled trial conducted by the U.S. Department of Veterans Affairs (VA) compared two- and eight-week steroid regimens to placebo in patients also receiving broad spectrum antibiotics for seven days, inhaled beta-agonists, inhaled ipratropium bromide, and inhaled Triamcinolone Acetonide starting day four.

The steroid arms received methylprednisolone 125 mg every six hours for three days, then oral prednisone was tapered gradually from 60 mg over two or eight weeks. Inclusion criteria were clinical diagnosis of COPD exacerbation, age >50 years, >30 pack years of smoking, and either an FEV1 <1.5 or inability to undergo spirometry because of severe dyspnea. Patients with asthma, systemic steroid use in the preceding 30 days, and prognosis of less than one year were excluded.

In all, 1,870 patients were screened to enroll 271 patients who were followed for 182 days. Fifty percent of screened patients were ineligible due to recent steroid use. Systemic steroid treatment significantly reduced treatment failure at 30 days (23% versus 33%) and 90 days (37% versus 48%), but not at 182 days (51% versus 54%). Treatment failure was defined as death from any cause, mechanical ventilation, readmission for COPD, or intensification of pharmacologic therapy—which accounted for 70% of treatment failures at 30 days, 62% at 90 days, and 58% at 182 days. Seventy-five percent of the time this involved initiation of open-label systemic steroids. Two- and eight-week steroid regimens were equally efficacious. Steroid therapy reduced LOS from 9.7 to 8.5 days and improved FEV1 by a maximum of 0.1 L after one day. Mortality was not affected. Hyperglycemia was more common in the steroid groups (15% vs. 4%). Subgroup analysis showed that patients previously hospitalized benefited most from steroid therapy.

This study helps define the benefits and risks of systemic steroid therapy in COPD exacerbation. It reduces treatment failure rates at one and three months and reduces LOS, but increases hyperglycemia in patients receiving inhaled corticosteroids and other COPD treatments. About half of patients in the placebo arm required intensification of treatment, usually initiation of systemic steroid therapy; the other half averted systemic steroid therapy over six months of follow-up. Overall, this study suggests a rationale for deferring or limiting systemic steroid therapy in those patients without prior hospitalization for COPD and those at high risk for hyperglycemia.

Antibiotics for Atypical Coverage in Pneumonia Patients

By Valerie J. Lang, MD

Shefet D, Robenshtok E, Paul M, et al. Empirical atypical coverage for inpatients with community-acquired pneumonia: systematic review of randomized controlled trials. Arch Intern Med. 2005:165:1992-2000.

Most guidelines recommend that inpatients with community-acquired pneumonia receive antibiotics that cover atypical organisms, though it is rare that an atypical organism causes pneumonia severe enough to require hospitalization. This review of 24 trials compared antibiotic regimens with and without atypical coverage in a total of 5,015 inpatients with community-acquired pneumonia. Atypical coverage was provided by quinolones or macrolides, and arms without atypical coverage included a wide variety of beta-lactam regimens. There was no difference in overall 30-day mortality with or without atypical coverage (RR 1.13 [95% CI, 0.82-1.54]).

For the outcome of clinical failure, there was a trend toward advantage in the quinolone monotherapy arms (RR, 0.89[95% CI, 0.77-1.02]), with a disadvantage in the macrolide monotherapy arms (RR, 1.17 [95% CI, 0.77-1.77]). However, when the studies with unclear or inadequate allocation concealment or allocation generation were excluded, the trend virtually resolved (RR, 0.99 [95%CI, 0.82-1.19]).

For the patients with documented atypical pathogens, there was a trend in favor of atypical coverage (RR, 0.52 [95% CI, 0.24-1.10]). This was significant for the subset of 43 patients with documented Legionella species, (RR, 0.17 [95% CI, 0.05-0.63]). Notably, there was no significant difference in results for different age groups overall.

Although these results support the authors’ conclusion that using antibiotics with or without atypical coverage achieve similar outcomes (except in the rare cases of Legionella species infections), most of the studies used treatment arms that are not in line with current guidelines for the treatment of community-acquired pneumonia in inpatients. Other outcomes of interest to hospitalists (duration of intravenous therapy and length of stay) were not addressed. None of the studies compared a drug without atypical coverage (e.g., ceftriaxone) with the same drug plus another with atypical coverage (e.g., ceftriaxone plus azithromycin).

While guidelines still call for atypical coverage, the results of this review may provide support for hospitalists when treating patients with multiple drug allergies or intolerances who cannot be provided atypical coverage without significant side effects.

In-Home Hospital Care for Seniors

By Valerie J. Lang, MD

Leff B, Burton L, Mader SL, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005:143(11):798-808.

Hospitalists are acutely aware of the hazards of hospitalization for older patients, and several models of providing hospital-level care in patients’ homes have been explored in other countries. This study evaluated a hospital-at-home program which provided acute, hospital-level care to patients ≥65-year-old in three U.S. cities. All patients required hospitalization and had one of the following diagnoses: community acquired pneumonia, CHF exacerbation, COPD exacerbation, or cellulitis. Most of the patients were admitted directly from the emergency department and were never admitted to the hospital.

The hospital-at-home program provided the following services: 1) at least eight-24 hours of continuous, one-on-one nursing; 2) intermittent nursing visits at least daily after continuous nursing was no longer required; 3) at least daily home visits and 24-hour availability by a hospital-at-home physician; 4) durable medical equipment; 5) skilled therapies and pharmacy support; 6) home radiology and ECG; and 7) intravenous fluids, antibiotics, other medications, oxygen, and other respiratory therapies. Patients were referred back to their primary care physicians after discharge from the hospital-at-home stay.

The study consisted of an observation phase followed by an intervention phase for comparison. The results show that the process of providing hospital-level care at home was feasible. Nurses arrived at patients’ homes within a mean of 20 minutes and provided a mean of 16.9 hours (range 0-71 hours) of continuous care, with a mean of 1.4 visits per day (range 0-5.3) after that. Physicians evaluated patients in the homes within a mean of 1.8 hours (range 0-4.5 hours) and provided a mean of 1.5 visits per day (range 0-5.3). There was variability among the sites for some measures. For example, oxygen was delivered to the home within an average of 0.6 or 0.7 hours at two sites, but within an average of 3.3 hours at the third site.

The intervention group had significantly less incident delirium (OR 0.26 [95% CI, 0.12-0.57]), less sedative medication use (OR 0.49 [95%CI, 0.30-0.81]), less use of chemical restraints (2% versus 7%; p=0.014), fewer critical complications (0% versus 6%; p≤0.001), and fewer deaths (0% versus 3%; p=0.050). Mean length of stay in the intervention group was 3.2 days vs. 4.9 days in the observation group (p=0.004). Mean costs were lower in the hospital-at-home group than the hospitalized group ($5,081 versus $7,480; p≤0.001).

There were important limitations to the study. Follow-up data was missing on a substantial number of patients (37% of observation group and 28% of intervention group). The 85 patients who were eligible but did not receive hospital-at-home care (either because they declined or the program wasn’t open for admissions from 10 p.m. to 6 a.m.) were combined with the 84 patients who did receive it under intention-to-treat, so the effects of the intervention may be underestimated.

Despite the limitations of the data, the findings of less delirium, sedative use, and chemical restraint use in the hospital-at-home group ring true, as patients were not subjected to the 24-hour noise, 4 a.m. blood draws, and unfamiliar surroundings that promote delirium, insomnia, and agitation in the hospital. Because delirium is common, difficult to prevent, and associated with longer lengths of stay, increased complications, and lower levels of functioning on discharge, the hospital-at-home model is worth studying further. If further evidence can be obtained to support this model, it may be worth pursuing in communities where there are adequate home care resources. Additionally, it may provide a new niche for hospitalists: the “Home Hospitalist.” TH

Benefits of Cardiac Resynchronization

By A. Rudmann, MD

Cleland J, Daubert J, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352:1539-1549.

A quarter to a third of patients with CHF have left or right bundle branch block, in which one side of the heart depolarizes and contracts before the other. Such electro-mechanical dyssynchrony is associated with decreased ejection fraction (EF), decreased cardiac output, and worse symptoms. A new pacemaker technology—called cardiac resynchronization therapy (CRT)—is a technically difficult procedure that involves placing a lead through the coronary sinus to the left side of the heart, re-establishing electro-mechanical synchrony. CRT improves EF and CHF symptoms, but its effect on mortality has been unknown.

In this unblinded trial funded and aided by Medtronic (a CRT device manufacturer) patients with class III-IV CHF despite standard medical therapy, ejection fraction <35%, and QRS >120 msec were randomized to CRT plus medical therapy or medical therapy alone. Patients with a major cardiovascular event in the preceding six weeks, conventional indication for pacemaker or defibrillator, continuous intravenous therapy for CHF, or atrial arrhythmia were excluded.

Eight-hundred-thirteen patients were followed for a mean of 2.5 years. The primary endpoint (a composite of death from any cause and first unplanned hospitalization for a major cardiovascular event) was reached by 39% of patients in the CRT arm versus 55% in the control arm. Death was also lower in the CRT group (20% versus 30%). Both outcomes were highly statistically significant. Other benefits of CRT included reduced hospitalization for worsening CHF (18% versus 33%), less severe symptoms, better quality of life, and higher left ventricular ejection fraction. Twelve percent of patients required more than one attempt to successfully insert the CRT device.

This study reports significant benefits for CRT added to medical therapy in patients with moderate-to-severe CHF, low EF, and cardiac dyssynchrony. The results are consistent with reported hemodynamic benefits of CRT. Limitations of the study include the unblinded methodology and close participation of the study sponsor in conducting the trial. Both raise questions about potential bias. Until other studies are available, clinicians should decide whether CRT is appropriate for individual patients. The cost effectiveness of CRT is not known.

Handoffs Finally Get Attention

By A. Rudmann, MD

Solet D, Norvell J, Rutan G, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80(12):1094-1099.

Handoffs involve the transfer of patient care responsibility from one clinician to another. In non-medical industries, analogous situations are known to be error-prone and have received substantial attention. However, despite the six-year-old Institute of Medicine study implicating poor communication as a major contributor to preventable deaths in U.S. hospitals, surprisingly little attention has been paid to handoffs by the medical community. A notable exception is AHRQ’s (the Agency for Healthcare Research and Quality) Web Morbidity and Mortality Rounds, which has highlighted the significance of poor communication among clinicians.

This article evaluates current handoff practices of the Indiana University School of Medicine (Indianapolis) internal medicine residency program. Major findings include significant variability in preparation, content, and method of handoffs across their four-hospital system. Barriers to effective handoff communication include lack of privacy, social hierarchy, language issues, lack of direct communication, inefficiency, and lack of formal education.

The authors propose Essential Elements for Successful Handoffs, including the following content items: complete team information, complete patient identification, brief history of present illness, active problems and past medical history, active medications, allergies, venous access status and contingencies, code status, pertinent lab data, concerns for the next 18-24 hours, long-term plans, and psychosocial concerns. Regarding process, the authors recommend both verbal and written communication routinely and bedside handoffs for high-risk patients. Additionally, they advise a formal handoff curriculum for residents, including both didactic instruction and attending role modeling.

While this may seem a tall order, the new 2006 National Patient Safety Goals now address handoff quality. As of January 1, JCAHO (Joint Commission on Accreditation of Healthcare Organizations) requires all accredited institutions to perform handoffs that are both interactive (at least offering the opportunity to interact) and appropriately informative with up-to-date clinical information about diagnoses and treatments, stability, and recent or anticipated changes. All clinicians should evaluate the quality of handoffs in their own practices and make improvements as necessary. This article offers good suggestions on where to start.

The Use of Systemic Steroids for COPD

By A. Rudmann, MD

Niewoehner D, Erbland M, Deupree R, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1999;340:1941-1947.

Systemic steroids are commonly prescribed for COPD exacerbation, despite adverse side effects including hyperglycemia, infections and osteoporosis. This randomized, double-blind, controlled trial conducted by the U.S. Department of Veterans Affairs (VA) compared two- and eight-week steroid regimens to placebo in patients also receiving broad spectrum antibiotics for seven days, inhaled beta-agonists, inhaled ipratropium bromide, and inhaled Triamcinolone Acetonide starting day four.

The steroid arms received methylprednisolone 125 mg every six hours for three days, then oral prednisone was tapered gradually from 60 mg over two or eight weeks. Inclusion criteria were clinical diagnosis of COPD exacerbation, age >50 years, >30 pack years of smoking, and either an FEV1 <1.5 or inability to undergo spirometry because of severe dyspnea. Patients with asthma, systemic steroid use in the preceding 30 days, and prognosis of less than one year were excluded.

In all, 1,870 patients were screened to enroll 271 patients who were followed for 182 days. Fifty percent of screened patients were ineligible due to recent steroid use. Systemic steroid treatment significantly reduced treatment failure at 30 days (23% versus 33%) and 90 days (37% versus 48%), but not at 182 days (51% versus 54%). Treatment failure was defined as death from any cause, mechanical ventilation, readmission for COPD, or intensification of pharmacologic therapy—which accounted for 70% of treatment failures at 30 days, 62% at 90 days, and 58% at 182 days. Seventy-five percent of the time this involved initiation of open-label systemic steroids. Two- and eight-week steroid regimens were equally efficacious. Steroid therapy reduced LOS from 9.7 to 8.5 days and improved FEV1 by a maximum of 0.1 L after one day. Mortality was not affected. Hyperglycemia was more common in the steroid groups (15% vs. 4%). Subgroup analysis showed that patients previously hospitalized benefited most from steroid therapy.

This study helps define the benefits and risks of systemic steroid therapy in COPD exacerbation. It reduces treatment failure rates at one and three months and reduces LOS, but increases hyperglycemia in patients receiving inhaled corticosteroids and other COPD treatments. About half of patients in the placebo arm required intensification of treatment, usually initiation of systemic steroid therapy; the other half averted systemic steroid therapy over six months of follow-up. Overall, this study suggests a rationale for deferring or limiting systemic steroid therapy in those patients without prior hospitalization for COPD and those at high risk for hyperglycemia.

Antibiotics for Atypical Coverage in Pneumonia Patients

By Valerie J. Lang, MD

Shefet D, Robenshtok E, Paul M, et al. Empirical atypical coverage for inpatients with community-acquired pneumonia: systematic review of randomized controlled trials. Arch Intern Med. 2005:165:1992-2000.

Most guidelines recommend that inpatients with community-acquired pneumonia receive antibiotics that cover atypical organisms, though it is rare that an atypical organism causes pneumonia severe enough to require hospitalization. This review of 24 trials compared antibiotic regimens with and without atypical coverage in a total of 5,015 inpatients with community-acquired pneumonia. Atypical coverage was provided by quinolones or macrolides, and arms without atypical coverage included a wide variety of beta-lactam regimens. There was no difference in overall 30-day mortality with or without atypical coverage (RR 1.13 [95% CI, 0.82-1.54]).

For the outcome of clinical failure, there was a trend toward advantage in the quinolone monotherapy arms (RR, 0.89[95% CI, 0.77-1.02]), with a disadvantage in the macrolide monotherapy arms (RR, 1.17 [95% CI, 0.77-1.77]). However, when the studies with unclear or inadequate allocation concealment or allocation generation were excluded, the trend virtually resolved (RR, 0.99 [95%CI, 0.82-1.19]).

For the patients with documented atypical pathogens, there was a trend in favor of atypical coverage (RR, 0.52 [95% CI, 0.24-1.10]). This was significant for the subset of 43 patients with documented Legionella species, (RR, 0.17 [95% CI, 0.05-0.63]). Notably, there was no significant difference in results for different age groups overall.

Although these results support the authors’ conclusion that using antibiotics with or without atypical coverage achieve similar outcomes (except in the rare cases of Legionella species infections), most of the studies used treatment arms that are not in line with current guidelines for the treatment of community-acquired pneumonia in inpatients. Other outcomes of interest to hospitalists (duration of intravenous therapy and length of stay) were not addressed. None of the studies compared a drug without atypical coverage (e.g., ceftriaxone) with the same drug plus another with atypical coverage (e.g., ceftriaxone plus azithromycin).

While guidelines still call for atypical coverage, the results of this review may provide support for hospitalists when treating patients with multiple drug allergies or intolerances who cannot be provided atypical coverage without significant side effects.

In-Home Hospital Care for Seniors

By Valerie J. Lang, MD

Leff B, Burton L, Mader SL, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005:143(11):798-808.

Hospitalists are acutely aware of the hazards of hospitalization for older patients, and several models of providing hospital-level care in patients’ homes have been explored in other countries. This study evaluated a hospital-at-home program which provided acute, hospital-level care to patients ≥65-year-old in three U.S. cities. All patients required hospitalization and had one of the following diagnoses: community acquired pneumonia, CHF exacerbation, COPD exacerbation, or cellulitis. Most of the patients were admitted directly from the emergency department and were never admitted to the hospital.

The hospital-at-home program provided the following services: 1) at least eight-24 hours of continuous, one-on-one nursing; 2) intermittent nursing visits at least daily after continuous nursing was no longer required; 3) at least daily home visits and 24-hour availability by a hospital-at-home physician; 4) durable medical equipment; 5) skilled therapies and pharmacy support; 6) home radiology and ECG; and 7) intravenous fluids, antibiotics, other medications, oxygen, and other respiratory therapies. Patients were referred back to their primary care physicians after discharge from the hospital-at-home stay.

The study consisted of an observation phase followed by an intervention phase for comparison. The results show that the process of providing hospital-level care at home was feasible. Nurses arrived at patients’ homes within a mean of 20 minutes and provided a mean of 16.9 hours (range 0-71 hours) of continuous care, with a mean of 1.4 visits per day (range 0-5.3) after that. Physicians evaluated patients in the homes within a mean of 1.8 hours (range 0-4.5 hours) and provided a mean of 1.5 visits per day (range 0-5.3). There was variability among the sites for some measures. For example, oxygen was delivered to the home within an average of 0.6 or 0.7 hours at two sites, but within an average of 3.3 hours at the third site.

The intervention group had significantly less incident delirium (OR 0.26 [95% CI, 0.12-0.57]), less sedative medication use (OR 0.49 [95%CI, 0.30-0.81]), less use of chemical restraints (2% versus 7%; p=0.014), fewer critical complications (0% versus 6%; p≤0.001), and fewer deaths (0% versus 3%; p=0.050). Mean length of stay in the intervention group was 3.2 days vs. 4.9 days in the observation group (p=0.004). Mean costs were lower in the hospital-at-home group than the hospitalized group ($5,081 versus $7,480; p≤0.001).

There were important limitations to the study. Follow-up data was missing on a substantial number of patients (37% of observation group and 28% of intervention group). The 85 patients who were eligible but did not receive hospital-at-home care (either because they declined or the program wasn’t open for admissions from 10 p.m. to 6 a.m.) were combined with the 84 patients who did receive it under intention-to-treat, so the effects of the intervention may be underestimated.

Despite the limitations of the data, the findings of less delirium, sedative use, and chemical restraint use in the hospital-at-home group ring true, as patients were not subjected to the 24-hour noise, 4 a.m. blood draws, and unfamiliar surroundings that promote delirium, insomnia, and agitation in the hospital. Because delirium is common, difficult to prevent, and associated with longer lengths of stay, increased complications, and lower levels of functioning on discharge, the hospital-at-home model is worth studying further. If further evidence can be obtained to support this model, it may be worth pursuing in communities where there are adequate home care resources. Additionally, it may provide a new niche for hospitalists: the “Home Hospitalist.” TH

Benefits of Cardiac Resynchronization

By A. Rudmann, MD

Cleland J, Daubert J, Erdmann E, et al. The effect of cardiac resynchronization on morbidity and mortality in heart failure. N Engl J Med. 2005;352:1539-1549.

A quarter to a third of patients with CHF have left or right bundle branch block, in which one side of the heart depolarizes and contracts before the other. Such electro-mechanical dyssynchrony is associated with decreased ejection fraction (EF), decreased cardiac output, and worse symptoms. A new pacemaker technology—called cardiac resynchronization therapy (CRT)—is a technically difficult procedure that involves placing a lead through the coronary sinus to the left side of the heart, re-establishing electro-mechanical synchrony. CRT improves EF and CHF symptoms, but its effect on mortality has been unknown.

In this unblinded trial funded and aided by Medtronic (a CRT device manufacturer) patients with class III-IV CHF despite standard medical therapy, ejection fraction <35%, and QRS >120 msec were randomized to CRT plus medical therapy or medical therapy alone. Patients with a major cardiovascular event in the preceding six weeks, conventional indication for pacemaker or defibrillator, continuous intravenous therapy for CHF, or atrial arrhythmia were excluded.

Eight-hundred-thirteen patients were followed for a mean of 2.5 years. The primary endpoint (a composite of death from any cause and first unplanned hospitalization for a major cardiovascular event) was reached by 39% of patients in the CRT arm versus 55% in the control arm. Death was also lower in the CRT group (20% versus 30%). Both outcomes were highly statistically significant. Other benefits of CRT included reduced hospitalization for worsening CHF (18% versus 33%), less severe symptoms, better quality of life, and higher left ventricular ejection fraction. Twelve percent of patients required more than one attempt to successfully insert the CRT device.

This study reports significant benefits for CRT added to medical therapy in patients with moderate-to-severe CHF, low EF, and cardiac dyssynchrony. The results are consistent with reported hemodynamic benefits of CRT. Limitations of the study include the unblinded methodology and close participation of the study sponsor in conducting the trial. Both raise questions about potential bias. Until other studies are available, clinicians should decide whether CRT is appropriate for individual patients. The cost effectiveness of CRT is not known.

Handoffs Finally Get Attention

By A. Rudmann, MD

Solet D, Norvell J, Rutan G, et al. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Acad Med. 2005;80(12):1094-1099.

Handoffs involve the transfer of patient care responsibility from one clinician to another. In non-medical industries, analogous situations are known to be error-prone and have received substantial attention. However, despite the six-year-old Institute of Medicine study implicating poor communication as a major contributor to preventable deaths in U.S. hospitals, surprisingly little attention has been paid to handoffs by the medical community. A notable exception is AHRQ’s (the Agency for Healthcare Research and Quality) Web Morbidity and Mortality Rounds, which has highlighted the significance of poor communication among clinicians.

This article evaluates current handoff practices of the Indiana University School of Medicine (Indianapolis) internal medicine residency program. Major findings include significant variability in preparation, content, and method of handoffs across their four-hospital system. Barriers to effective handoff communication include lack of privacy, social hierarchy, language issues, lack of direct communication, inefficiency, and lack of formal education.

The authors propose Essential Elements for Successful Handoffs, including the following content items: complete team information, complete patient identification, brief history of present illness, active problems and past medical history, active medications, allergies, venous access status and contingencies, code status, pertinent lab data, concerns for the next 18-24 hours, long-term plans, and psychosocial concerns. Regarding process, the authors recommend both verbal and written communication routinely and bedside handoffs for high-risk patients. Additionally, they advise a formal handoff curriculum for residents, including both didactic instruction and attending role modeling.

While this may seem a tall order, the new 2006 National Patient Safety Goals now address handoff quality. As of January 1, JCAHO (Joint Commission on Accreditation of Healthcare Organizations) requires all accredited institutions to perform handoffs that are both interactive (at least offering the opportunity to interact) and appropriately informative with up-to-date clinical information about diagnoses and treatments, stability, and recent or anticipated changes. All clinicians should evaluate the quality of handoffs in their own practices and make improvements as necessary. This article offers good suggestions on where to start.

The Use of Systemic Steroids for COPD

By A. Rudmann, MD

Niewoehner D, Erbland M, Deupree R, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1999;340:1941-1947.

Systemic steroids are commonly prescribed for COPD exacerbation, despite adverse side effects including hyperglycemia, infections and osteoporosis. This randomized, double-blind, controlled trial conducted by the U.S. Department of Veterans Affairs (VA) compared two- and eight-week steroid regimens to placebo in patients also receiving broad spectrum antibiotics for seven days, inhaled beta-agonists, inhaled ipratropium bromide, and inhaled Triamcinolone Acetonide starting day four.

The steroid arms received methylprednisolone 125 mg every six hours for three days, then oral prednisone was tapered gradually from 60 mg over two or eight weeks. Inclusion criteria were clinical diagnosis of COPD exacerbation, age >50 years, >30 pack years of smoking, and either an FEV1 <1.5 or inability to undergo spirometry because of severe dyspnea. Patients with asthma, systemic steroid use in the preceding 30 days, and prognosis of less than one year were excluded.

In all, 1,870 patients were screened to enroll 271 patients who were followed for 182 days. Fifty percent of screened patients were ineligible due to recent steroid use. Systemic steroid treatment significantly reduced treatment failure at 30 days (23% versus 33%) and 90 days (37% versus 48%), but not at 182 days (51% versus 54%). Treatment failure was defined as death from any cause, mechanical ventilation, readmission for COPD, or intensification of pharmacologic therapy—which accounted for 70% of treatment failures at 30 days, 62% at 90 days, and 58% at 182 days. Seventy-five percent of the time this involved initiation of open-label systemic steroids. Two- and eight-week steroid regimens were equally efficacious. Steroid therapy reduced LOS from 9.7 to 8.5 days and improved FEV1 by a maximum of 0.1 L after one day. Mortality was not affected. Hyperglycemia was more common in the steroid groups (15% vs. 4%). Subgroup analysis showed that patients previously hospitalized benefited most from steroid therapy.

This study helps define the benefits and risks of systemic steroid therapy in COPD exacerbation. It reduces treatment failure rates at one and three months and reduces LOS, but increases hyperglycemia in patients receiving inhaled corticosteroids and other COPD treatments. About half of patients in the placebo arm required intensification of treatment, usually initiation of systemic steroid therapy; the other half averted systemic steroid therapy over six months of follow-up. Overall, this study suggests a rationale for deferring or limiting systemic steroid therapy in those patients without prior hospitalization for COPD and those at high risk for hyperglycemia.

Antibiotics for Atypical Coverage in Pneumonia Patients

By Valerie J. Lang, MD

Shefet D, Robenshtok E, Paul M, et al. Empirical atypical coverage for inpatients with community-acquired pneumonia: systematic review of randomized controlled trials. Arch Intern Med. 2005:165:1992-2000.

Most guidelines recommend that inpatients with community-acquired pneumonia receive antibiotics that cover atypical organisms, though it is rare that an atypical organism causes pneumonia severe enough to require hospitalization. This review of 24 trials compared antibiotic regimens with and without atypical coverage in a total of 5,015 inpatients with community-acquired pneumonia. Atypical coverage was provided by quinolones or macrolides, and arms without atypical coverage included a wide variety of beta-lactam regimens. There was no difference in overall 30-day mortality with or without atypical coverage (RR 1.13 [95% CI, 0.82-1.54]).

For the outcome of clinical failure, there was a trend toward advantage in the quinolone monotherapy arms (RR, 0.89[95% CI, 0.77-1.02]), with a disadvantage in the macrolide monotherapy arms (RR, 1.17 [95% CI, 0.77-1.77]). However, when the studies with unclear or inadequate allocation concealment or allocation generation were excluded, the trend virtually resolved (RR, 0.99 [95%CI, 0.82-1.19]).

For the patients with documented atypical pathogens, there was a trend in favor of atypical coverage (RR, 0.52 [95% CI, 0.24-1.10]). This was significant for the subset of 43 patients with documented Legionella species, (RR, 0.17 [95% CI, 0.05-0.63]). Notably, there was no significant difference in results for different age groups overall.

Although these results support the authors’ conclusion that using antibiotics with or without atypical coverage achieve similar outcomes (except in the rare cases of Legionella species infections), most of the studies used treatment arms that are not in line with current guidelines for the treatment of community-acquired pneumonia in inpatients. Other outcomes of interest to hospitalists (duration of intravenous therapy and length of stay) were not addressed. None of the studies compared a drug without atypical coverage (e.g., ceftriaxone) with the same drug plus another with atypical coverage (e.g., ceftriaxone plus azithromycin).

While guidelines still call for atypical coverage, the results of this review may provide support for hospitalists when treating patients with multiple drug allergies or intolerances who cannot be provided atypical coverage without significant side effects.

In-Home Hospital Care for Seniors

By Valerie J. Lang, MD

Leff B, Burton L, Mader SL, et al. Hospital at home: feasibility and outcomes of a program to provide hospital-level care at home for acutely ill older patients. Ann Intern Med. 2005:143(11):798-808.

Hospitalists are acutely aware of the hazards of hospitalization for older patients, and several models of providing hospital-level care in patients’ homes have been explored in other countries. This study evaluated a hospital-at-home program which provided acute, hospital-level care to patients ≥65-year-old in three U.S. cities. All patients required hospitalization and had one of the following diagnoses: community acquired pneumonia, CHF exacerbation, COPD exacerbation, or cellulitis. Most of the patients were admitted directly from the emergency department and were never admitted to the hospital.

The hospital-at-home program provided the following services: 1) at least eight-24 hours of continuous, one-on-one nursing; 2) intermittent nursing visits at least daily after continuous nursing was no longer required; 3) at least daily home visits and 24-hour availability by a hospital-at-home physician; 4) durable medical equipment; 5) skilled therapies and pharmacy support; 6) home radiology and ECG; and 7) intravenous fluids, antibiotics, other medications, oxygen, and other respiratory therapies. Patients were referred back to their primary care physicians after discharge from the hospital-at-home stay.

The study consisted of an observation phase followed by an intervention phase for comparison. The results show that the process of providing hospital-level care at home was feasible. Nurses arrived at patients’ homes within a mean of 20 minutes and provided a mean of 16.9 hours (range 0-71 hours) of continuous care, with a mean of 1.4 visits per day (range 0-5.3) after that. Physicians evaluated patients in the homes within a mean of 1.8 hours (range 0-4.5 hours) and provided a mean of 1.5 visits per day (range 0-5.3). There was variability among the sites for some measures. For example, oxygen was delivered to the home within an average of 0.6 or 0.7 hours at two sites, but within an average of 3.3 hours at the third site.

The intervention group had significantly less incident delirium (OR 0.26 [95% CI, 0.12-0.57]), less sedative medication use (OR 0.49 [95%CI, 0.30-0.81]), less use of chemical restraints (2% versus 7%; p=0.014), fewer critical complications (0% versus 6%; p≤0.001), and fewer deaths (0% versus 3%; p=0.050). Mean length of stay in the intervention group was 3.2 days vs. 4.9 days in the observation group (p=0.004). Mean costs were lower in the hospital-at-home group than the hospitalized group ($5,081 versus $7,480; p≤0.001).

There were important limitations to the study. Follow-up data was missing on a substantial number of patients (37% of observation group and 28% of intervention group). The 85 patients who were eligible but did not receive hospital-at-home care (either because they declined or the program wasn’t open for admissions from 10 p.m. to 6 a.m.) were combined with the 84 patients who did receive it under intention-to-treat, so the effects of the intervention may be underestimated.

Despite the limitations of the data, the findings of less delirium, sedative use, and chemical restraint use in the hospital-at-home group ring true, as patients were not subjected to the 24-hour noise, 4 a.m. blood draws, and unfamiliar surroundings that promote delirium, insomnia, and agitation in the hospital. Because delirium is common, difficult to prevent, and associated with longer lengths of stay, increased complications, and lower levels of functioning on discharge, the hospital-at-home model is worth studying further. If further evidence can be obtained to support this model, it may be worth pursuing in communities where there are adequate home care resources. Additionally, it may provide a new niche for hospitalists: the “Home Hospitalist.” TH

Quite likely things are different in Minnesota than they are on either coast. People are polite, know how to work together, and are respectful about consuming resources. Or as Tom Anderson, MD, a HealthPartners Medical Group (HPMG) hospitalist says: “In Minnesota affable usually beats good.” Fortunately, the 25 physician members of the hospitalist team who belong to the 580-member HPMG, are beyond affable and good. By many measures they are excellent, and they are shaping the field of hospital medicine.

At the heart of the HPMG hospitalist program’s quality are its people. Burke Kealey, MD, HPMG’s assistant medical director, helped start the program in 1997, recruiting young, energetic, and personable physicians who liked practicing big city hospital medicine, Midwestern style. “Our hospitalist program was one of the early ones operating before the term ‘hospitalist’ was well-known,” says Dr. Kealey.

The hospitalists are employed neither by an academic medical nor a community hospital. Instead, they are members of a 580-multispecialty physician group that anchors HealthPartners Network, an organization that consistently ranks among The National Committee for Quality Assurance’s (NCQA) top five health plans regionally and top 10 nationally. Yet excellence has its price, as the perverse incentives of the U.S. healthcare system reveal. Mary Brainerd, HealthPartner’s CEO, comments that although the company consistently ranks high, it gets paid thousands of dollars less per patient by Medicare than poor performing plans.

“The way Medicare is set up, it actually punishes you for being good,” says Brainerd, referring to Medicare’s rules that qualify hospitals to receive additional payments each time a patient returns for more treatment—even if their return was caused by sub-par diagnosis and treatment. Under Medicare’s incentives, hospitals and doctors who order unnecessary tests, provide poor care, or even make patients worse often receive higher payments than those who provide efficient, high-quality care. That doesn’t stop HPMG from doing things correctly.

With the physician group employing both clinic and inpatient physicians, it’s more straightforward getting metrics and incentives aligned than in a healthcare environment where the outpatient physician’s loss may be the hospitalist’s gain—or vice versa. “Working closely with clinic and ER doctors decreases length of stay, improves clinical outcomes, and decreases costs,” says Dr. Kealey. “That helps the whole medical group.”

Another major contributor to clinical excellence goes beyond HPMG. Using the Minnesota mindset, HPMG’s physicians work with the area’s other medical heavyweights, the Mayo Clinic (Rochester, Minn.) and the Allina Medical Group (Minneapolis), forging a consensus on best practices and evidence-based guidelines (www.icsi.org). An example of HPMG’s outpatient and inpatient physician collaboration is their approach to CHF. After both groups tackled the job of operationalizing “perfect” CHF care in a one-day Rapid Design Workshop, “perfect treatment” outcomes rose from 22% in January 2005 to 50% in March 2005.

Nuts and Bolts

Scheduling logistics is among the challenges a hospitalist program’s manager faces, and Dr. Kealey and his colleagues have—through experience—done well. Each hospitalist selects a block schedule (either one week on, one week off or 14 days straight for 24 weeks). They also serve two night shift weeks (6 p.m.—8 a.m.), although residents run things at night. Hospitalists reconfigure their schedules every six months, helping to avoid burnout. Geographic deployment is another energy saver. Each hospitalist works in one or two units, allowing them to know patients, family, and the nursing staff well. It also cuts the nine-story hospital down to a size.

To communicate effectively, physicians use electronic technology. Voice pagers connect all HPMG physicians. Other devices sound alerts, allow for co-management of patients with chronic diseases, quick referrals to specialists within the group, in-box messaging, and a discharge summary to the primary physician in six to eight hours.

As for compensation, physicians receive a base salary, set at 80% of SHM’s annual average for the Midwest, accounting for 65% of pay. Of the balance, productivity as measured by relative value units (RVUs) accounts for 40%, with 20% each for high marks on patient and provider satisfaction surveys, and the medical director’s discretion.

Myriad Opportunities

The HPMG hospitalist program offers opportunities to pursue many professional paths, as its SHM award roster shows. SHM’s Award for Outstanding Service in Clinical Medicine to HPMG Hospitalists have included:

• 2002 Rusty Holman, Outstanding Service in Hospital Medicine;
• 2003 Burke Kealey, Clinical Excellence; and
• 2005 Shaun Frost, Clinical Excellence.

Adding depth to the program involves embracing physicians on unusual career paths, such as Tom Anderson, MD, one of HPMG’s family practice hospitalists. After finishing training at Ramsey County Hospital of St. Paul, Minn., which became Regions Hospital in 1997 (and where Dr. Kealey also trained), Dr. Anderson joined a seven-doctor rural practice in Iron Range, Wis.

“It was in a hard-working blue collar town, and we were throwbacks,” says Dr. Anderson, “doing all our own obstetrics, covering the ER, helping surgeons. I was a real person in that community. Everyone knew each other from the church or hardware store.” If the doctors wanted to change anything, they talked over doughnuts and coffee, deciding how it would affect them and their patients. Dr. Anderson loved the work, but wanted more family time than the all-consuming rural practice allowed.

A recruiting call from Dr. Kealey changed everything. Dr. Kealey calls Dr. Anderson “a bright and shining star, someone who sits in the front row and asks all the questions.”

Dr. Anderson joined HPMG’s hospitalist team in 2004, enjoying the one-week-on/one-week-off schedule and the continuity of care afforded by a large team. “This is a big busy hospital,” he says. “The patients are really sick, and we plan our 12-hour shift around them.” He starts with a 7 a.m. huddle of nurses and physicians to plan the day by prioritizing patient needs, reviewing orders, arranging time to talk to specialists, and visiting all patients. “By 9 a.m. we’ve planned the day, including 3 p.m. patient discharges. I like prioritizing what has to be done, and defining what has to be fixed.”

Rick Hilger, MD, board certified in internal medicine and pediatrics, is on another mission. After residency at the University of Minnesota Medical School (Duluth), he became Regions Hospital’s chief resident and then stayed on. He wanted a pediatrics hospitalist practice, which proved impractical because 95% of Regions’ pediatric cases now go to another hospital. “Down the line I’d like a 50/50 adult/peds mix, but that’s hard to accomplish in a hospitalist program,” he says.

Still looking for a challenge, Dr. Hilger chose the Institute for Healthcare Improvement’s “100K Lives” initiative, becoming the lead physician for Region’s rapid response team to prevent unnecessary code-blue calls. With the hospitalists’ geographic deployment to specific units that meant planning who would respond to codes and how that would be communicated. Dr. Hilger encouraged administration to hire full-time employees to field a rapid response team and created a pre-code team.

“At least 30%-40% of patients code outside the ICU,” he says. “We’ve observed that they often have unstable vital signs six to eight hours before coding. We’ve cut through administrative minutiae and red tape so that patients don’t sit there with unstable vitals for long.”

The pre-code team—an ICU trained nurse and respiratory therapist—are alerted to those signs and respond in five minutes or less, 24/7. The rest of the team is alerted via pagers, with hospitalists fielding an average of three calls per day.

Other hospitalists find their special niches. Shaun Frost, MD, is breaking ground in peri-surgical care in orthopedics, urology and neurology, and is active in process improvement teams. Howard Epstein, MD, leads the palliative care team, while John Degelau, MD, chief of hospital medical at North Memorial, pursues his interest in geriatrics. Rich Mahr, MD, is the physician champion for electronic health records.

So being an HPMG hospitalist allows physicians to pursue many avenues of clinical and process improvement, including national initiatives and teaching. Dr. Anderson sums up what HPMG is about: “I joined this group because of its passion for medicine. When we get older we’ll look back and say that we had our moment, our time to give it 100%.”

Dr. Kealey calls them “an energized creative group. Everyone wants to go to national meetings and to keep ahead of the pack, to ask what’s next to learn?” TH

Writer Marlene Piturro regularly writes practice profiles for The Hospitalist.

Quite likely things are different in Minnesota than they are on either coast. People are polite, know how to work together, and are respectful about consuming resources. Or as Tom Anderson, MD, a HealthPartners Medical Group (HPMG) hospitalist says: “In Minnesota affable usually beats good.” Fortunately, the 25 physician members of the hospitalist team who belong to the 580-member HPMG, are beyond affable and good. By many measures they are excellent, and they are shaping the field of hospital medicine.

At the heart of the HPMG hospitalist program’s quality are its people. Burke Kealey, MD, HPMG’s assistant medical director, helped start the program in 1997, recruiting young, energetic, and personable physicians who liked practicing big city hospital medicine, Midwestern style. “Our hospitalist program was one of the early ones operating before the term ‘hospitalist’ was well-known,” says Dr. Kealey.

The hospitalists are employed neither by an academic medical nor a community hospital. Instead, they are members of a 580-multispecialty physician group that anchors HealthPartners Network, an organization that consistently ranks among The National Committee for Quality Assurance’s (NCQA) top five health plans regionally and top 10 nationally. Yet excellence has its price, as the perverse incentives of the U.S. healthcare system reveal. Mary Brainerd, HealthPartner’s CEO, comments that although the company consistently ranks high, it gets paid thousands of dollars less per patient by Medicare than poor performing plans.

“The way Medicare is set up, it actually punishes you for being good,” says Brainerd, referring to Medicare’s rules that qualify hospitals to receive additional payments each time a patient returns for more treatment—even if their return was caused by sub-par diagnosis and treatment. Under Medicare’s incentives, hospitals and doctors who order unnecessary tests, provide poor care, or even make patients worse often receive higher payments than those who provide efficient, high-quality care. That doesn’t stop HPMG from doing things correctly.

With the physician group employing both clinic and inpatient physicians, it’s more straightforward getting metrics and incentives aligned than in a healthcare environment where the outpatient physician’s loss may be the hospitalist’s gain—or vice versa. “Working closely with clinic and ER doctors decreases length of stay, improves clinical outcomes, and decreases costs,” says Dr. Kealey. “That helps the whole medical group.”

Another major contributor to clinical excellence goes beyond HPMG. Using the Minnesota mindset, HPMG’s physicians work with the area’s other medical heavyweights, the Mayo Clinic (Rochester, Minn.) and the Allina Medical Group (Minneapolis), forging a consensus on best practices and evidence-based guidelines (www.icsi.org). An example of HPMG’s outpatient and inpatient physician collaboration is their approach to CHF. After both groups tackled the job of operationalizing “perfect” CHF care in a one-day Rapid Design Workshop, “perfect treatment” outcomes rose from 22% in January 2005 to 50% in March 2005.

Nuts and Bolts

Scheduling logistics is among the challenges a hospitalist program’s manager faces, and Dr. Kealey and his colleagues have—through experience—done well. Each hospitalist selects a block schedule (either one week on, one week off or 14 days straight for 24 weeks). They also serve two night shift weeks (6 p.m.—8 a.m.), although residents run things at night. Hospitalists reconfigure their schedules every six months, helping to avoid burnout. Geographic deployment is another energy saver. Each hospitalist works in one or two units, allowing them to know patients, family, and the nursing staff well. It also cuts the nine-story hospital down to a size.

To communicate effectively, physicians use electronic technology. Voice pagers connect all HPMG physicians. Other devices sound alerts, allow for co-management of patients with chronic diseases, quick referrals to specialists within the group, in-box messaging, and a discharge summary to the primary physician in six to eight hours.

As for compensation, physicians receive a base salary, set at 80% of SHM’s annual average for the Midwest, accounting for 65% of pay. Of the balance, productivity as measured by relative value units (RVUs) accounts for 40%, with 20% each for high marks on patient and provider satisfaction surveys, and the medical director’s discretion.

Myriad Opportunities

The HPMG hospitalist program offers opportunities to pursue many professional paths, as its SHM award roster shows. SHM’s Award for Outstanding Service in Clinical Medicine to HPMG Hospitalists have included:

• 2002 Rusty Holman, Outstanding Service in Hospital Medicine;
• 2003 Burke Kealey, Clinical Excellence; and
• 2005 Shaun Frost, Clinical Excellence.

Adding depth to the program involves embracing physicians on unusual career paths, such as Tom Anderson, MD, one of HPMG’s family practice hospitalists. After finishing training at Ramsey County Hospital of St. Paul, Minn., which became Regions Hospital in 1997 (and where Dr. Kealey also trained), Dr. Anderson joined a seven-doctor rural practice in Iron Range, Wis.

“It was in a hard-working blue collar town, and we were throwbacks,” says Dr. Anderson, “doing all our own obstetrics, covering the ER, helping surgeons. I was a real person in that community. Everyone knew each other from the church or hardware store.” If the doctors wanted to change anything, they talked over doughnuts and coffee, deciding how it would affect them and their patients. Dr. Anderson loved the work, but wanted more family time than the all-consuming rural practice allowed.

A recruiting call from Dr. Kealey changed everything. Dr. Kealey calls Dr. Anderson “a bright and shining star, someone who sits in the front row and asks all the questions.”

Dr. Anderson joined HPMG’s hospitalist team in 2004, enjoying the one-week-on/one-week-off schedule and the continuity of care afforded by a large team. “This is a big busy hospital,” he says. “The patients are really sick, and we plan our 12-hour shift around them.” He starts with a 7 a.m. huddle of nurses and physicians to plan the day by prioritizing patient needs, reviewing orders, arranging time to talk to specialists, and visiting all patients. “By 9 a.m. we’ve planned the day, including 3 p.m. patient discharges. I like prioritizing what has to be done, and defining what has to be fixed.”

Rick Hilger, MD, board certified in internal medicine and pediatrics, is on another mission. After residency at the University of Minnesota Medical School (Duluth), he became Regions Hospital’s chief resident and then stayed on. He wanted a pediatrics hospitalist practice, which proved impractical because 95% of Regions’ pediatric cases now go to another hospital. “Down the line I’d like a 50/50 adult/peds mix, but that’s hard to accomplish in a hospitalist program,” he says.

Still looking for a challenge, Dr. Hilger chose the Institute for Healthcare Improvement’s “100K Lives” initiative, becoming the lead physician for Region’s rapid response team to prevent unnecessary code-blue calls. With the hospitalists’ geographic deployment to specific units that meant planning who would respond to codes and how that would be communicated. Dr. Hilger encouraged administration to hire full-time employees to field a rapid response team and created a pre-code team.

“At least 30%-40% of patients code outside the ICU,” he says. “We’ve observed that they often have unstable vital signs six to eight hours before coding. We’ve cut through administrative minutiae and red tape so that patients don’t sit there with unstable vitals for long.”

The pre-code team—an ICU trained nurse and respiratory therapist—are alerted to those signs and respond in five minutes or less, 24/7. The rest of the team is alerted via pagers, with hospitalists fielding an average of three calls per day.

Other hospitalists find their special niches. Shaun Frost, MD, is breaking ground in peri-surgical care in orthopedics, urology and neurology, and is active in process improvement teams. Howard Epstein, MD, leads the palliative care team, while John Degelau, MD, chief of hospital medical at North Memorial, pursues his interest in geriatrics. Rich Mahr, MD, is the physician champion for electronic health records.

So being an HPMG hospitalist allows physicians to pursue many avenues of clinical and process improvement, including national initiatives and teaching. Dr. Anderson sums up what HPMG is about: “I joined this group because of its passion for medicine. When we get older we’ll look back and say that we had our moment, our time to give it 100%.”

Dr. Kealey calls them “an energized creative group. Everyone wants to go to national meetings and to keep ahead of the pack, to ask what’s next to learn?” TH

Writer Marlene Piturro regularly writes practice profiles for The Hospitalist.

Quite likely things are different in Minnesota than they are on either coast. People are polite, know how to work together, and are respectful about consuming resources. Or as Tom Anderson, MD, a HealthPartners Medical Group (HPMG) hospitalist says: “In Minnesota affable usually beats good.” Fortunately, the 25 physician members of the hospitalist team who belong to the 580-member HPMG, are beyond affable and good. By many measures they are excellent, and they are shaping the field of hospital medicine.

At the heart of the HPMG hospitalist program’s quality are its people. Burke Kealey, MD, HPMG’s assistant medical director, helped start the program in 1997, recruiting young, energetic, and personable physicians who liked practicing big city hospital medicine, Midwestern style. “Our hospitalist program was one of the early ones operating before the term ‘hospitalist’ was well-known,” says Dr. Kealey.

The hospitalists are employed neither by an academic medical nor a community hospital. Instead, they are members of a 580-multispecialty physician group that anchors HealthPartners Network, an organization that consistently ranks among The National Committee for Quality Assurance’s (NCQA) top five health plans regionally and top 10 nationally. Yet excellence has its price, as the perverse incentives of the U.S. healthcare system reveal. Mary Brainerd, HealthPartner’s CEO, comments that although the company consistently ranks high, it gets paid thousands of dollars less per patient by Medicare than poor performing plans.

“The way Medicare is set up, it actually punishes you for being good,” says Brainerd, referring to Medicare’s rules that qualify hospitals to receive additional payments each time a patient returns for more treatment—even if their return was caused by sub-par diagnosis and treatment. Under Medicare’s incentives, hospitals and doctors who order unnecessary tests, provide poor care, or even make patients worse often receive higher payments than those who provide efficient, high-quality care. That doesn’t stop HPMG from doing things correctly.

With the physician group employing both clinic and inpatient physicians, it’s more straightforward getting metrics and incentives aligned than in a healthcare environment where the outpatient physician’s loss may be the hospitalist’s gain—or vice versa. “Working closely with clinic and ER doctors decreases length of stay, improves clinical outcomes, and decreases costs,” says Dr. Kealey. “That helps the whole medical group.”

Another major contributor to clinical excellence goes beyond HPMG. Using the Minnesota mindset, HPMG’s physicians work with the area’s other medical heavyweights, the Mayo Clinic (Rochester, Minn.) and the Allina Medical Group (Minneapolis), forging a consensus on best practices and evidence-based guidelines (www.icsi.org). An example of HPMG’s outpatient and inpatient physician collaboration is their approach to CHF. After both groups tackled the job of operationalizing “perfect” CHF care in a one-day Rapid Design Workshop, “perfect treatment” outcomes rose from 22% in January 2005 to 50% in March 2005.

Nuts and Bolts

Scheduling logistics is among the challenges a hospitalist program’s manager faces, and Dr. Kealey and his colleagues have—through experience—done well. Each hospitalist selects a block schedule (either one week on, one week off or 14 days straight for 24 weeks). They also serve two night shift weeks (6 p.m.—8 a.m.), although residents run things at night. Hospitalists reconfigure their schedules every six months, helping to avoid burnout. Geographic deployment is another energy saver. Each hospitalist works in one or two units, allowing them to know patients, family, and the nursing staff well. It also cuts the nine-story hospital down to a size.

To communicate effectively, physicians use electronic technology. Voice pagers connect all HPMG physicians. Other devices sound alerts, allow for co-management of patients with chronic diseases, quick referrals to specialists within the group, in-box messaging, and a discharge summary to the primary physician in six to eight hours.

As for compensation, physicians receive a base salary, set at 80% of SHM’s annual average for the Midwest, accounting for 65% of pay. Of the balance, productivity as measured by relative value units (RVUs) accounts for 40%, with 20% each for high marks on patient and provider satisfaction surveys, and the medical director’s discretion.

Myriad Opportunities

The HPMG hospitalist program offers opportunities to pursue many professional paths, as its SHM award roster shows. SHM’s Award for Outstanding Service in Clinical Medicine to HPMG Hospitalists have included:

• 2002 Rusty Holman, Outstanding Service in Hospital Medicine;
• 2003 Burke Kealey, Clinical Excellence; and
• 2005 Shaun Frost, Clinical Excellence.

Adding depth to the program involves embracing physicians on unusual career paths, such as Tom Anderson, MD, one of HPMG’s family practice hospitalists. After finishing training at Ramsey County Hospital of St. Paul, Minn., which became Regions Hospital in 1997 (and where Dr. Kealey also trained), Dr. Anderson joined a seven-doctor rural practice in Iron Range, Wis.

“It was in a hard-working blue collar town, and we were throwbacks,” says Dr. Anderson, “doing all our own obstetrics, covering the ER, helping surgeons. I was a real person in that community. Everyone knew each other from the church or hardware store.” If the doctors wanted to change anything, they talked over doughnuts and coffee, deciding how it would affect them and their patients. Dr. Anderson loved the work, but wanted more family time than the all-consuming rural practice allowed.

A recruiting call from Dr. Kealey changed everything. Dr. Kealey calls Dr. Anderson “a bright and shining star, someone who sits in the front row and asks all the questions.”

Dr. Anderson joined HPMG’s hospitalist team in 2004, enjoying the one-week-on/one-week-off schedule and the continuity of care afforded by a large team. “This is a big busy hospital,” he says. “The patients are really sick, and we plan our 12-hour shift around them.” He starts with a 7 a.m. huddle of nurses and physicians to plan the day by prioritizing patient needs, reviewing orders, arranging time to talk to specialists, and visiting all patients. “By 9 a.m. we’ve planned the day, including 3 p.m. patient discharges. I like prioritizing what has to be done, and defining what has to be fixed.”

Rick Hilger, MD, board certified in internal medicine and pediatrics, is on another mission. After residency at the University of Minnesota Medical School (Duluth), he became Regions Hospital’s chief resident and then stayed on. He wanted a pediatrics hospitalist practice, which proved impractical because 95% of Regions’ pediatric cases now go to another hospital. “Down the line I’d like a 50/50 adult/peds mix, but that’s hard to accomplish in a hospitalist program,” he says.

Still looking for a challenge, Dr. Hilger chose the Institute for Healthcare Improvement’s “100K Lives” initiative, becoming the lead physician for Region’s rapid response team to prevent unnecessary code-blue calls. With the hospitalists’ geographic deployment to specific units that meant planning who would respond to codes and how that would be communicated. Dr. Hilger encouraged administration to hire full-time employees to field a rapid response team and created a pre-code team.

“At least 30%-40% of patients code outside the ICU,” he says. “We’ve observed that they often have unstable vital signs six to eight hours before coding. We’ve cut through administrative minutiae and red tape so that patients don’t sit there with unstable vitals for long.”

The pre-code team—an ICU trained nurse and respiratory therapist—are alerted to those signs and respond in five minutes or less, 24/7. The rest of the team is alerted via pagers, with hospitalists fielding an average of three calls per day.

Other hospitalists find their special niches. Shaun Frost, MD, is breaking ground in peri-surgical care in orthopedics, urology and neurology, and is active in process improvement teams. Howard Epstein, MD, leads the palliative care team, while John Degelau, MD, chief of hospital medical at North Memorial, pursues his interest in geriatrics. Rich Mahr, MD, is the physician champion for electronic health records.

So being an HPMG hospitalist allows physicians to pursue many avenues of clinical and process improvement, including national initiatives and teaching. Dr. Anderson sums up what HPMG is about: “I joined this group because of its passion for medicine. When we get older we’ll look back and say that we had our moment, our time to give it 100%.”

Dr. Kealey calls them “an energized creative group. Everyone wants to go to national meetings and to keep ahead of the pack, to ask what’s next to learn?” TH

Writer Marlene Piturro regularly writes practice profiles for The Hospitalist.

Editors’ note: “Alliances” is a series written about the relationships that hospitalists have with members of the clinical care team, from the team members’ points of view. Each installment of “Alliances” provides valuable, revealing feedback that hospitalists can use to continually improve their intrateam relationships and, ultimately, patient care.

At the bedside or in committee, hospitalists are earning high marks from their pharmacist colleagues for their flexibility, approachability, and availability. By most accounts, hospitalists make the job of hospital pharmacists much easier, say the clinical pharmacists whom The Hospitalist recently interviewed—two from large university teaching hospitals and one from a community-based for-profit facility. In fact, attempts to extricate even constructive recommendations for hospitalists from these PharmDs proved fruitless.

“I think they do just about everything right,” says Tom Bookwalter, PharmD, clinical pharmacist on the General Medicine Service at the University of California San Francisco Medical Center and a clinical professor of pharmacy at the UCSF School of Medicine. “I don’t find any fault with them.”

On the unit and in policy and procedure committee meetings, say the sources interviewed for this article, hospitalists develop good rapport with other staff members, address problems promptly, and are committed to improving processes for staff and patients alike.

Strengths of Hospitalists

As a clinical pharmacy specialist in general medicine on floor 15 at Brigham and Women’s Hospital (BWH) (Boston), Stephanie A. Wahlstrom, PharmD BCPS, begins rounds with the clinical team at 8 a.m. The group—typically consisting of Dr. Wahlstrom, a pharmacy student under her supervision, two or three physician assistants, a hospitalist, a nurse and a care coordinator—“runs the list” of patients to be seen until about 10:30 a.m. On floor 15, a general medicine unit, Dr. Wahlstrom and the clinical team usually care for 15 patients.

Most of Dr.Wahlstrom’s dealings with attending physicians in her four years at BWH have involved hospitalists. “Our team does accept other patients from Harvard Vanguard Medical Associates, so I do see those attending physicians, but I always round with the hospitalist from BWH.

“One of their major strengths is that they get to know the system so well, and they are committed to improving the hospital system,” she explains. “They know its efficiencies—and its inefficiencies—and they are familiar with processes and how long they take.”

For instance, a physician unfamiliar with the workings of the hospital laboratory timing might not know how long it would take to obtain lab results. A patient on enoxaparin who is being monitored would have an anti-Xa level drawn, and an attending physician from outside the hospital system would have to call the lab to find out when results would appear.

A hospitalist, on the other hand, “has an intuition about how long that lab [result] would take to come back,” says Dr. Wahlstrom, and times his or her return visit to the unit to review results with the pharmacist.

Robert Quinn, PharmD, is director of pharmacy services at Sierra Vista Regional Hospital, a 182-bed acute care facility owned by Tenet Healthcare Corporation and located in California. He is especially appreciative of hospitalists’ availability to staff.

“In ‘the old days,’ before hospitalists, one could feel disconnected from the medical staff. They didn’t always know or understand procedures,” says Dr. Quinn. In addition, “reaching community-based attending physicians was much more difficult. Now, [the hospitalists] know the ins and outs of the hospital system, and they know who to speak with in certain departments.

“Another physician not familiar with our system may call and ask for a pharmacist, but our hospitalists will know when they need to speak with the director of pharmacy services or when they should talk with a clinical pharmacist,” he continues. “They really do know the inner workings of the hospital on a much more intimate level.”

For instance, says Dr. Quinn, when hospitalists want a certain medication to be added to the hospital’s medication formulary, they know that their request should be routed to the director of pharmacy services. Direct patient care, including monitoring for blood levels of medications, drug information, and the like are the bailiwick of the clinical pharmacists.

“In my experience here at UCSF,” says Dr. Bookwalter, “[hospitalists] are very concerned about making the hospital work, which is one of their major missions. They’re also very collaborative. We really do work together—not just pharmacy and hospitalists—but with everybody.”

As an example of that collaborative approach, Dr. Bookwalter points to a palliative care program developed under the leadership of Hospitalist and SHM President Steve Pantilat, MD. The program has garnered Palliative Care Leadership Center status for the UCSF Medical Center.

Another physician not familiar with our system may call and ask for a pharmacist, but our hospitalists will know when they need to speak with the director of pharmacy services or when they should talk with a clinical pharmacist. They really do know the inner workings of the hospital on a much more intimate level.

—Robert Quinn, PharmD

Collaboration Is Primary

Dr. Bookwalter does have comparisons to his current situation on the General Medicine Service because he previously worked in the Intensive Care Nursery and with the General Surgery Service at UCSF. The latter, he says, “was very hierarchical. The team I was on included some very famous surgeons. They were all very personable and certainly knew what they were doing—they were really great. But, if you made a suggestion to them, chances were it would be rejected, since they insisted on ‘caring for their patients themselves.’”

At BWH Dr. Wahlstrom has also observed that hospitalists are very inclusive.

“When we do rounds, they ask the nurse to join us, so that we can have all points of care in our meetings,” she says. “If I recommend a change in a patient’s medication regimen, such as adding basal insulin for a patient, the hospitalist generally includes that in the patient’s plan immediately, and an order is written when we are on rounds. Then I approve it, and the patient can be started on medication promptly. We discuss what is going to happen and the care plan is made right there on the spot.”

Hospitalists with whom Dr. Wahlstrom works are comfortable with collaboration and open to ideas. “You’re not worried about suggesting ideas, or that your ideas might be rejected,” she explains. For instance, suggesting a change from IV to PO antibiotics would be welcomely discussed. “The hospitalists make the environment for presenting ideas regarding patient care open and encouraging.”

Communication a Plus

Availability of hospitalists is enhanced by their communication skills, says Dr. Quinn. “Once hospitalists get to know us, and we get to know them, the communication is just absolutely great,” he says. “Although I don’t get out as much as my clinicians do, if I have an issue I can go to the unit anytime and discuss it.”

The hospitalists with whom Dr. Quinn deals are interested in process issues as well as patient issues. For instance, if medication-administration records are not being placed in patients’ charts in a timely manner, hospital staff have the ability to quickly set up meetings with department managers and hospitalists to devise ways to improve procedures.

Meeting with other attending physicians is not as easy, says Dr. Quinn because they usually have very little time after making rounds and may have to be contacted at their practice office. “That’s one of the main advantages of having hospitalists,” he says. “They’re available. If anything happens, they’re there.”

During orientation at the UCSF Medical Center with new hospitalists, the General Medicine Service hospitalist residents take their teams on a tour of the pharmacy guided by Dr. Bookwalter. He explains the configuration of his department, which includes clinical pharmacists, pharmacy students, and a pharmacy practice resident. During the tour, he demonstrates how a medication order is processed, following it from the time the physician writes the prescription until the patient receives it. This contributes to both the residents’ and medical students’ understanding of how the hospital works.

If hospitalists have a concern about hospital policies, Dr. Bookwalter is there to aid them. “We promote rational drug therapy while the patient is in the hospital, smooth transitions in care, with the admit and discharge interviews, and we also follow up after patients leave to make sure they had no problems getting the medications they needed,” says Dr. Bookwalter.

During these contacts with patients, pharmacists also perform triage by asking patients how they feel at home. If they uncover problems during these interviews, “we first go to the team that took care of them in the hospital, and then to their primary physician,” he says.

A Boon for Patients, Staff

Are patients less comfortable with a new physician taking over their care? Dr. Quinn does not think this is a drawback. While the primary care physician may have a long-standing relationship with his or her patients, Dr. Quinn believes the availability of hospitalists can be very comforting to the patient.

“When a physician makes rounds and then leaves, patients may have a little bit of anxiety about whether they asked all their questions,” he speculates. It can be very comforting, he says, for the patient to know that the hospitalist is still on site.

Dr. Wahlstrom admits that sometimes she observes that patients may initially be uncomfortable meeting a physician other than their primary care physician. Again, building patient rapport seems to be no problem with the hospitalists with whom she works. “Patients seem to warm up to them right away,” she enthuses.

Dr. Quinn appreciates the fact that hospitalists are able and willing to participate in committees. “As a director of pharmacy services, I notice that their participation really helps—they understand the inner workings of the hospital and are able to look at situations in a different way.”

The hospital’s monthly hospitalist meeting is very well attended, Dr. Quinn reports: “[Our pharmacists] show up because we know that this is a tremendous forum for us to interact with physicians.”

Dr. Bookwalter also praises hospitalists’ interest in hospital safety and continuity of care. An innovative training program begun at UCSF Medical Center last year to address these issues entails sending pairs of pharmacy and medical students to patients’ homes after their hospital release.

“This has been very well received by both the pharmacy and medical students,” says Dr. Bookwalter. While at the patient’s home, the pharmacy student checks whether the patient has everything he or she needs, whether the patient understands how to take the medication, and whether it is being stored properly. If there are problems, the students can call the patient’s pharmacy, obtain special authorizations for third-party insurance coverage if needed, and help the patients obtain the care they need.

The program is designed to help students understand the change between hospital and home. “It’s a huge transition,” emphasizes Dr. Bookwalter. “Here in the hospital, the nurse is giving them their medicine every day, and then when they get home—and most of our patients are elderly—they get confused. Ultimately, we don’t want any discontinuities in care.”

High Ratings

It is their attention to innovation and collaboration among members of the multidisciplinary that our sources repeatedly praised about their hospitalist colleagues. Dr. Bookwalter doesn’t think there are any areas where hospitalists needed improvement.

“They all take it seriously, and they all perform well. You can really tell when you have someone on rotation who is not a hospitalist,” he says. “There are MDs who do research, are very well known, and are very familiar with the hospital, but it’s not the same collaborative experience. It’s like day and night.”

When pressed for recommendations he would give to hospitalists for improvement, Dr. Quinn admits he has one complaint: “I wish we had more. I’d like to see dozens of them!” TH

Writer Gretchen Henkel regularly writes “Alliances” for The Hospitalist.

Editors’ note: “Alliances” is a series written about the relationships that hospitalists have with members of the clinical care team, from the team members’ points of view. Each installment of “Alliances” provides valuable, revealing feedback that hospitalists can use to continually improve their intrateam relationships and, ultimately, patient care.

At the bedside or in committee, hospitalists are earning high marks from their pharmacist colleagues for their flexibility, approachability, and availability. By most accounts, hospitalists make the job of hospital pharmacists much easier, say the clinical pharmacists whom The Hospitalist recently interviewed—two from large university teaching hospitals and one from a community-based for-profit facility. In fact, attempts to extricate even constructive recommendations for hospitalists from these PharmDs proved fruitless.

“I think they do just about everything right,” says Tom Bookwalter, PharmD, clinical pharmacist on the General Medicine Service at the University of California San Francisco Medical Center and a clinical professor of pharmacy at the UCSF School of Medicine. “I don’t find any fault with them.”

On the unit and in policy and procedure committee meetings, say the sources interviewed for this article, hospitalists develop good rapport with other staff members, address problems promptly, and are committed to improving processes for staff and patients alike.

Strengths of Hospitalists

As a clinical pharmacy specialist in general medicine on floor 15 at Brigham and Women’s Hospital (BWH) (Boston), Stephanie A. Wahlstrom, PharmD BCPS, begins rounds with the clinical team at 8 a.m. The group—typically consisting of Dr. Wahlstrom, a pharmacy student under her supervision, two or three physician assistants, a hospitalist, a nurse and a care coordinator—“runs the list” of patients to be seen until about 10:30 a.m. On floor 15, a general medicine unit, Dr. Wahlstrom and the clinical team usually care for 15 patients.

Most of Dr.Wahlstrom’s dealings with attending physicians in her four years at BWH have involved hospitalists. “Our team does accept other patients from Harvard Vanguard Medical Associates, so I do see those attending physicians, but I always round with the hospitalist from BWH.

“One of their major strengths is that they get to know the system so well, and they are committed to improving the hospital system,” she explains. “They know its efficiencies—and its inefficiencies—and they are familiar with processes and how long they take.”

For instance, a physician unfamiliar with the workings of the hospital laboratory timing might not know how long it would take to obtain lab results. A patient on enoxaparin who is being monitored would have an anti-Xa level drawn, and an attending physician from outside the hospital system would have to call the lab to find out when results would appear.

A hospitalist, on the other hand, “has an intuition about how long that lab [result] would take to come back,” says Dr. Wahlstrom, and times his or her return visit to the unit to review results with the pharmacist.

Robert Quinn, PharmD, is director of pharmacy services at Sierra Vista Regional Hospital, a 182-bed acute care facility owned by Tenet Healthcare Corporation and located in California. He is especially appreciative of hospitalists’ availability to staff.

“In ‘the old days,’ before hospitalists, one could feel disconnected from the medical staff. They didn’t always know or understand procedures,” says Dr. Quinn. In addition, “reaching community-based attending physicians was much more difficult. Now, [the hospitalists] know the ins and outs of the hospital system, and they know who to speak with in certain departments.

“Another physician not familiar with our system may call and ask for a pharmacist, but our hospitalists will know when they need to speak with the director of pharmacy services or when they should talk with a clinical pharmacist,” he continues. “They really do know the inner workings of the hospital on a much more intimate level.”

For instance, says Dr. Quinn, when hospitalists want a certain medication to be added to the hospital’s medication formulary, they know that their request should be routed to the director of pharmacy services. Direct patient care, including monitoring for blood levels of medications, drug information, and the like are the bailiwick of the clinical pharmacists.

“In my experience here at UCSF,” says Dr. Bookwalter, “[hospitalists] are very concerned about making the hospital work, which is one of their major missions. They’re also very collaborative. We really do work together—not just pharmacy and hospitalists—but with everybody.”

As an example of that collaborative approach, Dr. Bookwalter points to a palliative care program developed under the leadership of Hospitalist and SHM President Steve Pantilat, MD. The program has garnered Palliative Care Leadership Center status for the UCSF Medical Center.

Another physician not familiar with our system may call and ask for a pharmacist, but our hospitalists will know when they need to speak with the director of pharmacy services or when they should talk with a clinical pharmacist. They really do know the inner workings of the hospital on a much more intimate level.

—Robert Quinn, PharmD

Collaboration Is Primary

Dr. Bookwalter does have comparisons to his current situation on the General Medicine Service because he previously worked in the Intensive Care Nursery and with the General Surgery Service at UCSF. The latter, he says, “was very hierarchical. The team I was on included some very famous surgeons. They were all very personable and certainly knew what they were doing—they were really great. But, if you made a suggestion to them, chances were it would be rejected, since they insisted on ‘caring for their patients themselves.’”

At BWH Dr. Wahlstrom has also observed that hospitalists are very inclusive.

“When we do rounds, they ask the nurse to join us, so that we can have all points of care in our meetings,” she says. “If I recommend a change in a patient’s medication regimen, such as adding basal insulin for a patient, the hospitalist generally includes that in the patient’s plan immediately, and an order is written when we are on rounds. Then I approve it, and the patient can be started on medication promptly. We discuss what is going to happen and the care plan is made right there on the spot.”

Hospitalists with whom Dr. Wahlstrom works are comfortable with collaboration and open to ideas. “You’re not worried about suggesting ideas, or that your ideas might be rejected,” she explains. For instance, suggesting a change from IV to PO antibiotics would be welcomely discussed. “The hospitalists make the environment for presenting ideas regarding patient care open and encouraging.”

Communication a Plus

Availability of hospitalists is enhanced by their communication skills, says Dr. Quinn. “Once hospitalists get to know us, and we get to know them, the communication is just absolutely great,” he says. “Although I don’t get out as much as my clinicians do, if I have an issue I can go to the unit anytime and discuss it.”

The hospitalists with whom Dr. Quinn deals are interested in process issues as well as patient issues. For instance, if medication-administration records are not being placed in patients’ charts in a timely manner, hospital staff have the ability to quickly set up meetings with department managers and hospitalists to devise ways to improve procedures.

Meeting with other attending physicians is not as easy, says Dr. Quinn because they usually have very little time after making rounds and may have to be contacted at their practice office. “That’s one of the main advantages of having hospitalists,” he says. “They’re available. If anything happens, they’re there.”

During orientation at the UCSF Medical Center with new hospitalists, the General Medicine Service hospitalist residents take their teams on a tour of the pharmacy guided by Dr. Bookwalter. He explains the configuration of his department, which includes clinical pharmacists, pharmacy students, and a pharmacy practice resident. During the tour, he demonstrates how a medication order is processed, following it from the time the physician writes the prescription until the patient receives it. This contributes to both the residents’ and medical students’ understanding of how the hospital works.

If hospitalists have a concern about hospital policies, Dr. Bookwalter is there to aid them. “We promote rational drug therapy while the patient is in the hospital, smooth transitions in care, with the admit and discharge interviews, and we also follow up after patients leave to make sure they had no problems getting the medications they needed,” says Dr. Bookwalter.

During these contacts with patients, pharmacists also perform triage by asking patients how they feel at home. If they uncover problems during these interviews, “we first go to the team that took care of them in the hospital, and then to their primary physician,” he says.

A Boon for Patients, Staff

Are patients less comfortable with a new physician taking over their care? Dr. Quinn does not think this is a drawback. While the primary care physician may have a long-standing relationship with his or her patients, Dr. Quinn believes the availability of hospitalists can be very comforting to the patient.

“When a physician makes rounds and then leaves, patients may have a little bit of anxiety about whether they asked all their questions,” he speculates. It can be very comforting, he says, for the patient to know that the hospitalist is still on site.

Dr. Wahlstrom admits that sometimes she observes that patients may initially be uncomfortable meeting a physician other than their primary care physician. Again, building patient rapport seems to be no problem with the hospitalists with whom she works. “Patients seem to warm up to them right away,” she enthuses.

Dr. Quinn appreciates the fact that hospitalists are able and willing to participate in committees. “As a director of pharmacy services, I notice that their participation really helps—they understand the inner workings of the hospital and are able to look at situations in a different way.”

The hospital’s monthly hospitalist meeting is very well attended, Dr. Quinn reports: “[Our pharmacists] show up because we know that this is a tremendous forum for us to interact with physicians.”

Dr. Bookwalter also praises hospitalists’ interest in hospital safety and continuity of care. An innovative training program begun at UCSF Medical Center last year to address these issues entails sending pairs of pharmacy and medical students to patients’ homes after their hospital release.

“This has been very well received by both the pharmacy and medical students,” says Dr. Bookwalter. While at the patient’s home, the pharmacy student checks whether the patient has everything he or she needs, whether the patient understands how to take the medication, and whether it is being stored properly. If there are problems, the students can call the patient’s pharmacy, obtain special authorizations for third-party insurance coverage if needed, and help the patients obtain the care they need.

The program is designed to help students understand the change between hospital and home. “It’s a huge transition,” emphasizes Dr. Bookwalter. “Here in the hospital, the nurse is giving them their medicine every day, and then when they get home—and most of our patients are elderly—they get confused. Ultimately, we don’t want any discontinuities in care.”

High Ratings

It is their attention to innovation and collaboration among members of the multidisciplinary that our sources repeatedly praised about their hospitalist colleagues. Dr. Bookwalter doesn’t think there are any areas where hospitalists needed improvement.

“They all take it seriously, and they all perform well. You can really tell when you have someone on rotation who is not a hospitalist,” he says. “There are MDs who do research, are very well known, and are very familiar with the hospital, but it’s not the same collaborative experience. It’s like day and night.”

When pressed for recommendations he would give to hospitalists for improvement, Dr. Quinn admits he has one complaint: “I wish we had more. I’d like to see dozens of them!” TH

Writer Gretchen Henkel regularly writes “Alliances” for The Hospitalist.

Editors’ note: “Alliances” is a series written about the relationships that hospitalists have with members of the clinical care team, from the team members’ points of view. Each installment of “Alliances” provides valuable, revealing feedback that hospitalists can use to continually improve their intrateam relationships and, ultimately, patient care.

At the bedside or in committee, hospitalists are earning high marks from their pharmacist colleagues for their flexibility, approachability, and availability. By most accounts, hospitalists make the job of hospital pharmacists much easier, say the clinical pharmacists whom The Hospitalist recently interviewed—two from large university teaching hospitals and one from a community-based for-profit facility. In fact, attempts to extricate even constructive recommendations for hospitalists from these PharmDs proved fruitless.

“I think they do just about everything right,” says Tom Bookwalter, PharmD, clinical pharmacist on the General Medicine Service at the University of California San Francisco Medical Center and a clinical professor of pharmacy at the UCSF School of Medicine. “I don’t find any fault with them.”

On the unit and in policy and procedure committee meetings, say the sources interviewed for this article, hospitalists develop good rapport with other staff members, address problems promptly, and are committed to improving processes for staff and patients alike.

Strengths of Hospitalists

As a clinical pharmacy specialist in general medicine on floor 15 at Brigham and Women’s Hospital (BWH) (Boston), Stephanie A. Wahlstrom, PharmD BCPS, begins rounds with the clinical team at 8 a.m. The group—typically consisting of Dr. Wahlstrom, a pharmacy student under her supervision, two or three physician assistants, a hospitalist, a nurse and a care coordinator—“runs the list” of patients to be seen until about 10:30 a.m. On floor 15, a general medicine unit, Dr. Wahlstrom and the clinical team usually care for 15 patients.

Most of Dr.Wahlstrom’s dealings with attending physicians in her four years at BWH have involved hospitalists. “Our team does accept other patients from Harvard Vanguard Medical Associates, so I do see those attending physicians, but I always round with the hospitalist from BWH.

“One of their major strengths is that they get to know the system so well, and they are committed to improving the hospital system,” she explains. “They know its efficiencies—and its inefficiencies—and they are familiar with processes and how long they take.”

For instance, a physician unfamiliar with the workings of the hospital laboratory timing might not know how long it would take to obtain lab results. A patient on enoxaparin who is being monitored would have an anti-Xa level drawn, and an attending physician from outside the hospital system would have to call the lab to find out when results would appear.

A hospitalist, on the other hand, “has an intuition about how long that lab [result] would take to come back,” says Dr. Wahlstrom, and times his or her return visit to the unit to review results with the pharmacist.

Robert Quinn, PharmD, is director of pharmacy services at Sierra Vista Regional Hospital, a 182-bed acute care facility owned by Tenet Healthcare Corporation and located in California. He is especially appreciative of hospitalists’ availability to staff.

“In ‘the old days,’ before hospitalists, one could feel disconnected from the medical staff. They didn’t always know or understand procedures,” says Dr. Quinn. In addition, “reaching community-based attending physicians was much more difficult. Now, [the hospitalists] know the ins and outs of the hospital system, and they know who to speak with in certain departments.

“Another physician not familiar with our system may call and ask for a pharmacist, but our hospitalists will know when they need to speak with the director of pharmacy services or when they should talk with a clinical pharmacist,” he continues. “They really do know the inner workings of the hospital on a much more intimate level.”

For instance, says Dr. Quinn, when hospitalists want a certain medication to be added to the hospital’s medication formulary, they know that their request should be routed to the director of pharmacy services. Direct patient care, including monitoring for blood levels of medications, drug information, and the like are the bailiwick of the clinical pharmacists.

“In my experience here at UCSF,” says Dr. Bookwalter, “[hospitalists] are very concerned about making the hospital work, which is one of their major missions. They’re also very collaborative. We really do work together—not just pharmacy and hospitalists—but with everybody.”

As an example of that collaborative approach, Dr. Bookwalter points to a palliative care program developed under the leadership of Hospitalist and SHM President Steve Pantilat, MD. The program has garnered Palliative Care Leadership Center status for the UCSF Medical Center.

Another physician not familiar with our system may call and ask for a pharmacist, but our hospitalists will know when they need to speak with the director of pharmacy services or when they should talk with a clinical pharmacist. They really do know the inner workings of the hospital on a much more intimate level.

—Robert Quinn, PharmD

Collaboration Is Primary

Dr. Bookwalter does have comparisons to his current situation on the General Medicine Service because he previously worked in the Intensive Care Nursery and with the General Surgery Service at UCSF. The latter, he says, “was very hierarchical. The team I was on included some very famous surgeons. They were all very personable and certainly knew what they were doing—they were really great. But, if you made a suggestion to them, chances were it would be rejected, since they insisted on ‘caring for their patients themselves.’”

At BWH Dr. Wahlstrom has also observed that hospitalists are very inclusive.

“When we do rounds, they ask the nurse to join us, so that we can have all points of care in our meetings,” she says. “If I recommend a change in a patient’s medication regimen, such as adding basal insulin for a patient, the hospitalist generally includes that in the patient’s plan immediately, and an order is written when we are on rounds. Then I approve it, and the patient can be started on medication promptly. We discuss what is going to happen and the care plan is made right there on the spot.”

Hospitalists with whom Dr. Wahlstrom works are comfortable with collaboration and open to ideas. “You’re not worried about suggesting ideas, or that your ideas might be rejected,” she explains. For instance, suggesting a change from IV to PO antibiotics would be welcomely discussed. “The hospitalists make the environment for presenting ideas regarding patient care open and encouraging.”

Communication a Plus

Availability of hospitalists is enhanced by their communication skills, says Dr. Quinn. “Once hospitalists get to know us, and we get to know them, the communication is just absolutely great,” he says. “Although I don’t get out as much as my clinicians do, if I have an issue I can go to the unit anytime and discuss it.”

The hospitalists with whom Dr. Quinn deals are interested in process issues as well as patient issues. For instance, if medication-administration records are not being placed in patients’ charts in a timely manner, hospital staff have the ability to quickly set up meetings with department managers and hospitalists to devise ways to improve procedures.

Meeting with other attending physicians is not as easy, says Dr. Quinn because they usually have very little time after making rounds and may have to be contacted at their practice office. “That’s one of the main advantages of having hospitalists,” he says. “They’re available. If anything happens, they’re there.”

During orientation at the UCSF Medical Center with new hospitalists, the General Medicine Service hospitalist residents take their teams on a tour of the pharmacy guided by Dr. Bookwalter. He explains the configuration of his department, which includes clinical pharmacists, pharmacy students, and a pharmacy practice resident. During the tour, he demonstrates how a medication order is processed, following it from the time the physician writes the prescription until the patient receives it. This contributes to both the residents’ and medical students’ understanding of how the hospital works.

If hospitalists have a concern about hospital policies, Dr. Bookwalter is there to aid them. “We promote rational drug therapy while the patient is in the hospital, smooth transitions in care, with the admit and discharge interviews, and we also follow up after patients leave to make sure they had no problems getting the medications they needed,” says Dr. Bookwalter.

During these contacts with patients, pharmacists also perform triage by asking patients how they feel at home. If they uncover problems during these interviews, “we first go to the team that took care of them in the hospital, and then to their primary physician,” he says.

A Boon for Patients, Staff

Are patients less comfortable with a new physician taking over their care? Dr. Quinn does not think this is a drawback. While the primary care physician may have a long-standing relationship with his or her patients, Dr. Quinn believes the availability of hospitalists can be very comforting to the patient.

“When a physician makes rounds and then leaves, patients may have a little bit of anxiety about whether they asked all their questions,” he speculates. It can be very comforting, he says, for the patient to know that the hospitalist is still on site.

Dr. Wahlstrom admits that sometimes she observes that patients may initially be uncomfortable meeting a physician other than their primary care physician. Again, building patient rapport seems to be no problem with the hospitalists with whom she works. “Patients seem to warm up to them right away,” she enthuses.

Dr. Quinn appreciates the fact that hospitalists are able and willing to participate in committees. “As a director of pharmacy services, I notice that their participation really helps—they understand the inner workings of the hospital and are able to look at situations in a different way.”

The hospital’s monthly hospitalist meeting is very well attended, Dr. Quinn reports: “[Our pharmacists] show up because we know that this is a tremendous forum for us to interact with physicians.”

Dr. Bookwalter also praises hospitalists’ interest in hospital safety and continuity of care. An innovative training program begun at UCSF Medical Center last year to address these issues entails sending pairs of pharmacy and medical students to patients’ homes after their hospital release.

“This has been very well received by both the pharmacy and medical students,” says Dr. Bookwalter. While at the patient’s home, the pharmacy student checks whether the patient has everything he or she needs, whether the patient understands how to take the medication, and whether it is being stored properly. If there are problems, the students can call the patient’s pharmacy, obtain special authorizations for third-party insurance coverage if needed, and help the patients obtain the care they need.

The program is designed to help students understand the change between hospital and home. “It’s a huge transition,” emphasizes Dr. Bookwalter. “Here in the hospital, the nurse is giving them their medicine every day, and then when they get home—and most of our patients are elderly—they get confused. Ultimately, we don’t want any discontinuities in care.”

High Ratings

It is their attention to innovation and collaboration among members of the multidisciplinary that our sources repeatedly praised about their hospitalist colleagues. Dr. Bookwalter doesn’t think there are any areas where hospitalists needed improvement.

“They all take it seriously, and they all perform well. You can really tell when you have someone on rotation who is not a hospitalist,” he says. “There are MDs who do research, are very well known, and are very familiar with the hospital, but it’s not the same collaborative experience. It’s like day and night.”

When pressed for recommendations he would give to hospitalists for improvement, Dr. Quinn admits he has one complaint: “I wish we had more. I’d like to see dozens of them!” TH

Writer Gretchen Henkel regularly writes “Alliances” for The Hospitalist.

A65-lb., 25-year-old, male cerebral palsy (CP) patient with pneumonia arrives at your Children’s Hospital via ambulance. Although chronologically this patient is an adult, in many ways he’s still a child, and the parents told the paramedics that they’ve always taken their son to Children’s. You’ve been the treating physician during the patient’s frequent hospital stays. Is Children’s Hospital still the best destination for this patient? Will the family’s insurance still cover an admission at Children’s?

During the hospital stay, the patient has complications. He has to be intubated. IV antibiotics need to be continued for a course after hospital discharge. A long recovery is expected. Is it time for the family to consider discharge to a long-term care facility rather than home? Are there any long-term care facilities in the area that accept young adult CP patients?

As the treating pediatric hospitalist, what is your role in helping this patient and his family transition from pediatric care to an adult-care medical home?

Introduction

Approximately 8.6 million children in the United States age 10–17 have a disability, according to the Adolescent Health Transition Project, which is housed at the Center on Human Development and Disability (CHDD) at the University of Washington, Seattle. Of these, 16% (or 1.4 million) experience limitations in their activities and will likely have difficulty making the transition to adult healthcare.1

Given enough time in the profession, every pediatric hospitalist will face the challenge of transitioning patients from child-centered to adult-oriented healthcare systems. The good news: Medical advances have made it increasingly possible for children who once would have died in childhood to survive into adulthood.

Example: One in 2,500 children is born with cystic fibrosis (CF); however, with the recent, unprecedented increase in the success of diagnosis and treatment modalities for the pulmonary component of CF, the estimated median survival age for those born in the 1990s is now 40.2 As of the year 2004, 41.8% of the 22,301 patients with CF were 18 or older.3 In fact, each year nearly 500,000 children with special healthcare needs reach adulthood, and 90% of children with a chronic illness and/or disability now survive to adulthood.4,5

The bad news: Many physicians whose practices focus on adults aren’t familiar with disease processes, such as CF, that have historically been considered pediatric illnesses.

For patients with chronic physical and medical conditions—particularly for those who are medically fragile and/or technology-dependent—the transition can prove especially difficult. And pediatric hospitalists in children’s hospitals face different challenges than those in facilities that admit patients of all ages. One thing remains the same, though, the goal: to provide uninterrupted, coordinated, developmentally appropriate healthcare.

Why Transition?

There are several good reasons for patients to be transitioned from pediatric care to adult care. First, as patients age medical issues develop that are beyond the sphere of pediatricians. In CF, for example, diabetes and biliary tract problems occur with greater frequency in adults. However, because so few CF patients historically survived to adulthood, few physicians who care for adults learned about the disease. Thus, the pediatricians who cared for CF patients continued to do so, leading to situations in which 30- and 40-year-olds have been hospitalized with children. But is that truly appropriate?

Adult patients may have high blood pressure, gynecologic issues, osteoporosis, or other problems the pediatrician may not be prepared to deal with. Example: A primary care pediatrician has been the “medical home” for a small, cerebral palsy patient since she was 10. She’s now 25. If she presents with a breast mass, will the pediatrician pick up on the condition adequately? Will they know where to send the patient?

“Adult providers know those systems better,” says Brett Pickering, MD, director of the Special Needs Clinic at San Diego’s UCSD Medical Center, Department of Pediatrics.

The adult patient has different emotional needs than the pediatric patient, and the pediatric hospitalist may not be in tune with adult needs. “Pediatricians do a lot of handholding,” says Dr. Pickering. “Adult providers are more matter of fact.”

Age restrictions on admissions, insurance, and funding issues also affect transition. For example, funding under the Social Security Act’s Title V Children with Special Health Care Needs typically ends at 21 despite a patient’s education or employment status.

Given these factors, what is the appropriate age to transition care from a pediatric floor or facility to an adult-oriented unit? According to the American Academy of Pediatrics, the responsibility of pediatrics continues through age 21, but there’s no hard-and-fast rule.

Challenges

The transition to adult-care facilities is typically a lengthy process involving multiple specialties and possibly joint care during a transition period—and a process that should ideally be coordinated by the patient’s primary care pediatrician. But hospitalists know that circumstances are typically far from ideal.

First, during a transition, the patient may feel abandoned by the medical team they’ve known for most of their lives. It takes time to develop trust and confidence in a new doctor. In this respect, pediatric hospitalists in facilities that care for patients of all ages have an advantage over hospitalists in children’s hospitals. They can call on their adult-care colleagues in other areas of the hospital for consultations and transfer care over time.

“The pediatric hospitalist must make bridges with their adult colleagues who are comfortable [with the issues] and willing to take on this patient population,” says Dr. Pickering.

Second, parents may feel an emotional dependency on the pediatric team and can feel threatened by the adult environment as they lose some control. To the parents, the patient will always be their child, Dr. Pickering notes.

Third, pediatric hospitalists may be reluctant to let go, particularly if they feel adult services are inferior to those they have provided, which brings us to the fourth major challenge: To whom do you transition care?

Many adult healthcare providers receive only limited training in disorders associated with pediatrics (e.g., CF, spina bifida). The Cystic Fibrosis Foundation is leading the way in educating physicians in what have historically been considered pediatric problems. In the 1980s, the foundation launched an educational program to train physicians already involved in adult pulmonary care in CF. Unfortunately, education in other areas has lagged. And finding a physician with both an interest in and knowledge of such disorders can prove challenging.

“It’s incumbent on our adult colleagues to take these patients on, but they need training,” says Dr. Pickering. “Long-term issues require long-term solutions.

How do you jazz people up to take care of this population?” she asks. Physicians must have at least a little bit of desire to learn about these special patient populations, but academic institutions also need to identify core knowledge and skills and make them part of training and certification requirements for primary care residents and physicians in practice. Continuing medical education for physicians, nurses, and allied healthcare professionals should include drug dosing, medical complications seen in transition populations, and related developmental, psychosocial, and behavioral issues.

Steps to a Successful Transition

So what should hospitalists do? In an April 2005 presentation at the SHM Annual Meeting, Joseph M. Geskey, DO, assistant professor of pediatrics and medicine, and director of inpatient pediatrics at Penn State College of Medicine, Hershey, Penn., recommended that pediatric hospitalists take the following steps:

1. Identify the key aspects of transition;
2. Bring stakeholders together;
3. Identify transitional needs;
4. Identify and provide resources;
5. Create an audit and evaluation process;
6. Decide who will hand off care of these patients when they are admitted to the hospital (the hospitalist or the disease-specific specialist);
7. Create an up-to-date medical summary that is portable and accessible. It should include important historic information, such as diagnostic data, procedures, operations, and medications;
8. Upon patient discharge, include specific instructions on who to call if the patient develops a problem after leaving the hospital;
9. Create a working group in your area that represents pediatric and adult hospitalists to examine transition issues in the hospitalized patient; and
10. Facilitate effective communication between patients and their families, primary care physicians and specialists; and
11. Know when to transfer care to a center with more expertise in caring for specific conditions.

Conclusion

Just as every patient is different and every patient’s circumstances are unique, every transition needs to be individualized. “It’s hard to set policy,” says Dr. Pickering. Open, direct communication, specific discharge instructions, an up-to-date medical summary and knowledge of the adult resources in your area can make any transition a success. TH

Keri Losavio regularly writes for “Pediatric Special Section.”

References

1. Adolescent Health Transition Project, Center on Human Development and Disability (CHDD) at the University of Washington, Seattle. Available at http://depts.washington.edu/healthtr/Providers/intro.htm. Last accessed January 16, 2006.
2. Bufi PL. Cystic fibrosis: therapeutic options for co-management. Available at www.thorne.com/altmedrev/fulltext/cystic.html. Last accessed January 16, 2006.
3. Cystic Fibrosis Foundation: 2004 Patient Registry Report. Available at www.cff.org/living_with_cf/. Last accessed Jan. 26, 2006
4. Newacheck PW, Taylor WR. Childhood chronic illness: prevalence, severity, and impact. Am J Pub Health. 1992;82(3):364-371.
5. Committee on Children with Disabilities and Committee on Adolescence, American Academy of Pediatrics. Transition of care provided for adolescents with special health care needs. Pediatrics. 1996;98(6):1203–1206.

Pediatric Special Section

In the Literature

By Mary Ann Queen, MD, and Amita Amonker, MD

Utilization of a Clinical Pathway Improves Care for Bronchiolitis

Cheney J, Barber S, Altamirano L, et al. A Clinical Pathway for Bronchiolitis is Effective in Reducing Readmission Rates. J Pediatr. 2005;147(5):622-626.

Bronchiolitis is the most common respiratory illness in infants that results in hospitalization. Many hospitals have developed clinical pathways to assist clinicians in managing this common infection; however, the effectiveness of such pathways has not been fully studied. Of those clinical practice guidelines analyzed, varying results have been identified.

To determine the effectiveness of a bronchiolitis pathway, this study compared infants managed prospectively using a pathway protocol with a retrospective analysis of infants managed without a pathway. Infants from a tertiary care children’s hospital and three regional hospitals were enrolled prospectively from May 2000 to August 2001. (One must note this study was completed in Australia, hence the difference from the typical Northern Hemisphere winter months.) The historical control group was admitted between May 1998 and August 1999 at the same four institutions. Two-hundred-twenty-nine patients admitted with bronchiolitis were treated using the pathway protocol. These patients were compared with 207 randomly selected control patients who were admitted prior to the institution of the bronchiolitis pathway. All patients were less than 12 months of age with their first episode of wheezing necessitating hospitalization.

These particular guidelines were developed and used to promote consistency of nursing management during a separate study on bronchiolitis. The pathway included an initial admission assessment. It also stated parameters for initiating and stopping both oxygen therapy and intravenous fluid therapy along with discharge guidelines.

The authors found no significant difference in length of stay or time in oxygen. Fifteen infants (7.2%) in the control group required readmission within two weeks of discharge compared with two infants (0.9%) in the pathway group (p=.001). Of the control group 33.8% received intravenous fluids (IVFs) compared with 19.2% of the pathway infants (p=.001). There was also greater steroid use in the control group but no difference in antibiotic usage. Specific data regarding steroids and antibiotics is not included.

The clinical pathway appears a useful tool for discharge planning with a decreased incidence of hospital readmission when specific discharge goals are utilized. The authors also reported a decreased use of IVFs in the pathway group. This was attributed to having specific parameters (O2 required, RR>60/min or inadequate oral feeding) for when to initiate them. It is unclear from the article whether meeting a single parameter or all three parameters triggered the initiation of IVFs.

The authors also point out the limitation of using a historical control given annual variations in severity sometimes seen with bronchiolitis. They attempted to minimize this by collecting data for each group over two consecutive winters.

Preprinted Paper Orders Reduce Medication Errors

Kozer E, Scolnik D, MacPherson A, et al. Using a preprinted order sheet to reduce prescription errors in a pediatric emergency department: A randomized, controlled trial. Pediatrics. 2005(116):1299-1302.

Medical errors, including medication errors, are common and are written about with increasing frequency in the lay press. Accreditation bodies and individual hospitals are striving for ways to decrease these errors. In some instances potential solutions include purchasing new computer systems for electronic physician order entry. This study looks at whether implementing a preprinted paper order sheet can decrease the incidence of medication errors in a pediatric ED.

This randomized, prospective study occurred during 18 days in July 2001 with nine days randomly assigned into each arm. The first arm used the hospital’s regular blank order sheets for all medication orders. The second arm used the experimental preprinted order sheet. This sheet required the staff to specify the dose, weight-adjusted dose, total daily dose, route of administration, and frequency for each medication ordered. Two medical students entered the data into a database that included information about patients’ demographics, diagnosis, acuity, details on the prescribing physician, the form used, and all medications prescribed and given to the patient. This information was subsequently reviewed by two blinded pediatric emergency physicians who determined if an error occurred and, if so, the degree of the error.

During the study period there were 2,157 visits to the ED with 95.4% charts available for review. Seven-hundred-ninety-five medications were prescribed with 376 ordered on the new form. Drug errors were identified in 68 (16.6%) orders when the regular form was used and in 37 (9.8%) orders on the new form. There was one severe error and 13 significant errors using the new form and 36 significant errors on the regular form. The new form was associated with a twofold decrease in the risk for a medication error even after accounting for the level of training of the ordering practitioner. There was an even greater reduction in the risk for a severe or significant error.

The literature has shown that computerized physician order entry can reduce the number of medication errors in the inpatient setting; however, it is not available in many hospitals and its effectiveness has not been shown in EDs. The authors point out that most medications ordered in the ED are prepared and given by nurses. The benefits of a computerized system in this setting is unclear.

This study occurred over an 18-day period with the new form only used for nine days outside of an earlier pilot period. One could speculate that the novelty of the form encouraged the physicians to examine orders more carefully, leading to decreased errors. It is unknown if the decrease in errors would be sustained over time.

Also important to note is that the definition of an error was limited to a mistake in dose, interval between doses, dose unit, and/or route. Errors such as legibility, medication allergy, or drug interactions are not discussed. However, as hospitals strive to implement technologies aimed at reducing errors this simple, economical solution may be of benefit.

No Association between Kawasaki Disease and Adenovirus

Shike H, Shimizu C, Kanegaye J, et al. Adenovirus, adeno-associated virus and Kawasaki disease. Pediatr Infect Dis J. 2005;24:1011-1014.

Kawasaki disease is a self-limited acute vasculitis of children with a suspected infectious etiology and defined seasonality. In an attempt to find a clue for a possible infectious cause of Kawasaki disease this study examined the seasonality of different viruses. The study recognized a similar bimodal seasonality for some serotypes of adenovirus. Adenovirus accounts for 5%-10% of respiratory tract infections in children and can mimic the clinical manifestations and laboratory abnormalities seen in Kawasaki disease.

This study postulated that infection with a non-cultivatable adenovirus or antecedent adenovirus infection might be a trigger for Kawasaki disease. The study analyzed patient samples using polymerase chain reaction primers for all 51 adenovirus serotypes, viral culture, and neutralization assay for the most common adenovirus serotypes. This study also investigated possible involvement of adeno-associated viruses (AAVs), because AAVs depend on helper viruses, such as adenovirus.

Kawasaki disease patients were enrolled during a 25-month period from February 2002 to February 2004 at Children’s Hospital and Health Center in San Diego. Illness day one was defined as the first day of fever. Clinical samples used in this study were collected within the first 14 days of fever onset and before intravenous immunoglobulin (IVIG) therapy.

Nasopharyngeal swabs were cultured for adenovirus. Standard adenoviral neutralization assays for the five most common serotypes were performed with the use of patient sera. Sera with a titer of 1/10 or greater were scored as positive. At least two clinical samples from each patient, including throat swabs, sera or urine, were tested by quantitative polymerase chain reaction (PCR) for adenovirus and AAV.

Nasopharyngeal viral cultures were collected before IVIG administration on illness day three—14 from 70 Kawasaki disease patients. Of the 70 patients, 52 patients fulfilled four of the five classic criteria or three of the five criteria with abnormal coronary arteries by echocardiogram. Of the remaining 18 patients with atypical Kawasaki disease, six had coronary artery abnormalities. Overall, seven patients had coronary artery aneurysms and 22 patients had coronary artery dilatation. Viral cultures were negative in 66 of the 70 Kawasaki disease patients. The viral isolates in four patients were respiratory syncytial (one), parainfluenza virus 3 (one) and adenovirus (two). Therefore adenovirus culture was negative in 97% of patients.

Fifteen Kawasaki disease patients with negative adenovirus cultures were evaluated by PCR assay on at least two clinical samples. Fourteen patients had a negative PCR result. The throat swab from one patient collected on illness day seven contained 800 adenovirus genome copies.

Results of the adenovirus neutralization assays from 26 Kawasaki disease patients revealed that neutralization titers against any of the five most common adenovirus serotypes were undetectable in four of 26 patients.

None of the 36 samples from the same 15 acute Kawasaki disease patients described for the PCR assay was positive for AAV.

This study concluded that despite the striking similarities between Kawasaki disease and adenovirus infection there is no evidence to suggest a link between the two.

Epidemiology and Clinical Description of Severe, Multifocal Staphylococcus aureus Infection

Miles F, Voss L, Segedin E, et al. Review of Staphylococcus aureus infections requiring admission to a paediatric intensive care unit. Arch Dis Child. 2005;90(12):1274-1278.

Staphylococcus aureus is a recognized cause of multifocal infection with a high mortality rate. Children with community acquired S. aureus bacteremia (SAB) have higher frequencies of unknown foci compared with hospital-acquired SAB. Those children with S. aureus sepsis (SAS) presenting to the pediatric intensive care unit tend to have multisystemic disease—either by direct invasion or toxin production—before the diagnosis is made and treatment is initiated.

This study evaluates the clinical features and mortality from SAS in those children who required intensive care management. A retrospective review of clinical notes from all children with SAS admitted from October 1993 to April 2004 to the PICU in Auckland Children’s Hospital in New Zealand was undertaken. Children coded for SAS were identified from the PICU database.

All clinical notes were reviewed by one investigator using a standardized questionnaire that sought information on patient demographics, clinical findings, investigations, microbiology, and management in the PICU. Cases were included if blood or an isolate from a site that is normally sterile was positive for S. aureus. Hospital-acquired infection was defined by an isolate obtained at least 48 hours after hospital admission; community acquired infection was defined by an isolate obtained within 48 hours of admission.

Fifty-eight patients were identified with SAS over the 10-year study period; 55 were community acquired. Children with staphylococcal illness comprised 1% of all admission to the PICU. Musculoskeletal symptoms (79%) dominated presentation rather than isolated pneumonia (10%). An aggressive search for foci and surgical drainage of infective foci was required in 50% of children.

Most children (67%) either presented with multiple site involvement or secondary sites developed during their hospital stay. These pathologies included pneumonia, septic arthritis, osteomyelitis, and soft tissue involvement (cellulitis, fasciitis, abscess). A transthoracic echocardiogram detected valve abnormalities in only 5% of children, and these children were known to have pre-existing cardiac lesions. Few children (12%) presenting with methicillin-resistant S. aureus (MRSA) had community-acquired infection. The median length of stay in the PICU was three (mean 5.8, range one-44) days. Mortality due to SAS was 8.6%. Ten children had significant morbidity after discharge; these morbidities included renal failure requiring dialysis (three), an ongoing oxygen requirement at three months follow-up (two), and problems relating to limb movement and function (eight). Two children with epidural abscesses were paraplegic.

Community-acquired SAS affects healthy children, is multifocal, and has a high morbidity and mortality. It is imperative to look for sites of dissemination and to drain and debride foci. Routine echocardiography had a low yield in the absence of pre-existing cardiac lesions, persisting fever, or persisting bacteremia.

Long-Term Outcomes for Childhood Headache

Brna P, Dooley J, Gordon K Dewan T. The prognosis of childhood headache. Arch Pediatr Adolesc Med. 2005;159(12):1157-1160.

Headaches affect most children and rank third among illness-related causes of school absenteeism. Although the short-term outcome for most children appears favorable, few studies have reported long-term outcome. The objective of this study was to evaluate the long-term prognosis of childhood headaches 20 years after initial diagnosis in a cohort of Atlantic Canadian children who had headaches diagnosed in 1983.

Ninety-five patients with headaches who consulted one of the authors in 1983 were subsequently studied in 1993. The 77 patients contacted in 1993 were followed up in 2003. A standard telephone interview was used. Data were collected regarding headache symptoms, severity, frequency, treatment, and precipitants. Headache severity was simply classified as mild, moderate, or severe.

Sixty (78%) of 77 patients responded (60 of the 95 in the original cohort). At 20 years 16 (27%) were headache free, 20 (33%) had tension-type headaches, 10 (17%) had migraine, 14 (23%) had migraine and tension-type headaches. Having more than one headache type was more than at diagnosis or initial follow-up, and headache type varied across time. Of those who had headaches at follow-up, 80% (35/44) described their headaches as moderate or severe, although improvement in headaches was reported by 29 (66%). Tension-type headaches were more likely than migraine to resolve. During the month before follow-up, non-prescription medications were used by six (14%). However, 20 (45%) felt that non-pharmacological methods were most effective. Medication use increased during the 10 years since the last follow-up. No patient used selective serotonin receptor agonists.

This study concluded that 20 years after the diagnosis of pediatric headache, most patients continue to have headache, although the headache classification often changed across time. Most patients report moderate or severe headache and increasingly choose to care for their headaches pharmacologically. TH

A65-lb., 25-year-old, male cerebral palsy (CP) patient with pneumonia arrives at your Children’s Hospital via ambulance. Although chronologically this patient is an adult, in many ways he’s still a child, and the parents told the paramedics that they’ve always taken their son to Children’s. You’ve been the treating physician during the patient’s frequent hospital stays. Is Children’s Hospital still the best destination for this patient? Will the family’s insurance still cover an admission at Children’s?

During the hospital stay, the patient has complications. He has to be intubated. IV antibiotics need to be continued for a course after hospital discharge. A long recovery is expected. Is it time for the family to consider discharge to a long-term care facility rather than home? Are there any long-term care facilities in the area that accept young adult CP patients?

As the treating pediatric hospitalist, what is your role in helping this patient and his family transition from pediatric care to an adult-care medical home?

Introduction

Approximately 8.6 million children in the United States age 10–17 have a disability, according to the Adolescent Health Transition Project, which is housed at the Center on Human Development and Disability (CHDD) at the University of Washington, Seattle. Of these, 16% (or 1.4 million) experience limitations in their activities and will likely have difficulty making the transition to adult healthcare.1

Given enough time in the profession, every pediatric hospitalist will face the challenge of transitioning patients from child-centered to adult-oriented healthcare systems. The good news: Medical advances have made it increasingly possible for children who once would have died in childhood to survive into adulthood.

Example: One in 2,500 children is born with cystic fibrosis (CF); however, with the recent, unprecedented increase in the success of diagnosis and treatment modalities for the pulmonary component of CF, the estimated median survival age for those born in the 1990s is now 40.2 As of the year 2004, 41.8% of the 22,301 patients with CF were 18 or older.3 In fact, each year nearly 500,000 children with special healthcare needs reach adulthood, and 90% of children with a chronic illness and/or disability now survive to adulthood.4,5

The bad news: Many physicians whose practices focus on adults aren’t familiar with disease processes, such as CF, that have historically been considered pediatric illnesses.

For patients with chronic physical and medical conditions—particularly for those who are medically fragile and/or technology-dependent—the transition can prove especially difficult. And pediatric hospitalists in children’s hospitals face different challenges than those in facilities that admit patients of all ages. One thing remains the same, though, the goal: to provide uninterrupted, coordinated, developmentally appropriate healthcare.

Why Transition?

There are several good reasons for patients to be transitioned from pediatric care to adult care. First, as patients age medical issues develop that are beyond the sphere of pediatricians. In CF, for example, diabetes and biliary tract problems occur with greater frequency in adults. However, because so few CF patients historically survived to adulthood, few physicians who care for adults learned about the disease. Thus, the pediatricians who cared for CF patients continued to do so, leading to situations in which 30- and 40-year-olds have been hospitalized with children. But is that truly appropriate?

Adult patients may have high blood pressure, gynecologic issues, osteoporosis, or other problems the pediatrician may not be prepared to deal with. Example: A primary care pediatrician has been the “medical home” for a small, cerebral palsy patient since she was 10. She’s now 25. If she presents with a breast mass, will the pediatrician pick up on the condition adequately? Will they know where to send the patient?

“Adult providers know those systems better,” says Brett Pickering, MD, director of the Special Needs Clinic at San Diego’s UCSD Medical Center, Department of Pediatrics.

The adult patient has different emotional needs than the pediatric patient, and the pediatric hospitalist may not be in tune with adult needs. “Pediatricians do a lot of handholding,” says Dr. Pickering. “Adult providers are more matter of fact.”

Age restrictions on admissions, insurance, and funding issues also affect transition. For example, funding under the Social Security Act’s Title V Children with Special Health Care Needs typically ends at 21 despite a patient’s education or employment status.

Given these factors, what is the appropriate age to transition care from a pediatric floor or facility to an adult-oriented unit? According to the American Academy of Pediatrics, the responsibility of pediatrics continues through age 21, but there’s no hard-and-fast rule.

Challenges

The transition to adult-care facilities is typically a lengthy process involving multiple specialties and possibly joint care during a transition period—and a process that should ideally be coordinated by the patient’s primary care pediatrician. But hospitalists know that circumstances are typically far from ideal.

First, during a transition, the patient may feel abandoned by the medical team they’ve known for most of their lives. It takes time to develop trust and confidence in a new doctor. In this respect, pediatric hospitalists in facilities that care for patients of all ages have an advantage over hospitalists in children’s hospitals. They can call on their adult-care colleagues in other areas of the hospital for consultations and transfer care over time.

“The pediatric hospitalist must make bridges with their adult colleagues who are comfortable [with the issues] and willing to take on this patient population,” says Dr. Pickering.

Second, parents may feel an emotional dependency on the pediatric team and can feel threatened by the adult environment as they lose some control. To the parents, the patient will always be their child, Dr. Pickering notes.

Third, pediatric hospitalists may be reluctant to let go, particularly if they feel adult services are inferior to those they have provided, which brings us to the fourth major challenge: To whom do you transition care?

Many adult healthcare providers receive only limited training in disorders associated with pediatrics (e.g., CF, spina bifida). The Cystic Fibrosis Foundation is leading the way in educating physicians in what have historically been considered pediatric problems. In the 1980s, the foundation launched an educational program to train physicians already involved in adult pulmonary care in CF. Unfortunately, education in other areas has lagged. And finding a physician with both an interest in and knowledge of such disorders can prove challenging.

“It’s incumbent on our adult colleagues to take these patients on, but they need training,” says Dr. Pickering. “Long-term issues require long-term solutions.

How do you jazz people up to take care of this population?” she asks. Physicians must have at least a little bit of desire to learn about these special patient populations, but academic institutions also need to identify core knowledge and skills and make them part of training and certification requirements for primary care residents and physicians in practice. Continuing medical education for physicians, nurses, and allied healthcare professionals should include drug dosing, medical complications seen in transition populations, and related developmental, psychosocial, and behavioral issues.

Steps to a Successful Transition

So what should hospitalists do? In an April 2005 presentation at the SHM Annual Meeting, Joseph M. Geskey, DO, assistant professor of pediatrics and medicine, and director of inpatient pediatrics at Penn State College of Medicine, Hershey, Penn., recommended that pediatric hospitalists take the following steps:

1. Identify the key aspects of transition;
2. Bring stakeholders together;
3. Identify transitional needs;
4. Identify and provide resources;
5. Create an audit and evaluation process;
6. Decide who will hand off care of these patients when they are admitted to the hospital (the hospitalist or the disease-specific specialist);
7. Create an up-to-date medical summary that is portable and accessible. It should include important historic information, such as diagnostic data, procedures, operations, and medications;
8. Upon patient discharge, include specific instructions on who to call if the patient develops a problem after leaving the hospital;
9. Create a working group in your area that represents pediatric and adult hospitalists to examine transition issues in the hospitalized patient; and
10. Facilitate effective communication between patients and their families, primary care physicians and specialists; and
11. Know when to transfer care to a center with more expertise in caring for specific conditions.

Conclusion

Just as every patient is different and every patient’s circumstances are unique, every transition needs to be individualized. “It’s hard to set policy,” says Dr. Pickering. Open, direct communication, specific discharge instructions, an up-to-date medical summary and knowledge of the adult resources in your area can make any transition a success. TH

Keri Losavio regularly writes for “Pediatric Special Section.”

References

1. Adolescent Health Transition Project, Center on Human Development and Disability (CHDD) at the University of Washington, Seattle. Available at http://depts.washington.edu/healthtr/Providers/intro.htm. Last accessed January 16, 2006.
2. Bufi PL. Cystic fibrosis: therapeutic options for co-management. Available at www.thorne.com/altmedrev/fulltext/cystic.html. Last accessed January 16, 2006.
3. Cystic Fibrosis Foundation: 2004 Patient Registry Report. Available at www.cff.org/living_with_cf/. Last accessed Jan. 26, 2006
4. Newacheck PW, Taylor WR. Childhood chronic illness: prevalence, severity, and impact. Am J Pub Health. 1992;82(3):364-371.
5. Committee on Children with Disabilities and Committee on Adolescence, American Academy of Pediatrics. Transition of care provided for adolescents with special health care needs. Pediatrics. 1996;98(6):1203–1206.

Pediatric Special Section

In the Literature

By Mary Ann Queen, MD, and Amita Amonker, MD

Utilization of a Clinical Pathway Improves Care for Bronchiolitis

Cheney J, Barber S, Altamirano L, et al. A Clinical Pathway for Bronchiolitis is Effective in Reducing Readmission Rates. J Pediatr. 2005;147(5):622-626.

Bronchiolitis is the most common respiratory illness in infants that results in hospitalization. Many hospitals have developed clinical pathways to assist clinicians in managing this common infection; however, the effectiveness of such pathways has not been fully studied. Of those clinical practice guidelines analyzed, varying results have been identified.

To determine the effectiveness of a bronchiolitis pathway, this study compared infants managed prospectively using a pathway protocol with a retrospective analysis of infants managed without a pathway. Infants from a tertiary care children’s hospital and three regional hospitals were enrolled prospectively from May 2000 to August 2001. (One must note this study was completed in Australia, hence the difference from the typical Northern Hemisphere winter months.) The historical control group was admitted between May 1998 and August 1999 at the same four institutions. Two-hundred-twenty-nine patients admitted with bronchiolitis were treated using the pathway protocol. These patients were compared with 207 randomly selected control patients who were admitted prior to the institution of the bronchiolitis pathway. All patients were less than 12 months of age with their first episode of wheezing necessitating hospitalization.

These particular guidelines were developed and used to promote consistency of nursing management during a separate study on bronchiolitis. The pathway included an initial admission assessment. It also stated parameters for initiating and stopping both oxygen therapy and intravenous fluid therapy along with discharge guidelines.

The authors found no significant difference in length of stay or time in oxygen. Fifteen infants (7.2%) in the control group required readmission within two weeks of discharge compared with two infants (0.9%) in the pathway group (p=.001). Of the control group 33.8% received intravenous fluids (IVFs) compared with 19.2% of the pathway infants (p=.001). There was also greater steroid use in the control group but no difference in antibiotic usage. Specific data regarding steroids and antibiotics is not included.

The clinical pathway appears a useful tool for discharge planning with a decreased incidence of hospital readmission when specific discharge goals are utilized. The authors also reported a decreased use of IVFs in the pathway group. This was attributed to having specific parameters (O2 required, RR>60/min or inadequate oral feeding) for when to initiate them. It is unclear from the article whether meeting a single parameter or all three parameters triggered the initiation of IVFs.

The authors also point out the limitation of using a historical control given annual variations in severity sometimes seen with bronchiolitis. They attempted to minimize this by collecting data for each group over two consecutive winters.

Preprinted Paper Orders Reduce Medication Errors

Kozer E, Scolnik D, MacPherson A, et al. Using a preprinted order sheet to reduce prescription errors in a pediatric emergency department: A randomized, controlled trial. Pediatrics. 2005(116):1299-1302.

Medical errors, including medication errors, are common and are written about with increasing frequency in the lay press. Accreditation bodies and individual hospitals are striving for ways to decrease these errors. In some instances potential solutions include purchasing new computer systems for electronic physician order entry. This study looks at whether implementing a preprinted paper order sheet can decrease the incidence of medication errors in a pediatric ED.

This randomized, prospective study occurred during 18 days in July 2001 with nine days randomly assigned into each arm. The first arm used the hospital’s regular blank order sheets for all medication orders. The second arm used the experimental preprinted order sheet. This sheet required the staff to specify the dose, weight-adjusted dose, total daily dose, route of administration, and frequency for each medication ordered. Two medical students entered the data into a database that included information about patients’ demographics, diagnosis, acuity, details on the prescribing physician, the form used, and all medications prescribed and given to the patient. This information was subsequently reviewed by two blinded pediatric emergency physicians who determined if an error occurred and, if so, the degree of the error.

During the study period there were 2,157 visits to the ED with 95.4% charts available for review. Seven-hundred-ninety-five medications were prescribed with 376 ordered on the new form. Drug errors were identified in 68 (16.6%) orders when the regular form was used and in 37 (9.8%) orders on the new form. There was one severe error and 13 significant errors using the new form and 36 significant errors on the regular form. The new form was associated with a twofold decrease in the risk for a medication error even after accounting for the level of training of the ordering practitioner. There was an even greater reduction in the risk for a severe or significant error.

The literature has shown that computerized physician order entry can reduce the number of medication errors in the inpatient setting; however, it is not available in many hospitals and its effectiveness has not been shown in EDs. The authors point out that most medications ordered in the ED are prepared and given by nurses. The benefits of a computerized system in this setting is unclear.

This study occurred over an 18-day period with the new form only used for nine days outside of an earlier pilot period. One could speculate that the novelty of the form encouraged the physicians to examine orders more carefully, leading to decreased errors. It is unknown if the decrease in errors would be sustained over time.

Also important to note is that the definition of an error was limited to a mistake in dose, interval between doses, dose unit, and/or route. Errors such as legibility, medication allergy, or drug interactions are not discussed. However, as hospitals strive to implement technologies aimed at reducing errors this simple, economical solution may be of benefit.

No Association between Kawasaki Disease and Adenovirus

Shike H, Shimizu C, Kanegaye J, et al. Adenovirus, adeno-associated virus and Kawasaki disease. Pediatr Infect Dis J. 2005;24:1011-1014.

Kawasaki disease is a self-limited acute vasculitis of children with a suspected infectious etiology and defined seasonality. In an attempt to find a clue for a possible infectious cause of Kawasaki disease this study examined the seasonality of different viruses. The study recognized a similar bimodal seasonality for some serotypes of adenovirus. Adenovirus accounts for 5%-10% of respiratory tract infections in children and can mimic the clinical manifestations and laboratory abnormalities seen in Kawasaki disease.

This study postulated that infection with a non-cultivatable adenovirus or antecedent adenovirus infection might be a trigger for Kawasaki disease. The study analyzed patient samples using polymerase chain reaction primers for all 51 adenovirus serotypes, viral culture, and neutralization assay for the most common adenovirus serotypes. This study also investigated possible involvement of adeno-associated viruses (AAVs), because AAVs depend on helper viruses, such as adenovirus.

Kawasaki disease patients were enrolled during a 25-month period from February 2002 to February 2004 at Children’s Hospital and Health Center in San Diego. Illness day one was defined as the first day of fever. Clinical samples used in this study were collected within the first 14 days of fever onset and before intravenous immunoglobulin (IVIG) therapy.

Nasopharyngeal swabs were cultured for adenovirus. Standard adenoviral neutralization assays for the five most common serotypes were performed with the use of patient sera. Sera with a titer of 1/10 or greater were scored as positive. At least two clinical samples from each patient, including throat swabs, sera or urine, were tested by quantitative polymerase chain reaction (PCR) for adenovirus and AAV.

Nasopharyngeal viral cultures were collected before IVIG administration on illness day three—14 from 70 Kawasaki disease patients. Of the 70 patients, 52 patients fulfilled four of the five classic criteria or three of the five criteria with abnormal coronary arteries by echocardiogram. Of the remaining 18 patients with atypical Kawasaki disease, six had coronary artery abnormalities. Overall, seven patients had coronary artery aneurysms and 22 patients had coronary artery dilatation. Viral cultures were negative in 66 of the 70 Kawasaki disease patients. The viral isolates in four patients were respiratory syncytial (one), parainfluenza virus 3 (one) and adenovirus (two). Therefore adenovirus culture was negative in 97% of patients.

Fifteen Kawasaki disease patients with negative adenovirus cultures were evaluated by PCR assay on at least two clinical samples. Fourteen patients had a negative PCR result. The throat swab from one patient collected on illness day seven contained 800 adenovirus genome copies.

Results of the adenovirus neutralization assays from 26 Kawasaki disease patients revealed that neutralization titers against any of the five most common adenovirus serotypes were undetectable in four of 26 patients.

None of the 36 samples from the same 15 acute Kawasaki disease patients described for the PCR assay was positive for AAV.

This study concluded that despite the striking similarities between Kawasaki disease and adenovirus infection there is no evidence to suggest a link between the two.

Epidemiology and Clinical Description of Severe, Multifocal Staphylococcus aureus Infection

Miles F, Voss L, Segedin E, et al. Review of Staphylococcus aureus infections requiring admission to a paediatric intensive care unit. Arch Dis Child. 2005;90(12):1274-1278.

Staphylococcus aureus is a recognized cause of multifocal infection with a high mortality rate. Children with community acquired S. aureus bacteremia (SAB) have higher frequencies of unknown foci compared with hospital-acquired SAB. Those children with S. aureus sepsis (SAS) presenting to the pediatric intensive care unit tend to have multisystemic disease—either by direct invasion or toxin production—before the diagnosis is made and treatment is initiated.

This study evaluates the clinical features and mortality from SAS in those children who required intensive care management. A retrospective review of clinical notes from all children with SAS admitted from October 1993 to April 2004 to the PICU in Auckland Children’s Hospital in New Zealand was undertaken. Children coded for SAS were identified from the PICU database.

All clinical notes were reviewed by one investigator using a standardized questionnaire that sought information on patient demographics, clinical findings, investigations, microbiology, and management in the PICU. Cases were included if blood or an isolate from a site that is normally sterile was positive for S. aureus. Hospital-acquired infection was defined by an isolate obtained at least 48 hours after hospital admission; community acquired infection was defined by an isolate obtained within 48 hours of admission.

Fifty-eight patients were identified with SAS over the 10-year study period; 55 were community acquired. Children with staphylococcal illness comprised 1% of all admission to the PICU. Musculoskeletal symptoms (79%) dominated presentation rather than isolated pneumonia (10%). An aggressive search for foci and surgical drainage of infective foci was required in 50% of children.

Most children (67%) either presented with multiple site involvement or secondary sites developed during their hospital stay. These pathologies included pneumonia, septic arthritis, osteomyelitis, and soft tissue involvement (cellulitis, fasciitis, abscess). A transthoracic echocardiogram detected valve abnormalities in only 5% of children, and these children were known to have pre-existing cardiac lesions. Few children (12%) presenting with methicillin-resistant S. aureus (MRSA) had community-acquired infection. The median length of stay in the PICU was three (mean 5.8, range one-44) days. Mortality due to SAS was 8.6%. Ten children had significant morbidity after discharge; these morbidities included renal failure requiring dialysis (three), an ongoing oxygen requirement at three months follow-up (two), and problems relating to limb movement and function (eight). Two children with epidural abscesses were paraplegic.

Community-acquired SAS affects healthy children, is multifocal, and has a high morbidity and mortality. It is imperative to look for sites of dissemination and to drain and debride foci. Routine echocardiography had a low yield in the absence of pre-existing cardiac lesions, persisting fever, or persisting bacteremia.

Long-Term Outcomes for Childhood Headache

Brna P, Dooley J, Gordon K Dewan T. The prognosis of childhood headache. Arch Pediatr Adolesc Med. 2005;159(12):1157-1160.

Headaches affect most children and rank third among illness-related causes of school absenteeism. Although the short-term outcome for most children appears favorable, few studies have reported long-term outcome. The objective of this study was to evaluate the long-term prognosis of childhood headaches 20 years after initial diagnosis in a cohort of Atlantic Canadian children who had headaches diagnosed in 1983.

Ninety-five patients with headaches who consulted one of the authors in 1983 were subsequently studied in 1993. The 77 patients contacted in 1993 were followed up in 2003. A standard telephone interview was used. Data were collected regarding headache symptoms, severity, frequency, treatment, and precipitants. Headache severity was simply classified as mild, moderate, or severe.

Sixty (78%) of 77 patients responded (60 of the 95 in the original cohort). At 20 years 16 (27%) were headache free, 20 (33%) had tension-type headaches, 10 (17%) had migraine, 14 (23%) had migraine and tension-type headaches. Having more than one headache type was more than at diagnosis or initial follow-up, and headache type varied across time. Of those who had headaches at follow-up, 80% (35/44) described their headaches as moderate or severe, although improvement in headaches was reported by 29 (66%). Tension-type headaches were more likely than migraine to resolve. During the month before follow-up, non-prescription medications were used by six (14%). However, 20 (45%) felt that non-pharmacological methods were most effective. Medication use increased during the 10 years since the last follow-up. No patient used selective serotonin receptor agonists.

This study concluded that 20 years after the diagnosis of pediatric headache, most patients continue to have headache, although the headache classification often changed across time. Most patients report moderate or severe headache and increasingly choose to care for their headaches pharmacologically. TH

A65-lb., 25-year-old, male cerebral palsy (CP) patient with pneumonia arrives at your Children’s Hospital via ambulance. Although chronologically this patient is an adult, in many ways he’s still a child, and the parents told the paramedics that they’ve always taken their son to Children’s. You’ve been the treating physician during the patient’s frequent hospital stays. Is Children’s Hospital still the best destination for this patient? Will the family’s insurance still cover an admission at Children’s?

During the hospital stay, the patient has complications. He has to be intubated. IV antibiotics need to be continued for a course after hospital discharge. A long recovery is expected. Is it time for the family to consider discharge to a long-term care facility rather than home? Are there any long-term care facilities in the area that accept young adult CP patients?

As the treating pediatric hospitalist, what is your role in helping this patient and his family transition from pediatric care to an adult-care medical home?

Introduction

Approximately 8.6 million children in the United States age 10–17 have a disability, according to the Adolescent Health Transition Project, which is housed at the Center on Human Development and Disability (CHDD) at the University of Washington, Seattle. Of these, 16% (or 1.4 million) experience limitations in their activities and will likely have difficulty making the transition to adult healthcare.1

Given enough time in the profession, every pediatric hospitalist will face the challenge of transitioning patients from child-centered to adult-oriented healthcare systems. The good news: Medical advances have made it increasingly possible for children who once would have died in childhood to survive into adulthood.

Example: One in 2,500 children is born with cystic fibrosis (CF); however, with the recent, unprecedented increase in the success of diagnosis and treatment modalities for the pulmonary component of CF, the estimated median survival age for those born in the 1990s is now 40.2 As of the year 2004, 41.8% of the 22,301 patients with CF were 18 or older.3 In fact, each year nearly 500,000 children with special healthcare needs reach adulthood, and 90% of children with a chronic illness and/or disability now survive to adulthood.4,5

The bad news: Many physicians whose practices focus on adults aren’t familiar with disease processes, such as CF, that have historically been considered pediatric illnesses.

For patients with chronic physical and medical conditions—particularly for those who are medically fragile and/or technology-dependent—the transition can prove especially difficult. And pediatric hospitalists in children’s hospitals face different challenges than those in facilities that admit patients of all ages. One thing remains the same, though, the goal: to provide uninterrupted, coordinated, developmentally appropriate healthcare.

Why Transition?

There are several good reasons for patients to be transitioned from pediatric care to adult care. First, as patients age medical issues develop that are beyond the sphere of pediatricians. In CF, for example, diabetes and biliary tract problems occur with greater frequency in adults. However, because so few CF patients historically survived to adulthood, few physicians who care for adults learned about the disease. Thus, the pediatricians who cared for CF patients continued to do so, leading to situations in which 30- and 40-year-olds have been hospitalized with children. But is that truly appropriate?

Adult patients may have high blood pressure, gynecologic issues, osteoporosis, or other problems the pediatrician may not be prepared to deal with. Example: A primary care pediatrician has been the “medical home” for a small, cerebral palsy patient since she was 10. She’s now 25. If she presents with a breast mass, will the pediatrician pick up on the condition adequately? Will they know where to send the patient?

“Adult providers know those systems better,” says Brett Pickering, MD, director of the Special Needs Clinic at San Diego’s UCSD Medical Center, Department of Pediatrics.

The adult patient has different emotional needs than the pediatric patient, and the pediatric hospitalist may not be in tune with adult needs. “Pediatricians do a lot of handholding,” says Dr. Pickering. “Adult providers are more matter of fact.”

Age restrictions on admissions, insurance, and funding issues also affect transition. For example, funding under the Social Security Act’s Title V Children with Special Health Care Needs typically ends at 21 despite a patient’s education or employment status.

Given these factors, what is the appropriate age to transition care from a pediatric floor or facility to an adult-oriented unit? According to the American Academy of Pediatrics, the responsibility of pediatrics continues through age 21, but there’s no hard-and-fast rule.

Challenges

The transition to adult-care facilities is typically a lengthy process involving multiple specialties and possibly joint care during a transition period—and a process that should ideally be coordinated by the patient’s primary care pediatrician. But hospitalists know that circumstances are typically far from ideal.

First, during a transition, the patient may feel abandoned by the medical team they’ve known for most of their lives. It takes time to develop trust and confidence in a new doctor. In this respect, pediatric hospitalists in facilities that care for patients of all ages have an advantage over hospitalists in children’s hospitals. They can call on their adult-care colleagues in other areas of the hospital for consultations and transfer care over time.

“The pediatric hospitalist must make bridges with their adult colleagues who are comfortable [with the issues] and willing to take on this patient population,” says Dr. Pickering.

Second, parents may feel an emotional dependency on the pediatric team and can feel threatened by the adult environment as they lose some control. To the parents, the patient will always be their child, Dr. Pickering notes.

Third, pediatric hospitalists may be reluctant to let go, particularly if they feel adult services are inferior to those they have provided, which brings us to the fourth major challenge: To whom do you transition care?

Many adult healthcare providers receive only limited training in disorders associated with pediatrics (e.g., CF, spina bifida). The Cystic Fibrosis Foundation is leading the way in educating physicians in what have historically been considered pediatric problems. In the 1980s, the foundation launched an educational program to train physicians already involved in adult pulmonary care in CF. Unfortunately, education in other areas has lagged. And finding a physician with both an interest in and knowledge of such disorders can prove challenging.

“It’s incumbent on our adult colleagues to take these patients on, but they need training,” says Dr. Pickering. “Long-term issues require long-term solutions.

How do you jazz people up to take care of this population?” she asks. Physicians must have at least a little bit of desire to learn about these special patient populations, but academic institutions also need to identify core knowledge and skills and make them part of training and certification requirements for primary care residents and physicians in practice. Continuing medical education for physicians, nurses, and allied healthcare professionals should include drug dosing, medical complications seen in transition populations, and related developmental, psychosocial, and behavioral issues.

Steps to a Successful Transition

So what should hospitalists do? In an April 2005 presentation at the SHM Annual Meeting, Joseph M. Geskey, DO, assistant professor of pediatrics and medicine, and director of inpatient pediatrics at Penn State College of Medicine, Hershey, Penn., recommended that pediatric hospitalists take the following steps:

1. Identify the key aspects of transition;
2. Bring stakeholders together;
3. Identify transitional needs;
4. Identify and provide resources;
5. Create an audit and evaluation process;
6. Decide who will hand off care of these patients when they are admitted to the hospital (the hospitalist or the disease-specific specialist);
7. Create an up-to-date medical summary that is portable and accessible. It should include important historic information, such as diagnostic data, procedures, operations, and medications;
8. Upon patient discharge, include specific instructions on who to call if the patient develops a problem after leaving the hospital;
9. Create a working group in your area that represents pediatric and adult hospitalists to examine transition issues in the hospitalized patient; and
10. Facilitate effective communication between patients and their families, primary care physicians and specialists; and
11. Know when to transfer care to a center with more expertise in caring for specific conditions.

Conclusion

Just as every patient is different and every patient’s circumstances are unique, every transition needs to be individualized. “It’s hard to set policy,” says Dr. Pickering. Open, direct communication, specific discharge instructions, an up-to-date medical summary and knowledge of the adult resources in your area can make any transition a success. TH

Keri Losavio regularly writes for “Pediatric Special Section.”

References

1. Adolescent Health Transition Project, Center on Human Development and Disability (CHDD) at the University of Washington, Seattle. Available at http://depts.washington.edu/healthtr/Providers/intro.htm. Last accessed January 16, 2006.
2. Bufi PL. Cystic fibrosis: therapeutic options for co-management. Available at www.thorne.com/altmedrev/fulltext/cystic.html. Last accessed January 16, 2006.
3. Cystic Fibrosis Foundation: 2004 Patient Registry Report. Available at www.cff.org/living_with_cf/. Last accessed Jan. 26, 2006
4. Newacheck PW, Taylor WR. Childhood chronic illness: prevalence, severity, and impact. Am J Pub Health. 1992;82(3):364-371.
5. Committee on Children with Disabilities and Committee on Adolescence, American Academy of Pediatrics. Transition of care provided for adolescents with special health care needs. Pediatrics. 1996;98(6):1203–1206.

Pediatric Special Section

In the Literature

By Mary Ann Queen, MD, and Amita Amonker, MD

Utilization of a Clinical Pathway Improves Care for Bronchiolitis

Cheney J, Barber S, Altamirano L, et al. A Clinical Pathway for Bronchiolitis is Effective in Reducing Readmission Rates. J Pediatr. 2005;147(5):622-626.

Bronchiolitis is the most common respiratory illness in infants that results in hospitalization. Many hospitals have developed clinical pathways to assist clinicians in managing this common infection; however, the effectiveness of such pathways has not been fully studied. Of those clinical practice guidelines analyzed, varying results have been identified.

To determine the effectiveness of a bronchiolitis pathway, this study compared infants managed prospectively using a pathway protocol with a retrospective analysis of infants managed without a pathway. Infants from a tertiary care children’s hospital and three regional hospitals were enrolled prospectively from May 2000 to August 2001. (One must note this study was completed in Australia, hence the difference from the typical Northern Hemisphere winter months.) The historical control group was admitted between May 1998 and August 1999 at the same four institutions. Two-hundred-twenty-nine patients admitted with bronchiolitis were treated using the pathway protocol. These patients were compared with 207 randomly selected control patients who were admitted prior to the institution of the bronchiolitis pathway. All patients were less than 12 months of age with their first episode of wheezing necessitating hospitalization.

These particular guidelines were developed and used to promote consistency of nursing management during a separate study on bronchiolitis. The pathway included an initial admission assessment. It also stated parameters for initiating and stopping both oxygen therapy and intravenous fluid therapy along with discharge guidelines.

The authors found no significant difference in length of stay or time in oxygen. Fifteen infants (7.2%) in the control group required readmission within two weeks of discharge compared with two infants (0.9%) in the pathway group (p=.001). Of the control group 33.8% received intravenous fluids (IVFs) compared with 19.2% of the pathway infants (p=.001). There was also greater steroid use in the control group but no difference in antibiotic usage. Specific data regarding steroids and antibiotics is not included.

The clinical pathway appears a useful tool for discharge planning with a decreased incidence of hospital readmission when specific discharge goals are utilized. The authors also reported a decreased use of IVFs in the pathway group. This was attributed to having specific parameters (O2 required, RR>60/min or inadequate oral feeding) for when to initiate them. It is unclear from the article whether meeting a single parameter or all three parameters triggered the initiation of IVFs.

The authors also point out the limitation of using a historical control given annual variations in severity sometimes seen with bronchiolitis. They attempted to minimize this by collecting data for each group over two consecutive winters.

Preprinted Paper Orders Reduce Medication Errors

Kozer E, Scolnik D, MacPherson A, et al. Using a preprinted order sheet to reduce prescription errors in a pediatric emergency department: A randomized, controlled trial. Pediatrics. 2005(116):1299-1302.

Medical errors, including medication errors, are common and are written about with increasing frequency in the lay press. Accreditation bodies and individual hospitals are striving for ways to decrease these errors. In some instances potential solutions include purchasing new computer systems for electronic physician order entry. This study looks at whether implementing a preprinted paper order sheet can decrease the incidence of medication errors in a pediatric ED.

This randomized, prospective study occurred during 18 days in July 2001 with nine days randomly assigned into each arm. The first arm used the hospital’s regular blank order sheets for all medication orders. The second arm used the experimental preprinted order sheet. This sheet required the staff to specify the dose, weight-adjusted dose, total daily dose, route of administration, and frequency for each medication ordered. Two medical students entered the data into a database that included information about patients’ demographics, diagnosis, acuity, details on the prescribing physician, the form used, and all medications prescribed and given to the patient. This information was subsequently reviewed by two blinded pediatric emergency physicians who determined if an error occurred and, if so, the degree of the error.

During the study period there were 2,157 visits to the ED with 95.4% charts available for review. Seven-hundred-ninety-five medications were prescribed with 376 ordered on the new form. Drug errors were identified in 68 (16.6%) orders when the regular form was used and in 37 (9.8%) orders on the new form. There was one severe error and 13 significant errors using the new form and 36 significant errors on the regular form. The new form was associated with a twofold decrease in the risk for a medication error even after accounting for the level of training of the ordering practitioner. There was an even greater reduction in the risk for a severe or significant error.

The literature has shown that computerized physician order entry can reduce the number of medication errors in the inpatient setting; however, it is not available in many hospitals and its effectiveness has not been shown in EDs. The authors point out that most medications ordered in the ED are prepared and given by nurses. The benefits of a computerized system in this setting is unclear.

This study occurred over an 18-day period with the new form only used for nine days outside of an earlier pilot period. One could speculate that the novelty of the form encouraged the physicians to examine orders more carefully, leading to decreased errors. It is unknown if the decrease in errors would be sustained over time.

Also important to note is that the definition of an error was limited to a mistake in dose, interval between doses, dose unit, and/or route. Errors such as legibility, medication allergy, or drug interactions are not discussed. However, as hospitals strive to implement technologies aimed at reducing errors this simple, economical solution may be of benefit.

No Association between Kawasaki Disease and Adenovirus

Shike H, Shimizu C, Kanegaye J, et al. Adenovirus, adeno-associated virus and Kawasaki disease. Pediatr Infect Dis J. 2005;24:1011-1014.

Kawasaki disease is a self-limited acute vasculitis of children with a suspected infectious etiology and defined seasonality. In an attempt to find a clue for a possible infectious cause of Kawasaki disease this study examined the seasonality of different viruses. The study recognized a similar bimodal seasonality for some serotypes of adenovirus. Adenovirus accounts for 5%-10% of respiratory tract infections in children and can mimic the clinical manifestations and laboratory abnormalities seen in Kawasaki disease.

This study postulated that infection with a non-cultivatable adenovirus or antecedent adenovirus infection might be a trigger for Kawasaki disease. The study analyzed patient samples using polymerase chain reaction primers for all 51 adenovirus serotypes, viral culture, and neutralization assay for the most common adenovirus serotypes. This study also investigated possible involvement of adeno-associated viruses (AAVs), because AAVs depend on helper viruses, such as adenovirus.

Kawasaki disease patients were enrolled during a 25-month period from February 2002 to February 2004 at Children’s Hospital and Health Center in San Diego. Illness day one was defined as the first day of fever. Clinical samples used in this study were collected within the first 14 days of fever onset and before intravenous immunoglobulin (IVIG) therapy.

Nasopharyngeal swabs were cultured for adenovirus. Standard adenoviral neutralization assays for the five most common serotypes were performed with the use of patient sera. Sera with a titer of 1/10 or greater were scored as positive. At least two clinical samples from each patient, including throat swabs, sera or urine, were tested by quantitative polymerase chain reaction (PCR) for adenovirus and AAV.

Nasopharyngeal viral cultures were collected before IVIG administration on illness day three—14 from 70 Kawasaki disease patients. Of the 70 patients, 52 patients fulfilled four of the five classic criteria or three of the five criteria with abnormal coronary arteries by echocardiogram. Of the remaining 18 patients with atypical Kawasaki disease, six had coronary artery abnormalities. Overall, seven patients had coronary artery aneurysms and 22 patients had coronary artery dilatation. Viral cultures were negative in 66 of the 70 Kawasaki disease patients. The viral isolates in four patients were respiratory syncytial (one), parainfluenza virus 3 (one) and adenovirus (two). Therefore adenovirus culture was negative in 97% of patients.

Fifteen Kawasaki disease patients with negative adenovirus cultures were evaluated by PCR assay on at least two clinical samples. Fourteen patients had a negative PCR result. The throat swab from one patient collected on illness day seven contained 800 adenovirus genome copies.

Results of the adenovirus neutralization assays from 26 Kawasaki disease patients revealed that neutralization titers against any of the five most common adenovirus serotypes were undetectable in four of 26 patients.

None of the 36 samples from the same 15 acute Kawasaki disease patients described for the PCR assay was positive for AAV.

This study concluded that despite the striking similarities between Kawasaki disease and adenovirus infection there is no evidence to suggest a link between the two.

Epidemiology and Clinical Description of Severe, Multifocal Staphylococcus aureus Infection

Miles F, Voss L, Segedin E, et al. Review of Staphylococcus aureus infections requiring admission to a paediatric intensive care unit. Arch Dis Child. 2005;90(12):1274-1278.

Staphylococcus aureus is a recognized cause of multifocal infection with a high mortality rate. Children with community acquired S. aureus bacteremia (SAB) have higher frequencies of unknown foci compared with hospital-acquired SAB. Those children with S. aureus sepsis (SAS) presenting to the pediatric intensive care unit tend to have multisystemic disease—either by direct invasion or toxin production—before the diagnosis is made and treatment is initiated.

This study evaluates the clinical features and mortality from SAS in those children who required intensive care management. A retrospective review of clinical notes from all children with SAS admitted from October 1993 to April 2004 to the PICU in Auckland Children’s Hospital in New Zealand was undertaken. Children coded for SAS were identified from the PICU database.

All clinical notes were reviewed by one investigator using a standardized questionnaire that sought information on patient demographics, clinical findings, investigations, microbiology, and management in the PICU. Cases were included if blood or an isolate from a site that is normally sterile was positive for S. aureus. Hospital-acquired infection was defined by an isolate obtained at least 48 hours after hospital admission; community acquired infection was defined by an isolate obtained within 48 hours of admission.

Fifty-eight patients were identified with SAS over the 10-year study period; 55 were community acquired. Children with staphylococcal illness comprised 1% of all admission to the PICU. Musculoskeletal symptoms (79%) dominated presentation rather than isolated pneumonia (10%). An aggressive search for foci and surgical drainage of infective foci was required in 50% of children.

Most children (67%) either presented with multiple site involvement or secondary sites developed during their hospital stay. These pathologies included pneumonia, septic arthritis, osteomyelitis, and soft tissue involvement (cellulitis, fasciitis, abscess). A transthoracic echocardiogram detected valve abnormalities in only 5% of children, and these children were known to have pre-existing cardiac lesions. Few children (12%) presenting with methicillin-resistant S. aureus (MRSA) had community-acquired infection. The median length of stay in the PICU was three (mean 5.8, range one-44) days. Mortality due to SAS was 8.6%. Ten children had significant morbidity after discharge; these morbidities included renal failure requiring dialysis (three), an ongoing oxygen requirement at three months follow-up (two), and problems relating to limb movement and function (eight). Two children with epidural abscesses were paraplegic.

Community-acquired SAS affects healthy children, is multifocal, and has a high morbidity and mortality. It is imperative to look for sites of dissemination and to drain and debride foci. Routine echocardiography had a low yield in the absence of pre-existing cardiac lesions, persisting fever, or persisting bacteremia.

Long-Term Outcomes for Childhood Headache

Brna P, Dooley J, Gordon K Dewan T. The prognosis of childhood headache. Arch Pediatr Adolesc Med. 2005;159(12):1157-1160.

Headaches affect most children and rank third among illness-related causes of school absenteeism. Although the short-term outcome for most children appears favorable, few studies have reported long-term outcome. The objective of this study was to evaluate the long-term prognosis of childhood headaches 20 years after initial diagnosis in a cohort of Atlantic Canadian children who had headaches diagnosed in 1983.

Ninety-five patients with headaches who consulted one of the authors in 1983 were subsequently studied in 1993. The 77 patients contacted in 1993 were followed up in 2003. A standard telephone interview was used. Data were collected regarding headache symptoms, severity, frequency, treatment, and precipitants. Headache severity was simply classified as mild, moderate, or severe.

Sixty (78%) of 77 patients responded (60 of the 95 in the original cohort). At 20 years 16 (27%) were headache free, 20 (33%) had tension-type headaches, 10 (17%) had migraine, 14 (23%) had migraine and tension-type headaches. Having more than one headache type was more than at diagnosis or initial follow-up, and headache type varied across time. Of those who had headaches at follow-up, 80% (35/44) described their headaches as moderate or severe, although improvement in headaches was reported by 29 (66%). Tension-type headaches were more likely than migraine to resolve. During the month before follow-up, non-prescription medications were used by six (14%). However, 20 (45%) felt that non-pharmacological methods were most effective. Medication use increased during the 10 years since the last follow-up. No patient used selective serotonin receptor agonists.

This study concluded that 20 years after the diagnosis of pediatric headache, most patients continue to have headache, although the headache classification often changed across time. Most patients report moderate or severe headache and increasingly choose to care for their headaches pharmacologically. TH

The Benchmarks Committee has completed the data accumulation portion of the SHM 2005-2006 Productivity and Compensation Survey. As you might recall, we set a goal of 400 group respondents. With a final push for responses in early December, we exceeded our target. The responses were invaluable in making this survey a worthwhile effort and a credible reflection of the national hospitalist movement.

The Benchmarks Committee would like to specially thank those who attempted to complete the survey online and gave us feedback on this process. We had a few glitches with the online survey, and thanks to these folks and their communication we learned a few valuable lessons regarding this electronic process. We were able to intervene immediately and re-direct folks to the written survey. We’ll apply these lessons to the electronic component of future surveys as well.

Over the next few months we will be analyzing the data in preparation for presentation of the results to be offered up initially at the SHM Annual Meeting in Washington, D.C., the first week in May. (Visit www.hospitalmedicine.org under “Upcoming Events” to register.) Additionally, results will be available to survey participants online later in the year following the national presentation.

On a different note, the committee continues to work on the Hospitalist Dashboard Project. We are creating a dashboard that deals with metrics in the categories of resource utilization, clinical quality, productivity, and satisfaction.

Subsequently, we have worked through a Delphi process to whittle a long list of possible metrics down to 10 key metrics. These have been divided among the committee members, who will use an agreed-upon outline to write a brief description of the metric, how it is measured, and how it can be utilized to manage a hospitalist practice. The final product will be a white paper made available to the SHM membership.

How to Develop a Hospital-Based Palliative Care Program

Why your hospital needs such a program and how to create it

By Eva H. Chittenden, MD, and the SHM Palliative Care Task Force

Palliative care consists of medical care focused on the relief of suffering for patients living with chronic, advanced illness and it also helps their families. It is offered at any stage of disease, concurrently with all other appropriate medical treatment.

Palliative care providers treat the many physical symptoms that patients experience, including pain, dyspnea, nausea, and delirium. In addition, providers assist patients and families with complex medical decision-making, and attend to patients’ and families’ spiritual and psychosocial needs. Physicians work closely with an interdisciplinary team of nurses, chaplains, social workers, and pharmacists. Care continues beyond the point of death, with phone calls and consolation letters, as well as bereavement services.

Arguments for inpatient Palliative Care

The clinical imperative: We need better quality of care for people with serious and complex illness. The multicenter SUPPORT study, published in JAMA in 1995, looked at more than 9,000 hospitalized patients with life-threatening illness and demonstrated significant problems with pain and symptom control and with patient-doctor communication.1 Of the patients who died, more than 50% had moderate to severe pain more than half the time during the last three days of their lives. Of patients preferring do-not-resuscitate status, less than 50% of their physicians were aware of their wishes.

In another study, Nelson, et al. documented that more than half of cancer patients receiving intensive care had moderate to severe pain, anxiety, thirst, and hunger, and that 75% had moderate to severe discomfort of some kind.2 These studies have been a wake-up call to clinicians and hospitals across the country.

Patient and Family Preferences

Family members—especially women—shoulder most of the care of patients with serious illness. A minority of caregivers are over age 65 themselves and in ill health. When asked what they want from the medical system, family caregivers ask for help with transportation and personal care of their loved one at home, and for better home nursing support. They want 24/7 access to providers, better communication with their doctors, and to be remembered and contacted after the death of their family member.3-5 Caregiving itself has been shown to increase likelihood of premature mortality and lead to financial crisis.6

In the SUPPORT study, one-third of families lost most of their savings due to illness.7 Patients want pain and symptom control, avoidance of inappropriate prolongation of the dying process, and relief of burdens on family.8 Palliative care programs, both inpatient and ambulatory, can help provide families with needed services and improve communication at all levels.

The Demographic Argument

Hospitals need palliative care to effectively treat the growing numbers of people with serious, advanced, and complex illness. By 2030, the number of people over age 85 will double to almost 10 million.9 Many of these patients will have multiple chronic conditions, making their care complicated and expensive. And for many chronic conditions, including heart and lung disease, diabetes, and hypertension, death is not predictable.

Therefore, people need better care throughout the multiyear course of advanced illness. And while the Medicare Hospice Benefit is helpful for care of the dying (defined as people with six months or less to live) we need additional approaches for the much larger number of patients with chronic, progressive illness, years to live, continued benefit from disease-modifying therapy, and obvious palliative care needs.

The Educational Imperative

Hospitals are the site of training for most clinicians. Researchers have documented significant deficits in palliative care knowledge, skills, and attitudes among medical students, residents, and practicing physicians. Medical school and residency curricula, although improving, offer relatively little teaching in palliative care principles and practice.10,11

In 2000 the Liaison Committee on Medical Education mandated that medical school curricula include “important aspects of … end-of-life-care.” That same year the Accreditation Council for Graduate Medical Education encouraged internal medicine training programs to provide instruction in the principles of palliative care. Inpatient palliative care programs could provide much of this teaching through medical student and resident rotations, informal teaching during the consultation process, and through workshops and grand rounds.

The Financial Argument

Medical costs are rising exponentially due to multiple factors, including effective yet expensive new technologies and an expanding elderly population with more chronic conditions. Under the current Diagnosis Related Group (DRG) system, long, high-intensity hospital stays are causing a fiscal crisis for hospitals. The hospital and insurer of the future will have to work together to learn how to treat serious and complex illness efficiently and in the most cost-effective manner possible. Palliative care programs have the potential to ease this looming crisis through decreasing length of stay, both in the ICU and on the floors, and decreasing direct costs, including radiology, pharmacy, and laboratory costs. Researchers are beginning to document the positive fiscal impacts in rigorous studies.

Palliative Care: The Bottom Line

Palliative care teams have demonstrated improvement in pain and other symptom scores, in patient and family satisfaction with care, and in patient-provider communication. In addition, they have improved compliance with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) quality measures. They have had these positive effects while simultaneously showing decreases in length of stay and costs. As a result, many programs have gained significant financial and administrative support from their hospitals.

Hospitalists and Palliative Care

Many hospitalist groups have found that building and staffing a palliative care consultation team is an important addition to their portfolio of services, further solidifying their value in the eyes of their hospital administration. The professional fee revenues are one more funding source, and palliative care is a critical service the group can provide the institution to improve the quality of care, improve patient satisfaction, and decrease costs.

The work involved in starting a program, including needs assessment, internal marketing, building a financial case, and developing a staffing model, is similar to that done when starting a hospitalist program. Hospitalists are ideally positioned to start palliative care services because they have already built relationships with key administrators and opinion leaders, and they understand the institution’s method for evaluating financial data, and how to access outcome and satisfaction data.

What Hospitalists Gain

By leading and staffing palliative care programs, hospitalists gain visibility and respect from colleagues, and improve their patients’ quality of care and their hospital’s financial bottom line. Clinically palliative care adds variety and depth to the work life of hospitalists and allows them to work with a rich interdisciplinary team. Although hospitalists should obtain additional training, they already possess the building blocks to provide excellent palliative care, such as skillfully leading family conferences and treating complex symptoms. When wearing the palliative care “hat,” providers have the luxury of spending more time at a patient’s bedside discussing what is truly important to the patient and his or her loved ones. The work is meaningful and rewarding.

Obtaining the Tools to Start a Program

The Center to Advance Palliative Care (CAPC), funded by the Robert Wood Johnson Foundation, is dedicated to advancing inpatient palliative care programs through their Web site (www.capc.org) and through their manual, “A Guide to Building a Hospital-Based Palliative Care Program,” available for purchase on its Web site.

In addition, CAPC sponsors the six national Palliative Care Leadership Centers (PCLCs) that each hold two-day, hands-on workshops on the nuts and bolts of starting inpatient palliative care programs, followed by a year of personalized mentoring by phone. The University of California, San Francisco’s PCLC, which is tailored specifically to hospitalists, will hold its last workshop in April 2006. For more information, visit www.capc.org/palliative-care-leadership-initiative.

At the upcoming SHM Annual Meeting in May, the Palliative Care Taskforce will present a workshop, “The Basic Why and How to Develop a Hospital-Based Palliative Care Program.”

Obtaining the Clinical Expertise

There are numerous opportunities for hospitalists to gain clinical expertise in palliative care, including Web-based and written materials and CME courses. Highlights include the Education in Palliative and End of Life Care programs; courses and study guides through the American Association of Hospice and Palliative Medicine, as well as Fast Facts (one-page synopses of relevant palliative care concepts that can be made into handouts or downloaded to one’s PDA). For more information on these resources and others, visit www.capc.org/palliative-care-professional-development/Education_Material_for _Professionals.

In addition, on Thursday, May 4, at 1:20, there will be a breakout session on pain management at the SHM Annual Meeting.

Hospitalists and other physicians can get certified in Hospice and Palliative Medicine by documenting relevant clinical experience and sitting for a qualifying exam. The American Board of Hospice and Palliative Medicine will administer its last exam in November 2006 (final application deadline is May 31, 2006). In September 2006 the field of Hospice and Palliative Medicine is expected to win American Board of Medical Specialties’ (ABMS) recognition as a subspecialty. After that the ABMS will take over administration of the exams. There will likely be a grandfathering period with the ABMS in which relevant clinical experience can substitute for completion of an ACGME-approved palliative care fellowship. For more information, visit the AAHPM Web site at www.abhpm.org/gfxc_100.aspx.

Summary/Conclusions

Inpatient palliative care programs benefit patients, hospitalists, and hospitals alike. Hospitalists are in the perfect position to lead the next generation of inpatient palliative care programs. Currently, about 20% of hospitals in the United States have programs. With the help of hospitalists, the percentage can increase significantly.

Special thanks to Diane Meier, MD, whose work inspired and informed this article.

References

1. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatment. The SUPPORT Principal Investigators. JAMA. 1995;274:1591-1598.
2. Nelson JE, Meier DE, Oei EJ, et al. Self-reported
3. symptom experience of critically ill cancer patients receiving intensive care. Crit Care Med. 2001;29 (2):277-282.
4. Emanuel EJ, Fairclough DL, Slutsman J, et al. Assistance from family members, friends, paid care givers, and volunteers in the care of terminally ill patients. N Engl J Med. 1999;341 (13):956-963.
5. Emanuel EJ, Fairclough DL, Slutsman J, et al. Understanding economic and other burdens of terminal Illness: the experience of patients and their caregivers. Ann Intern Med. 2000;132(6):451-459.
6. Tolle et al. The Oregon report card: Improving care of the dying. 1999. Available at www.ohsu.edu/ethics/barriers2.pdf. Last accessed Feb. 3, 2006.
7. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the caregiver health effects study. JAMA. 1999;282 (23):2215-2219.
8. Covinsky KE, Goldman L, Cook EF, et al. The impact of serious illness on patients’ families. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. JAMA. 1994;272:1839-1844.
9. Singer PA, Martin DK, Kelner M. Quality end-of-life care: patients’ perspectives. JAMA. 1999;281(2):163-168.
10. U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin. Table 2a. US Census Bureau/CDC. 2002. Available at www.census.gov/ipc/www/usinterimproj/. Last accessed Feb. 3, 2006.
11. Meier DE, Morrison RS, Cassel CK. Improving palliative care. Ann Intern Med. 1997;127:225-230.
12. Billings JA, Block S. Palliative care in undergraduate medical education. Status report and future directions. JAMA. 1997;278:733-738.

Update:

New Hospitalist Productivity & Compensation Data

Survey results to be presented at 2006 SHM Annual Meeting

By the end of the data collection period in December 2005 approximately 400 hospital medicine programs had submitted responses for SHM’s 2005-2006 Hospitalist Productivity and Compensation Survey—a 35% increase from 2003. In addition to salary and production trends, this year’s survey should provide new insights into hospitalist responsibilities, the concerns of hospitalist program leaders, night coverage arrangements, and the use of nurse practitioners and physician assistants.

SHM thanks the program leaders who completed the comprehensive survey questionnaire. The following participants were randomly selected to receive awards:

• Danny Moore, MD, of Gilmore Memorial Hospital (Amory, Miss.) received a complimentary registration at the SHM Leadership Academy; and
• Four hospitalists received complimentary registration to the SHM Annual Meeting: Adrienne L. Bennett, MD, PhD, Ohio State University College of Medicine (Columbus, Ohio); Jasvinder S. Dhillon, St. Mary’s Hospital PICU Pediatric Hospitalist Program (Richmond, Va.); Howard Dubin, MD, Inpatient Medical Services of Bristol Hospital (Cheshire, Conn.); and Sujith Sundararaj MD, Signature Healthcare Solutions (Chicago).

The results of the 2005-2006 Hospitalist Productivity and Compensation Survey will be presented for the first time on Thursday, May 4 at 8:10 a.m. at the SHM Annual Meeting. A panel representing different perspectives within hospital medicine will react to the data. The panelists—SHM co-founder John Nelson, MD, President-Elect Mary Jo Gorman, MD, and Past-President Bob Wachter, MD—will represent hospital-employed practices, private groups, and academic programs, respectively. A report of the survey results will be available to survey participants for free. SHM members will be able to purchase the report at a discounted price. TH

The Benchmarks Committee has completed the data accumulation portion of the SHM 2005-2006 Productivity and Compensation Survey. As you might recall, we set a goal of 400 group respondents. With a final push for responses in early December, we exceeded our target. The responses were invaluable in making this survey a worthwhile effort and a credible reflection of the national hospitalist movement.

The Benchmarks Committee would like to specially thank those who attempted to complete the survey online and gave us feedback on this process. We had a few glitches with the online survey, and thanks to these folks and their communication we learned a few valuable lessons regarding this electronic process. We were able to intervene immediately and re-direct folks to the written survey. We’ll apply these lessons to the electronic component of future surveys as well.

Over the next few months we will be analyzing the data in preparation for presentation of the results to be offered up initially at the SHM Annual Meeting in Washington, D.C., the first week in May. (Visit www.hospitalmedicine.org under “Upcoming Events” to register.) Additionally, results will be available to survey participants online later in the year following the national presentation.

On a different note, the committee continues to work on the Hospitalist Dashboard Project. We are creating a dashboard that deals with metrics in the categories of resource utilization, clinical quality, productivity, and satisfaction.

Subsequently, we have worked through a Delphi process to whittle a long list of possible metrics down to 10 key metrics. These have been divided among the committee members, who will use an agreed-upon outline to write a brief description of the metric, how it is measured, and how it can be utilized to manage a hospitalist practice. The final product will be a white paper made available to the SHM membership.

How to Develop a Hospital-Based Palliative Care Program

Why your hospital needs such a program and how to create it

By Eva H. Chittenden, MD, and the SHM Palliative Care Task Force

Palliative care consists of medical care focused on the relief of suffering for patients living with chronic, advanced illness and it also helps their families. It is offered at any stage of disease, concurrently with all other appropriate medical treatment.

Palliative care providers treat the many physical symptoms that patients experience, including pain, dyspnea, nausea, and delirium. In addition, providers assist patients and families with complex medical decision-making, and attend to patients’ and families’ spiritual and psychosocial needs. Physicians work closely with an interdisciplinary team of nurses, chaplains, social workers, and pharmacists. Care continues beyond the point of death, with phone calls and consolation letters, as well as bereavement services.

Arguments for inpatient Palliative Care

The clinical imperative: We need better quality of care for people with serious and complex illness. The multicenter SUPPORT study, published in JAMA in 1995, looked at more than 9,000 hospitalized patients with life-threatening illness and demonstrated significant problems with pain and symptom control and with patient-doctor communication.1 Of the patients who died, more than 50% had moderate to severe pain more than half the time during the last three days of their lives. Of patients preferring do-not-resuscitate status, less than 50% of their physicians were aware of their wishes.

In another study, Nelson, et al. documented that more than half of cancer patients receiving intensive care had moderate to severe pain, anxiety, thirst, and hunger, and that 75% had moderate to severe discomfort of some kind.2 These studies have been a wake-up call to clinicians and hospitals across the country.

Patient and Family Preferences

Family members—especially women—shoulder most of the care of patients with serious illness. A minority of caregivers are over age 65 themselves and in ill health. When asked what they want from the medical system, family caregivers ask for help with transportation and personal care of their loved one at home, and for better home nursing support. They want 24/7 access to providers, better communication with their doctors, and to be remembered and contacted after the death of their family member.3-5 Caregiving itself has been shown to increase likelihood of premature mortality and lead to financial crisis.6

In the SUPPORT study, one-third of families lost most of their savings due to illness.7 Patients want pain and symptom control, avoidance of inappropriate prolongation of the dying process, and relief of burdens on family.8 Palliative care programs, both inpatient and ambulatory, can help provide families with needed services and improve communication at all levels.

The Demographic Argument

Hospitals need palliative care to effectively treat the growing numbers of people with serious, advanced, and complex illness. By 2030, the number of people over age 85 will double to almost 10 million.9 Many of these patients will have multiple chronic conditions, making their care complicated and expensive. And for many chronic conditions, including heart and lung disease, diabetes, and hypertension, death is not predictable.

Therefore, people need better care throughout the multiyear course of advanced illness. And while the Medicare Hospice Benefit is helpful for care of the dying (defined as people with six months or less to live) we need additional approaches for the much larger number of patients with chronic, progressive illness, years to live, continued benefit from disease-modifying therapy, and obvious palliative care needs.

The Educational Imperative

Hospitals are the site of training for most clinicians. Researchers have documented significant deficits in palliative care knowledge, skills, and attitudes among medical students, residents, and practicing physicians. Medical school and residency curricula, although improving, offer relatively little teaching in palliative care principles and practice.10,11

In 2000 the Liaison Committee on Medical Education mandated that medical school curricula include “important aspects of … end-of-life-care.” That same year the Accreditation Council for Graduate Medical Education encouraged internal medicine training programs to provide instruction in the principles of palliative care. Inpatient palliative care programs could provide much of this teaching through medical student and resident rotations, informal teaching during the consultation process, and through workshops and grand rounds.

The Financial Argument

Medical costs are rising exponentially due to multiple factors, including effective yet expensive new technologies and an expanding elderly population with more chronic conditions. Under the current Diagnosis Related Group (DRG) system, long, high-intensity hospital stays are causing a fiscal crisis for hospitals. The hospital and insurer of the future will have to work together to learn how to treat serious and complex illness efficiently and in the most cost-effective manner possible. Palliative care programs have the potential to ease this looming crisis through decreasing length of stay, both in the ICU and on the floors, and decreasing direct costs, including radiology, pharmacy, and laboratory costs. Researchers are beginning to document the positive fiscal impacts in rigorous studies.

Palliative Care: The Bottom Line

Palliative care teams have demonstrated improvement in pain and other symptom scores, in patient and family satisfaction with care, and in patient-provider communication. In addition, they have improved compliance with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) quality measures. They have had these positive effects while simultaneously showing decreases in length of stay and costs. As a result, many programs have gained significant financial and administrative support from their hospitals.

Hospitalists and Palliative Care

Many hospitalist groups have found that building and staffing a palliative care consultation team is an important addition to their portfolio of services, further solidifying their value in the eyes of their hospital administration. The professional fee revenues are one more funding source, and palliative care is a critical service the group can provide the institution to improve the quality of care, improve patient satisfaction, and decrease costs.

The work involved in starting a program, including needs assessment, internal marketing, building a financial case, and developing a staffing model, is similar to that done when starting a hospitalist program. Hospitalists are ideally positioned to start palliative care services because they have already built relationships with key administrators and opinion leaders, and they understand the institution’s method for evaluating financial data, and how to access outcome and satisfaction data.

What Hospitalists Gain

By leading and staffing palliative care programs, hospitalists gain visibility and respect from colleagues, and improve their patients’ quality of care and their hospital’s financial bottom line. Clinically palliative care adds variety and depth to the work life of hospitalists and allows them to work with a rich interdisciplinary team. Although hospitalists should obtain additional training, they already possess the building blocks to provide excellent palliative care, such as skillfully leading family conferences and treating complex symptoms. When wearing the palliative care “hat,” providers have the luxury of spending more time at a patient’s bedside discussing what is truly important to the patient and his or her loved ones. The work is meaningful and rewarding.

Obtaining the Tools to Start a Program

The Center to Advance Palliative Care (CAPC), funded by the Robert Wood Johnson Foundation, is dedicated to advancing inpatient palliative care programs through their Web site (www.capc.org) and through their manual, “A Guide to Building a Hospital-Based Palliative Care Program,” available for purchase on its Web site.

In addition, CAPC sponsors the six national Palliative Care Leadership Centers (PCLCs) that each hold two-day, hands-on workshops on the nuts and bolts of starting inpatient palliative care programs, followed by a year of personalized mentoring by phone. The University of California, San Francisco’s PCLC, which is tailored specifically to hospitalists, will hold its last workshop in April 2006. For more information, visit www.capc.org/palliative-care-leadership-initiative.

At the upcoming SHM Annual Meeting in May, the Palliative Care Taskforce will present a workshop, “The Basic Why and How to Develop a Hospital-Based Palliative Care Program.”

Obtaining the Clinical Expertise

There are numerous opportunities for hospitalists to gain clinical expertise in palliative care, including Web-based and written materials and CME courses. Highlights include the Education in Palliative and End of Life Care programs; courses and study guides through the American Association of Hospice and Palliative Medicine, as well as Fast Facts (one-page synopses of relevant palliative care concepts that can be made into handouts or downloaded to one’s PDA). For more information on these resources and others, visit www.capc.org/palliative-care-professional-development/Education_Material_for _Professionals.

In addition, on Thursday, May 4, at 1:20, there will be a breakout session on pain management at the SHM Annual Meeting.

Hospitalists and other physicians can get certified in Hospice and Palliative Medicine by documenting relevant clinical experience and sitting for a qualifying exam. The American Board of Hospice and Palliative Medicine will administer its last exam in November 2006 (final application deadline is May 31, 2006). In September 2006 the field of Hospice and Palliative Medicine is expected to win American Board of Medical Specialties’ (ABMS) recognition as a subspecialty. After that the ABMS will take over administration of the exams. There will likely be a grandfathering period with the ABMS in which relevant clinical experience can substitute for completion of an ACGME-approved palliative care fellowship. For more information, visit the AAHPM Web site at www.abhpm.org/gfxc_100.aspx.

Summary/Conclusions

Inpatient palliative care programs benefit patients, hospitalists, and hospitals alike. Hospitalists are in the perfect position to lead the next generation of inpatient palliative care programs. Currently, about 20% of hospitals in the United States have programs. With the help of hospitalists, the percentage can increase significantly.

Special thanks to Diane Meier, MD, whose work inspired and informed this article.

References

1. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatment. The SUPPORT Principal Investigators. JAMA. 1995;274:1591-1598.
2. Nelson JE, Meier DE, Oei EJ, et al. Self-reported
3. symptom experience of critically ill cancer patients receiving intensive care. Crit Care Med. 2001;29 (2):277-282.
4. Emanuel EJ, Fairclough DL, Slutsman J, et al. Assistance from family members, friends, paid care givers, and volunteers in the care of terminally ill patients. N Engl J Med. 1999;341 (13):956-963.
5. Emanuel EJ, Fairclough DL, Slutsman J, et al. Understanding economic and other burdens of terminal Illness: the experience of patients and their caregivers. Ann Intern Med. 2000;132(6):451-459.
6. Tolle et al. The Oregon report card: Improving care of the dying. 1999. Available at www.ohsu.edu/ethics/barriers2.pdf. Last accessed Feb. 3, 2006.
7. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the caregiver health effects study. JAMA. 1999;282 (23):2215-2219.
8. Covinsky KE, Goldman L, Cook EF, et al. The impact of serious illness on patients’ families. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. JAMA. 1994;272:1839-1844.
9. Singer PA, Martin DK, Kelner M. Quality end-of-life care: patients’ perspectives. JAMA. 1999;281(2):163-168.
10. U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin. Table 2a. US Census Bureau/CDC. 2002. Available at www.census.gov/ipc/www/usinterimproj/. Last accessed Feb. 3, 2006.
11. Meier DE, Morrison RS, Cassel CK. Improving palliative care. Ann Intern Med. 1997;127:225-230.
12. Billings JA, Block S. Palliative care in undergraduate medical education. Status report and future directions. JAMA. 1997;278:733-738.

Update:

New Hospitalist Productivity & Compensation Data

Survey results to be presented at 2006 SHM Annual Meeting

By the end of the data collection period in December 2005 approximately 400 hospital medicine programs had submitted responses for SHM’s 2005-2006 Hospitalist Productivity and Compensation Survey—a 35% increase from 2003. In addition to salary and production trends, this year’s survey should provide new insights into hospitalist responsibilities, the concerns of hospitalist program leaders, night coverage arrangements, and the use of nurse practitioners and physician assistants.

SHM thanks the program leaders who completed the comprehensive survey questionnaire. The following participants were randomly selected to receive awards:

• Danny Moore, MD, of Gilmore Memorial Hospital (Amory, Miss.) received a complimentary registration at the SHM Leadership Academy; and
• Four hospitalists received complimentary registration to the SHM Annual Meeting: Adrienne L. Bennett, MD, PhD, Ohio State University College of Medicine (Columbus, Ohio); Jasvinder S. Dhillon, St. Mary’s Hospital PICU Pediatric Hospitalist Program (Richmond, Va.); Howard Dubin, MD, Inpatient Medical Services of Bristol Hospital (Cheshire, Conn.); and Sujith Sundararaj MD, Signature Healthcare Solutions (Chicago).

The results of the 2005-2006 Hospitalist Productivity and Compensation Survey will be presented for the first time on Thursday, May 4 at 8:10 a.m. at the SHM Annual Meeting. A panel representing different perspectives within hospital medicine will react to the data. The panelists—SHM co-founder John Nelson, MD, President-Elect Mary Jo Gorman, MD, and Past-President Bob Wachter, MD—will represent hospital-employed practices, private groups, and academic programs, respectively. A report of the survey results will be available to survey participants for free. SHM members will be able to purchase the report at a discounted price. TH

The Benchmarks Committee has completed the data accumulation portion of the SHM 2005-2006 Productivity and Compensation Survey. As you might recall, we set a goal of 400 group respondents. With a final push for responses in early December, we exceeded our target. The responses were invaluable in making this survey a worthwhile effort and a credible reflection of the national hospitalist movement.

The Benchmarks Committee would like to specially thank those who attempted to complete the survey online and gave us feedback on this process. We had a few glitches with the online survey, and thanks to these folks and their communication we learned a few valuable lessons regarding this electronic process. We were able to intervene immediately and re-direct folks to the written survey. We’ll apply these lessons to the electronic component of future surveys as well.

Over the next few months we will be analyzing the data in preparation for presentation of the results to be offered up initially at the SHM Annual Meeting in Washington, D.C., the first week in May. (Visit www.hospitalmedicine.org under “Upcoming Events” to register.) Additionally, results will be available to survey participants online later in the year following the national presentation.

On a different note, the committee continues to work on the Hospitalist Dashboard Project. We are creating a dashboard that deals with metrics in the categories of resource utilization, clinical quality, productivity, and satisfaction.

Subsequently, we have worked through a Delphi process to whittle a long list of possible metrics down to 10 key metrics. These have been divided among the committee members, who will use an agreed-upon outline to write a brief description of the metric, how it is measured, and how it can be utilized to manage a hospitalist practice. The final product will be a white paper made available to the SHM membership.

How to Develop a Hospital-Based Palliative Care Program

Why your hospital needs such a program and how to create it

By Eva H. Chittenden, MD, and the SHM Palliative Care Task Force

Palliative care consists of medical care focused on the relief of suffering for patients living with chronic, advanced illness and it also helps their families. It is offered at any stage of disease, concurrently with all other appropriate medical treatment.

Palliative care providers treat the many physical symptoms that patients experience, including pain, dyspnea, nausea, and delirium. In addition, providers assist patients and families with complex medical decision-making, and attend to patients’ and families’ spiritual and psychosocial needs. Physicians work closely with an interdisciplinary team of nurses, chaplains, social workers, and pharmacists. Care continues beyond the point of death, with phone calls and consolation letters, as well as bereavement services.

Arguments for inpatient Palliative Care

The clinical imperative: We need better quality of care for people with serious and complex illness. The multicenter SUPPORT study, published in JAMA in 1995, looked at more than 9,000 hospitalized patients with life-threatening illness and demonstrated significant problems with pain and symptom control and with patient-doctor communication.1 Of the patients who died, more than 50% had moderate to severe pain more than half the time during the last three days of their lives. Of patients preferring do-not-resuscitate status, less than 50% of their physicians were aware of their wishes.

In another study, Nelson, et al. documented that more than half of cancer patients receiving intensive care had moderate to severe pain, anxiety, thirst, and hunger, and that 75% had moderate to severe discomfort of some kind.2 These studies have been a wake-up call to clinicians and hospitals across the country.

Patient and Family Preferences

Family members—especially women—shoulder most of the care of patients with serious illness. A minority of caregivers are over age 65 themselves and in ill health. When asked what they want from the medical system, family caregivers ask for help with transportation and personal care of their loved one at home, and for better home nursing support. They want 24/7 access to providers, better communication with their doctors, and to be remembered and contacted after the death of their family member.3-5 Caregiving itself has been shown to increase likelihood of premature mortality and lead to financial crisis.6

In the SUPPORT study, one-third of families lost most of their savings due to illness.7 Patients want pain and symptom control, avoidance of inappropriate prolongation of the dying process, and relief of burdens on family.8 Palliative care programs, both inpatient and ambulatory, can help provide families with needed services and improve communication at all levels.

The Demographic Argument

Hospitals need palliative care to effectively treat the growing numbers of people with serious, advanced, and complex illness. By 2030, the number of people over age 85 will double to almost 10 million.9 Many of these patients will have multiple chronic conditions, making their care complicated and expensive. And for many chronic conditions, including heart and lung disease, diabetes, and hypertension, death is not predictable.

Therefore, people need better care throughout the multiyear course of advanced illness. And while the Medicare Hospice Benefit is helpful for care of the dying (defined as people with six months or less to live) we need additional approaches for the much larger number of patients with chronic, progressive illness, years to live, continued benefit from disease-modifying therapy, and obvious palliative care needs.

The Educational Imperative

Hospitals are the site of training for most clinicians. Researchers have documented significant deficits in palliative care knowledge, skills, and attitudes among medical students, residents, and practicing physicians. Medical school and residency curricula, although improving, offer relatively little teaching in palliative care principles and practice.10,11

In 2000 the Liaison Committee on Medical Education mandated that medical school curricula include “important aspects of … end-of-life-care.” That same year the Accreditation Council for Graduate Medical Education encouraged internal medicine training programs to provide instruction in the principles of palliative care. Inpatient palliative care programs could provide much of this teaching through medical student and resident rotations, informal teaching during the consultation process, and through workshops and grand rounds.

The Financial Argument

Medical costs are rising exponentially due to multiple factors, including effective yet expensive new technologies and an expanding elderly population with more chronic conditions. Under the current Diagnosis Related Group (DRG) system, long, high-intensity hospital stays are causing a fiscal crisis for hospitals. The hospital and insurer of the future will have to work together to learn how to treat serious and complex illness efficiently and in the most cost-effective manner possible. Palliative care programs have the potential to ease this looming crisis through decreasing length of stay, both in the ICU and on the floors, and decreasing direct costs, including radiology, pharmacy, and laboratory costs. Researchers are beginning to document the positive fiscal impacts in rigorous studies.

Palliative Care: The Bottom Line

Palliative care teams have demonstrated improvement in pain and other symptom scores, in patient and family satisfaction with care, and in patient-provider communication. In addition, they have improved compliance with Joint Commission on Accreditation of Healthcare Organizations (JCAHO) quality measures. They have had these positive effects while simultaneously showing decreases in length of stay and costs. As a result, many programs have gained significant financial and administrative support from their hospitals.

Hospitalists and Palliative Care

Many hospitalist groups have found that building and staffing a palliative care consultation team is an important addition to their portfolio of services, further solidifying their value in the eyes of their hospital administration. The professional fee revenues are one more funding source, and palliative care is a critical service the group can provide the institution to improve the quality of care, improve patient satisfaction, and decrease costs.

The work involved in starting a program, including needs assessment, internal marketing, building a financial case, and developing a staffing model, is similar to that done when starting a hospitalist program. Hospitalists are ideally positioned to start palliative care services because they have already built relationships with key administrators and opinion leaders, and they understand the institution’s method for evaluating financial data, and how to access outcome and satisfaction data.

What Hospitalists Gain

By leading and staffing palliative care programs, hospitalists gain visibility and respect from colleagues, and improve their patients’ quality of care and their hospital’s financial bottom line. Clinically palliative care adds variety and depth to the work life of hospitalists and allows them to work with a rich interdisciplinary team. Although hospitalists should obtain additional training, they already possess the building blocks to provide excellent palliative care, such as skillfully leading family conferences and treating complex symptoms. When wearing the palliative care “hat,” providers have the luxury of spending more time at a patient’s bedside discussing what is truly important to the patient and his or her loved ones. The work is meaningful and rewarding.

Obtaining the Tools to Start a Program

The Center to Advance Palliative Care (CAPC), funded by the Robert Wood Johnson Foundation, is dedicated to advancing inpatient palliative care programs through their Web site (www.capc.org) and through their manual, “A Guide to Building a Hospital-Based Palliative Care Program,” available for purchase on its Web site.

In addition, CAPC sponsors the six national Palliative Care Leadership Centers (PCLCs) that each hold two-day, hands-on workshops on the nuts and bolts of starting inpatient palliative care programs, followed by a year of personalized mentoring by phone. The University of California, San Francisco’s PCLC, which is tailored specifically to hospitalists, will hold its last workshop in April 2006. For more information, visit www.capc.org/palliative-care-leadership-initiative.

At the upcoming SHM Annual Meeting in May, the Palliative Care Taskforce will present a workshop, “The Basic Why and How to Develop a Hospital-Based Palliative Care Program.”

Obtaining the Clinical Expertise

There are numerous opportunities for hospitalists to gain clinical expertise in palliative care, including Web-based and written materials and CME courses. Highlights include the Education in Palliative and End of Life Care programs; courses and study guides through the American Association of Hospice and Palliative Medicine, as well as Fast Facts (one-page synopses of relevant palliative care concepts that can be made into handouts or downloaded to one’s PDA). For more information on these resources and others, visit www.capc.org/palliative-care-professional-development/Education_Material_for _Professionals.

In addition, on Thursday, May 4, at 1:20, there will be a breakout session on pain management at the SHM Annual Meeting.

Hospitalists and other physicians can get certified in Hospice and Palliative Medicine by documenting relevant clinical experience and sitting for a qualifying exam. The American Board of Hospice and Palliative Medicine will administer its last exam in November 2006 (final application deadline is May 31, 2006). In September 2006 the field of Hospice and Palliative Medicine is expected to win American Board of Medical Specialties’ (ABMS) recognition as a subspecialty. After that the ABMS will take over administration of the exams. There will likely be a grandfathering period with the ABMS in which relevant clinical experience can substitute for completion of an ACGME-approved palliative care fellowship. For more information, visit the AAHPM Web site at www.abhpm.org/gfxc_100.aspx.

Summary/Conclusions

Inpatient palliative care programs benefit patients, hospitalists, and hospitals alike. Hospitalists are in the perfect position to lead the next generation of inpatient palliative care programs. Currently, about 20% of hospitals in the United States have programs. With the help of hospitalists, the percentage can increase significantly.

Special thanks to Diane Meier, MD, whose work inspired and informed this article.

References

1. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatment. The SUPPORT Principal Investigators. JAMA. 1995;274:1591-1598.
2. Nelson JE, Meier DE, Oei EJ, et al. Self-reported
3. symptom experience of critically ill cancer patients receiving intensive care. Crit Care Med. 2001;29 (2):277-282.
4. Emanuel EJ, Fairclough DL, Slutsman J, et al. Assistance from family members, friends, paid care givers, and volunteers in the care of terminally ill patients. N Engl J Med. 1999;341 (13):956-963.
5. Emanuel EJ, Fairclough DL, Slutsman J, et al. Understanding economic and other burdens of terminal Illness: the experience of patients and their caregivers. Ann Intern Med. 2000;132(6):451-459.
6. Tolle et al. The Oregon report card: Improving care of the dying. 1999. Available at www.ohsu.edu/ethics/barriers2.pdf. Last accessed Feb. 3, 2006.
7. Schulz R, Beach SR. Caregiving as a risk factor for mortality: the caregiver health effects study. JAMA. 1999;282 (23):2215-2219.
8. Covinsky KE, Goldman L, Cook EF, et al. The impact of serious illness on patients’ families. SUPPORT Investigators. Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment. JAMA. 1994;272:1839-1844.
9. Singer PA, Martin DK, Kelner M. Quality end-of-life care: patients’ perspectives. JAMA. 1999;281(2):163-168.
10. U.S. Interim Projections by Age, Sex, Race, and Hispanic Origin. Table 2a. US Census Bureau/CDC. 2002. Available at www.census.gov/ipc/www/usinterimproj/. Last accessed Feb. 3, 2006.
11. Meier DE, Morrison RS, Cassel CK. Improving palliative care. Ann Intern Med. 1997;127:225-230.
12. Billings JA, Block S. Palliative care in undergraduate medical education. Status report and future directions. JAMA. 1997;278:733-738.

Update:

New Hospitalist Productivity & Compensation Data

Survey results to be presented at 2006 SHM Annual Meeting

By the end of the data collection period in December 2005 approximately 400 hospital medicine programs had submitted responses for SHM’s 2005-2006 Hospitalist Productivity and Compensation Survey—a 35% increase from 2003. In addition to salary and production trends, this year’s survey should provide new insights into hospitalist responsibilities, the concerns of hospitalist program leaders, night coverage arrangements, and the use of nurse practitioners and physician assistants.

SHM thanks the program leaders who completed the comprehensive survey questionnaire. The following participants were randomly selected to receive awards:

• Danny Moore, MD, of Gilmore Memorial Hospital (Amory, Miss.) received a complimentary registration at the SHM Leadership Academy; and
• Four hospitalists received complimentary registration to the SHM Annual Meeting: Adrienne L. Bennett, MD, PhD, Ohio State University College of Medicine (Columbus, Ohio); Jasvinder S. Dhillon, St. Mary’s Hospital PICU Pediatric Hospitalist Program (Richmond, Va.); Howard Dubin, MD, Inpatient Medical Services of Bristol Hospital (Cheshire, Conn.); and Sujith Sundararaj MD, Signature Healthcare Solutions (Chicago).

The results of the 2005-2006 Hospitalist Productivity and Compensation Survey will be presented for the first time on Thursday, May 4 at 8:10 a.m. at the SHM Annual Meeting. A panel representing different perspectives within hospital medicine will react to the data. The panelists—SHM co-founder John Nelson, MD, President-Elect Mary Jo Gorman, MD, and Past-President Bob Wachter, MD—will represent hospital-employed practices, private groups, and academic programs, respectively. A report of the survey results will be available to survey participants for free. SHM members will be able to purchase the report at a discounted price. TH

A48-year-old male presents with three weeks of worsening shortness of breath and pleuritic chest discomfort. A week before the onset of these symptoms, he noticed increasing fatigue, weight loss, abdominal discomfort, and persistent hematuria He was otherwise healthy and was taking no medications.

Physical examination reveals a tachypneic yet hemodynamically stable patient, with left upper quadrant fullness. CT chest and abdomen, reveal the following (see right).

You suspect that this finding is secondary to an extrapulmonary process. What unifying diagnosis most likely accounts for these findings? What is your diagnosis?

1. Antiphospholipid syndrome
2. Antithrombin III deficiency
3. Renal cell carcinoma
4. Protein C deficiency
5. Prostate carcinoma

Discussion

The answer is C: Renal cell carcinoma (RCC) with caval extension causing PE; this suggests that the PE was due to tumor thrombus. The photo on p. 8 shows areas of increased attenuation in the prominent right and left pulmonary arteries, consistent with a saddle pulmonary embolism. An MRI of the abdomen (see photo above) reveals a large left renal mass extending to Gerota’s fascia and into the left renal vein, protruding slightly into the inferior vena cava (IVC).

The MRI demonstrates an occlusive thrombus in the left renal vein with propagation into the inferior vena cava. The patient underwent a left radical nephrectomy, an inferior vena cava thrombectomy, and a saddle embolectomy. Histological examination of the mass and thrombus confirmed the diagnosis. He had an uneventful recovery and was discharged from the hospital.

RCC accounts for approximately 80% of all primary renal neoplasms, and commonly is termed the “internist’s tumor.” Hematuria is the most common symptom. It is accompanied by flank pain and a palpable abdominal mass in less than 15% of cases.1 Diagnosis of RCC is often made late due to delayed clinical presentation and 20% of patients have metastatic disease at initial diagnosis.2 PE due to tumor thrombus as an initial manifestation of RCC is rare, but is a well-recognized entity leading to dyspnea, pleuritic chest pain, hypoxemia, and—in severe cases—acute cor pulmonale with hemodynamic failure.3-5

Staging CT is required in patients with suspected RCC, and MRI is needed, with transesophageal echocardiography used adjunctively, to evaluate cephalic thrombus extension when indicated.6 IVC tumor thrombus occurs in 4%-10% of all cases, most often originating in the renal vein and extending cranially, subsequently propagating to the lungs.7 Survival in local non-metastatic disease with IVC thrombus is no different whether renal vein extension occurs or not, and ranges from 40%-69%, following surgical resection and thrombectomy.8 In those with distant metastases who require venal caval thrombectomy, five-year survivals range from 0%-12.5%.2

The first case of successful removal of a PE secondary to RCC was documented in 1977.1 The goal of surgery is tumor resection and prevention of recurrent embolic events. It is the only effective means of improving survival in the presence of intravascular tumor. Preoperative anticoagulation may be warranted in patients who present with PE, but should be discontinued following definitive surgical treatment secondary to increased risks of hemorrhage.8 TH

References

1. Daughtry JD, Stewart BH, Golding LAR, Groves LK. Pulmonary embolus presenting as the initial manifestation of renal cell carcinoma. Ann Thorac Surg. 1977;24:178-181.
2. Goetzl MA, Goluboff ET, Murphy AM, et al. A contemporary evaluation of cytoreductive nephrectomy with tumor thrombus: morbidity and long term survival. Urol Oncol. 2004; 22:182-187.
3. Kubota H, Furuse A, Kotsuka Y, et al. Successful management of massive pulmonary tumor embolism from renal cell carcinoma. Ann Thorac Surg. 1996;61:708-710.
4. Gayer G, Mini S, Olchovsky D, et al. Pulmonary embolism—the initial manifestation of renal cell carcinoma in a young woman. Emerg Radiol. 2003;10:43-45.
5. Eggener SE, Dalton DP. Bilateral pulmonary artery tumour emboli from renal carcinoma. Lancet Oncol. 2004;5:173.
6. Tsuji Y, Goto A, Hara I, et al. Renal cell carcinoma with extension of tumor thrombus into vena cava: Surgical strategy and prognosis. J Vasc Surg. 2001;33:789-796.
7. Zisman A, Pantuck AJ, Chao DH, et al. Renal cell carcinoma with tumor thrombus: is cytoreductive nephrectomy for advanced disease associated with an increased complication rate? J Urol. 2002;168:962-967.
8. Nesbitt JC, Soltero ER, Dinney CPN, et al. Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus. Ann Thorac Surg. 1997;63:1592-1600.

A48-year-old male presents with three weeks of worsening shortness of breath and pleuritic chest discomfort. A week before the onset of these symptoms, he noticed increasing fatigue, weight loss, abdominal discomfort, and persistent hematuria He was otherwise healthy and was taking no medications.

Physical examination reveals a tachypneic yet hemodynamically stable patient, with left upper quadrant fullness. CT chest and abdomen, reveal the following (see right).

You suspect that this finding is secondary to an extrapulmonary process. What unifying diagnosis most likely accounts for these findings? What is your diagnosis?

1. Antiphospholipid syndrome
2. Antithrombin III deficiency
3. Renal cell carcinoma
4. Protein C deficiency
5. Prostate carcinoma

Discussion

The answer is C: Renal cell carcinoma (RCC) with caval extension causing PE; this suggests that the PE was due to tumor thrombus. The photo on p. 8 shows areas of increased attenuation in the prominent right and left pulmonary arteries, consistent with a saddle pulmonary embolism. An MRI of the abdomen (see photo above) reveals a large left renal mass extending to Gerota’s fascia and into the left renal vein, protruding slightly into the inferior vena cava (IVC).

The MRI demonstrates an occlusive thrombus in the left renal vein with propagation into the inferior vena cava. The patient underwent a left radical nephrectomy, an inferior vena cava thrombectomy, and a saddle embolectomy. Histological examination of the mass and thrombus confirmed the diagnosis. He had an uneventful recovery and was discharged from the hospital.

RCC accounts for approximately 80% of all primary renal neoplasms, and commonly is termed the “internist’s tumor.” Hematuria is the most common symptom. It is accompanied by flank pain and a palpable abdominal mass in less than 15% of cases.1 Diagnosis of RCC is often made late due to delayed clinical presentation and 20% of patients have metastatic disease at initial diagnosis.2 PE due to tumor thrombus as an initial manifestation of RCC is rare, but is a well-recognized entity leading to dyspnea, pleuritic chest pain, hypoxemia, and—in severe cases—acute cor pulmonale with hemodynamic failure.3-5

Staging CT is required in patients with suspected RCC, and MRI is needed, with transesophageal echocardiography used adjunctively, to evaluate cephalic thrombus extension when indicated.6 IVC tumor thrombus occurs in 4%-10% of all cases, most often originating in the renal vein and extending cranially, subsequently propagating to the lungs.7 Survival in local non-metastatic disease with IVC thrombus is no different whether renal vein extension occurs or not, and ranges from 40%-69%, following surgical resection and thrombectomy.8 In those with distant metastases who require venal caval thrombectomy, five-year survivals range from 0%-12.5%.2

The first case of successful removal of a PE secondary to RCC was documented in 1977.1 The goal of surgery is tumor resection and prevention of recurrent embolic events. It is the only effective means of improving survival in the presence of intravascular tumor. Preoperative anticoagulation may be warranted in patients who present with PE, but should be discontinued following definitive surgical treatment secondary to increased risks of hemorrhage.8 TH

References

1. Daughtry JD, Stewart BH, Golding LAR, Groves LK. Pulmonary embolus presenting as the initial manifestation of renal cell carcinoma. Ann Thorac Surg. 1977;24:178-181.
2. Goetzl MA, Goluboff ET, Murphy AM, et al. A contemporary evaluation of cytoreductive nephrectomy with tumor thrombus: morbidity and long term survival. Urol Oncol. 2004; 22:182-187.
3. Kubota H, Furuse A, Kotsuka Y, et al. Successful management of massive pulmonary tumor embolism from renal cell carcinoma. Ann Thorac Surg. 1996;61:708-710.
4. Gayer G, Mini S, Olchovsky D, et al. Pulmonary embolism—the initial manifestation of renal cell carcinoma in a young woman. Emerg Radiol. 2003;10:43-45.
5. Eggener SE, Dalton DP. Bilateral pulmonary artery tumour emboli from renal carcinoma. Lancet Oncol. 2004;5:173.
6. Tsuji Y, Goto A, Hara I, et al. Renal cell carcinoma with extension of tumor thrombus into vena cava: Surgical strategy and prognosis. J Vasc Surg. 2001;33:789-796.
7. Zisman A, Pantuck AJ, Chao DH, et al. Renal cell carcinoma with tumor thrombus: is cytoreductive nephrectomy for advanced disease associated with an increased complication rate? J Urol. 2002;168:962-967.
8. Nesbitt JC, Soltero ER, Dinney CPN, et al. Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus. Ann Thorac Surg. 1997;63:1592-1600.

A48-year-old male presents with three weeks of worsening shortness of breath and pleuritic chest discomfort. A week before the onset of these symptoms, he noticed increasing fatigue, weight loss, abdominal discomfort, and persistent hematuria He was otherwise healthy and was taking no medications.

Physical examination reveals a tachypneic yet hemodynamically stable patient, with left upper quadrant fullness. CT chest and abdomen, reveal the following (see right).

You suspect that this finding is secondary to an extrapulmonary process. What unifying diagnosis most likely accounts for these findings? What is your diagnosis?

1. Antiphospholipid syndrome
2. Antithrombin III deficiency
3. Renal cell carcinoma
4. Protein C deficiency
5. Prostate carcinoma

Discussion

The answer is C: Renal cell carcinoma (RCC) with caval extension causing PE; this suggests that the PE was due to tumor thrombus. The photo on p. 8 shows areas of increased attenuation in the prominent right and left pulmonary arteries, consistent with a saddle pulmonary embolism. An MRI of the abdomen (see photo above) reveals a large left renal mass extending to Gerota’s fascia and into the left renal vein, protruding slightly into the inferior vena cava (IVC).

The MRI demonstrates an occlusive thrombus in the left renal vein with propagation into the inferior vena cava. The patient underwent a left radical nephrectomy, an inferior vena cava thrombectomy, and a saddle embolectomy. Histological examination of the mass and thrombus confirmed the diagnosis. He had an uneventful recovery and was discharged from the hospital.

RCC accounts for approximately 80% of all primary renal neoplasms, and commonly is termed the “internist’s tumor.” Hematuria is the most common symptom. It is accompanied by flank pain and a palpable abdominal mass in less than 15% of cases.1 Diagnosis of RCC is often made late due to delayed clinical presentation and 20% of patients have metastatic disease at initial diagnosis.2 PE due to tumor thrombus as an initial manifestation of RCC is rare, but is a well-recognized entity leading to dyspnea, pleuritic chest pain, hypoxemia, and—in severe cases—acute cor pulmonale with hemodynamic failure.3-5

Staging CT is required in patients with suspected RCC, and MRI is needed, with transesophageal echocardiography used adjunctively, to evaluate cephalic thrombus extension when indicated.6 IVC tumor thrombus occurs in 4%-10% of all cases, most often originating in the renal vein and extending cranially, subsequently propagating to the lungs.7 Survival in local non-metastatic disease with IVC thrombus is no different whether renal vein extension occurs or not, and ranges from 40%-69%, following surgical resection and thrombectomy.8 In those with distant metastases who require venal caval thrombectomy, five-year survivals range from 0%-12.5%.2

The first case of successful removal of a PE secondary to RCC was documented in 1977.1 The goal of surgery is tumor resection and prevention of recurrent embolic events. It is the only effective means of improving survival in the presence of intravascular tumor. Preoperative anticoagulation may be warranted in patients who present with PE, but should be discontinued following definitive surgical treatment secondary to increased risks of hemorrhage.8 TH

References

1. Daughtry JD, Stewart BH, Golding LAR, Groves LK. Pulmonary embolus presenting as the initial manifestation of renal cell carcinoma. Ann Thorac Surg. 1977;24:178-181.
2. Goetzl MA, Goluboff ET, Murphy AM, et al. A contemporary evaluation of cytoreductive nephrectomy with tumor thrombus: morbidity and long term survival. Urol Oncol. 2004; 22:182-187.
3. Kubota H, Furuse A, Kotsuka Y, et al. Successful management of massive pulmonary tumor embolism from renal cell carcinoma. Ann Thorac Surg. 1996;61:708-710.
4. Gayer G, Mini S, Olchovsky D, et al. Pulmonary embolism—the initial manifestation of renal cell carcinoma in a young woman. Emerg Radiol. 2003;10:43-45.
5. Eggener SE, Dalton DP. Bilateral pulmonary artery tumour emboli from renal carcinoma. Lancet Oncol. 2004;5:173.
6. Tsuji Y, Goto A, Hara I, et al. Renal cell carcinoma with extension of tumor thrombus into vena cava: Surgical strategy and prognosis. J Vasc Surg. 2001;33:789-796.
7. Zisman A, Pantuck AJ, Chao DH, et al. Renal cell carcinoma with tumor thrombus: is cytoreductive nephrectomy for advanced disease associated with an increased complication rate? J Urol. 2002;168:962-967.
8. Nesbitt JC, Soltero ER, Dinney CPN, et al. Surgical management of renal cell carcinoma with inferior vena cava tumor thrombus. Ann Thorac Surg. 1997;63:1592-1600.