Andrew D. Auerbach, MD, MPH

Sepsis is the most expensive condition treated in the hospital, resulting in an aggregate cost of $20.3 billion or 5.2% of total aggregate cost for all hospitalizations in the United States.[1] Rates of sepsis and sepsis‐related mortality are rising in the United States.[2, 3] Timely treatment of sepsis, including adequate fluid resuscitation and appropriate antibiotic administration, decreases morbidity, mortality, and costs.[4, 5, 6] Consequently, the Surviving Sepsis Campaign recommends timely care with the implementation of sepsis bundles and protocols.[4] Though effective, sepsis protocols require dedicated personnel with specialized training, who must be highly vigilant and constantly monitor a patient's condition for the course of an entire hospitalization.[7, 8] As such, delays in administering evidence‐based therapies are common.[8, 9]

Automated electronic sepsis alerts are being developed and implemented to facilitate the delivery of timely sepsis care. Electronic alert systems synthesize electronic health data routinely collected for clinical purposes in real time or near real time to automatically identify sepsis based on prespecified diagnostic criteria, and immediately alert providers that their patient may meet sepsis criteria via electronic notifications (eg, through electronic health record [EHR], e‐mail, or pager alerts).

However, little data exist to describe whether automated, electronic systems achieve their intended goal of earlier, more effective sepsis care. To examine this question, we performed a systematic review on automated electronic sepsis alerts to assess their suitability for clinical use. Our 2 objectives were: (1) to describe the diagnostic accuracy of alert systems in identifying sepsis using electronic data available in real‐time or near real‐time, and (2) to evaluate the effectiveness of sepsis alert systems on sepsis care process measures and clinical outcomes.

MATERIALS AND METHODS

RESULTS

DISCUSSION

The use of sepsis alert systems derived from electronic health data and targeting hospitalized patients improve a subset of sepsis process of care measures, but at the cost of poor positive predictive value and no clear improvement in mortality or length of stay. There is insufficient evidence for the effectiveness of automated electronic sepsis alert systems in the emergency department.

We found considerable variability in the diagnostic accuracy of automated electronic sepsis alert systems. There was moderate evidence that alert systems designed to identify severe sepsis (eg, SIRS criteria plus measures of shock) had greater diagnostic accuracy than alert systems that detected sepsis based on SIRS criteria alone. Given that SIRS criteria are highly prevalent among hospitalized patients with noninfectious diseases,[20] sepsis alert systems triggered by standard SIRS criteria may have poorer predictive value with an increased risk of alert fatigueexcessive electronic warnings resulting in physicians disregarding clinically useful alerts.[21] The potential for alert fatigue is even greater in critical care settings. A retrospective analysis of physiological alarms in the ICU estimated on average 6 alarms per hour with only 15% of alarms considered to be clinically relevant.[22]

The fact that sepsis alert systems improve intermediate process measures among ward and ED patients but not ICU patients likely reflects differences in both the patients and the clinical settings.[23] First, patients in the ICU may already be prescribed broad spectrum antibiotics, aggressively fluid resuscitated, and have other diagnostic testing performed before the activation of a sepsis alert, so it would be less likely to see an improvement in the rates of process measures assessing initiation or escalation of therapy compared to patients treated on the wards or in the ED. The apparent lack of benefit of these systems in the ICU may merely represent a ceiling effect. Second, nurses and physicians are already vigilantly monitoring patients in the ICU for signs of clinical deterioration, so additional alert systems may be redundant. Third, patients in the ICU are connected to standard bedside monitors that continuously monitor for the presence of abnormal vital signs. An additional sepsis alert system triggered by SIRS criteria alone may be superfluous to the existing infrastructure. Fourth, the majority of patients in the ICU will trigger the sepsis alert system,[10] so there likely is a high noise‐to‐signal ratio with resultant alert fatigue.[21]

In addition to greater emphasis on alert systems of greater diagnostic accuracy and effectiveness, our review notes several important gaps that limit evidence supporting the usefulness of automated sepsis alert systems. First, there are little data to describe the optimal design of sepsis alerts[24, 25] or the frequency with which they are appropriately acted upon or dismissed. In addition, we found little data to support whether effectiveness of alert systems differed based on whether clinical decision support was included with the alert itself (eg, direct prompting with specific clinical management recommendations) or the configuration of the alert (eg, interruptive alert or informational).[24, 25] Most of the studies we reviewed employed alerts primarily targeting physicians; we found little evidence for systems that also alerted other providers (eg, nurses or rapid response teams). Few studies provided data on harms of these systems (eg, excess antimicrobial use, fluid overload due to aggressive fluid resuscitation) or how often these treatments were administered to patients who did not eventually have sepsis. Few studies employed study designs that limited biases (eg, randomized or quasiexperimental designs) or used an intention‐to‐treat approach. Studies that exclude false positive alerts in analyses could bias estimates toward making sepsis alert systems appear more effective than they actually were. Finally, although presumably, deploying automated sepsis alerts in the ED would facilitate more timely recognition and treatment, more rigorously conducted studies are needed to identify whether using these alerts in the ED are of greater value compared to the wards and ICU. Given the limited number of studies included in this review, we were unable to make strong conclusions regarding the clinical benefits and cost‐effectiveness of implementing automated sepsis alerts.

Our review has certain limitations. First, despite our extensive literature search strategy, we may have missed studies published in the grey literature or in non‐English languages. Second, there is potential publication bias given the number of abstracts that we identified addressing 1 of our prespecified research questions compared to the number of peer‐reviewed publications identified by our search strategy.

CONCLUSION

Automated electronic sepsis alert systems have promise in delivering early goal‐directed therapies to patients. However, at present, automated sepsis alerts derived from electronic health data may improve care processes but tend to have poor PPV and have not been shown to improve mortality or length of stay. Future efforts should develop and study methods for sepsis alert systems that avoid the potential for alert fatigue while improving outcomes.

Sepsis is the most expensive condition treated in the hospital, resulting in an aggregate cost of $20.3 billion or 5.2% of total aggregate cost for all hospitalizations in the United States.[1] Rates of sepsis and sepsis‐related mortality are rising in the United States.[2, 3] Timely treatment of sepsis, including adequate fluid resuscitation and appropriate antibiotic administration, decreases morbidity, mortality, and costs.[4, 5, 6] Consequently, the Surviving Sepsis Campaign recommends timely care with the implementation of sepsis bundles and protocols.[4] Though effective, sepsis protocols require dedicated personnel with specialized training, who must be highly vigilant and constantly monitor a patient's condition for the course of an entire hospitalization.[7, 8] As such, delays in administering evidence‐based therapies are common.[8, 9]

Automated electronic sepsis alerts are being developed and implemented to facilitate the delivery of timely sepsis care. Electronic alert systems synthesize electronic health data routinely collected for clinical purposes in real time or near real time to automatically identify sepsis based on prespecified diagnostic criteria, and immediately alert providers that their patient may meet sepsis criteria via electronic notifications (eg, through electronic health record [EHR], e‐mail, or pager alerts).

However, little data exist to describe whether automated, electronic systems achieve their intended goal of earlier, more effective sepsis care. To examine this question, we performed a systematic review on automated electronic sepsis alerts to assess their suitability for clinical use. Our 2 objectives were: (1) to describe the diagnostic accuracy of alert systems in identifying sepsis using electronic data available in real‐time or near real‐time, and (2) to evaluate the effectiveness of sepsis alert systems on sepsis care process measures and clinical outcomes.

MATERIALS AND METHODS

RESULTS

DISCUSSION

The use of sepsis alert systems derived from electronic health data and targeting hospitalized patients improve a subset of sepsis process of care measures, but at the cost of poor positive predictive value and no clear improvement in mortality or length of stay. There is insufficient evidence for the effectiveness of automated electronic sepsis alert systems in the emergency department.

We found considerable variability in the diagnostic accuracy of automated electronic sepsis alert systems. There was moderate evidence that alert systems designed to identify severe sepsis (eg, SIRS criteria plus measures of shock) had greater diagnostic accuracy than alert systems that detected sepsis based on SIRS criteria alone. Given that SIRS criteria are highly prevalent among hospitalized patients with noninfectious diseases,[20] sepsis alert systems triggered by standard SIRS criteria may have poorer predictive value with an increased risk of alert fatigueexcessive electronic warnings resulting in physicians disregarding clinically useful alerts.[21] The potential for alert fatigue is even greater in critical care settings. A retrospective analysis of physiological alarms in the ICU estimated on average 6 alarms per hour with only 15% of alarms considered to be clinically relevant.[22]

The fact that sepsis alert systems improve intermediate process measures among ward and ED patients but not ICU patients likely reflects differences in both the patients and the clinical settings.[23] First, patients in the ICU may already be prescribed broad spectrum antibiotics, aggressively fluid resuscitated, and have other diagnostic testing performed before the activation of a sepsis alert, so it would be less likely to see an improvement in the rates of process measures assessing initiation or escalation of therapy compared to patients treated on the wards or in the ED. The apparent lack of benefit of these systems in the ICU may merely represent a ceiling effect. Second, nurses and physicians are already vigilantly monitoring patients in the ICU for signs of clinical deterioration, so additional alert systems may be redundant. Third, patients in the ICU are connected to standard bedside monitors that continuously monitor for the presence of abnormal vital signs. An additional sepsis alert system triggered by SIRS criteria alone may be superfluous to the existing infrastructure. Fourth, the majority of patients in the ICU will trigger the sepsis alert system,[10] so there likely is a high noise‐to‐signal ratio with resultant alert fatigue.[21]

In addition to greater emphasis on alert systems of greater diagnostic accuracy and effectiveness, our review notes several important gaps that limit evidence supporting the usefulness of automated sepsis alert systems. First, there are little data to describe the optimal design of sepsis alerts[24, 25] or the frequency with which they are appropriately acted upon or dismissed. In addition, we found little data to support whether effectiveness of alert systems differed based on whether clinical decision support was included with the alert itself (eg, direct prompting with specific clinical management recommendations) or the configuration of the alert (eg, interruptive alert or informational).[24, 25] Most of the studies we reviewed employed alerts primarily targeting physicians; we found little evidence for systems that also alerted other providers (eg, nurses or rapid response teams). Few studies provided data on harms of these systems (eg, excess antimicrobial use, fluid overload due to aggressive fluid resuscitation) or how often these treatments were administered to patients who did not eventually have sepsis. Few studies employed study designs that limited biases (eg, randomized or quasiexperimental designs) or used an intention‐to‐treat approach. Studies that exclude false positive alerts in analyses could bias estimates toward making sepsis alert systems appear more effective than they actually were. Finally, although presumably, deploying automated sepsis alerts in the ED would facilitate more timely recognition and treatment, more rigorously conducted studies are needed to identify whether using these alerts in the ED are of greater value compared to the wards and ICU. Given the limited number of studies included in this review, we were unable to make strong conclusions regarding the clinical benefits and cost‐effectiveness of implementing automated sepsis alerts.

Our review has certain limitations. First, despite our extensive literature search strategy, we may have missed studies published in the grey literature or in non‐English languages. Second, there is potential publication bias given the number of abstracts that we identified addressing 1 of our prespecified research questions compared to the number of peer‐reviewed publications identified by our search strategy.

CONCLUSION

Automated electronic sepsis alert systems have promise in delivering early goal‐directed therapies to patients. However, at present, automated sepsis alerts derived from electronic health data may improve care processes but tend to have poor PPV and have not been shown to improve mortality or length of stay. Future efforts should develop and study methods for sepsis alert systems that avoid the potential for alert fatigue while improving outcomes.

Sepsis is the most expensive condition treated in the hospital, resulting in an aggregate cost of $20.3 billion or 5.2% of total aggregate cost for all hospitalizations in the United States.[1] Rates of sepsis and sepsis‐related mortality are rising in the United States.[2, 3] Timely treatment of sepsis, including adequate fluid resuscitation and appropriate antibiotic administration, decreases morbidity, mortality, and costs.[4, 5, 6] Consequently, the Surviving Sepsis Campaign recommends timely care with the implementation of sepsis bundles and protocols.[4] Though effective, sepsis protocols require dedicated personnel with specialized training, who must be highly vigilant and constantly monitor a patient's condition for the course of an entire hospitalization.[7, 8] As such, delays in administering evidence‐based therapies are common.[8, 9]

Automated electronic sepsis alerts are being developed and implemented to facilitate the delivery of timely sepsis care. Electronic alert systems synthesize electronic health data routinely collected for clinical purposes in real time or near real time to automatically identify sepsis based on prespecified diagnostic criteria, and immediately alert providers that their patient may meet sepsis criteria via electronic notifications (eg, through electronic health record [EHR], e‐mail, or pager alerts).

However, little data exist to describe whether automated, electronic systems achieve their intended goal of earlier, more effective sepsis care. To examine this question, we performed a systematic review on automated electronic sepsis alerts to assess their suitability for clinical use. Our 2 objectives were: (1) to describe the diagnostic accuracy of alert systems in identifying sepsis using electronic data available in real‐time or near real‐time, and (2) to evaluate the effectiveness of sepsis alert systems on sepsis care process measures and clinical outcomes.

MATERIALS AND METHODS

RESULTS

DISCUSSION

The use of sepsis alert systems derived from electronic health data and targeting hospitalized patients improve a subset of sepsis process of care measures, but at the cost of poor positive predictive value and no clear improvement in mortality or length of stay. There is insufficient evidence for the effectiveness of automated electronic sepsis alert systems in the emergency department.

We found considerable variability in the diagnostic accuracy of automated electronic sepsis alert systems. There was moderate evidence that alert systems designed to identify severe sepsis (eg, SIRS criteria plus measures of shock) had greater diagnostic accuracy than alert systems that detected sepsis based on SIRS criteria alone. Given that SIRS criteria are highly prevalent among hospitalized patients with noninfectious diseases,[20] sepsis alert systems triggered by standard SIRS criteria may have poorer predictive value with an increased risk of alert fatigueexcessive electronic warnings resulting in physicians disregarding clinically useful alerts.[21] The potential for alert fatigue is even greater in critical care settings. A retrospective analysis of physiological alarms in the ICU estimated on average 6 alarms per hour with only 15% of alarms considered to be clinically relevant.[22]

The fact that sepsis alert systems improve intermediate process measures among ward and ED patients but not ICU patients likely reflects differences in both the patients and the clinical settings.[23] First, patients in the ICU may already be prescribed broad spectrum antibiotics, aggressively fluid resuscitated, and have other diagnostic testing performed before the activation of a sepsis alert, so it would be less likely to see an improvement in the rates of process measures assessing initiation or escalation of therapy compared to patients treated on the wards or in the ED. The apparent lack of benefit of these systems in the ICU may merely represent a ceiling effect. Second, nurses and physicians are already vigilantly monitoring patients in the ICU for signs of clinical deterioration, so additional alert systems may be redundant. Third, patients in the ICU are connected to standard bedside monitors that continuously monitor for the presence of abnormal vital signs. An additional sepsis alert system triggered by SIRS criteria alone may be superfluous to the existing infrastructure. Fourth, the majority of patients in the ICU will trigger the sepsis alert system,[10] so there likely is a high noise‐to‐signal ratio with resultant alert fatigue.[21]

In addition to greater emphasis on alert systems of greater diagnostic accuracy and effectiveness, our review notes several important gaps that limit evidence supporting the usefulness of automated sepsis alert systems. First, there are little data to describe the optimal design of sepsis alerts[24, 25] or the frequency with which they are appropriately acted upon or dismissed. In addition, we found little data to support whether effectiveness of alert systems differed based on whether clinical decision support was included with the alert itself (eg, direct prompting with specific clinical management recommendations) or the configuration of the alert (eg, interruptive alert or informational).[24, 25] Most of the studies we reviewed employed alerts primarily targeting physicians; we found little evidence for systems that also alerted other providers (eg, nurses or rapid response teams). Few studies provided data on harms of these systems (eg, excess antimicrobial use, fluid overload due to aggressive fluid resuscitation) or how often these treatments were administered to patients who did not eventually have sepsis. Few studies employed study designs that limited biases (eg, randomized or quasiexperimental designs) or used an intention‐to‐treat approach. Studies that exclude false positive alerts in analyses could bias estimates toward making sepsis alert systems appear more effective than they actually were. Finally, although presumably, deploying automated sepsis alerts in the ED would facilitate more timely recognition and treatment, more rigorously conducted studies are needed to identify whether using these alerts in the ED are of greater value compared to the wards and ICU. Given the limited number of studies included in this review, we were unable to make strong conclusions regarding the clinical benefits and cost‐effectiveness of implementing automated sepsis alerts.

Our review has certain limitations. First, despite our extensive literature search strategy, we may have missed studies published in the grey literature or in non‐English languages. Second, there is potential publication bias given the number of abstracts that we identified addressing 1 of our prespecified research questions compared to the number of peer‐reviewed publications identified by our search strategy.

CONCLUSION

Automated electronic sepsis alert systems have promise in delivering early goal‐directed therapies to patients. However, at present, automated sepsis alerts derived from electronic health data may improve care processes but tend to have poor PPV and have not been shown to improve mortality or length of stay. Future efforts should develop and study methods for sepsis alert systems that avoid the potential for alert fatigue while improving outcomes.

Medication reconciliation, when performed well, effectively identifies discrepancies and reduces medication errors in the hospital setting.[1, 2, 3] This process involves 4 major steps: (1) obtain and document a comprehensive medication history on admission, (2) compare the medication history to medication orders in the hospital and identify and resolve discrepancies, (3) provide the patient with a written list of discharge medications, and (4) educate the patient about their discharge medication regimen.[4, 5, 6]

However, medication reconciliation has been challenging to implement given difficulties with accurate medication information, patients' ability to communicate or remember, and clinician's not having enough time, motivation, or clear roles.[5, 7, 8, 9, 10, 11] Lack of role clarity is generally a barrier to quality improvement; therefore, we studied the perceptions of physicians, nurses, and pharmacists about their roles and responsibilities in completing inpatient medication reconciliation.

METHODS

We independently surveyed attending and resident physicians, nurses, and pharmacists at the University of California San Francisco (UCSF) Medical Center via email who were actively caring for hospitalized patients in April 2010. We collected data on demographics, roles on specific tasks in the medication reconciliation process from admission through discharge, and attitudes and barriers toward medication reconciliation and health information technology systems. Responses to questions used a 4‐point Likert scale. We calculated frequencies and proportions, and used the Fisher exact test to evaluate differences in role agreement for specific medication reconciliation tasks.

RESULTS

Of 256 active clinicians, 78 completed the survey (30.5% overall response rate) providing care in various hospital services (medicine, surgery, cardiology, neurology, pediatrics, obstetrics/gynecology). We received responses from 7 attending physicians (16% response rate), 14 resident physicians (19% response rate), 35 nurses (43% response rate), and 22 pharmacists (43% response rate). Most clinicians worked more than 5 years at UCSF, except residents (14 years).

Overall agreement was poor to fair on whose primary role it was for specific medication reconciliation tasks from admission through discharge (Table 1). Clinicians mainly agreed that it was a physician's responsibility to decide which medications should be continued or discontinued on admission and discharge, although agreement between attending and resident physicians varied. Fisher exact test revealed significant differences in agreement among attending and resident physicians, nurses, and pharmacists to obtain and document a medication history on admission (P=0.001), provide a list of the discharge medications (P<0.001), or educate patients on the postdischarge medication regimen (P<0.001). For these tasks, the physician, nurse, pharmacist or a combination of these clinicians (multiple category) were each identified to be responsible.

Most clinicians believed that maintaining a patient's list of medications improves patient care (94%100% agreement). However, when asked whether clinicians other than yourself should be responsible for an accurate medication list, most nurses (73%) and pharmacists (52%) agreed with this statement compared to resident (50%) and attending physicians (29%). Most clinicians agreed that information technology systems for reconciling medications were complicated, and that patients who do not know their medications, accessing outside medical records, working with inaccurate lists, or nonEnglish‐speaking patients are barriers to reconciliation.

DISCUSSION

We found fair agreement among clinicians that physicians were responsible for reconciling medications on admission and discharge. However, attending and resident physicians each believed it was their primary responsibility, respectively, suggesting the need for better communication between each other. We found poor agreement among clinicians about whose primary role it was to perform the other main steps of medication reconciliation including obtaining and documenting a medication history, and providing a medication list and educating the patient at discharge. For these tasks, there was more confusion among physicians, nurses, and pharmacists. Our findings highlight the need for better role clarity and good communication among team members, particularly at discharge.

Nearly all clinicians agreed that updating patients' medication lists improves patient care. However, most nurses and pharmacists preferred that physicians be responsible for updating information and reconciling medications. They also noted a number of patient‐related and information system barriers to effective reconciliation as others have identified.[7, 8, 9, 10, 11] Although standardizing medication information reporting and implementing technology that can integrate medical records to create, update, and share information between patients and providers can help streamline the medication reconciliation process,[4, 5, 7, 8, 12] these procedures are unlikely to be effective unless good interprofessional communication, role clarity, and clinician understanding of how the system works are in place.

When this study was conducted, our institution's policy required that medication reconciliation be completed, but no specific roles or standard work documents existed. Since then, we have clarified the role of the physician to be responsible for completing medication reconciliation with ancillary help from nurses, pharmacists, and other clinicians, particularly when obtaining a medication history and preparing the patient for discharge. This role clarity has led to focused training and standard work guide documents as guidance to clinicians in different hospital settings about expectations and how to complete medication reconciliation. Clearly, no single reconciliation workflow process will meet the needs of all hospitals. However, it is crucial that interprofessional teams are established with clearly defined roles and responsibilities, and how these roles and responsibilities may change in various situations or services.[8]

Our study had several limitations. We surveyed 1 academic medical center, thus limiting the generalizability of our findings to other organizations or settings. Our small sample size and low response rate could be susceptible to selection bias. However, our findings are similar to other studies.[7, 10, 11] Finally, we included clinicians practicing on various services throughout our hospital, and the local medication reconciliation process could have contributed to the poor agreement. Nonetheless, differences in perceived roles and attitudes for completing medication reconciliation were observed.

In conclusion, lack of agreement among clinicians about their specific roles and responsibilities in the medication reconciliation process exists, and this may result in incomplete reconciliation, inefficiency, duplication of work, and possibly more confusion about a patient's medication regimen. Clinically meaningful and efficient medication reconciliation requires interprofessional teamwork with clear roles and responsibilities, good communication and better information reporting, and tracking systems to successfully combine the steps of medication reconciliation and ensure patient safety.[8, 12]

Disclosures: Funded by research grant NHLBI R01 HL086473 to Dr. Auerbach, and through UCSF‐ CTSI grant number KL2 RR024130 to Dr. Lee from the National Center for Research Resources, the National Center for Advancing Translational Sciences, and the Office of the Director, National Institutes of Health. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. Dr. Lee had full access to all study data and takes responsibility for data integrity and data analysis accuracy. The authors report no conflicts of interest.

Medication reconciliation, when performed well, effectively identifies discrepancies and reduces medication errors in the hospital setting.[1, 2, 3] This process involves 4 major steps: (1) obtain and document a comprehensive medication history on admission, (2) compare the medication history to medication orders in the hospital and identify and resolve discrepancies, (3) provide the patient with a written list of discharge medications, and (4) educate the patient about their discharge medication regimen.[4, 5, 6]

However, medication reconciliation has been challenging to implement given difficulties with accurate medication information, patients' ability to communicate or remember, and clinician's not having enough time, motivation, or clear roles.[5, 7, 8, 9, 10, 11] Lack of role clarity is generally a barrier to quality improvement; therefore, we studied the perceptions of physicians, nurses, and pharmacists about their roles and responsibilities in completing inpatient medication reconciliation.

METHODS

We independently surveyed attending and resident physicians, nurses, and pharmacists at the University of California San Francisco (UCSF) Medical Center via email who were actively caring for hospitalized patients in April 2010. We collected data on demographics, roles on specific tasks in the medication reconciliation process from admission through discharge, and attitudes and barriers toward medication reconciliation and health information technology systems. Responses to questions used a 4‐point Likert scale. We calculated frequencies and proportions, and used the Fisher exact test to evaluate differences in role agreement for specific medication reconciliation tasks.

RESULTS

Of 256 active clinicians, 78 completed the survey (30.5% overall response rate) providing care in various hospital services (medicine, surgery, cardiology, neurology, pediatrics, obstetrics/gynecology). We received responses from 7 attending physicians (16% response rate), 14 resident physicians (19% response rate), 35 nurses (43% response rate), and 22 pharmacists (43% response rate). Most clinicians worked more than 5 years at UCSF, except residents (14 years).

Overall agreement was poor to fair on whose primary role it was for specific medication reconciliation tasks from admission through discharge (Table 1). Clinicians mainly agreed that it was a physician's responsibility to decide which medications should be continued or discontinued on admission and discharge, although agreement between attending and resident physicians varied. Fisher exact test revealed significant differences in agreement among attending and resident physicians, nurses, and pharmacists to obtain and document a medication history on admission (P=0.001), provide a list of the discharge medications (P<0.001), or educate patients on the postdischarge medication regimen (P<0.001). For these tasks, the physician, nurse, pharmacist or a combination of these clinicians (multiple category) were each identified to be responsible.

Most clinicians believed that maintaining a patient's list of medications improves patient care (94%100% agreement). However, when asked whether clinicians other than yourself should be responsible for an accurate medication list, most nurses (73%) and pharmacists (52%) agreed with this statement compared to resident (50%) and attending physicians (29%). Most clinicians agreed that information technology systems for reconciling medications were complicated, and that patients who do not know their medications, accessing outside medical records, working with inaccurate lists, or nonEnglish‐speaking patients are barriers to reconciliation.

DISCUSSION

We found fair agreement among clinicians that physicians were responsible for reconciling medications on admission and discharge. However, attending and resident physicians each believed it was their primary responsibility, respectively, suggesting the need for better communication between each other. We found poor agreement among clinicians about whose primary role it was to perform the other main steps of medication reconciliation including obtaining and documenting a medication history, and providing a medication list and educating the patient at discharge. For these tasks, there was more confusion among physicians, nurses, and pharmacists. Our findings highlight the need for better role clarity and good communication among team members, particularly at discharge.

Nearly all clinicians agreed that updating patients' medication lists improves patient care. However, most nurses and pharmacists preferred that physicians be responsible for updating information and reconciling medications. They also noted a number of patient‐related and information system barriers to effective reconciliation as others have identified.[7, 8, 9, 10, 11] Although standardizing medication information reporting and implementing technology that can integrate medical records to create, update, and share information between patients and providers can help streamline the medication reconciliation process,[4, 5, 7, 8, 12] these procedures are unlikely to be effective unless good interprofessional communication, role clarity, and clinician understanding of how the system works are in place.

When this study was conducted, our institution's policy required that medication reconciliation be completed, but no specific roles or standard work documents existed. Since then, we have clarified the role of the physician to be responsible for completing medication reconciliation with ancillary help from nurses, pharmacists, and other clinicians, particularly when obtaining a medication history and preparing the patient for discharge. This role clarity has led to focused training and standard work guide documents as guidance to clinicians in different hospital settings about expectations and how to complete medication reconciliation. Clearly, no single reconciliation workflow process will meet the needs of all hospitals. However, it is crucial that interprofessional teams are established with clearly defined roles and responsibilities, and how these roles and responsibilities may change in various situations or services.[8]

Our study had several limitations. We surveyed 1 academic medical center, thus limiting the generalizability of our findings to other organizations or settings. Our small sample size and low response rate could be susceptible to selection bias. However, our findings are similar to other studies.[7, 10, 11] Finally, we included clinicians practicing on various services throughout our hospital, and the local medication reconciliation process could have contributed to the poor agreement. Nonetheless, differences in perceived roles and attitudes for completing medication reconciliation were observed.

In conclusion, lack of agreement among clinicians about their specific roles and responsibilities in the medication reconciliation process exists, and this may result in incomplete reconciliation, inefficiency, duplication of work, and possibly more confusion about a patient's medication regimen. Clinically meaningful and efficient medication reconciliation requires interprofessional teamwork with clear roles and responsibilities, good communication and better information reporting, and tracking systems to successfully combine the steps of medication reconciliation and ensure patient safety.[8, 12]

Disclosures: Funded by research grant NHLBI R01 HL086473 to Dr. Auerbach, and through UCSF‐ CTSI grant number KL2 RR024130 to Dr. Lee from the National Center for Research Resources, the National Center for Advancing Translational Sciences, and the Office of the Director, National Institutes of Health. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. Dr. Lee had full access to all study data and takes responsibility for data integrity and data analysis accuracy. The authors report no conflicts of interest.

Medication reconciliation, when performed well, effectively identifies discrepancies and reduces medication errors in the hospital setting.[1, 2, 3] This process involves 4 major steps: (1) obtain and document a comprehensive medication history on admission, (2) compare the medication history to medication orders in the hospital and identify and resolve discrepancies, (3) provide the patient with a written list of discharge medications, and (4) educate the patient about their discharge medication regimen.[4, 5, 6]

However, medication reconciliation has been challenging to implement given difficulties with accurate medication information, patients' ability to communicate or remember, and clinician's not having enough time, motivation, or clear roles.[5, 7, 8, 9, 10, 11] Lack of role clarity is generally a barrier to quality improvement; therefore, we studied the perceptions of physicians, nurses, and pharmacists about their roles and responsibilities in completing inpatient medication reconciliation.

METHODS

We independently surveyed attending and resident physicians, nurses, and pharmacists at the University of California San Francisco (UCSF) Medical Center via email who were actively caring for hospitalized patients in April 2010. We collected data on demographics, roles on specific tasks in the medication reconciliation process from admission through discharge, and attitudes and barriers toward medication reconciliation and health information technology systems. Responses to questions used a 4‐point Likert scale. We calculated frequencies and proportions, and used the Fisher exact test to evaluate differences in role agreement for specific medication reconciliation tasks.

RESULTS

Of 256 active clinicians, 78 completed the survey (30.5% overall response rate) providing care in various hospital services (medicine, surgery, cardiology, neurology, pediatrics, obstetrics/gynecology). We received responses from 7 attending physicians (16% response rate), 14 resident physicians (19% response rate), 35 nurses (43% response rate), and 22 pharmacists (43% response rate). Most clinicians worked more than 5 years at UCSF, except residents (14 years).

Overall agreement was poor to fair on whose primary role it was for specific medication reconciliation tasks from admission through discharge (Table 1). Clinicians mainly agreed that it was a physician's responsibility to decide which medications should be continued or discontinued on admission and discharge, although agreement between attending and resident physicians varied. Fisher exact test revealed significant differences in agreement among attending and resident physicians, nurses, and pharmacists to obtain and document a medication history on admission (P=0.001), provide a list of the discharge medications (P<0.001), or educate patients on the postdischarge medication regimen (P<0.001). For these tasks, the physician, nurse, pharmacist or a combination of these clinicians (multiple category) were each identified to be responsible.

Most clinicians believed that maintaining a patient's list of medications improves patient care (94%100% agreement). However, when asked whether clinicians other than yourself should be responsible for an accurate medication list, most nurses (73%) and pharmacists (52%) agreed with this statement compared to resident (50%) and attending physicians (29%). Most clinicians agreed that information technology systems for reconciling medications were complicated, and that patients who do not know their medications, accessing outside medical records, working with inaccurate lists, or nonEnglish‐speaking patients are barriers to reconciliation.

DISCUSSION

We found fair agreement among clinicians that physicians were responsible for reconciling medications on admission and discharge. However, attending and resident physicians each believed it was their primary responsibility, respectively, suggesting the need for better communication between each other. We found poor agreement among clinicians about whose primary role it was to perform the other main steps of medication reconciliation including obtaining and documenting a medication history, and providing a medication list and educating the patient at discharge. For these tasks, there was more confusion among physicians, nurses, and pharmacists. Our findings highlight the need for better role clarity and good communication among team members, particularly at discharge.

Nearly all clinicians agreed that updating patients' medication lists improves patient care. However, most nurses and pharmacists preferred that physicians be responsible for updating information and reconciling medications. They also noted a number of patient‐related and information system barriers to effective reconciliation as others have identified.[7, 8, 9, 10, 11] Although standardizing medication information reporting and implementing technology that can integrate medical records to create, update, and share information between patients and providers can help streamline the medication reconciliation process,[4, 5, 7, 8, 12] these procedures are unlikely to be effective unless good interprofessional communication, role clarity, and clinician understanding of how the system works are in place.

When this study was conducted, our institution's policy required that medication reconciliation be completed, but no specific roles or standard work documents existed. Since then, we have clarified the role of the physician to be responsible for completing medication reconciliation with ancillary help from nurses, pharmacists, and other clinicians, particularly when obtaining a medication history and preparing the patient for discharge. This role clarity has led to focused training and standard work guide documents as guidance to clinicians in different hospital settings about expectations and how to complete medication reconciliation. Clearly, no single reconciliation workflow process will meet the needs of all hospitals. However, it is crucial that interprofessional teams are established with clearly defined roles and responsibilities, and how these roles and responsibilities may change in various situations or services.[8]

Our study had several limitations. We surveyed 1 academic medical center, thus limiting the generalizability of our findings to other organizations or settings. Our small sample size and low response rate could be susceptible to selection bias. However, our findings are similar to other studies.[7, 10, 11] Finally, we included clinicians practicing on various services throughout our hospital, and the local medication reconciliation process could have contributed to the poor agreement. Nonetheless, differences in perceived roles and attitudes for completing medication reconciliation were observed.

In conclusion, lack of agreement among clinicians about their specific roles and responsibilities in the medication reconciliation process exists, and this may result in incomplete reconciliation, inefficiency, duplication of work, and possibly more confusion about a patient's medication regimen. Clinically meaningful and efficient medication reconciliation requires interprofessional teamwork with clear roles and responsibilities, good communication and better information reporting, and tracking systems to successfully combine the steps of medication reconciliation and ensure patient safety.[8, 12]

Disclosures: Funded by research grant NHLBI R01 HL086473 to Dr. Auerbach, and through UCSF‐ CTSI grant number KL2 RR024130 to Dr. Lee from the National Center for Research Resources, the National Center for Advancing Translational Sciences, and the Office of the Director, National Institutes of Health. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of the National Institutes of Health. Dr. Lee had full access to all study data and takes responsibility for data integrity and data analysis accuracy. The authors report no conflicts of interest.

In this issue of the Journal of Hospital Medicine, Schaffer and colleagues report their analysis of malpractice claims against hospitalists compared to other physician specialties.[1] In contrast to previous work examining medical liability,[2, 3] Schaffer and colleagues have been able to identify hospitalists specifically.[2, 3]

Perhaps surprisingly, their main finding was that the rate of claims against hospitalists was significantly lower than for nonhospitalist internists, emergency medicine physicians, general surgeons, and obstetriciansgynecologists. We say surprisingly, because health systems utilizing hospitalists generally include features that might increase the risk for malpractice claims.

For example, new patients are typically assigned to whichever hospitalist is up for the next admission. Research shows that strained patientphysician relationships increase the risk for malpractice claims.[4, 5] Schaffer's data suggest that lack of a preexisting relationship is a challenge, but one to which most hospitalists have grown accustomed. Hospitalists develop and hone skills that allow them to quickly establish rapport with patients and families. Moreover, though patients seldom choose their hospitalist, they often do select the hospital in which they receive their care. The research group of 1 of the authors was recently surprised to find patients had high levels of trust with their hospital physicians, despite frequently being unable to name them or identify their role.[6] We suspect patients in the study had high levels of trust with the hospital and transferred this trust to their assigned physicians as representatives of the organization. Certainly, this hypothesis needs to be tested, and in no way does it minimize the importance of a strong patient‐physician relationship.

In addition, patientphysician continuity has long been felt to be paramount to safe and effective care; however, it is difficult to achieve in hospitalist systems. Hospitalized patients experience multiple handoffs, including those at admission, for night coverage, and at the time of service change (ie, end of rotation/stint). The potential for loss of information is enormous. Though increased attention has been dedicated to handoffs among housestaff, little work has been done to describe issues related to handoffs among practicing physicians. However, some discontinuity may be advantageous. A physician newly taking over patient care from another may not be anchored to the initial diagnosis and treatment plan established by the first. This free second look may actually prevent missed/delayed diagnoses and optimize plans of care, further reducing harm from care and risk of malpractice.[7]

Hospital discharge is another highly risky time, due to issues such as tests pending at the time of discharge and the need to manage ongoing workup and treatment of unresolved issues.[8, 9] The responsibility for tying up these loose ends may be unclear as patients are transitioned from the care of hospitalists to outpatient physicians. Prior research has shown that patients are at particularly high risk for preventable adverse events after hospital discharge.[10, 11] More recently, healthcare policy has focused on measuring and incentivizing the reduction of readmissions.[12] Although only a portion of readmissions are truly preventable,[13] and many patients who suffer adverse events after discharge are not readmitted,[11] the efforts resulting from these policy initiatives may have improved the overall safety of transitions of care.

A particularly important contribution of Schaffer and colleagues' study is that it helps us identify patient safety issues related to hospital medicine. Despite intense national efforts over the past 10 to 15 years, progress has been slow in reducing the rate of adverse events among hospitalized patients.[14, 15, 16] Although adverse events and medical liability do not always correlate,[17, 18] the contributing factors identified in Schaffer and colleagues' study help direct our patient safety efforts.

Clinical judgment was the most common factor associated with hospitalist malpractice claims, with examples including failure or delay in ordering a necessary diagnostic test or specialist consultation. These results may be misinterpreted by some to suggest that ordering more tests and services may reduce risk for malpractice claims. However, there is no evidence to support the belief that these defensive medicine behaviors actually reduce risk. In fact, the opposite may be true. Research shows that abnormal tests are frequently overlooked,[9, 19] and failure to act on abnormal results is a common cause of diagnostic error.[20] Experts have called for the development of diagnosis‐related quality measures and better strategies to enhance trainees' clinical reasoning skills.[21] We suggest that future research also clarify the effect of interruptions, distractions, and workload on cognitive errors in hospital settings.

Communication failures were the second most common contributing factor. As previously mentioned, communication failures may occur between hospitalists during handoffs. We also have major opportunities to improve interprofessional teamwork, especially between physicians and nurses.[22, 23] An increasing number of hospitalist groups are collaborating with other hospital‐based professionals to implement novel strategies to improve teamwork,[24, 25] many of which were recently summarized in a review published in this journal.[26]

Documentation was the third most common contributing factor. Most malpractice claims are filed long after the alleged injury has occurred.[18] Unless the clinicians involved and the hospital in which they work are aware of an event that might result in a malpractice claim, the investigation may be severely delayed. As time goes on, professionals are less able to recall details pertinent to understanding contributing factors to an event. Thus, documentation is critical. As the saying goes, if it wasn't documented, it didn't happen. The flipside of too little documentation is, of course, too much. The increasing use of electronic health records makes it easy to copy and paste outdated information, the sloppiness of which can only hurt when attempting to defend a malpractice claim.[27]

In conclusion, despite a model with inherent features that might contribute to medical malpractice risk, hospital medicine has a claim rate lower than many other specialties. Though reassuring, hospitalists should remember that the most productive way to approach malpractice risk is reframe the problem as one that attempts to reduce risk for patients, rather than for physicians. Improving patient safety is a core value for hospital medicine. Schaffer and colleagues' study identifies factors contributing to patient safety risk in hospital medicine, allowing us to renew our efforts in focused areas.

In this issue of the Journal of Hospital Medicine, Schaffer and colleagues report their analysis of malpractice claims against hospitalists compared to other physician specialties.[1] In contrast to previous work examining medical liability,[2, 3] Schaffer and colleagues have been able to identify hospitalists specifically.[2, 3]

Perhaps surprisingly, their main finding was that the rate of claims against hospitalists was significantly lower than for nonhospitalist internists, emergency medicine physicians, general surgeons, and obstetriciansgynecologists. We say surprisingly, because health systems utilizing hospitalists generally include features that might increase the risk for malpractice claims.

For example, new patients are typically assigned to whichever hospitalist is up for the next admission. Research shows that strained patientphysician relationships increase the risk for malpractice claims.[4, 5] Schaffer's data suggest that lack of a preexisting relationship is a challenge, but one to which most hospitalists have grown accustomed. Hospitalists develop and hone skills that allow them to quickly establish rapport with patients and families. Moreover, though patients seldom choose their hospitalist, they often do select the hospital in which they receive their care. The research group of 1 of the authors was recently surprised to find patients had high levels of trust with their hospital physicians, despite frequently being unable to name them or identify their role.[6] We suspect patients in the study had high levels of trust with the hospital and transferred this trust to their assigned physicians as representatives of the organization. Certainly, this hypothesis needs to be tested, and in no way does it minimize the importance of a strong patient‐physician relationship.

In addition, patientphysician continuity has long been felt to be paramount to safe and effective care; however, it is difficult to achieve in hospitalist systems. Hospitalized patients experience multiple handoffs, including those at admission, for night coverage, and at the time of service change (ie, end of rotation/stint). The potential for loss of information is enormous. Though increased attention has been dedicated to handoffs among housestaff, little work has been done to describe issues related to handoffs among practicing physicians. However, some discontinuity may be advantageous. A physician newly taking over patient care from another may not be anchored to the initial diagnosis and treatment plan established by the first. This free second look may actually prevent missed/delayed diagnoses and optimize plans of care, further reducing harm from care and risk of malpractice.[7]

Hospital discharge is another highly risky time, due to issues such as tests pending at the time of discharge and the need to manage ongoing workup and treatment of unresolved issues.[8, 9] The responsibility for tying up these loose ends may be unclear as patients are transitioned from the care of hospitalists to outpatient physicians. Prior research has shown that patients are at particularly high risk for preventable adverse events after hospital discharge.[10, 11] More recently, healthcare policy has focused on measuring and incentivizing the reduction of readmissions.[12] Although only a portion of readmissions are truly preventable,[13] and many patients who suffer adverse events after discharge are not readmitted,[11] the efforts resulting from these policy initiatives may have improved the overall safety of transitions of care.

A particularly important contribution of Schaffer and colleagues' study is that it helps us identify patient safety issues related to hospital medicine. Despite intense national efforts over the past 10 to 15 years, progress has been slow in reducing the rate of adverse events among hospitalized patients.[14, 15, 16] Although adverse events and medical liability do not always correlate,[17, 18] the contributing factors identified in Schaffer and colleagues' study help direct our patient safety efforts.

Clinical judgment was the most common factor associated with hospitalist malpractice claims, with examples including failure or delay in ordering a necessary diagnostic test or specialist consultation. These results may be misinterpreted by some to suggest that ordering more tests and services may reduce risk for malpractice claims. However, there is no evidence to support the belief that these defensive medicine behaviors actually reduce risk. In fact, the opposite may be true. Research shows that abnormal tests are frequently overlooked,[9, 19] and failure to act on abnormal results is a common cause of diagnostic error.[20] Experts have called for the development of diagnosis‐related quality measures and better strategies to enhance trainees' clinical reasoning skills.[21] We suggest that future research also clarify the effect of interruptions, distractions, and workload on cognitive errors in hospital settings.

Communication failures were the second most common contributing factor. As previously mentioned, communication failures may occur between hospitalists during handoffs. We also have major opportunities to improve interprofessional teamwork, especially between physicians and nurses.[22, 23] An increasing number of hospitalist groups are collaborating with other hospital‐based professionals to implement novel strategies to improve teamwork,[24, 25] many of which were recently summarized in a review published in this journal.[26]

Documentation was the third most common contributing factor. Most malpractice claims are filed long after the alleged injury has occurred.[18] Unless the clinicians involved and the hospital in which they work are aware of an event that might result in a malpractice claim, the investigation may be severely delayed. As time goes on, professionals are less able to recall details pertinent to understanding contributing factors to an event. Thus, documentation is critical. As the saying goes, if it wasn't documented, it didn't happen. The flipside of too little documentation is, of course, too much. The increasing use of electronic health records makes it easy to copy and paste outdated information, the sloppiness of which can only hurt when attempting to defend a malpractice claim.[27]

In conclusion, despite a model with inherent features that might contribute to medical malpractice risk, hospital medicine has a claim rate lower than many other specialties. Though reassuring, hospitalists should remember that the most productive way to approach malpractice risk is reframe the problem as one that attempts to reduce risk for patients, rather than for physicians. Improving patient safety is a core value for hospital medicine. Schaffer and colleagues' study identifies factors contributing to patient safety risk in hospital medicine, allowing us to renew our efforts in focused areas.

In this issue of the Journal of Hospital Medicine, Schaffer and colleagues report their analysis of malpractice claims against hospitalists compared to other physician specialties.[1] In contrast to previous work examining medical liability,[2, 3] Schaffer and colleagues have been able to identify hospitalists specifically.[2, 3]

Perhaps surprisingly, their main finding was that the rate of claims against hospitalists was significantly lower than for nonhospitalist internists, emergency medicine physicians, general surgeons, and obstetriciansgynecologists. We say surprisingly, because health systems utilizing hospitalists generally include features that might increase the risk for malpractice claims.

For example, new patients are typically assigned to whichever hospitalist is up for the next admission. Research shows that strained patientphysician relationships increase the risk for malpractice claims.[4, 5] Schaffer's data suggest that lack of a preexisting relationship is a challenge, but one to which most hospitalists have grown accustomed. Hospitalists develop and hone skills that allow them to quickly establish rapport with patients and families. Moreover, though patients seldom choose their hospitalist, they often do select the hospital in which they receive their care. The research group of 1 of the authors was recently surprised to find patients had high levels of trust with their hospital physicians, despite frequently being unable to name them or identify their role.[6] We suspect patients in the study had high levels of trust with the hospital and transferred this trust to their assigned physicians as representatives of the organization. Certainly, this hypothesis needs to be tested, and in no way does it minimize the importance of a strong patient‐physician relationship.

In addition, patientphysician continuity has long been felt to be paramount to safe and effective care; however, it is difficult to achieve in hospitalist systems. Hospitalized patients experience multiple handoffs, including those at admission, for night coverage, and at the time of service change (ie, end of rotation/stint). The potential for loss of information is enormous. Though increased attention has been dedicated to handoffs among housestaff, little work has been done to describe issues related to handoffs among practicing physicians. However, some discontinuity may be advantageous. A physician newly taking over patient care from another may not be anchored to the initial diagnosis and treatment plan established by the first. This free second look may actually prevent missed/delayed diagnoses and optimize plans of care, further reducing harm from care and risk of malpractice.[7]

Hospital discharge is another highly risky time, due to issues such as tests pending at the time of discharge and the need to manage ongoing workup and treatment of unresolved issues.[8, 9] The responsibility for tying up these loose ends may be unclear as patients are transitioned from the care of hospitalists to outpatient physicians. Prior research has shown that patients are at particularly high risk for preventable adverse events after hospital discharge.[10, 11] More recently, healthcare policy has focused on measuring and incentivizing the reduction of readmissions.[12] Although only a portion of readmissions are truly preventable,[13] and many patients who suffer adverse events after discharge are not readmitted,[11] the efforts resulting from these policy initiatives may have improved the overall safety of transitions of care.

A particularly important contribution of Schaffer and colleagues' study is that it helps us identify patient safety issues related to hospital medicine. Despite intense national efforts over the past 10 to 15 years, progress has been slow in reducing the rate of adverse events among hospitalized patients.[14, 15, 16] Although adverse events and medical liability do not always correlate,[17, 18] the contributing factors identified in Schaffer and colleagues' study help direct our patient safety efforts.

Clinical judgment was the most common factor associated with hospitalist malpractice claims, with examples including failure or delay in ordering a necessary diagnostic test or specialist consultation. These results may be misinterpreted by some to suggest that ordering more tests and services may reduce risk for malpractice claims. However, there is no evidence to support the belief that these defensive medicine behaviors actually reduce risk. In fact, the opposite may be true. Research shows that abnormal tests are frequently overlooked,[9, 19] and failure to act on abnormal results is a common cause of diagnostic error.[20] Experts have called for the development of diagnosis‐related quality measures and better strategies to enhance trainees' clinical reasoning skills.[21] We suggest that future research also clarify the effect of interruptions, distractions, and workload on cognitive errors in hospital settings.

Communication failures were the second most common contributing factor. As previously mentioned, communication failures may occur between hospitalists during handoffs. We also have major opportunities to improve interprofessional teamwork, especially between physicians and nurses.[22, 23] An increasing number of hospitalist groups are collaborating with other hospital‐based professionals to implement novel strategies to improve teamwork,[24, 25] many of which were recently summarized in a review published in this journal.[26]

Documentation was the third most common contributing factor. Most malpractice claims are filed long after the alleged injury has occurred.[18] Unless the clinicians involved and the hospital in which they work are aware of an event that might result in a malpractice claim, the investigation may be severely delayed. As time goes on, professionals are less able to recall details pertinent to understanding contributing factors to an event. Thus, documentation is critical. As the saying goes, if it wasn't documented, it didn't happen. The flipside of too little documentation is, of course, too much. The increasing use of electronic health records makes it easy to copy and paste outdated information, the sloppiness of which can only hurt when attempting to defend a malpractice claim.[27]

In conclusion, despite a model with inherent features that might contribute to medical malpractice risk, hospital medicine has a claim rate lower than many other specialties. Though reassuring, hospitalists should remember that the most productive way to approach malpractice risk is reframe the problem as one that attempts to reduce risk for patients, rather than for physicians. Improving patient safety is a core value for hospital medicine. Schaffer and colleagues' study identifies factors contributing to patient safety risk in hospital medicine, allowing us to renew our efforts in focused areas.

We agree with Drs. Arora and Mahmud that emerging mobile health (mHealth) approaches to improving patient engagement will need to demonstrate their value to advance health and healthcare. The potential for mHealth to do this has been often described[1, 2] but, so far, rarely measured or demonstrated.

The technology costs of our tablet‐based intervention[3] were low: 2 iPads at $400 each. The real expense was for personnel: research assistants needed to teach patients how to use the technology effectively. In the future, we hope to shift device and software orientation to patient‐care assistants, nurses, or even digital assistants, nonmedical personnel who have technical expertise with the health‐related devices and software needed to engage with the electronic health record and educational materials. Thus, at least part of the challenge of cost‐effectiveness aside from improved outcomeswill be demonstrating eventual time savings for providers who no longer need to hand deliver or explain paper pamphlets or printouts, or shepherd patients through their digitally assisted education.

One day we may muse, what did we do before mHealth? as we might do now when using mobile technologies for nonhealth‐related tasks like getting directions or making a call. Indeed, who can remember the last time they routinely used a paper map or phonebook for these daily tasks? Our prescription for tablets is a step in that direction, but we will need to also reimagine patient education and related daily tasks at the hospital and system level to realize the potential of lower costs and higher quality care we can achieve using mHealth.[4]

We agree with Drs. Arora and Mahmud that emerging mobile health (mHealth) approaches to improving patient engagement will need to demonstrate their value to advance health and healthcare. The potential for mHealth to do this has been often described[1, 2] but, so far, rarely measured or demonstrated.

The technology costs of our tablet‐based intervention[3] were low: 2 iPads at $400 each. The real expense was for personnel: research assistants needed to teach patients how to use the technology effectively. In the future, we hope to shift device and software orientation to patient‐care assistants, nurses, or even digital assistants, nonmedical personnel who have technical expertise with the health‐related devices and software needed to engage with the electronic health record and educational materials. Thus, at least part of the challenge of cost‐effectiveness aside from improved outcomeswill be demonstrating eventual time savings for providers who no longer need to hand deliver or explain paper pamphlets or printouts, or shepherd patients through their digitally assisted education.

One day we may muse, what did we do before mHealth? as we might do now when using mobile technologies for nonhealth‐related tasks like getting directions or making a call. Indeed, who can remember the last time they routinely used a paper map or phonebook for these daily tasks? Our prescription for tablets is a step in that direction, but we will need to also reimagine patient education and related daily tasks at the hospital and system level to realize the potential of lower costs and higher quality care we can achieve using mHealth.[4]

We agree with Drs. Arora and Mahmud that emerging mobile health (mHealth) approaches to improving patient engagement will need to demonstrate their value to advance health and healthcare. The potential for mHealth to do this has been often described[1, 2] but, so far, rarely measured or demonstrated.

The technology costs of our tablet‐based intervention[3] were low: 2 iPads at $400 each. The real expense was for personnel: research assistants needed to teach patients how to use the technology effectively. In the future, we hope to shift device and software orientation to patient‐care assistants, nurses, or even digital assistants, nonmedical personnel who have technical expertise with the health‐related devices and software needed to engage with the electronic health record and educational materials. Thus, at least part of the challenge of cost‐effectiveness aside from improved outcomeswill be demonstrating eventual time savings for providers who no longer need to hand deliver or explain paper pamphlets or printouts, or shepherd patients through their digitally assisted education.

One day we may muse, what did we do before mHealth? as we might do now when using mobile technologies for nonhealth‐related tasks like getting directions or making a call. Indeed, who can remember the last time they routinely used a paper map or phonebook for these daily tasks? Our prescription for tablets is a step in that direction, but we will need to also reimagine patient education and related daily tasks at the hospital and system level to realize the potential of lower costs and higher quality care we can achieve using mHealth.[4]

In 2002, based on consensus practice guidelines,[1] the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced a core measure mandating the collection of routine blood cultures in the emergency department (ED) for all patients hospitalized with community‐acquired pneumonia (CAP) to benchmark the quality of hospital care. However, due to the limited utility and false‐positive results of routine blood cultures,[2, 3, 4, 5, 6] performance measures and practice guidelines were modified in 2005 and 2007, respectively, to recommend routine collection in only the sickest patients with CAP.[2, 7] Despite recommendations for a more narrow set of indications, the collection of blood cultures in patients hospitalized with CAP continued to increase.[8]

Distinguishing CAP from other respiratory illnesses may be challenging. Among patients presenting to the ED with an acute respiratory illness, only a minority of patients (10%30%) are diagnosed with pneumonia.[9] Therefore, the harms and costs of inappropriate diagnostic tests for CAP may be further magnified if applied to a larger population of patients who present to the ED with similar clinical signs and symptoms as pneumonia. Using a national sample of ED visits, we examined whether there was a similar increase in the frequency of blood culture collection among patients who were hospitalized with respiratory symptoms due to an illness other than pneumonia.

METHOD

RESULTS

This study included 4854 ED visits, representing approximately 17 million visits by adult patients hospitalized with respiratory symptoms due to a nonpneumonia illness. The most common primary ED provider's diagnoses for these visits included heart failure (15.9%), chronic obstructive pulmonary disease (12.6%), chest pain (11.9%), respiratory insufficiency or failure (8.8%), and asthma (5.5%). The characteristics of these visits are shown in Table 1.

The proportion of blood cultures collected in the ED for patients hospitalized with respiratory symptoms due to a nonpneumonia illness increased from 9.9% (95% confidence interval [CI]: 7.1%‐13.5%) in 2002 to 20.4% (95% CI: 16.1%‐25.6%) in 2010 (P<0.001 for the trend). This observed increase paralleled the increase in the frequency of culture collection in patients hospitalized with CAP (P=0.12 for the difference in temporal trends). The estimated absolute number of visits for respiratory symptoms due a nonpneumonia illness with a blood culture collected increased from 211,000 (95% CI: 126,000296,000) in 2002 to 526,000 (95% CI: 361,000692,000) in 2010, which was similar in magnitude to the estimated number of visits for CAP with a culture collected (Table 2).

DISCUSSION

In this national study of ED visits, we found that the collection of blood cultures in patients hospitalized with respiratory symptoms due to an illness other than pneumonia continued to increase from 2002 to 2010 in a parallel fashion to the trend observed for patients hospitalized with CAP. Our findings suggest that the heightened attention of collecting blood cultures for suspected pneumonia had unintended consequences, which led to an increase in the collection of blood cultures in patients hospitalized with conditions that mimic pneumonia in the ED.

There can be a great deal of diagnostic uncertainty when treating patients in the ED who present with acute respiratory symptoms. Unfortunately, the initial history and physical exam are often insufficient to effectively rule in CAP.[13] Furthermore, the challenge of diagnosing pneumonia is amplified in the subset of patients who present with evolving, atypical, or occult disease. Faced with this diagnostic uncertainty, ED providers may feel pressured to comply with performance measures for CAP, promoting the overuse of inappropriate diagnostic tests and treatments. For instance, efforts to comply with early antibiotic administration in patients with CAP have led to an increase in unnecessary antibiotic use among patients with a diagnosis other than CAP.[14] Due to concerns for these unintended consequences, the core measure for early antibiotic administration was effectively retired in 2012.

Although a smaller percentage of ED visits for respiratory symptoms had a blood culture collected compared to CAP visits, there was a similar absolute number of visits with a blood culture collected during the study period. While a fraction of these patients may present with an infectious etiology aside from pneumonia, the majority of these cases likely represent situations where blood cultures add little diagnostic value at the expense of potentially longer hospital stays and broad spectrum antimicrobial use due to false‐positive results,[5, 15] as well as higher costs incurred by the test itself.[15, 16]

Although recommendations for routine culture collection for all patients hospitalized with CAP have been revised, the JCAHO/CMS core measure (PN‐3b) announced in 2002 mandates that if a culture is collected in the ED, it should be collected prior to antibiotic administration. Due to inherent uncertainty and challenges in making a timely diagnosis of pneumonia, this measure may encourage providers to reflexively order cultures in all patients presenting with respiratory symptoms in whom antibiotic administration is anticipated. The observed increasing trend in culture collection in patients hospitalized with respiratory symptoms due to a nonpneumonia illness should prompt JCAHO and CMS to reevaluate the risks and benefits of this core measure, with consideration of eliminating it altogether to discourage overuse in this population.

Our study had certain limitations. First, the omission of 2005 and 2006 data prohibited an evaluation of whether culture rates slowed down among patients hospitalized with respiratory symptoms due to a nonpneumonia illness after revisions in recommendations for obtaining cultures in patients with CAP. Second, there may have been misclassification of culture collection due to errors in chart abstraction. However, abstraction errors in the NHAMCS typically result in undercoding.[17] Therefore, our findings likely underestimate the magnitude and frequency of culture collection in this population.

In conclusion, collecting blood cultures in the ED for patients hospitalized with respiratory symptoms due to a nonpneumonia illness has increased in a parallel fashion compared to the trend in culture collection in patients hospitalized with CAP from 2002 to 2010. This suggests an important potential unintended consequence of blood culture recommendations for CAP on patients who present with conditions that resemble pneumonia. More attention to the judicious use of blood cultures in these patients to reduce harm and costs is needed.

In 2002, based on consensus practice guidelines,[1] the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced a core measure mandating the collection of routine blood cultures in the emergency department (ED) for all patients hospitalized with community‐acquired pneumonia (CAP) to benchmark the quality of hospital care. However, due to the limited utility and false‐positive results of routine blood cultures,[2, 3, 4, 5, 6] performance measures and practice guidelines were modified in 2005 and 2007, respectively, to recommend routine collection in only the sickest patients with CAP.[2, 7] Despite recommendations for a more narrow set of indications, the collection of blood cultures in patients hospitalized with CAP continued to increase.[8]

Distinguishing CAP from other respiratory illnesses may be challenging. Among patients presenting to the ED with an acute respiratory illness, only a minority of patients (10%30%) are diagnosed with pneumonia.[9] Therefore, the harms and costs of inappropriate diagnostic tests for CAP may be further magnified if applied to a larger population of patients who present to the ED with similar clinical signs and symptoms as pneumonia. Using a national sample of ED visits, we examined whether there was a similar increase in the frequency of blood culture collection among patients who were hospitalized with respiratory symptoms due to an illness other than pneumonia.

METHOD

RESULTS

This study included 4854 ED visits, representing approximately 17 million visits by adult patients hospitalized with respiratory symptoms due to a nonpneumonia illness. The most common primary ED provider's diagnoses for these visits included heart failure (15.9%), chronic obstructive pulmonary disease (12.6%), chest pain (11.9%), respiratory insufficiency or failure (8.8%), and asthma (5.5%). The characteristics of these visits are shown in Table 1.

The proportion of blood cultures collected in the ED for patients hospitalized with respiratory symptoms due to a nonpneumonia illness increased from 9.9% (95% confidence interval [CI]: 7.1%‐13.5%) in 2002 to 20.4% (95% CI: 16.1%‐25.6%) in 2010 (P<0.001 for the trend). This observed increase paralleled the increase in the frequency of culture collection in patients hospitalized with CAP (P=0.12 for the difference in temporal trends). The estimated absolute number of visits for respiratory symptoms due a nonpneumonia illness with a blood culture collected increased from 211,000 (95% CI: 126,000296,000) in 2002 to 526,000 (95% CI: 361,000692,000) in 2010, which was similar in magnitude to the estimated number of visits for CAP with a culture collected (Table 2).

DISCUSSION

In this national study of ED visits, we found that the collection of blood cultures in patients hospitalized with respiratory symptoms due to an illness other than pneumonia continued to increase from 2002 to 2010 in a parallel fashion to the trend observed for patients hospitalized with CAP. Our findings suggest that the heightened attention of collecting blood cultures for suspected pneumonia had unintended consequences, which led to an increase in the collection of blood cultures in patients hospitalized with conditions that mimic pneumonia in the ED.

There can be a great deal of diagnostic uncertainty when treating patients in the ED who present with acute respiratory symptoms. Unfortunately, the initial history and physical exam are often insufficient to effectively rule in CAP.[13] Furthermore, the challenge of diagnosing pneumonia is amplified in the subset of patients who present with evolving, atypical, or occult disease. Faced with this diagnostic uncertainty, ED providers may feel pressured to comply with performance measures for CAP, promoting the overuse of inappropriate diagnostic tests and treatments. For instance, efforts to comply with early antibiotic administration in patients with CAP have led to an increase in unnecessary antibiotic use among patients with a diagnosis other than CAP.[14] Due to concerns for these unintended consequences, the core measure for early antibiotic administration was effectively retired in 2012.

Although a smaller percentage of ED visits for respiratory symptoms had a blood culture collected compared to CAP visits, there was a similar absolute number of visits with a blood culture collected during the study period. While a fraction of these patients may present with an infectious etiology aside from pneumonia, the majority of these cases likely represent situations where blood cultures add little diagnostic value at the expense of potentially longer hospital stays and broad spectrum antimicrobial use due to false‐positive results,[5, 15] as well as higher costs incurred by the test itself.[15, 16]

Although recommendations for routine culture collection for all patients hospitalized with CAP have been revised, the JCAHO/CMS core measure (PN‐3b) announced in 2002 mandates that if a culture is collected in the ED, it should be collected prior to antibiotic administration. Due to inherent uncertainty and challenges in making a timely diagnosis of pneumonia, this measure may encourage providers to reflexively order cultures in all patients presenting with respiratory symptoms in whom antibiotic administration is anticipated. The observed increasing trend in culture collection in patients hospitalized with respiratory symptoms due to a nonpneumonia illness should prompt JCAHO and CMS to reevaluate the risks and benefits of this core measure, with consideration of eliminating it altogether to discourage overuse in this population.

Our study had certain limitations. First, the omission of 2005 and 2006 data prohibited an evaluation of whether culture rates slowed down among patients hospitalized with respiratory symptoms due to a nonpneumonia illness after revisions in recommendations for obtaining cultures in patients with CAP. Second, there may have been misclassification of culture collection due to errors in chart abstraction. However, abstraction errors in the NHAMCS typically result in undercoding.[17] Therefore, our findings likely underestimate the magnitude and frequency of culture collection in this population.

In conclusion, collecting blood cultures in the ED for patients hospitalized with respiratory symptoms due to a nonpneumonia illness has increased in a parallel fashion compared to the trend in culture collection in patients hospitalized with CAP from 2002 to 2010. This suggests an important potential unintended consequence of blood culture recommendations for CAP on patients who present with conditions that resemble pneumonia. More attention to the judicious use of blood cultures in these patients to reduce harm and costs is needed.

In 2002, based on consensus practice guidelines,[1] the Centers for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) announced a core measure mandating the collection of routine blood cultures in the emergency department (ED) for all patients hospitalized with community‐acquired pneumonia (CAP) to benchmark the quality of hospital care. However, due to the limited utility and false‐positive results of routine blood cultures,[2, 3, 4, 5, 6] performance measures and practice guidelines were modified in 2005 and 2007, respectively, to recommend routine collection in only the sickest patients with CAP.[2, 7] Despite recommendations for a more narrow set of indications, the collection of blood cultures in patients hospitalized with CAP continued to increase.[8]

Distinguishing CAP from other respiratory illnesses may be challenging. Among patients presenting to the ED with an acute respiratory illness, only a minority of patients (10%30%) are diagnosed with pneumonia.[9] Therefore, the harms and costs of inappropriate diagnostic tests for CAP may be further magnified if applied to a larger population of patients who present to the ED with similar clinical signs and symptoms as pneumonia. Using a national sample of ED visits, we examined whether there was a similar increase in the frequency of blood culture collection among patients who were hospitalized with respiratory symptoms due to an illness other than pneumonia.

METHOD

RESULTS

This study included 4854 ED visits, representing approximately 17 million visits by adult patients hospitalized with respiratory symptoms due to a nonpneumonia illness. The most common primary ED provider's diagnoses for these visits included heart failure (15.9%), chronic obstructive pulmonary disease (12.6%), chest pain (11.9%), respiratory insufficiency or failure (8.8%), and asthma (5.5%). The characteristics of these visits are shown in Table 1.

The proportion of blood cultures collected in the ED for patients hospitalized with respiratory symptoms due to a nonpneumonia illness increased from 9.9% (95% confidence interval [CI]: 7.1%‐13.5%) in 2002 to 20.4% (95% CI: 16.1%‐25.6%) in 2010 (P<0.001 for the trend). This observed increase paralleled the increase in the frequency of culture collection in patients hospitalized with CAP (P=0.12 for the difference in temporal trends). The estimated absolute number of visits for respiratory symptoms due a nonpneumonia illness with a blood culture collected increased from 211,000 (95% CI: 126,000296,000) in 2002 to 526,000 (95% CI: 361,000692,000) in 2010, which was similar in magnitude to the estimated number of visits for CAP with a culture collected (Table 2).

DISCUSSION

In this national study of ED visits, we found that the collection of blood cultures in patients hospitalized with respiratory symptoms due to an illness other than pneumonia continued to increase from 2002 to 2010 in a parallel fashion to the trend observed for patients hospitalized with CAP. Our findings suggest that the heightened attention of collecting blood cultures for suspected pneumonia had unintended consequences, which led to an increase in the collection of blood cultures in patients hospitalized with conditions that mimic pneumonia in the ED.

There can be a great deal of diagnostic uncertainty when treating patients in the ED who present with acute respiratory symptoms. Unfortunately, the initial history and physical exam are often insufficient to effectively rule in CAP.[13] Furthermore, the challenge of diagnosing pneumonia is amplified in the subset of patients who present with evolving, atypical, or occult disease. Faced with this diagnostic uncertainty, ED providers may feel pressured to comply with performance measures for CAP, promoting the overuse of inappropriate diagnostic tests and treatments. For instance, efforts to comply with early antibiotic administration in patients with CAP have led to an increase in unnecessary antibiotic use among patients with a diagnosis other than CAP.[14] Due to concerns for these unintended consequences, the core measure for early antibiotic administration was effectively retired in 2012.

Although a smaller percentage of ED visits for respiratory symptoms had a blood culture collected compared to CAP visits, there was a similar absolute number of visits with a blood culture collected during the study period. While a fraction of these patients may present with an infectious etiology aside from pneumonia, the majority of these cases likely represent situations where blood cultures add little diagnostic value at the expense of potentially longer hospital stays and broad spectrum antimicrobial use due to false‐positive results,[5, 15] as well as higher costs incurred by the test itself.[15, 16]

Although recommendations for routine culture collection for all patients hospitalized with CAP have been revised, the JCAHO/CMS core measure (PN‐3b) announced in 2002 mandates that if a culture is collected in the ED, it should be collected prior to antibiotic administration. Due to inherent uncertainty and challenges in making a timely diagnosis of pneumonia, this measure may encourage providers to reflexively order cultures in all patients presenting with respiratory symptoms in whom antibiotic administration is anticipated. The observed increasing trend in culture collection in patients hospitalized with respiratory symptoms due to a nonpneumonia illness should prompt JCAHO and CMS to reevaluate the risks and benefits of this core measure, with consideration of eliminating it altogether to discourage overuse in this population.

Our study had certain limitations. First, the omission of 2005 and 2006 data prohibited an evaluation of whether culture rates slowed down among patients hospitalized with respiratory symptoms due to a nonpneumonia illness after revisions in recommendations for obtaining cultures in patients with CAP. Second, there may have been misclassification of culture collection due to errors in chart abstraction. However, abstraction errors in the NHAMCS typically result in undercoding.[17] Therefore, our findings likely underestimate the magnitude and frequency of culture collection in this population.

In conclusion, collecting blood cultures in the ED for patients hospitalized with respiratory symptoms due to a nonpneumonia illness has increased in a parallel fashion compared to the trend in culture collection in patients hospitalized with CAP from 2002 to 2010. This suggests an important potential unintended consequence of blood culture recommendations for CAP on patients who present with conditions that resemble pneumonia. More attention to the judicious use of blood cultures in these patients to reduce harm and costs is needed.