Jane Jerrard

Within hospital medicine lives a small subspecialty that addresses a specific and real need in today’s hospitals: psychiatric hospitalists. These physicians provide medical and psychiatric care to hospitalized patients, negating the need for a referral to a psychiatrist.

“There’s little or no compensation for a psychiatrist consultation on a medical patient, so they don’t want to do it,” says Robert P. Albanese, MD, associate professor of psychiatry and medicine at Medical University of South Carolina (MUSC) in Charleston. A psychiatric hospitalist can diagnose and treat medical conditions as well as often overlooked or untreated conditions, such as schizophrenia, major depression, and delirium, as well as substance abuse issues.

Many hospitalized patients with these problems are either on Medicare or uninsured; some are homeless. Because these patients seek emergency care for advanced diseases, general hospitalists are likely to treat their medical problems.

A small percentage of medical facilities across the U.S. have hired psychiatric hospitalists to screen patients, provide psychiatric consults, and take pressure off other hospital staff, including general hospitalists. This summer, St. Luke’s Episcopal Hospital in Houston added a psychiatric hospitalist to its team of five hospitalists and plans to hire a second.

While the job market for psychiatric hospitalists will never come close to the meteoric rise in general hospitalist positions, Dr. Albanese says: “I think we’re on the threshold of some growth. We’ll see more small, community-based hospitals starting psychiatric programs.”

Built-In Roadblocks

Psychiatric hospitalists are limited partly because hospitals don’t have the patient load to necessitate hiring them.

“Back in the ’50s, there were around 650,000 hospital beds for patients with mental illness,” says Dr. Albanese. “Today, it’s estimated that there are between 25,000 and 45,000, according to the National Alliance on Mental Illness [NAMI].”

That drastic reduction is in state psychiatric facilities. Across the U.S., state budget cuts have resulted in mass closings of public psychiatric hospitals over the past 40 years—and the so-called “deinstitutionalization” of patients—while remaining state facilities have suffered significant cuts in funding. According to NAMI, there were 50,000 mentally ill homeless people in California because of deinstitutionalization between 1957 and 1988.

“There’s not a lot out there on psychiatric hospitalists because there aren’t many beds—they’ve kicked out [the patients],” explains Dr. Albanese. “Time’s arrow points to no major increase in the number of beds any time soon. This is a big problem everywhere because there are still a lot of psychiatric patients out there.”

Another factor keeping the number of psychiatric hospitalists fairly static is that most psychiatric medical students aren’t interested in inpatient care, says Dr. Albanese.

Dual-Boarded Specialists

According to the Accreditation Council for Graduate Medical Education, 29 universities offer a combined residency program in internal medicine and psychiatry or family medicine and psychiatry. Dr. Albanese’s university, MUSC, is one of them.

“Our focus is on training young physicians who are interested in becoming dual-boarded to work in a psychiatric setting,” he says. “We’re looking at hospital psychiatry as a special area within our expertise.”

MUSC’s program is highly selective. “We have a five-year residency, and we take two medical students each year,” says Dr. Albanese. “I believe that Rush-Presbyterian in Chicago has the largest program. They take four students per year.”

Despite the lack of beds for mentally ill patients, Dr. Albanese hopes for more psychiatric hospitalists to address those patients’ needs.

“These patients have such a shortened life expectancy, I think there will be increased focus on meeting their needs,” he says. He points to an article in USA Today from May 3, “Mentally ill die 25 year earlier on average,” that documented the trend. TH

Jane Jerrard is a frequent contributor to The Hospitalist.

Within hospital medicine lives a small subspecialty that addresses a specific and real need in today’s hospitals: psychiatric hospitalists. These physicians provide medical and psychiatric care to hospitalized patients, negating the need for a referral to a psychiatrist.

“There’s little or no compensation for a psychiatrist consultation on a medical patient, so they don’t want to do it,” says Robert P. Albanese, MD, associate professor of psychiatry and medicine at Medical University of South Carolina (MUSC) in Charleston. A psychiatric hospitalist can diagnose and treat medical conditions as well as often overlooked or untreated conditions, such as schizophrenia, major depression, and delirium, as well as substance abuse issues.

Many hospitalized patients with these problems are either on Medicare or uninsured; some are homeless. Because these patients seek emergency care for advanced diseases, general hospitalists are likely to treat their medical problems.

A small percentage of medical facilities across the U.S. have hired psychiatric hospitalists to screen patients, provide psychiatric consults, and take pressure off other hospital staff, including general hospitalists. This summer, St. Luke’s Episcopal Hospital in Houston added a psychiatric hospitalist to its team of five hospitalists and plans to hire a second.

While the job market for psychiatric hospitalists will never come close to the meteoric rise in general hospitalist positions, Dr. Albanese says: “I think we’re on the threshold of some growth. We’ll see more small, community-based hospitals starting psychiatric programs.”

Built-In Roadblocks

Psychiatric hospitalists are limited partly because hospitals don’t have the patient load to necessitate hiring them.

“Back in the ’50s, there were around 650,000 hospital beds for patients with mental illness,” says Dr. Albanese. “Today, it’s estimated that there are between 25,000 and 45,000, according to the National Alliance on Mental Illness [NAMI].”

That drastic reduction is in state psychiatric facilities. Across the U.S., state budget cuts have resulted in mass closings of public psychiatric hospitals over the past 40 years—and the so-called “deinstitutionalization” of patients—while remaining state facilities have suffered significant cuts in funding. According to NAMI, there were 50,000 mentally ill homeless people in California because of deinstitutionalization between 1957 and 1988.

“There’s not a lot out there on psychiatric hospitalists because there aren’t many beds—they’ve kicked out [the patients],” explains Dr. Albanese. “Time’s arrow points to no major increase in the number of beds any time soon. This is a big problem everywhere because there are still a lot of psychiatric patients out there.”

Another factor keeping the number of psychiatric hospitalists fairly static is that most psychiatric medical students aren’t interested in inpatient care, says Dr. Albanese.

Dual-Boarded Specialists

According to the Accreditation Council for Graduate Medical Education, 29 universities offer a combined residency program in internal medicine and psychiatry or family medicine and psychiatry. Dr. Albanese’s university, MUSC, is one of them.

“Our focus is on training young physicians who are interested in becoming dual-boarded to work in a psychiatric setting,” he says. “We’re looking at hospital psychiatry as a special area within our expertise.”

MUSC’s program is highly selective. “We have a five-year residency, and we take two medical students each year,” says Dr. Albanese. “I believe that Rush-Presbyterian in Chicago has the largest program. They take four students per year.”

Despite the lack of beds for mentally ill patients, Dr. Albanese hopes for more psychiatric hospitalists to address those patients’ needs.

“These patients have such a shortened life expectancy, I think there will be increased focus on meeting their needs,” he says. He points to an article in USA Today from May 3, “Mentally ill die 25 year earlier on average,” that documented the trend. TH

Jane Jerrard is a frequent contributor to The Hospitalist.

Within hospital medicine lives a small subspecialty that addresses a specific and real need in today’s hospitals: psychiatric hospitalists. These physicians provide medical and psychiatric care to hospitalized patients, negating the need for a referral to a psychiatrist.

“There’s little or no compensation for a psychiatrist consultation on a medical patient, so they don’t want to do it,” says Robert P. Albanese, MD, associate professor of psychiatry and medicine at Medical University of South Carolina (MUSC) in Charleston. A psychiatric hospitalist can diagnose and treat medical conditions as well as often overlooked or untreated conditions, such as schizophrenia, major depression, and delirium, as well as substance abuse issues.

Many hospitalized patients with these problems are either on Medicare or uninsured; some are homeless. Because these patients seek emergency care for advanced diseases, general hospitalists are likely to treat their medical problems.

A small percentage of medical facilities across the U.S. have hired psychiatric hospitalists to screen patients, provide psychiatric consults, and take pressure off other hospital staff, including general hospitalists. This summer, St. Luke’s Episcopal Hospital in Houston added a psychiatric hospitalist to its team of five hospitalists and plans to hire a second.

While the job market for psychiatric hospitalists will never come close to the meteoric rise in general hospitalist positions, Dr. Albanese says: “I think we’re on the threshold of some growth. We’ll see more small, community-based hospitals starting psychiatric programs.”

Built-In Roadblocks

Psychiatric hospitalists are limited partly because hospitals don’t have the patient load to necessitate hiring them.

“Back in the ’50s, there were around 650,000 hospital beds for patients with mental illness,” says Dr. Albanese. “Today, it’s estimated that there are between 25,000 and 45,000, according to the National Alliance on Mental Illness [NAMI].”

That drastic reduction is in state psychiatric facilities. Across the U.S., state budget cuts have resulted in mass closings of public psychiatric hospitals over the past 40 years—and the so-called “deinstitutionalization” of patients—while remaining state facilities have suffered significant cuts in funding. According to NAMI, there were 50,000 mentally ill homeless people in California because of deinstitutionalization between 1957 and 1988.

“There’s not a lot out there on psychiatric hospitalists because there aren’t many beds—they’ve kicked out [the patients],” explains Dr. Albanese. “Time’s arrow points to no major increase in the number of beds any time soon. This is a big problem everywhere because there are still a lot of psychiatric patients out there.”

Another factor keeping the number of psychiatric hospitalists fairly static is that most psychiatric medical students aren’t interested in inpatient care, says Dr. Albanese.

Dual-Boarded Specialists

According to the Accreditation Council for Graduate Medical Education, 29 universities offer a combined residency program in internal medicine and psychiatry or family medicine and psychiatry. Dr. Albanese’s university, MUSC, is one of them.

“Our focus is on training young physicians who are interested in becoming dual-boarded to work in a psychiatric setting,” he says. “We’re looking at hospital psychiatry as a special area within our expertise.”

MUSC’s program is highly selective. “We have a five-year residency, and we take two medical students each year,” says Dr. Albanese. “I believe that Rush-Presbyterian in Chicago has the largest program. They take four students per year.”

Despite the lack of beds for mentally ill patients, Dr. Albanese hopes for more psychiatric hospitalists to address those patients’ needs.

“These patients have such a shortened life expectancy, I think there will be increased focus on meeting their needs,” he says. He points to an article in USA Today from May 3, “Mentally ill die 25 year earlier on average,” that documented the trend. TH

Jane Jerrard is a frequent contributor to The Hospitalist.

A new concept on Capitol Hill could reshape physicians’ treatment choices: comparative effectiveness research, or CER.

CER is a set of standards for examining the effectiveness of different therapies for a specific medical condition or set of patients to determine the best option. It may involve comparing competing medications or analyzing treatment approaches, such as surgery, devices, and drug therapies.

The healthcare community—and Capitol Hill—should keep an eye on CER.

“We need to look at evidence-based medicine and see what is the most effective treatment,” says Andrew Fishmann, MD, FCCP, FACP, co-founder of Cogent Healthcare and director of intensive care at Good Samaritan Hospital in Los Angeles. “The answer may also be the most expensive, but other factors such as decreased length of stay and fewer complications can help bring that cost down.”

One example that CER might address is back surgery—an issue many physicians cannot agree on. “There are billions of dollars spent on back surgery that may not be necessary,” Dr. Fishmann points out.

CER could ultimately provide guidelines that would standardize treatments for all types of conditions: “A big organization like Cogent would like to think that a patient with pneumonia receives the same treatment whether he’s in California or in Mississippi—but there are many reasons this is probably not true,” says Dr. Fishmann.

CER So Far

The Medicare Modernization Act of 2003 gave CER a jumpstart with $65 million in appropriations and authorized the Agency for Healthcare Research and Quality (AHRQ) to conduct research.

“Since 2004, [the AHRQ has] received $15 million a year for CER,” says Emily Rowe, director of government relations for the Coalition for Health Services Research in Washington, D.C., and a member of the Friends of AHRQ coalition. “They’re pretty limited in what they can produce on that budget, but to date they’ve done some interesting work.”

That work includes eight published reports on treatment options for breast cancer, gastroesophageal reflux disease (GERD), cancer-related anemia, low-bone density, depression, and more, with 20 additional reports “in the pipeline,” says Rowe.

All available reports can be downloaded from http://effectivehealthcare. ahrq.gov, where results have been published in separate versions for physicians and consumers.

“The most interesting example of [CER from AHRQ] is synthesized research that shows that drugs can be as effective as surgery for severe heart burn,” or GERD, says Rowe. “This shows the promise of CER.”

So AHRQ is at work on CER projects but, says Rowe, “It needs a more serious investment.” Some in Congress agree.

New Laws, More Money

The Enhanced Health Care Value for All Act of 2007 (HR 2184) was introduced by Reps. Tom Allen, D-Maine, and Jo Ann Emerson, R-Mo, in May. This bill would provide $3 billion over five years to fund CER.

Under the legislation, the AHRQ would remain the federal agency charged with supporting CER, but a new comparative effectiveness advisory board would be established, comprising employers, consumers, healthcare providers, researchers, and others. The board would offer advice on research priorities and methodologies.

Some, including the Blue Cross Blue Shield Association (BCBSA), have called for a new executive-branch agency or a new coalition to oversee CER. Dr. Fishmann, who is serving a second term on the National Advisory Council for AHRQ, strongly disagrees. “This is evidence-based medicine,” he stresses. “AHRQ is the perfect entity for this. What an organization like AHRQ will do is look at everything and address the issue impartially.”

Quality, Costs, Results

Congress views CER as a means of saving costs in healthcare, but CER would not provide immediate savings; rather, it’s a first step toward lowering healthcare costs. In fact, House Ways and Means Subcommittee Chairman Pete Stark, R-Calif., expressed concern about “moving” CER legislation this year, because it would require immediate investment without immediate savings.

“I don’t know where you come up with that money when everyone else in healthcare is fighting for more funds,” Dr. Fishmann says of the current legislation. “But Congress can come up with the funds if they want to.”

Rowe won’t speculate on whether the House bill will pass but does say: “The appropriators and budgeters are getting ready to fund this, so that if the legislation passes the money will be there. And interest in CER is gaining in both parties of Congress.”

While legislators focus on costs and savings, healthcare professionals are interested in improving quality.

“It is a quality issue, but a better term is value,” says Rowe. “The idea is, ‘Let’s get what we pay for.’ The U.S. needs better medical outcomes, and the idea of CER is not what treatments costs less but that it’s worth it if you have to spend more if the outcomes are improved.”

And Dr. Fishmann thinks CER will change how we provide care. “It’s going to standardize the delivery of healthcare,” he predicts. “If you don’t follow these standards, someone is going to ask why not—it might be the payer, your colleagues, your hospital.” Once CER reports are available and shared with the public, he points out, “as patients get educated, and payers too, they’ll stop paying for treatments that go against the standard.”

Hospitalists and CER

How will comparative effectiveness affect hospital medicine?

“They’re looking at ischemic heart disease, pneumonia, diabetes, stroke—all hospitalized diseases,” says Dr. Fishmann of current CER projects. “Right now, everyone is practicing their trade, and everyone is doing things differently. I think in terms of hospitalists, it clearly will affect how you treat patients, and for how long.”

Regardless of the current House bill, it seems CER is on the horizon, for hospitalists and for all of healthcare.

“The good news is, I don’t think this is going away any time soon,” says Rowe of CER. “The train has left the station and it’s steaming away.” TH

A new concept on Capitol Hill could reshape physicians’ treatment choices: comparative effectiveness research, or CER.

CER is a set of standards for examining the effectiveness of different therapies for a specific medical condition or set of patients to determine the best option. It may involve comparing competing medications or analyzing treatment approaches, such as surgery, devices, and drug therapies.

The healthcare community—and Capitol Hill—should keep an eye on CER.

“We need to look at evidence-based medicine and see what is the most effective treatment,” says Andrew Fishmann, MD, FCCP, FACP, co-founder of Cogent Healthcare and director of intensive care at Good Samaritan Hospital in Los Angeles. “The answer may also be the most expensive, but other factors such as decreased length of stay and fewer complications can help bring that cost down.”

One example that CER might address is back surgery—an issue many physicians cannot agree on. “There are billions of dollars spent on back surgery that may not be necessary,” Dr. Fishmann points out.

CER could ultimately provide guidelines that would standardize treatments for all types of conditions: “A big organization like Cogent would like to think that a patient with pneumonia receives the same treatment whether he’s in California or in Mississippi—but there are many reasons this is probably not true,” says Dr. Fishmann.

CER So Far

The Medicare Modernization Act of 2003 gave CER a jumpstart with $65 million in appropriations and authorized the Agency for Healthcare Research and Quality (AHRQ) to conduct research.

“Since 2004, [the AHRQ has] received $15 million a year for CER,” says Emily Rowe, director of government relations for the Coalition for Health Services Research in Washington, D.C., and a member of the Friends of AHRQ coalition. “They’re pretty limited in what they can produce on that budget, but to date they’ve done some interesting work.”

That work includes eight published reports on treatment options for breast cancer, gastroesophageal reflux disease (GERD), cancer-related anemia, low-bone density, depression, and more, with 20 additional reports “in the pipeline,” says Rowe.

All available reports can be downloaded from http://effectivehealthcare. ahrq.gov, where results have been published in separate versions for physicians and consumers.

“The most interesting example of [CER from AHRQ] is synthesized research that shows that drugs can be as effective as surgery for severe heart burn,” or GERD, says Rowe. “This shows the promise of CER.”

So AHRQ is at work on CER projects but, says Rowe, “It needs a more serious investment.” Some in Congress agree.

New Laws, More Money

The Enhanced Health Care Value for All Act of 2007 (HR 2184) was introduced by Reps. Tom Allen, D-Maine, and Jo Ann Emerson, R-Mo, in May. This bill would provide $3 billion over five years to fund CER.

Under the legislation, the AHRQ would remain the federal agency charged with supporting CER, but a new comparative effectiveness advisory board would be established, comprising employers, consumers, healthcare providers, researchers, and others. The board would offer advice on research priorities and methodologies.

Some, including the Blue Cross Blue Shield Association (BCBSA), have called for a new executive-branch agency or a new coalition to oversee CER. Dr. Fishmann, who is serving a second term on the National Advisory Council for AHRQ, strongly disagrees. “This is evidence-based medicine,” he stresses. “AHRQ is the perfect entity for this. What an organization like AHRQ will do is look at everything and address the issue impartially.”

Quality, Costs, Results

Congress views CER as a means of saving costs in healthcare, but CER would not provide immediate savings; rather, it’s a first step toward lowering healthcare costs. In fact, House Ways and Means Subcommittee Chairman Pete Stark, R-Calif., expressed concern about “moving” CER legislation this year, because it would require immediate investment without immediate savings.

“I don’t know where you come up with that money when everyone else in healthcare is fighting for more funds,” Dr. Fishmann says of the current legislation. “But Congress can come up with the funds if they want to.”

Rowe won’t speculate on whether the House bill will pass but does say: “The appropriators and budgeters are getting ready to fund this, so that if the legislation passes the money will be there. And interest in CER is gaining in both parties of Congress.”

While legislators focus on costs and savings, healthcare professionals are interested in improving quality.

“It is a quality issue, but a better term is value,” says Rowe. “The idea is, ‘Let’s get what we pay for.’ The U.S. needs better medical outcomes, and the idea of CER is not what treatments costs less but that it’s worth it if you have to spend more if the outcomes are improved.”

And Dr. Fishmann thinks CER will change how we provide care. “It’s going to standardize the delivery of healthcare,” he predicts. “If you don’t follow these standards, someone is going to ask why not—it might be the payer, your colleagues, your hospital.” Once CER reports are available and shared with the public, he points out, “as patients get educated, and payers too, they’ll stop paying for treatments that go against the standard.”

Hospitalists and CER

How will comparative effectiveness affect hospital medicine?

“They’re looking at ischemic heart disease, pneumonia, diabetes, stroke—all hospitalized diseases,” says Dr. Fishmann of current CER projects. “Right now, everyone is practicing their trade, and everyone is doing things differently. I think in terms of hospitalists, it clearly will affect how you treat patients, and for how long.”

Regardless of the current House bill, it seems CER is on the horizon, for hospitalists and for all of healthcare.

“The good news is, I don’t think this is going away any time soon,” says Rowe of CER. “The train has left the station and it’s steaming away.” TH

A new concept on Capitol Hill could reshape physicians’ treatment choices: comparative effectiveness research, or CER.

CER is a set of standards for examining the effectiveness of different therapies for a specific medical condition or set of patients to determine the best option. It may involve comparing competing medications or analyzing treatment approaches, such as surgery, devices, and drug therapies.

The healthcare community—and Capitol Hill—should keep an eye on CER.

“We need to look at evidence-based medicine and see what is the most effective treatment,” says Andrew Fishmann, MD, FCCP, FACP, co-founder of Cogent Healthcare and director of intensive care at Good Samaritan Hospital in Los Angeles. “The answer may also be the most expensive, but other factors such as decreased length of stay and fewer complications can help bring that cost down.”

One example that CER might address is back surgery—an issue many physicians cannot agree on. “There are billions of dollars spent on back surgery that may not be necessary,” Dr. Fishmann points out.

CER could ultimately provide guidelines that would standardize treatments for all types of conditions: “A big organization like Cogent would like to think that a patient with pneumonia receives the same treatment whether he’s in California or in Mississippi—but there are many reasons this is probably not true,” says Dr. Fishmann.

CER So Far

The Medicare Modernization Act of 2003 gave CER a jumpstart with $65 million in appropriations and authorized the Agency for Healthcare Research and Quality (AHRQ) to conduct research.

“Since 2004, [the AHRQ has] received $15 million a year for CER,” says Emily Rowe, director of government relations for the Coalition for Health Services Research in Washington, D.C., and a member of the Friends of AHRQ coalition. “They’re pretty limited in what they can produce on that budget, but to date they’ve done some interesting work.”

That work includes eight published reports on treatment options for breast cancer, gastroesophageal reflux disease (GERD), cancer-related anemia, low-bone density, depression, and more, with 20 additional reports “in the pipeline,” says Rowe.

All available reports can be downloaded from http://effectivehealthcare. ahrq.gov, where results have been published in separate versions for physicians and consumers.

“The most interesting example of [CER from AHRQ] is synthesized research that shows that drugs can be as effective as surgery for severe heart burn,” or GERD, says Rowe. “This shows the promise of CER.”

So AHRQ is at work on CER projects but, says Rowe, “It needs a more serious investment.” Some in Congress agree.

New Laws, More Money

The Enhanced Health Care Value for All Act of 2007 (HR 2184) was introduced by Reps. Tom Allen, D-Maine, and Jo Ann Emerson, R-Mo, in May. This bill would provide $3 billion over five years to fund CER.

Under the legislation, the AHRQ would remain the federal agency charged with supporting CER, but a new comparative effectiveness advisory board would be established, comprising employers, consumers, healthcare providers, researchers, and others. The board would offer advice on research priorities and methodologies.

Some, including the Blue Cross Blue Shield Association (BCBSA), have called for a new executive-branch agency or a new coalition to oversee CER. Dr. Fishmann, who is serving a second term on the National Advisory Council for AHRQ, strongly disagrees. “This is evidence-based medicine,” he stresses. “AHRQ is the perfect entity for this. What an organization like AHRQ will do is look at everything and address the issue impartially.”

Quality, Costs, Results

Congress views CER as a means of saving costs in healthcare, but CER would not provide immediate savings; rather, it’s a first step toward lowering healthcare costs. In fact, House Ways and Means Subcommittee Chairman Pete Stark, R-Calif., expressed concern about “moving” CER legislation this year, because it would require immediate investment without immediate savings.

“I don’t know where you come up with that money when everyone else in healthcare is fighting for more funds,” Dr. Fishmann says of the current legislation. “But Congress can come up with the funds if they want to.”

Rowe won’t speculate on whether the House bill will pass but does say: “The appropriators and budgeters are getting ready to fund this, so that if the legislation passes the money will be there. And interest in CER is gaining in both parties of Congress.”

While legislators focus on costs and savings, healthcare professionals are interested in improving quality.

“It is a quality issue, but a better term is value,” says Rowe. “The idea is, ‘Let’s get what we pay for.’ The U.S. needs better medical outcomes, and the idea of CER is not what treatments costs less but that it’s worth it if you have to spend more if the outcomes are improved.”

And Dr. Fishmann thinks CER will change how we provide care. “It’s going to standardize the delivery of healthcare,” he predicts. “If you don’t follow these standards, someone is going to ask why not—it might be the payer, your colleagues, your hospital.” Once CER reports are available and shared with the public, he points out, “as patients get educated, and payers too, they’ll stop paying for treatments that go against the standard.”

Hospitalists and CER

How will comparative effectiveness affect hospital medicine?

“They’re looking at ischemic heart disease, pneumonia, diabetes, stroke—all hospitalized diseases,” says Dr. Fishmann of current CER projects. “Right now, everyone is practicing their trade, and everyone is doing things differently. I think in terms of hospitalists, it clearly will affect how you treat patients, and for how long.”

Regardless of the current House bill, it seems CER is on the horizon, for hospitalists and for all of healthcare.

“The good news is, I don’t think this is going away any time soon,” says Rowe of CER. “The train has left the station and it’s steaming away.” TH

This is the last article in a series on the four pillars of career satisfaction in hospital medicine.

What kind of support do you get from your hospital medicine group? From your hospital? How cohesive is your group? Do these things really matter?

The answers can be found in the SHM white paper “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (available online at www.hospitalmedicine.org). SHM’s Career Satisfaction Task Force (CSTF) drafted the document to be used by hospitalists and hospital medicine practices as a toolkit for ensuring or improving job satisfaction. It outlines the four pillars of career satisfaction: autonomy/control (see the June edition of The Hospitalist, p. 14), workload/ schedule (July edition, p. 10), reward/ recognition (August edition, p. 10), and community/environment. This article looks at the last of these.

The Fourth Pillar

Hospitalists belong, in some sense, to four communities and must address the expectations of each group: administration, referring and nonreferring physicians, house staff and other healthcare staff, and medical students.

The hospitalist’s community includes his/her practice as well as hospitalists from other groups. The patient community is not just patients and their family members, but the broader public community served by the hospital medicine group and the hospital. The home community, consisting of the hospitalist’s family and friends, is also a vital part of the individual’s environment.

Each of these communities contributes to job satisfaction. A sense of shared values and connection with others, as well as social and work support, can ensure satisfaction; a sense of isolation, lack of support, and unresolved conflict can lead to unhappiness with a job.

Working within a strong community “makes everything else easier,” says CSTF member Noah Harris, MD, a hospitalist at Presbyterian Hospital, Albuquerque, N.M.

“Twenty years ago, there was a medical community in hospitals where physicians came together,” recalls Dr. Harris. “With managed care, physicians have become much less invested in the hospital and you see fewer [primary care] physicians there. Hospitalists have filled that gap. The question is how to restructure the hospital medical community.”

A hospitalist might struggle with the issue this way:

“I’m one of only three hospitalists at a hospital in a rural community. I feel it’s important to work as a team with primary care physicians, the emergency department, and other medical subspecialists.”

“How do hospitalists come in as the new kid on the block and reach out to other physicians?” asks Dr. Harris. “This is important, and if hospitalists feel like they’re more a part of the community, then that makes [their work] easier.”

According to Dr. Harris, the key to building a community in your workplace is communication. Strengthen it or establish it where there is none. When you communicate, focus on common goals with the other parties.

“Community has to do with shared expectations,” Dr. Harris points out. “Everyone—particularly the various types of physicians in the hospital—has to know what they expect from hospitalists.” It may be up to individual hospitalists to educate others as to what those expectations should be.

Of course, communication should start at the top. “On one level, there has to be formal communication with administrators and [physician leaders],” says Dr. Harris. “There has to be some sort of ongoing communication with the hospital administrators because they work with all the other groups as well.”

However, less formal communication is up to the hospitalist. The more you communicate with others, the more you’ll build your community.

Here are tips for how the hospitalist in the aforementioned example might work with each group of physicians:

ED doctors: “This hospitalist needs to get to know the other physicians and healthcare professionals,” Dr. Harris advises. “Make yourself available. When you have a minute, go down to the emergency department to update the ED physicians on admissions they’ve seen. Make a point to chat.”

Primary care physicians (PCPs): It may be more difficult to initiate informal communications with these docs if they’re not often in the hospital.

“One thing that helps is for the hospitalist to focus on communicating by phone, fax, or e-mail to PCPs when their patients are in the hospital,” says Dr. Harris. “In our office, we assigned a secretary to make sure PCPs get discharge summaries. That really helped with the community.”

If you want to strengthen ties to your community PCPs, issue an invitation to an event. “Our group would have an annual holiday party and invite all our referring physicians,” says Dr. Harris. “We’d have a speaker and get to know each other a little better.”

Surgeons: Dr. Harris suggests hospitalists can guide surgeons’ expectations for their working relationship with you and strengthen a sense of community.

“If there’s a particular issue, you can use that,” says Dr. Harris. “We were seeing a lot of elderly patients admitted with hip fractures. One thing we did to get a working relationship [with orthopedic surgeons] is we came up with a set of orders for these patients. The surgeons welcomed this because they wanted help with elderly patients who had multiple conditions. This was a way to work with them in a kind of formal way that helps patients. “It’s good to come up with order sets, but the big part of this is the negotiation with the other physicians that leads up to the order sets,” Dr. Harris says.

If you’re doing something like this to help in obstetrics, neurosurgery, or orthopedics, make it a two-way conversation.

“Above all else, it’s important to work with nonphysician healthcare workers,” says Dr. Harris, “especially nurses and physical therapists.”

The Rural Factor

The example above involves a small hospital medicine program in a rural area. Are there built-in problems with building community in this environment?

“I don’t think [it’s] necessarily more difficult” to build community in this setting, says Dr. Harris, “particularly if the hospital and physicians are on board with bringing in hospitalists. They might even be easier because you have fewer folks to deal with.”

But there may be an underlying problem with working at a smaller hospital. “If you’re the only hospitalist, or even the only hospitalist on a given shift, you’re practicing in a vacuum,” says Dr. Harris. If this is the case, you can broaden your hospitalist community by establishing a network with nearby hospitals and/or hospital medicine groups, and by becoming active in a regional or national group. TH

This is the last article in a series on the four pillars of career satisfaction in hospital medicine.

What kind of support do you get from your hospital medicine group? From your hospital? How cohesive is your group? Do these things really matter?

The answers can be found in the SHM white paper “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (available online at www.hospitalmedicine.org). SHM’s Career Satisfaction Task Force (CSTF) drafted the document to be used by hospitalists and hospital medicine practices as a toolkit for ensuring or improving job satisfaction. It outlines the four pillars of career satisfaction: autonomy/control (see the June edition of The Hospitalist, p. 14), workload/ schedule (July edition, p. 10), reward/ recognition (August edition, p. 10), and community/environment. This article looks at the last of these.

The Fourth Pillar

Hospitalists belong, in some sense, to four communities and must address the expectations of each group: administration, referring and nonreferring physicians, house staff and other healthcare staff, and medical students.

The hospitalist’s community includes his/her practice as well as hospitalists from other groups. The patient community is not just patients and their family members, but the broader public community served by the hospital medicine group and the hospital. The home community, consisting of the hospitalist’s family and friends, is also a vital part of the individual’s environment.

Each of these communities contributes to job satisfaction. A sense of shared values and connection with others, as well as social and work support, can ensure satisfaction; a sense of isolation, lack of support, and unresolved conflict can lead to unhappiness with a job.

Working within a strong community “makes everything else easier,” says CSTF member Noah Harris, MD, a hospitalist at Presbyterian Hospital, Albuquerque, N.M.

“Twenty years ago, there was a medical community in hospitals where physicians came together,” recalls Dr. Harris. “With managed care, physicians have become much less invested in the hospital and you see fewer [primary care] physicians there. Hospitalists have filled that gap. The question is how to restructure the hospital medical community.”

A hospitalist might struggle with the issue this way:

“I’m one of only three hospitalists at a hospital in a rural community. I feel it’s important to work as a team with primary care physicians, the emergency department, and other medical subspecialists.”

“How do hospitalists come in as the new kid on the block and reach out to other physicians?” asks Dr. Harris. “This is important, and if hospitalists feel like they’re more a part of the community, then that makes [their work] easier.”

According to Dr. Harris, the key to building a community in your workplace is communication. Strengthen it or establish it where there is none. When you communicate, focus on common goals with the other parties.

“Community has to do with shared expectations,” Dr. Harris points out. “Everyone—particularly the various types of physicians in the hospital—has to know what they expect from hospitalists.” It may be up to individual hospitalists to educate others as to what those expectations should be.

Of course, communication should start at the top. “On one level, there has to be formal communication with administrators and [physician leaders],” says Dr. Harris. “There has to be some sort of ongoing communication with the hospital administrators because they work with all the other groups as well.”

However, less formal communication is up to the hospitalist. The more you communicate with others, the more you’ll build your community.

Here are tips for how the hospitalist in the aforementioned example might work with each group of physicians:

ED doctors: “This hospitalist needs to get to know the other physicians and healthcare professionals,” Dr. Harris advises. “Make yourself available. When you have a minute, go down to the emergency department to update the ED physicians on admissions they’ve seen. Make a point to chat.”

Primary care physicians (PCPs): It may be more difficult to initiate informal communications with these docs if they’re not often in the hospital.

“One thing that helps is for the hospitalist to focus on communicating by phone, fax, or e-mail to PCPs when their patients are in the hospital,” says Dr. Harris. “In our office, we assigned a secretary to make sure PCPs get discharge summaries. That really helped with the community.”

If you want to strengthen ties to your community PCPs, issue an invitation to an event. “Our group would have an annual holiday party and invite all our referring physicians,” says Dr. Harris. “We’d have a speaker and get to know each other a little better.”

Surgeons: Dr. Harris suggests hospitalists can guide surgeons’ expectations for their working relationship with you and strengthen a sense of community.

“If there’s a particular issue, you can use that,” says Dr. Harris. “We were seeing a lot of elderly patients admitted with hip fractures. One thing we did to get a working relationship [with orthopedic surgeons] is we came up with a set of orders for these patients. The surgeons welcomed this because they wanted help with elderly patients who had multiple conditions. This was a way to work with them in a kind of formal way that helps patients. “It’s good to come up with order sets, but the big part of this is the negotiation with the other physicians that leads up to the order sets,” Dr. Harris says.

If you’re doing something like this to help in obstetrics, neurosurgery, or orthopedics, make it a two-way conversation.

“Above all else, it’s important to work with nonphysician healthcare workers,” says Dr. Harris, “especially nurses and physical therapists.”

The Rural Factor

The example above involves a small hospital medicine program in a rural area. Are there built-in problems with building community in this environment?

“I don’t think [it’s] necessarily more difficult” to build community in this setting, says Dr. Harris, “particularly if the hospital and physicians are on board with bringing in hospitalists. They might even be easier because you have fewer folks to deal with.”

But there may be an underlying problem with working at a smaller hospital. “If you’re the only hospitalist, or even the only hospitalist on a given shift, you’re practicing in a vacuum,” says Dr. Harris. If this is the case, you can broaden your hospitalist community by establishing a network with nearby hospitals and/or hospital medicine groups, and by becoming active in a regional or national group. TH

This is the last article in a series on the four pillars of career satisfaction in hospital medicine.

What kind of support do you get from your hospital medicine group? From your hospital? How cohesive is your group? Do these things really matter?

The answers can be found in the SHM white paper “A Challenge for a New Specialty: A White Paper on Hospitalist Career Satisfaction” (available online at www.hospitalmedicine.org). SHM’s Career Satisfaction Task Force (CSTF) drafted the document to be used by hospitalists and hospital medicine practices as a toolkit for ensuring or improving job satisfaction. It outlines the four pillars of career satisfaction: autonomy/control (see the June edition of The Hospitalist, p. 14), workload/ schedule (July edition, p. 10), reward/ recognition (August edition, p. 10), and community/environment. This article looks at the last of these.

The Fourth Pillar

Hospitalists belong, in some sense, to four communities and must address the expectations of each group: administration, referring and nonreferring physicians, house staff and other healthcare staff, and medical students.

The hospitalist’s community includes his/her practice as well as hospitalists from other groups. The patient community is not just patients and their family members, but the broader public community served by the hospital medicine group and the hospital. The home community, consisting of the hospitalist’s family and friends, is also a vital part of the individual’s environment.

Each of these communities contributes to job satisfaction. A sense of shared values and connection with others, as well as social and work support, can ensure satisfaction; a sense of isolation, lack of support, and unresolved conflict can lead to unhappiness with a job.

Working within a strong community “makes everything else easier,” says CSTF member Noah Harris, MD, a hospitalist at Presbyterian Hospital, Albuquerque, N.M.

“Twenty years ago, there was a medical community in hospitals where physicians came together,” recalls Dr. Harris. “With managed care, physicians have become much less invested in the hospital and you see fewer [primary care] physicians there. Hospitalists have filled that gap. The question is how to restructure the hospital medical community.”

A hospitalist might struggle with the issue this way:

“I’m one of only three hospitalists at a hospital in a rural community. I feel it’s important to work as a team with primary care physicians, the emergency department, and other medical subspecialists.”

“How do hospitalists come in as the new kid on the block and reach out to other physicians?” asks Dr. Harris. “This is important, and if hospitalists feel like they’re more a part of the community, then that makes [their work] easier.”

According to Dr. Harris, the key to building a community in your workplace is communication. Strengthen it or establish it where there is none. When you communicate, focus on common goals with the other parties.

“Community has to do with shared expectations,” Dr. Harris points out. “Everyone—particularly the various types of physicians in the hospital—has to know what they expect from hospitalists.” It may be up to individual hospitalists to educate others as to what those expectations should be.

Of course, communication should start at the top. “On one level, there has to be formal communication with administrators and [physician leaders],” says Dr. Harris. “There has to be some sort of ongoing communication with the hospital administrators because they work with all the other groups as well.”

However, less formal communication is up to the hospitalist. The more you communicate with others, the more you’ll build your community.

Here are tips for how the hospitalist in the aforementioned example might work with each group of physicians:

ED doctors: “This hospitalist needs to get to know the other physicians and healthcare professionals,” Dr. Harris advises. “Make yourself available. When you have a minute, go down to the emergency department to update the ED physicians on admissions they’ve seen. Make a point to chat.”

Primary care physicians (PCPs): It may be more difficult to initiate informal communications with these docs if they’re not often in the hospital.

“One thing that helps is for the hospitalist to focus on communicating by phone, fax, or e-mail to PCPs when their patients are in the hospital,” says Dr. Harris. “In our office, we assigned a secretary to make sure PCPs get discharge summaries. That really helped with the community.”

If you want to strengthen ties to your community PCPs, issue an invitation to an event. “Our group would have an annual holiday party and invite all our referring physicians,” says Dr. Harris. “We’d have a speaker and get to know each other a little better.”

Surgeons: Dr. Harris suggests hospitalists can guide surgeons’ expectations for their working relationship with you and strengthen a sense of community.

“If there’s a particular issue, you can use that,” says Dr. Harris. “We were seeing a lot of elderly patients admitted with hip fractures. One thing we did to get a working relationship [with orthopedic surgeons] is we came up with a set of orders for these patients. The surgeons welcomed this because they wanted help with elderly patients who had multiple conditions. This was a way to work with them in a kind of formal way that helps patients. “It’s good to come up with order sets, but the big part of this is the negotiation with the other physicians that leads up to the order sets,” Dr. Harris says.

If you’re doing something like this to help in obstetrics, neurosurgery, or orthopedics, make it a two-way conversation.

“Above all else, it’s important to work with nonphysician healthcare workers,” says Dr. Harris, “especially nurses and physical therapists.”

The Rural Factor

The example above involves a small hospital medicine program in a rural area. Are there built-in problems with building community in this environment?

“I don’t think [it’s] necessarily more difficult” to build community in this setting, says Dr. Harris, “particularly if the hospital and physicians are on board with bringing in hospitalists. They might even be easier because you have fewer folks to deal with.”

But there may be an underlying problem with working at a smaller hospital. “If you’re the only hospitalist, or even the only hospitalist on a given shift, you’re practicing in a vacuum,” says Dr. Harris. If this is the case, you can broaden your hospitalist community by establishing a network with nearby hospitals and/or hospital medicine groups, and by becoming active in a regional or national group. TH

Dr. Wachter

Anyone who has attended the closing session of an SHM Annual Meeting or read one of his editorial pieces in The Hospitalist or other publications knows that Bob Wachter, MD, sees the world in a unique and uniquely informed way.

This fall, Dr. Wachter—professor and associate chairman of the Department of Medicine at the University of California, San Francisco (UCSF), co-founder of SHM, and the man who coined the term “hospitalist” (along with Lee Goldman, MD)—will regularly share his one-of-a-kind perspective via a Weblog, or blog. Tentatively titled “Wachter’s World,” the hospital medicine blog will debut at www.the-hospitalist.org in time for the “Management of the Hospitalized Patient” session Oct. 4-6 at UCSF. The in-depth course serves as the West Coast regional meeting of SHM.

“Even an old guy like me realizes that blogs are incredibly hot,” says Dr. Wachter. “And as I read more of them and began relying on them more for information and insights, I started looking for one in our field that was lively, engaging and informative, one I’d like to read. I couldn’t find anything, so I thought I should start one.”

When Dr. Wachter approached SHM about hosting his blog, the organization’s leadership was quite interested—especially because SHM was already considering starting its own blog.

“SHM’s audience is perfect for the growing blog medium,” says Larry Wellikson, MD, the CEO of SHM. “We saw this with the enormous response to the SHM blogs at the May 2007 Annual Meeting.”

So “Wachter’s World” will be found on The Hospitalist’s Web site, where Dr. Wachter will post regular updates—he estimates typically three or four times a week.

“SHM’s partnership with Bob Wachter to launch an innovative blog, housed on the Web site for the most widely read publication in hospital medicine, SHM’s The Hospitalist, just makes sense as hospitalists need to hear new ideas and meet the challenge to be the change agents for the hospital of the future,” Dr. Wellikson says. “Wachter has proven himself a nationally sought-after thought leader who has something to say about hospital medicine, patient safety, improving quality, and the future of medicine.”

Dr. Wachter has a unique perspective on, well, everything. His years of experience working in hospital medicine as well as his high-level involvement in shaping the field—such as his position as chair of the American Board of Internal Medicine (ABIM) Committee on Hospital Medicine Focused Recognition—allows him ground-level and big-picture views of issues and trends that affect hospitalists’ work.

He often makes unique connections and forms original opinions on those issues—whether addressing road bumps a hospitalist runs into on the job or policy points that may change that job—and he plans to share those connections and opinions in his blog.

“I want to comment on the confluence of real stuff we all see day to day and the things that influence our field,” Dr. Wachter says. And he certainly has plenty of subjects to cover.

“There are so many issues that cross my retina every day that I think are of interest to hospitalists,” he says. “I see things in context—how they develop and how they all fit together, including trends as they develop. This blog will show my point of view—not on the differences in healthcare policy between Clinton’s camp and Obama’s camp—but closer to the ground. I’ll cover what relates to all of us.” TH

Dr. Wachter

Anyone who has attended the closing session of an SHM Annual Meeting or read one of his editorial pieces in The Hospitalist or other publications knows that Bob Wachter, MD, sees the world in a unique and uniquely informed way.

This fall, Dr. Wachter—professor and associate chairman of the Department of Medicine at the University of California, San Francisco (UCSF), co-founder of SHM, and the man who coined the term “hospitalist” (along with Lee Goldman, MD)—will regularly share his one-of-a-kind perspective via a Weblog, or blog. Tentatively titled “Wachter’s World,” the hospital medicine blog will debut at www.the-hospitalist.org in time for the “Management of the Hospitalized Patient” session Oct. 4-6 at UCSF. The in-depth course serves as the West Coast regional meeting of SHM.

“Even an old guy like me realizes that blogs are incredibly hot,” says Dr. Wachter. “And as I read more of them and began relying on them more for information and insights, I started looking for one in our field that was lively, engaging and informative, one I’d like to read. I couldn’t find anything, so I thought I should start one.”

When Dr. Wachter approached SHM about hosting his blog, the organization’s leadership was quite interested—especially because SHM was already considering starting its own blog.

“SHM’s audience is perfect for the growing blog medium,” says Larry Wellikson, MD, the CEO of SHM. “We saw this with the enormous response to the SHM blogs at the May 2007 Annual Meeting.”

So “Wachter’s World” will be found on The Hospitalist’s Web site, where Dr. Wachter will post regular updates—he estimates typically three or four times a week.

“SHM’s partnership with Bob Wachter to launch an innovative blog, housed on the Web site for the most widely read publication in hospital medicine, SHM’s The Hospitalist, just makes sense as hospitalists need to hear new ideas and meet the challenge to be the change agents for the hospital of the future,” Dr. Wellikson says. “Wachter has proven himself a nationally sought-after thought leader who has something to say about hospital medicine, patient safety, improving quality, and the future of medicine.”

Dr. Wachter has a unique perspective on, well, everything. His years of experience working in hospital medicine as well as his high-level involvement in shaping the field—such as his position as chair of the American Board of Internal Medicine (ABIM) Committee on Hospital Medicine Focused Recognition—allows him ground-level and big-picture views of issues and trends that affect hospitalists’ work.

He often makes unique connections and forms original opinions on those issues—whether addressing road bumps a hospitalist runs into on the job or policy points that may change that job—and he plans to share those connections and opinions in his blog.

“I want to comment on the confluence of real stuff we all see day to day and the things that influence our field,” Dr. Wachter says. And he certainly has plenty of subjects to cover.

“There are so many issues that cross my retina every day that I think are of interest to hospitalists,” he says. “I see things in context—how they develop and how they all fit together, including trends as they develop. This blog will show my point of view—not on the differences in healthcare policy between Clinton’s camp and Obama’s camp—but closer to the ground. I’ll cover what relates to all of us.” TH

Dr. Wachter

Anyone who has attended the closing session of an SHM Annual Meeting or read one of his editorial pieces in The Hospitalist or other publications knows that Bob Wachter, MD, sees the world in a unique and uniquely informed way.

This fall, Dr. Wachter—professor and associate chairman of the Department of Medicine at the University of California, San Francisco (UCSF), co-founder of SHM, and the man who coined the term “hospitalist” (along with Lee Goldman, MD)—will regularly share his one-of-a-kind perspective via a Weblog, or blog. Tentatively titled “Wachter’s World,” the hospital medicine blog will debut at www.the-hospitalist.org in time for the “Management of the Hospitalized Patient” session Oct. 4-6 at UCSF. The in-depth course serves as the West Coast regional meeting of SHM.

“Even an old guy like me realizes that blogs are incredibly hot,” says Dr. Wachter. “And as I read more of them and began relying on them more for information and insights, I started looking for one in our field that was lively, engaging and informative, one I’d like to read. I couldn’t find anything, so I thought I should start one.”

When Dr. Wachter approached SHM about hosting his blog, the organization’s leadership was quite interested—especially because SHM was already considering starting its own blog.

“SHM’s audience is perfect for the growing blog medium,” says Larry Wellikson, MD, the CEO of SHM. “We saw this with the enormous response to the SHM blogs at the May 2007 Annual Meeting.”

So “Wachter’s World” will be found on The Hospitalist’s Web site, where Dr. Wachter will post regular updates—he estimates typically three or four times a week.

“SHM’s partnership with Bob Wachter to launch an innovative blog, housed on the Web site for the most widely read publication in hospital medicine, SHM’s The Hospitalist, just makes sense as hospitalists need to hear new ideas and meet the challenge to be the change agents for the hospital of the future,” Dr. Wellikson says. “Wachter has proven himself a nationally sought-after thought leader who has something to say about hospital medicine, patient safety, improving quality, and the future of medicine.”

Dr. Wachter has a unique perspective on, well, everything. His years of experience working in hospital medicine as well as his high-level involvement in shaping the field—such as his position as chair of the American Board of Internal Medicine (ABIM) Committee on Hospital Medicine Focused Recognition—allows him ground-level and big-picture views of issues and trends that affect hospitalists’ work.

He often makes unique connections and forms original opinions on those issues—whether addressing road bumps a hospitalist runs into on the job or policy points that may change that job—and he plans to share those connections and opinions in his blog.

“I want to comment on the confluence of real stuff we all see day to day and the things that influence our field,” Dr. Wachter says. And he certainly has plenty of subjects to cover.

“There are so many issues that cross my retina every day that I think are of interest to hospitalists,” he says. “I see things in context—how they develop and how they all fit together, including trends as they develop. This blog will show my point of view—not on the differences in healthcare policy between Clinton’s camp and Obama’s camp—but closer to the ground. I’ll cover what relates to all of us.” TH

With the current focus in hospital medicine on quality and reporting quality measures, you don’t hear much about pediatric patients. What’s happening with quality and children?

In “Pediatric Hospitalist Quality Forum: Standards, Reporting and Improvement,” Erin Stucky, MD, academic director, Children’s Hospital and Health Center in San Diego, Calif., and Lakshmi Halasyamani, MD, assistant chairperson of the Department of Internal Medicine at St. Joseph Mercy Hospital in Ann Arbor, Mich., provided an overview of what’s happening in pediatric quality of care and strategies for organizational and clinical improvement.

“The pediatric quality landscape is emerging, and you have a tremendous opportunity to help shape that landscape,” Dr. Stucky told the audience of hospitalist-pediatricians.

Dr. Halasyamani provided an overview of national organizations that are implementing quality indicators for hospitalized adult patients, from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to the Hospital Quality Alliance to the Institute for Healthcare Improvement. These groups and others have shown some interest in pediatric-specific quality initiatives, but “organizations are trying to coordinate things,” explained Dr. Stucky. “We can’t let the local efforts die while we’re focusing on the national level.”

QI at the Local Level

There are steps a hospitalist can take to improve quality and safety at his or her hospital.

“What can you do?” asked Dr. Halasyamani. The most obvious thing is to continue your education by pursuing CMEs, classes, and workshops in relevant areas. You can improve physician awareness, which forces everyone to look at the bigger picture. But this alone may not change behaviors. At a process and systems level, implementing a multidisciplinary team is a good step. “And you must dispel the myth that to be more effective, it has to be more difficult,” added Dr. Halasyamani.

Elements of success, or sustainability, for a quality improvement (QI) effort include establishing absolute team clarity and unity on goals, ensuring you have the organizational support to eliminate any barriers, and a built-in measurement system for what you’re trying to demonstrate. You’ll need organizational structures for your project to recruit your team, as well as a clear reporting structure. “Make sure the stakeholders are at the table,” advised Dr. Halasyamani.

Leadership in pediatric QI is in our hands.

—Erin Stucky, MD, academic director, Children’s Hospital and Health Center in San Diego

A Case Study

The presenters supplied a local example of a QI initiative hospitalists can follow. Dr. Stucky outlined an asthma QI project her hospitalist-led team had undertaken.

Her team reviews their algorithms every six to 12 months. “Even if review says what we’re doing is good, we still need to look at it and make sure we’re making that decision personally,” explained Dr. Stucky. In looking at the asthma data, the team noticed some pediatric patients were receiving a lot of chest X-rays.

“We looked at our first- and second-quarter data, and compared it to the [Pediatric Health Information System] data,” said Dr. Stucky. “We saw that we ordered chest X-rays at about the national average [on 61% and 62% of eligible patients versus an average of 66%], but is that average a good number?” The team decided to break down the data to see where X-rays were ordered—in the ED and on the ward—and why.

The team mapped a new asthma pathway for the ED based on the end of first-hour events, asthma scores, and medical history. “We decided to involve a respiratory therapist more with decisions on hospital placement” in the ED, said Dr. Stucky. The therapist then drove the protocols for mild, moderate, and severe cases.

The team changed the chest X-ray order set on the ward to read, “Consider ordering CRX if it will affect your treatment plan, and you must check or write the indication if ordering one.”

The result: The percentage of patients with chest X-rays in hospital beds dropped to 55%.

“Performance improvement is here to stay,” pronounced Dr. Stucky. “Leadership in pediatric QI is in our hands.” TH

With the current focus in hospital medicine on quality and reporting quality measures, you don’t hear much about pediatric patients. What’s happening with quality and children?

In “Pediatric Hospitalist Quality Forum: Standards, Reporting and Improvement,” Erin Stucky, MD, academic director, Children’s Hospital and Health Center in San Diego, Calif., and Lakshmi Halasyamani, MD, assistant chairperson of the Department of Internal Medicine at St. Joseph Mercy Hospital in Ann Arbor, Mich., provided an overview of what’s happening in pediatric quality of care and strategies for organizational and clinical improvement.

“The pediatric quality landscape is emerging, and you have a tremendous opportunity to help shape that landscape,” Dr. Stucky told the audience of hospitalist-pediatricians.

Dr. Halasyamani provided an overview of national organizations that are implementing quality indicators for hospitalized adult patients, from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to the Hospital Quality Alliance to the Institute for Healthcare Improvement. These groups and others have shown some interest in pediatric-specific quality initiatives, but “organizations are trying to coordinate things,” explained Dr. Stucky. “We can’t let the local efforts die while we’re focusing on the national level.”

QI at the Local Level

There are steps a hospitalist can take to improve quality and safety at his or her hospital.

“What can you do?” asked Dr. Halasyamani. The most obvious thing is to continue your education by pursuing CMEs, classes, and workshops in relevant areas. You can improve physician awareness, which forces everyone to look at the bigger picture. But this alone may not change behaviors. At a process and systems level, implementing a multidisciplinary team is a good step. “And you must dispel the myth that to be more effective, it has to be more difficult,” added Dr. Halasyamani.

Elements of success, or sustainability, for a quality improvement (QI) effort include establishing absolute team clarity and unity on goals, ensuring you have the organizational support to eliminate any barriers, and a built-in measurement system for what you’re trying to demonstrate. You’ll need organizational structures for your project to recruit your team, as well as a clear reporting structure. “Make sure the stakeholders are at the table,” advised Dr. Halasyamani.

Leadership in pediatric QI is in our hands.

—Erin Stucky, MD, academic director, Children’s Hospital and Health Center in San Diego

A Case Study

The presenters supplied a local example of a QI initiative hospitalists can follow. Dr. Stucky outlined an asthma QI project her hospitalist-led team had undertaken.

Her team reviews their algorithms every six to 12 months. “Even if review says what we’re doing is good, we still need to look at it and make sure we’re making that decision personally,” explained Dr. Stucky. In looking at the asthma data, the team noticed some pediatric patients were receiving a lot of chest X-rays.

“We looked at our first- and second-quarter data, and compared it to the [Pediatric Health Information System] data,” said Dr. Stucky. “We saw that we ordered chest X-rays at about the national average [on 61% and 62% of eligible patients versus an average of 66%], but is that average a good number?” The team decided to break down the data to see where X-rays were ordered—in the ED and on the ward—and why.

The team mapped a new asthma pathway for the ED based on the end of first-hour events, asthma scores, and medical history. “We decided to involve a respiratory therapist more with decisions on hospital placement” in the ED, said Dr. Stucky. The therapist then drove the protocols for mild, moderate, and severe cases.

The team changed the chest X-ray order set on the ward to read, “Consider ordering CRX if it will affect your treatment plan, and you must check or write the indication if ordering one.”

The result: The percentage of patients with chest X-rays in hospital beds dropped to 55%.

“Performance improvement is here to stay,” pronounced Dr. Stucky. “Leadership in pediatric QI is in our hands.” TH

With the current focus in hospital medicine on quality and reporting quality measures, you don’t hear much about pediatric patients. What’s happening with quality and children?

In “Pediatric Hospitalist Quality Forum: Standards, Reporting and Improvement,” Erin Stucky, MD, academic director, Children’s Hospital and Health Center in San Diego, Calif., and Lakshmi Halasyamani, MD, assistant chairperson of the Department of Internal Medicine at St. Joseph Mercy Hospital in Ann Arbor, Mich., provided an overview of what’s happening in pediatric quality of care and strategies for organizational and clinical improvement.

“The pediatric quality landscape is emerging, and you have a tremendous opportunity to help shape that landscape,” Dr. Stucky told the audience of hospitalist-pediatricians.

Dr. Halasyamani provided an overview of national organizations that are implementing quality indicators for hospitalized adult patients, from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) to the Hospital Quality Alliance to the Institute for Healthcare Improvement. These groups and others have shown some interest in pediatric-specific quality initiatives, but “organizations are trying to coordinate things,” explained Dr. Stucky. “We can’t let the local efforts die while we’re focusing on the national level.”

QI at the Local Level

There are steps a hospitalist can take to improve quality and safety at his or her hospital.

“What can you do?” asked Dr. Halasyamani. The most obvious thing is to continue your education by pursuing CMEs, classes, and workshops in relevant areas. You can improve physician awareness, which forces everyone to look at the bigger picture. But this alone may not change behaviors. At a process and systems level, implementing a multidisciplinary team is a good step. “And you must dispel the myth that to be more effective, it has to be more difficult,” added Dr. Halasyamani.

Elements of success, or sustainability, for a quality improvement (QI) effort include establishing absolute team clarity and unity on goals, ensuring you have the organizational support to eliminate any barriers, and a built-in measurement system for what you’re trying to demonstrate. You’ll need organizational structures for your project to recruit your team, as well as a clear reporting structure. “Make sure the stakeholders are at the table,” advised Dr. Halasyamani.

Leadership in pediatric QI is in our hands.

—Erin Stucky, MD, academic director, Children’s Hospital and Health Center in San Diego

A Case Study

The presenters supplied a local example of a QI initiative hospitalists can follow. Dr. Stucky outlined an asthma QI project her hospitalist-led team had undertaken.

Her team reviews their algorithms every six to 12 months. “Even if review says what we’re doing is good, we still need to look at it and make sure we’re making that decision personally,” explained Dr. Stucky. In looking at the asthma data, the team noticed some pediatric patients were receiving a lot of chest X-rays.

“We looked at our first- and second-quarter data, and compared it to the [Pediatric Health Information System] data,” said Dr. Stucky. “We saw that we ordered chest X-rays at about the national average [on 61% and 62% of eligible patients versus an average of 66%], but is that average a good number?” The team decided to break down the data to see where X-rays were ordered—in the ED and on the ward—and why.

The team mapped a new asthma pathway for the ED based on the end of first-hour events, asthma scores, and medical history. “We decided to involve a respiratory therapist more with decisions on hospital placement” in the ED, said Dr. Stucky. The therapist then drove the protocols for mild, moderate, and severe cases.

The team changed the chest X-ray order set on the ward to read, “Consider ordering CRX if it will affect your treatment plan, and you must check or write the indication if ordering one.”

The result: The percentage of patients with chest X-rays in hospital beds dropped to 55%.

“Performance improvement is here to stay,” pronounced Dr. Stucky. “Leadership in pediatric QI is in our hands.” TH

Sanjay Saint, MD, MPH

Moving up the ranks of academic hospital medicine—from instructor to assistant professor, and especially from assistant professor to associate professor—was covered in-depth by professors Scott Flanders, MD, and Sanjay Saint, MD, MPH, of the University of Michigan in Ann Arbor, and Stephan D. Fihn, MD, MPH, head of the Division of General Internal Medicine at the University of Washington, in the session “How to Get Promoted as an Academic Hospitalist.”

Choose a Track

Dr. Flanders said there are several tracks within hospital medicine in academia. They include:

Clinician-Investigator: This is usually a tenure-track position, where 60% to 80% of the hospitalist’s time is protected for research. Usually, you’ll receive at least partial salary support for about three years, after which you’re responsible for finding independent funding to cover most of your salary. Retention and promotion are based on academic productivity including publications, grants, and national recognition.

Clinician-Educator: With approximately 10% to 30% of their time protected for research, these professionals usually get indefinite salary support—although they’re expected to generate most of their salary through clinical work. Retention and promotion are based on teaching accomplishments and clinical skills and, to a lesser extent, academic productivity.

Clinician-Administrator: With any­where from 10% to 50% of their time protected for administrative work, these experienced hospitalists serve as directors, associate or assistant directors in a hospital medicine group, or in a clerkship role at a university. Retention and promotion are based on administrative skills, teaching prowess, clinical skills, and academic productivity.

Criteria for Promotion

Regardless of which track you’re on, when applying for a promotion you’ll be evaluated in these domains: clinical work, teaching, and administrative and scholarly work.

“These are universal to all institutions,” said Dr. Flanders. “You need to demonstrate excellence in each.” More specifically, you’ll need five to seven letters from impartial faculty outside your institution—preferably leaders in the field who hold at least the rank you are trying to achieve.

“Ask yourself as you get halfway between your associate and assistant professorship,” said Dr. Flanders, “who outside your institution knows you and your work.”

Steps for Promotion

Dr. Flanders offered advice on how to prepare for a successful career in academia.

“It helps if you develop a clinical niche,” he said. “Become the expert in one area in your group or institution.”

He also advised working toward giving clinical lectures to faculty and trainees in other departments, performing grand rounds in other departments, and speaking at neighboring institutions. To establish excellence in teaching, get feedback from students and work on improving your methods. Be innovative in your teaching and document your work in an education portfolio.

When focusing on administrative excellence, if you’re a director or an assistant director of a hospital medicine program, “make substantial contributions,” said Dr. Flanders. “… demonstrate that you’ve done leadership in … QI projects, and that this was important for your institution and more importantly, for other institutions.”

To generate scholarly work, write up your clinical cases as vignettes, case reports, or clinical problem solving; evaluate and disseminate your QI interventions; and establish connections with trained researchers.

“Ultimately, the goal is to have a national reputation,” Dr. Flanders reiterated. “It’s easiest if you’ve got 10 to 12 [articles in] peer-reviewed publications.”

Good Habits

Dr. Saint provided a list of seven habits of highly effective junior faculty members. They include:

• Know the rules. Understand what’s expected of you and the criteria for promotion;
• Develop expertise;
• Learn how to diversify your portfolio. Balance the risk between high-, moderate-, and low-risk projects;
• Find and utilize good mentors and collaborators;
• Quickly demonstrate academic productivity;
• Build a superb team. Hire the right research assistant; and
• Manage your time wisely. Guard your protected time. TH

Sanjay Saint, MD, MPH

Moving up the ranks of academic hospital medicine—from instructor to assistant professor, and especially from assistant professor to associate professor—was covered in-depth by professors Scott Flanders, MD, and Sanjay Saint, MD, MPH, of the University of Michigan in Ann Arbor, and Stephan D. Fihn, MD, MPH, head of the Division of General Internal Medicine at the University of Washington, in the session “How to Get Promoted as an Academic Hospitalist.”

Choose a Track

Dr. Flanders said there are several tracks within hospital medicine in academia. They include:

Clinician-Investigator: This is usually a tenure-track position, where 60% to 80% of the hospitalist’s time is protected for research. Usually, you’ll receive at least partial salary support for about three years, after which you’re responsible for finding independent funding to cover most of your salary. Retention and promotion are based on academic productivity including publications, grants, and national recognition.

Clinician-Educator: With approximately 10% to 30% of their time protected for research, these professionals usually get indefinite salary support—although they’re expected to generate most of their salary through clinical work. Retention and promotion are based on teaching accomplishments and clinical skills and, to a lesser extent, academic productivity.

Clinician-Administrator: With any­where from 10% to 50% of their time protected for administrative work, these experienced hospitalists serve as directors, associate or assistant directors in a hospital medicine group, or in a clerkship role at a university. Retention and promotion are based on administrative skills, teaching prowess, clinical skills, and academic productivity.

Criteria for Promotion

Regardless of which track you’re on, when applying for a promotion you’ll be evaluated in these domains: clinical work, teaching, and administrative and scholarly work.

“These are universal to all institutions,” said Dr. Flanders. “You need to demonstrate excellence in each.” More specifically, you’ll need five to seven letters from impartial faculty outside your institution—preferably leaders in the field who hold at least the rank you are trying to achieve.

“Ask yourself as you get halfway between your associate and assistant professorship,” said Dr. Flanders, “who outside your institution knows you and your work.”

Steps for Promotion

Dr. Flanders offered advice on how to prepare for a successful career in academia.

“It helps if you develop a clinical niche,” he said. “Become the expert in one area in your group or institution.”

He also advised working toward giving clinical lectures to faculty and trainees in other departments, performing grand rounds in other departments, and speaking at neighboring institutions. To establish excellence in teaching, get feedback from students and work on improving your methods. Be innovative in your teaching and document your work in an education portfolio.

When focusing on administrative excellence, if you’re a director or an assistant director of a hospital medicine program, “make substantial contributions,” said Dr. Flanders. “… demonstrate that you’ve done leadership in … QI projects, and that this was important for your institution and more importantly, for other institutions.”

To generate scholarly work, write up your clinical cases as vignettes, case reports, or clinical problem solving; evaluate and disseminate your QI interventions; and establish connections with trained researchers.

“Ultimately, the goal is to have a national reputation,” Dr. Flanders reiterated. “It’s easiest if you’ve got 10 to 12 [articles in] peer-reviewed publications.”

Good Habits

Dr. Saint provided a list of seven habits of highly effective junior faculty members. They include:

• Know the rules. Understand what’s expected of you and the criteria for promotion;
• Develop expertise;
• Learn how to diversify your portfolio. Balance the risk between high-, moderate-, and low-risk projects;
• Find and utilize good mentors and collaborators;
• Quickly demonstrate academic productivity;
• Build a superb team. Hire the right research assistant; and
• Manage your time wisely. Guard your protected time. TH

Sanjay Saint, MD, MPH

Moving up the ranks of academic hospital medicine—from instructor to assistant professor, and especially from assistant professor to associate professor—was covered in-depth by professors Scott Flanders, MD, and Sanjay Saint, MD, MPH, of the University of Michigan in Ann Arbor, and Stephan D. Fihn, MD, MPH, head of the Division of General Internal Medicine at the University of Washington, in the session “How to Get Promoted as an Academic Hospitalist.”

Choose a Track

Dr. Flanders said there are several tracks within hospital medicine in academia. They include:

Clinician-Investigator: This is usually a tenure-track position, where 60% to 80% of the hospitalist’s time is protected for research. Usually, you’ll receive at least partial salary support for about three years, after which you’re responsible for finding independent funding to cover most of your salary. Retention and promotion are based on academic productivity including publications, grants, and national recognition.

Clinician-Educator: With approximately 10% to 30% of their time protected for research, these professionals usually get indefinite salary support—although they’re expected to generate most of their salary through clinical work. Retention and promotion are based on teaching accomplishments and clinical skills and, to a lesser extent, academic productivity.

Clinician-Administrator: With any­where from 10% to 50% of their time protected for administrative work, these experienced hospitalists serve as directors, associate or assistant directors in a hospital medicine group, or in a clerkship role at a university. Retention and promotion are based on administrative skills, teaching prowess, clinical skills, and academic productivity.

Criteria for Promotion

Regardless of which track you’re on, when applying for a promotion you’ll be evaluated in these domains: clinical work, teaching, and administrative and scholarly work.

“These are universal to all institutions,” said Dr. Flanders. “You need to demonstrate excellence in each.” More specifically, you’ll need five to seven letters from impartial faculty outside your institution—preferably leaders in the field who hold at least the rank you are trying to achieve.

“Ask yourself as you get halfway between your associate and assistant professorship,” said Dr. Flanders, “who outside your institution knows you and your work.”

Steps for Promotion

Dr. Flanders offered advice on how to prepare for a successful career in academia.

“It helps if you develop a clinical niche,” he said. “Become the expert in one area in your group or institution.”

He also advised working toward giving clinical lectures to faculty and trainees in other departments, performing grand rounds in other departments, and speaking at neighboring institutions. To establish excellence in teaching, get feedback from students and work on improving your methods. Be innovative in your teaching and document your work in an education portfolio.

When focusing on administrative excellence, if you’re a director or an assistant director of a hospital medicine program, “make substantial contributions,” said Dr. Flanders. “… demonstrate that you’ve done leadership in … QI projects, and that this was important for your institution and more importantly, for other institutions.”

To generate scholarly work, write up your clinical cases as vignettes, case reports, or clinical problem solving; evaluate and disseminate your QI interventions; and establish connections with trained researchers.

“Ultimately, the goal is to have a national reputation,” Dr. Flanders reiterated. “It’s easiest if you’ve got 10 to 12 [articles in] peer-reviewed publications.”

Good Habits

Dr. Saint provided a list of seven habits of highly effective junior faculty members. They include:

• Know the rules. Understand what’s expected of you and the criteria for promotion;
• Develop expertise;
• Learn how to diversify your portfolio. Balance the risk between high-, moderate-, and low-risk projects;
• Find and utilize good mentors and collaborators;
• Quickly demonstrate academic productivity;
• Build a superb team. Hire the right research assistant; and
• Manage your time wisely. Guard your protected time. TH

Research—not to mention common sense—shows that good communication between caregivers is essential for patient safety, particularly communication among doctors and nursing staff.

In the session “Nurse-Hospitalist Communication,” presenters Win Whitcomb, MD, Mercy Medical Center in Springfield, Mass., and Sally Szumlas, RN, MS, University of Chicago, each told their side of the story, outlining perceived problems and best practices for clear communications between MDs and RNs.

The RN Perspective

Szumlas began with an overview of the problem. “Nurses, through training, tend to be very descriptive, while MDs want to hear succinct information only,” she said. “This can lead to frustration, missed information, and poor communication.”

At the University of Chicago, a project focused on nurse-physician communications took the following steps to improve communication: The hospital instituted multidisciplinary rounding using the call light—indicating that when the physician reaches the patient’s bedside, he or she pushes the call light and the nurse will join if possible. The hospital also implemented the SBAR form—with sections for the nurse to fill in situation, background, assessment, and recommendations. This form ensures a standardized approach to critical communication, particularly when the nurse phones a physician with questions or patient information.

Szumlas concluded by listing common communication roadblocks, including a misunderstanding of roles, real and perceived power differentials, gender and ethnic differences, and differences in styles of communication.

The Hospitalist’s Viewpoint

Win Whitcomb, MD

Dr. Whitcomb presented the hospitalist’s view of nurse-MD communications, saying, “My sense is that collaborating with nurses is among the most satisfying thing we do.” However, he went on, there are common problems with communications between the two groups. “Interruptions are too frequent,” he pointed out. “We still practice telephone medicine too frequently, and nurses are not always available—they’re busy.”

And the addition of hospitalists has created communication problems that didn’t exist before. These include nurses not knowing which hospitalist to contact, or not being able to reach the hospitalist on duty. Nurses can be stuck bringing a hospitalist who’s starting a new shift up to speed on patients, or placating family members who want to see the unavailable hospitalist immediately.

Dr. Whitcomb offered an action plan hospital medicine programs can implement immediately: He suggested establishing a forum for improving nurse-physician communications, using dialogue, and creating action plans. In addition to this forum, the nurse leader and the hospital medicine director should meet regularly. You should also integrate nursing staff into daily rounds “any way that you can. Interdisciplinary rounds are very difficult,” Dr. Whitcomb admitted. “Everyone is busy.”

Additionally, hospital medicine programs should establish standards for team communication. “Seriously consider a daily goals sheet,” urged Dr. Whitcomb, “one for nurses and hospitalists to use to communicate their plan of care.” Adopt an SBAR tool for critical communications, and create an RN-MD communication log sheet on each patient’s chart. “This can replace the ‘stickies’ I find on the front the chart that aren’t dated or signed,” pointed out Dr. Whitcomb.

Hospitalists can also smooth communication problems by using a concise but detailed patient sign-out at shift changes; and nocturnists should add routine rounds to proactively address issues. Nurses, on the other hand, can help by pooling non-urgent calls during the night and, when appropriate, using text messaging when a quick return call is not critical.

Other basic best practices include distributing the hospitalists’ census to all nursing units by 8 a.m. (as well as to the receptionist), placing the hospitalist schedule at all nursing units, ensuring that day hospitalists leave their beepers on until designated times around the end of their shift, and dedicating a universal pager for rapid responses, codes, emergencies, and coverage questions. TH

Research—not to mention common sense—shows that good communication between caregivers is essential for patient safety, particularly communication among doctors and nursing staff.

In the session “Nurse-Hospitalist Communication,” presenters Win Whitcomb, MD, Mercy Medical Center in Springfield, Mass., and Sally Szumlas, RN, MS, University of Chicago, each told their side of the story, outlining perceived problems and best practices for clear communications between MDs and RNs.

The RN Perspective

Szumlas began with an overview of the problem. “Nurses, through training, tend to be very descriptive, while MDs want to hear succinct information only,” she said. “This can lead to frustration, missed information, and poor communication.”

At the University of Chicago, a project focused on nurse-physician communications took the following steps to improve communication: The hospital instituted multidisciplinary rounding using the call light—indicating that when the physician reaches the patient’s bedside, he or she pushes the call light and the nurse will join if possible. The hospital also implemented the SBAR form—with sections for the nurse to fill in situation, background, assessment, and recommendations. This form ensures a standardized approach to critical communication, particularly when the nurse phones a physician with questions or patient information.

Szumlas concluded by listing common communication roadblocks, including a misunderstanding of roles, real and perceived power differentials, gender and ethnic differences, and differences in styles of communication.

The Hospitalist’s Viewpoint

Win Whitcomb, MD

Dr. Whitcomb presented the hospitalist’s view of nurse-MD communications, saying, “My sense is that collaborating with nurses is among the most satisfying thing we do.” However, he went on, there are common problems with communications between the two groups. “Interruptions are too frequent,” he pointed out. “We still practice telephone medicine too frequently, and nurses are not always available—they’re busy.”

And the addition of hospitalists has created communication problems that didn’t exist before. These include nurses not knowing which hospitalist to contact, or not being able to reach the hospitalist on duty. Nurses can be stuck bringing a hospitalist who’s starting a new shift up to speed on patients, or placating family members who want to see the unavailable hospitalist immediately.

Dr. Whitcomb offered an action plan hospital medicine programs can implement immediately: He suggested establishing a forum for improving nurse-physician communications, using dialogue, and creating action plans. In addition to this forum, the nurse leader and the hospital medicine director should meet regularly. You should also integrate nursing staff into daily rounds “any way that you can. Interdisciplinary rounds are very difficult,” Dr. Whitcomb admitted. “Everyone is busy.”

Additionally, hospital medicine programs should establish standards for team communication. “Seriously consider a daily goals sheet,” urged Dr. Whitcomb, “one for nurses and hospitalists to use to communicate their plan of care.” Adopt an SBAR tool for critical communications, and create an RN-MD communication log sheet on each patient’s chart. “This can replace the ‘stickies’ I find on the front the chart that aren’t dated or signed,” pointed out Dr. Whitcomb.

Hospitalists can also smooth communication problems by using a concise but detailed patient sign-out at shift changes; and nocturnists should add routine rounds to proactively address issues. Nurses, on the other hand, can help by pooling non-urgent calls during the night and, when appropriate, using text messaging when a quick return call is not critical.

Other basic best practices include distributing the hospitalists’ census to all nursing units by 8 a.m. (as well as to the receptionist), placing the hospitalist schedule at all nursing units, ensuring that day hospitalists leave their beepers on until designated times around the end of their shift, and dedicating a universal pager for rapid responses, codes, emergencies, and coverage questions. TH

Research—not to mention common sense—shows that good communication between caregivers is essential for patient safety, particularly communication among doctors and nursing staff.

In the session “Nurse-Hospitalist Communication,” presenters Win Whitcomb, MD, Mercy Medical Center in Springfield, Mass., and Sally Szumlas, RN, MS, University of Chicago, each told their side of the story, outlining perceived problems and best practices for clear communications between MDs and RNs.

The RN Perspective

Szumlas began with an overview of the problem. “Nurses, through training, tend to be very descriptive, while MDs want to hear succinct information only,” she said. “This can lead to frustration, missed information, and poor communication.”

At the University of Chicago, a project focused on nurse-physician communications took the following steps to improve communication: The hospital instituted multidisciplinary rounding using the call light—indicating that when the physician reaches the patient’s bedside, he or she pushes the call light and the nurse will join if possible. The hospital also implemented the SBAR form—with sections for the nurse to fill in situation, background, assessment, and recommendations. This form ensures a standardized approach to critical communication, particularly when the nurse phones a physician with questions or patient information.

Szumlas concluded by listing common communication roadblocks, including a misunderstanding of roles, real and perceived power differentials, gender and ethnic differences, and differences in styles of communication.

The Hospitalist’s Viewpoint

Win Whitcomb, MD

Dr. Whitcomb presented the hospitalist’s view of nurse-MD communications, saying, “My sense is that collaborating with nurses is among the most satisfying thing we do.” However, he went on, there are common problems with communications between the two groups. “Interruptions are too frequent,” he pointed out. “We still practice telephone medicine too frequently, and nurses are not always available—they’re busy.”

And the addition of hospitalists has created communication problems that didn’t exist before. These include nurses not knowing which hospitalist to contact, or not being able to reach the hospitalist on duty. Nurses can be stuck bringing a hospitalist who’s starting a new shift up to speed on patients, or placating family members who want to see the unavailable hospitalist immediately.

Dr. Whitcomb offered an action plan hospital medicine programs can implement immediately: He suggested establishing a forum for improving nurse-physician communications, using dialogue, and creating action plans. In addition to this forum, the nurse leader and the hospital medicine director should meet regularly. You should also integrate nursing staff into daily rounds “any way that you can. Interdisciplinary rounds are very difficult,” Dr. Whitcomb admitted. “Everyone is busy.”

Additionally, hospital medicine programs should establish standards for team communication. “Seriously consider a daily goals sheet,” urged Dr. Whitcomb, “one for nurses and hospitalists to use to communicate their plan of care.” Adopt an SBAR tool for critical communications, and create an RN-MD communication log sheet on each patient’s chart. “This can replace the ‘stickies’ I find on the front the chart that aren’t dated or signed,” pointed out Dr. Whitcomb.

Hospitalists can also smooth communication problems by using a concise but detailed patient sign-out at shift changes; and nocturnists should add routine rounds to proactively address issues. Nurses, on the other hand, can help by pooling non-urgent calls during the night and, when appropriate, using text messaging when a quick return call is not critical.

Other basic best practices include distributing the hospitalists’ census to all nursing units by 8 a.m. (as well as to the receptionist), placing the hospitalist schedule at all nursing units, ensuring that day hospitalists leave their beepers on until designated times around the end of their shift, and dedicating a universal pager for rapid responses, codes, emergencies, and coverage questions. TH

The session “Ethical and Legal Issues around Pain Management in Hospitalized Patients” shed light on issues that many hospitalists are aware of but perhaps not well versed in.

Speaker Vijay Rajput, MD, FACP, associate professor of medicine at the University of Medicine and Dentistry of New Jersey (UMDNJ), Robert Wood Johnson Medical School, and Cooper University Hospital, Camden, N.J., covered the many conflicts surrounding pain management, the law, and your conscience.

Hard Facts

Dr. Rajput shared what he called “hard facts” on pain medication, which include:

• 90% of cancer pain can be controlled with available options;
• 70% of the time chronic, nonmalignant pain is poorly managed, especially in nursing homes;
• 11% of admissions in the emergency department seek treatment for a chronic pain condition;
• 8.2% of, or 19.5 million, Americans use an illicit drug at least once a month; and
• 31.2 million reported non-medical use of pain relievers including hydrocodone (Vicodin), acetaminophen and hydrocodone (Lortab), oxycodone (Percocet), and others.

Dr. Rajput discussed barriers that lead to undertreatment of pain in hospitalized patients.

“There may be prioritization of diagnosis over pain relief by surgical colleagues on hospitalized patients,” he said. “There are also inadequacies in assessing pain, educational deficiencies, and cultural challenges. Some physicians are ruled by regulatory and ethical concerns in prescribing for pain.”

Pain Management and the Law

There are several legal concerns regarding pain management that most physicians are aware of. In addition to liability for repercussions of undermedicating or overmedicating, the failure to refer a patient to a pain management specialist, the use of opioids when caring for end-of-life patients, and failure to get informed consent related to risk of treatment can all mean malpractice suits.

“The general rule for avoiding a malpractice charge is to follow national standards of care and any applicable clinical practice guidelines,” said Dr. Rajput. “There are Web-based databases that serve as national guidelines clearinghouses that you can refer to.”

The Ethical Side of Pain

“There are few common domains of ethical and legal issues in pain relief,” stated Dr. Rajput. These include the pain issues around end-of-life and palliative care of terminally ill patients, a subordination of pain relief to diagnosis, chronic pain issues and substance abuse, pain control in a patient’s transfer to a nursing home, and the risk of discontinuity of pain control after discharge.

“The ethical duty to relieve pain is well established,” Dr. Rajput said. Despite this, it is still common to subordinate pain relief to diagnosis. In 2003, the American Journal of Surgery stated, “Analgesia should be given prior to diagnosis only with the knowledge and consent of the surgeon who assumes the responsibility for decision-making.”

This “decision-making” can affect hospitalists because 86% of ED physicians follow this literature, and 89% of surgeons still prefer to hold the pain medication prior to surgical evaluation.

“Without ongoing education, senior physicians risk providing less, not more, pain control,” Dr. Rajput pointed out. “This will become more critical as we are co-managing more and more surgical patients in hospitals.”

What about End-of-Life Care?

The legal case of Estate of Henry James v. Hilhaven Corp. established that healthcare facilities have a duty to treat pain. However, Dr. Rajput stressed, patients, families, and physicians all remain confused about the role of opioids in caring for dying patients.

Dr. Rajput reviewed two cases where physicians were sued for undertreatment or negligent treatment of pain, and 11 cases where physicians were sued for administering medications that resulted in the deaths of terminally ill patients.

In a criminal prosecution involving the care of the dying, Dr. Rajput explained, the basic elements must be proved: There must be a criminal act, and that act must be intentional. Acts involving terminal pain are not investigated unless a nurse, supervisor, or ethics committee is informed. Nurses are the most common informants.

“Almost all cases are in hospital settings,” said Dr. Rajput. “And there are three major categories: withdrawal of life-sustaining support with accompanying pain meds, the use of opioids and sedations, and terminal care that includes the use of fatal agents such as insulin, potassium chloride, and chloroform.”

In 1997, the Supreme Court endorsed terminal sedation as an alternative to physician-assisted suicide, intensifying the legal debate in the so-called right-to-die controversy.

“Long before the Supreme Court intervention,” said Dr. Rajput, “terminal sedation was a palliative care option to relieve physical or non-physical pain, or to produce an unconscious state before the withdrawal of life support.”

There are clinical safeguards for terminal sedation. These include ensuring the effectiveness of palliative care, obtaining fully informed consent from the patient, maintaining diagnostic and prognostic clarity with respect to the patient’s disease and lifespan, obtaining an independent second opinion, and providing documentation and review.

Double Effect and Futility

In the “rule of double effect” in palliative care (or providing treatment to relieve suffering even though a foreseeable, unintended consequence of that treatment is to hasten death), the difference between permissible and prohibited action relies heavily on the clinician’s intent, Dr. Rajput pointed out.

He quoted the article “The Rule of Double Effect—A Critique of the Rule in End-of-Life Decision-Making,” saying, “A proportionately good effect (relief of suffering) may overcome a foreseeable bad effect (causing death) … as long as the actor does not intend to accomplish the bad effect.”

Another concept—medical futility—leads to three conceptual possibilities at end-of-life care:

• The treatment does not provide positive effects;
• The radical treatment has side effects that outweigh any positive effect; or
• It is futile to treat a disease when the patient is suffering from a more real-time, life-threatening disease.

In the event of physiological futility, a physician can withhold the treatment modality on the basis of having no effect on patient care, Dr. Rajput explained. But the decision needs to meet professional standards, and the physician must inform the patient and his or her family and give them an opportunity to seek a second opinion.

But what if there is no physiological futility?

“If it’s a matter of the appropriateness of sustaining a severely deteriorated life,” said Dr. Rajput, “then the scope of professional judgment is limited. This should not be a unilateral medical judgment.” You must include the patient and their family in decision-making, and you may want to consult with your hospital ethics committee.

“The bottom line is, futility is an elusive concept,” said Dr. Rajput. “The term is used more to make value-laden judgments,” He added, “Avoid the word ‘futility’ in communication and documentation. It can stop conversation.” Rather, communicate your

goals of care and treatments.

To determine those goals, your clinical ethical reasoning should follow these steps:

• State the problem plainly;
• Gather and organize the data;
• Consider the patient’s goals and preferences;
• Ask if this is an ethical problem;
• Ask if more information or dialogue is needed; and
• Determine the best course of action and support your position.

The complete PowerPoint presentation of “Ethical and Legal Issues around Pain Management in Hospitalized Patients” is available on the SHM Web site at www.hospitalmedicine.org/microsite/index.cfm. TH

The session “Ethical and Legal Issues around Pain Management in Hospitalized Patients” shed light on issues that many hospitalists are aware of but perhaps not well versed in.

Speaker Vijay Rajput, MD, FACP, associate professor of medicine at the University of Medicine and Dentistry of New Jersey (UMDNJ), Robert Wood Johnson Medical School, and Cooper University Hospital, Camden, N.J., covered the many conflicts surrounding pain management, the law, and your conscience.

Hard Facts

Dr. Rajput shared what he called “hard facts” on pain medication, which include:

• 90% of cancer pain can be controlled with available options;
• 70% of the time chronic, nonmalignant pain is poorly managed, especially in nursing homes;
• 11% of admissions in the emergency department seek treatment for a chronic pain condition;
• 8.2% of, or 19.5 million, Americans use an illicit drug at least once a month; and
• 31.2 million reported non-medical use of pain relievers including hydrocodone (Vicodin), acetaminophen and hydrocodone (Lortab), oxycodone (Percocet), and others.

Dr. Rajput discussed barriers that lead to undertreatment of pain in hospitalized patients.

“There may be prioritization of diagnosis over pain relief by surgical colleagues on hospitalized patients,” he said. “There are also inadequacies in assessing pain, educational deficiencies, and cultural challenges. Some physicians are ruled by regulatory and ethical concerns in prescribing for pain.”

Pain Management and the Law

There are several legal concerns regarding pain management that most physicians are aware of. In addition to liability for repercussions of undermedicating or overmedicating, the failure to refer a patient to a pain management specialist, the use of opioids when caring for end-of-life patients, and failure to get informed consent related to risk of treatment can all mean malpractice suits.

“The general rule for avoiding a malpractice charge is to follow national standards of care and any applicable clinical practice guidelines,” said Dr. Rajput. “There are Web-based databases that serve as national guidelines clearinghouses that you can refer to.”

The Ethical Side of Pain

“There are few common domains of ethical and legal issues in pain relief,” stated Dr. Rajput. These include the pain issues around end-of-life and palliative care of terminally ill patients, a subordination of pain relief to diagnosis, chronic pain issues and substance abuse, pain control in a patient’s transfer to a nursing home, and the risk of discontinuity of pain control after discharge.

“The ethical duty to relieve pain is well established,” Dr. Rajput said. Despite this, it is still common to subordinate pain relief to diagnosis. In 2003, the American Journal of Surgery stated, “Analgesia should be given prior to diagnosis only with the knowledge and consent of the surgeon who assumes the responsibility for decision-making.”

This “decision-making” can affect hospitalists because 86% of ED physicians follow this literature, and 89% of surgeons still prefer to hold the pain medication prior to surgical evaluation.

“Without ongoing education, senior physicians risk providing less, not more, pain control,” Dr. Rajput pointed out. “This will become more critical as we are co-managing more and more surgical patients in hospitals.”

What about End-of-Life Care?

The legal case of Estate of Henry James v. Hilhaven Corp. established that healthcare facilities have a duty to treat pain. However, Dr. Rajput stressed, patients, families, and physicians all remain confused about the role of opioids in caring for dying patients.

Dr. Rajput reviewed two cases where physicians were sued for undertreatment or negligent treatment of pain, and 11 cases where physicians were sued for administering medications that resulted in the deaths of terminally ill patients.

In a criminal prosecution involving the care of the dying, Dr. Rajput explained, the basic elements must be proved: There must be a criminal act, and that act must be intentional. Acts involving terminal pain are not investigated unless a nurse, supervisor, or ethics committee is informed. Nurses are the most common informants.

“Almost all cases are in hospital settings,” said Dr. Rajput. “And there are three major categories: withdrawal of life-sustaining support with accompanying pain meds, the use of opioids and sedations, and terminal care that includes the use of fatal agents such as insulin, potassium chloride, and chloroform.”

In 1997, the Supreme Court endorsed terminal sedation as an alternative to physician-assisted suicide, intensifying the legal debate in the so-called right-to-die controversy.

“Long before the Supreme Court intervention,” said Dr. Rajput, “terminal sedation was a palliative care option to relieve physical or non-physical pain, or to produce an unconscious state before the withdrawal of life support.”

There are clinical safeguards for terminal sedation. These include ensuring the effectiveness of palliative care, obtaining fully informed consent from the patient, maintaining diagnostic and prognostic clarity with respect to the patient’s disease and lifespan, obtaining an independent second opinion, and providing documentation and review.

Double Effect and Futility

In the “rule of double effect” in palliative care (or providing treatment to relieve suffering even though a foreseeable, unintended consequence of that treatment is to hasten death), the difference between permissible and prohibited action relies heavily on the clinician’s intent, Dr. Rajput pointed out.

He quoted the article “The Rule of Double Effect—A Critique of the Rule in End-of-Life Decision-Making,” saying, “A proportionately good effect (relief of suffering) may overcome a foreseeable bad effect (causing death) … as long as the actor does not intend to accomplish the bad effect.”

Another concept—medical futility—leads to three conceptual possibilities at end-of-life care:

• The treatment does not provide positive effects;
• The radical treatment has side effects that outweigh any positive effect; or
• It is futile to treat a disease when the patient is suffering from a more real-time, life-threatening disease.

In the event of physiological futility, a physician can withhold the treatment modality on the basis of having no effect on patient care, Dr. Rajput explained. But the decision needs to meet professional standards, and the physician must inform the patient and his or her family and give them an opportunity to seek a second opinion.

But what if there is no physiological futility?

“If it’s a matter of the appropriateness of sustaining a severely deteriorated life,” said Dr. Rajput, “then the scope of professional judgment is limited. This should not be a unilateral medical judgment.” You must include the patient and their family in decision-making, and you may want to consult with your hospital ethics committee.

“The bottom line is, futility is an elusive concept,” said Dr. Rajput. “The term is used more to make value-laden judgments,” He added, “Avoid the word ‘futility’ in communication and documentation. It can stop conversation.” Rather, communicate your

goals of care and treatments.

To determine those goals, your clinical ethical reasoning should follow these steps:

• State the problem plainly;
• Gather and organize the data;
• Consider the patient’s goals and preferences;
• Ask if this is an ethical problem;
• Ask if more information or dialogue is needed; and
• Determine the best course of action and support your position.

The complete PowerPoint presentation of “Ethical and Legal Issues around Pain Management in Hospitalized Patients” is available on the SHM Web site at www.hospitalmedicine.org/microsite/index.cfm. TH

The session “Ethical and Legal Issues around Pain Management in Hospitalized Patients” shed light on issues that many hospitalists are aware of but perhaps not well versed in.

Speaker Vijay Rajput, MD, FACP, associate professor of medicine at the University of Medicine and Dentistry of New Jersey (UMDNJ), Robert Wood Johnson Medical School, and Cooper University Hospital, Camden, N.J., covered the many conflicts surrounding pain management, the law, and your conscience.

Hard Facts

Dr. Rajput shared what he called “hard facts” on pain medication, which include:

• 90% of cancer pain can be controlled with available options;
• 70% of the time chronic, nonmalignant pain is poorly managed, especially in nursing homes;
• 11% of admissions in the emergency department seek treatment for a chronic pain condition;
• 8.2% of, or 19.5 million, Americans use an illicit drug at least once a month; and
• 31.2 million reported non-medical use of pain relievers including hydrocodone (Vicodin), acetaminophen and hydrocodone (Lortab), oxycodone (Percocet), and others.

Dr. Rajput discussed barriers that lead to undertreatment of pain in hospitalized patients.

“There may be prioritization of diagnosis over pain relief by surgical colleagues on hospitalized patients,” he said. “There are also inadequacies in assessing pain, educational deficiencies, and cultural challenges. Some physicians are ruled by regulatory and ethical concerns in prescribing for pain.”

Pain Management and the Law

There are several legal concerns regarding pain management that most physicians are aware of. In addition to liability for repercussions of undermedicating or overmedicating, the failure to refer a patient to a pain management specialist, the use of opioids when caring for end-of-life patients, and failure to get informed consent related to risk of treatment can all mean malpractice suits.

“The general rule for avoiding a malpractice charge is to follow national standards of care and any applicable clinical practice guidelines,” said Dr. Rajput. “There are Web-based databases that serve as national guidelines clearinghouses that you can refer to.”

The Ethical Side of Pain

“There are few common domains of ethical and legal issues in pain relief,” stated Dr. Rajput. These include the pain issues around end-of-life and palliative care of terminally ill patients, a subordination of pain relief to diagnosis, chronic pain issues and substance abuse, pain control in a patient’s transfer to a nursing home, and the risk of discontinuity of pain control after discharge.

“The ethical duty to relieve pain is well established,” Dr. Rajput said. Despite this, it is still common to subordinate pain relief to diagnosis. In 2003, the American Journal of Surgery stated, “Analgesia should be given prior to diagnosis only with the knowledge and consent of the surgeon who assumes the responsibility for decision-making.”

This “decision-making” can affect hospitalists because 86% of ED physicians follow this literature, and 89% of surgeons still prefer to hold the pain medication prior to surgical evaluation.

“Without ongoing education, senior physicians risk providing less, not more, pain control,” Dr. Rajput pointed out. “This will become more critical as we are co-managing more and more surgical patients in hospitals.”

What about End-of-Life Care?

The legal case of Estate of Henry James v. Hilhaven Corp. established that healthcare facilities have a duty to treat pain. However, Dr. Rajput stressed, patients, families, and physicians all remain confused about the role of opioids in caring for dying patients.

Dr. Rajput reviewed two cases where physicians were sued for undertreatment or negligent treatment of pain, and 11 cases where physicians were sued for administering medications that resulted in the deaths of terminally ill patients.

In a criminal prosecution involving the care of the dying, Dr. Rajput explained, the basic elements must be proved: There must be a criminal act, and that act must be intentional. Acts involving terminal pain are not investigated unless a nurse, supervisor, or ethics committee is informed. Nurses are the most common informants.

“Almost all cases are in hospital settings,” said Dr. Rajput. “And there are three major categories: withdrawal of life-sustaining support with accompanying pain meds, the use of opioids and sedations, and terminal care that includes the use of fatal agents such as insulin, potassium chloride, and chloroform.”

In 1997, the Supreme Court endorsed terminal sedation as an alternative to physician-assisted suicide, intensifying the legal debate in the so-called right-to-die controversy.

“Long before the Supreme Court intervention,” said Dr. Rajput, “terminal sedation was a palliative care option to relieve physical or non-physical pain, or to produce an unconscious state before the withdrawal of life support.”

There are clinical safeguards for terminal sedation. These include ensuring the effectiveness of palliative care, obtaining fully informed consent from the patient, maintaining diagnostic and prognostic clarity with respect to the patient’s disease and lifespan, obtaining an independent second opinion, and providing documentation and review.

Double Effect and Futility

In the “rule of double effect” in palliative care (or providing treatment to relieve suffering even though a foreseeable, unintended consequence of that treatment is to hasten death), the difference between permissible and prohibited action relies heavily on the clinician’s intent, Dr. Rajput pointed out.

He quoted the article “The Rule of Double Effect—A Critique of the Rule in End-of-Life Decision-Making,” saying, “A proportionately good effect (relief of suffering) may overcome a foreseeable bad effect (causing death) … as long as the actor does not intend to accomplish the bad effect.”

Another concept—medical futility—leads to three conceptual possibilities at end-of-life care:

• The treatment does not provide positive effects;
• The radical treatment has side effects that outweigh any positive effect; or
• It is futile to treat a disease when the patient is suffering from a more real-time, life-threatening disease.

In the event of physiological futility, a physician can withhold the treatment modality on the basis of having no effect on patient care, Dr. Rajput explained. But the decision needs to meet professional standards, and the physician must inform the patient and his or her family and give them an opportunity to seek a second opinion.

But what if there is no physiological futility?

“If it’s a matter of the appropriateness of sustaining a severely deteriorated life,” said Dr. Rajput, “then the scope of professional judgment is limited. This should not be a unilateral medical judgment.” You must include the patient and their family in decision-making, and you may want to consult with your hospital ethics committee.

“The bottom line is, futility is an elusive concept,” said Dr. Rajput. “The term is used more to make value-laden judgments,” He added, “Avoid the word ‘futility’ in communication and documentation. It can stop conversation.” Rather, communicate your

goals of care and treatments.

To determine those goals, your clinical ethical reasoning should follow these steps:

• State the problem plainly;
• Gather and organize the data;
• Consider the patient’s goals and preferences;
• Ask if this is an ethical problem;
• Ask if more information or dialogue is needed; and
• Determine the best course of action and support your position.

The complete PowerPoint presentation of “Ethical and Legal Issues around Pain Management in Hospitalized Patients” is available on the SHM Web site at www.hospitalmedicine.org/microsite/index.cfm. TH

Attendees at the session “Managing Hospitalized Elders,” presented by Robert Palmer, MD, MPH, head of the section of Geriatric Medicine at Cleveland Clinic in Ohio, gained insights into the unique dangers hospitalization presents to their oldest patients.

“As every hospital-based physician knows, increasingly, hospital care is geriatric care,” said Dr. Palmer. “We’re seeing not only more people over 65, we’re seeing more people over age 85—the most complex and challenging cases. The question is, how do we work our way through the chronic diseases, the acute on top of chronic disease, deal with the psychosocial issues and family issues of the frail elderly person during hospitalization.”

The problem is that simply being hospitalized may trigger or exacerbate a functional decline in an elderly patient. Hospitalization itself can lead to delirium, undernutrition, immobility, pressure ulcers, incontinence, and ultimately placement in a nursing home.

“The process of care, a hostile environment, bed rest, starvation, medications—especially those that are inappropriate for use with older people—and depression all conspire to create a dysfunctional older person,” stressed Dr. Palmer. Common co-morbid conditions in the elderly include dehydration, chronic obstructive pulmonary disease (COPD), hypertension, chronic heart failure, diabetes, and anemia.

“We rarely treat these patients for just one condition,” Dr. Palmer pointed out.

Common Geriatric Syndromes

Common clinical presentations in elderly hospitalized patients include dysfunction, delirium, depression, and dementia.

“Some well-designed cohort studies show that 20% to 32% of these patients lose independent performance of one or more basic activities of daily living [ADL] at discharge,” said Dr. Palmer. Basic ADLs include bathing, dressing, moving from bed to chair, using the toilet, and eating. Why is this important? Patients admitted who were dependent in all six basic ADLs were at greater risk for in-hospital mortality or one-year mortality, 90-day nursing home use, and up to 50% higher DRG hospital costs.

“Not all older patients are at risk,” Dr. Palmer assured his audience. Risk factors for functional decline to watch for include patients over 75, those who are cognitively impaired, those dependent in two or more instrumental ADLs (shopping, housekeeping, taking medications), depression, and pressure ulcers.

Focus on Delirium

Dr. Palmer paid special attention to delirium.

“This is the most risky syndrome during hospitalization,” he warned. Delirium, or the acute decline of attention and cognition, can be called several things: acute confusional state, acute change in mental state, metabolic encephalopathy, toxic encephalopathy, acute brain syndrome, or acute toxic psychosis.

However it is categorized, delirium is found in 10% to 15% of hospitalized elders upon admission, and 10% to 15% of elderly patients develop it after admission. In ICUs, 70% to 84% of elderly patients suffer from delirium.

What causes delirium during hospitalization? Risk factors include severe illness, dementia, dehydration, sensory impairments (trouble hearing or seeing), and psychoactive medications. Identifiable precipitants of delirium are the use of physical restraints, malnutrition, the addition of three or more new medications, use of a bladder catheter, and any iatrogenic event.

“The major concern with delirium is the increased risk of mortality,” said Dr. Palmer. “But it also leads to prolonged length of stay, increased costs, and potential nursing home placement upon discharge.”

Diagnosing delirium versus dementia is based on four factors:

• The onset of confusion is abrupt with delirium and gradual for the early stages of dementia;
• Consciousness is fluctuating and clouded with delirium; with dementia it’s not affected;
• Attention span will be reduced with delirium but not with dementia; and
• A delirious patient will show hyperactive or hypoactive psychomotor changes, whereas this change will not show in early stages of dementia.

When evaluating for delirium, search for the cause and any possible precipitating factors, advised Dr. Palmer: “Consider multiple etiologies, and remember that fluctuation in the course is the rule.” Eliminating precipitating factors can help. Evaluation should include a targeted history and physical, and lab work to check things like drug levels and neuroimaging.

You may be able to manage delirium with nonpharmacologic changes in environment such as adding orienting stimuli of clocks, TV, and personal items; minimizing abrupt relocations; and sitting the patient in an upright position. You can also increase sensory input, said Dr. Palmer. You may also try a short course of meds: For severe agitation, haloperidol (0.5 to 1 mg every four hours as needed) or for anxiety symptoms use lorazepam (0.5 to 1 mg every four to six hours as needed).

Dr. Palmer offered a partial list of medications to avoid for elderly patients. “These patients are very vulnerable to bad outcomes,” he warned. His list included:

• Diphenhydramine;
• Hydroxyzine;
• Meperidine;
• Propoxyphene;
• Diazepam;
• Chlordiazepoxide;
• Amitriptyline;
• Imipramine;
• Doxepin;
• Promethazine;
• Prochlorperazine;
• Trimethobenzamide; and
• Famotidine (high dose).

Additionally, you should be aware that the following classes of drugs could cause delirium in the elderly:

• Antidepressants;
• Antianxiety medications;
• Antibiotics;
• Antihypertensives;
• Antihistamines;
• Antiarrhythmics;
• Antipsychotics; and
• Anti-inflammatory medications.

“Basically, any pharmacological class that begins with ‘anti’ should be avoided with elderly patients,” said Dr. Palmer.

Assess and Manage Undernutrition

An astonishing 40% to 60% of hospitalized, ill elderly patients suffer from malnutrition.

“This is often not diagnosed or adequately treated,” said Dr. Palmer. “It’s associated with terrible outcomes of hospital care, including length of stay, mortality, and affected ADL activities.”

There is no single blood test for malnutrition, Dr. Palmer continued, but indicators include a body mass index of less than 19, reduced muscle mass, reduced skin fold thickness, and biochemical measures including serum albumin of less than three and low hemoglobin and serum cholesterol.

To guard against dehydration and undernutrition in your elderly patients, Dr. Palmer advised assessing nutritional status at admission, prescribing and monitoring daily calorie and fluid intake for high-risk patients, giving priority to providing calories over restricted diet, and including consultation with a dietitian.

Take off the Restraints

“Why do we order bed rest for the weak and sick?” asked Dr. Palmer. He urged hospitalists to avoid bed-rest orders and instead encourage elderly patients to get out of bed and get physical activity or even physical therapy for transfer-dependent and gait-impaired patients.

Most of all, he said, “Avoid physical restraints.” These limit mobility, obviously, and can lead to pressure ulcers, deconditioning, falls, constipation, and incontinence.

Where to Send the Patient

Plan for discharging an independent elderly patient back home, not to a nursing home if you can, urged Dr. Palmer.

“Comprehensive discharge planning almost always requires an interdisciplinary team,” he said. “Goals of care and advanced directives should be discussed with the patient and family members, and post acute care needs should be considered.”

Following a “functional trajectory” from admission to discharge begins the first day. Dr. Palmer recommends the hospitalist, a nurse, and the case manager all interview the patient and family, establish a baseline and outline the expected hospital course including estimated length of stay and discharge site—nursing home, skilled nursing facility, or home.

“Work with physical or occupational therapy early to mobilize the patient and improve their functioning,” advised Dr. Palmer.

This type of comprehensive discharge planning, along with home follow-up, has reduced readmission rates. TH

Attendees at the session “Managing Hospitalized Elders,” presented by Robert Palmer, MD, MPH, head of the section of Geriatric Medicine at Cleveland Clinic in Ohio, gained insights into the unique dangers hospitalization presents to their oldest patients.

“As every hospital-based physician knows, increasingly, hospital care is geriatric care,” said Dr. Palmer. “We’re seeing not only more people over 65, we’re seeing more people over age 85—the most complex and challenging cases. The question is, how do we work our way through the chronic diseases, the acute on top of chronic disease, deal with the psychosocial issues and family issues of the frail elderly person during hospitalization.”

The problem is that simply being hospitalized may trigger or exacerbate a functional decline in an elderly patient. Hospitalization itself can lead to delirium, undernutrition, immobility, pressure ulcers, incontinence, and ultimately placement in a nursing home.

“The process of care, a hostile environment, bed rest, starvation, medications—especially those that are inappropriate for use with older people—and depression all conspire to create a dysfunctional older person,” stressed Dr. Palmer. Common co-morbid conditions in the elderly include dehydration, chronic obstructive pulmonary disease (COPD), hypertension, chronic heart failure, diabetes, and anemia.

“We rarely treat these patients for just one condition,” Dr. Palmer pointed out.

Common Geriatric Syndromes

Common clinical presentations in elderly hospitalized patients include dysfunction, delirium, depression, and dementia.

“Some well-designed cohort studies show that 20% to 32% of these patients lose independent performance of one or more basic activities of daily living [ADL] at discharge,” said Dr. Palmer. Basic ADLs include bathing, dressing, moving from bed to chair, using the toilet, and eating. Why is this important? Patients admitted who were dependent in all six basic ADLs were at greater risk for in-hospital mortality or one-year mortality, 90-day nursing home use, and up to 50% higher DRG hospital costs.

“Not all older patients are at risk,” Dr. Palmer assured his audience. Risk factors for functional decline to watch for include patients over 75, those who are cognitively impaired, those dependent in two or more instrumental ADLs (shopping, housekeeping, taking medications), depression, and pressure ulcers.

Focus on Delirium

Dr. Palmer paid special attention to delirium.

“This is the most risky syndrome during hospitalization,” he warned. Delirium, or the acute decline of attention and cognition, can be called several things: acute confusional state, acute change in mental state, metabolic encephalopathy, toxic encephalopathy, acute brain syndrome, or acute toxic psychosis.

However it is categorized, delirium is found in 10% to 15% of hospitalized elders upon admission, and 10% to 15% of elderly patients develop it after admission. In ICUs, 70% to 84% of elderly patients suffer from delirium.

What causes delirium during hospitalization? Risk factors include severe illness, dementia, dehydration, sensory impairments (trouble hearing or seeing), and psychoactive medications. Identifiable precipitants of delirium are the use of physical restraints, malnutrition, the addition of three or more new medications, use of a bladder catheter, and any iatrogenic event.

“The major concern with delirium is the increased risk of mortality,” said Dr. Palmer. “But it also leads to prolonged length of stay, increased costs, and potential nursing home placement upon discharge.”

Diagnosing delirium versus dementia is based on four factors:

• The onset of confusion is abrupt with delirium and gradual for the early stages of dementia;
• Consciousness is fluctuating and clouded with delirium; with dementia it’s not affected;
• Attention span will be reduced with delirium but not with dementia; and
• A delirious patient will show hyperactive or hypoactive psychomotor changes, whereas this change will not show in early stages of dementia.

When evaluating for delirium, search for the cause and any possible precipitating factors, advised Dr. Palmer: “Consider multiple etiologies, and remember that fluctuation in the course is the rule.” Eliminating precipitating factors can help. Evaluation should include a targeted history and physical, and lab work to check things like drug levels and neuroimaging.

You may be able to manage delirium with nonpharmacologic changes in environment such as adding orienting stimuli of clocks, TV, and personal items; minimizing abrupt relocations; and sitting the patient in an upright position. You can also increase sensory input, said Dr. Palmer. You may also try a short course of meds: For severe agitation, haloperidol (0.5 to 1 mg every four hours as needed) or for anxiety symptoms use lorazepam (0.5 to 1 mg every four to six hours as needed).

Dr. Palmer offered a partial list of medications to avoid for elderly patients. “These patients are very vulnerable to bad outcomes,” he warned. His list included:

• Diphenhydramine;
• Hydroxyzine;
• Meperidine;
• Propoxyphene;
• Diazepam;
• Chlordiazepoxide;
• Amitriptyline;
• Imipramine;
• Doxepin;
• Promethazine;
• Prochlorperazine;
• Trimethobenzamide; and
• Famotidine (high dose).

Additionally, you should be aware that the following classes of drugs could cause delirium in the elderly:

• Antidepressants;
• Antianxiety medications;
• Antibiotics;
• Antihypertensives;
• Antihistamines;
• Antiarrhythmics;
• Antipsychotics; and
• Anti-inflammatory medications.

“Basically, any pharmacological class that begins with ‘anti’ should be avoided with elderly patients,” said Dr. Palmer.

Assess and Manage Undernutrition

An astonishing 40% to 60% of hospitalized, ill elderly patients suffer from malnutrition.

“This is often not diagnosed or adequately treated,” said Dr. Palmer. “It’s associated with terrible outcomes of hospital care, including length of stay, mortality, and affected ADL activities.”

There is no single blood test for malnutrition, Dr. Palmer continued, but indicators include a body mass index of less than 19, reduced muscle mass, reduced skin fold thickness, and biochemical measures including serum albumin of less than three and low hemoglobin and serum cholesterol.

To guard against dehydration and undernutrition in your elderly patients, Dr. Palmer advised assessing nutritional status at admission, prescribing and monitoring daily calorie and fluid intake for high-risk patients, giving priority to providing calories over restricted diet, and including consultation with a dietitian.

Take off the Restraints

“Why do we order bed rest for the weak and sick?” asked Dr. Palmer. He urged hospitalists to avoid bed-rest orders and instead encourage elderly patients to get out of bed and get physical activity or even physical therapy for transfer-dependent and gait-impaired patients.

Most of all, he said, “Avoid physical restraints.” These limit mobility, obviously, and can lead to pressure ulcers, deconditioning, falls, constipation, and incontinence.

Where to Send the Patient

Plan for discharging an independent elderly patient back home, not to a nursing home if you can, urged Dr. Palmer.

“Comprehensive discharge planning almost always requires an interdisciplinary team,” he said. “Goals of care and advanced directives should be discussed with the patient and family members, and post acute care needs should be considered.”

Following a “functional trajectory” from admission to discharge begins the first day. Dr. Palmer recommends the hospitalist, a nurse, and the case manager all interview the patient and family, establish a baseline and outline the expected hospital course including estimated length of stay and discharge site—nursing home, skilled nursing facility, or home.

“Work with physical or occupational therapy early to mobilize the patient and improve their functioning,” advised Dr. Palmer.

This type of comprehensive discharge planning, along with home follow-up, has reduced readmission rates. TH

Attendees at the session “Managing Hospitalized Elders,” presented by Robert Palmer, MD, MPH, head of the section of Geriatric Medicine at Cleveland Clinic in Ohio, gained insights into the unique dangers hospitalization presents to their oldest patients.

“As every hospital-based physician knows, increasingly, hospital care is geriatric care,” said Dr. Palmer. “We’re seeing not only more people over 65, we’re seeing more people over age 85—the most complex and challenging cases. The question is, how do we work our way through the chronic diseases, the acute on top of chronic disease, deal with the psychosocial issues and family issues of the frail elderly person during hospitalization.”

The problem is that simply being hospitalized may trigger or exacerbate a functional decline in an elderly patient. Hospitalization itself can lead to delirium, undernutrition, immobility, pressure ulcers, incontinence, and ultimately placement in a nursing home.

“The process of care, a hostile environment, bed rest, starvation, medications—especially those that are inappropriate for use with older people—and depression all conspire to create a dysfunctional older person,” stressed Dr. Palmer. Common co-morbid conditions in the elderly include dehydration, chronic obstructive pulmonary disease (COPD), hypertension, chronic heart failure, diabetes, and anemia.

“We rarely treat these patients for just one condition,” Dr. Palmer pointed out.

Common Geriatric Syndromes

Common clinical presentations in elderly hospitalized patients include dysfunction, delirium, depression, and dementia.

“Some well-designed cohort studies show that 20% to 32% of these patients lose independent performance of one or more basic activities of daily living [ADL] at discharge,” said Dr. Palmer. Basic ADLs include bathing, dressing, moving from bed to chair, using the toilet, and eating. Why is this important? Patients admitted who were dependent in all six basic ADLs were at greater risk for in-hospital mortality or one-year mortality, 90-day nursing home use, and up to 50% higher DRG hospital costs.

“Not all older patients are at risk,” Dr. Palmer assured his audience. Risk factors for functional decline to watch for include patients over 75, those who are cognitively impaired, those dependent in two or more instrumental ADLs (shopping, housekeeping, taking medications), depression, and pressure ulcers.

Focus on Delirium

Dr. Palmer paid special attention to delirium.

“This is the most risky syndrome during hospitalization,” he warned. Delirium, or the acute decline of attention and cognition, can be called several things: acute confusional state, acute change in mental state, metabolic encephalopathy, toxic encephalopathy, acute brain syndrome, or acute toxic psychosis.

However it is categorized, delirium is found in 10% to 15% of hospitalized elders upon admission, and 10% to 15% of elderly patients develop it after admission. In ICUs, 70% to 84% of elderly patients suffer from delirium.

What causes delirium during hospitalization? Risk factors include severe illness, dementia, dehydration, sensory impairments (trouble hearing or seeing), and psychoactive medications. Identifiable precipitants of delirium are the use of physical restraints, malnutrition, the addition of three or more new medications, use of a bladder catheter, and any iatrogenic event.

“The major concern with delirium is the increased risk of mortality,” said Dr. Palmer. “But it also leads to prolonged length of stay, increased costs, and potential nursing home placement upon discharge.”

Diagnosing delirium versus dementia is based on four factors:

• The onset of confusion is abrupt with delirium and gradual for the early stages of dementia;
• Consciousness is fluctuating and clouded with delirium; with dementia it’s not affected;
• Attention span will be reduced with delirium but not with dementia; and
• A delirious patient will show hyperactive or hypoactive psychomotor changes, whereas this change will not show in early stages of dementia.

When evaluating for delirium, search for the cause and any possible precipitating factors, advised Dr. Palmer: “Consider multiple etiologies, and remember that fluctuation in the course is the rule.” Eliminating precipitating factors can help. Evaluation should include a targeted history and physical, and lab work to check things like drug levels and neuroimaging.

You may be able to manage delirium with nonpharmacologic changes in environment such as adding orienting stimuli of clocks, TV, and personal items; minimizing abrupt relocations; and sitting the patient in an upright position. You can also increase sensory input, said Dr. Palmer. You may also try a short course of meds: For severe agitation, haloperidol (0.5 to 1 mg every four hours as needed) or for anxiety symptoms use lorazepam (0.5 to 1 mg every four to six hours as needed).

Dr. Palmer offered a partial list of medications to avoid for elderly patients. “These patients are very vulnerable to bad outcomes,” he warned. His list included:

• Diphenhydramine;
• Hydroxyzine;
• Meperidine;
• Propoxyphene;
• Diazepam;
• Chlordiazepoxide;
• Amitriptyline;
• Imipramine;
• Doxepin;
• Promethazine;
• Prochlorperazine;
• Trimethobenzamide; and
• Famotidine (high dose).

Additionally, you should be aware that the following classes of drugs could cause delirium in the elderly:

• Antidepressants;
• Antianxiety medications;
• Antibiotics;
• Antihypertensives;
• Antihistamines;
• Antiarrhythmics;
• Antipsychotics; and
• Anti-inflammatory medications.

“Basically, any pharmacological class that begins with ‘anti’ should be avoided with elderly patients,” said Dr. Palmer.

Assess and Manage Undernutrition

An astonishing 40% to 60% of hospitalized, ill elderly patients suffer from malnutrition.

“This is often not diagnosed or adequately treated,” said Dr. Palmer. “It’s associated with terrible outcomes of hospital care, including length of stay, mortality, and affected ADL activities.”

There is no single blood test for malnutrition, Dr. Palmer continued, but indicators include a body mass index of less than 19, reduced muscle mass, reduced skin fold thickness, and biochemical measures including serum albumin of less than three and low hemoglobin and serum cholesterol.

To guard against dehydration and undernutrition in your elderly patients, Dr. Palmer advised assessing nutritional status at admission, prescribing and monitoring daily calorie and fluid intake for high-risk patients, giving priority to providing calories over restricted diet, and including consultation with a dietitian.

Take off the Restraints

“Why do we order bed rest for the weak and sick?” asked Dr. Palmer. He urged hospitalists to avoid bed-rest orders and instead encourage elderly patients to get out of bed and get physical activity or even physical therapy for transfer-dependent and gait-impaired patients.

Most of all, he said, “Avoid physical restraints.” These limit mobility, obviously, and can lead to pressure ulcers, deconditioning, falls, constipation, and incontinence.

Where to Send the Patient

Plan for discharging an independent elderly patient back home, not to a nursing home if you can, urged Dr. Palmer.

“Comprehensive discharge planning almost always requires an interdisciplinary team,” he said. “Goals of care and advanced directives should be discussed with the patient and family members, and post acute care needs should be considered.”

Following a “functional trajectory” from admission to discharge begins the first day. Dr. Palmer recommends the hospitalist, a nurse, and the case manager all interview the patient and family, establish a baseline and outline the expected hospital course including estimated length of stay and discharge site—nursing home, skilled nursing facility, or home.

“Work with physical or occupational therapy early to mobilize the patient and improve their functioning,” advised Dr. Palmer.

This type of comprehensive discharge planning, along with home follow-up, has reduced readmission rates. TH

Sunil Kripalani, MD, MSc

In “Developing Hand-off Standards for Hospitalists,” members of an SHM task force on hand-offs presented their findings from an extensive literature review and went on to propose basic standards for hospitalist hand-offs. The speakers included task force members Vineet Arora, MD, MA, assistant professor of medicine, University of Chicago; Lakshmi Halasyamani, MD, associate chairperson of the Department of Internal Medicine at St. Joseph Mercy Hospital in Ann Arbor, Mich.; Sunil Kripalani, MD, MSc, an instructor at Emory University, Atlanta, Ga.; and Efren Manjarrez, MD, assistant clinical professor of medicine at the Miller School of Medicine, University of Miami.

Vineet Arora, MD, MA

Literature Review: Slim Pickings

Although the group hoped to determine best practices based on a literature review of hand-offs, shift changes and handovers (excluding transitions in and out of hospitals) they couldn’t find enough appropriate research to support this goal.

After a PubMed search, and a review of the Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Net—which is a categorized, reviewed collection of articles and references—the task force reported the following: Of the 334 promising articles they initially identified, only 107 were deemed relevant after a title review. And of those, a significant article review found only 10 met the criteria for inclusion. Three studies of hand-offs appeared in nursing publications and were the only provider-specific studies. The remaining seven were studies of technology solutions for hand-offs—although all articles revealed that any technology fixes were “homegrown,” as nothing specific to hand-offs is widely available commercially.

Efren Manjarrez, MD

Those 10 studies included few interventions, with no studies of hospitalist-specific hand-offs. Studies of shift changes predominated, and there were few studies that included patient outcomes.

“A summary of the literature supports the use of supplementing verbal hand-offs with written documentation in some structured format,” said Dr. Manjarrez. “It also showed a technology solution provided added benefits such as reduced rounding time and prep time and increased time with patients.”

The literature summary also suggests involving the patient in the hand-off conversation. “Signing out in front of the patient does wonders for your patient satisfaction rate,” remarked Dr. Manjarrez.

Lakshmi Halasyamani, MD

As part of the literature review, the task force found and examined five major expert consensus and policy white papers deemed relevant to hand-offs. Dr. Arora cited these papers from the Australian Council for Safety and Quality in Healthcare, the British Medical Association Junior Doctors Committee, the University Health Consortium, the Department of Defense Patient Safety Program, and the Joint Commission’s (formerly JCAHO’s) National Patient Safety Goal 2006.

Dr. Arora reminded attendees that the Joint Commission’s National Patient Safety Goal states that, “hospitals should implement a standardized approach to hand-off communications. This applies to all staff, not just physicians.”

Common themes found in the five white papers include:

• Frontline providers must be educated about acceptable hand-off practices;
• Adequate time must be made by all parties for hand-offs, and interruptions should be reduced during hand-off communications;
• Information must be up to date;
• Interactive questioning should be facilitated;
• Ill patients must be made a priority; and
• Actions to be undertaken should be clearly delineated.

Recommended Standards for Hand-offs

Based on their literature review, the SHM task force has created basic standards for hospitalists to use for hand-offs.

“Our standards needed to be broad enough to work at all hospital medicine programs, so they’re pretty basic,” said Dr. Arora. “They’re actually minimal standards to be met—they’re fairly simplistic, and we do not consider them to be best practices by any means.”

The standards begin with what seems like an obvious statement, but a necessary one for some hospital medicine groups: “A formally recognized hand-off plan should be instituted at the end of a shift or a change in service.” The standards also state that, “Effective hand-offs will require not only a program policy, but standards for verbal exchange and content exchange,” said Dr. Arora.

To guide hospital medicine groups through this exchange, the speakers offered three mnemonic devices: The 3 T’s, the 4 I’s and the 3 A’s.

The 3 T’s: Your program should have a policy in place that stipulates:

• Time set aside for hand-offs. Ensure that busy hospitalists have adequate time blocked out.
• Template or technology solution. “You need a structured template to help people do their work,” said Dr. Arora. “The program needs to decide what kind of template to adopt—and a move to standardization meets that Joint Commission goal.”
• Train new staff on hand-off expectations. Keep everyone in your practice, including appropriate hospital staff, in the loop.

The 4 I’s of verbal, or face-to-face, exchange include:

• Interruptions are limited. There will always be interruptions, but you can take steps to limit them during hand-offs by designating a time and/or place as “interruption free,” or having someone cover the pagers of the involved hospitalists during hand-offs.
• Interactive process is used. “There should be some interactive dialogue” between the physicians, insisted Dr. Arora.
• Ill patients are given priority. Make sure that you give your sickest patients top priority during hand-offs.
• Insight given to receiver on what to expect or do. What would you do if you were staying on for the next shift? Give the receiver a list of “to-do” items.

The 3 A’s of content exchange standards are:

• All data are up to date. This can be a real problem in healthcare. Make sure all information you turn over, both written and oral, reflects your latest knowledge.
• Anticipated events are emphasized. “What do you anticipate will be a problem?” asked Dr. Arora. Think this through and let the receiver know.
• Action items are highlighted. Again, include a to-do list with the information.

What’s Next?

The task force didn’t stop with these new basic standards. They put together a research agenda, a “wish list” of what’s needed in hospital medicine research to improve hand-offs.

“We need to use research to evaluate these standards rigorously,” said Dr. Arora. “And we must emphasize controlled interventions because only 10 of the articles we found were controlled interventions. We have to urge the research community to do more in this area.”

The group would also like to encourage the development of patient-based outcomes that are sensitive to hand-off quality. “This is talked about a lot, but few people are doing anything about it,” Dr. Arora pointed out.

And finally, they’d like to enable additional funding for further research on hand-offs.

Attendees at the session were polled on their hand-off practices. By a show of hands, approximately 40% indicated they had a standardized hand-off procedure. However, virtually no one thought their procedure was ideal.

The task force encouraged attendees and other hospitalists to share their thoughts and input on hand-off standards. If you have ideas for the task force, you can e-mail them at handoffs@hospitalmedicine.org.

The task force plans to revise their recommendations, with attention to SHM member input. They’d also like to engage an expert panel for an external review of their work before they disseminate it. TH

Sunil Kripalani, MD, MSc

In “Developing Hand-off Standards for Hospitalists,” members of an SHM task force on hand-offs presented their findings from an extensive literature review and went on to propose basic standards for hospitalist hand-offs. The speakers included task force members Vineet Arora, MD, MA, assistant professor of medicine, University of Chicago; Lakshmi Halasyamani, MD, associate chairperson of the Department of Internal Medicine at St. Joseph Mercy Hospital in Ann Arbor, Mich.; Sunil Kripalani, MD, MSc, an instructor at Emory University, Atlanta, Ga.; and Efren Manjarrez, MD, assistant clinical professor of medicine at the Miller School of Medicine, University of Miami.

Vineet Arora, MD, MA

Literature Review: Slim Pickings

Although the group hoped to determine best practices based on a literature review of hand-offs, shift changes and handovers (excluding transitions in and out of hospitals) they couldn’t find enough appropriate research to support this goal.

After a PubMed search, and a review of the Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Net—which is a categorized, reviewed collection of articles and references—the task force reported the following: Of the 334 promising articles they initially identified, only 107 were deemed relevant after a title review. And of those, a significant article review found only 10 met the criteria for inclusion. Three studies of hand-offs appeared in nursing publications and were the only provider-specific studies. The remaining seven were studies of technology solutions for hand-offs—although all articles revealed that any technology fixes were “homegrown,” as nothing specific to hand-offs is widely available commercially.

Efren Manjarrez, MD

Those 10 studies included few interventions, with no studies of hospitalist-specific hand-offs. Studies of shift changes predominated, and there were few studies that included patient outcomes.

“A summary of the literature supports the use of supplementing verbal hand-offs with written documentation in some structured format,” said Dr. Manjarrez. “It also showed a technology solution provided added benefits such as reduced rounding time and prep time and increased time with patients.”

The literature summary also suggests involving the patient in the hand-off conversation. “Signing out in front of the patient does wonders for your patient satisfaction rate,” remarked Dr. Manjarrez.

Lakshmi Halasyamani, MD

As part of the literature review, the task force found and examined five major expert consensus and policy white papers deemed relevant to hand-offs. Dr. Arora cited these papers from the Australian Council for Safety and Quality in Healthcare, the British Medical Association Junior Doctors Committee, the University Health Consortium, the Department of Defense Patient Safety Program, and the Joint Commission’s (formerly JCAHO’s) National Patient Safety Goal 2006.

Dr. Arora reminded attendees that the Joint Commission’s National Patient Safety Goal states that, “hospitals should implement a standardized approach to hand-off communications. This applies to all staff, not just physicians.”

Common themes found in the five white papers include:

• Frontline providers must be educated about acceptable hand-off practices;
• Adequate time must be made by all parties for hand-offs, and interruptions should be reduced during hand-off communications;
• Information must be up to date;
• Interactive questioning should be facilitated;
• Ill patients must be made a priority; and
• Actions to be undertaken should be clearly delineated.

Recommended Standards for Hand-offs

Based on their literature review, the SHM task force has created basic standards for hospitalists to use for hand-offs.

“Our standards needed to be broad enough to work at all hospital medicine programs, so they’re pretty basic,” said Dr. Arora. “They’re actually minimal standards to be met—they’re fairly simplistic, and we do not consider them to be best practices by any means.”

The standards begin with what seems like an obvious statement, but a necessary one for some hospital medicine groups: “A formally recognized hand-off plan should be instituted at the end of a shift or a change in service.” The standards also state that, “Effective hand-offs will require not only a program policy, but standards for verbal exchange and content exchange,” said Dr. Arora.

To guide hospital medicine groups through this exchange, the speakers offered three mnemonic devices: The 3 T’s, the 4 I’s and the 3 A’s.

The 3 T’s: Your program should have a policy in place that stipulates:

• Time set aside for hand-offs. Ensure that busy hospitalists have adequate time blocked out.
• Template or technology solution. “You need a structured template to help people do their work,” said Dr. Arora. “The program needs to decide what kind of template to adopt—and a move to standardization meets that Joint Commission goal.”
• Train new staff on hand-off expectations. Keep everyone in your practice, including appropriate hospital staff, in the loop.

The 4 I’s of verbal, or face-to-face, exchange include:

• Interruptions are limited. There will always be interruptions, but you can take steps to limit them during hand-offs by designating a time and/or place as “interruption free,” or having someone cover the pagers of the involved hospitalists during hand-offs.
• Interactive process is used. “There should be some interactive dialogue” between the physicians, insisted Dr. Arora.
• Ill patients are given priority. Make sure that you give your sickest patients top priority during hand-offs.
• Insight given to receiver on what to expect or do. What would you do if you were staying on for the next shift? Give the receiver a list of “to-do” items.

The 3 A’s of content exchange standards are:

• All data are up to date. This can be a real problem in healthcare. Make sure all information you turn over, both written and oral, reflects your latest knowledge.
• Anticipated events are emphasized. “What do you anticipate will be a problem?” asked Dr. Arora. Think this through and let the receiver know.
• Action items are highlighted. Again, include a to-do list with the information.

What’s Next?

The task force didn’t stop with these new basic standards. They put together a research agenda, a “wish list” of what’s needed in hospital medicine research to improve hand-offs.

“We need to use research to evaluate these standards rigorously,” said Dr. Arora. “And we must emphasize controlled interventions because only 10 of the articles we found were controlled interventions. We have to urge the research community to do more in this area.”

The group would also like to encourage the development of patient-based outcomes that are sensitive to hand-off quality. “This is talked about a lot, but few people are doing anything about it,” Dr. Arora pointed out.

And finally, they’d like to enable additional funding for further research on hand-offs.

Attendees at the session were polled on their hand-off practices. By a show of hands, approximately 40% indicated they had a standardized hand-off procedure. However, virtually no one thought their procedure was ideal.

The task force encouraged attendees and other hospitalists to share their thoughts and input on hand-off standards. If you have ideas for the task force, you can e-mail them at handoffs@hospitalmedicine.org.

The task force plans to revise their recommendations, with attention to SHM member input. They’d also like to engage an expert panel for an external review of their work before they disseminate it. TH

Sunil Kripalani, MD, MSc

In “Developing Hand-off Standards for Hospitalists,” members of an SHM task force on hand-offs presented their findings from an extensive literature review and went on to propose basic standards for hospitalist hand-offs. The speakers included task force members Vineet Arora, MD, MA, assistant professor of medicine, University of Chicago; Lakshmi Halasyamani, MD, associate chairperson of the Department of Internal Medicine at St. Joseph Mercy Hospital in Ann Arbor, Mich.; Sunil Kripalani, MD, MSc, an instructor at Emory University, Atlanta, Ga.; and Efren Manjarrez, MD, assistant clinical professor of medicine at the Miller School of Medicine, University of Miami.

Vineet Arora, MD, MA

Literature Review: Slim Pickings

Although the group hoped to determine best practices based on a literature review of hand-offs, shift changes and handovers (excluding transitions in and out of hospitals) they couldn’t find enough appropriate research to support this goal.

After a PubMed search, and a review of the Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Net—which is a categorized, reviewed collection of articles and references—the task force reported the following: Of the 334 promising articles they initially identified, only 107 were deemed relevant after a title review. And of those, a significant article review found only 10 met the criteria for inclusion. Three studies of hand-offs appeared in nursing publications and were the only provider-specific studies. The remaining seven were studies of technology solutions for hand-offs—although all articles revealed that any technology fixes were “homegrown,” as nothing specific to hand-offs is widely available commercially.

Efren Manjarrez, MD

Those 10 studies included few interventions, with no studies of hospitalist-specific hand-offs. Studies of shift changes predominated, and there were few studies that included patient outcomes.

“A summary of the literature supports the use of supplementing verbal hand-offs with written documentation in some structured format,” said Dr. Manjarrez. “It also showed a technology solution provided added benefits such as reduced rounding time and prep time and increased time with patients.”

The literature summary also suggests involving the patient in the hand-off conversation. “Signing out in front of the patient does wonders for your patient satisfaction rate,” remarked Dr. Manjarrez.

Lakshmi Halasyamani, MD

As part of the literature review, the task force found and examined five major expert consensus and policy white papers deemed relevant to hand-offs. Dr. Arora cited these papers from the Australian Council for Safety and Quality in Healthcare, the British Medical Association Junior Doctors Committee, the University Health Consortium, the Department of Defense Patient Safety Program, and the Joint Commission’s (formerly JCAHO’s) National Patient Safety Goal 2006.

Dr. Arora reminded attendees that the Joint Commission’s National Patient Safety Goal states that, “hospitals should implement a standardized approach to hand-off communications. This applies to all staff, not just physicians.”

Common themes found in the five white papers include:

• Frontline providers must be educated about acceptable hand-off practices;
• Adequate time must be made by all parties for hand-offs, and interruptions should be reduced during hand-off communications;
• Information must be up to date;
• Interactive questioning should be facilitated;
• Ill patients must be made a priority; and
• Actions to be undertaken should be clearly delineated.

Recommended Standards for Hand-offs

Based on their literature review, the SHM task force has created basic standards for hospitalists to use for hand-offs.

“Our standards needed to be broad enough to work at all hospital medicine programs, so they’re pretty basic,” said Dr. Arora. “They’re actually minimal standards to be met—they’re fairly simplistic, and we do not consider them to be best practices by any means.”

The standards begin with what seems like an obvious statement, but a necessary one for some hospital medicine groups: “A formally recognized hand-off plan should be instituted at the end of a shift or a change in service.” The standards also state that, “Effective hand-offs will require not only a program policy, but standards for verbal exchange and content exchange,” said Dr. Arora.

To guide hospital medicine groups through this exchange, the speakers offered three mnemonic devices: The 3 T’s, the 4 I’s and the 3 A’s.

The 3 T’s: Your program should have a policy in place that stipulates:

• Time set aside for hand-offs. Ensure that busy hospitalists have adequate time blocked out.
• Template or technology solution. “You need a structured template to help people do their work,” said Dr. Arora. “The program needs to decide what kind of template to adopt—and a move to standardization meets that Joint Commission goal.”
• Train new staff on hand-off expectations. Keep everyone in your practice, including appropriate hospital staff, in the loop.

The 4 I’s of verbal, or face-to-face, exchange include:

• Interruptions are limited. There will always be interruptions, but you can take steps to limit them during hand-offs by designating a time and/or place as “interruption free,” or having someone cover the pagers of the involved hospitalists during hand-offs.
• Interactive process is used. “There should be some interactive dialogue” between the physicians, insisted Dr. Arora.
• Ill patients are given priority. Make sure that you give your sickest patients top priority during hand-offs.
• Insight given to receiver on what to expect or do. What would you do if you were staying on for the next shift? Give the receiver a list of “to-do” items.

The 3 A’s of content exchange standards are:

• All data are up to date. This can be a real problem in healthcare. Make sure all information you turn over, both written and oral, reflects your latest knowledge.
• Anticipated events are emphasized. “What do you anticipate will be a problem?” asked Dr. Arora. Think this through and let the receiver know.
• Action items are highlighted. Again, include a to-do list with the information.

What’s Next?

The task force didn’t stop with these new basic standards. They put together a research agenda, a “wish list” of what’s needed in hospital medicine research to improve hand-offs.

“We need to use research to evaluate these standards rigorously,” said Dr. Arora. “And we must emphasize controlled interventions because only 10 of the articles we found were controlled interventions. We have to urge the research community to do more in this area.”

The group would also like to encourage the development of patient-based outcomes that are sensitive to hand-off quality. “This is talked about a lot, but few people are doing anything about it,” Dr. Arora pointed out.

And finally, they’d like to enable additional funding for further research on hand-offs.

Attendees at the session were polled on their hand-off practices. By a show of hands, approximately 40% indicated they had a standardized hand-off procedure. However, virtually no one thought their procedure was ideal.

The task force encouraged attendees and other hospitalists to share their thoughts and input on hand-off standards. If you have ideas for the task force, you can e-mail them at handoffs@hospitalmedicine.org.

The task force plans to revise their recommendations, with attention to SHM member input. They’d also like to engage an expert panel for an external review of their work before they disseminate it. TH