Karla Feuer

Like many family medicine practices, Chris Heck, MD’s, group in Waynesboro, Va., made the tough decision two years ago to limit their practice to outpatient services. According to Dr. Heck, one partner, Tom McNamara, DO, MMM, CPE, was reluctant to give up hospital work.

So, maybe it’s not surprising Dr. McNamara now fills a unique dual role, as president and chief executive officer and a working hospitalist at Carilion Stonewall Jackson Hospital in Lexington, Va. Dr. McNamara is the first physician CEO at Stonewall Jackson, and the first doctor of osteopathic medicine CEO at one of the hospitals in the Carilion Clinic, a Virginia-based multispecialty organization with more than 400 doctors and eight hospitals.

Serving double duty as CEO and a hospitalist at a critical-access, 25-bed hospital seems to suit Dr. McNamara. “It has allowed me to quickly and thoroughly learn about our staff and our patients,” he says. “And it has given me insight into quality, cost, and feedback programs from both sides, so that I can make informed decisions.”

Both Perspectives

When Dr. McNamara first agreed to be CEO and work shifts, he feared he might have difficulty considering doctors’ requests impartially, or that physicians might feel uneasy working with their boss during patient encounters.

Neither fear has panned out. He says the physicians and recruits he works with generally feel they have an advocate in the executive suite. In addition, when they come to him with suggestions and requests, “they bring very thorough arguments because they know I know exactly where they’re coming from,” he adds.

Dr. McNamara already has put this unique perspective to use several times since taking the jobs in April. For example, when he started the staff was experiencing glitches when filing lab reports in patients’ electronic health records. “They were changing the process when I came in, but since I had broad experiences,” he says, “I was able to help make the changes smoother.”

Dr. McNamara also improved the hospital’s hand-washing practices by having dispensers placed in hallways, where their use could be more readily observed. The idea was to increase documentation of hand washing. “I had this thought because I had used the dispensers [at another hospital] myself,” he says.

Dr. McNamara’s hands-on experience also has made the hospitalist recruiting process easier, according to Howard Graman, MD, medical director of Carilion. “[Dr. McNamara] knows the profile of the job and the kind of person who would like it,” Dr. Graman says. “He’s a savvy judge of character.”

Double-Duty Accolades

Dr. McNamara’s bosses are happy with how he has handled the juggling act, so far. Dr. Graman says Dr. McNamara has helped him to better understand the institution, how to make improvements, and how to respond to staff. “It’s great for employees to see the head of the hospital working,” he says.

The man Dr. McNamara replaced, Steve Arner, now vice president of cardiac and vascular services for a larger Carilion hospital, agrees there are advantages to having the hospital’s CEO also be a working physician. “On the floor or in the emergency department, [Tom] can test the processes, especially new ones,” Arner says, “and see first hand the impact on practitioners and patients.”

Dr. McNamara peers think he’s effective in both of his roles. “As CEO, Tom may touch a dozen topics in a given day,” Arner says. “The boiler breaks, he does a community lecture, talks to unhappy cafeteria workers. It’s so many different things.” Because Dr. McNamara is a working physician, his words greatly affect the groups he lectures. “The fact that he is still treating patients builds confidence, especially in a small community, that the hospital is a high-quality institution,” Dr. Arner adds.

Even the nursing department is in Dr. McNamara’s corner. Shelia Hatmaker, Stonewall Jackson’s director of nursing for more than two years, appreciates the fact Dr. McNamara respects the role of nurses and understands how to address nurse-specific issues. “Tom values the partnership with nurses who are with the patients all day,” Hatmaker says. “He is my boss, but he respects and seeks out opinions from a nursing point of view.”

As CEO, “Tom can create an environment where the staff feels safe to practice and speak up when something is wrong,” she says. “They have to feel comfortable saying they almost made a mistake, because it’s often the system that needs changing.”

Agent of Change

Those system changes are now Dr. McNamara’s problem, but he’s well prepared, having earned a master’s degree in medical management from Carnegie Mellon University in 2006, 19 years after finishing his residency in family practice at McKeesport Hospital in Pennsylvania, and receiving certifications from the American College of Physician Executives.

Nevertheless, Dr. McNamara had serious reservations about leaving clinical medicine. “Clinical medicine is why I became a doctor in the first place,” he says.

Working as a hospitalist and serving as the hospital’s chief executive allows Dr. McNamara to provide patient care and lead at the same time, setting an example for admission-time standards, physician-to-physician communication, and relationships with specialists, nurses, and ancillary staff, says Dennis Means, MD, also a member of the Carilion management team. From a practical point of view, it also gives the regularly rotating doctors a break. Dr. McNamara works weekend shifts every few weeks.

Still, the new CEO has more than patient care to consider. “I’ve really been struck by how high costs are and how much reimbursements are being cut back,” he says. “I was always aware of cost issues, but now I have to figure out the best way to use our scarce resources. It doesn’t change what I do for patients, but I’m even more aware that money is very tight and I have to recognize that we can’t meet every need.”

It helps to be part of the larger Carilion system, as Stonewall Jackson is in the process of integrating with the other Carilion facilities. “We are a very small facility providing basic services, but we can tap into the capabilities of much larger Carilion institutions and people to serve this community,” Dr. McNamara says.

Hatmaker, the nursing director, isn’t surprised to hear that’s how Dr. McNamara the new CEO feels. “That’s Tom,” she says. “He wants to take care of this community. And the patients just might have the head of the hospital as their doctor. How cool.” TH

Like many family medicine practices, Chris Heck, MD’s, group in Waynesboro, Va., made the tough decision two years ago to limit their practice to outpatient services. According to Dr. Heck, one partner, Tom McNamara, DO, MMM, CPE, was reluctant to give up hospital work.

So, maybe it’s not surprising Dr. McNamara now fills a unique dual role, as president and chief executive officer and a working hospitalist at Carilion Stonewall Jackson Hospital in Lexington, Va. Dr. McNamara is the first physician CEO at Stonewall Jackson, and the first doctor of osteopathic medicine CEO at one of the hospitals in the Carilion Clinic, a Virginia-based multispecialty organization with more than 400 doctors and eight hospitals.

Serving double duty as CEO and a hospitalist at a critical-access, 25-bed hospital seems to suit Dr. McNamara. “It has allowed me to quickly and thoroughly learn about our staff and our patients,” he says. “And it has given me insight into quality, cost, and feedback programs from both sides, so that I can make informed decisions.”

Both Perspectives

When Dr. McNamara first agreed to be CEO and work shifts, he feared he might have difficulty considering doctors’ requests impartially, or that physicians might feel uneasy working with their boss during patient encounters.

Neither fear has panned out. He says the physicians and recruits he works with generally feel they have an advocate in the executive suite. In addition, when they come to him with suggestions and requests, “they bring very thorough arguments because they know I know exactly where they’re coming from,” he adds.

Dr. McNamara already has put this unique perspective to use several times since taking the jobs in April. For example, when he started the staff was experiencing glitches when filing lab reports in patients’ electronic health records. “They were changing the process when I came in, but since I had broad experiences,” he says, “I was able to help make the changes smoother.”

Dr. McNamara also improved the hospital’s hand-washing practices by having dispensers placed in hallways, where their use could be more readily observed. The idea was to increase documentation of hand washing. “I had this thought because I had used the dispensers [at another hospital] myself,” he says.

Dr. McNamara’s hands-on experience also has made the hospitalist recruiting process easier, according to Howard Graman, MD, medical director of Carilion. “[Dr. McNamara] knows the profile of the job and the kind of person who would like it,” Dr. Graman says. “He’s a savvy judge of character.”

Double-Duty Accolades

Dr. McNamara’s bosses are happy with how he has handled the juggling act, so far. Dr. Graman says Dr. McNamara has helped him to better understand the institution, how to make improvements, and how to respond to staff. “It’s great for employees to see the head of the hospital working,” he says.

The man Dr. McNamara replaced, Steve Arner, now vice president of cardiac and vascular services for a larger Carilion hospital, agrees there are advantages to having the hospital’s CEO also be a working physician. “On the floor or in the emergency department, [Tom] can test the processes, especially new ones,” Arner says, “and see first hand the impact on practitioners and patients.”

Dr. McNamara peers think he’s effective in both of his roles. “As CEO, Tom may touch a dozen topics in a given day,” Arner says. “The boiler breaks, he does a community lecture, talks to unhappy cafeteria workers. It’s so many different things.” Because Dr. McNamara is a working physician, his words greatly affect the groups he lectures. “The fact that he is still treating patients builds confidence, especially in a small community, that the hospital is a high-quality institution,” Dr. Arner adds.

Even the nursing department is in Dr. McNamara’s corner. Shelia Hatmaker, Stonewall Jackson’s director of nursing for more than two years, appreciates the fact Dr. McNamara respects the role of nurses and understands how to address nurse-specific issues. “Tom values the partnership with nurses who are with the patients all day,” Hatmaker says. “He is my boss, but he respects and seeks out opinions from a nursing point of view.”

As CEO, “Tom can create an environment where the staff feels safe to practice and speak up when something is wrong,” she says. “They have to feel comfortable saying they almost made a mistake, because it’s often the system that needs changing.”

Agent of Change

Those system changes are now Dr. McNamara’s problem, but he’s well prepared, having earned a master’s degree in medical management from Carnegie Mellon University in 2006, 19 years after finishing his residency in family practice at McKeesport Hospital in Pennsylvania, and receiving certifications from the American College of Physician Executives.

Nevertheless, Dr. McNamara had serious reservations about leaving clinical medicine. “Clinical medicine is why I became a doctor in the first place,” he says.

Working as a hospitalist and serving as the hospital’s chief executive allows Dr. McNamara to provide patient care and lead at the same time, setting an example for admission-time standards, physician-to-physician communication, and relationships with specialists, nurses, and ancillary staff, says Dennis Means, MD, also a member of the Carilion management team. From a practical point of view, it also gives the regularly rotating doctors a break. Dr. McNamara works weekend shifts every few weeks.

Still, the new CEO has more than patient care to consider. “I’ve really been struck by how high costs are and how much reimbursements are being cut back,” he says. “I was always aware of cost issues, but now I have to figure out the best way to use our scarce resources. It doesn’t change what I do for patients, but I’m even more aware that money is very tight and I have to recognize that we can’t meet every need.”

It helps to be part of the larger Carilion system, as Stonewall Jackson is in the process of integrating with the other Carilion facilities. “We are a very small facility providing basic services, but we can tap into the capabilities of much larger Carilion institutions and people to serve this community,” Dr. McNamara says.

Hatmaker, the nursing director, isn’t surprised to hear that’s how Dr. McNamara the new CEO feels. “That’s Tom,” she says. “He wants to take care of this community. And the patients just might have the head of the hospital as their doctor. How cool.” TH

Like many family medicine practices, Chris Heck, MD’s, group in Waynesboro, Va., made the tough decision two years ago to limit their practice to outpatient services. According to Dr. Heck, one partner, Tom McNamara, DO, MMM, CPE, was reluctant to give up hospital work.

So, maybe it’s not surprising Dr. McNamara now fills a unique dual role, as president and chief executive officer and a working hospitalist at Carilion Stonewall Jackson Hospital in Lexington, Va. Dr. McNamara is the first physician CEO at Stonewall Jackson, and the first doctor of osteopathic medicine CEO at one of the hospitals in the Carilion Clinic, a Virginia-based multispecialty organization with more than 400 doctors and eight hospitals.

Serving double duty as CEO and a hospitalist at a critical-access, 25-bed hospital seems to suit Dr. McNamara. “It has allowed me to quickly and thoroughly learn about our staff and our patients,” he says. “And it has given me insight into quality, cost, and feedback programs from both sides, so that I can make informed decisions.”

Both Perspectives

When Dr. McNamara first agreed to be CEO and work shifts, he feared he might have difficulty considering doctors’ requests impartially, or that physicians might feel uneasy working with their boss during patient encounters.

Neither fear has panned out. He says the physicians and recruits he works with generally feel they have an advocate in the executive suite. In addition, when they come to him with suggestions and requests, “they bring very thorough arguments because they know I know exactly where they’re coming from,” he adds.

Dr. McNamara already has put this unique perspective to use several times since taking the jobs in April. For example, when he started the staff was experiencing glitches when filing lab reports in patients’ electronic health records. “They were changing the process when I came in, but since I had broad experiences,” he says, “I was able to help make the changes smoother.”

Dr. McNamara also improved the hospital’s hand-washing practices by having dispensers placed in hallways, where their use could be more readily observed. The idea was to increase documentation of hand washing. “I had this thought because I had used the dispensers [at another hospital] myself,” he says.

Dr. McNamara’s hands-on experience also has made the hospitalist recruiting process easier, according to Howard Graman, MD, medical director of Carilion. “[Dr. McNamara] knows the profile of the job and the kind of person who would like it,” Dr. Graman says. “He’s a savvy judge of character.”

Double-Duty Accolades

Dr. McNamara’s bosses are happy with how he has handled the juggling act, so far. Dr. Graman says Dr. McNamara has helped him to better understand the institution, how to make improvements, and how to respond to staff. “It’s great for employees to see the head of the hospital working,” he says.

The man Dr. McNamara replaced, Steve Arner, now vice president of cardiac and vascular services for a larger Carilion hospital, agrees there are advantages to having the hospital’s CEO also be a working physician. “On the floor or in the emergency department, [Tom] can test the processes, especially new ones,” Arner says, “and see first hand the impact on practitioners and patients.”

Dr. McNamara peers think he’s effective in both of his roles. “As CEO, Tom may touch a dozen topics in a given day,” Arner says. “The boiler breaks, he does a community lecture, talks to unhappy cafeteria workers. It’s so many different things.” Because Dr. McNamara is a working physician, his words greatly affect the groups he lectures. “The fact that he is still treating patients builds confidence, especially in a small community, that the hospital is a high-quality institution,” Dr. Arner adds.

Even the nursing department is in Dr. McNamara’s corner. Shelia Hatmaker, Stonewall Jackson’s director of nursing for more than two years, appreciates the fact Dr. McNamara respects the role of nurses and understands how to address nurse-specific issues. “Tom values the partnership with nurses who are with the patients all day,” Hatmaker says. “He is my boss, but he respects and seeks out opinions from a nursing point of view.”

As CEO, “Tom can create an environment where the staff feels safe to practice and speak up when something is wrong,” she says. “They have to feel comfortable saying they almost made a mistake, because it’s often the system that needs changing.”

Agent of Change

Those system changes are now Dr. McNamara’s problem, but he’s well prepared, having earned a master’s degree in medical management from Carnegie Mellon University in 2006, 19 years after finishing his residency in family practice at McKeesport Hospital in Pennsylvania, and receiving certifications from the American College of Physician Executives.

Nevertheless, Dr. McNamara had serious reservations about leaving clinical medicine. “Clinical medicine is why I became a doctor in the first place,” he says.

Working as a hospitalist and serving as the hospital’s chief executive allows Dr. McNamara to provide patient care and lead at the same time, setting an example for admission-time standards, physician-to-physician communication, and relationships with specialists, nurses, and ancillary staff, says Dennis Means, MD, also a member of the Carilion management team. From a practical point of view, it also gives the regularly rotating doctors a break. Dr. McNamara works weekend shifts every few weeks.

Still, the new CEO has more than patient care to consider. “I’ve really been struck by how high costs are and how much reimbursements are being cut back,” he says. “I was always aware of cost issues, but now I have to figure out the best way to use our scarce resources. It doesn’t change what I do for patients, but I’m even more aware that money is very tight and I have to recognize that we can’t meet every need.”

It helps to be part of the larger Carilion system, as Stonewall Jackson is in the process of integrating with the other Carilion facilities. “We are a very small facility providing basic services, but we can tap into the capabilities of much larger Carilion institutions and people to serve this community,” Dr. McNamara says.

Hatmaker, the nursing director, isn’t surprised to hear that’s how Dr. McNamara the new CEO feels. “That’s Tom,” she says. “He wants to take care of this community. And the patients just might have the head of the hospital as their doctor. How cool.” TH

With hospitalists playing key roles in improving transitions in care, a new study has tested a low-cost process that shows increases in outpatient follow-up and completed workups soon after hospital discharge.

The improvements potentially could lead to better patient outcomes and lower readmission rates, according to Richard B. Balaban, MD, who as the medical director of Cambridge Health Alliance’s (CHA) Somerville, Mass., primary-care center and a hospitalist at CHA’s Cambridge Hospital has a unique, dual perspective on the discharge process.

Dr. Balaban’s team’s discharge-transfer intervention process, tested in one of the few randomized controlled studies on the subject of transitions of care, is intended to improve communication between hospitalists and primary-care providers, as well as promptly connect inpatients to outpatient providers. It’s also designed to better equip patients to participate in their care and to improve accountability within the medical team.

The study, published in the August 2008 issue of the Journal of General Internal Medicine, garnered praise from Mark Williams, MD, FACP, professor and chief of the Division of Hospital Medicine at Northwestern University’s Feinberg School of Medicine in Chicago and principal investigator of SHM’s Project BOOST study (see “BOOST Sites Chosen,” August 2008, p. 1), which is examining ways to improve transitions of care.1 “This small but well-done study demonstrates how using interventions similar to components in the Project BOOST toolkit resulted in a significant improvement in outpatient follow-up, and a trend toward a reduction in hospitalizations and emergency room visits,” Dr. Williams says.

The four-part process calls for:

• The patient to receive a comprehensive, “user-friendly” discharge instruction form;
• Electronic transfer of the discharge instruction form to RNs at the patient’s primary-care site;
• A primary-care RN to call the patient by the next business day to monitor his or her condition; and
• The review and modification of the discharge plan by the primary-care provider as needed.

The research team, which included Joel S. Weissman, PhD, of Massachusetts General Hospital, Harvard Medical School, and the Harvard School of Public Health; Peter A. Samuel of Harvard Medical School; and Stephanie Woolhandler, MD, of CHA and Harvard Medical School, thinks the discharge process, a key task for hospitalists, should be treated as vital as the admissions process. “Hospitalists need to improve the level of detail in discharge plans; this form and process supports that,” Dr. Balaban says. By providing this quality information to outpatient providers, collaboration is improved, making hospitalists more effective, he says.

Proof in the Pudding

The process was tested at Somerville Hospital, a 100-bed community hospital and teaching facility affiliated with Harvard Medical School. Approx-imately 25% of Somerville’s patients are non-English-speakers; the process was designed to serve a culturally diverse population.

All patients in the study, conducted between June 2006 and January 2007, had received care from hospitalist-led teams and received outpatient care at CHA facilities. Ninety-six patients were studied; 47 took part in the new discharge process and the rest were discharged according to existing procedures. Outcomes were compared with those of 100 patients who previously had been discharged from the hospital.

The team measured four undesirable outcomes after discharge:

• No outpatient follow-up within 21 days;
• Readmission within 31 days;
• Emergency department visit within 31 days; and
• Failure by the primary-care provider to complete an outpatient workup recommended by hospital doctors.

The study found just 25.5% of the patients who completed the new process had one or more undesirable outcomes, compared with 55.1% of the control group patients and 55% in the historical group. The most significant improvements were in the rates of outpatient follow-up and completed workups (see “Better Process Equals Better Outcomes”).

The process was especially effective among patients discharged on weekends, and had a greater effect on patients who did not speak English, were hospitalized one or two days, and were age 60 and older. The effect of the new process also was evident in outpatient treatment, Dr. Balaban says. At least seven of the 47 patients discharged through the new process had their treatment plan changed by the RNs who made the follow-up phone call. “They weren’t big changes, things like calling in prescriptions and making urgent appointments,” he says, “but they made a difference: for example, providing a pneumonia patient with a thermometer to monitor possible infections, and a scale so that a patient with congestive heart failure could monitor weight gain possibly caused by harmful retention of fluid.”

Dr. Balaban’s team plans to conduct a larger study, though not randomized, at Cambridge Hospital to test the new process on all discharges. “There usually is little collaboration on discharges,” Dr. Balaban says. “This process provides detail, a record of critical information, and creates interchange between care teams. Discharge should be looked at as a continuing, key part of care.” TH

Karla Feuer is a freelance writer based in North Carolina.

Reference

1. Balaban RB, Weissmann JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med. 2008;8:1228-1233.

With hospitalists playing key roles in improving transitions in care, a new study has tested a low-cost process that shows increases in outpatient follow-up and completed workups soon after hospital discharge.

The improvements potentially could lead to better patient outcomes and lower readmission rates, according to Richard B. Balaban, MD, who as the medical director of Cambridge Health Alliance’s (CHA) Somerville, Mass., primary-care center and a hospitalist at CHA’s Cambridge Hospital has a unique, dual perspective on the discharge process.

Dr. Balaban’s team’s discharge-transfer intervention process, tested in one of the few randomized controlled studies on the subject of transitions of care, is intended to improve communication between hospitalists and primary-care providers, as well as promptly connect inpatients to outpatient providers. It’s also designed to better equip patients to participate in their care and to improve accountability within the medical team.

The study, published in the August 2008 issue of the Journal of General Internal Medicine, garnered praise from Mark Williams, MD, FACP, professor and chief of the Division of Hospital Medicine at Northwestern University’s Feinberg School of Medicine in Chicago and principal investigator of SHM’s Project BOOST study (see “BOOST Sites Chosen,” August 2008, p. 1), which is examining ways to improve transitions of care.1 “This small but well-done study demonstrates how using interventions similar to components in the Project BOOST toolkit resulted in a significant improvement in outpatient follow-up, and a trend toward a reduction in hospitalizations and emergency room visits,” Dr. Williams says.

The four-part process calls for:

• The patient to receive a comprehensive, “user-friendly” discharge instruction form;
• Electronic transfer of the discharge instruction form to RNs at the patient’s primary-care site;
• A primary-care RN to call the patient by the next business day to monitor his or her condition; and
• The review and modification of the discharge plan by the primary-care provider as needed.

The research team, which included Joel S. Weissman, PhD, of Massachusetts General Hospital, Harvard Medical School, and the Harvard School of Public Health; Peter A. Samuel of Harvard Medical School; and Stephanie Woolhandler, MD, of CHA and Harvard Medical School, thinks the discharge process, a key task for hospitalists, should be treated as vital as the admissions process. “Hospitalists need to improve the level of detail in discharge plans; this form and process supports that,” Dr. Balaban says. By providing this quality information to outpatient providers, collaboration is improved, making hospitalists more effective, he says.

Proof in the Pudding

The process was tested at Somerville Hospital, a 100-bed community hospital and teaching facility affiliated with Harvard Medical School. Approx-imately 25% of Somerville’s patients are non-English-speakers; the process was designed to serve a culturally diverse population.

All patients in the study, conducted between June 2006 and January 2007, had received care from hospitalist-led teams and received outpatient care at CHA facilities. Ninety-six patients were studied; 47 took part in the new discharge process and the rest were discharged according to existing procedures. Outcomes were compared with those of 100 patients who previously had been discharged from the hospital.

The team measured four undesirable outcomes after discharge:

• No outpatient follow-up within 21 days;
• Readmission within 31 days;
• Emergency department visit within 31 days; and
• Failure by the primary-care provider to complete an outpatient workup recommended by hospital doctors.

The study found just 25.5% of the patients who completed the new process had one or more undesirable outcomes, compared with 55.1% of the control group patients and 55% in the historical group. The most significant improvements were in the rates of outpatient follow-up and completed workups (see “Better Process Equals Better Outcomes”).

The process was especially effective among patients discharged on weekends, and had a greater effect on patients who did not speak English, were hospitalized one or two days, and were age 60 and older. The effect of the new process also was evident in outpatient treatment, Dr. Balaban says. At least seven of the 47 patients discharged through the new process had their treatment plan changed by the RNs who made the follow-up phone call. “They weren’t big changes, things like calling in prescriptions and making urgent appointments,” he says, “but they made a difference: for example, providing a pneumonia patient with a thermometer to monitor possible infections, and a scale so that a patient with congestive heart failure could monitor weight gain possibly caused by harmful retention of fluid.”

Dr. Balaban’s team plans to conduct a larger study, though not randomized, at Cambridge Hospital to test the new process on all discharges. “There usually is little collaboration on discharges,” Dr. Balaban says. “This process provides detail, a record of critical information, and creates interchange between care teams. Discharge should be looked at as a continuing, key part of care.” TH

Karla Feuer is a freelance writer based in North Carolina.

Reference

1. Balaban RB, Weissmann JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med. 2008;8:1228-1233.

With hospitalists playing key roles in improving transitions in care, a new study has tested a low-cost process that shows increases in outpatient follow-up and completed workups soon after hospital discharge.

The improvements potentially could lead to better patient outcomes and lower readmission rates, according to Richard B. Balaban, MD, who as the medical director of Cambridge Health Alliance’s (CHA) Somerville, Mass., primary-care center and a hospitalist at CHA’s Cambridge Hospital has a unique, dual perspective on the discharge process.

Dr. Balaban’s team’s discharge-transfer intervention process, tested in one of the few randomized controlled studies on the subject of transitions of care, is intended to improve communication between hospitalists and primary-care providers, as well as promptly connect inpatients to outpatient providers. It’s also designed to better equip patients to participate in their care and to improve accountability within the medical team.

The study, published in the August 2008 issue of the Journal of General Internal Medicine, garnered praise from Mark Williams, MD, FACP, professor and chief of the Division of Hospital Medicine at Northwestern University’s Feinberg School of Medicine in Chicago and principal investigator of SHM’s Project BOOST study (see “BOOST Sites Chosen,” August 2008, p. 1), which is examining ways to improve transitions of care.1 “This small but well-done study demonstrates how using interventions similar to components in the Project BOOST toolkit resulted in a significant improvement in outpatient follow-up, and a trend toward a reduction in hospitalizations and emergency room visits,” Dr. Williams says.

The four-part process calls for:

• The patient to receive a comprehensive, “user-friendly” discharge instruction form;
• Electronic transfer of the discharge instruction form to RNs at the patient’s primary-care site;
• A primary-care RN to call the patient by the next business day to monitor his or her condition; and
• The review and modification of the discharge plan by the primary-care provider as needed.

The research team, which included Joel S. Weissman, PhD, of Massachusetts General Hospital, Harvard Medical School, and the Harvard School of Public Health; Peter A. Samuel of Harvard Medical School; and Stephanie Woolhandler, MD, of CHA and Harvard Medical School, thinks the discharge process, a key task for hospitalists, should be treated as vital as the admissions process. “Hospitalists need to improve the level of detail in discharge plans; this form and process supports that,” Dr. Balaban says. By providing this quality information to outpatient providers, collaboration is improved, making hospitalists more effective, he says.

Proof in the Pudding

The process was tested at Somerville Hospital, a 100-bed community hospital and teaching facility affiliated with Harvard Medical School. Approx-imately 25% of Somerville’s patients are non-English-speakers; the process was designed to serve a culturally diverse population.

All patients in the study, conducted between June 2006 and January 2007, had received care from hospitalist-led teams and received outpatient care at CHA facilities. Ninety-six patients were studied; 47 took part in the new discharge process and the rest were discharged according to existing procedures. Outcomes were compared with those of 100 patients who previously had been discharged from the hospital.

The team measured four undesirable outcomes after discharge:

• No outpatient follow-up within 21 days;
• Readmission within 31 days;
• Emergency department visit within 31 days; and
• Failure by the primary-care provider to complete an outpatient workup recommended by hospital doctors.

The study found just 25.5% of the patients who completed the new process had one or more undesirable outcomes, compared with 55.1% of the control group patients and 55% in the historical group. The most significant improvements were in the rates of outpatient follow-up and completed workups (see “Better Process Equals Better Outcomes”).

The process was especially effective among patients discharged on weekends, and had a greater effect on patients who did not speak English, were hospitalized one or two days, and were age 60 and older. The effect of the new process also was evident in outpatient treatment, Dr. Balaban says. At least seven of the 47 patients discharged through the new process had their treatment plan changed by the RNs who made the follow-up phone call. “They weren’t big changes, things like calling in prescriptions and making urgent appointments,” he says, “but they made a difference: for example, providing a pneumonia patient with a thermometer to monitor possible infections, and a scale so that a patient with congestive heart failure could monitor weight gain possibly caused by harmful retention of fluid.”

Dr. Balaban’s team plans to conduct a larger study, though not randomized, at Cambridge Hospital to test the new process on all discharges. “There usually is little collaboration on discharges,” Dr. Balaban says. “This process provides detail, a record of critical information, and creates interchange between care teams. Discharge should be looked at as a continuing, key part of care.” TH

Karla Feuer is a freelance writer based in North Carolina.

Reference

1. Balaban RB, Weissmann JS, Samuel PA, Woolhandler S. Redefining and redesigning hospital discharge to enhance patient care: a randomized controlled study. J Gen Intern Med. 2008;8:1228-1233.

One patient was as “fat as a whale,” according to his medical record. A patient who fell out of bed at night had “a nocturnal misadventure,” according to his chart, which provided no further information. Another medical record stated that a patient had been seen without the physician reviewing previous documentation. Yet another chart says the doctor referred the patient to a physician whose “credentials he was unsure of.”

Whether humorous or serious, medical records all too often include inappropriate information. While some of it may seem merely tasteless or silly, inappropriate remarks can cause serious problems—medical, legal, regulatory, and financial.

Because records are critical in so many areas of medical practice, hospitalists need to work harder to ensure they are accurate and appropriate. Experts say there should be more training in documentation.

“Doctors are trained to think about clinical and legal issues in documentation, but far less about the regulatory and billing aspects,” says David Grace, MD, area medical officer for The Schumacher Group, Hospital Medicine Division, in Lafayette, La., who saw the records of the obese patient and the one who fell at night.

As area medical officer, Dr. Grace reviews records and is developing a fellowship for Schumacher’s hospitalists in which documentation will be taught early on. “You have to teach doctors how to be hospitalists, and proper documentation is critical,” he says.

Patrick O’Rourke, an attorney for the University of Colorado, Denver, and legal columnist for The Hospitalist, also believes doctors need more training in documentation. He works with them on that in order to help them “stay out of court.”

The Courtroom

O’Rourke, who has worked on medical malpractice cases for his university’s Health Sciences Center and in private practice for 11 years, says the most common inappropriate wording he sees is back-handed denigration.

“Phrases like ‘hysterical’ or ‘oversensitive,’ ” he says. “Don’t question a patient’s mental condition when the presenting problem is physical. These kinds of comments can look very callous to a jury.”

O’Rourke also says while most physicians are good at documenting what they did or saw, they don’t usually do a lot to explain why. “Making clear your thought process is good in court, in part because doctors often don’t remember a lot years later in front of a jury.”

Documentation should reflect the process of differential diagnosis, O’Rourke says. “If a patient is having difficulty breathing, for example, it could be pneumonia, reactive airway disease, allergies, or a cold. The record should explain the basis for the doctor’s diagnosis and treatment actions.”

Never go back and change records—that undermines their credibility with juries, O’Rourke advises. “You have to make corrections with an addendum, the date and time, and reason for the change,” he says. “Since records go to insurers and other providers, they have to match. In court, the doctor really loses credibility when they don’t.”

It’s also risky to overuse medical abbreviations, says O’Rourke. “A recent study found that 5% of 30,000 medical errors were due to medical abbreviations.” He notes that the Institute for Safe Medication Practices has a list of error-prone abbreviations, symbols, and dose designations on its Web site (www.ismp.org/Tools/errorproneabbreviations.pdf).

Legibility

Another big problem with documentation is legibility, says O’Rourke, noting that many lawsuits have arisen from wrong medications and dosages. “Illegibility causes many medical errors that are preventable,” he says.

“Physicians must remember that just because they can read their writing doesn’t mean others can,” says O’Rourke. “Doctors think the records are their records, but they’re really the patients’ records. If other doctors, pharmacists, etc., can’t read them, why make them?”

Joseph Li, MD, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston, also says illegibility is a big problem. “Physician signatures must be legible,” he notes. “It’s critical to know who wrote the notes. If someone doesn’t know something or can’t read something, they can find out.”

Yet “just telling physicians to write legibly doesn’t work,” says Dr. Li, who is also an assistant professor at Harvard Medical School. “Doctors need to print their name beneath their signature.”

Dr. Li’s group uses templates for admission and progress notes. They include the names of each physician with a check box so they can indicate who wrote the notes. “This is how we comply with that guideline from the Joint Commission on Hospital Accreditation,” he says.

Robert Rohr, MD, vice president for medical affairs at Cortland Regional Medical Center in New York, has reviewed malpractice cases for hospitals and lawyers and in his current role focuses on deficiencies in documentation. He has seen numerous kinds of inappropriate information in medical records. Among his suggestions:

Don’t try to settle a dispute in a chart. Dr. Rohr recalls a patient who had a leaking abdominal hernia. A resident wrote in the chart the patient should have surgery within six hours or he would die. The surgeon disagreed. The patient lived without having surgery within the six hours, but if the case had been litigated, the chart note could have been used against the surgeon. “Settle things face to face or on the phone. The medical record must only detail your best thinking about the patient,” says Dr. Rohr. “Don’t be speculative. Agree on a course of action with other physicians and make documentation represent the agreed-upon plan. Showing differences of opinions helps plaintiffs’ lawyers.”

Don’t use charts as note pads for drawings, doodles, or other extraneous markings. “Nothing should be on the record that doesn’t help the next physician care for the patient,” says Dr. Rohr. “It makes the chart look unprofessional. Not good in court or anywhere else.”

Don’t leave the impression that you haven’t done a complete exam. Dr. Rohr saw the documentation that says a patient was “seen without chart.” Instead, he says, doctors should collect as much history as possible. “There are other ways to get information,” he asserts. “Doctors should shy away from making statements in charts about what isn’t available. Instead, outline all the information that is.”

Don’t just run through standard descriptions. Give a specific description of what you have actually examined and then state that “no other abnormalities were seen.” Errors and inappropriate information often go into records within standard exam information, Dr. Rohr and others say.

Avoid controversy in the chart—or, in Dr. Rohr’s words, “Don’t confess to malpractice.” “Don’t put things in charts that indicate you haven’t given the patient your best,” he says, recalling the physician whose chart mentioned a referral to a physician with uncertain credentials.

Be careful in documentation about whether a patient can afford a treatment. Payment issues should be worked out elsewhere. “You are in jeopardy if you give a patient less treatment because they can’t pay for it,” he warns. “It would look bad to a jury. You can include that a patient refused a treatment, but you don’t have to say why.”

Be as complete as possible, including all pertinent detail of a patient’s history. “You need to be thorough for the medical professionals who will treat the patient after you and you need to note certain conditions accurately for appropriate payments to physicians and facilities.” That need to create records that serve regulatory and billing purposes is becoming increasingly important to physicians and hospitals. TH

Karla Feuer is a journalist based in New York.

One patient was as “fat as a whale,” according to his medical record. A patient who fell out of bed at night had “a nocturnal misadventure,” according to his chart, which provided no further information. Another medical record stated that a patient had been seen without the physician reviewing previous documentation. Yet another chart says the doctor referred the patient to a physician whose “credentials he was unsure of.”

Whether humorous or serious, medical records all too often include inappropriate information. While some of it may seem merely tasteless or silly, inappropriate remarks can cause serious problems—medical, legal, regulatory, and financial.

Because records are critical in so many areas of medical practice, hospitalists need to work harder to ensure they are accurate and appropriate. Experts say there should be more training in documentation.

“Doctors are trained to think about clinical and legal issues in documentation, but far less about the regulatory and billing aspects,” says David Grace, MD, area medical officer for The Schumacher Group, Hospital Medicine Division, in Lafayette, La., who saw the records of the obese patient and the one who fell at night.

As area medical officer, Dr. Grace reviews records and is developing a fellowship for Schumacher’s hospitalists in which documentation will be taught early on. “You have to teach doctors how to be hospitalists, and proper documentation is critical,” he says.

Patrick O’Rourke, an attorney for the University of Colorado, Denver, and legal columnist for The Hospitalist, also believes doctors need more training in documentation. He works with them on that in order to help them “stay out of court.”

The Courtroom

O’Rourke, who has worked on medical malpractice cases for his university’s Health Sciences Center and in private practice for 11 years, says the most common inappropriate wording he sees is back-handed denigration.

“Phrases like ‘hysterical’ or ‘oversensitive,’ ” he says. “Don’t question a patient’s mental condition when the presenting problem is physical. These kinds of comments can look very callous to a jury.”

O’Rourke also says while most physicians are good at documenting what they did or saw, they don’t usually do a lot to explain why. “Making clear your thought process is good in court, in part because doctors often don’t remember a lot years later in front of a jury.”

Documentation should reflect the process of differential diagnosis, O’Rourke says. “If a patient is having difficulty breathing, for example, it could be pneumonia, reactive airway disease, allergies, or a cold. The record should explain the basis for the doctor’s diagnosis and treatment actions.”

Never go back and change records—that undermines their credibility with juries, O’Rourke advises. “You have to make corrections with an addendum, the date and time, and reason for the change,” he says. “Since records go to insurers and other providers, they have to match. In court, the doctor really loses credibility when they don’t.”

It’s also risky to overuse medical abbreviations, says O’Rourke. “A recent study found that 5% of 30,000 medical errors were due to medical abbreviations.” He notes that the Institute for Safe Medication Practices has a list of error-prone abbreviations, symbols, and dose designations on its Web site (www.ismp.org/Tools/errorproneabbreviations.pdf).

Legibility

Another big problem with documentation is legibility, says O’Rourke, noting that many lawsuits have arisen from wrong medications and dosages. “Illegibility causes many medical errors that are preventable,” he says.

“Physicians must remember that just because they can read their writing doesn’t mean others can,” says O’Rourke. “Doctors think the records are their records, but they’re really the patients’ records. If other doctors, pharmacists, etc., can’t read them, why make them?”

Joseph Li, MD, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston, also says illegibility is a big problem. “Physician signatures must be legible,” he notes. “It’s critical to know who wrote the notes. If someone doesn’t know something or can’t read something, they can find out.”

Yet “just telling physicians to write legibly doesn’t work,” says Dr. Li, who is also an assistant professor at Harvard Medical School. “Doctors need to print their name beneath their signature.”

Dr. Li’s group uses templates for admission and progress notes. They include the names of each physician with a check box so they can indicate who wrote the notes. “This is how we comply with that guideline from the Joint Commission on Hospital Accreditation,” he says.

Robert Rohr, MD, vice president for medical affairs at Cortland Regional Medical Center in New York, has reviewed malpractice cases for hospitals and lawyers and in his current role focuses on deficiencies in documentation. He has seen numerous kinds of inappropriate information in medical records. Among his suggestions:

Don’t try to settle a dispute in a chart. Dr. Rohr recalls a patient who had a leaking abdominal hernia. A resident wrote in the chart the patient should have surgery within six hours or he would die. The surgeon disagreed. The patient lived without having surgery within the six hours, but if the case had been litigated, the chart note could have been used against the surgeon. “Settle things face to face or on the phone. The medical record must only detail your best thinking about the patient,” says Dr. Rohr. “Don’t be speculative. Agree on a course of action with other physicians and make documentation represent the agreed-upon plan. Showing differences of opinions helps plaintiffs’ lawyers.”

Don’t use charts as note pads for drawings, doodles, or other extraneous markings. “Nothing should be on the record that doesn’t help the next physician care for the patient,” says Dr. Rohr. “It makes the chart look unprofessional. Not good in court or anywhere else.”

Don’t leave the impression that you haven’t done a complete exam. Dr. Rohr saw the documentation that says a patient was “seen without chart.” Instead, he says, doctors should collect as much history as possible. “There are other ways to get information,” he asserts. “Doctors should shy away from making statements in charts about what isn’t available. Instead, outline all the information that is.”

Don’t just run through standard descriptions. Give a specific description of what you have actually examined and then state that “no other abnormalities were seen.” Errors and inappropriate information often go into records within standard exam information, Dr. Rohr and others say.

Avoid controversy in the chart—or, in Dr. Rohr’s words, “Don’t confess to malpractice.” “Don’t put things in charts that indicate you haven’t given the patient your best,” he says, recalling the physician whose chart mentioned a referral to a physician with uncertain credentials.

Be careful in documentation about whether a patient can afford a treatment. Payment issues should be worked out elsewhere. “You are in jeopardy if you give a patient less treatment because they can’t pay for it,” he warns. “It would look bad to a jury. You can include that a patient refused a treatment, but you don’t have to say why.”

Be as complete as possible, including all pertinent detail of a patient’s history. “You need to be thorough for the medical professionals who will treat the patient after you and you need to note certain conditions accurately for appropriate payments to physicians and facilities.” That need to create records that serve regulatory and billing purposes is becoming increasingly important to physicians and hospitals. TH

Karla Feuer is a journalist based in New York.

One patient was as “fat as a whale,” according to his medical record. A patient who fell out of bed at night had “a nocturnal misadventure,” according to his chart, which provided no further information. Another medical record stated that a patient had been seen without the physician reviewing previous documentation. Yet another chart says the doctor referred the patient to a physician whose “credentials he was unsure of.”

Whether humorous or serious, medical records all too often include inappropriate information. While some of it may seem merely tasteless or silly, inappropriate remarks can cause serious problems—medical, legal, regulatory, and financial.

Because records are critical in so many areas of medical practice, hospitalists need to work harder to ensure they are accurate and appropriate. Experts say there should be more training in documentation.

“Doctors are trained to think about clinical and legal issues in documentation, but far less about the regulatory and billing aspects,” says David Grace, MD, area medical officer for The Schumacher Group, Hospital Medicine Division, in Lafayette, La., who saw the records of the obese patient and the one who fell at night.

As area medical officer, Dr. Grace reviews records and is developing a fellowship for Schumacher’s hospitalists in which documentation will be taught early on. “You have to teach doctors how to be hospitalists, and proper documentation is critical,” he says.

Patrick O’Rourke, an attorney for the University of Colorado, Denver, and legal columnist for The Hospitalist, also believes doctors need more training in documentation. He works with them on that in order to help them “stay out of court.”

The Courtroom

O’Rourke, who has worked on medical malpractice cases for his university’s Health Sciences Center and in private practice for 11 years, says the most common inappropriate wording he sees is back-handed denigration.

“Phrases like ‘hysterical’ or ‘oversensitive,’ ” he says. “Don’t question a patient’s mental condition when the presenting problem is physical. These kinds of comments can look very callous to a jury.”

O’Rourke also says while most physicians are good at documenting what they did or saw, they don’t usually do a lot to explain why. “Making clear your thought process is good in court, in part because doctors often don’t remember a lot years later in front of a jury.”

Documentation should reflect the process of differential diagnosis, O’Rourke says. “If a patient is having difficulty breathing, for example, it could be pneumonia, reactive airway disease, allergies, or a cold. The record should explain the basis for the doctor’s diagnosis and treatment actions.”

Never go back and change records—that undermines their credibility with juries, O’Rourke advises. “You have to make corrections with an addendum, the date and time, and reason for the change,” he says. “Since records go to insurers and other providers, they have to match. In court, the doctor really loses credibility when they don’t.”

It’s also risky to overuse medical abbreviations, says O’Rourke. “A recent study found that 5% of 30,000 medical errors were due to medical abbreviations.” He notes that the Institute for Safe Medication Practices has a list of error-prone abbreviations, symbols, and dose designations on its Web site (www.ismp.org/Tools/errorproneabbreviations.pdf).

Legibility

Another big problem with documentation is legibility, says O’Rourke, noting that many lawsuits have arisen from wrong medications and dosages. “Illegibility causes many medical errors that are preventable,” he says.

“Physicians must remember that just because they can read their writing doesn’t mean others can,” says O’Rourke. “Doctors think the records are their records, but they’re really the patients’ records. If other doctors, pharmacists, etc., can’t read them, why make them?”

Joseph Li, MD, director of hospital medicine at Beth Israel Deaconess Medical Center in Boston, also says illegibility is a big problem. “Physician signatures must be legible,” he notes. “It’s critical to know who wrote the notes. If someone doesn’t know something or can’t read something, they can find out.”

Yet “just telling physicians to write legibly doesn’t work,” says Dr. Li, who is also an assistant professor at Harvard Medical School. “Doctors need to print their name beneath their signature.”

Dr. Li’s group uses templates for admission and progress notes. They include the names of each physician with a check box so they can indicate who wrote the notes. “This is how we comply with that guideline from the Joint Commission on Hospital Accreditation,” he says.

Robert Rohr, MD, vice president for medical affairs at Cortland Regional Medical Center in New York, has reviewed malpractice cases for hospitals and lawyers and in his current role focuses on deficiencies in documentation. He has seen numerous kinds of inappropriate information in medical records. Among his suggestions:

Don’t try to settle a dispute in a chart. Dr. Rohr recalls a patient who had a leaking abdominal hernia. A resident wrote in the chart the patient should have surgery within six hours or he would die. The surgeon disagreed. The patient lived without having surgery within the six hours, but if the case had been litigated, the chart note could have been used against the surgeon. “Settle things face to face or on the phone. The medical record must only detail your best thinking about the patient,” says Dr. Rohr. “Don’t be speculative. Agree on a course of action with other physicians and make documentation represent the agreed-upon plan. Showing differences of opinions helps plaintiffs’ lawyers.”

Don’t use charts as note pads for drawings, doodles, or other extraneous markings. “Nothing should be on the record that doesn’t help the next physician care for the patient,” says Dr. Rohr. “It makes the chart look unprofessional. Not good in court or anywhere else.”

Don’t leave the impression that you haven’t done a complete exam. Dr. Rohr saw the documentation that says a patient was “seen without chart.” Instead, he says, doctors should collect as much history as possible. “There are other ways to get information,” he asserts. “Doctors should shy away from making statements in charts about what isn’t available. Instead, outline all the information that is.”

Don’t just run through standard descriptions. Give a specific description of what you have actually examined and then state that “no other abnormalities were seen.” Errors and inappropriate information often go into records within standard exam information, Dr. Rohr and others say.

Avoid controversy in the chart—or, in Dr. Rohr’s words, “Don’t confess to malpractice.” “Don’t put things in charts that indicate you haven’t given the patient your best,” he says, recalling the physician whose chart mentioned a referral to a physician with uncertain credentials.

Be careful in documentation about whether a patient can afford a treatment. Payment issues should be worked out elsewhere. “You are in jeopardy if you give a patient less treatment because they can’t pay for it,” he warns. “It would look bad to a jury. You can include that a patient refused a treatment, but you don’t have to say why.”

Be as complete as possible, including all pertinent detail of a patient’s history. “You need to be thorough for the medical professionals who will treat the patient after you and you need to note certain conditions accurately for appropriate payments to physicians and facilities.” That need to create records that serve regulatory and billing purposes is becoming increasingly important to physicians and hospitals. TH

Karla Feuer is a journalist based in New York.

With hospitals facing increasing pressure to improve safety based on measurements, hospitalists need to build a key role in improving quality by developing safety scorecards, say leading hospital medicine experts.

A framework for designing scorecards was recently suggested by researchers at Johns Hopkins University in Baltimore in an article published by the Journal of the American Medical Association.1 The commentary suggests a framework to help healthcare organizations develop safety scorecards, evaluate their validity, and understand measures appropriate to present as rates.

Their framework is intended to build scorecards that monitor progress in improving patient safety over time or relative to a benchmark. The authors urged organizations to think of safety on a continuum and look for improvements, rather than regard practices as either safe or unsafe. They also stated that their term “safety scorecard” acknowledges an overlap between quality and safety.

To build their framework, the researchers adapted elements of the “Users’ Guide to the Medical Literature: A Manual for Evidence-Based Clinical Practice,” to address three key questions:

• Is the measure important?
• Is the measure valid? and
• Can the measure be used to improve safety in healthcare organizations?

The resulting worksheet to evaluate a scorecard guides hospitals through questions aimed at determining whether their institution meets the three criteria.

Initial Reaction

“This worksheet would be very important to follow, a good step forward in efforts to improve quality because its questions make clear where a group might be falling down in developing a scorecard,” says hospitalist Brian Bossard, MD, director of Inpatient Physician Associates at BryanLGH Medical Center in Lincoln, Neb. Dr. Bossard, who is also the medical staff quality designee, says he believes large national hospitalist groups should be involved in planning scorecards as part of a multidisciplinary team.

Other experts also tout hospitalists’ importance in the vanguard of creating these vital instruments.

“Hospitalists should be on or chairing safety committees, and there should be investments in training them in these areas,” says Eric Kupersmith, MD, division head of hospital medicine and assistant professor of medicine for the Cooper Health System, University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School in Newark. “Because we are frontline physicians experiencing what is happening with patients and orchestrating as well as delivering care, we should provide feedback.”

Dr. Kupersmith, who is on his facility’s patient safety committee and has participated in a root-cause analysis of hand-offs as well as worked on medical reconciliation and pneumonia core measure performance improvement, says SHM “should help take the lead in bringing together specialists, administrators, and nurses with hospitalists who should have a major impact in designing a scorecard as a society.”

As hospitalists mature as clinicians, they become system- and process-oriented, says Dr. Kupersmith. As a result, “We should be part of re-engineering efforts because of our experience bringing people together,” he says. “We’re in a good position to analyze the process.”

Use with Care

There is also value in hospitalists’ anecdotal experiences, Dr. Kupersmith says, but “there needs to be a filter between anecdotes and a facility’s leadership to ensure that the information provided is broadly important. Decisions shouldn’t be made on anecdotes, but creative ideas can come from them.”

Randy Ferrance, DC, MD, and chief of the medical staff at Riverside Tappahannock Hospital in Tappahan-nock, Va., regards anecdotal information in much the same light. “It should be seen as guidelines, not rules,” he cautions. “There is still an art to medicine even though it is clearly science. Sometimes the best available evidence may be anecdotal. It’s not hard data, but it can be valuable.”

Dr. Ferrance at one time chaired his hospital’s quality improvement committee; the panel now reports to him. He believes hospitalists are fortunate that “we became a specialty after evidence-based medicine really came to the forefront. We are fortunate to have the backing of much hard data.”

Still, he acknowledges the difficulty of establishing proof that an action affects patient outcome. “It’s hard, but what we can do is look at what might help result in things like decreased morbidity, length of stays and complications, and a faster return to a patient’s normal functions. Then we might see influence on patient outcomes.”

Beyond Core Measures

Richard Rohr, MD, vice president for medical affairs at Cortland Regional Medical Center in New York, works extensively on quality improvements. He urges hospitalists and institutions to go beyond required measures.

“A lot of what we’re doing now is imposed by government, insurers or the Joint Commission,” says Dr. Rohr. “In day-to-day work, we should look for areas to go beyond what is required.”

He believes hospitalists should look at specific issues underlying the Johns Hopkins framework’s three core questions.

For example, within the first core question “Is the measure important?” he suggests hospitalists consider what their facility’s priorities are. “There are thousands of things that could address safety,” he says. “Hospitalists should look at how a measure fits in to their organization’s priorities. At an institution known for cardiac care, look at safety measures in cardiology.”

He also suggests looking at a facility’s potential problem areas to help determine if a measure is important. “I worked at a facility that had a rule that Coumadin had to be ordered one day at a time,” says Dr. Rohr. “Since patient use of the medication was closely monitored, there were very few patients with serious bleeding.”

The point, he says, is that hospitalists should “make sure the safety process they’re interested in truly addresses a true problem and is not already in place. Try to add something of value.”

Hospitalists are in a good position to do this, he says, because of their day-to-day perspective on patients. “Hospitalists should start by looking at what their organization has addressed and what’s causing patient problems day to day and then set priorities,” he advises.

Institutional Support

Of critical importance also, Dr. Rohr says, is to see what their organization can support before deciding what safety measure to explore.

“Is it feasible to collect data to use this measure?” he asks. “That’s partly dependent on where your facility is in using electronic medical records. Does the benefit of researching and implementing outweigh the cost? You may have to spend some staff time to decide what is worthwhile.”

The last task may be easier for hospitalists working at more academic hospitals, he says, which is also an important part of trying to answer the Johns Hopkins framework’s second question: “Is the measure valid?”

It’s often hard to answer that one, Dr. Rohr acknowledges. “Research has at times shown that a process may show statistically significant improvement, but it does not show up clinically,” he says. “Aspirin and beta-blockers for heart patients, for example, has a statistically significant difference—but it is small.”

Most hospitalists try to see patients and do this kind of work on the side, he concedes: “They should do some research, but value what they see when treating patients. You have a good sense of what has helped patients.”

Dr. Wright

Julia Wright, MD, associate professor of medicine at the University of Wisconsin School of Medicine and Public Health and medical director for hospital medicine at the University of Wisconsin Hospital in Madison, agrees.

“The expertise of our specialty is that we deliver care that is not just clinical, asking, ‘Did I meet the guidelines?’’’ she says. “We’re with patients. We should help determine how quality and safety models are addressing how care is delivered.”

She also believes hospitalists should work closely with hospital administrators on these issues. “Hospitalists have an intrinsic sense of value in delivering care,” she notes. “We are unique in that we can combine consideration of hospital goals with knowledge of care at patient levels. This provides great value to the institutions.”

Culture of Safety

While he agrees with the importance of involving hospitalists deeply in safety efforts, Dr. Kupersmith believes institutions should strive to create a culture that focuses on safety and looks at all its processes in that light.

“You shouldn’t just track hard outcomes,” he suggests. “Track the outcomes of your processes. This gives an overall sense of safety awareness in all personnel. If you focus on the process and culture, you might find a significant change in outcomes.” This also helps address the difficulty of finding data on outcomes, he says.

He agrees with the researchers’ view that safety is on a continuum, and he thinks acknowledging that can help establish an institutional culture around safety. “There is always going to be patient danger,” he says. “You want to get to a point where it is minimized because of an awareness of actions. That focus on safety will lead to less danger.”

As a result, he believes quality improvement strategies must address culture. “You need to provide education for all on safety and provide oversight and monitoring with expectations that can be tracked,” he says. “You need to create this mandate and speak in the quality language from the top. Then you start to have people bring in information that affects outcomes.” TH

Karla Feuer is a journalist based in New York.

Reference

1. Pronovost PJ, Berenholtz SM, Needham DM. A framework for health care organizations to develop and evaluate a safety scorecard. JAMA. 2007;298(17):2063-2065.

With hospitals facing increasing pressure to improve safety based on measurements, hospitalists need to build a key role in improving quality by developing safety scorecards, say leading hospital medicine experts.

A framework for designing scorecards was recently suggested by researchers at Johns Hopkins University in Baltimore in an article published by the Journal of the American Medical Association.1 The commentary suggests a framework to help healthcare organizations develop safety scorecards, evaluate their validity, and understand measures appropriate to present as rates.

Their framework is intended to build scorecards that monitor progress in improving patient safety over time or relative to a benchmark. The authors urged organizations to think of safety on a continuum and look for improvements, rather than regard practices as either safe or unsafe. They also stated that their term “safety scorecard” acknowledges an overlap between quality and safety.

To build their framework, the researchers adapted elements of the “Users’ Guide to the Medical Literature: A Manual for Evidence-Based Clinical Practice,” to address three key questions:

• Is the measure important?
• Is the measure valid? and
• Can the measure be used to improve safety in healthcare organizations?

The resulting worksheet to evaluate a scorecard guides hospitals through questions aimed at determining whether their institution meets the three criteria.

Initial Reaction

“This worksheet would be very important to follow, a good step forward in efforts to improve quality because its questions make clear where a group might be falling down in developing a scorecard,” says hospitalist Brian Bossard, MD, director of Inpatient Physician Associates at BryanLGH Medical Center in Lincoln, Neb. Dr. Bossard, who is also the medical staff quality designee, says he believes large national hospitalist groups should be involved in planning scorecards as part of a multidisciplinary team.

Other experts also tout hospitalists’ importance in the vanguard of creating these vital instruments.

“Hospitalists should be on or chairing safety committees, and there should be investments in training them in these areas,” says Eric Kupersmith, MD, division head of hospital medicine and assistant professor of medicine for the Cooper Health System, University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School in Newark. “Because we are frontline physicians experiencing what is happening with patients and orchestrating as well as delivering care, we should provide feedback.”

Dr. Kupersmith, who is on his facility’s patient safety committee and has participated in a root-cause analysis of hand-offs as well as worked on medical reconciliation and pneumonia core measure performance improvement, says SHM “should help take the lead in bringing together specialists, administrators, and nurses with hospitalists who should have a major impact in designing a scorecard as a society.”

As hospitalists mature as clinicians, they become system- and process-oriented, says Dr. Kupersmith. As a result, “We should be part of re-engineering efforts because of our experience bringing people together,” he says. “We’re in a good position to analyze the process.”

Use with Care

There is also value in hospitalists’ anecdotal experiences, Dr. Kupersmith says, but “there needs to be a filter between anecdotes and a facility’s leadership to ensure that the information provided is broadly important. Decisions shouldn’t be made on anecdotes, but creative ideas can come from them.”

Randy Ferrance, DC, MD, and chief of the medical staff at Riverside Tappahannock Hospital in Tappahan-nock, Va., regards anecdotal information in much the same light. “It should be seen as guidelines, not rules,” he cautions. “There is still an art to medicine even though it is clearly science. Sometimes the best available evidence may be anecdotal. It’s not hard data, but it can be valuable.”

Dr. Ferrance at one time chaired his hospital’s quality improvement committee; the panel now reports to him. He believes hospitalists are fortunate that “we became a specialty after evidence-based medicine really came to the forefront. We are fortunate to have the backing of much hard data.”

Still, he acknowledges the difficulty of establishing proof that an action affects patient outcome. “It’s hard, but what we can do is look at what might help result in things like decreased morbidity, length of stays and complications, and a faster return to a patient’s normal functions. Then we might see influence on patient outcomes.”

Beyond Core Measures

Richard Rohr, MD, vice president for medical affairs at Cortland Regional Medical Center in New York, works extensively on quality improvements. He urges hospitalists and institutions to go beyond required measures.

“A lot of what we’re doing now is imposed by government, insurers or the Joint Commission,” says Dr. Rohr. “In day-to-day work, we should look for areas to go beyond what is required.”

He believes hospitalists should look at specific issues underlying the Johns Hopkins framework’s three core questions.

For example, within the first core question “Is the measure important?” he suggests hospitalists consider what their facility’s priorities are. “There are thousands of things that could address safety,” he says. “Hospitalists should look at how a measure fits in to their organization’s priorities. At an institution known for cardiac care, look at safety measures in cardiology.”

He also suggests looking at a facility’s potential problem areas to help determine if a measure is important. “I worked at a facility that had a rule that Coumadin had to be ordered one day at a time,” says Dr. Rohr. “Since patient use of the medication was closely monitored, there were very few patients with serious bleeding.”

The point, he says, is that hospitalists should “make sure the safety process they’re interested in truly addresses a true problem and is not already in place. Try to add something of value.”

Hospitalists are in a good position to do this, he says, because of their day-to-day perspective on patients. “Hospitalists should start by looking at what their organization has addressed and what’s causing patient problems day to day and then set priorities,” he advises.

Institutional Support

Of critical importance also, Dr. Rohr says, is to see what their organization can support before deciding what safety measure to explore.

“Is it feasible to collect data to use this measure?” he asks. “That’s partly dependent on where your facility is in using electronic medical records. Does the benefit of researching and implementing outweigh the cost? You may have to spend some staff time to decide what is worthwhile.”

The last task may be easier for hospitalists working at more academic hospitals, he says, which is also an important part of trying to answer the Johns Hopkins framework’s second question: “Is the measure valid?”

It’s often hard to answer that one, Dr. Rohr acknowledges. “Research has at times shown that a process may show statistically significant improvement, but it does not show up clinically,” he says. “Aspirin and beta-blockers for heart patients, for example, has a statistically significant difference—but it is small.”

Most hospitalists try to see patients and do this kind of work on the side, he concedes: “They should do some research, but value what they see when treating patients. You have a good sense of what has helped patients.”

Dr. Wright

Julia Wright, MD, associate professor of medicine at the University of Wisconsin School of Medicine and Public Health and medical director for hospital medicine at the University of Wisconsin Hospital in Madison, agrees.

“The expertise of our specialty is that we deliver care that is not just clinical, asking, ‘Did I meet the guidelines?’’’ she says. “We’re with patients. We should help determine how quality and safety models are addressing how care is delivered.”

She also believes hospitalists should work closely with hospital administrators on these issues. “Hospitalists have an intrinsic sense of value in delivering care,” she notes. “We are unique in that we can combine consideration of hospital goals with knowledge of care at patient levels. This provides great value to the institutions.”

Culture of Safety

While he agrees with the importance of involving hospitalists deeply in safety efforts, Dr. Kupersmith believes institutions should strive to create a culture that focuses on safety and looks at all its processes in that light.

“You shouldn’t just track hard outcomes,” he suggests. “Track the outcomes of your processes. This gives an overall sense of safety awareness in all personnel. If you focus on the process and culture, you might find a significant change in outcomes.” This also helps address the difficulty of finding data on outcomes, he says.

He agrees with the researchers’ view that safety is on a continuum, and he thinks acknowledging that can help establish an institutional culture around safety. “There is always going to be patient danger,” he says. “You want to get to a point where it is minimized because of an awareness of actions. That focus on safety will lead to less danger.”

As a result, he believes quality improvement strategies must address culture. “You need to provide education for all on safety and provide oversight and monitoring with expectations that can be tracked,” he says. “You need to create this mandate and speak in the quality language from the top. Then you start to have people bring in information that affects outcomes.” TH

Karla Feuer is a journalist based in New York.

Reference

1. Pronovost PJ, Berenholtz SM, Needham DM. A framework for health care organizations to develop and evaluate a safety scorecard. JAMA. 2007;298(17):2063-2065.

With hospitals facing increasing pressure to improve safety based on measurements, hospitalists need to build a key role in improving quality by developing safety scorecards, say leading hospital medicine experts.

A framework for designing scorecards was recently suggested by researchers at Johns Hopkins University in Baltimore in an article published by the Journal of the American Medical Association.1 The commentary suggests a framework to help healthcare organizations develop safety scorecards, evaluate their validity, and understand measures appropriate to present as rates.

Their framework is intended to build scorecards that monitor progress in improving patient safety over time or relative to a benchmark. The authors urged organizations to think of safety on a continuum and look for improvements, rather than regard practices as either safe or unsafe. They also stated that their term “safety scorecard” acknowledges an overlap between quality and safety.

To build their framework, the researchers adapted elements of the “Users’ Guide to the Medical Literature: A Manual for Evidence-Based Clinical Practice,” to address three key questions:

• Is the measure important?
• Is the measure valid? and
• Can the measure be used to improve safety in healthcare organizations?

The resulting worksheet to evaluate a scorecard guides hospitals through questions aimed at determining whether their institution meets the three criteria.

Initial Reaction

“This worksheet would be very important to follow, a good step forward in efforts to improve quality because its questions make clear where a group might be falling down in developing a scorecard,” says hospitalist Brian Bossard, MD, director of Inpatient Physician Associates at BryanLGH Medical Center in Lincoln, Neb. Dr. Bossard, who is also the medical staff quality designee, says he believes large national hospitalist groups should be involved in planning scorecards as part of a multidisciplinary team.

Other experts also tout hospitalists’ importance in the vanguard of creating these vital instruments.

“Hospitalists should be on or chairing safety committees, and there should be investments in training them in these areas,” says Eric Kupersmith, MD, division head of hospital medicine and assistant professor of medicine for the Cooper Health System, University of Medicine and Dentistry of New Jersey Robert Wood Johnson Medical School in Newark. “Because we are frontline physicians experiencing what is happening with patients and orchestrating as well as delivering care, we should provide feedback.”

Dr. Kupersmith, who is on his facility’s patient safety committee and has participated in a root-cause analysis of hand-offs as well as worked on medical reconciliation and pneumonia core measure performance improvement, says SHM “should help take the lead in bringing together specialists, administrators, and nurses with hospitalists who should have a major impact in designing a scorecard as a society.”

As hospitalists mature as clinicians, they become system- and process-oriented, says Dr. Kupersmith. As a result, “We should be part of re-engineering efforts because of our experience bringing people together,” he says. “We’re in a good position to analyze the process.”

Use with Care

There is also value in hospitalists’ anecdotal experiences, Dr. Kupersmith says, but “there needs to be a filter between anecdotes and a facility’s leadership to ensure that the information provided is broadly important. Decisions shouldn’t be made on anecdotes, but creative ideas can come from them.”

Randy Ferrance, DC, MD, and chief of the medical staff at Riverside Tappahannock Hospital in Tappahan-nock, Va., regards anecdotal information in much the same light. “It should be seen as guidelines, not rules,” he cautions. “There is still an art to medicine even though it is clearly science. Sometimes the best available evidence may be anecdotal. It’s not hard data, but it can be valuable.”

Dr. Ferrance at one time chaired his hospital’s quality improvement committee; the panel now reports to him. He believes hospitalists are fortunate that “we became a specialty after evidence-based medicine really came to the forefront. We are fortunate to have the backing of much hard data.”

Still, he acknowledges the difficulty of establishing proof that an action affects patient outcome. “It’s hard, but what we can do is look at what might help result in things like decreased morbidity, length of stays and complications, and a faster return to a patient’s normal functions. Then we might see influence on patient outcomes.”

Beyond Core Measures

Richard Rohr, MD, vice president for medical affairs at Cortland Regional Medical Center in New York, works extensively on quality improvements. He urges hospitalists and institutions to go beyond required measures.

“A lot of what we’re doing now is imposed by government, insurers or the Joint Commission,” says Dr. Rohr. “In day-to-day work, we should look for areas to go beyond what is required.”

He believes hospitalists should look at specific issues underlying the Johns Hopkins framework’s three core questions.

For example, within the first core question “Is the measure important?” he suggests hospitalists consider what their facility’s priorities are. “There are thousands of things that could address safety,” he says. “Hospitalists should look at how a measure fits in to their organization’s priorities. At an institution known for cardiac care, look at safety measures in cardiology.”

He also suggests looking at a facility’s potential problem areas to help determine if a measure is important. “I worked at a facility that had a rule that Coumadin had to be ordered one day at a time,” says Dr. Rohr. “Since patient use of the medication was closely monitored, there were very few patients with serious bleeding.”

The point, he says, is that hospitalists should “make sure the safety process they’re interested in truly addresses a true problem and is not already in place. Try to add something of value.”

Hospitalists are in a good position to do this, he says, because of their day-to-day perspective on patients. “Hospitalists should start by looking at what their organization has addressed and what’s causing patient problems day to day and then set priorities,” he advises.

Institutional Support

Of critical importance also, Dr. Rohr says, is to see what their organization can support before deciding what safety measure to explore.

“Is it feasible to collect data to use this measure?” he asks. “That’s partly dependent on where your facility is in using electronic medical records. Does the benefit of researching and implementing outweigh the cost? You may have to spend some staff time to decide what is worthwhile.”

The last task may be easier for hospitalists working at more academic hospitals, he says, which is also an important part of trying to answer the Johns Hopkins framework’s second question: “Is the measure valid?”

It’s often hard to answer that one, Dr. Rohr acknowledges. “Research has at times shown that a process may show statistically significant improvement, but it does not show up clinically,” he says. “Aspirin and beta-blockers for heart patients, for example, has a statistically significant difference—but it is small.”

Most hospitalists try to see patients and do this kind of work on the side, he concedes: “They should do some research, but value what they see when treating patients. You have a good sense of what has helped patients.”

Dr. Wright

Julia Wright, MD, associate professor of medicine at the University of Wisconsin School of Medicine and Public Health and medical director for hospital medicine at the University of Wisconsin Hospital in Madison, agrees.

“The expertise of our specialty is that we deliver care that is not just clinical, asking, ‘Did I meet the guidelines?’’’ she says. “We’re with patients. We should help determine how quality and safety models are addressing how care is delivered.”

She also believes hospitalists should work closely with hospital administrators on these issues. “Hospitalists have an intrinsic sense of value in delivering care,” she notes. “We are unique in that we can combine consideration of hospital goals with knowledge of care at patient levels. This provides great value to the institutions.”

Culture of Safety

While he agrees with the importance of involving hospitalists deeply in safety efforts, Dr. Kupersmith believes institutions should strive to create a culture that focuses on safety and looks at all its processes in that light.

“You shouldn’t just track hard outcomes,” he suggests. “Track the outcomes of your processes. This gives an overall sense of safety awareness in all personnel. If you focus on the process and culture, you might find a significant change in outcomes.” This also helps address the difficulty of finding data on outcomes, he says.

He agrees with the researchers’ view that safety is on a continuum, and he thinks acknowledging that can help establish an institutional culture around safety. “There is always going to be patient danger,” he says. “You want to get to a point where it is minimized because of an awareness of actions. That focus on safety will lead to less danger.”

As a result, he believes quality improvement strategies must address culture. “You need to provide education for all on safety and provide oversight and monitoring with expectations that can be tracked,” he says. “You need to create this mandate and speak in the quality language from the top. Then you start to have people bring in information that affects outcomes.” TH

Karla Feuer is a journalist based in New York.

Reference

1. Pronovost PJ, Berenholtz SM, Needham DM. A framework for health care organizations to develop and evaluate a safety scorecard. JAMA. 2007;298(17):2063-2065.

One hospitalist spent three weeks without a break treating victims of Hurricane Katrina in 2005. Another couldn’t get to work when the I-35W bridge collapsed in Minneapolis on Aug. 1, 2007, but there were enough physicians on hand for that tragedy and fewer victims to treat than feared.

Yet another shudders when he recalls treating victims of an 89-car pile-up caused by a dust storm in southern Idaho.

Not all hospitalists have been in the trenches treating victims of disasters. But two emerging trends likely will put hospitalists on the front lines of preparing for disasters and treating victims.

The first is the increasing recognition that there are many threats to the safety of the public, including terrorism, natural disasters, disease outbreaks, and criminal acts like the mass killings a year ago at Virginia Tech in Blacksburg.

The second is the rapidly expanding role hospitalists have in caring for critically ill and injured patients.

“Hospitalists will be a key,” says Timothy Close, senior safety officer for the University of Colorado Hospital in Denver and chairman of its emergency management committee. “Because of their understanding of all hospital services and treatments, they can handle a multitude of clinical roles. Facilities should deploy hospitalists’ understanding of the organization to facilitate patient care.”

Close, who has 15 years of experience in planning and preparedness, urges organizations to implement plans “that are realistic and doable based on local resources and conditions.” He also urges facilities to conduct emergency drills and have hospitalists participate.

He has dealt with crises wrought by fires, workplace violence, severe weather, and abductions, but adds it is important to remember that “you never know what’s going to happen.”

Close helped treat the victims of the dust storm pile-up. “It was caused by an unfortunate series of events,” he says. “A new land owner plowed during a dry time, and when the winds came it was catastrophic. The cars ran right into the dust cloud with zero visibility.”

Prepare for the Unseen

Lisa Kirkland, MD, a hospitalist at the Mayo Clinic in Rochester, Minn., agrees disaster planning should be local in the sense of preparing for specific events. Tornadoes are the most likely weather-related crisis to occur in Rochester, she says, and the area is not a prime terrorism target.

Yet disasters don’t have to happen suddenly or involve mass casualties. “A disaster is anything that overwhelms the usual system,” she says. “Putting a community under quarantine during an outbreak of influenza or bird flu, for example, could require the initiation of disaster plans since staff couldn’t get to hospitals.”

In this sort of scenario, like during the SARS outbreak in Toronto in 2003, patient care would be largely medical, rather than surgical, so hospitalists would be key providers of treatment, Dr. Kirkland says.

Hospitalists would also be key in maintaining effective communication, internally and with the outside world because of their thorough knowledge of hospital services, she adds.

Some 75 miles away in Minneapolis, many victims of the I-35W bridge collapse were taken to Hennepin County Medical Center (HCMC). Glen Varns, MD, hospitalist program leader at HCMC, was unable to get to work because he lives on the other side of the bridge. But he says hospitalists played a critical role in dealing with the crisis.

“Since our hospitalists are most familiar with the inner workings of the facility, they played a huge role in determining who needed to be hospitalized and where in the hospital they would best be treated,” he says. “This included reviewing the existing patient census when the collapse happened so we could discharge and transfer inpatients appropriately to ensure that the hospital was in the best position to deal with the collapse victims.”

Because the bridge collapsed during the early evening, there was plenty of staff on-hand to treat the victims, including residents who worked hand-in-hand with hospitalists in making admission and transfer decisions.

Challenge for Hospitalists

In smaller facilities where there are no residents, or in small emergency departments (ED) and intensive-care units, hospitalists will and should have even more critical roles in handling disasters and planning for them, Dr. Varns says.

He believes all hospitalists—but especially those in small, nonteaching facilities—should get triage training. “Hospitalists have a very broad skill set—especially with increasing responsibility for co-management of surgical cases—but they should develop triage skills,” says Dr. Varns, who suggests hospitalists take a two or three-day advanced trauma life support course.

Steven B. Deitelzweig, MD, FACP, system chairman, department of hospital medicine and vice president of medical affairs for the Ochsner Health System in the New Orleans area, agrees.

“I think the folks who are closest to guiding the care should be offering input into triage decisions,” he says. “Hospitalists can be invaluable in doing triage of inpatients. They provide objective detailed information.”

Dr. Deitelzweig, who experienced the three-week lock-down following Katrina, suggests hospitalist groups create a system of prioritizing evacuation of patients—including what kind of support they’ll need.

He believes hospitalists will be invaluable during crises because they are “front-line decision-makers, along with ED physicians and intensivists.” Hospitalists should be on disaster-preparedness committees and a key part of communication during an actual crisis, he urges.

“Communication is critical during a crisis—and hospitalists know their systems,” he continues, noting that Ochsner has out-of-state cell phones, satellite phones, ham radios, spectral light phones, radio frequency antennas in secure places, and more.

In addition to equipment and supplies, hospitalists need to be prepared to do whatever is needed in a crisis, Dr. Deitelzweig says. “In a disaster, you might have to do a procedure usually done by a specialist—with supervision—to extend that person,” he says. “You also may have to go past the physician role. That’s where leadership shows. Our CEO served food in the cafeteria during Katrina. During a disaster, you have to be a flat organization and just do what needs to be done. That gives emotional support to everyone.”

Still, the need to prepare before a disaster cannot be overemphasized, he says.

Ochsner now has two teams of pre-selected physicians, including hospitalists, dedicated to working through specific types of crises. Having the list of essential personnel online at all times is intended to prevent last-minute scurrying around to find the right people, he says.

In addition, providing balanced scheduling—especially in long-lasting crisis situations like Katrina—is important, says Dr. Deitelzweig. “Timing for release must be included, and having more staff on hand than necessary can help alleviate stress,” he advises.

Lessons of Katrina

Neal Axon, MD, an assistant professor at the Medical University of South Carolina, says he and his colleagues learned from those who went through Katrina as they prepared for the most likely disaster in Charleston: a severe hurricane.

Dr. Axon, a senior hospitalist in his group, says the facility has a system that generates e-mail, pages, text messages, and cell phone calls to keep hospital staff informed about potential crises. He also says the preparedness plan provides for relief of staff working for extended periods.

In addition, the hospital has trailers and inflatable tents to extend its facilities if there is a surge in patients. It also has a facility to provide decontamination for exposure to chemicals and radiation.

Brian Bossard, MD, director of Inpatient Physician Associates and medical staff quality designee at BryanLGH Medical Center in Lincoln Neb., says preparedness plans should be tested and updated regularly—especially the systems used to call in staff.

Dr. Bossard strongly believes hospitalists should be involved in disaster planning: “Every day hospitalists work hospital systems. We have a broad scope and perspective. That’s what you need in a disaster.” TH

Karla Feuer is a journalist based in New York.

One hospitalist spent three weeks without a break treating victims of Hurricane Katrina in 2005. Another couldn’t get to work when the I-35W bridge collapsed in Minneapolis on Aug. 1, 2007, but there were enough physicians on hand for that tragedy and fewer victims to treat than feared.

Yet another shudders when he recalls treating victims of an 89-car pile-up caused by a dust storm in southern Idaho.

Not all hospitalists have been in the trenches treating victims of disasters. But two emerging trends likely will put hospitalists on the front lines of preparing for disasters and treating victims.

The first is the increasing recognition that there are many threats to the safety of the public, including terrorism, natural disasters, disease outbreaks, and criminal acts like the mass killings a year ago at Virginia Tech in Blacksburg.

The second is the rapidly expanding role hospitalists have in caring for critically ill and injured patients.

“Hospitalists will be a key,” says Timothy Close, senior safety officer for the University of Colorado Hospital in Denver and chairman of its emergency management committee. “Because of their understanding of all hospital services and treatments, they can handle a multitude of clinical roles. Facilities should deploy hospitalists’ understanding of the organization to facilitate patient care.”

Close, who has 15 years of experience in planning and preparedness, urges organizations to implement plans “that are realistic and doable based on local resources and conditions.” He also urges facilities to conduct emergency drills and have hospitalists participate.

He has dealt with crises wrought by fires, workplace violence, severe weather, and abductions, but adds it is important to remember that “you never know what’s going to happen.”

Close helped treat the victims of the dust storm pile-up. “It was caused by an unfortunate series of events,” he says. “A new land owner plowed during a dry time, and when the winds came it was catastrophic. The cars ran right into the dust cloud with zero visibility.”

Prepare for the Unseen

Lisa Kirkland, MD, a hospitalist at the Mayo Clinic in Rochester, Minn., agrees disaster planning should be local in the sense of preparing for specific events. Tornadoes are the most likely weather-related crisis to occur in Rochester, she says, and the area is not a prime terrorism target.

Yet disasters don’t have to happen suddenly or involve mass casualties. “A disaster is anything that overwhelms the usual system,” she says. “Putting a community under quarantine during an outbreak of influenza or bird flu, for example, could require the initiation of disaster plans since staff couldn’t get to hospitals.”

In this sort of scenario, like during the SARS outbreak in Toronto in 2003, patient care would be largely medical, rather than surgical, so hospitalists would be key providers of treatment, Dr. Kirkland says.

Hospitalists would also be key in maintaining effective communication, internally and with the outside world because of their thorough knowledge of hospital services, she adds.

Some 75 miles away in Minneapolis, many victims of the I-35W bridge collapse were taken to Hennepin County Medical Center (HCMC). Glen Varns, MD, hospitalist program leader at HCMC, was unable to get to work because he lives on the other side of the bridge. But he says hospitalists played a critical role in dealing with the crisis.

“Since our hospitalists are most familiar with the inner workings of the facility, they played a huge role in determining who needed to be hospitalized and where in the hospital they would best be treated,” he says. “This included reviewing the existing patient census when the collapse happened so we could discharge and transfer inpatients appropriately to ensure that the hospital was in the best position to deal with the collapse victims.”

Because the bridge collapsed during the early evening, there was plenty of staff on-hand to treat the victims, including residents who worked hand-in-hand with hospitalists in making admission and transfer decisions.

Challenge for Hospitalists

In smaller facilities where there are no residents, or in small emergency departments (ED) and intensive-care units, hospitalists will and should have even more critical roles in handling disasters and planning for them, Dr. Varns says.

He believes all hospitalists—but especially those in small, nonteaching facilities—should get triage training. “Hospitalists have a very broad skill set—especially with increasing responsibility for co-management of surgical cases—but they should develop triage skills,” says Dr. Varns, who suggests hospitalists take a two or three-day advanced trauma life support course.

Steven B. Deitelzweig, MD, FACP, system chairman, department of hospital medicine and vice president of medical affairs for the Ochsner Health System in the New Orleans area, agrees.

“I think the folks who are closest to guiding the care should be offering input into triage decisions,” he says. “Hospitalists can be invaluable in doing triage of inpatients. They provide objective detailed information.”

Dr. Deitelzweig, who experienced the three-week lock-down following Katrina, suggests hospitalist groups create a system of prioritizing evacuation of patients—including what kind of support they’ll need.

He believes hospitalists will be invaluable during crises because they are “front-line decision-makers, along with ED physicians and intensivists.” Hospitalists should be on disaster-preparedness committees and a key part of communication during an actual crisis, he urges.

“Communication is critical during a crisis—and hospitalists know their systems,” he continues, noting that Ochsner has out-of-state cell phones, satellite phones, ham radios, spectral light phones, radio frequency antennas in secure places, and more.

In addition to equipment and supplies, hospitalists need to be prepared to do whatever is needed in a crisis, Dr. Deitelzweig says. “In a disaster, you might have to do a procedure usually done by a specialist—with supervision—to extend that person,” he says. “You also may have to go past the physician role. That’s where leadership shows. Our CEO served food in the cafeteria during Katrina. During a disaster, you have to be a flat organization and just do what needs to be done. That gives emotional support to everyone.”

Still, the need to prepare before a disaster cannot be overemphasized, he says.

Ochsner now has two teams of pre-selected physicians, including hospitalists, dedicated to working through specific types of crises. Having the list of essential personnel online at all times is intended to prevent last-minute scurrying around to find the right people, he says.

In addition, providing balanced scheduling—especially in long-lasting crisis situations like Katrina—is important, says Dr. Deitelzweig. “Timing for release must be included, and having more staff on hand than necessary can help alleviate stress,” he advises.

Lessons of Katrina

Neal Axon, MD, an assistant professor at the Medical University of South Carolina, says he and his colleagues learned from those who went through Katrina as they prepared for the most likely disaster in Charleston: a severe hurricane.

Dr. Axon, a senior hospitalist in his group, says the facility has a system that generates e-mail, pages, text messages, and cell phone calls to keep hospital staff informed about potential crises. He also says the preparedness plan provides for relief of staff working for extended periods.

In addition, the hospital has trailers and inflatable tents to extend its facilities if there is a surge in patients. It also has a facility to provide decontamination for exposure to chemicals and radiation.

Brian Bossard, MD, director of Inpatient Physician Associates and medical staff quality designee at BryanLGH Medical Center in Lincoln Neb., says preparedness plans should be tested and updated regularly—especially the systems used to call in staff.

Dr. Bossard strongly believes hospitalists should be involved in disaster planning: “Every day hospitalists work hospital systems. We have a broad scope and perspective. That’s what you need in a disaster.” TH

Karla Feuer is a journalist based in New York.

One hospitalist spent three weeks without a break treating victims of Hurricane Katrina in 2005. Another couldn’t get to work when the I-35W bridge collapsed in Minneapolis on Aug. 1, 2007, but there were enough physicians on hand for that tragedy and fewer victims to treat than feared.

Yet another shudders when he recalls treating victims of an 89-car pile-up caused by a dust storm in southern Idaho.

Not all hospitalists have been in the trenches treating victims of disasters. But two emerging trends likely will put hospitalists on the front lines of preparing for disasters and treating victims.

The first is the increasing recognition that there are many threats to the safety of the public, including terrorism, natural disasters, disease outbreaks, and criminal acts like the mass killings a year ago at Virginia Tech in Blacksburg.

The second is the rapidly expanding role hospitalists have in caring for critically ill and injured patients.

“Hospitalists will be a key,” says Timothy Close, senior safety officer for the University of Colorado Hospital in Denver and chairman of its emergency management committee. “Because of their understanding of all hospital services and treatments, they can handle a multitude of clinical roles. Facilities should deploy hospitalists’ understanding of the organization to facilitate patient care.”

Close, who has 15 years of experience in planning and preparedness, urges organizations to implement plans “that are realistic and doable based on local resources and conditions.” He also urges facilities to conduct emergency drills and have hospitalists participate.

He has dealt with crises wrought by fires, workplace violence, severe weather, and abductions, but adds it is important to remember that “you never know what’s going to happen.”

Close helped treat the victims of the dust storm pile-up. “It was caused by an unfortunate series of events,” he says. “A new land owner plowed during a dry time, and when the winds came it was catastrophic. The cars ran right into the dust cloud with zero visibility.”

Prepare for the Unseen

Lisa Kirkland, MD, a hospitalist at the Mayo Clinic in Rochester, Minn., agrees disaster planning should be local in the sense of preparing for specific events. Tornadoes are the most likely weather-related crisis to occur in Rochester, she says, and the area is not a prime terrorism target.

Yet disasters don’t have to happen suddenly or involve mass casualties. “A disaster is anything that overwhelms the usual system,” she says. “Putting a community under quarantine during an outbreak of influenza or bird flu, for example, could require the initiation of disaster plans since staff couldn’t get to hospitals.”

In this sort of scenario, like during the SARS outbreak in Toronto in 2003, patient care would be largely medical, rather than surgical, so hospitalists would be key providers of treatment, Dr. Kirkland says.

Hospitalists would also be key in maintaining effective communication, internally and with the outside world because of their thorough knowledge of hospital services, she adds.

Some 75 miles away in Minneapolis, many victims of the I-35W bridge collapse were taken to Hennepin County Medical Center (HCMC). Glen Varns, MD, hospitalist program leader at HCMC, was unable to get to work because he lives on the other side of the bridge. But he says hospitalists played a critical role in dealing with the crisis.

“Since our hospitalists are most familiar with the inner workings of the facility, they played a huge role in determining who needed to be hospitalized and where in the hospital they would best be treated,” he says. “This included reviewing the existing patient census when the collapse happened so we could discharge and transfer inpatients appropriately to ensure that the hospital was in the best position to deal with the collapse victims.”

Because the bridge collapsed during the early evening, there was plenty of staff on-hand to treat the victims, including residents who worked hand-in-hand with hospitalists in making admission and transfer decisions.

Challenge for Hospitalists

In smaller facilities where there are no residents, or in small emergency departments (ED) and intensive-care units, hospitalists will and should have even more critical roles in handling disasters and planning for them, Dr. Varns says.

He believes all hospitalists—but especially those in small, nonteaching facilities—should get triage training. “Hospitalists have a very broad skill set—especially with increasing responsibility for co-management of surgical cases—but they should develop triage skills,” says Dr. Varns, who suggests hospitalists take a two or three-day advanced trauma life support course.

Steven B. Deitelzweig, MD, FACP, system chairman, department of hospital medicine and vice president of medical affairs for the Ochsner Health System in the New Orleans area, agrees.

“I think the folks who are closest to guiding the care should be offering input into triage decisions,” he says. “Hospitalists can be invaluable in doing triage of inpatients. They provide objective detailed information.”

Dr. Deitelzweig, who experienced the three-week lock-down following Katrina, suggests hospitalist groups create a system of prioritizing evacuation of patients—including what kind of support they’ll need.

He believes hospitalists will be invaluable during crises because they are “front-line decision-makers, along with ED physicians and intensivists.” Hospitalists should be on disaster-preparedness committees and a key part of communication during an actual crisis, he urges.

“Communication is critical during a crisis—and hospitalists know their systems,” he continues, noting that Ochsner has out-of-state cell phones, satellite phones, ham radios, spectral light phones, radio frequency antennas in secure places, and more.

In addition to equipment and supplies, hospitalists need to be prepared to do whatever is needed in a crisis, Dr. Deitelzweig says. “In a disaster, you might have to do a procedure usually done by a specialist—with supervision—to extend that person,” he says. “You also may have to go past the physician role. That’s where leadership shows. Our CEO served food in the cafeteria during Katrina. During a disaster, you have to be a flat organization and just do what needs to be done. That gives emotional support to everyone.”

Still, the need to prepare before a disaster cannot be overemphasized, he says.

Ochsner now has two teams of pre-selected physicians, including hospitalists, dedicated to working through specific types of crises. Having the list of essential personnel online at all times is intended to prevent last-minute scurrying around to find the right people, he says.

In addition, providing balanced scheduling—especially in long-lasting crisis situations like Katrina—is important, says Dr. Deitelzweig. “Timing for release must be included, and having more staff on hand than necessary can help alleviate stress,” he advises.

Lessons of Katrina

Neal Axon, MD, an assistant professor at the Medical University of South Carolina, says he and his colleagues learned from those who went through Katrina as they prepared for the most likely disaster in Charleston: a severe hurricane.

Dr. Axon, a senior hospitalist in his group, says the facility has a system that generates e-mail, pages, text messages, and cell phone calls to keep hospital staff informed about potential crises. He also says the preparedness plan provides for relief of staff working for extended periods.

In addition, the hospital has trailers and inflatable tents to extend its facilities if there is a surge in patients. It also has a facility to provide decontamination for exposure to chemicals and radiation.

Brian Bossard, MD, director of Inpatient Physician Associates and medical staff quality designee at BryanLGH Medical Center in Lincoln Neb., says preparedness plans should be tested and updated regularly—especially the systems used to call in staff.

Dr. Bossard strongly believes hospitalists should be involved in disaster planning: “Every day hospitalists work hospital systems. We have a broad scope and perspective. That’s what you need in a disaster.” TH

Karla Feuer is a journalist based in New York.

The middle-age man came to Kaiser Foundation Hospital’s emergency department (ED) in the middle of the night in the late stages of a heart attack.

No catheterization lab operates at night at the Santa Clara, Calif., teaching hospital. The emergency team called a cardiologist for advice and gave the man clot-busting medication.

Still, he did not respond well to treatment.

Jean Laumeyer, MD, of the hospitalist staff, was called in. She had seen many similar cases in her 11 years of working the night shift. Within an hour, Dr. Laumeyer stabilized the man’s condition with “a combination of blood thinners, beta-blockers, pain medications … i.e., general medical management.”

The next day, a woman walked up to Dr. Laumeyer’s husband at a car wash and told him his wife had saved her husband’s life.

“Cases like that are what makes me feel good about working at night,” says Dr. Laumeyer. “I’d seen many cases like it and when you do something a lot, you get good at it. And at night you really have to work well as a team, and we did.”

Dr. Laumeyer is one of the growing number of hospitalists working at night. They are filling critical roles in patient care as hospital medicine becomes more complex and oriented to acute care.

Focus on Quality

Whether they work other shifts or are dedicated nocturnalists like Dr. Laumeyer, a mother of three, night-shift hospitalists are increasingly playing key roles in admissions, medication reconciliation, co-management of surgical patients, and more. They are becoming increasingly important to patient care, to outpatient colleagues’ practices, and the effectiveness of today’s hospitals (see The Hospitalist, May 2006, p. 22).

“These days, a patient typically has to be very sick to be in a hospital,” says Janet Nagamine, MD, who has also been a hospitalist at Kaiser, and, years ago, an intensive care nurse. “Many patients who would have been in intensive care units 20 years ago are in step-down units today.” Now, she is primarily involved in risk management and consulting on quality and safety. She chairs SHM’s Hospital Quality and Patient Safety Committee.

Dr. Nagamine believes typical night-staffing patterns established decades ago may not always be what is needed for optimal patient care, especially lab and ancillary services (see The Hospitalist, April 2007, p 39). “The hospitalists working at night are on the front lines of dealing with this,” she says.

Dahlia Rizk, MD, director of the hospitalist program at Beth Israel Medical Center in New York’s Union Square facility, agrees hospitalists are grappling with some vexing issues in hospital medicine. “We’re involved in every medical issue within quality improvement and patient satisfaction,” says Dr. Rizk. “We are the go-to people for administrators dealing with these issues, on the training of new doctors, and in promoting good communication with other professionals and the community.”

Dr. Rizk is building a 24-hour, seven-day hospitalist program at Beth Israel, where the hospitalist staff has grown from two to 12 full-time physicians in 6 1/2 years. That staff handles nights with an on-call system.

The Challenges

Recent research does not indicate a statistically significant difference in patient outcomes when comparing day and night shifts. But some studies find challenges at night, including in EDs and with discharges.

A 2006 study in Academic Emergency Medicine found that while there are no marked deficits in ED patient care at night, there is a small but measurable increase in early mortality.1

Another 2006 study, published by the Medical Journal of Australia, found that over an 11-year period, more patients were discharged from the ICU in the afternoon and night and that they had an increased risk of death.2 Similar results were reported in a study published in December 2006 by Critical Care Medicine.3

ICUs and EDs are areas where night-shift hospitalists often work, treating patients who typically have symptoms of cardiac or respiratory distress, abdominal pain, and infectious diseases. They are often elderly.

As a result, night-shift hospitalists must work to build excellent relationships with the ED staff and doctors, other hospital staff, and the specialists who will pick up care of the admitted patients, says Robert Newborn, MD, medical director of the adult hospitalist program at Northern Westchester Hospital (NWH), a 175-bed community hospital in Mount Kisco, N.Y.

Dr. Newborn became director of NWH’s hospitalist program in 2004 when it was launched. He had served nearly 10 years as an attending physician in the ED and before that as associate director of the ED at NY Hospital-Cornell Medical Center in New York. NWH’s adult hospitalist program has five full-time physicians reporting to Dr. Newborn. Two pediatric hospitalists work during the day.

The adult-disease hospitalists work the nights in shifts, which Dr. Newborn believes is good for their professional development. “Rotating shifts are beneficial because you learn to work in all environments,” he says.

The NWH hospitalists work 12-hour shifts with face-to-face hand-offs with colleagues at the beginning and end. They review the census of patients (typically about 35) and get a thorough run-down on potential new admissions.

A Critical Shift

To Corina Suciu, MD, a hospitalist at NWH for 16 months, these sessions are obviously critical for patient care, but also for building a tight-knit group of physician colleagues.

Recently she began an 8 p.m. to 8 a.m. shift with a hand-off from the earlier shift. It looked like a pretty typical night.

Dr. Suciu began with the pending admission of a 26-year-old schizophrenic male who was acutely paranoid and needed a full medical exam.

After that, she needed to determine the medication status of a 90-year-old man who had suffered from diarrhea for days and had been falling at home—particularly dangerous because he was taking blood-thinning medication. The patient was taking five or six medications for heart rate, asthma, cholesterol, and more.

The man was not able to accurately report his full medication regimen. Neither was his wife. Dr. Suciu could not reach other family members by phone.

Dr. Suciu knew she needed precise dosages on the patient’s blood thinning (Coumadin) and heart rate (digoxin) medications, at least, in order to proceed with a treatment plan. “Medication reconciliation is an important part of a hospitalist’s job and it is hard, especially at night when there usually isn’t a pharmacist,” she says.

That night, everyone was lucky. The patient had his medications in-hand and the pharmacist was still on-site at 9:30 p.m. He determined the dosage and Dr. Suciu continued with the admission and treatment plan.

As she worked the phone and computer for the 90-year-old, Dr. Suciu got beeped by the emergency staff regarding a less typical case. A 21-year-old woman came to the ED unable to speak. A stroke was suspected. The patient had been in a year earlier, but tests at the time proved inconclusive. The emergency team admitted her for further testing.

Dr. Suciu talked by phone and face to face with nurses familiar with the patient. Then she headed to the ED to examine the young woman and talk to her family.

On the way, she ran into the patient’s neurologist. After discussion, they agreed the patient’s status was inconclusive, so testing was needed as soon as possible.

After gathering more information from the emergency team, Dr. Suciu spent 30 minutes examining the patient and talking to the patient’s family. Next she ordered testing, including a stroke work-up. She planned to monitor the woman through the night.

At 10:45 p.m., the patient was ready to be moved from the ED for a battery of tests to determine if she was suffering a stroke.

By her 8 a.m. hand-off, Dr. Suciu reported that the initial tests on the 21-year-old were fine. Her condition may have been related to a migraine headache. The 90-year-old man was stable.

Communication is Key

Facilitating admissions, moving treatment forward, and reconciling medications are typical duties for a night-shift hospitalist. A critical skill is communicating with the specialists and other outpatient doctors who will care for the patients longer-term.

“I always call the consulting specialists at night because 90% of the time they help a lot,” says Dr. Suciu. “We help them because we give immediate care, which improves the patient’s condition, even saves lives, and gets the patient ready for treatment the next day by the specialist.”

Dr. Laumeyer, who started working nights when it was impossible to juggle the needs of her children—then ages 1, 4, and 6—with her 2,400-patient clinic work, says hospitalists must work hard at night to determine the right time to call a specialist.

“I don’t call a specialist until a patient is stabilized,” she says. “Then I try to have clear questions, a sense of when the patient will be admitted, what I will have done, and what needs to come next. Even if they have to come in before morning, I try to make one call.”

An advantage to working nights often, Dr. Laumeyer says, is that hospitalists can learn what specific physicians like to know, how they want to work, and at what point they want to be involved. “Our chief cardiologist says she starts getting dressed as soon as she knows it’s me on the phone because she knows she’ll have to come in,” she says. “I take pride in that.”

While she feels strongly that hospitalists need to be prepared and clear when they call specialists at night, they should never hesitate to call. “If they’re sleepy or cranky, it doesn’t matter,” Dr. Laumeyer says. “What matters is advancing patient care.”

Her Kaiser colleague, Dr. Nagamine, teaches teamwork and communication skills. “This is critical for hospitalists,” she says. Especially at night, “they must be specific about what they need and its urgency.”

Dr. Nagamine believes structured communication systems, such as those used by the military and in aviation, would benefit medical professionals and patients. One example is the Navy’s situation, background, assessment, and recommendations system. “We’re pretty good at background, but we don’t always clearly state the situation and expectations,” she says. “We assume the person will take the information we’ve given them and come up with the same thinking we have. But just by being present in a situation, you know more.”

Dr. Nagamine believes the onus is on night-shift hospitalists to convey a clear picture of what is needed from a colleague because, obviously, “communication failures take patients down.”

She believes the healthcare industry needs to better understand these issues and notes that the Joint Commission on Accreditation of Hospitals urges a standardized structure for communicating that reduces variability in information. “A shy, inexperienced person will say less,” she says. “These systems help to take the person out of the conversation to be sure communications are effective.”

NWH’s Dr. Newborn believes his staff, and hospitalists in general, are “skilled at appropriately triaging the need for specialists to come in at night.”

In his experience, most specialists are happy to have hospitalists on board because they improve patient care and the specialists’ lives and practices. “They are glad that treatment for their patients doesn’t wait until 7 a.m., that they don’t have to come in at night as often, that they don’t have to do all their admissions and that they get patient referrals,” he says. “As a result, they’re generally happy to take hospitalists’ calls in the middle of the night.”

Lab and ancillary services have increased, too. In the ED, advanced imaging, blood drawing, and electrocardiograms are available all night, says Dr. Newborn. There is a computerized system of patient and medication information that can warn doctors and other staff about potential medication problems.

Nevertheless, night-shift hospitalists are on their own more than their day-time colleagues.

At Beth Israel in Manhattan, the day-shift hospitalists are part of a teaching service. “The hospitalist communicates with the resident who is the in-house physician, or the ICU intensivist, or the fellows who are post-residents training in a specialty,” says Dr. Rizk.

The Beth Israel hospitalists are on a team or are assigned patients based on floors or wards rather than shifts. “The advantage is that one hospitalist cares for a given patient for a longer term, working with all the acquired knowledge,” says Dr. Rizk. “We minimize the number of providers working with a patient and the physician knows the goals for care and the treatment plan well.”

At night, the Beth Israel hospitalists are on-call, but because of the hospital’s growth, Dr. Rizk is working to establish a 24-hour, seven-day hospitalist program that will not be a teaching service. She is recruiting for two night-shift hospitalists who will staff the units.

She knows from her efforts to expand her staff in general that recruitment of night hospitalists will be a challenge. Dr. Rizk agrees with many who think night-shift hospitalists must be given incentives such as higher salaries, more time off, or hybrid schedules (such as one month of night shifts per year).

Yet there are benefits to working at night, she and others agree. “Since it’s shift work, when your beeper is off, you are off,” she says. “You can have more time off, and it can suit personal needs and lifestyles.”

It can be quieter at night with few meetings and little committee work. It can be a good fit for a physician who is between residency and working toward further specialization.

Most importantly, she says, it makes it possible to really focus on patients.

“It’s medicine without the committee,” says Dr. Laumeyer at Kaiser. “At night, there are fewer people to run decisions by, but you can learn and make a big difference.”

She cautions, however, “You have to be comfortable with what you can do on your own and get help with what you can’t.”

Dr. Nagamine agrees. “The most important thing is to recognize the limits of your experience and the scope of your practice. You also must be very aware that what you’re doing at night may be different than it would at 2 p.m. As long as you recognize a discrepancy, you can decide if you need to take another step to ensure the best patient care.” TH

Karla Feuer is a journalist based in New York.

References

1. Silbergleit R, Kronick SL, Philpott S, Lowell MJ, Wagner C. Quality of emergency care on the night shift. Acad Emerg Med. 2006 Mar;13(3):325-330.
2. Tobin AE, Santamaria JD. After-hours discharges from intensive care are associated with increased mortality. Med J Aust. 2006;184(7):334-337.
3. Priestap FA, Martin CM. Impact of intensive care unit discharge time on patient outcome. Crit Care Med. 2006 Dec;34(12):2946-2951.

The middle-age man came to Kaiser Foundation Hospital’s emergency department (ED) in the middle of the night in the late stages of a heart attack.

No catheterization lab operates at night at the Santa Clara, Calif., teaching hospital. The emergency team called a cardiologist for advice and gave the man clot-busting medication.

Still, he did not respond well to treatment.

Jean Laumeyer, MD, of the hospitalist staff, was called in. She had seen many similar cases in her 11 years of working the night shift. Within an hour, Dr. Laumeyer stabilized the man’s condition with “a combination of blood thinners, beta-blockers, pain medications … i.e., general medical management.”

The next day, a woman walked up to Dr. Laumeyer’s husband at a car wash and told him his wife had saved her husband’s life.

“Cases like that are what makes me feel good about working at night,” says Dr. Laumeyer. “I’d seen many cases like it and when you do something a lot, you get good at it. And at night you really have to work well as a team, and we did.”

Dr. Laumeyer is one of the growing number of hospitalists working at night. They are filling critical roles in patient care as hospital medicine becomes more complex and oriented to acute care.

Focus on Quality

Whether they work other shifts or are dedicated nocturnalists like Dr. Laumeyer, a mother of three, night-shift hospitalists are increasingly playing key roles in admissions, medication reconciliation, co-management of surgical patients, and more. They are becoming increasingly important to patient care, to outpatient colleagues’ practices, and the effectiveness of today’s hospitals (see The Hospitalist, May 2006, p. 22).

“These days, a patient typically has to be very sick to be in a hospital,” says Janet Nagamine, MD, who has also been a hospitalist at Kaiser, and, years ago, an intensive care nurse. “Many patients who would have been in intensive care units 20 years ago are in step-down units today.” Now, she is primarily involved in risk management and consulting on quality and safety. She chairs SHM’s Hospital Quality and Patient Safety Committee.

Dr. Nagamine believes typical night-staffing patterns established decades ago may not always be what is needed for optimal patient care, especially lab and ancillary services (see The Hospitalist, April 2007, p 39). “The hospitalists working at night are on the front lines of dealing with this,” she says.

Dahlia Rizk, MD, director of the hospitalist program at Beth Israel Medical Center in New York’s Union Square facility, agrees hospitalists are grappling with some vexing issues in hospital medicine. “We’re involved in every medical issue within quality improvement and patient satisfaction,” says Dr. Rizk. “We are the go-to people for administrators dealing with these issues, on the training of new doctors, and in promoting good communication with other professionals and the community.”

Dr. Rizk is building a 24-hour, seven-day hospitalist program at Beth Israel, where the hospitalist staff has grown from two to 12 full-time physicians in 6 1/2 years. That staff handles nights with an on-call system.

The Challenges

Recent research does not indicate a statistically significant difference in patient outcomes when comparing day and night shifts. But some studies find challenges at night, including in EDs and with discharges.

A 2006 study in Academic Emergency Medicine found that while there are no marked deficits in ED patient care at night, there is a small but measurable increase in early mortality.1

Another 2006 study, published by the Medical Journal of Australia, found that over an 11-year period, more patients were discharged from the ICU in the afternoon and night and that they had an increased risk of death.2 Similar results were reported in a study published in December 2006 by Critical Care Medicine.3

ICUs and EDs are areas where night-shift hospitalists often work, treating patients who typically have symptoms of cardiac or respiratory distress, abdominal pain, and infectious diseases. They are often elderly.

As a result, night-shift hospitalists must work to build excellent relationships with the ED staff and doctors, other hospital staff, and the specialists who will pick up care of the admitted patients, says Robert Newborn, MD, medical director of the adult hospitalist program at Northern Westchester Hospital (NWH), a 175-bed community hospital in Mount Kisco, N.Y.

Dr. Newborn became director of NWH’s hospitalist program in 2004 when it was launched. He had served nearly 10 years as an attending physician in the ED and before that as associate director of the ED at NY Hospital-Cornell Medical Center in New York. NWH’s adult hospitalist program has five full-time physicians reporting to Dr. Newborn. Two pediatric hospitalists work during the day.

The adult-disease hospitalists work the nights in shifts, which Dr. Newborn believes is good for their professional development. “Rotating shifts are beneficial because you learn to work in all environments,” he says.

The NWH hospitalists work 12-hour shifts with face-to-face hand-offs with colleagues at the beginning and end. They review the census of patients (typically about 35) and get a thorough run-down on potential new admissions.

A Critical Shift

To Corina Suciu, MD, a hospitalist at NWH for 16 months, these sessions are obviously critical for patient care, but also for building a tight-knit group of physician colleagues.

Recently she began an 8 p.m. to 8 a.m. shift with a hand-off from the earlier shift. It looked like a pretty typical night.

Dr. Suciu began with the pending admission of a 26-year-old schizophrenic male who was acutely paranoid and needed a full medical exam.

After that, she needed to determine the medication status of a 90-year-old man who had suffered from diarrhea for days and had been falling at home—particularly dangerous because he was taking blood-thinning medication. The patient was taking five or six medications for heart rate, asthma, cholesterol, and more.

The man was not able to accurately report his full medication regimen. Neither was his wife. Dr. Suciu could not reach other family members by phone.

Dr. Suciu knew she needed precise dosages on the patient’s blood thinning (Coumadin) and heart rate (digoxin) medications, at least, in order to proceed with a treatment plan. “Medication reconciliation is an important part of a hospitalist’s job and it is hard, especially at night when there usually isn’t a pharmacist,” she says.

That night, everyone was lucky. The patient had his medications in-hand and the pharmacist was still on-site at 9:30 p.m. He determined the dosage and Dr. Suciu continued with the admission and treatment plan.

As she worked the phone and computer for the 90-year-old, Dr. Suciu got beeped by the emergency staff regarding a less typical case. A 21-year-old woman came to the ED unable to speak. A stroke was suspected. The patient had been in a year earlier, but tests at the time proved inconclusive. The emergency team admitted her for further testing.

Dr. Suciu talked by phone and face to face with nurses familiar with the patient. Then she headed to the ED to examine the young woman and talk to her family.

On the way, she ran into the patient’s neurologist. After discussion, they agreed the patient’s status was inconclusive, so testing was needed as soon as possible.

After gathering more information from the emergency team, Dr. Suciu spent 30 minutes examining the patient and talking to the patient’s family. Next she ordered testing, including a stroke work-up. She planned to monitor the woman through the night.

At 10:45 p.m., the patient was ready to be moved from the ED for a battery of tests to determine if she was suffering a stroke.

By her 8 a.m. hand-off, Dr. Suciu reported that the initial tests on the 21-year-old were fine. Her condition may have been related to a migraine headache. The 90-year-old man was stable.

Communication is Key

Facilitating admissions, moving treatment forward, and reconciling medications are typical duties for a night-shift hospitalist. A critical skill is communicating with the specialists and other outpatient doctors who will care for the patients longer-term.

“I always call the consulting specialists at night because 90% of the time they help a lot,” says Dr. Suciu. “We help them because we give immediate care, which improves the patient’s condition, even saves lives, and gets the patient ready for treatment the next day by the specialist.”

Dr. Laumeyer, who started working nights when it was impossible to juggle the needs of her children—then ages 1, 4, and 6—with her 2,400-patient clinic work, says hospitalists must work hard at night to determine the right time to call a specialist.

“I don’t call a specialist until a patient is stabilized,” she says. “Then I try to have clear questions, a sense of when the patient will be admitted, what I will have done, and what needs to come next. Even if they have to come in before morning, I try to make one call.”

An advantage to working nights often, Dr. Laumeyer says, is that hospitalists can learn what specific physicians like to know, how they want to work, and at what point they want to be involved. “Our chief cardiologist says she starts getting dressed as soon as she knows it’s me on the phone because she knows she’ll have to come in,” she says. “I take pride in that.”

While she feels strongly that hospitalists need to be prepared and clear when they call specialists at night, they should never hesitate to call. “If they’re sleepy or cranky, it doesn’t matter,” Dr. Laumeyer says. “What matters is advancing patient care.”

Her Kaiser colleague, Dr. Nagamine, teaches teamwork and communication skills. “This is critical for hospitalists,” she says. Especially at night, “they must be specific about what they need and its urgency.”

Dr. Nagamine believes structured communication systems, such as those used by the military and in aviation, would benefit medical professionals and patients. One example is the Navy’s situation, background, assessment, and recommendations system. “We’re pretty good at background, but we don’t always clearly state the situation and expectations,” she says. “We assume the person will take the information we’ve given them and come up with the same thinking we have. But just by being present in a situation, you know more.”

Dr. Nagamine believes the onus is on night-shift hospitalists to convey a clear picture of what is needed from a colleague because, obviously, “communication failures take patients down.”

She believes the healthcare industry needs to better understand these issues and notes that the Joint Commission on Accreditation of Hospitals urges a standardized structure for communicating that reduces variability in information. “A shy, inexperienced person will say less,” she says. “These systems help to take the person out of the conversation to be sure communications are effective.”

NWH’s Dr. Newborn believes his staff, and hospitalists in general, are “skilled at appropriately triaging the need for specialists to come in at night.”

In his experience, most specialists are happy to have hospitalists on board because they improve patient care and the specialists’ lives and practices. “They are glad that treatment for their patients doesn’t wait until 7 a.m., that they don’t have to come in at night as often, that they don’t have to do all their admissions and that they get patient referrals,” he says. “As a result, they’re generally happy to take hospitalists’ calls in the middle of the night.”

Lab and ancillary services have increased, too. In the ED, advanced imaging, blood drawing, and electrocardiograms are available all night, says Dr. Newborn. There is a computerized system of patient and medication information that can warn doctors and other staff about potential medication problems.

Nevertheless, night-shift hospitalists are on their own more than their day-time colleagues.

At Beth Israel in Manhattan, the day-shift hospitalists are part of a teaching service. “The hospitalist communicates with the resident who is the in-house physician, or the ICU intensivist, or the fellows who are post-residents training in a specialty,” says Dr. Rizk.

The Beth Israel hospitalists are on a team or are assigned patients based on floors or wards rather than shifts. “The advantage is that one hospitalist cares for a given patient for a longer term, working with all the acquired knowledge,” says Dr. Rizk. “We minimize the number of providers working with a patient and the physician knows the goals for care and the treatment plan well.”

At night, the Beth Israel hospitalists are on-call, but because of the hospital’s growth, Dr. Rizk is working to establish a 24-hour, seven-day hospitalist program that will not be a teaching service. She is recruiting for two night-shift hospitalists who will staff the units.

She knows from her efforts to expand her staff in general that recruitment of night hospitalists will be a challenge. Dr. Rizk agrees with many who think night-shift hospitalists must be given incentives such as higher salaries, more time off, or hybrid schedules (such as one month of night shifts per year).

Yet there are benefits to working at night, she and others agree. “Since it’s shift work, when your beeper is off, you are off,” she says. “You can have more time off, and it can suit personal needs and lifestyles.”

It can be quieter at night with few meetings and little committee work. It can be a good fit for a physician who is between residency and working toward further specialization.

Most importantly, she says, it makes it possible to really focus on patients.

“It’s medicine without the committee,” says Dr. Laumeyer at Kaiser. “At night, there are fewer people to run decisions by, but you can learn and make a big difference.”

She cautions, however, “You have to be comfortable with what you can do on your own and get help with what you can’t.”

Dr. Nagamine agrees. “The most important thing is to recognize the limits of your experience and the scope of your practice. You also must be very aware that what you’re doing at night may be different than it would at 2 p.m. As long as you recognize a discrepancy, you can decide if you need to take another step to ensure the best patient care.” TH

Karla Feuer is a journalist based in New York.

References

1. Silbergleit R, Kronick SL, Philpott S, Lowell MJ, Wagner C. Quality of emergency care on the night shift. Acad Emerg Med. 2006 Mar;13(3):325-330.
2. Tobin AE, Santamaria JD. After-hours discharges from intensive care are associated with increased mortality. Med J Aust. 2006;184(7):334-337.
3. Priestap FA, Martin CM. Impact of intensive care unit discharge time on patient outcome. Crit Care Med. 2006 Dec;34(12):2946-2951.

The middle-age man came to Kaiser Foundation Hospital’s emergency department (ED) in the middle of the night in the late stages of a heart attack.

No catheterization lab operates at night at the Santa Clara, Calif., teaching hospital. The emergency team called a cardiologist for advice and gave the man clot-busting medication.

Still, he did not respond well to treatment.

Jean Laumeyer, MD, of the hospitalist staff, was called in. She had seen many similar cases in her 11 years of working the night shift. Within an hour, Dr. Laumeyer stabilized the man’s condition with “a combination of blood thinners, beta-blockers, pain medications … i.e., general medical management.”

The next day, a woman walked up to Dr. Laumeyer’s husband at a car wash and told him his wife had saved her husband’s life.

“Cases like that are what makes me feel good about working at night,” says Dr. Laumeyer. “I’d seen many cases like it and when you do something a lot, you get good at it. And at night you really have to work well as a team, and we did.”

Dr. Laumeyer is one of the growing number of hospitalists working at night. They are filling critical roles in patient care as hospital medicine becomes more complex and oriented to acute care.

Focus on Quality

Whether they work other shifts or are dedicated nocturnalists like Dr. Laumeyer, a mother of three, night-shift hospitalists are increasingly playing key roles in admissions, medication reconciliation, co-management of surgical patients, and more. They are becoming increasingly important to patient care, to outpatient colleagues’ practices, and the effectiveness of today’s hospitals (see The Hospitalist, May 2006, p. 22).

“These days, a patient typically has to be very sick to be in a hospital,” says Janet Nagamine, MD, who has also been a hospitalist at Kaiser, and, years ago, an intensive care nurse. “Many patients who would have been in intensive care units 20 years ago are in step-down units today.” Now, she is primarily involved in risk management and consulting on quality and safety. She chairs SHM’s Hospital Quality and Patient Safety Committee.

Dr. Nagamine believes typical night-staffing patterns established decades ago may not always be what is needed for optimal patient care, especially lab and ancillary services (see The Hospitalist, April 2007, p 39). “The hospitalists working at night are on the front lines of dealing with this,” she says.

Dahlia Rizk, MD, director of the hospitalist program at Beth Israel Medical Center in New York’s Union Square facility, agrees hospitalists are grappling with some vexing issues in hospital medicine. “We’re involved in every medical issue within quality improvement and patient satisfaction,” says Dr. Rizk. “We are the go-to people for administrators dealing with these issues, on the training of new doctors, and in promoting good communication with other professionals and the community.”

Dr. Rizk is building a 24-hour, seven-day hospitalist program at Beth Israel, where the hospitalist staff has grown from two to 12 full-time physicians in 6 1/2 years. That staff handles nights with an on-call system.

The Challenges

Recent research does not indicate a statistically significant difference in patient outcomes when comparing day and night shifts. But some studies find challenges at night, including in EDs and with discharges.

A 2006 study in Academic Emergency Medicine found that while there are no marked deficits in ED patient care at night, there is a small but measurable increase in early mortality.1

Another 2006 study, published by the Medical Journal of Australia, found that over an 11-year period, more patients were discharged from the ICU in the afternoon and night and that they had an increased risk of death.2 Similar results were reported in a study published in December 2006 by Critical Care Medicine.3

ICUs and EDs are areas where night-shift hospitalists often work, treating patients who typically have symptoms of cardiac or respiratory distress, abdominal pain, and infectious diseases. They are often elderly.

As a result, night-shift hospitalists must work to build excellent relationships with the ED staff and doctors, other hospital staff, and the specialists who will pick up care of the admitted patients, says Robert Newborn, MD, medical director of the adult hospitalist program at Northern Westchester Hospital (NWH), a 175-bed community hospital in Mount Kisco, N.Y.

Dr. Newborn became director of NWH’s hospitalist program in 2004 when it was launched. He had served nearly 10 years as an attending physician in the ED and before that as associate director of the ED at NY Hospital-Cornell Medical Center in New York. NWH’s adult hospitalist program has five full-time physicians reporting to Dr. Newborn. Two pediatric hospitalists work during the day.

The adult-disease hospitalists work the nights in shifts, which Dr. Newborn believes is good for their professional development. “Rotating shifts are beneficial because you learn to work in all environments,” he says.

The NWH hospitalists work 12-hour shifts with face-to-face hand-offs with colleagues at the beginning and end. They review the census of patients (typically about 35) and get a thorough run-down on potential new admissions.

A Critical Shift

To Corina Suciu, MD, a hospitalist at NWH for 16 months, these sessions are obviously critical for patient care, but also for building a tight-knit group of physician colleagues.

Recently she began an 8 p.m. to 8 a.m. shift with a hand-off from the earlier shift. It looked like a pretty typical night.

Dr. Suciu began with the pending admission of a 26-year-old schizophrenic male who was acutely paranoid and needed a full medical exam.

After that, she needed to determine the medication status of a 90-year-old man who had suffered from diarrhea for days and had been falling at home—particularly dangerous because he was taking blood-thinning medication. The patient was taking five or six medications for heart rate, asthma, cholesterol, and more.

The man was not able to accurately report his full medication regimen. Neither was his wife. Dr. Suciu could not reach other family members by phone.

Dr. Suciu knew she needed precise dosages on the patient’s blood thinning (Coumadin) and heart rate (digoxin) medications, at least, in order to proceed with a treatment plan. “Medication reconciliation is an important part of a hospitalist’s job and it is hard, especially at night when there usually isn’t a pharmacist,” she says.

That night, everyone was lucky. The patient had his medications in-hand and the pharmacist was still on-site at 9:30 p.m. He determined the dosage and Dr. Suciu continued with the admission and treatment plan.

As she worked the phone and computer for the 90-year-old, Dr. Suciu got beeped by the emergency staff regarding a less typical case. A 21-year-old woman came to the ED unable to speak. A stroke was suspected. The patient had been in a year earlier, but tests at the time proved inconclusive. The emergency team admitted her for further testing.

Dr. Suciu talked by phone and face to face with nurses familiar with the patient. Then she headed to the ED to examine the young woman and talk to her family.

On the way, she ran into the patient’s neurologist. After discussion, they agreed the patient’s status was inconclusive, so testing was needed as soon as possible.

After gathering more information from the emergency team, Dr. Suciu spent 30 minutes examining the patient and talking to the patient’s family. Next she ordered testing, including a stroke work-up. She planned to monitor the woman through the night.

At 10:45 p.m., the patient was ready to be moved from the ED for a battery of tests to determine if she was suffering a stroke.

By her 8 a.m. hand-off, Dr. Suciu reported that the initial tests on the 21-year-old were fine. Her condition may have been related to a migraine headache. The 90-year-old man was stable.

Communication is Key

Facilitating admissions, moving treatment forward, and reconciling medications are typical duties for a night-shift hospitalist. A critical skill is communicating with the specialists and other outpatient doctors who will care for the patients longer-term.

“I always call the consulting specialists at night because 90% of the time they help a lot,” says Dr. Suciu. “We help them because we give immediate care, which improves the patient’s condition, even saves lives, and gets the patient ready for treatment the next day by the specialist.”

Dr. Laumeyer, who started working nights when it was impossible to juggle the needs of her children—then ages 1, 4, and 6—with her 2,400-patient clinic work, says hospitalists must work hard at night to determine the right time to call a specialist.

“I don’t call a specialist until a patient is stabilized,” she says. “Then I try to have clear questions, a sense of when the patient will be admitted, what I will have done, and what needs to come next. Even if they have to come in before morning, I try to make one call.”

An advantage to working nights often, Dr. Laumeyer says, is that hospitalists can learn what specific physicians like to know, how they want to work, and at what point they want to be involved. “Our chief cardiologist says she starts getting dressed as soon as she knows it’s me on the phone because she knows she’ll have to come in,” she says. “I take pride in that.”

While she feels strongly that hospitalists need to be prepared and clear when they call specialists at night, they should never hesitate to call. “If they’re sleepy or cranky, it doesn’t matter,” Dr. Laumeyer says. “What matters is advancing patient care.”

Her Kaiser colleague, Dr. Nagamine, teaches teamwork and communication skills. “This is critical for hospitalists,” she says. Especially at night, “they must be specific about what they need and its urgency.”

Dr. Nagamine believes structured communication systems, such as those used by the military and in aviation, would benefit medical professionals and patients. One example is the Navy’s situation, background, assessment, and recommendations system. “We’re pretty good at background, but we don’t always clearly state the situation and expectations,” she says. “We assume the person will take the information we’ve given them and come up with the same thinking we have. But just by being present in a situation, you know more.”

Dr. Nagamine believes the onus is on night-shift hospitalists to convey a clear picture of what is needed from a colleague because, obviously, “communication failures take patients down.”

She believes the healthcare industry needs to better understand these issues and notes that the Joint Commission on Accreditation of Hospitals urges a standardized structure for communicating that reduces variability in information. “A shy, inexperienced person will say less,” she says. “These systems help to take the person out of the conversation to be sure communications are effective.”

NWH’s Dr. Newborn believes his staff, and hospitalists in general, are “skilled at appropriately triaging the need for specialists to come in at night.”

In his experience, most specialists are happy to have hospitalists on board because they improve patient care and the specialists’ lives and practices. “They are glad that treatment for their patients doesn’t wait until 7 a.m., that they don’t have to come in at night as often, that they don’t have to do all their admissions and that they get patient referrals,” he says. “As a result, they’re generally happy to take hospitalists’ calls in the middle of the night.”

Lab and ancillary services have increased, too. In the ED, advanced imaging, blood drawing, and electrocardiograms are available all night, says Dr. Newborn. There is a computerized system of patient and medication information that can warn doctors and other staff about potential medication problems.

Nevertheless, night-shift hospitalists are on their own more than their day-time colleagues.

At Beth Israel in Manhattan, the day-shift hospitalists are part of a teaching service. “The hospitalist communicates with the resident who is the in-house physician, or the ICU intensivist, or the fellows who are post-residents training in a specialty,” says Dr. Rizk.

The Beth Israel hospitalists are on a team or are assigned patients based on floors or wards rather than shifts. “The advantage is that one hospitalist cares for a given patient for a longer term, working with all the acquired knowledge,” says Dr. Rizk. “We minimize the number of providers working with a patient and the physician knows the goals for care and the treatment plan well.”

At night, the Beth Israel hospitalists are on-call, but because of the hospital’s growth, Dr. Rizk is working to establish a 24-hour, seven-day hospitalist program that will not be a teaching service. She is recruiting for two night-shift hospitalists who will staff the units.

She knows from her efforts to expand her staff in general that recruitment of night hospitalists will be a challenge. Dr. Rizk agrees with many who think night-shift hospitalists must be given incentives such as higher salaries, more time off, or hybrid schedules (such as one month of night shifts per year).

Yet there are benefits to working at night, she and others agree. “Since it’s shift work, when your beeper is off, you are off,” she says. “You can have more time off, and it can suit personal needs and lifestyles.”

It can be quieter at night with few meetings and little committee work. It can be a good fit for a physician who is between residency and working toward further specialization.

Most importantly, she says, it makes it possible to really focus on patients.

“It’s medicine without the committee,” says Dr. Laumeyer at Kaiser. “At night, there are fewer people to run decisions by, but you can learn and make a big difference.”

She cautions, however, “You have to be comfortable with what you can do on your own and get help with what you can’t.”

Dr. Nagamine agrees. “The most important thing is to recognize the limits of your experience and the scope of your practice. You also must be very aware that what you’re doing at night may be different than it would at 2 p.m. As long as you recognize a discrepancy, you can decide if you need to take another step to ensure the best patient care.” TH

Karla Feuer is a journalist based in New York.

References

1. Silbergleit R, Kronick SL, Philpott S, Lowell MJ, Wagner C. Quality of emergency care on the night shift. Acad Emerg Med. 2006 Mar;13(3):325-330.
2. Tobin AE, Santamaria JD. After-hours discharges from intensive care are associated with increased mortality. Med J Aust. 2006;184(7):334-337.
3. Priestap FA, Martin CM. Impact of intensive care unit discharge time on patient outcome. Crit Care Med. 2006 Dec;34(12):2946-2951.