Mark Reid, MD

In 2010, the Centers for Medicare and Medicaid Services implemented value‐based purchasing, a payment model that incentivizes hospitals for reaching certain quality and patient experience thresholds and penalizes those that do not, in part on the basis of patient satisfaction scores.[1] Although low patient satisfaction scores will adversely affect institutions financially, they also reflect patients' perceptions of their care. Some studies suggest that hospitals with higher patient satisfaction scores score higher overall on clinical care processes such as core measures compliance, readmission rates, lower mortality rates, and other quality‐of‐care metrics.[2, 3, 4, 5, 6, 7, 8, 9, 10, 11]

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey assesses patients' experience following their hospital stay.[1] The percent of top box scores (ie, response of always on a four point scale, or scores of 9 or 10 on a 10‐point scale) are utilized to compare hospitals and determine the reimbursement or penalty a hospital will receive. Although these scores are available to the public on the Hospital Compare website,[12] physicians may not know how their hospital is ranked or how they are individually perceived by their patients. Additionally, these surveys are typically conducted 48 hours to 6 weeks after patients are discharged, and the results are distributed back to the hospitals well after the time that care was provided, thereby offering providers no chance of improving patient satisfaction during a given hospital stay.

Institutions across the country are trying to improve their HCAHPS scores, but there is limited research identifying specific measures providers can implement. Some studies have suggested that utilizing etiquette‐based communication and sitting at the bedside[13, 14] may help improve patient experience with their providers, and more recently, it has been suggested that providing real‐time deidentified patient experience survey results with education and a rewards/emncentive system to residents may help as well.[15]

Surveys conducted during a patient's hospitalization can offer real‐time actionable feedback to providers. We performed a quality‐improvement project that was designed to determine if real‐time feedback to hospitalist physicians, followed by coaching, and revisits to the patients' bedside could improve the results recorded on provider‐specific patient surveys and/or patients' HCAHPS scores or percentile rankings.

METHODS

RESULTS

From April 14, 2014 to September 19, 2014, we enrolled 227 patients in the control group and 228 in the intervention group (Figure 1). Patient demographics are summarized in Table 1. Of the 132 patients in the intervention group who reported anything less than top box scores for any of the 3 questions (thus prompting a revisit by their provider), 106 (80%) were revisited by their provider at least once during their hospitalization.

Figure 1

Daily Surveys

The proportion of patients in both study groups reporting top box scores tended to increase from the first day to the last day of the survey (Figure 2); however, we found no statistically significant differences between the proportion of patients who reported top box scores on first day or last day in the intervention group compared to the control group. The comments made by the patients are summarized in Supporting Table 1 in the online version of this article.

Figure 2

DISCUSSION

The important findings of this study were that (1) daily patient satisfaction scores improved from first day to last day regardless of study group, (2) patients whose providers received real‐time feedback had a trend toward higher HCAHPS proportions for the 3 provider‐related questions as well as the overall rating of the hospital but were not statistically significant, (3) the percentile differences in these 3 questions as well as the overall rating of the hospital were significantly higher in the intervention group as was the median score for the overall hospital rating.

Our original sample size calculation was based upon our own preliminary data, indicating that our baseline top box scores for the daily survey was around 75%. The daily survey top box score on the first day was, however, much lower (Figure 2). Accordingly, although we did not find a significant difference in these daily scores, we were underpowered to find such a difference. Additionally, because only a small percentage of patients are selected for the HCAHPS survey, our ability to detect a difference in this secondary outcome was also limited. We felt that it was important to analyze the percentile comparisons in addition to the proportion of top box scores on the HCAHPS, because the metrics for value‐based purchasing are based upon, in part, how a hospital system compares to other systems. Finally, to improve our power to detect a difference given a small sample size, we converted the scoring system for overall hospital ranking to a continuous variable, which again was noted to be significant.

To our knowledge, this is the first randomized investigation designed to assess the effect of real‐time, patient‐specific feedback to physicians. Real‐time feedback is increasingly being incorporated into medical practice, but there is only limited information available describing how this type of feedback affects outcomes.[22, 23, 24] Banka et al.[15] found that HCAHPS scores improved as a result of real‐time feedback given to residents, but the study was not randomized, utilized a pre‐post design that resulted in there being differences between the patients studied before and after the intervention, and did not provide patient‐specific data to the residents. Tabib et al.[25] found that operating costs decreased 17% after instituting real‐time feedback to providers about these costs. Reeves et al.[26] conducted a cluster randomized trial of a patient feedback survey that was designed to improve nursing care, but the results were reviewed by the nurses several months after patients had been discharged.

The differences in median top box scores and percentile rank that we observed could have resulted from the real‐time feedback, the educational coaching, the fact that the providers revisited the majority of the patients, or a combination of all of the above. Gross et al.[27] found that longer visits lead to higher satisfaction, though others have not found this to necessarily be the case.[28, 29] Lin et al.[30] found that patient satisfaction was affected by the perceived duration of the visit as well as whether expectations on visit length were met and/or exceeded. Brown et al.[31] found that training providers in communication skills improved the providers perception of their communication skills, although patient experience scores did not improve. We feel that the results seen are more likely a combination thereof as opposed to any 1 component of the intervention.

The most commonly reported complaints or concerns in patients' undirected comments often related to communication issues. Comments on subsequent surveys suggested that patient satisfaction improved over time in the intervention group, indicating that perhaps physicians did try to improve in areas that were highlighted by the real‐time feedback, and that patients perceived the physician efforts to do so (eg, They're doing better than the last time you asked. They sat down and talked to me and listened better. They came back and explained to me about my care. They listened better. They should do this survey at the clinic. See Supporting Table 1 in the online version of this article).

Our study has several limitations. First, we did not randomize providers, and many of our providers (approximately 65%) participated in both the control group and also in the intervention group, and thus received real‐time feedback at some point during the study, which could have affected their overall practice and limited our ability to find a difference between the 2 groups. In an attempt to control for this possibility, the study was conducted on an intermittent basis during the study time frame. Furthermore, the proportion of patients who reported top box scores at the beginning of the study did not have a clear trend of change by the end of the study, suggesting that overall clinician practices with respect to patient satisfaction did not change during this short time period.

Second, only a small number of our patients were randomly selected for the HCAHPS survey, which limited our ability to detect significant differences in HCAHPS proportions. Third, the HCAHPS percentiles at our institution at that time were low. Accordingly, the improvements that we observed in patient satisfaction scores might not be reproducible at institutions with higher satisfactions scores. Fourth, time and resources were needed to obtain patient feedback to provide to providers during this study. There are, however, other ways to obtain feedback that are less resource intensive (eg, electronic feedback, the utilization of volunteers, or partnering this with manager rounding). Finally, the study was conducted at a single, university‐affiliated public teaching hospital and was a quality‐improvement initiative, and thus our results are not generalizable to other institutions.

In conclusion, real‐time feedback of patient experience to their providers, coupled with provider education, coaching, and revisits, seems to improve satisfaction of patients hospitalized on general internal medicine units who were cared for by hospitalists.

Disclosure: Nothing to report.

In 2010, the Centers for Medicare and Medicaid Services implemented value‐based purchasing, a payment model that incentivizes hospitals for reaching certain quality and patient experience thresholds and penalizes those that do not, in part on the basis of patient satisfaction scores.[1] Although low patient satisfaction scores will adversely affect institutions financially, they also reflect patients' perceptions of their care. Some studies suggest that hospitals with higher patient satisfaction scores score higher overall on clinical care processes such as core measures compliance, readmission rates, lower mortality rates, and other quality‐of‐care metrics.[2, 3, 4, 5, 6, 7, 8, 9, 10, 11]

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey assesses patients' experience following their hospital stay.[1] The percent of top box scores (ie, response of always on a four point scale, or scores of 9 or 10 on a 10‐point scale) are utilized to compare hospitals and determine the reimbursement or penalty a hospital will receive. Although these scores are available to the public on the Hospital Compare website,[12] physicians may not know how their hospital is ranked or how they are individually perceived by their patients. Additionally, these surveys are typically conducted 48 hours to 6 weeks after patients are discharged, and the results are distributed back to the hospitals well after the time that care was provided, thereby offering providers no chance of improving patient satisfaction during a given hospital stay.

Institutions across the country are trying to improve their HCAHPS scores, but there is limited research identifying specific measures providers can implement. Some studies have suggested that utilizing etiquette‐based communication and sitting at the bedside[13, 14] may help improve patient experience with their providers, and more recently, it has been suggested that providing real‐time deidentified patient experience survey results with education and a rewards/emncentive system to residents may help as well.[15]

Surveys conducted during a patient's hospitalization can offer real‐time actionable feedback to providers. We performed a quality‐improvement project that was designed to determine if real‐time feedback to hospitalist physicians, followed by coaching, and revisits to the patients' bedside could improve the results recorded on provider‐specific patient surveys and/or patients' HCAHPS scores or percentile rankings.

METHODS

RESULTS

From April 14, 2014 to September 19, 2014, we enrolled 227 patients in the control group and 228 in the intervention group (Figure 1). Patient demographics are summarized in Table 1. Of the 132 patients in the intervention group who reported anything less than top box scores for any of the 3 questions (thus prompting a revisit by their provider), 106 (80%) were revisited by their provider at least once during their hospitalization.

Figure 1

Daily Surveys

The proportion of patients in both study groups reporting top box scores tended to increase from the first day to the last day of the survey (Figure 2); however, we found no statistically significant differences between the proportion of patients who reported top box scores on first day or last day in the intervention group compared to the control group. The comments made by the patients are summarized in Supporting Table 1 in the online version of this article.

Figure 2

DISCUSSION

The important findings of this study were that (1) daily patient satisfaction scores improved from first day to last day regardless of study group, (2) patients whose providers received real‐time feedback had a trend toward higher HCAHPS proportions for the 3 provider‐related questions as well as the overall rating of the hospital but were not statistically significant, (3) the percentile differences in these 3 questions as well as the overall rating of the hospital were significantly higher in the intervention group as was the median score for the overall hospital rating.

Our original sample size calculation was based upon our own preliminary data, indicating that our baseline top box scores for the daily survey was around 75%. The daily survey top box score on the first day was, however, much lower (Figure 2). Accordingly, although we did not find a significant difference in these daily scores, we were underpowered to find such a difference. Additionally, because only a small percentage of patients are selected for the HCAHPS survey, our ability to detect a difference in this secondary outcome was also limited. We felt that it was important to analyze the percentile comparisons in addition to the proportion of top box scores on the HCAHPS, because the metrics for value‐based purchasing are based upon, in part, how a hospital system compares to other systems. Finally, to improve our power to detect a difference given a small sample size, we converted the scoring system for overall hospital ranking to a continuous variable, which again was noted to be significant.

To our knowledge, this is the first randomized investigation designed to assess the effect of real‐time, patient‐specific feedback to physicians. Real‐time feedback is increasingly being incorporated into medical practice, but there is only limited information available describing how this type of feedback affects outcomes.[22, 23, 24] Banka et al.[15] found that HCAHPS scores improved as a result of real‐time feedback given to residents, but the study was not randomized, utilized a pre‐post design that resulted in there being differences between the patients studied before and after the intervention, and did not provide patient‐specific data to the residents. Tabib et al.[25] found that operating costs decreased 17% after instituting real‐time feedback to providers about these costs. Reeves et al.[26] conducted a cluster randomized trial of a patient feedback survey that was designed to improve nursing care, but the results were reviewed by the nurses several months after patients had been discharged.

The differences in median top box scores and percentile rank that we observed could have resulted from the real‐time feedback, the educational coaching, the fact that the providers revisited the majority of the patients, or a combination of all of the above. Gross et al.[27] found that longer visits lead to higher satisfaction, though others have not found this to necessarily be the case.[28, 29] Lin et al.[30] found that patient satisfaction was affected by the perceived duration of the visit as well as whether expectations on visit length were met and/or exceeded. Brown et al.[31] found that training providers in communication skills improved the providers perception of their communication skills, although patient experience scores did not improve. We feel that the results seen are more likely a combination thereof as opposed to any 1 component of the intervention.

The most commonly reported complaints or concerns in patients' undirected comments often related to communication issues. Comments on subsequent surveys suggested that patient satisfaction improved over time in the intervention group, indicating that perhaps physicians did try to improve in areas that were highlighted by the real‐time feedback, and that patients perceived the physician efforts to do so (eg, They're doing better than the last time you asked. They sat down and talked to me and listened better. They came back and explained to me about my care. They listened better. They should do this survey at the clinic. See Supporting Table 1 in the online version of this article).

Our study has several limitations. First, we did not randomize providers, and many of our providers (approximately 65%) participated in both the control group and also in the intervention group, and thus received real‐time feedback at some point during the study, which could have affected their overall practice and limited our ability to find a difference between the 2 groups. In an attempt to control for this possibility, the study was conducted on an intermittent basis during the study time frame. Furthermore, the proportion of patients who reported top box scores at the beginning of the study did not have a clear trend of change by the end of the study, suggesting that overall clinician practices with respect to patient satisfaction did not change during this short time period.

Second, only a small number of our patients were randomly selected for the HCAHPS survey, which limited our ability to detect significant differences in HCAHPS proportions. Third, the HCAHPS percentiles at our institution at that time were low. Accordingly, the improvements that we observed in patient satisfaction scores might not be reproducible at institutions with higher satisfactions scores. Fourth, time and resources were needed to obtain patient feedback to provide to providers during this study. There are, however, other ways to obtain feedback that are less resource intensive (eg, electronic feedback, the utilization of volunteers, or partnering this with manager rounding). Finally, the study was conducted at a single, university‐affiliated public teaching hospital and was a quality‐improvement initiative, and thus our results are not generalizable to other institutions.

In conclusion, real‐time feedback of patient experience to their providers, coupled with provider education, coaching, and revisits, seems to improve satisfaction of patients hospitalized on general internal medicine units who were cared for by hospitalists.

Disclosure: Nothing to report.

In 2010, the Centers for Medicare and Medicaid Services implemented value‐based purchasing, a payment model that incentivizes hospitals for reaching certain quality and patient experience thresholds and penalizes those that do not, in part on the basis of patient satisfaction scores.[1] Although low patient satisfaction scores will adversely affect institutions financially, they also reflect patients' perceptions of their care. Some studies suggest that hospitals with higher patient satisfaction scores score higher overall on clinical care processes such as core measures compliance, readmission rates, lower mortality rates, and other quality‐of‐care metrics.[2, 3, 4, 5, 6, 7, 8, 9, 10, 11]

The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey assesses patients' experience following their hospital stay.[1] The percent of top box scores (ie, response of always on a four point scale, or scores of 9 or 10 on a 10‐point scale) are utilized to compare hospitals and determine the reimbursement or penalty a hospital will receive. Although these scores are available to the public on the Hospital Compare website,[12] physicians may not know how their hospital is ranked or how they are individually perceived by their patients. Additionally, these surveys are typically conducted 48 hours to 6 weeks after patients are discharged, and the results are distributed back to the hospitals well after the time that care was provided, thereby offering providers no chance of improving patient satisfaction during a given hospital stay.

Institutions across the country are trying to improve their HCAHPS scores, but there is limited research identifying specific measures providers can implement. Some studies have suggested that utilizing etiquette‐based communication and sitting at the bedside[13, 14] may help improve patient experience with their providers, and more recently, it has been suggested that providing real‐time deidentified patient experience survey results with education and a rewards/emncentive system to residents may help as well.[15]

Surveys conducted during a patient's hospitalization can offer real‐time actionable feedback to providers. We performed a quality‐improvement project that was designed to determine if real‐time feedback to hospitalist physicians, followed by coaching, and revisits to the patients' bedside could improve the results recorded on provider‐specific patient surveys and/or patients' HCAHPS scores or percentile rankings.

METHODS

RESULTS

From April 14, 2014 to September 19, 2014, we enrolled 227 patients in the control group and 228 in the intervention group (Figure 1). Patient demographics are summarized in Table 1. Of the 132 patients in the intervention group who reported anything less than top box scores for any of the 3 questions (thus prompting a revisit by their provider), 106 (80%) were revisited by their provider at least once during their hospitalization.

Figure 1

Daily Surveys

The proportion of patients in both study groups reporting top box scores tended to increase from the first day to the last day of the survey (Figure 2); however, we found no statistically significant differences between the proportion of patients who reported top box scores on first day or last day in the intervention group compared to the control group. The comments made by the patients are summarized in Supporting Table 1 in the online version of this article.

Figure 2

DISCUSSION

The important findings of this study were that (1) daily patient satisfaction scores improved from first day to last day regardless of study group, (2) patients whose providers received real‐time feedback had a trend toward higher HCAHPS proportions for the 3 provider‐related questions as well as the overall rating of the hospital but were not statistically significant, (3) the percentile differences in these 3 questions as well as the overall rating of the hospital were significantly higher in the intervention group as was the median score for the overall hospital rating.

Our original sample size calculation was based upon our own preliminary data, indicating that our baseline top box scores for the daily survey was around 75%. The daily survey top box score on the first day was, however, much lower (Figure 2). Accordingly, although we did not find a significant difference in these daily scores, we were underpowered to find such a difference. Additionally, because only a small percentage of patients are selected for the HCAHPS survey, our ability to detect a difference in this secondary outcome was also limited. We felt that it was important to analyze the percentile comparisons in addition to the proportion of top box scores on the HCAHPS, because the metrics for value‐based purchasing are based upon, in part, how a hospital system compares to other systems. Finally, to improve our power to detect a difference given a small sample size, we converted the scoring system for overall hospital ranking to a continuous variable, which again was noted to be significant.

To our knowledge, this is the first randomized investigation designed to assess the effect of real‐time, patient‐specific feedback to physicians. Real‐time feedback is increasingly being incorporated into medical practice, but there is only limited information available describing how this type of feedback affects outcomes.[22, 23, 24] Banka et al.[15] found that HCAHPS scores improved as a result of real‐time feedback given to residents, but the study was not randomized, utilized a pre‐post design that resulted in there being differences between the patients studied before and after the intervention, and did not provide patient‐specific data to the residents. Tabib et al.[25] found that operating costs decreased 17% after instituting real‐time feedback to providers about these costs. Reeves et al.[26] conducted a cluster randomized trial of a patient feedback survey that was designed to improve nursing care, but the results were reviewed by the nurses several months after patients had been discharged.

The differences in median top box scores and percentile rank that we observed could have resulted from the real‐time feedback, the educational coaching, the fact that the providers revisited the majority of the patients, or a combination of all of the above. Gross et al.[27] found that longer visits lead to higher satisfaction, though others have not found this to necessarily be the case.[28, 29] Lin et al.[30] found that patient satisfaction was affected by the perceived duration of the visit as well as whether expectations on visit length were met and/or exceeded. Brown et al.[31] found that training providers in communication skills improved the providers perception of their communication skills, although patient experience scores did not improve. We feel that the results seen are more likely a combination thereof as opposed to any 1 component of the intervention.

The most commonly reported complaints or concerns in patients' undirected comments often related to communication issues. Comments on subsequent surveys suggested that patient satisfaction improved over time in the intervention group, indicating that perhaps physicians did try to improve in areas that were highlighted by the real‐time feedback, and that patients perceived the physician efforts to do so (eg, They're doing better than the last time you asked. They sat down and talked to me and listened better. They came back and explained to me about my care. They listened better. They should do this survey at the clinic. See Supporting Table 1 in the online version of this article).

Our study has several limitations. First, we did not randomize providers, and many of our providers (approximately 65%) participated in both the control group and also in the intervention group, and thus received real‐time feedback at some point during the study, which could have affected their overall practice and limited our ability to find a difference between the 2 groups. In an attempt to control for this possibility, the study was conducted on an intermittent basis during the study time frame. Furthermore, the proportion of patients who reported top box scores at the beginning of the study did not have a clear trend of change by the end of the study, suggesting that overall clinician practices with respect to patient satisfaction did not change during this short time period.

Second, only a small number of our patients were randomly selected for the HCAHPS survey, which limited our ability to detect significant differences in HCAHPS proportions. Third, the HCAHPS percentiles at our institution at that time were low. Accordingly, the improvements that we observed in patient satisfaction scores might not be reproducible at institutions with higher satisfactions scores. Fourth, time and resources were needed to obtain patient feedback to provide to providers during this study. There are, however, other ways to obtain feedback that are less resource intensive (eg, electronic feedback, the utilization of volunteers, or partnering this with manager rounding). Finally, the study was conducted at a single, university‐affiliated public teaching hospital and was a quality‐improvement initiative, and thus our results are not generalizable to other institutions.

In conclusion, real‐time feedback of patient experience to their providers, coupled with provider education, coaching, and revisits, seems to improve satisfaction of patients hospitalized on general internal medicine units who were cared for by hospitalists.

Disclosure: Nothing to report.

Proton pump inhibitors (PPIs) are the third most commonly prescribed class of medication in the United States, with $13.6 billion in yearly sales.1 Despite their effectiveness in treating acid reflux2 and their mortality benefit in the treatment of patients with gastrointestinal bleeding,3 recent literature has identified a number of risks associated with PPIs, including an increased incidence of Clostridium difficile infection,4 decreased effectiveness of clopidogrel in patients with acute coronary syndrome,5 increased risk of community‐ and hospital‐acquired pneumonia, and an increased risk of hip fracture.69 Additionally, in March of 2011, the US Food and Drug Administration (FDA) issued a warning regarding the potential for PPIs to cause low magnesium levels which can, in turn, cause muscle spasms, an irregular heartbeat, and convulsions.10

Inappropriate PPI prescription practice has been demonstrated in the primary care setting,11 as well as in small studies conducted in the hospital setting.1216 We hypothesized that many hospitalized patients receive these medications without having an accepted indication, and examined 2 populations of hospitalized patients, including administrative data from 6.5 million discharges from US university hospitals, to look for appropriate diagnoses justifying their use.

METHODS

We performed a retrospective review of administrative data collected between January 1, 2008 and December 31, 2009 from 2 patient populations: (a) those discharged from Denver Health (DH), a university‐affiliated public safety net hospital in Denver, CO; and (b) patients discharged from 112 academic health centers and 256 of their affiliated hospitals that participate in the University HealthSystem Consortium (UHC). The Colorado Multiple Institution Review Board reviewed and approved the conduct of this study.

Inclusion criteria for both populations were age >18 or <90 years, and hospitalization on a Medicine service. Prisoners and women known to be pregnant were excluded. In both cohorts, if patients had more than 1 admission during the 2‐year study period, only data from the first admission were used.

We recorded demographics, admitting diagnosis, and discharge diagnoses together with information pertaining to the name, route, and duration of administration of all PPIs (ie, omeprazole, lansoprazole, esomeprazole, pantoprazole, rabeprazole). We created a broadly inclusive set of valid indications for PPIs by incorporating diagnoses that could be identified by International Classification of Diseases, Ninth Revision.

(ICD‐9) codes from a number of previously published sources including the National Institute of Clinical Excellence (NICE) guidelines issued by the National Health Service (NHS) of the United Kingdom in 200012, 1721 (Table 1).

To assess the accuracy of the administrative data from DH, we also reviewed the Emergency Department histories, admission histories, progress notes, electronic pharmacy records, endoscopy reports, and discharge summaries of 123 patients randomly selected (ie, a 5% sample) from the group of patients identified by administrative data to have received a PPI without a valid indication, looking for any accepted indication that might have been missed in the administrative data.

All analyses were performed using SAS Enterprise Guide 4.1 (SAS Institute, Cary, NC). A Student t test was used to compare continuous variables and a chi‐square test was used to compare categorical variables. Bonferroni corrections were used for multiple comparisons, such that P values less than 0.01 were considered to be significant for categorical variables.

RESULTS

Inclusion criteria were met by 9875 patients in the Denver Health database and 6,592,100 patients in the UHC database. The demographics and primary discharge diagnoses for these patients are summarized in Table 2.

Only 39% and 27% of the patients in the DH and UHC databases, respectively, had a valid indication for PPIs on the basis of discharge diagnoses (Table 3). In the DH data, if admission ICD‐9 codes were also inspected for valid PPI indications, 1579 (40%) of patients receiving PPIs had a valid indication (admission ICD‐9 codes were not available for patients in the UHC database). Thirty‐one percent of Denver Health patients spent time in the intensive care unit (ICU) during their hospital stay and 65% of those patients received a PPI without a valid indication, as compared to 59% of patients who remained on the General Medicine ward (Table 3).

Higher rates of concurrent C. difficile infections were observed in patients receiving PPIs in both databases; a higher rate of concurrent diagnosis of pneumonia was seen in patients receiving PPIs in the UHC population, with a nonsignificant trend towards the same finding in DH patients (Table 4).

Chart review in the DH population found valid indications for PPIs in 19% of patients who were thought not have a valid indication on the basis of the administrative data (Table 5). For 56% of those in whom no valid indication was confirmed, physicians identified prophylaxis as the justification.

DISCUSSION

The important finding of this study was that the majority of patients in 2 large groups of Medicine patients hospitalized in university‐affiliated hospitals received PPIs without having a valid indication. To our knowledge, the more than 900,000 UHC patients who received a PPI during their hospitalization represent the largest inpatient population evaluated for appropriateness of PPI prescriptions.

Our finding that 41% of the patients admitted to the DH Medicine service received a PPI during their hospital stay is similar to what has been observed by others.9, 14, 22 The rate of PPI prescription was lower in the UHC population (14%) for unclear reasons. By our definition, 61% lacked an adequate diagnosis to justify the prescription of the PPI. After performing a chart review on a randomly selected 5% of these records, we found that the DH administrative database had failed to identify 19% of patients who had a valid indication for receiving a PPI. Adjusting the administrative data accordingly still resulted in 50% of DH patients not having a valid indication for receiving a PPI. This is consistent with the 54% recorded by Batuwitage and colleagues11 in the outpatient setting by direct chart review, as well as a range of 60%‐75% for hospitalized patients in other studies.12, 13, 15, 23, 24

Stomach acidity is believed to provide an important host defense against lower gastrointestinal tract infections including Salmonella, Campylobacter, and Clostridium difficile.25 A recent study by Howell et al26 showed a doseresponse effect between PPI use and C. difficile infection, supporting a causal connection between loss of stomach acidity and development of Clostridium difficile‐associated diarrhea (CDAD). We found that C. difficile infection was more common in both populations of patients receiving PPIs (although the relative risk was much higher in the UHC database) (Table 5). The rate of CDAD in DH patients who received PPIs was 2.6 times higher than in patients who did not receive these acid suppressive agents.

The role of acid suppression in increasing risk for community‐acquired pneumonia is not entirely clear. Theories regarding the loss of an important host defense and bacterial proliferation head the list.6, 8, 27 Gastric and duodenal bacterial overgrowth is significantly more common in patients receiving PPIs than in patients receiving histamine type‐2 (H2) blockers.28 Previous studies have identified an increased rate of hospital‐acquired pneumonia and recurrent community‐acquired pneumonia27 in patients receiving any form of acid suppression therapy, but the risk appears to be greater in patients receiving PPIs than in those receiving H2 receptor antagonists (H2RAs).9 Significantly more patients in the UHC population who were taking PPIs had a concurrent diagnosis of pneumonia, consistent with previous studies alerting to this association6, 8, 9, 27 and consistent with the nonsignificant trend observed in the DH population.

Our study has a number of limitations. Our database comes from a single university‐affiliated public hospital with residents and hospitalists writing orders for all medications. The hospitals in the UHC are also teaching hospitals. Accordingly, our results might not generalize to other settings or reflect prescribing patterns in private, nonteaching hospital environments. Because our study was retrospective, we could not confirm the decision‐making process supporting the prescription of PPIs. Similarly, we could not temporarily relate the existence of the indication with the time the PPI was prescribed. Our list of appropriate indications for prescribing PPIs was developed by reviewing a number of references, and other studies have used slightly different lists (albeit the more commonly recognized indications are the same), but it may be argued that the list either includes or misses diagnoses in error.

While there is considerable debate about the use of PPIs for stress ulcer prophylaxis,29 we specifically chose not to include this as one of our valid indications for PPIs for 4 reasons. First, the American Society of Health‐System Pharmacists (ASHP) Report does not recommend prophylaxis for non‐ICU patients, and only recommends prophylaxis for those ICU patients with a coagulopathy, those requiring mechanical ventilation for more than 48 hours, those with a history of gastrointestinal ulceration or bleeding in the year prior to admission, and those with 2 or more of the following indications: sepsis, ICU stay >1 week, occult bleeding lasting 6 or more days, receiving high‐dose corticosteroids, and selected surgical situations.30 At the time the guideline was written, the authors note that there was insufficient data on PPIs to make any recommendations on their use, but no subsequent guidelines have been issued.30 Second, a review by Mohebbi and Hesch published in 2009, and a meta‐analysis by Lin and colleagues published in 2010, summarize subsequent randomized trials that suggest that PPIs and H2 blockers are, at best, similarly effective at preventing upper gastrointestinal (GI) bleeding among critically ill patients.31, 32 Third, the NICE guidelines do not include stress ulcer prophylaxis as an appropriate indication for PPIs except in the prevention and treatment of NSAID [non‐steroidal anti‐inflammatory drug]‐associated ulcers.19 Finally, H2RAs are currently the only medications with an FDA‐approved indication for stress ulcer prophylaxis. We acknowledge that PPIs may be a reasonable and acceptable choice for stress ulcer prophylaxis in patients who meet indications, but we were unable to identify such patients in either of our administrative databases.

In our Denver Health population, only 31% of our patients spent any time in the intensive care unit, and only a fraction of these would have both an accepted indication for stress ulcer prophylaxis by the ASHP guidelines and an intolerance or contraindication to an H2RA or sulcralfate. While our administrative database lacked the detail necessary to identify this small group of patients, the number of patients who might have been misclassified as not having a valid PPI indication was likely very small. Similar to the findings of previous studies,15, 18, 23, 29 prophylaxis against gastrointestinal bleeding was the stated justification for prescribing the PPI in 56% of the DH patient charts reviewed. It is impossible for us to estimate the number of patients in our administrative database for whom stress ulcer prophylaxis was justified by existing guidelines, as it would be necessary to gather a number of specific clinical details for each patient including: 1) ICU stay; 2) presence of coagulopathy; 3) duration of mechanical ventilation; 4) presence of sepsis; 5) duration of ICU stay; 6) presence of occult bleeding for >6 days; and 7) use of high‐dose corticosteroids. This level of clinical detail would likely only be available through a prospective study design, as has been suggested by other authors.33 Further research into the use, safety, and effectiveness of PPIs specifically for stress ulcer prophylaxis is warranted.

In conclusion, we found that 73% of nearly 1 million Medicine patients discharged from academic medical centers received a PPI without a valid indication during their hospitalization. The implications of our findings are broad. PPIs are more expensive31 than H2RAs and there is increasing evidence that they have significant side effects. In both databases we examined, the rate of C. difficile infection was higher in patients receiving PPIs than others. The prescribing habits of physicians in these university hospital settings appear to be far out of line with published guidelines and evidence‐based practice. Reducing inappropriate prescribing of PPIs would be an important educational and quality assurance project in most institutions.

Proton pump inhibitors (PPIs) are the third most commonly prescribed class of medication in the United States, with $13.6 billion in yearly sales.1 Despite their effectiveness in treating acid reflux2 and their mortality benefit in the treatment of patients with gastrointestinal bleeding,3 recent literature has identified a number of risks associated with PPIs, including an increased incidence of Clostridium difficile infection,4 decreased effectiveness of clopidogrel in patients with acute coronary syndrome,5 increased risk of community‐ and hospital‐acquired pneumonia, and an increased risk of hip fracture.69 Additionally, in March of 2011, the US Food and Drug Administration (FDA) issued a warning regarding the potential for PPIs to cause low magnesium levels which can, in turn, cause muscle spasms, an irregular heartbeat, and convulsions.10

Inappropriate PPI prescription practice has been demonstrated in the primary care setting,11 as well as in small studies conducted in the hospital setting.1216 We hypothesized that many hospitalized patients receive these medications without having an accepted indication, and examined 2 populations of hospitalized patients, including administrative data from 6.5 million discharges from US university hospitals, to look for appropriate diagnoses justifying their use.

METHODS

We performed a retrospective review of administrative data collected between January 1, 2008 and December 31, 2009 from 2 patient populations: (a) those discharged from Denver Health (DH), a university‐affiliated public safety net hospital in Denver, CO; and (b) patients discharged from 112 academic health centers and 256 of their affiliated hospitals that participate in the University HealthSystem Consortium (UHC). The Colorado Multiple Institution Review Board reviewed and approved the conduct of this study.

Inclusion criteria for both populations were age >18 or <90 years, and hospitalization on a Medicine service. Prisoners and women known to be pregnant were excluded. In both cohorts, if patients had more than 1 admission during the 2‐year study period, only data from the first admission were used.

We recorded demographics, admitting diagnosis, and discharge diagnoses together with information pertaining to the name, route, and duration of administration of all PPIs (ie, omeprazole, lansoprazole, esomeprazole, pantoprazole, rabeprazole). We created a broadly inclusive set of valid indications for PPIs by incorporating diagnoses that could be identified by International Classification of Diseases, Ninth Revision.

(ICD‐9) codes from a number of previously published sources including the National Institute of Clinical Excellence (NICE) guidelines issued by the National Health Service (NHS) of the United Kingdom in 200012, 1721 (Table 1).

To assess the accuracy of the administrative data from DH, we also reviewed the Emergency Department histories, admission histories, progress notes, electronic pharmacy records, endoscopy reports, and discharge summaries of 123 patients randomly selected (ie, a 5% sample) from the group of patients identified by administrative data to have received a PPI without a valid indication, looking for any accepted indication that might have been missed in the administrative data.

All analyses were performed using SAS Enterprise Guide 4.1 (SAS Institute, Cary, NC). A Student t test was used to compare continuous variables and a chi‐square test was used to compare categorical variables. Bonferroni corrections were used for multiple comparisons, such that P values less than 0.01 were considered to be significant for categorical variables.

RESULTS

Inclusion criteria were met by 9875 patients in the Denver Health database and 6,592,100 patients in the UHC database. The demographics and primary discharge diagnoses for these patients are summarized in Table 2.

Only 39% and 27% of the patients in the DH and UHC databases, respectively, had a valid indication for PPIs on the basis of discharge diagnoses (Table 3). In the DH data, if admission ICD‐9 codes were also inspected for valid PPI indications, 1579 (40%) of patients receiving PPIs had a valid indication (admission ICD‐9 codes were not available for patients in the UHC database). Thirty‐one percent of Denver Health patients spent time in the intensive care unit (ICU) during their hospital stay and 65% of those patients received a PPI without a valid indication, as compared to 59% of patients who remained on the General Medicine ward (Table 3).

Higher rates of concurrent C. difficile infections were observed in patients receiving PPIs in both databases; a higher rate of concurrent diagnosis of pneumonia was seen in patients receiving PPIs in the UHC population, with a nonsignificant trend towards the same finding in DH patients (Table 4).

Chart review in the DH population found valid indications for PPIs in 19% of patients who were thought not have a valid indication on the basis of the administrative data (Table 5). For 56% of those in whom no valid indication was confirmed, physicians identified prophylaxis as the justification.

DISCUSSION

The important finding of this study was that the majority of patients in 2 large groups of Medicine patients hospitalized in university‐affiliated hospitals received PPIs without having a valid indication. To our knowledge, the more than 900,000 UHC patients who received a PPI during their hospitalization represent the largest inpatient population evaluated for appropriateness of PPI prescriptions.

Our finding that 41% of the patients admitted to the DH Medicine service received a PPI during their hospital stay is similar to what has been observed by others.9, 14, 22 The rate of PPI prescription was lower in the UHC population (14%) for unclear reasons. By our definition, 61% lacked an adequate diagnosis to justify the prescription of the PPI. After performing a chart review on a randomly selected 5% of these records, we found that the DH administrative database had failed to identify 19% of patients who had a valid indication for receiving a PPI. Adjusting the administrative data accordingly still resulted in 50% of DH patients not having a valid indication for receiving a PPI. This is consistent with the 54% recorded by Batuwitage and colleagues11 in the outpatient setting by direct chart review, as well as a range of 60%‐75% for hospitalized patients in other studies.12, 13, 15, 23, 24

Stomach acidity is believed to provide an important host defense against lower gastrointestinal tract infections including Salmonella, Campylobacter, and Clostridium difficile.25 A recent study by Howell et al26 showed a doseresponse effect between PPI use and C. difficile infection, supporting a causal connection between loss of stomach acidity and development of Clostridium difficile‐associated diarrhea (CDAD). We found that C. difficile infection was more common in both populations of patients receiving PPIs (although the relative risk was much higher in the UHC database) (Table 5). The rate of CDAD in DH patients who received PPIs was 2.6 times higher than in patients who did not receive these acid suppressive agents.

The role of acid suppression in increasing risk for community‐acquired pneumonia is not entirely clear. Theories regarding the loss of an important host defense and bacterial proliferation head the list.6, 8, 27 Gastric and duodenal bacterial overgrowth is significantly more common in patients receiving PPIs than in patients receiving histamine type‐2 (H2) blockers.28 Previous studies have identified an increased rate of hospital‐acquired pneumonia and recurrent community‐acquired pneumonia27 in patients receiving any form of acid suppression therapy, but the risk appears to be greater in patients receiving PPIs than in those receiving H2 receptor antagonists (H2RAs).9 Significantly more patients in the UHC population who were taking PPIs had a concurrent diagnosis of pneumonia, consistent with previous studies alerting to this association6, 8, 9, 27 and consistent with the nonsignificant trend observed in the DH population.

Our study has a number of limitations. Our database comes from a single university‐affiliated public hospital with residents and hospitalists writing orders for all medications. The hospitals in the UHC are also teaching hospitals. Accordingly, our results might not generalize to other settings or reflect prescribing patterns in private, nonteaching hospital environments. Because our study was retrospective, we could not confirm the decision‐making process supporting the prescription of PPIs. Similarly, we could not temporarily relate the existence of the indication with the time the PPI was prescribed. Our list of appropriate indications for prescribing PPIs was developed by reviewing a number of references, and other studies have used slightly different lists (albeit the more commonly recognized indications are the same), but it may be argued that the list either includes or misses diagnoses in error.

While there is considerable debate about the use of PPIs for stress ulcer prophylaxis,29 we specifically chose not to include this as one of our valid indications for PPIs for 4 reasons. First, the American Society of Health‐System Pharmacists (ASHP) Report does not recommend prophylaxis for non‐ICU patients, and only recommends prophylaxis for those ICU patients with a coagulopathy, those requiring mechanical ventilation for more than 48 hours, those with a history of gastrointestinal ulceration or bleeding in the year prior to admission, and those with 2 or more of the following indications: sepsis, ICU stay >1 week, occult bleeding lasting 6 or more days, receiving high‐dose corticosteroids, and selected surgical situations.30 At the time the guideline was written, the authors note that there was insufficient data on PPIs to make any recommendations on their use, but no subsequent guidelines have been issued.30 Second, a review by Mohebbi and Hesch published in 2009, and a meta‐analysis by Lin and colleagues published in 2010, summarize subsequent randomized trials that suggest that PPIs and H2 blockers are, at best, similarly effective at preventing upper gastrointestinal (GI) bleeding among critically ill patients.31, 32 Third, the NICE guidelines do not include stress ulcer prophylaxis as an appropriate indication for PPIs except in the prevention and treatment of NSAID [non‐steroidal anti‐inflammatory drug]‐associated ulcers.19 Finally, H2RAs are currently the only medications with an FDA‐approved indication for stress ulcer prophylaxis. We acknowledge that PPIs may be a reasonable and acceptable choice for stress ulcer prophylaxis in patients who meet indications, but we were unable to identify such patients in either of our administrative databases.

In our Denver Health population, only 31% of our patients spent any time in the intensive care unit, and only a fraction of these would have both an accepted indication for stress ulcer prophylaxis by the ASHP guidelines and an intolerance or contraindication to an H2RA or sulcralfate. While our administrative database lacked the detail necessary to identify this small group of patients, the number of patients who might have been misclassified as not having a valid PPI indication was likely very small. Similar to the findings of previous studies,15, 18, 23, 29 prophylaxis against gastrointestinal bleeding was the stated justification for prescribing the PPI in 56% of the DH patient charts reviewed. It is impossible for us to estimate the number of patients in our administrative database for whom stress ulcer prophylaxis was justified by existing guidelines, as it would be necessary to gather a number of specific clinical details for each patient including: 1) ICU stay; 2) presence of coagulopathy; 3) duration of mechanical ventilation; 4) presence of sepsis; 5) duration of ICU stay; 6) presence of occult bleeding for >6 days; and 7) use of high‐dose corticosteroids. This level of clinical detail would likely only be available through a prospective study design, as has been suggested by other authors.33 Further research into the use, safety, and effectiveness of PPIs specifically for stress ulcer prophylaxis is warranted.

In conclusion, we found that 73% of nearly 1 million Medicine patients discharged from academic medical centers received a PPI without a valid indication during their hospitalization. The implications of our findings are broad. PPIs are more expensive31 than H2RAs and there is increasing evidence that they have significant side effects. In both databases we examined, the rate of C. difficile infection was higher in patients receiving PPIs than others. The prescribing habits of physicians in these university hospital settings appear to be far out of line with published guidelines and evidence‐based practice. Reducing inappropriate prescribing of PPIs would be an important educational and quality assurance project in most institutions.

Proton pump inhibitors (PPIs) are the third most commonly prescribed class of medication in the United States, with $13.6 billion in yearly sales.1 Despite their effectiveness in treating acid reflux2 and their mortality benefit in the treatment of patients with gastrointestinal bleeding,3 recent literature has identified a number of risks associated with PPIs, including an increased incidence of Clostridium difficile infection,4 decreased effectiveness of clopidogrel in patients with acute coronary syndrome,5 increased risk of community‐ and hospital‐acquired pneumonia, and an increased risk of hip fracture.69 Additionally, in March of 2011, the US Food and Drug Administration (FDA) issued a warning regarding the potential for PPIs to cause low magnesium levels which can, in turn, cause muscle spasms, an irregular heartbeat, and convulsions.10

Inappropriate PPI prescription practice has been demonstrated in the primary care setting,11 as well as in small studies conducted in the hospital setting.1216 We hypothesized that many hospitalized patients receive these medications without having an accepted indication, and examined 2 populations of hospitalized patients, including administrative data from 6.5 million discharges from US university hospitals, to look for appropriate diagnoses justifying their use.

METHODS

We performed a retrospective review of administrative data collected between January 1, 2008 and December 31, 2009 from 2 patient populations: (a) those discharged from Denver Health (DH), a university‐affiliated public safety net hospital in Denver, CO; and (b) patients discharged from 112 academic health centers and 256 of their affiliated hospitals that participate in the University HealthSystem Consortium (UHC). The Colorado Multiple Institution Review Board reviewed and approved the conduct of this study.

Inclusion criteria for both populations were age >18 or <90 years, and hospitalization on a Medicine service. Prisoners and women known to be pregnant were excluded. In both cohorts, if patients had more than 1 admission during the 2‐year study period, only data from the first admission were used.

We recorded demographics, admitting diagnosis, and discharge diagnoses together with information pertaining to the name, route, and duration of administration of all PPIs (ie, omeprazole, lansoprazole, esomeprazole, pantoprazole, rabeprazole). We created a broadly inclusive set of valid indications for PPIs by incorporating diagnoses that could be identified by International Classification of Diseases, Ninth Revision.

(ICD‐9) codes from a number of previously published sources including the National Institute of Clinical Excellence (NICE) guidelines issued by the National Health Service (NHS) of the United Kingdom in 200012, 1721 (Table 1).

To assess the accuracy of the administrative data from DH, we also reviewed the Emergency Department histories, admission histories, progress notes, electronic pharmacy records, endoscopy reports, and discharge summaries of 123 patients randomly selected (ie, a 5% sample) from the group of patients identified by administrative data to have received a PPI without a valid indication, looking for any accepted indication that might have been missed in the administrative data.

All analyses were performed using SAS Enterprise Guide 4.1 (SAS Institute, Cary, NC). A Student t test was used to compare continuous variables and a chi‐square test was used to compare categorical variables. Bonferroni corrections were used for multiple comparisons, such that P values less than 0.01 were considered to be significant for categorical variables.

RESULTS

Inclusion criteria were met by 9875 patients in the Denver Health database and 6,592,100 patients in the UHC database. The demographics and primary discharge diagnoses for these patients are summarized in Table 2.

Only 39% and 27% of the patients in the DH and UHC databases, respectively, had a valid indication for PPIs on the basis of discharge diagnoses (Table 3). In the DH data, if admission ICD‐9 codes were also inspected for valid PPI indications, 1579 (40%) of patients receiving PPIs had a valid indication (admission ICD‐9 codes were not available for patients in the UHC database). Thirty‐one percent of Denver Health patients spent time in the intensive care unit (ICU) during their hospital stay and 65% of those patients received a PPI without a valid indication, as compared to 59% of patients who remained on the General Medicine ward (Table 3).

Higher rates of concurrent C. difficile infections were observed in patients receiving PPIs in both databases; a higher rate of concurrent diagnosis of pneumonia was seen in patients receiving PPIs in the UHC population, with a nonsignificant trend towards the same finding in DH patients (Table 4).

Chart review in the DH population found valid indications for PPIs in 19% of patients who were thought not have a valid indication on the basis of the administrative data (Table 5). For 56% of those in whom no valid indication was confirmed, physicians identified prophylaxis as the justification.

DISCUSSION

The important finding of this study was that the majority of patients in 2 large groups of Medicine patients hospitalized in university‐affiliated hospitals received PPIs without having a valid indication. To our knowledge, the more than 900,000 UHC patients who received a PPI during their hospitalization represent the largest inpatient population evaluated for appropriateness of PPI prescriptions.

Our finding that 41% of the patients admitted to the DH Medicine service received a PPI during their hospital stay is similar to what has been observed by others.9, 14, 22 The rate of PPI prescription was lower in the UHC population (14%) for unclear reasons. By our definition, 61% lacked an adequate diagnosis to justify the prescription of the PPI. After performing a chart review on a randomly selected 5% of these records, we found that the DH administrative database had failed to identify 19% of patients who had a valid indication for receiving a PPI. Adjusting the administrative data accordingly still resulted in 50% of DH patients not having a valid indication for receiving a PPI. This is consistent with the 54% recorded by Batuwitage and colleagues11 in the outpatient setting by direct chart review, as well as a range of 60%‐75% for hospitalized patients in other studies.12, 13, 15, 23, 24

Stomach acidity is believed to provide an important host defense against lower gastrointestinal tract infections including Salmonella, Campylobacter, and Clostridium difficile.25 A recent study by Howell et al26 showed a doseresponse effect between PPI use and C. difficile infection, supporting a causal connection between loss of stomach acidity and development of Clostridium difficile‐associated diarrhea (CDAD). We found that C. difficile infection was more common in both populations of patients receiving PPIs (although the relative risk was much higher in the UHC database) (Table 5). The rate of CDAD in DH patients who received PPIs was 2.6 times higher than in patients who did not receive these acid suppressive agents.

The role of acid suppression in increasing risk for community‐acquired pneumonia is not entirely clear. Theories regarding the loss of an important host defense and bacterial proliferation head the list.6, 8, 27 Gastric and duodenal bacterial overgrowth is significantly more common in patients receiving PPIs than in patients receiving histamine type‐2 (H2) blockers.28 Previous studies have identified an increased rate of hospital‐acquired pneumonia and recurrent community‐acquired pneumonia27 in patients receiving any form of acid suppression therapy, but the risk appears to be greater in patients receiving PPIs than in those receiving H2 receptor antagonists (H2RAs).9 Significantly more patients in the UHC population who were taking PPIs had a concurrent diagnosis of pneumonia, consistent with previous studies alerting to this association6, 8, 9, 27 and consistent with the nonsignificant trend observed in the DH population.

Our study has a number of limitations. Our database comes from a single university‐affiliated public hospital with residents and hospitalists writing orders for all medications. The hospitals in the UHC are also teaching hospitals. Accordingly, our results might not generalize to other settings or reflect prescribing patterns in private, nonteaching hospital environments. Because our study was retrospective, we could not confirm the decision‐making process supporting the prescription of PPIs. Similarly, we could not temporarily relate the existence of the indication with the time the PPI was prescribed. Our list of appropriate indications for prescribing PPIs was developed by reviewing a number of references, and other studies have used slightly different lists (albeit the more commonly recognized indications are the same), but it may be argued that the list either includes or misses diagnoses in error.

While there is considerable debate about the use of PPIs for stress ulcer prophylaxis,29 we specifically chose not to include this as one of our valid indications for PPIs for 4 reasons. First, the American Society of Health‐System Pharmacists (ASHP) Report does not recommend prophylaxis for non‐ICU patients, and only recommends prophylaxis for those ICU patients with a coagulopathy, those requiring mechanical ventilation for more than 48 hours, those with a history of gastrointestinal ulceration or bleeding in the year prior to admission, and those with 2 or more of the following indications: sepsis, ICU stay >1 week, occult bleeding lasting 6 or more days, receiving high‐dose corticosteroids, and selected surgical situations.30 At the time the guideline was written, the authors note that there was insufficient data on PPIs to make any recommendations on their use, but no subsequent guidelines have been issued.30 Second, a review by Mohebbi and Hesch published in 2009, and a meta‐analysis by Lin and colleagues published in 2010, summarize subsequent randomized trials that suggest that PPIs and H2 blockers are, at best, similarly effective at preventing upper gastrointestinal (GI) bleeding among critically ill patients.31, 32 Third, the NICE guidelines do not include stress ulcer prophylaxis as an appropriate indication for PPIs except in the prevention and treatment of NSAID [non‐steroidal anti‐inflammatory drug]‐associated ulcers.19 Finally, H2RAs are currently the only medications with an FDA‐approved indication for stress ulcer prophylaxis. We acknowledge that PPIs may be a reasonable and acceptable choice for stress ulcer prophylaxis in patients who meet indications, but we were unable to identify such patients in either of our administrative databases.

In our Denver Health population, only 31% of our patients spent any time in the intensive care unit, and only a fraction of these would have both an accepted indication for stress ulcer prophylaxis by the ASHP guidelines and an intolerance or contraindication to an H2RA or sulcralfate. While our administrative database lacked the detail necessary to identify this small group of patients, the number of patients who might have been misclassified as not having a valid PPI indication was likely very small. Similar to the findings of previous studies,15, 18, 23, 29 prophylaxis against gastrointestinal bleeding was the stated justification for prescribing the PPI in 56% of the DH patient charts reviewed. It is impossible for us to estimate the number of patients in our administrative database for whom stress ulcer prophylaxis was justified by existing guidelines, as it would be necessary to gather a number of specific clinical details for each patient including: 1) ICU stay; 2) presence of coagulopathy; 3) duration of mechanical ventilation; 4) presence of sepsis; 5) duration of ICU stay; 6) presence of occult bleeding for >6 days; and 7) use of high‐dose corticosteroids. This level of clinical detail would likely only be available through a prospective study design, as has been suggested by other authors.33 Further research into the use, safety, and effectiveness of PPIs specifically for stress ulcer prophylaxis is warranted.

In conclusion, we found that 73% of nearly 1 million Medicine patients discharged from academic medical centers received a PPI without a valid indication during their hospitalization. The implications of our findings are broad. PPIs are more expensive31 than H2RAs and there is increasing evidence that they have significant side effects. In both databases we examined, the rate of C. difficile infection was higher in patients receiving PPIs than others. The prescribing habits of physicians in these university hospital settings appear to be far out of line with published guidelines and evidence‐based practice. Reducing inappropriate prescribing of PPIs would be an important educational and quality assurance project in most institutions.

Communication failures are well‐recognized as causes of medical errors.1, 2 Specifically, handoffs of patient care responsibilities, which are increasingly prevalent in academic medical centers,3 have been cited as the most frequent cause of teamwork breakdown resulting in the harmful medical errors found in malpractice claims.1 The Institute of Medicine has recently identified patient handoffs as the moment where patient care errors are most likely to occur.4 A survey of 125 U.S. medical schools, however, found that only 8% specifically taught students how to hand off patient care.3

In July 2003, the American Council of Graduate Medical Education (ACGME) mandated that residency programs decrease resident work hours to improve patient care and safety by reducing fatigue,5 and a recent Institute of Medicine report suggests that they be decreased even further.4 Studies examining outcomes during the first 2 years after reducing duty hours did not find reductions in risk‐adjusted mortality.68 One proposed explanation for this lack of improvement is that the reduction in fatigue‐related medical errors is being offset by discontinuity of care with due to the increased number of patient handoffs resulting from shortened duty hours,911 one recent study found that omission of key information during patient sign outs frequently resulted in adverse patient care outcomes.12

In 2007, the Joint Commission developed a new National Patient Safety Goal that requires organizations to improve communication between caregivers.13 We recently developed an approach by which Internal Medicine residents hand off patient care using a structured process, written and verbal templates, formal training about handoffs, and direct attending supervision.14 Because fourth‐year medical students perform the duties of interns when working as subinterns, we recognized that education about handoffs should occur prior to the time students became interns. Accordingly, we developed a course designed to teach patient handoffs to medical students at the transition between their third and fourth years of training.

Setting

The Handoff Selective was developed by faculty of Denver Health and the University of Colorado Denver School of Medicine.

Program Description

The Selective was first offered in April 2007 as part of an Integrated Clinician's Course (ICC), a 2‐week course for students beginning their fourth year, which starts in April at the University of Colorado. The ICC includes both mandatory and selective sessions that are focused on developing clinical skills and preparing them for their subinternships. The Handoff Selective was conducted in a computerized teaching laboratory, lasted a total of 2 hours and consisted of 2 parts. Each of the 5 Denver Health Hospital Medicine faculty members versed in handoff education taught 2 sessions of 6 to 8 students.

Part 1: Didactic

During the first hour of class, the faculty presented a lecture that summarized the relevant literature on handoffs and explained the importance of the topic. The objectives of the didactic were to: (1) understand the importance of handoffs; (2) explore different communication elements and structures; (3) gain exposure to handoffs outside of healthcare; and (4) learn a structure for handoffs of patient care in hospitalized patients.

We used 3 video clips of handoffs from 2 football games to demonstrate the importance of practice, training, and 2‐way communications in handoffs. The first video clip showed a runner trying to make a spontaneous handoff while being tackled. The receiver was not expecting the handoff and was preoccupied with blocking another player. This attempted handoff resulted in a fumble, which we related to an adverse patient event.

The next 2 video clips showed 2 complex, seldom used, but well‐known football handoffsthe hook and lateral and the Statue of Liberty. Both handoffs were successfully executed presumably as a result of education, practice and the active participation of both players (handing off and receiving) in the process. We then related the teaching and practicing of complex communication to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO; now simply the Joint Commission) data suggesting that most sentinel events have their root cause in communication and training failures.2

Basic communication elements and process structures were then explored using scenarios from everyday life and evidence from fields outside of medicine. We emphasized that structures for communication (modes, vehicles, and settings) must be chosen according to the occasion and that handoffs are common and important in all occupations. In discussing modes (verbal, written, or nonverbal), vehicles (paper, telephone, or e‐mail), and settings (face‐to face, virtual, or disconnected), we emphasized that the most effective structures for communication (verbal, face‐to face meetings, with written materials and other visual aids at the patient's bedside) were also the most time‐consuming (Figure 1). While our standard for resident handoffs is a face‐to‐face verbal interaction with preprinted written materials as an aid, we also emphasized that for complex patients (eg, mental status changes, concern for an acute abdomen) more robust communication is often needed. Accordingly, a more time‐consuming bedside handoff with simultaneous, focused physical exam and history‐taking by both oncoming and off‐going providers may be most appropriate.

Figure 1

As real‐life examples, we asked our students to communicate a happy birthday wish to their mother, who lives in another state. Almost uniformly, in addition to a written aid (birthday card), they choose the telephone as a vehicle for their verbal mode in a virtual setting with 2‐way communication possible. In contrast, when asked to propose marriage to a significant other in another state, students felt that a face‐to‐face meeting with verbal and nonverbal (ie, ring) modes was appropriate. This time‐consuming mode of communication was felt to be necessary to create a sentiment of importance and avert any possible miscommunication.

The didactic session concluded by demonstrating how to use standardized written and verbal templates for handoffs of the care of a hospitalized patient. We explore the differentiation between written and verbal handoffs in our discussion below.

Program Evaluation

We developed a 2‐part survey to evaluate the effectiveness of the Selective and to solicit feedback about the didactic and practicum portions of the course. The first part of the survey (Table 2) contained 16 items to assess the students' knowledge of, and attitudes toward handing off patient care, along with their comfort with the handoff process. Responses to this section were scored using a 5‐point Likert scale with 1 indicating strongly disagree and 5 indicating strongly agree. This part of the survey was administered both prior to and after the Selective.

The second part (Table 3) contained 12 items and was designed to evaluate the perceived usefulness of the different components of the class. This section was only administered at the end of the Selective. It utilized a 4‐point Likert scale with 1 indicating that the component was not useful at all, and 4 indicating that it was extremely useful. The first 6 items of the second section allowed students to evaluate the didactic portion of the handoff. The second 6 items allowed students to evaluate the practicum. Responses to all 12 items were then combined to determine an overall composite usefulness for the Selective.

The Selective was also evaluated qualitatively through the use of open‐ended, written comments that were solicited at the end of the survey. All surveys were administered anonymously.

Results

More students chose the Selective than we had capacity to accommodate (60 of a class of 150). The pre‐ and postcourse survey response rate was 56 of 60 (93%) and 58 of 60 (97%), respectively. After the Selective, the mean score in response to whether handoffs are well taught in medical school increased from 1.6 to 3.5 (P < 0.003). Our students' self‐perceived skills and knowledge about handoffs improved after the Selective (Table 2). The greatest changes in perceived knowledge occurred in questions regarding the what, how, and when of read‐backs, and the knowledge of standard verbal and written handoff structures. The responses to the survey elements which assessed our students' attitudes regarding the importance of standardization and whether they felt handoffs were safer with faculty supervision did not change after the Selective (Table 2).

A total of 92% of the students felt that the course was extremely useful or useful. The role‐playing activity was thought to be more helpful than the didactic, but 84% of the students still rated the didactic portion as useful or extremely useful (Table 3). The element which was the least well received in the didactic portion was the use of video clips to demonstrate successful and unsuccessful (fumbled) college football handoffs, although the majority (64%) of students still found it useful.

The major theme generated from the comments section of the survey was that the Selective should be a required course.

Discussion

We know of no previously published literature that has addressed teaching handoffs to medical students. Horwitz et al.15 developed a sign‐out curriculum for Internal Medicine residents and found that none of their house‐staff had any previous training in handoffs during medical school, consistent with the finding that only 8% of U.S. medical schools provided formal instruction on handoffs.3 Prior to taking the Selective, our students had no knowledge of verbal or written templates for patient handoffs, although both before and after the course they felt that standardization was an important component of the process.

A number of verbal structures for handing off patient care have been described in the literature and there is not a consensus as to which functions best. Perhaps the most cited verbal communication format is SBAR (ie, situation, background, assessment and recommendation).16, 17 This tool was developed by Leonard et al.18 specifically for use by nurses to provide 1‐way communication to physicians pertaining to a change in patient status. We considered teaching the SBAR approach to the students but felt that it did not provide a suitable structure for handoffs because the transfer of care is not generally an event‐based situation and the literature on handoffs indicates that an optimal verbal system includes 2‐way communication.

Additional mnemonics for handoffs found in the literature include SIGNOUT (ie, Sick or DNR, Identifying information, General hospital course, New events of the day, Overall health status, Upcoming possibilities with plan, and Tasks to complete),14 I PASS the BATON (ie, Introduction, Patient, Assessment, Situation, Safety, Background, Actions, Timing, Ownership, Next)19 and the SAIF‐IR system (see boxed text).14

We developed the SAIF‐IR mnemonic to maximize efficiency and effectiveness while differentiating the verbal portion of the handoff from the written and incorporating 2‐way communication into its structure. In the Summary statement, we emphasize that this is not a history of present illness. We ask our students to summarize, in 1 to 3 sentences, the patient's presentation and working diagnosis. When discussing patient issues, we ask our students to only verbalize Active issues, although the written template has inactive, chronic issues listed. Here, we also ask our students to express their level of concern for the active issues and patient in general. If‐then's and Follow‐ups are usually verbalized together. Based on the offgoing provider's knowledge of the patient, we encourage the offgoing provider to anticipate potential problems and advise the oncoming provider on potential responses. Much of this advice is difficult to express in the written format and thus may not be found on the written handoff when the verbal handoff occurs. We encourage oncoming providers to take notes on the preprinted handoff sheet as part of the handoff process.

Through Interactive questioning and Read‐backs, we train our students and house‐staff to use the active listening techniques used outside of healthcare, in settings such as nuclear power plants and National Aeronautics and Space Administration mission control, where poor handoff communication may also result in safety concerns and adverse events.20 Interactive questioning allows the oncoming provider to correct or clarify any information given by the off‐going provider. Read‐backs are a method of confirming follow‐up activity or contingency plans. Together, the SAIF‐IR mnemonic builds a 2‐way communication structure into the patient handoff with both offgoing and oncoming providers having predefined roles.

Much of the information on our written handoff (patient identifying information, medications, language preference, code status, admission date) is not verbalized unless it is part of the active issues or the if‐then, follow‐ups (ie, medication titration for a patient admitted with an acute coronary syndrome or cor status in a patient newly made comfort care). By not reading extraneous information, we seek to emphasize the Active issues as well as the If‐then, Follow‐ups. We feel this emphasis maximizes the effectiveness of the handoff, while the purposeful nonverbalization of written materials such as identifying information maximizes its efficiency. Future work may examine which verbal and written structures for patient handoffs most benefit patient care and workflow through standard communication.

While our students found the Handoff Selective to be useful and to improve their self‐perceived ability to perform handoffs, we were not able to determine whether our program affected downstream outcomes such as adverse events relating to failures in handoff communication. Additionally, since we only taught and evaluated our Selective at the University of Colorado Denver School of Medicine, the response of our students may not generalize to other medical schools. Multicentered, prospective, randomized controlled trials may determine whether handoff education programs are successful in reducing patient adverse events related to transfers of care.

While handoffs occur frequently and are increasingly recognized as a vulnerable time in patient care, little is known about how to effectively teach handoffs to medical students during their clinical years. We developed a formal course to teach the importance of handoffs and how the process should be conducted. Our students reported that the Handoff Selective we developed improved their knowledge about the process and their perception of their ability to perform handoffs in a time‐appropriate and effective manner. In response to the feedback we received from our students, the Handoff Selective is the only course in the ICC that has been made mandatory for all students.

Communication failures are well‐recognized as causes of medical errors.1, 2 Specifically, handoffs of patient care responsibilities, which are increasingly prevalent in academic medical centers,3 have been cited as the most frequent cause of teamwork breakdown resulting in the harmful medical errors found in malpractice claims.1 The Institute of Medicine has recently identified patient handoffs as the moment where patient care errors are most likely to occur.4 A survey of 125 U.S. medical schools, however, found that only 8% specifically taught students how to hand off patient care.3

In July 2003, the American Council of Graduate Medical Education (ACGME) mandated that residency programs decrease resident work hours to improve patient care and safety by reducing fatigue,5 and a recent Institute of Medicine report suggests that they be decreased even further.4 Studies examining outcomes during the first 2 years after reducing duty hours did not find reductions in risk‐adjusted mortality.68 One proposed explanation for this lack of improvement is that the reduction in fatigue‐related medical errors is being offset by discontinuity of care with due to the increased number of patient handoffs resulting from shortened duty hours,911 one recent study found that omission of key information during patient sign outs frequently resulted in adverse patient care outcomes.12

In 2007, the Joint Commission developed a new National Patient Safety Goal that requires organizations to improve communication between caregivers.13 We recently developed an approach by which Internal Medicine residents hand off patient care using a structured process, written and verbal templates, formal training about handoffs, and direct attending supervision.14 Because fourth‐year medical students perform the duties of interns when working as subinterns, we recognized that education about handoffs should occur prior to the time students became interns. Accordingly, we developed a course designed to teach patient handoffs to medical students at the transition between their third and fourth years of training.

Setting

The Handoff Selective was developed by faculty of Denver Health and the University of Colorado Denver School of Medicine.

Program Description

The Selective was first offered in April 2007 as part of an Integrated Clinician's Course (ICC), a 2‐week course for students beginning their fourth year, which starts in April at the University of Colorado. The ICC includes both mandatory and selective sessions that are focused on developing clinical skills and preparing them for their subinternships. The Handoff Selective was conducted in a computerized teaching laboratory, lasted a total of 2 hours and consisted of 2 parts. Each of the 5 Denver Health Hospital Medicine faculty members versed in handoff education taught 2 sessions of 6 to 8 students.

Part 1: Didactic

During the first hour of class, the faculty presented a lecture that summarized the relevant literature on handoffs and explained the importance of the topic. The objectives of the didactic were to: (1) understand the importance of handoffs; (2) explore different communication elements and structures; (3) gain exposure to handoffs outside of healthcare; and (4) learn a structure for handoffs of patient care in hospitalized patients.

We used 3 video clips of handoffs from 2 football games to demonstrate the importance of practice, training, and 2‐way communications in handoffs. The first video clip showed a runner trying to make a spontaneous handoff while being tackled. The receiver was not expecting the handoff and was preoccupied with blocking another player. This attempted handoff resulted in a fumble, which we related to an adverse patient event.

The next 2 video clips showed 2 complex, seldom used, but well‐known football handoffsthe hook and lateral and the Statue of Liberty. Both handoffs were successfully executed presumably as a result of education, practice and the active participation of both players (handing off and receiving) in the process. We then related the teaching and practicing of complex communication to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO; now simply the Joint Commission) data suggesting that most sentinel events have their root cause in communication and training failures.2

Basic communication elements and process structures were then explored using scenarios from everyday life and evidence from fields outside of medicine. We emphasized that structures for communication (modes, vehicles, and settings) must be chosen according to the occasion and that handoffs are common and important in all occupations. In discussing modes (verbal, written, or nonverbal), vehicles (paper, telephone, or e‐mail), and settings (face‐to face, virtual, or disconnected), we emphasized that the most effective structures for communication (verbal, face‐to face meetings, with written materials and other visual aids at the patient's bedside) were also the most time‐consuming (Figure 1). While our standard for resident handoffs is a face‐to‐face verbal interaction with preprinted written materials as an aid, we also emphasized that for complex patients (eg, mental status changes, concern for an acute abdomen) more robust communication is often needed. Accordingly, a more time‐consuming bedside handoff with simultaneous, focused physical exam and history‐taking by both oncoming and off‐going providers may be most appropriate.

Figure 1

As real‐life examples, we asked our students to communicate a happy birthday wish to their mother, who lives in another state. Almost uniformly, in addition to a written aid (birthday card), they choose the telephone as a vehicle for their verbal mode in a virtual setting with 2‐way communication possible. In contrast, when asked to propose marriage to a significant other in another state, students felt that a face‐to‐face meeting with verbal and nonverbal (ie, ring) modes was appropriate. This time‐consuming mode of communication was felt to be necessary to create a sentiment of importance and avert any possible miscommunication.

The didactic session concluded by demonstrating how to use standardized written and verbal templates for handoffs of the care of a hospitalized patient. We explore the differentiation between written and verbal handoffs in our discussion below.

Program Evaluation

We developed a 2‐part survey to evaluate the effectiveness of the Selective and to solicit feedback about the didactic and practicum portions of the course. The first part of the survey (Table 2) contained 16 items to assess the students' knowledge of, and attitudes toward handing off patient care, along with their comfort with the handoff process. Responses to this section were scored using a 5‐point Likert scale with 1 indicating strongly disagree and 5 indicating strongly agree. This part of the survey was administered both prior to and after the Selective.

The second part (Table 3) contained 12 items and was designed to evaluate the perceived usefulness of the different components of the class. This section was only administered at the end of the Selective. It utilized a 4‐point Likert scale with 1 indicating that the component was not useful at all, and 4 indicating that it was extremely useful. The first 6 items of the second section allowed students to evaluate the didactic portion of the handoff. The second 6 items allowed students to evaluate the practicum. Responses to all 12 items were then combined to determine an overall composite usefulness for the Selective.

The Selective was also evaluated qualitatively through the use of open‐ended, written comments that were solicited at the end of the survey. All surveys were administered anonymously.

Results

More students chose the Selective than we had capacity to accommodate (60 of a class of 150). The pre‐ and postcourse survey response rate was 56 of 60 (93%) and 58 of 60 (97%), respectively. After the Selective, the mean score in response to whether handoffs are well taught in medical school increased from 1.6 to 3.5 (P < 0.003). Our students' self‐perceived skills and knowledge about handoffs improved after the Selective (Table 2). The greatest changes in perceived knowledge occurred in questions regarding the what, how, and when of read‐backs, and the knowledge of standard verbal and written handoff structures. The responses to the survey elements which assessed our students' attitudes regarding the importance of standardization and whether they felt handoffs were safer with faculty supervision did not change after the Selective (Table 2).

A total of 92% of the students felt that the course was extremely useful or useful. The role‐playing activity was thought to be more helpful than the didactic, but 84% of the students still rated the didactic portion as useful or extremely useful (Table 3). The element which was the least well received in the didactic portion was the use of video clips to demonstrate successful and unsuccessful (fumbled) college football handoffs, although the majority (64%) of students still found it useful.

The major theme generated from the comments section of the survey was that the Selective should be a required course.

Discussion

We know of no previously published literature that has addressed teaching handoffs to medical students. Horwitz et al.15 developed a sign‐out curriculum for Internal Medicine residents and found that none of their house‐staff had any previous training in handoffs during medical school, consistent with the finding that only 8% of U.S. medical schools provided formal instruction on handoffs.3 Prior to taking the Selective, our students had no knowledge of verbal or written templates for patient handoffs, although both before and after the course they felt that standardization was an important component of the process.

A number of verbal structures for handing off patient care have been described in the literature and there is not a consensus as to which functions best. Perhaps the most cited verbal communication format is SBAR (ie, situation, background, assessment and recommendation).16, 17 This tool was developed by Leonard et al.18 specifically for use by nurses to provide 1‐way communication to physicians pertaining to a change in patient status. We considered teaching the SBAR approach to the students but felt that it did not provide a suitable structure for handoffs because the transfer of care is not generally an event‐based situation and the literature on handoffs indicates that an optimal verbal system includes 2‐way communication.

Additional mnemonics for handoffs found in the literature include SIGNOUT (ie, Sick or DNR, Identifying information, General hospital course, New events of the day, Overall health status, Upcoming possibilities with plan, and Tasks to complete),14 I PASS the BATON (ie, Introduction, Patient, Assessment, Situation, Safety, Background, Actions, Timing, Ownership, Next)19 and the SAIF‐IR system (see boxed text).14

We developed the SAIF‐IR mnemonic to maximize efficiency and effectiveness while differentiating the verbal portion of the handoff from the written and incorporating 2‐way communication into its structure. In the Summary statement, we emphasize that this is not a history of present illness. We ask our students to summarize, in 1 to 3 sentences, the patient's presentation and working diagnosis. When discussing patient issues, we ask our students to only verbalize Active issues, although the written template has inactive, chronic issues listed. Here, we also ask our students to express their level of concern for the active issues and patient in general. If‐then's and Follow‐ups are usually verbalized together. Based on the offgoing provider's knowledge of the patient, we encourage the offgoing provider to anticipate potential problems and advise the oncoming provider on potential responses. Much of this advice is difficult to express in the written format and thus may not be found on the written handoff when the verbal handoff occurs. We encourage oncoming providers to take notes on the preprinted handoff sheet as part of the handoff process.

Through Interactive questioning and Read‐backs, we train our students and house‐staff to use the active listening techniques used outside of healthcare, in settings such as nuclear power plants and National Aeronautics and Space Administration mission control, where poor handoff communication may also result in safety concerns and adverse events.20 Interactive questioning allows the oncoming provider to correct or clarify any information given by the off‐going provider. Read‐backs are a method of confirming follow‐up activity or contingency plans. Together, the SAIF‐IR mnemonic builds a 2‐way communication structure into the patient handoff with both offgoing and oncoming providers having predefined roles.

Much of the information on our written handoff (patient identifying information, medications, language preference, code status, admission date) is not verbalized unless it is part of the active issues or the if‐then, follow‐ups (ie, medication titration for a patient admitted with an acute coronary syndrome or cor status in a patient newly made comfort care). By not reading extraneous information, we seek to emphasize the Active issues as well as the If‐then, Follow‐ups. We feel this emphasis maximizes the effectiveness of the handoff, while the purposeful nonverbalization of written materials such as identifying information maximizes its efficiency. Future work may examine which verbal and written structures for patient handoffs most benefit patient care and workflow through standard communication.

While our students found the Handoff Selective to be useful and to improve their self‐perceived ability to perform handoffs, we were not able to determine whether our program affected downstream outcomes such as adverse events relating to failures in handoff communication. Additionally, since we only taught and evaluated our Selective at the University of Colorado Denver School of Medicine, the response of our students may not generalize to other medical schools. Multicentered, prospective, randomized controlled trials may determine whether handoff education programs are successful in reducing patient adverse events related to transfers of care.

While handoffs occur frequently and are increasingly recognized as a vulnerable time in patient care, little is known about how to effectively teach handoffs to medical students during their clinical years. We developed a formal course to teach the importance of handoffs and how the process should be conducted. Our students reported that the Handoff Selective we developed improved their knowledge about the process and their perception of their ability to perform handoffs in a time‐appropriate and effective manner. In response to the feedback we received from our students, the Handoff Selective is the only course in the ICC that has been made mandatory for all students.

Communication failures are well‐recognized as causes of medical errors.1, 2 Specifically, handoffs of patient care responsibilities, which are increasingly prevalent in academic medical centers,3 have been cited as the most frequent cause of teamwork breakdown resulting in the harmful medical errors found in malpractice claims.1 The Institute of Medicine has recently identified patient handoffs as the moment where patient care errors are most likely to occur.4 A survey of 125 U.S. medical schools, however, found that only 8% specifically taught students how to hand off patient care.3

In July 2003, the American Council of Graduate Medical Education (ACGME) mandated that residency programs decrease resident work hours to improve patient care and safety by reducing fatigue,5 and a recent Institute of Medicine report suggests that they be decreased even further.4 Studies examining outcomes during the first 2 years after reducing duty hours did not find reductions in risk‐adjusted mortality.68 One proposed explanation for this lack of improvement is that the reduction in fatigue‐related medical errors is being offset by discontinuity of care with due to the increased number of patient handoffs resulting from shortened duty hours,911 one recent study found that omission of key information during patient sign outs frequently resulted in adverse patient care outcomes.12

In 2007, the Joint Commission developed a new National Patient Safety Goal that requires organizations to improve communication between caregivers.13 We recently developed an approach by which Internal Medicine residents hand off patient care using a structured process, written and verbal templates, formal training about handoffs, and direct attending supervision.14 Because fourth‐year medical students perform the duties of interns when working as subinterns, we recognized that education about handoffs should occur prior to the time students became interns. Accordingly, we developed a course designed to teach patient handoffs to medical students at the transition between their third and fourth years of training.

Setting

The Handoff Selective was developed by faculty of Denver Health and the University of Colorado Denver School of Medicine.

Program Description

The Selective was first offered in April 2007 as part of an Integrated Clinician's Course (ICC), a 2‐week course for students beginning their fourth year, which starts in April at the University of Colorado. The ICC includes both mandatory and selective sessions that are focused on developing clinical skills and preparing them for their subinternships. The Handoff Selective was conducted in a computerized teaching laboratory, lasted a total of 2 hours and consisted of 2 parts. Each of the 5 Denver Health Hospital Medicine faculty members versed in handoff education taught 2 sessions of 6 to 8 students.

Part 1: Didactic

During the first hour of class, the faculty presented a lecture that summarized the relevant literature on handoffs and explained the importance of the topic. The objectives of the didactic were to: (1) understand the importance of handoffs; (2) explore different communication elements and structures; (3) gain exposure to handoffs outside of healthcare; and (4) learn a structure for handoffs of patient care in hospitalized patients.

We used 3 video clips of handoffs from 2 football games to demonstrate the importance of practice, training, and 2‐way communications in handoffs. The first video clip showed a runner trying to make a spontaneous handoff while being tackled. The receiver was not expecting the handoff and was preoccupied with blocking another player. This attempted handoff resulted in a fumble, which we related to an adverse patient event.

The next 2 video clips showed 2 complex, seldom used, but well‐known football handoffsthe hook and lateral and the Statue of Liberty. Both handoffs were successfully executed presumably as a result of education, practice and the active participation of both players (handing off and receiving) in the process. We then related the teaching and practicing of complex communication to the Joint Commission on Accreditation of Healthcare Organizations (JCAHO; now simply the Joint Commission) data suggesting that most sentinel events have their root cause in communication and training failures.2

Basic communication elements and process structures were then explored using scenarios from everyday life and evidence from fields outside of medicine. We emphasized that structures for communication (modes, vehicles, and settings) must be chosen according to the occasion and that handoffs are common and important in all occupations. In discussing modes (verbal, written, or nonverbal), vehicles (paper, telephone, or e‐mail), and settings (face‐to face, virtual, or disconnected), we emphasized that the most effective structures for communication (verbal, face‐to face meetings, with written materials and other visual aids at the patient's bedside) were also the most time‐consuming (Figure 1). While our standard for resident handoffs is a face‐to‐face verbal interaction with preprinted written materials as an aid, we also emphasized that for complex patients (eg, mental status changes, concern for an acute abdomen) more robust communication is often needed. Accordingly, a more time‐consuming bedside handoff with simultaneous, focused physical exam and history‐taking by both oncoming and off‐going providers may be most appropriate.

Figure 1

As real‐life examples, we asked our students to communicate a happy birthday wish to their mother, who lives in another state. Almost uniformly, in addition to a written aid (birthday card), they choose the telephone as a vehicle for their verbal mode in a virtual setting with 2‐way communication possible. In contrast, when asked to propose marriage to a significant other in another state, students felt that a face‐to‐face meeting with verbal and nonverbal (ie, ring) modes was appropriate. This time‐consuming mode of communication was felt to be necessary to create a sentiment of importance and avert any possible miscommunication.

The didactic session concluded by demonstrating how to use standardized written and verbal templates for handoffs of the care of a hospitalized patient. We explore the differentiation between written and verbal handoffs in our discussion below.

Program Evaluation

We developed a 2‐part survey to evaluate the effectiveness of the Selective and to solicit feedback about the didactic and practicum portions of the course. The first part of the survey (Table 2) contained 16 items to assess the students' knowledge of, and attitudes toward handing off patient care, along with their comfort with the handoff process. Responses to this section were scored using a 5‐point Likert scale with 1 indicating strongly disagree and 5 indicating strongly agree. This part of the survey was administered both prior to and after the Selective.

The second part (Table 3) contained 12 items and was designed to evaluate the perceived usefulness of the different components of the class. This section was only administered at the end of the Selective. It utilized a 4‐point Likert scale with 1 indicating that the component was not useful at all, and 4 indicating that it was extremely useful. The first 6 items of the second section allowed students to evaluate the didactic portion of the handoff. The second 6 items allowed students to evaluate the practicum. Responses to all 12 items were then combined to determine an overall composite usefulness for the Selective.

The Selective was also evaluated qualitatively through the use of open‐ended, written comments that were solicited at the end of the survey. All surveys were administered anonymously.

Results

More students chose the Selective than we had capacity to accommodate (60 of a class of 150). The pre‐ and postcourse survey response rate was 56 of 60 (93%) and 58 of 60 (97%), respectively. After the Selective, the mean score in response to whether handoffs are well taught in medical school increased from 1.6 to 3.5 (P < 0.003). Our students' self‐perceived skills and knowledge about handoffs improved after the Selective (Table 2). The greatest changes in perceived knowledge occurred in questions regarding the what, how, and when of read‐backs, and the knowledge of standard verbal and written handoff structures. The responses to the survey elements which assessed our students' attitudes regarding the importance of standardization and whether they felt handoffs were safer with faculty supervision did not change after the Selective (Table 2).

A total of 92% of the students felt that the course was extremely useful or useful. The role‐playing activity was thought to be more helpful than the didactic, but 84% of the students still rated the didactic portion as useful or extremely useful (Table 3). The element which was the least well received in the didactic portion was the use of video clips to demonstrate successful and unsuccessful (fumbled) college football handoffs, although the majority (64%) of students still found it useful.

The major theme generated from the comments section of the survey was that the Selective should be a required course.

Discussion

We know of no previously published literature that has addressed teaching handoffs to medical students. Horwitz et al.15 developed a sign‐out curriculum for Internal Medicine residents and found that none of their house‐staff had any previous training in handoffs during medical school, consistent with the finding that only 8% of U.S. medical schools provided formal instruction on handoffs.3 Prior to taking the Selective, our students had no knowledge of verbal or written templates for patient handoffs, although both before and after the course they felt that standardization was an important component of the process.

A number of verbal structures for handing off patient care have been described in the literature and there is not a consensus as to which functions best. Perhaps the most cited verbal communication format is SBAR (ie, situation, background, assessment and recommendation).16, 17 This tool was developed by Leonard et al.18 specifically for use by nurses to provide 1‐way communication to physicians pertaining to a change in patient status. We considered teaching the SBAR approach to the students but felt that it did not provide a suitable structure for handoffs because the transfer of care is not generally an event‐based situation and the literature on handoffs indicates that an optimal verbal system includes 2‐way communication.

Additional mnemonics for handoffs found in the literature include SIGNOUT (ie, Sick or DNR, Identifying information, General hospital course, New events of the day, Overall health status, Upcoming possibilities with plan, and Tasks to complete),14 I PASS the BATON (ie, Introduction, Patient, Assessment, Situation, Safety, Background, Actions, Timing, Ownership, Next)19 and the SAIF‐IR system (see boxed text).14

We developed the SAIF‐IR mnemonic to maximize efficiency and effectiveness while differentiating the verbal portion of the handoff from the written and incorporating 2‐way communication into its structure. In the Summary statement, we emphasize that this is not a history of present illness. We ask our students to summarize, in 1 to 3 sentences, the patient's presentation and working diagnosis. When discussing patient issues, we ask our students to only verbalize Active issues, although the written template has inactive, chronic issues listed. Here, we also ask our students to express their level of concern for the active issues and patient in general. If‐then's and Follow‐ups are usually verbalized together. Based on the offgoing provider's knowledge of the patient, we encourage the offgoing provider to anticipate potential problems and advise the oncoming provider on potential responses. Much of this advice is difficult to express in the written format and thus may not be found on the written handoff when the verbal handoff occurs. We encourage oncoming providers to take notes on the preprinted handoff sheet as part of the handoff process.

Through Interactive questioning and Read‐backs, we train our students and house‐staff to use the active listening techniques used outside of healthcare, in settings such as nuclear power plants and National Aeronautics and Space Administration mission control, where poor handoff communication may also result in safety concerns and adverse events.20 Interactive questioning allows the oncoming provider to correct or clarify any information given by the off‐going provider. Read‐backs are a method of confirming follow‐up activity or contingency plans. Together, the SAIF‐IR mnemonic builds a 2‐way communication structure into the patient handoff with both offgoing and oncoming providers having predefined roles.

Much of the information on our written handoff (patient identifying information, medications, language preference, code status, admission date) is not verbalized unless it is part of the active issues or the if‐then, follow‐ups (ie, medication titration for a patient admitted with an acute coronary syndrome or cor status in a patient newly made comfort care). By not reading extraneous information, we seek to emphasize the Active issues as well as the If‐then, Follow‐ups. We feel this emphasis maximizes the effectiveness of the handoff, while the purposeful nonverbalization of written materials such as identifying information maximizes its efficiency. Future work may examine which verbal and written structures for patient handoffs most benefit patient care and workflow through standard communication.

While our students found the Handoff Selective to be useful and to improve their self‐perceived ability to perform handoffs, we were not able to determine whether our program affected downstream outcomes such as adverse events relating to failures in handoff communication. Additionally, since we only taught and evaluated our Selective at the University of Colorado Denver School of Medicine, the response of our students may not generalize to other medical schools. Multicentered, prospective, randomized controlled trials may determine whether handoff education programs are successful in reducing patient adverse events related to transfers of care.

While handoffs occur frequently and are increasingly recognized as a vulnerable time in patient care, little is known about how to effectively teach handoffs to medical students during their clinical years. We developed a formal course to teach the importance of handoffs and how the process should be conducted. Our students reported that the Handoff Selective we developed improved their knowledge about the process and their perception of their ability to perform handoffs in a time‐appropriate and effective manner. In response to the feedback we received from our students, the Handoff Selective is the only course in the ICC that has been made mandatory for all students.