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Value of Ultra-Brief Cognitive Assessments in Predicting Negative Hospital Outcomes
Clinical question: What is the value of ultra-brief cognitive assessments in predicting hospital outcomes?
Background: Cognitive assessment tools can be used to predict patient outcomes in the hospital setting. Physician time constraints limit use of longer traditional cognitive testing, and little is known about the effectiveness of ultra-brief (less than one minute) assessments and their predictive value.
Study design: Secondary data analysis of a quality improvement project.
Setting: Tertiary, Veterans Administration hospital.
Synopsis: Using data from a prior inpatient database, 3,232 patients over the age of 60 were screened on admission using the modified Richmond Agitation and Sedation Scale (mRASS) for arousal and the months of the year backwards (MOTYB) for attention. Abnormal mRASS and incorrect MOTYB predicted negative hospital outcomes: increased length of stay (incident rate ratio 1.23, 95% CI 1.17-1.3); increased restraint use (risk ratio 5.05, 95% CI); increased hospital mortality (RR 3.46, 95% CI 1.24-9.63); and decreased rates of being discharged home (RR 2.97, 95% CI: 2.42-3.64).
This study highlights the value of two ultra-brief cognitive assessment tools in the prediction of potential poor outcomes during inpatient admission. Hospitalists need to identify high-risk patients, and these tools allow for rapid assessment at the time of admission, without a significant time constraint for the busy hospitalist.
Bottom Line: The use of ultra-brief cognitive assessment tools in patients over age 60 can predict negative inpatient outcomes.
Citation: Yevchak AM, Doherty K, Archambault EG, Kelly B, Fonda JR, Rudolph JL. The association between an ultra-brief cognitive screening in older adults and hospital outcomes. J Hosp Med. 2015;10(10):651-657.
Clinical question: What is the value of ultra-brief cognitive assessments in predicting hospital outcomes?
Background: Cognitive assessment tools can be used to predict patient outcomes in the hospital setting. Physician time constraints limit use of longer traditional cognitive testing, and little is known about the effectiveness of ultra-brief (less than one minute) assessments and their predictive value.
Study design: Secondary data analysis of a quality improvement project.
Setting: Tertiary, Veterans Administration hospital.
Synopsis: Using data from a prior inpatient database, 3,232 patients over the age of 60 were screened on admission using the modified Richmond Agitation and Sedation Scale (mRASS) for arousal and the months of the year backwards (MOTYB) for attention. Abnormal mRASS and incorrect MOTYB predicted negative hospital outcomes: increased length of stay (incident rate ratio 1.23, 95% CI 1.17-1.3); increased restraint use (risk ratio 5.05, 95% CI); increased hospital mortality (RR 3.46, 95% CI 1.24-9.63); and decreased rates of being discharged home (RR 2.97, 95% CI: 2.42-3.64).
This study highlights the value of two ultra-brief cognitive assessment tools in the prediction of potential poor outcomes during inpatient admission. Hospitalists need to identify high-risk patients, and these tools allow for rapid assessment at the time of admission, without a significant time constraint for the busy hospitalist.
Bottom Line: The use of ultra-brief cognitive assessment tools in patients over age 60 can predict negative inpatient outcomes.
Citation: Yevchak AM, Doherty K, Archambault EG, Kelly B, Fonda JR, Rudolph JL. The association between an ultra-brief cognitive screening in older adults and hospital outcomes. J Hosp Med. 2015;10(10):651-657.
Clinical question: What is the value of ultra-brief cognitive assessments in predicting hospital outcomes?
Background: Cognitive assessment tools can be used to predict patient outcomes in the hospital setting. Physician time constraints limit use of longer traditional cognitive testing, and little is known about the effectiveness of ultra-brief (less than one minute) assessments and their predictive value.
Study design: Secondary data analysis of a quality improvement project.
Setting: Tertiary, Veterans Administration hospital.
Synopsis: Using data from a prior inpatient database, 3,232 patients over the age of 60 were screened on admission using the modified Richmond Agitation and Sedation Scale (mRASS) for arousal and the months of the year backwards (MOTYB) for attention. Abnormal mRASS and incorrect MOTYB predicted negative hospital outcomes: increased length of stay (incident rate ratio 1.23, 95% CI 1.17-1.3); increased restraint use (risk ratio 5.05, 95% CI); increased hospital mortality (RR 3.46, 95% CI 1.24-9.63); and decreased rates of being discharged home (RR 2.97, 95% CI: 2.42-3.64).
This study highlights the value of two ultra-brief cognitive assessment tools in the prediction of potential poor outcomes during inpatient admission. Hospitalists need to identify high-risk patients, and these tools allow for rapid assessment at the time of admission, without a significant time constraint for the busy hospitalist.
Bottom Line: The use of ultra-brief cognitive assessment tools in patients over age 60 can predict negative inpatient outcomes.
Citation: Yevchak AM, Doherty K, Archambault EG, Kelly B, Fonda JR, Rudolph JL. The association between an ultra-brief cognitive screening in older adults and hospital outcomes. J Hosp Med. 2015;10(10):651-657.
Criteria for Appropriate Use of Peripherally Inserted Central Catheters
Clinical question: What are criteria for appropriate and inappropriate use of PICCs?
Background: PICCs are commonly used in medical care in a variety of clinical contexts; however, criteria defining the appropriate use of PICCs and practices related to PICC placement have not been previously established.
Study design: A multispecialty panel classified indications for PICC use as appropriate or inappropriate using the RAND/UCLA Appropriateness Method.
Synopsis: Selected appropriate PICC uses include:
- Infusion of peripherally compatible infusates, intermittent infusions, or infrequent phlebotomy in patients with poor or difficult venous access when the expected duration of use is at least six days;
- Phlebotomy at least every eight hours when the expected duration of use is at least six days; and
- Invasive hemodynamic monitoring in a critically ill patient only if the duration of use is expected to exceed 15 days.
Selected appropriate PICC-related practices:
- Verify PICC tip position using a chest radiograph only after non-ECG or non-fluoroscopically guided PICC insertion;
- Provide an interval without a PICC to allow resolution of bacteremia when managing PICC-related bloodstream infections; and
- For PICC-related DVT, provide at least three months of systemic anticoagulation if not otherwise contraindicated.
Selected inappropriate PICC-related practices:
- Adjustment of PICC tips that reside in the lower third of the superior vena cava, cavoatrial junction, or right atrium; and
- Removal or replacement of PICCs that are clinically necessary, well positioned, and functional in the setting of PICC-related DVT or without evidence of catheter-associated bloodstream infection.
Bottom line: A multispecialty expert panel provides guidance for appropriate use of PICCs and PICC-related practices.
Citation: Chopra V, Flanders SA, Saint S, et al. The Michigan appropriateness guide for intravenous catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med. 2015;163(6):S1-S40.
Clinical question: What are criteria for appropriate and inappropriate use of PICCs?
Background: PICCs are commonly used in medical care in a variety of clinical contexts; however, criteria defining the appropriate use of PICCs and practices related to PICC placement have not been previously established.
Study design: A multispecialty panel classified indications for PICC use as appropriate or inappropriate using the RAND/UCLA Appropriateness Method.
Synopsis: Selected appropriate PICC uses include:
- Infusion of peripherally compatible infusates, intermittent infusions, or infrequent phlebotomy in patients with poor or difficult venous access when the expected duration of use is at least six days;
- Phlebotomy at least every eight hours when the expected duration of use is at least six days; and
- Invasive hemodynamic monitoring in a critically ill patient only if the duration of use is expected to exceed 15 days.
Selected appropriate PICC-related practices:
- Verify PICC tip position using a chest radiograph only after non-ECG or non-fluoroscopically guided PICC insertion;
- Provide an interval without a PICC to allow resolution of bacteremia when managing PICC-related bloodstream infections; and
- For PICC-related DVT, provide at least three months of systemic anticoagulation if not otherwise contraindicated.
Selected inappropriate PICC-related practices:
- Adjustment of PICC tips that reside in the lower third of the superior vena cava, cavoatrial junction, or right atrium; and
- Removal or replacement of PICCs that are clinically necessary, well positioned, and functional in the setting of PICC-related DVT or without evidence of catheter-associated bloodstream infection.
Bottom line: A multispecialty expert panel provides guidance for appropriate use of PICCs and PICC-related practices.
Citation: Chopra V, Flanders SA, Saint S, et al. The Michigan appropriateness guide for intravenous catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med. 2015;163(6):S1-S40.
Clinical question: What are criteria for appropriate and inappropriate use of PICCs?
Background: PICCs are commonly used in medical care in a variety of clinical contexts; however, criteria defining the appropriate use of PICCs and practices related to PICC placement have not been previously established.
Study design: A multispecialty panel classified indications for PICC use as appropriate or inappropriate using the RAND/UCLA Appropriateness Method.
Synopsis: Selected appropriate PICC uses include:
- Infusion of peripherally compatible infusates, intermittent infusions, or infrequent phlebotomy in patients with poor or difficult venous access when the expected duration of use is at least six days;
- Phlebotomy at least every eight hours when the expected duration of use is at least six days; and
- Invasive hemodynamic monitoring in a critically ill patient only if the duration of use is expected to exceed 15 days.
Selected appropriate PICC-related practices:
- Verify PICC tip position using a chest radiograph only after non-ECG or non-fluoroscopically guided PICC insertion;
- Provide an interval without a PICC to allow resolution of bacteremia when managing PICC-related bloodstream infections; and
- For PICC-related DVT, provide at least three months of systemic anticoagulation if not otherwise contraindicated.
Selected inappropriate PICC-related practices:
- Adjustment of PICC tips that reside in the lower third of the superior vena cava, cavoatrial junction, or right atrium; and
- Removal or replacement of PICCs that are clinically necessary, well positioned, and functional in the setting of PICC-related DVT or without evidence of catheter-associated bloodstream infection.
Bottom line: A multispecialty expert panel provides guidance for appropriate use of PICCs and PICC-related practices.
Citation: Chopra V, Flanders SA, Saint S, et al. The Michigan appropriateness guide for intravenous catheters (MAGIC): results from a multispecialty panel using the RAND/UCLA appropriateness method. Ann Intern Med. 2015;163(6):S1-S40.
ACP Guidelines for Evaluation of Suspected Pulmonary Embolism
Clinical question: What are best practices for evaluating patients with suspected acute pulmonary embolism (PE)?
Background: Use of CT in the evaluation of PE has increased across all clinical settings without improving mortality. Contrast CT carries the risks of radiation exposure, contrast-induced nephropathy, and incidental findings that require further investigation. The authors highlight evidence-based strategies for evaluation of PE, focusing on delivering high-value care.
Study design: Clinical guideline.
Setting: Literature review of studies across all adult clinical settings.
Synopsis: The clinical guidelines committee of the American College of Physicians conducted a literature search surrounding evaluation of suspected acute PE. From their review, they concluded:
- Pretest probability should initially be determined based on validated prediction tools (Wells score, Revised Geneva);
- In patients found to have low pretest probability and meeting the pulmonary embolism rule-out criteria (PERC), clinicians can forego d-dimer testing;
- In those with intermediate pretest probability or those with low pre-test probability who do not pass PERC, d-dimer measurement should be obtained;
- The d-dimer threshold should be age adjusted and imaging should not be pursued in patients whose d-dimer level falls below this cutoff, while those with positive d-dimers should receive CT pulmonary angiography (CTPA); and
- Patients with high pretest probability should undergo CTPA (or V/Q scan if CTPA is contraindicated) without d-dimer testing.
Bottom line: In suspected acute PE, first determine pretest probability using Wells and Revised Geneva, and then use this probability in conjunction with the PERC and d-dimer (as indicated) to guide decisions about imaging.
Citation: Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD. Evaluation of patients with suspected acute pulmonary embolism: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med. 2015;163(9):701-711.
Clinical question: What are best practices for evaluating patients with suspected acute pulmonary embolism (PE)?
Background: Use of CT in the evaluation of PE has increased across all clinical settings without improving mortality. Contrast CT carries the risks of radiation exposure, contrast-induced nephropathy, and incidental findings that require further investigation. The authors highlight evidence-based strategies for evaluation of PE, focusing on delivering high-value care.
Study design: Clinical guideline.
Setting: Literature review of studies across all adult clinical settings.
Synopsis: The clinical guidelines committee of the American College of Physicians conducted a literature search surrounding evaluation of suspected acute PE. From their review, they concluded:
- Pretest probability should initially be determined based on validated prediction tools (Wells score, Revised Geneva);
- In patients found to have low pretest probability and meeting the pulmonary embolism rule-out criteria (PERC), clinicians can forego d-dimer testing;
- In those with intermediate pretest probability or those with low pre-test probability who do not pass PERC, d-dimer measurement should be obtained;
- The d-dimer threshold should be age adjusted and imaging should not be pursued in patients whose d-dimer level falls below this cutoff, while those with positive d-dimers should receive CT pulmonary angiography (CTPA); and
- Patients with high pretest probability should undergo CTPA (or V/Q scan if CTPA is contraindicated) without d-dimer testing.
Bottom line: In suspected acute PE, first determine pretest probability using Wells and Revised Geneva, and then use this probability in conjunction with the PERC and d-dimer (as indicated) to guide decisions about imaging.
Citation: Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD. Evaluation of patients with suspected acute pulmonary embolism: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med. 2015;163(9):701-711.
Clinical question: What are best practices for evaluating patients with suspected acute pulmonary embolism (PE)?
Background: Use of CT in the evaluation of PE has increased across all clinical settings without improving mortality. Contrast CT carries the risks of radiation exposure, contrast-induced nephropathy, and incidental findings that require further investigation. The authors highlight evidence-based strategies for evaluation of PE, focusing on delivering high-value care.
Study design: Clinical guideline.
Setting: Literature review of studies across all adult clinical settings.
Synopsis: The clinical guidelines committee of the American College of Physicians conducted a literature search surrounding evaluation of suspected acute PE. From their review, they concluded:
- Pretest probability should initially be determined based on validated prediction tools (Wells score, Revised Geneva);
- In patients found to have low pretest probability and meeting the pulmonary embolism rule-out criteria (PERC), clinicians can forego d-dimer testing;
- In those with intermediate pretest probability or those with low pre-test probability who do not pass PERC, d-dimer measurement should be obtained;
- The d-dimer threshold should be age adjusted and imaging should not be pursued in patients whose d-dimer level falls below this cutoff, while those with positive d-dimers should receive CT pulmonary angiography (CTPA); and
- Patients with high pretest probability should undergo CTPA (or V/Q scan if CTPA is contraindicated) without d-dimer testing.
Bottom line: In suspected acute PE, first determine pretest probability using Wells and Revised Geneva, and then use this probability in conjunction with the PERC and d-dimer (as indicated) to guide decisions about imaging.
Citation: Raja AS, Greenberg JO, Qaseem A, Denberg TD, Fitterman N, Schuur JD. Evaluation of patients with suspected acute pulmonary embolism: best practice advice from the clinical guidelines committee of the American College of Physicians. Ann Intern Med. 2015;163(9):701-711.
Early Palliative Care Can Save Money
Clinical question: Does time to consult after admission change the effect palliative care consultation has on cost of care?
Background: Studies have shown that early palliative care involvement improves quality of life and survival among cancer patients while reducing the cost of care. Little is known about the optimal timing of palliative care consultation and its effect on cost.
Study design: Prospective, observational study.
Setting: Multi-site, high-volume, tertiary care hospitals with established palliative care teams.
Synopsis: Clinical and cost data were collected for 969 adult patients with advanced cancer admitted to the five participating hospitals. Among those, 256 patients received palliative care consultation and 713 received usual care. Subsamples were created based on time to consultation after admission.
The study found that earlier consultation yielded larger effects on cost savings. There was a 24% reduction in total cost if consultation occurred within two days (95% CI, -$3,438 to -$1,122; P<0.001), with estimated savings of $2,280. For consultation within six days of admission, there was a $1,312 savings (95% CI, -$2,568 to -$ 1,122; P<0.04), consistent with a 14% reduction in total cost.
There are notable limitations to this study. Half of eligible patients were excluded due to incomplete data collection, resulting in a small sample size. Further, these results can be generalized only to inpatients with advanced cancer.
Bottom line: Reducing the time to consultation with palliative care increases cost savings. In advanced cancer patients, a 24% reduction in total costs was realized for consultation within two days following admission.
Citation: May P, Garrido MM, Cassel JB, et al. Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: earlier consultation is associated with larger cost-saving effect. J Clin Oncol. 2015;33(25):2745-2752.
Clinical question: Does time to consult after admission change the effect palliative care consultation has on cost of care?
Background: Studies have shown that early palliative care involvement improves quality of life and survival among cancer patients while reducing the cost of care. Little is known about the optimal timing of palliative care consultation and its effect on cost.
Study design: Prospective, observational study.
Setting: Multi-site, high-volume, tertiary care hospitals with established palliative care teams.
Synopsis: Clinical and cost data were collected for 969 adult patients with advanced cancer admitted to the five participating hospitals. Among those, 256 patients received palliative care consultation and 713 received usual care. Subsamples were created based on time to consultation after admission.
The study found that earlier consultation yielded larger effects on cost savings. There was a 24% reduction in total cost if consultation occurred within two days (95% CI, -$3,438 to -$1,122; P<0.001), with estimated savings of $2,280. For consultation within six days of admission, there was a $1,312 savings (95% CI, -$2,568 to -$ 1,122; P<0.04), consistent with a 14% reduction in total cost.
There are notable limitations to this study. Half of eligible patients were excluded due to incomplete data collection, resulting in a small sample size. Further, these results can be generalized only to inpatients with advanced cancer.
Bottom line: Reducing the time to consultation with palliative care increases cost savings. In advanced cancer patients, a 24% reduction in total costs was realized for consultation within two days following admission.
Citation: May P, Garrido MM, Cassel JB, et al. Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: earlier consultation is associated with larger cost-saving effect. J Clin Oncol. 2015;33(25):2745-2752.
Clinical question: Does time to consult after admission change the effect palliative care consultation has on cost of care?
Background: Studies have shown that early palliative care involvement improves quality of life and survival among cancer patients while reducing the cost of care. Little is known about the optimal timing of palliative care consultation and its effect on cost.
Study design: Prospective, observational study.
Setting: Multi-site, high-volume, tertiary care hospitals with established palliative care teams.
Synopsis: Clinical and cost data were collected for 969 adult patients with advanced cancer admitted to the five participating hospitals. Among those, 256 patients received palliative care consultation and 713 received usual care. Subsamples were created based on time to consultation after admission.
The study found that earlier consultation yielded larger effects on cost savings. There was a 24% reduction in total cost if consultation occurred within two days (95% CI, -$3,438 to -$1,122; P<0.001), with estimated savings of $2,280. For consultation within six days of admission, there was a $1,312 savings (95% CI, -$2,568 to -$ 1,122; P<0.04), consistent with a 14% reduction in total cost.
There are notable limitations to this study. Half of eligible patients were excluded due to incomplete data collection, resulting in a small sample size. Further, these results can be generalized only to inpatients with advanced cancer.
Bottom line: Reducing the time to consultation with palliative care increases cost savings. In advanced cancer patients, a 24% reduction in total costs was realized for consultation within two days following admission.
Citation: May P, Garrido MM, Cassel JB, et al. Prospective cohort study of hospital palliative care teams for inpatients with advanced cancer: earlier consultation is associated with larger cost-saving effect. J Clin Oncol. 2015;33(25):2745-2752.
Effectiveness of Antipsychotics in Treatment of Delirium
Clinical questions: Are antipsychotics for the treatment of delirium safe and effective? Does efficacy differ between ICU and non-ICU settings? Does efficacy differ between first- and second-generation antipsychotics (SGA)?
Background: Delirium is common in hospitalized patients. Data are mixed about the use of antipsychotics for treatment of delirium, and safety concerns are well founded. A 2007 Cochrane review failed to show compelling evidence for their efficacy, yet they remain widely used for this purpose.
Study design: Systematic review and meta-analysis.
Setting: Fifteen RCTs of adults with delirium.
Synopsis: The primary outcome measure was response rate at the study endpoint, defined using severity of delirium and global scales.
In a comparison of pooled or individual antipsychotics vs. placebo or usual care (UC), antipsychotics were found to be superior, with a response rate of 0.22 (95% CI, 0.15-0.34, P<.00001), NNT=2. Subgroup analysis revealed this superiority to be greater in non-ICU settings, with ICU antipsychotic use only marginally better than UC. Antipsychotics were superior in time to response (TTR). Mortality rates were no different.
There were no differences between chlorpromazine and haloperidol in any outcomes. Among head-to-head comparisons of SGAs, no differences were found. Pooled or individual SGAs, however, had the same overall efficacy as haloperidol but shorter TTR and fewer extrapyramidal side effects. Subgroup analysis showed a small but significant advantage in the use of SGAs over haloperidol in the ICU.
Bottom line: Antipsychotics are more effective than placebo or usual care in the treatment of delirium. There appears to be a benefit to using second-generation antipsychotics over haloperidol.
Citation: Kishi T, Hirota T, Matsunaga S, Iwata N. Antipsychotic medications for the treatment of delirium: a systematic review and meta-analysis of randomised controlled trials. J Neurol Neurosurg Psychiatry. 2015;0:1-8.
Clinical questions: Are antipsychotics for the treatment of delirium safe and effective? Does efficacy differ between ICU and non-ICU settings? Does efficacy differ between first- and second-generation antipsychotics (SGA)?
Background: Delirium is common in hospitalized patients. Data are mixed about the use of antipsychotics for treatment of delirium, and safety concerns are well founded. A 2007 Cochrane review failed to show compelling evidence for their efficacy, yet they remain widely used for this purpose.
Study design: Systematic review and meta-analysis.
Setting: Fifteen RCTs of adults with delirium.
Synopsis: The primary outcome measure was response rate at the study endpoint, defined using severity of delirium and global scales.
In a comparison of pooled or individual antipsychotics vs. placebo or usual care (UC), antipsychotics were found to be superior, with a response rate of 0.22 (95% CI, 0.15-0.34, P<.00001), NNT=2. Subgroup analysis revealed this superiority to be greater in non-ICU settings, with ICU antipsychotic use only marginally better than UC. Antipsychotics were superior in time to response (TTR). Mortality rates were no different.
There were no differences between chlorpromazine and haloperidol in any outcomes. Among head-to-head comparisons of SGAs, no differences were found. Pooled or individual SGAs, however, had the same overall efficacy as haloperidol but shorter TTR and fewer extrapyramidal side effects. Subgroup analysis showed a small but significant advantage in the use of SGAs over haloperidol in the ICU.
Bottom line: Antipsychotics are more effective than placebo or usual care in the treatment of delirium. There appears to be a benefit to using second-generation antipsychotics over haloperidol.
Citation: Kishi T, Hirota T, Matsunaga S, Iwata N. Antipsychotic medications for the treatment of delirium: a systematic review and meta-analysis of randomised controlled trials. J Neurol Neurosurg Psychiatry. 2015;0:1-8.
Clinical questions: Are antipsychotics for the treatment of delirium safe and effective? Does efficacy differ between ICU and non-ICU settings? Does efficacy differ between first- and second-generation antipsychotics (SGA)?
Background: Delirium is common in hospitalized patients. Data are mixed about the use of antipsychotics for treatment of delirium, and safety concerns are well founded. A 2007 Cochrane review failed to show compelling evidence for their efficacy, yet they remain widely used for this purpose.
Study design: Systematic review and meta-analysis.
Setting: Fifteen RCTs of adults with delirium.
Synopsis: The primary outcome measure was response rate at the study endpoint, defined using severity of delirium and global scales.
In a comparison of pooled or individual antipsychotics vs. placebo or usual care (UC), antipsychotics were found to be superior, with a response rate of 0.22 (95% CI, 0.15-0.34, P<.00001), NNT=2. Subgroup analysis revealed this superiority to be greater in non-ICU settings, with ICU antipsychotic use only marginally better than UC. Antipsychotics were superior in time to response (TTR). Mortality rates were no different.
There were no differences between chlorpromazine and haloperidol in any outcomes. Among head-to-head comparisons of SGAs, no differences were found. Pooled or individual SGAs, however, had the same overall efficacy as haloperidol but shorter TTR and fewer extrapyramidal side effects. Subgroup analysis showed a small but significant advantage in the use of SGAs over haloperidol in the ICU.
Bottom line: Antipsychotics are more effective than placebo or usual care in the treatment of delirium. There appears to be a benefit to using second-generation antipsychotics over haloperidol.
Citation: Kishi T, Hirota T, Matsunaga S, Iwata N. Antipsychotic medications for the treatment of delirium: a systematic review and meta-analysis of randomised controlled trials. J Neurol Neurosurg Psychiatry. 2015;0:1-8.
Predictors for Surgical Management of Small Bowel Obstruction
Clinical question: Are there clinical or computerized tomography (CT) findings that identify which patients will need early surgical management in adhesive small bowel obstruction (ASBO)?
Background: Previous studies determined adverse outcomes resulting from delayed surgery in patients with ASBO: increased length of stay (LOS), complications, and mortality. Most patients respond to nonoperative management, however.
Study design: Prospective observational study.
Setting: Three academic and tertiary referral medical centers.
Synopsis: Using multivariate analysis of 202 patients admitted with presumed adhesive ASBO without immediate surgical need, of whom 52 required eventual surgical intervention, this study found three predictors for needing operative care: no flatus (odds ratio [OR], 3.28; 95% confidence interval [CI], 1.51-7.12; P=0.003), as well as the CT findings of a high-grade obstruction, defined as only minimal passage of air and fluid into the distal small bowel or colon (OR, 2.44; 95% CI, 1.10-5.43; P=0.028) or the presence of free fluid (OR, 2.59; 95% CI, 1.13-5.90; P=0.023).
Despite these associations, clinicians should not view these findings as indications for surgery. Of the patients who responded to nonoperative management, one-third had no flatus, and on CT one-third had high-grade obstruction and half had free fluid. Instead, because patients with these findings are at an increased risk of failing nonoperative management, they should be observed more closely and reassessed more frequently.
Bottom line: Patients without flatus or with the presence of free fluid or high-grade obstruction on CT are at an increased risk of requiring surgical management for ASBO.
Citation: Kulvatunyou N, Pandit V, Moutamn S, et al. A multi-institution prospective observational study of small bowel obstruction: clinical and computerized tomography predictors of which patients may require early surgery. J Trauma Acute Care Surg. 2015;79(3):393-398.
Clinical question: Are there clinical or computerized tomography (CT) findings that identify which patients will need early surgical management in adhesive small bowel obstruction (ASBO)?
Background: Previous studies determined adverse outcomes resulting from delayed surgery in patients with ASBO: increased length of stay (LOS), complications, and mortality. Most patients respond to nonoperative management, however.
Study design: Prospective observational study.
Setting: Three academic and tertiary referral medical centers.
Synopsis: Using multivariate analysis of 202 patients admitted with presumed adhesive ASBO without immediate surgical need, of whom 52 required eventual surgical intervention, this study found three predictors for needing operative care: no flatus (odds ratio [OR], 3.28; 95% confidence interval [CI], 1.51-7.12; P=0.003), as well as the CT findings of a high-grade obstruction, defined as only minimal passage of air and fluid into the distal small bowel or colon (OR, 2.44; 95% CI, 1.10-5.43; P=0.028) or the presence of free fluid (OR, 2.59; 95% CI, 1.13-5.90; P=0.023).
Despite these associations, clinicians should not view these findings as indications for surgery. Of the patients who responded to nonoperative management, one-third had no flatus, and on CT one-third had high-grade obstruction and half had free fluid. Instead, because patients with these findings are at an increased risk of failing nonoperative management, they should be observed more closely and reassessed more frequently.
Bottom line: Patients without flatus or with the presence of free fluid or high-grade obstruction on CT are at an increased risk of requiring surgical management for ASBO.
Citation: Kulvatunyou N, Pandit V, Moutamn S, et al. A multi-institution prospective observational study of small bowel obstruction: clinical and computerized tomography predictors of which patients may require early surgery. J Trauma Acute Care Surg. 2015;79(3):393-398.
Clinical question: Are there clinical or computerized tomography (CT) findings that identify which patients will need early surgical management in adhesive small bowel obstruction (ASBO)?
Background: Previous studies determined adverse outcomes resulting from delayed surgery in patients with ASBO: increased length of stay (LOS), complications, and mortality. Most patients respond to nonoperative management, however.
Study design: Prospective observational study.
Setting: Three academic and tertiary referral medical centers.
Synopsis: Using multivariate analysis of 202 patients admitted with presumed adhesive ASBO without immediate surgical need, of whom 52 required eventual surgical intervention, this study found three predictors for needing operative care: no flatus (odds ratio [OR], 3.28; 95% confidence interval [CI], 1.51-7.12; P=0.003), as well as the CT findings of a high-grade obstruction, defined as only minimal passage of air and fluid into the distal small bowel or colon (OR, 2.44; 95% CI, 1.10-5.43; P=0.028) or the presence of free fluid (OR, 2.59; 95% CI, 1.13-5.90; P=0.023).
Despite these associations, clinicians should not view these findings as indications for surgery. Of the patients who responded to nonoperative management, one-third had no flatus, and on CT one-third had high-grade obstruction and half had free fluid. Instead, because patients with these findings are at an increased risk of failing nonoperative management, they should be observed more closely and reassessed more frequently.
Bottom line: Patients without flatus or with the presence of free fluid or high-grade obstruction on CT are at an increased risk of requiring surgical management for ASBO.
Citation: Kulvatunyou N, Pandit V, Moutamn S, et al. A multi-institution prospective observational study of small bowel obstruction: clinical and computerized tomography predictors of which patients may require early surgery. J Trauma Acute Care Surg. 2015;79(3):393-398.
Adding Advanced Molecular Techniques to Standard Blood Cultures May Improve Patient Outcomes
Clinical question: Does the addition of rapid multiplex polymerase chain reaction molecular techniques to standard blood culture bottle (BCB) processing, with or without antimicrobial stewardship recommendations, affect antimicrobial utilization and patient outcomes?
Background: Standard BCB processing typically requires two days to provide identification and susceptibility testing results. PCR-based molecular testing is available to test positive BCB and deliver specific susceptibility results more rapidly, typically within one hour. Earlier results could improve antimicrobial utilization, limit antimicrobial resistance, decrease the risk of Clostridium difficile colitis, improve patient outcomes, and decrease healthcare costs. The impact of these techniques on outcomes is uncertain.
Study design: Prospective, randomized controlled trial (RCT).
Setting: Single large tertiary academic medical center.
Synopsis: Nearly 750 patients were randomized to conventional BCB processing (control), BCB with rapid multiplex PCR and templated recommendations (rmPCR), or BCB with rapid multiplex PCR and real-time antimicrobial stewardship provided by an infectious disease physician or specially trained pharmacist (rmPCR/AS). Time to microorganism identification was reduced from 22.3 hours in the control arm to 1.3 hours in the intervention arms. Both intervention groups had decreased use of broad spectrum piperacillin-tazobactam, increased use of narrow spectrum β-lactam, and decreased treatment of contaminants. Time to appropriate empiric treatment modification was shortest in the rmPCR/AS group.
Groups did not differ in mortality, length of stay, or cost, although an adequately powered study may show beneficial effects in these outcomes.
Bottom line: The addition of rapid multiplex PCR, ideally combined with antimicrobial stewardship, improves antimicrobial utilization in patients with positive blood cultures.
Citation: Banerjee R, Teng CB, Cunningham SA, et al. Randomized trial of rapid multiplex polymerase chain reaction-based blood culture identification and susceptibility testing. Clin Infect Dis. 2015;61(7):1071-1080.
Clinical question: Does the addition of rapid multiplex polymerase chain reaction molecular techniques to standard blood culture bottle (BCB) processing, with or without antimicrobial stewardship recommendations, affect antimicrobial utilization and patient outcomes?
Background: Standard BCB processing typically requires two days to provide identification and susceptibility testing results. PCR-based molecular testing is available to test positive BCB and deliver specific susceptibility results more rapidly, typically within one hour. Earlier results could improve antimicrobial utilization, limit antimicrobial resistance, decrease the risk of Clostridium difficile colitis, improve patient outcomes, and decrease healthcare costs. The impact of these techniques on outcomes is uncertain.
Study design: Prospective, randomized controlled trial (RCT).
Setting: Single large tertiary academic medical center.
Synopsis: Nearly 750 patients were randomized to conventional BCB processing (control), BCB with rapid multiplex PCR and templated recommendations (rmPCR), or BCB with rapid multiplex PCR and real-time antimicrobial stewardship provided by an infectious disease physician or specially trained pharmacist (rmPCR/AS). Time to microorganism identification was reduced from 22.3 hours in the control arm to 1.3 hours in the intervention arms. Both intervention groups had decreased use of broad spectrum piperacillin-tazobactam, increased use of narrow spectrum β-lactam, and decreased treatment of contaminants. Time to appropriate empiric treatment modification was shortest in the rmPCR/AS group.
Groups did not differ in mortality, length of stay, or cost, although an adequately powered study may show beneficial effects in these outcomes.
Bottom line: The addition of rapid multiplex PCR, ideally combined with antimicrobial stewardship, improves antimicrobial utilization in patients with positive blood cultures.
Citation: Banerjee R, Teng CB, Cunningham SA, et al. Randomized trial of rapid multiplex polymerase chain reaction-based blood culture identification and susceptibility testing. Clin Infect Dis. 2015;61(7):1071-1080.
Clinical question: Does the addition of rapid multiplex polymerase chain reaction molecular techniques to standard blood culture bottle (BCB) processing, with or without antimicrobial stewardship recommendations, affect antimicrobial utilization and patient outcomes?
Background: Standard BCB processing typically requires two days to provide identification and susceptibility testing results. PCR-based molecular testing is available to test positive BCB and deliver specific susceptibility results more rapidly, typically within one hour. Earlier results could improve antimicrobial utilization, limit antimicrobial resistance, decrease the risk of Clostridium difficile colitis, improve patient outcomes, and decrease healthcare costs. The impact of these techniques on outcomes is uncertain.
Study design: Prospective, randomized controlled trial (RCT).
Setting: Single large tertiary academic medical center.
Synopsis: Nearly 750 patients were randomized to conventional BCB processing (control), BCB with rapid multiplex PCR and templated recommendations (rmPCR), or BCB with rapid multiplex PCR and real-time antimicrobial stewardship provided by an infectious disease physician or specially trained pharmacist (rmPCR/AS). Time to microorganism identification was reduced from 22.3 hours in the control arm to 1.3 hours in the intervention arms. Both intervention groups had decreased use of broad spectrum piperacillin-tazobactam, increased use of narrow spectrum β-lactam, and decreased treatment of contaminants. Time to appropriate empiric treatment modification was shortest in the rmPCR/AS group.
Groups did not differ in mortality, length of stay, or cost, although an adequately powered study may show beneficial effects in these outcomes.
Bottom line: The addition of rapid multiplex PCR, ideally combined with antimicrobial stewardship, improves antimicrobial utilization in patients with positive blood cultures.
Citation: Banerjee R, Teng CB, Cunningham SA, et al. Randomized trial of rapid multiplex polymerase chain reaction-based blood culture identification and susceptibility testing. Clin Infect Dis. 2015;61(7):1071-1080.
Some Readmission Risk Factors Not Captured by Medicare
Clinical question: Are there patient characteristics not currently measured by the Medicare readmission program that account for differences in hospital readmission rates?
Background: The Medicare Hospital Readmissions Reduction Program (HRRP) financially penalizes hospitals with higher than expected 30-day readmission rates. During 2014, more than 2,000 U.S. hospitals were fined $480 million for high readmission rates. HRRP accounts for differences in patient age, gender, discharge diagnosis, and diagnoses identified in Medicare claims over the previous 12 months; however, the impact of other factors is uncertain.
Study design: Survey data from the Health and Retirement Study, with linked Medicare claims.
Setting: Community-dwelling U.S. adults, older than 50 years.
Synopsis: Investigators analyzed more than 33,000 admissions from 2000 to 2012. They found 22 patient characteristics not included in the HRRP calculation that were statistically significantly predictive of hospital-wide, 30-day readmission and were more likely to be present among patients cared for in hospitals in the highest quintile of readmission rates. These characteristics reduced by 48% the differences in readmission rate between the highest- and lowest-performing quintiles. Examples include patient ethnicity, education level, personal as well as household income level, presence of prescription drug plan, Medicaid enrollment, cognitive status, and numerous others.
Bottom line: Patient characteristics account for much of the difference in readmission rates between high- and low-performing hospitals, suggesting that HRRP penalties reflect who hospitals treat as much as how well they treat them.
Citation: Barnett ML, Hsu J, McWilliams JM. Patient characteristics and differences in hospital readmission rates. JAMA Intern Med. 2015;175(11):1803-1812.
Clinical question: Are there patient characteristics not currently measured by the Medicare readmission program that account for differences in hospital readmission rates?
Background: The Medicare Hospital Readmissions Reduction Program (HRRP) financially penalizes hospitals with higher than expected 30-day readmission rates. During 2014, more than 2,000 U.S. hospitals were fined $480 million for high readmission rates. HRRP accounts for differences in patient age, gender, discharge diagnosis, and diagnoses identified in Medicare claims over the previous 12 months; however, the impact of other factors is uncertain.
Study design: Survey data from the Health and Retirement Study, with linked Medicare claims.
Setting: Community-dwelling U.S. adults, older than 50 years.
Synopsis: Investigators analyzed more than 33,000 admissions from 2000 to 2012. They found 22 patient characteristics not included in the HRRP calculation that were statistically significantly predictive of hospital-wide, 30-day readmission and were more likely to be present among patients cared for in hospitals in the highest quintile of readmission rates. These characteristics reduced by 48% the differences in readmission rate between the highest- and lowest-performing quintiles. Examples include patient ethnicity, education level, personal as well as household income level, presence of prescription drug plan, Medicaid enrollment, cognitive status, and numerous others.
Bottom line: Patient characteristics account for much of the difference in readmission rates between high- and low-performing hospitals, suggesting that HRRP penalties reflect who hospitals treat as much as how well they treat them.
Citation: Barnett ML, Hsu J, McWilliams JM. Patient characteristics and differences in hospital readmission rates. JAMA Intern Med. 2015;175(11):1803-1812.
Clinical question: Are there patient characteristics not currently measured by the Medicare readmission program that account for differences in hospital readmission rates?
Background: The Medicare Hospital Readmissions Reduction Program (HRRP) financially penalizes hospitals with higher than expected 30-day readmission rates. During 2014, more than 2,000 U.S. hospitals were fined $480 million for high readmission rates. HRRP accounts for differences in patient age, gender, discharge diagnosis, and diagnoses identified in Medicare claims over the previous 12 months; however, the impact of other factors is uncertain.
Study design: Survey data from the Health and Retirement Study, with linked Medicare claims.
Setting: Community-dwelling U.S. adults, older than 50 years.
Synopsis: Investigators analyzed more than 33,000 admissions from 2000 to 2012. They found 22 patient characteristics not included in the HRRP calculation that were statistically significantly predictive of hospital-wide, 30-day readmission and were more likely to be present among patients cared for in hospitals in the highest quintile of readmission rates. These characteristics reduced by 48% the differences in readmission rate between the highest- and lowest-performing quintiles. Examples include patient ethnicity, education level, personal as well as household income level, presence of prescription drug plan, Medicaid enrollment, cognitive status, and numerous others.
Bottom line: Patient characteristics account for much of the difference in readmission rates between high- and low-performing hospitals, suggesting that HRRP penalties reflect who hospitals treat as much as how well they treat them.
Citation: Barnett ML, Hsu J, McWilliams JM. Patient characteristics and differences in hospital readmission rates. JAMA Intern Med. 2015;175(11):1803-1812.
Evolving Practice of Hospital Medicine
Hospitalists are physicians whose primary focus is the general medical care of hospitalized patients. Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency.1 With emergency department (ED) diversion reaching rates upward of 70%, lack of access to inpatient beds leads to delayed care with worsened outcomes.25
To improve access to hospital beds, hospitals may increase capacity by either adding beds or by more efficiently using existing beds. Operations management principles have been applied to healthcare to ensure efficient use of beds. These include: reducing variability of scheduled admissions, remeasuring length of stay (LOS) and bed demand after implementing strategies to reduce practice variation, and employing queuing theory to generate predictions of optimal beds needed.6 The Joint Commission implemented a leadership standard (LD 04.03.11) that hospitals develop and implement plans to identify and mitigate impediments to efficient patient flow through the hospital.
To improve access, hospital leaders expect hospitalists to staff in inpatient medicine programs, surgical comanagement, short stay and chest pain units, and active bed management.7 In the following review, we define hospitalists' roles in the aforementioned programs and their effect on patient flow. We also touch on preoperative clinics, palliative care, geographic rounding, and flexible staffing models.
ACUTE INPATIENT CARE
Hospitalists are one of the fastest growing physician groups in the United States.810 Hospitalists improve efficiency and quality of care across a variety of demographic, geographic, and healthcare settings.11, 12 A 2002 retrospective cohort study in a community‐based urban teaching hospital showed that hospitalists decreased LOS by 0.61 days and lowered risk for death in the hospital (adjusted relative hazard, 0.71; 95% confidence interval [CI], 0.540.93).13 A 2004 prospective quasi‐experimental observational study done at an academic teaching hospital showed an adjusted LOS that was 16.2% lower, and adjusted cost 9.7% lower, for patients on the hospitalists' service.14 In 2007, Lindenauer and colleagues found that a national sample of hospitalists decreased LOS by 0.4 days and lowered cost by $286 per patient.15 The findings of these individual studies were supported in a 2009 systematic review of 33 studies by Peterson which showed that hospitalists decrease LOS.16 In a recent study, Kuo and Goodwin showed that while hospitalists decrease LOS and cost, the patients they care for have higher Medicare costs after discharge by $322 per patient, and are more likely to be readmitted (odds ratio, 1.08; CI, 1.041.14).17
The hospitalist model of care continues to grow, and hospitalists will soon number as many as 30,000.18 For acute medical inpatients, the evidence suggests that hospitalists improve patient flow by decreasing LOS while improving other aspects of quality of care. However, Kuo and Goodwin's findings suggest that the transition of care from inpatient to outpatient settings still requires attention.17
SURGICAL COMANAGEMENT
The Society of Hospital Medicine (SHM) core competencies include perioperative medicine.19, 20 In the 2006 SHM national survey, 85% of hospital medicine groups indicated that they participated in surgical comanagement.21
Hospitalists have improved patient flow and outcomes for orthopedic patients. Hospitalist management of hip fracture patients decreases time to surgery and LOS compared to standard care.2224 Phy and colleagues studied 466 patients for 2 years after the inception of hospital medicine comanagement of surgical patients, and found that care by hospitalists decreased LOS by 2.2 days.22 In a retrospective study of 118 patients, Roy and colleagues found that hospitalist‐managed patients had shorter time to consultation and surgery, decreased LOS, and lower costs.23 In a retrospective cohort study, Batsis looked at mortality in 466 patients with hip fracture, and found no difference between hospitalist management and standard care.24 In patients undergoing elective hip and knee arthroplasty, Huddleston and colleagues reported that patients managed by hospitalists had fewer complications and shorter LOS. The nurses and orthopedic surgeons preferred the hospitalistorthopedist comanagement model.25
The benefits of hospitalist comanagement are not limited to adult patients undergoing orthopedic surgery. For high‐risk patients undergoing lower extremity reconstruction surgery, Pinzur and colleagues noted that LOS was shorter for a cohort of patients managed by hospitalists than for a group of historical controls not treated by hospitalists.26 Simon and colleagues studied comanagement for pediatric spinal fusion patients, and found a decrease in LOS from 6.5 to 4.8 days.27
Several factors should be considered in developing and implementing a successful comanagement program. Since comanagement duties may fall upon hospitalists in order to protect surgeons' time,28 hospital medicine groups should ensure adequate staffing prior to taking on additional services. Clear guidelines to delineate roles and responsibilities of the comanaging groups also need to be developed and implemented.29, 30
Comanaging may also involve additional training. Hospitalists who manage neurologic, neurosurgical, trauma, and psychiatric patients report being undertrained for such conditions.31, 32 Hospital medicine groups need to ensure training needs are met and supported. Given the successes of comanagement and the increasing complexity of surgical patients,33 this practice will likely expand to a greater variety of non‐medical patients.
SHORT STAY UNITS
In 2003, short stay units (SSU) were present in approximately 20% of US hospitals, with 11% of hospitals planning on opening one in the next year.34 SSU are designed to manage acute, self‐limited medical conditions that require brief staysusually less than 72 hours. Approximately 80% of SSU patients are discharged home, avoiding hospitalization.35 Historically, SSU have been under the domain of the ED; however, there is an emerging role for hospitalist‐run SSU.36
Despite demand for SSU, little research has been performed on hospitalist‐led SSU. In 2000, Abenhaim and colleagues showed that a hospitalist‐run SSU at a university‐affiliated teaching hospital had a shorter LOS and lower rates of complications and readmissions when compared to medicine teaching services.37 In 2008, Northwestern Memorial Hospital opened a 30‐bed hospitalist‐run SSU; for those patients, LOS decreased by 2 days.38 In 2010, Leykum and colleagues showed that a hospitalist‐run observation unit can decrease LOS from 2.4 days to 2.2 days.39 Careful selection of SSU patients is needed to obtain these results. Lucas and colleagues found that whether or not SSU patients required assistance of specialists was the strongest predictor of unsuccessful stays (>72 hours or inpatient conversion) in SSU.36
Whether SSU are run by hospital medicine or emergency medicine is decided at an institutional level. Location of SSU in a specifically designated area is crucial, as it allows physicians to round efficiently on patients and to work with staff trained in observation services. Development of admission criteria that include specific diagnoses which match hospitalists' scope of practice is also important (Table 1).32
| Evaluation of Diagnostic Syndromes | Treatment of Emergent Conditions |
|---|---|
| |
| Chest pain | Asthma |
| Abdominal pain | Congestive heart failure |
| Fever | Dehydration |
| Gastrointestinal bleed | Hypoglycemia or hyperglycemia |
| Syncope | Hypercalcemia |
| Dizziness | Atrial fibrillation |
| Headache | |
| Chest trauma | |
| Abdominal trauma | |
The protocol‐based and diagnosis‐specific nature of SSU may enhance quality of care through standardization. Future research may delineate the utility of SSU.
CHEST PAIN UNITS
In the United States, in 2004, approximately 6 million patients present annually to EDs with chest pain.40 Cost of care of patients unnecessarily admitted to coronary care units has been estimated to be nearly $3 billion annually.41 Still, as many as 3% of patients with acute myocardial infarction are discharged home.42 Chest pain units (CPU) were developed to facilitate evaluation of patients with chest pain, at low risk for acute coronary syndrome, without requiring inpatient admission. A number of studies have suggested that admission to a CPU is a safe and cost‐effective alternative to hospital admission.4348
CPU have traditionally been staffed by ED physicians and/or cardiologists. In a prepost study, Krantz and colleagues found that a CPU model, incorporating hospitalists at an academic public safety‐net hospital, decreased ED LOS with no difference in 30‐day cardiac event rate.49 Myers and colleagues created a hospitalist‐directed nonteaching service in an academic medical center to admit low‐risk chest pain patients. Patients admitted to the hospitalist service had a statistically significant lower median LOS (23 hours vs 33 hours) and approximately half the median hospital charges than those admitted to teaching services.50 At the same academic medical center, Bayley and colleagues showed that 91% of patients admitted for chest pain waited more than 3 hours for a bed. This adversely affected ED revenue by tying up beds, resulting in an estimated annual loss of $168,300 of hospital revenue. Creation of a hospitalist‐managed service for low‐acuity chest pain patients reduced hospital LOS by 7 hours.51 Somekh and colleagues demonstrated that a protocol‐driven, cardiologist‐run CPU results in a decreased LOS and readmission rate compared to usual care.52 In a non‐peer reviewed case study, Cox Health opened an 8‐bed, hospitalist‐led CPU in 2003. They decreased LOS from 72 to 18 hours, while increasing revenue by $2.5 million a year.53 These studies suggest that hospitalist‐run CPU can decrease LOS, increase revenue, and relieve ED overcrowding.
Development of a successful CPU depends upon clear inclusion/exclusion criteria; close collaboration among ED physicians, hospitalists, and cardiologists; the development of evidence‐based protocols, and the availability of stress testing.
ACTIVE BED MANAGEMENT
As of 2007, 90% of EDs were crowded beyond their capacity.2 ED crowding leads to ambulance diversion,54 which can delay care and increase mortality rates.55 One of the main causes of ED crowding is the boarding of admitted patients.56 Boarded, admitted patients have been shown to have decreased quality of care and patient satisfaction.35
Active bed management (ABM) by hospitalists can decrease ED diversion. Howell and colleagues instituted ABM where hospitalists, as active bed managers, facilitate placement of patients to their inpatient destinations to assist ED flow.57 This 24‐hour, hospitalist‐led, active bed management service decreased both ED LOS and ambulance diversion. The bed manager collaborated real‐time with medicine and ED attending physicians, nursing supervisors, and charge nurses to change patient care status, and assign and facilitate transfer of patients to appropriate units. These hospitalist bed managers were also empowered to activate additional resources when pre‐diversion rounds identified resource limitations and impending ED divert. They found overall ED LOS for admitted patients decreased by 98 minutes, while LOS for non‐admitted patients stayed the same. AMB decreased diversion due to critically ill and telemetry patients by 28% (786 hours), and diversion due to lower acuity patients by 6% (182 hours). This intervention proved cost‐effective. Three full‐time equivalent (FTE) hospitalists' salaries staff 1 active bed manager working 24/7. Nearly 1000 hours of diversion were avoided at an annual savings of $1086 per hour of diversion decreased.
ABM is a new frontier for hospitals in general, and hospitalists in particular. Chadaga and colleagues found that a hospital medicine‐ED team participating in active bed management, while caring for admitted patients boarded in the ED, can decrease ED diversion and improve patient flow. The percentage of patients transferred to a medicine floor and discharged within 8 hours was reduced by 67% (P < 0.01), while the number of discharges from the ED of admitted medicine patients increased by 61% (P < 0.001).58
To decrease initial investment, components of ABM (ED triage, bed assignment, discharge facilitation) can be instituted in parts. Hospital medicine groups with limited resources may only provide a triage service by phone for difficult ED cases. Bedside evaluations and collaboration with nursing staff to improve bed placement may be a next step, with floor and/or intensive care unit (ICU) rounds to facilitate early discharges as a final component.
OTHER AREAS
Preoperative Clinics
In 2005, SHM cited preoperative clinics as an important aspect of preoperative care.59 Sehgal and Wachter included preoperative clinics as an area for expanding the role of hospitalists in the United States.60 These clinics can decrease delays to surgery, LOS, and cancellations on the day of surgery.61 The Cleveland Clinic established the Internal Medicine Preoperative Assessment, Consultation, and Treatment (IMPACT) Center in 1997, and has decreased surgery delay rate by 49%.59 At Kaiser Bellflower Medical Center, a preoperative medicine service that provides preoperative screening decreased the number of surgical procedures cancelled on the day of surgery by more than half.62 Gates Hospitalists LLC's perioperative care decreased delay to surgery and lost operating room time.63 In order for a preoperative service to be successful, there must be buy‐in from hospitalists, surgeons, and primary care physicians, as well as adequate staffing and clinical support.59
Palliative Care
Palliative care has been identified by SHM as a core competency in hospital medicine.64 There are several key components in delivery of quality palliative care, including communication about prognosis, pain and symptom control, and hospice eligibility.65 Hospitalists are in a unique position to offer and improve palliative care for hospitalized patients. The majority of hospitalists report spending significant amounts of time caring for dying patients; thereby, hospitalists frequently provide end‐of‐life care.66, 67 Compared to community‐based physicians, patients cared for by hospitalists have higher odds of having documented family discussions regarding end‐of‐life care, and have fewer or no key symptoms (pain, anxiety, or dyspnea).66 In addition, hospitalists' availability improves response time when a patient's clinical status changes or deteriorates, leading to prompter delivery of symptom alleviation.65 Hospitalists are becoming more experienced with end‐of‐life care, as they are exposed to terminally ill patients on a daily basis. More experience leads to improved recognition of patients with limited prognosis, which leads to earlier discussions about goals of care and faster delivery of palliative care. Perhaps this could decrease LOS and be a future area of study.
Geographic Rounding
In the last 5 years, hospital administrators have promoted geographic rounding, where hospitalists see all their patients in 1 geographic location.69 The driving forces behind this include poor patient satisfaction with physician availability, large amounts of time spent by hospitalists in transit to and from patient locations, and frustrations regarding communication with nursing.70 Several groups have instituted this with success. Cleveland Clinic and Virtua Memorial Hospital have found improved patient satisfaction and decreased LOS.69, 70 O'Leary and colleagues found improved awareness of care plans by the entire team.71 Caution should be taken to assure proper physician‐to‐patient ratios, avoid physician isolation, and coordinate physician shifts with bed assignments.69 To address some of these issues, groups have used a hybrid model where a hospitalist is primarily located on one unit but can flex or overflow onto another unit.70 Steps to success with geographic rounding include buy‐in from the institution and nursing, assuring a safe physician‐to‐patient ratio, avoiding wasted beds, and facilitating multidisciplinary rounds.69
Flexible Staffing Models
In SHM's 2010 State of Hospital Medicine Report, 70% of hospitalist groups used a fixed shift‐based staffing model (ie, 7 days on/7 days off).72 Flexible staffing models in which physician coverage is adjusted to patient volume are growing in popularity. This model can be tailored for each institution by examining admission and patient volume trends to increase coverage during busy periods and decrease coverage during slower periods. Potential benefits include alleviating burn out, reducing LOS, and improving patient outcomes. Nursing data suggests that a higher patient‐to‐nursing ratio is associated with increased 30‐day mortality,73 and an ED study found that increasing physician coverage during the evening shift shortened ED LOS by 20%.74 To date, none of these endpoints have been studied for hospital medicine.
CONCLUSION
While many hospital medicine groups were started to provide acute inpatient medical care, most have found that their value to hospitals reaches beyond bedside care. With an epidemic of ED diversion and lack of access to hospital beds and services, optimizing throughput has become imperative for hospital systems. While hospital access can be improved with addition of new beds, improving throughput by decreasing LOS maximizes utilization of existing resources.
We have reviewed how hospitalists improve patient flow in acute inpatient medicine, surgical comanagement, short stay units, chest pain units, and active bed management. In each instance, the literature supports measures for decreasing LOS while maintaining or improving quality of care. Hinami and colleagues showed physician satisfaction with hospitalist‐provided patient care.75 Most studies have been limited by tracking upstream effects of improved efficiency. As there is now some evidence that decreasing LOS may increase readmissions,17 future studies should incorporate this metric into their outcomes. The effect of formal operations management principles on patient flow and bed efficiency is not well known and should be further examined.
In addition, we have touched on other areas (perioperative clinics, palliative care, geographic rounding, and flexible staffing models) where hospitalists may impact patient throughput. These areas represent excellent opportunities for future research.
Hospitalist participation in many of these areas is in its infancy. Hospital medicine programs interested in expanding their services, beyond acute inpatient care, have the opportunity to develop standards and continue research on the effect of hospital medicine‐led services on patient care and flow.
Acknowledgements
Disclosure: All authors disclose no relevant or financial conflicts of interest.
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- , , . Access block cause emergency department overcrowding and ambulance diversion in Perth, Western Australia. Emerg Med J. 2005;22:351–354.
- , , , . The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007;24:665–668.
- , . Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52:126–136.
- , , , , , . Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149:804–810.
- , , , et al. A hospitalist‐led emergency department team improves hospital bed efficiency. J Hosp Med. 2010;5(suppl 1):17–18.
- Society of Hospital Medicine. Perioperative care (a special supplement to The Hospitalist). Philadelphia, PA: Society of Hospital Medicine; 2005. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home136:591–596.
- Hospitalist Management Advisor. Hospitalist branch into preoperative medicine with preop assessments. Marblehead, MA: HCPro, 2006. Available at: http://www.hcpro.com/HOM‐57460–3615/Hospitalists‐branch‐into‐perioperative‐medicine‐with‐preop‐assessments.html. Accessed February 15, 2012.
- . The preoperative medicine service: an innovative practice at Kaiser Bellflower Medical Center. The Permanente Journal. 2002;6:13–16.
- . A preop evaluation service delivers unexpected benefits. Today's Hospitalist. January 2008.
- , , , , . The core competencies in hospital medicine: a framework for curriculum development. J Hosp Med. 2006;1:1–67.
- , , , , , . Common myths about caring for patients with terminal illness: opportunities to improve care in the hospital setting. J Hosp Med. 2007;2:357–365.
- . End‐of‐life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004;116:669–675.
- , , , . Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343–349.
- , . Palliative care and hospitalist: an opportunity for cross‐fertilization. Am J Med. 2001;111(suppl):10S–14S.
- . Giving hospitalists their space. ACP Hospitalist. February 2008.
- . Having problems findings your patients? Today's Hospitalists. June 2010.
- , , , et al. Impact of localizing physicians to hospital units on nurse–physician communication and agreement on the plan of care. J Gen Intern Med. 24(11):1223–1227.
- Medical Group Management Association and Society of Hospital Medicine (SHM). State of Hospital Medicine 2010 Report Based on 2009. Available online at http://www.mgma.com/store/Surveys‐and‐Benchmarking/State‐of‐Hospital‐Medicine‐2010‐Report‐Based‐on‐2009 ‐Data‐Print‐Edition/.
- , , , et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987–1993.
- , . Reduced length of stay in medical emergency department patients: a prospective controlled study on emergency physician staffing. Eur J Emerg Med. 2004;11(1):29–34.
- , , , . Provider expectations and experiences of comanagement. J Hosp Med. 2011;6(7):401–404.
Hospitalists are physicians whose primary focus is the general medical care of hospitalized patients. Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency.1 With emergency department (ED) diversion reaching rates upward of 70%, lack of access to inpatient beds leads to delayed care with worsened outcomes.25
To improve access to hospital beds, hospitals may increase capacity by either adding beds or by more efficiently using existing beds. Operations management principles have been applied to healthcare to ensure efficient use of beds. These include: reducing variability of scheduled admissions, remeasuring length of stay (LOS) and bed demand after implementing strategies to reduce practice variation, and employing queuing theory to generate predictions of optimal beds needed.6 The Joint Commission implemented a leadership standard (LD 04.03.11) that hospitals develop and implement plans to identify and mitigate impediments to efficient patient flow through the hospital.
To improve access, hospital leaders expect hospitalists to staff in inpatient medicine programs, surgical comanagement, short stay and chest pain units, and active bed management.7 In the following review, we define hospitalists' roles in the aforementioned programs and their effect on patient flow. We also touch on preoperative clinics, palliative care, geographic rounding, and flexible staffing models.
ACUTE INPATIENT CARE
Hospitalists are one of the fastest growing physician groups in the United States.810 Hospitalists improve efficiency and quality of care across a variety of demographic, geographic, and healthcare settings.11, 12 A 2002 retrospective cohort study in a community‐based urban teaching hospital showed that hospitalists decreased LOS by 0.61 days and lowered risk for death in the hospital (adjusted relative hazard, 0.71; 95% confidence interval [CI], 0.540.93).13 A 2004 prospective quasi‐experimental observational study done at an academic teaching hospital showed an adjusted LOS that was 16.2% lower, and adjusted cost 9.7% lower, for patients on the hospitalists' service.14 In 2007, Lindenauer and colleagues found that a national sample of hospitalists decreased LOS by 0.4 days and lowered cost by $286 per patient.15 The findings of these individual studies were supported in a 2009 systematic review of 33 studies by Peterson which showed that hospitalists decrease LOS.16 In a recent study, Kuo and Goodwin showed that while hospitalists decrease LOS and cost, the patients they care for have higher Medicare costs after discharge by $322 per patient, and are more likely to be readmitted (odds ratio, 1.08; CI, 1.041.14).17
The hospitalist model of care continues to grow, and hospitalists will soon number as many as 30,000.18 For acute medical inpatients, the evidence suggests that hospitalists improve patient flow by decreasing LOS while improving other aspects of quality of care. However, Kuo and Goodwin's findings suggest that the transition of care from inpatient to outpatient settings still requires attention.17
SURGICAL COMANAGEMENT
The Society of Hospital Medicine (SHM) core competencies include perioperative medicine.19, 20 In the 2006 SHM national survey, 85% of hospital medicine groups indicated that they participated in surgical comanagement.21
Hospitalists have improved patient flow and outcomes for orthopedic patients. Hospitalist management of hip fracture patients decreases time to surgery and LOS compared to standard care.2224 Phy and colleagues studied 466 patients for 2 years after the inception of hospital medicine comanagement of surgical patients, and found that care by hospitalists decreased LOS by 2.2 days.22 In a retrospective study of 118 patients, Roy and colleagues found that hospitalist‐managed patients had shorter time to consultation and surgery, decreased LOS, and lower costs.23 In a retrospective cohort study, Batsis looked at mortality in 466 patients with hip fracture, and found no difference between hospitalist management and standard care.24 In patients undergoing elective hip and knee arthroplasty, Huddleston and colleagues reported that patients managed by hospitalists had fewer complications and shorter LOS. The nurses and orthopedic surgeons preferred the hospitalistorthopedist comanagement model.25
The benefits of hospitalist comanagement are not limited to adult patients undergoing orthopedic surgery. For high‐risk patients undergoing lower extremity reconstruction surgery, Pinzur and colleagues noted that LOS was shorter for a cohort of patients managed by hospitalists than for a group of historical controls not treated by hospitalists.26 Simon and colleagues studied comanagement for pediatric spinal fusion patients, and found a decrease in LOS from 6.5 to 4.8 days.27
Several factors should be considered in developing and implementing a successful comanagement program. Since comanagement duties may fall upon hospitalists in order to protect surgeons' time,28 hospital medicine groups should ensure adequate staffing prior to taking on additional services. Clear guidelines to delineate roles and responsibilities of the comanaging groups also need to be developed and implemented.29, 30
Comanaging may also involve additional training. Hospitalists who manage neurologic, neurosurgical, trauma, and psychiatric patients report being undertrained for such conditions.31, 32 Hospital medicine groups need to ensure training needs are met and supported. Given the successes of comanagement and the increasing complexity of surgical patients,33 this practice will likely expand to a greater variety of non‐medical patients.
SHORT STAY UNITS
In 2003, short stay units (SSU) were present in approximately 20% of US hospitals, with 11% of hospitals planning on opening one in the next year.34 SSU are designed to manage acute, self‐limited medical conditions that require brief staysusually less than 72 hours. Approximately 80% of SSU patients are discharged home, avoiding hospitalization.35 Historically, SSU have been under the domain of the ED; however, there is an emerging role for hospitalist‐run SSU.36
Despite demand for SSU, little research has been performed on hospitalist‐led SSU. In 2000, Abenhaim and colleagues showed that a hospitalist‐run SSU at a university‐affiliated teaching hospital had a shorter LOS and lower rates of complications and readmissions when compared to medicine teaching services.37 In 2008, Northwestern Memorial Hospital opened a 30‐bed hospitalist‐run SSU; for those patients, LOS decreased by 2 days.38 In 2010, Leykum and colleagues showed that a hospitalist‐run observation unit can decrease LOS from 2.4 days to 2.2 days.39 Careful selection of SSU patients is needed to obtain these results. Lucas and colleagues found that whether or not SSU patients required assistance of specialists was the strongest predictor of unsuccessful stays (>72 hours or inpatient conversion) in SSU.36
Whether SSU are run by hospital medicine or emergency medicine is decided at an institutional level. Location of SSU in a specifically designated area is crucial, as it allows physicians to round efficiently on patients and to work with staff trained in observation services. Development of admission criteria that include specific diagnoses which match hospitalists' scope of practice is also important (Table 1).32
| Evaluation of Diagnostic Syndromes | Treatment of Emergent Conditions |
|---|---|
| |
| Chest pain | Asthma |
| Abdominal pain | Congestive heart failure |
| Fever | Dehydration |
| Gastrointestinal bleed | Hypoglycemia or hyperglycemia |
| Syncope | Hypercalcemia |
| Dizziness | Atrial fibrillation |
| Headache | |
| Chest trauma | |
| Abdominal trauma | |
The protocol‐based and diagnosis‐specific nature of SSU may enhance quality of care through standardization. Future research may delineate the utility of SSU.
CHEST PAIN UNITS
In the United States, in 2004, approximately 6 million patients present annually to EDs with chest pain.40 Cost of care of patients unnecessarily admitted to coronary care units has been estimated to be nearly $3 billion annually.41 Still, as many as 3% of patients with acute myocardial infarction are discharged home.42 Chest pain units (CPU) were developed to facilitate evaluation of patients with chest pain, at low risk for acute coronary syndrome, without requiring inpatient admission. A number of studies have suggested that admission to a CPU is a safe and cost‐effective alternative to hospital admission.4348
CPU have traditionally been staffed by ED physicians and/or cardiologists. In a prepost study, Krantz and colleagues found that a CPU model, incorporating hospitalists at an academic public safety‐net hospital, decreased ED LOS with no difference in 30‐day cardiac event rate.49 Myers and colleagues created a hospitalist‐directed nonteaching service in an academic medical center to admit low‐risk chest pain patients. Patients admitted to the hospitalist service had a statistically significant lower median LOS (23 hours vs 33 hours) and approximately half the median hospital charges than those admitted to teaching services.50 At the same academic medical center, Bayley and colleagues showed that 91% of patients admitted for chest pain waited more than 3 hours for a bed. This adversely affected ED revenue by tying up beds, resulting in an estimated annual loss of $168,300 of hospital revenue. Creation of a hospitalist‐managed service for low‐acuity chest pain patients reduced hospital LOS by 7 hours.51 Somekh and colleagues demonstrated that a protocol‐driven, cardiologist‐run CPU results in a decreased LOS and readmission rate compared to usual care.52 In a non‐peer reviewed case study, Cox Health opened an 8‐bed, hospitalist‐led CPU in 2003. They decreased LOS from 72 to 18 hours, while increasing revenue by $2.5 million a year.53 These studies suggest that hospitalist‐run CPU can decrease LOS, increase revenue, and relieve ED overcrowding.
Development of a successful CPU depends upon clear inclusion/exclusion criteria; close collaboration among ED physicians, hospitalists, and cardiologists; the development of evidence‐based protocols, and the availability of stress testing.
ACTIVE BED MANAGEMENT
As of 2007, 90% of EDs were crowded beyond their capacity.2 ED crowding leads to ambulance diversion,54 which can delay care and increase mortality rates.55 One of the main causes of ED crowding is the boarding of admitted patients.56 Boarded, admitted patients have been shown to have decreased quality of care and patient satisfaction.35
Active bed management (ABM) by hospitalists can decrease ED diversion. Howell and colleagues instituted ABM where hospitalists, as active bed managers, facilitate placement of patients to their inpatient destinations to assist ED flow.57 This 24‐hour, hospitalist‐led, active bed management service decreased both ED LOS and ambulance diversion. The bed manager collaborated real‐time with medicine and ED attending physicians, nursing supervisors, and charge nurses to change patient care status, and assign and facilitate transfer of patients to appropriate units. These hospitalist bed managers were also empowered to activate additional resources when pre‐diversion rounds identified resource limitations and impending ED divert. They found overall ED LOS for admitted patients decreased by 98 minutes, while LOS for non‐admitted patients stayed the same. AMB decreased diversion due to critically ill and telemetry patients by 28% (786 hours), and diversion due to lower acuity patients by 6% (182 hours). This intervention proved cost‐effective. Three full‐time equivalent (FTE) hospitalists' salaries staff 1 active bed manager working 24/7. Nearly 1000 hours of diversion were avoided at an annual savings of $1086 per hour of diversion decreased.
ABM is a new frontier for hospitals in general, and hospitalists in particular. Chadaga and colleagues found that a hospital medicine‐ED team participating in active bed management, while caring for admitted patients boarded in the ED, can decrease ED diversion and improve patient flow. The percentage of patients transferred to a medicine floor and discharged within 8 hours was reduced by 67% (P < 0.01), while the number of discharges from the ED of admitted medicine patients increased by 61% (P < 0.001).58
To decrease initial investment, components of ABM (ED triage, bed assignment, discharge facilitation) can be instituted in parts. Hospital medicine groups with limited resources may only provide a triage service by phone for difficult ED cases. Bedside evaluations and collaboration with nursing staff to improve bed placement may be a next step, with floor and/or intensive care unit (ICU) rounds to facilitate early discharges as a final component.
OTHER AREAS
Preoperative Clinics
In 2005, SHM cited preoperative clinics as an important aspect of preoperative care.59 Sehgal and Wachter included preoperative clinics as an area for expanding the role of hospitalists in the United States.60 These clinics can decrease delays to surgery, LOS, and cancellations on the day of surgery.61 The Cleveland Clinic established the Internal Medicine Preoperative Assessment, Consultation, and Treatment (IMPACT) Center in 1997, and has decreased surgery delay rate by 49%.59 At Kaiser Bellflower Medical Center, a preoperative medicine service that provides preoperative screening decreased the number of surgical procedures cancelled on the day of surgery by more than half.62 Gates Hospitalists LLC's perioperative care decreased delay to surgery and lost operating room time.63 In order for a preoperative service to be successful, there must be buy‐in from hospitalists, surgeons, and primary care physicians, as well as adequate staffing and clinical support.59
Palliative Care
Palliative care has been identified by SHM as a core competency in hospital medicine.64 There are several key components in delivery of quality palliative care, including communication about prognosis, pain and symptom control, and hospice eligibility.65 Hospitalists are in a unique position to offer and improve palliative care for hospitalized patients. The majority of hospitalists report spending significant amounts of time caring for dying patients; thereby, hospitalists frequently provide end‐of‐life care.66, 67 Compared to community‐based physicians, patients cared for by hospitalists have higher odds of having documented family discussions regarding end‐of‐life care, and have fewer or no key symptoms (pain, anxiety, or dyspnea).66 In addition, hospitalists' availability improves response time when a patient's clinical status changes or deteriorates, leading to prompter delivery of symptom alleviation.65 Hospitalists are becoming more experienced with end‐of‐life care, as they are exposed to terminally ill patients on a daily basis. More experience leads to improved recognition of patients with limited prognosis, which leads to earlier discussions about goals of care and faster delivery of palliative care. Perhaps this could decrease LOS and be a future area of study.
Geographic Rounding
In the last 5 years, hospital administrators have promoted geographic rounding, where hospitalists see all their patients in 1 geographic location.69 The driving forces behind this include poor patient satisfaction with physician availability, large amounts of time spent by hospitalists in transit to and from patient locations, and frustrations regarding communication with nursing.70 Several groups have instituted this with success. Cleveland Clinic and Virtua Memorial Hospital have found improved patient satisfaction and decreased LOS.69, 70 O'Leary and colleagues found improved awareness of care plans by the entire team.71 Caution should be taken to assure proper physician‐to‐patient ratios, avoid physician isolation, and coordinate physician shifts with bed assignments.69 To address some of these issues, groups have used a hybrid model where a hospitalist is primarily located on one unit but can flex or overflow onto another unit.70 Steps to success with geographic rounding include buy‐in from the institution and nursing, assuring a safe physician‐to‐patient ratio, avoiding wasted beds, and facilitating multidisciplinary rounds.69
Flexible Staffing Models
In SHM's 2010 State of Hospital Medicine Report, 70% of hospitalist groups used a fixed shift‐based staffing model (ie, 7 days on/7 days off).72 Flexible staffing models in which physician coverage is adjusted to patient volume are growing in popularity. This model can be tailored for each institution by examining admission and patient volume trends to increase coverage during busy periods and decrease coverage during slower periods. Potential benefits include alleviating burn out, reducing LOS, and improving patient outcomes. Nursing data suggests that a higher patient‐to‐nursing ratio is associated with increased 30‐day mortality,73 and an ED study found that increasing physician coverage during the evening shift shortened ED LOS by 20%.74 To date, none of these endpoints have been studied for hospital medicine.
CONCLUSION
While many hospital medicine groups were started to provide acute inpatient medical care, most have found that their value to hospitals reaches beyond bedside care. With an epidemic of ED diversion and lack of access to hospital beds and services, optimizing throughput has become imperative for hospital systems. While hospital access can be improved with addition of new beds, improving throughput by decreasing LOS maximizes utilization of existing resources.
We have reviewed how hospitalists improve patient flow in acute inpatient medicine, surgical comanagement, short stay units, chest pain units, and active bed management. In each instance, the literature supports measures for decreasing LOS while maintaining or improving quality of care. Hinami and colleagues showed physician satisfaction with hospitalist‐provided patient care.75 Most studies have been limited by tracking upstream effects of improved efficiency. As there is now some evidence that decreasing LOS may increase readmissions,17 future studies should incorporate this metric into their outcomes. The effect of formal operations management principles on patient flow and bed efficiency is not well known and should be further examined.
In addition, we have touched on other areas (perioperative clinics, palliative care, geographic rounding, and flexible staffing models) where hospitalists may impact patient throughput. These areas represent excellent opportunities for future research.
Hospitalist participation in many of these areas is in its infancy. Hospital medicine programs interested in expanding their services, beyond acute inpatient care, have the opportunity to develop standards and continue research on the effect of hospital medicine‐led services on patient care and flow.
Acknowledgements
Disclosure: All authors disclose no relevant or financial conflicts of interest.
Hospitalists are physicians whose primary focus is the general medical care of hospitalized patients. Hospitalists are uniquely positioned to implement strategies to improve patient flow and efficiency.1 With emergency department (ED) diversion reaching rates upward of 70%, lack of access to inpatient beds leads to delayed care with worsened outcomes.25
To improve access to hospital beds, hospitals may increase capacity by either adding beds or by more efficiently using existing beds. Operations management principles have been applied to healthcare to ensure efficient use of beds. These include: reducing variability of scheduled admissions, remeasuring length of stay (LOS) and bed demand after implementing strategies to reduce practice variation, and employing queuing theory to generate predictions of optimal beds needed.6 The Joint Commission implemented a leadership standard (LD 04.03.11) that hospitals develop and implement plans to identify and mitigate impediments to efficient patient flow through the hospital.
To improve access, hospital leaders expect hospitalists to staff in inpatient medicine programs, surgical comanagement, short stay and chest pain units, and active bed management.7 In the following review, we define hospitalists' roles in the aforementioned programs and their effect on patient flow. We also touch on preoperative clinics, palliative care, geographic rounding, and flexible staffing models.
ACUTE INPATIENT CARE
Hospitalists are one of the fastest growing physician groups in the United States.810 Hospitalists improve efficiency and quality of care across a variety of demographic, geographic, and healthcare settings.11, 12 A 2002 retrospective cohort study in a community‐based urban teaching hospital showed that hospitalists decreased LOS by 0.61 days and lowered risk for death in the hospital (adjusted relative hazard, 0.71; 95% confidence interval [CI], 0.540.93).13 A 2004 prospective quasi‐experimental observational study done at an academic teaching hospital showed an adjusted LOS that was 16.2% lower, and adjusted cost 9.7% lower, for patients on the hospitalists' service.14 In 2007, Lindenauer and colleagues found that a national sample of hospitalists decreased LOS by 0.4 days and lowered cost by $286 per patient.15 The findings of these individual studies were supported in a 2009 systematic review of 33 studies by Peterson which showed that hospitalists decrease LOS.16 In a recent study, Kuo and Goodwin showed that while hospitalists decrease LOS and cost, the patients they care for have higher Medicare costs after discharge by $322 per patient, and are more likely to be readmitted (odds ratio, 1.08; CI, 1.041.14).17
The hospitalist model of care continues to grow, and hospitalists will soon number as many as 30,000.18 For acute medical inpatients, the evidence suggests that hospitalists improve patient flow by decreasing LOS while improving other aspects of quality of care. However, Kuo and Goodwin's findings suggest that the transition of care from inpatient to outpatient settings still requires attention.17
SURGICAL COMANAGEMENT
The Society of Hospital Medicine (SHM) core competencies include perioperative medicine.19, 20 In the 2006 SHM national survey, 85% of hospital medicine groups indicated that they participated in surgical comanagement.21
Hospitalists have improved patient flow and outcomes for orthopedic patients. Hospitalist management of hip fracture patients decreases time to surgery and LOS compared to standard care.2224 Phy and colleagues studied 466 patients for 2 years after the inception of hospital medicine comanagement of surgical patients, and found that care by hospitalists decreased LOS by 2.2 days.22 In a retrospective study of 118 patients, Roy and colleagues found that hospitalist‐managed patients had shorter time to consultation and surgery, decreased LOS, and lower costs.23 In a retrospective cohort study, Batsis looked at mortality in 466 patients with hip fracture, and found no difference between hospitalist management and standard care.24 In patients undergoing elective hip and knee arthroplasty, Huddleston and colleagues reported that patients managed by hospitalists had fewer complications and shorter LOS. The nurses and orthopedic surgeons preferred the hospitalistorthopedist comanagement model.25
The benefits of hospitalist comanagement are not limited to adult patients undergoing orthopedic surgery. For high‐risk patients undergoing lower extremity reconstruction surgery, Pinzur and colleagues noted that LOS was shorter for a cohort of patients managed by hospitalists than for a group of historical controls not treated by hospitalists.26 Simon and colleagues studied comanagement for pediatric spinal fusion patients, and found a decrease in LOS from 6.5 to 4.8 days.27
Several factors should be considered in developing and implementing a successful comanagement program. Since comanagement duties may fall upon hospitalists in order to protect surgeons' time,28 hospital medicine groups should ensure adequate staffing prior to taking on additional services. Clear guidelines to delineate roles and responsibilities of the comanaging groups also need to be developed and implemented.29, 30
Comanaging may also involve additional training. Hospitalists who manage neurologic, neurosurgical, trauma, and psychiatric patients report being undertrained for such conditions.31, 32 Hospital medicine groups need to ensure training needs are met and supported. Given the successes of comanagement and the increasing complexity of surgical patients,33 this practice will likely expand to a greater variety of non‐medical patients.
SHORT STAY UNITS
In 2003, short stay units (SSU) were present in approximately 20% of US hospitals, with 11% of hospitals planning on opening one in the next year.34 SSU are designed to manage acute, self‐limited medical conditions that require brief staysusually less than 72 hours. Approximately 80% of SSU patients are discharged home, avoiding hospitalization.35 Historically, SSU have been under the domain of the ED; however, there is an emerging role for hospitalist‐run SSU.36
Despite demand for SSU, little research has been performed on hospitalist‐led SSU. In 2000, Abenhaim and colleagues showed that a hospitalist‐run SSU at a university‐affiliated teaching hospital had a shorter LOS and lower rates of complications and readmissions when compared to medicine teaching services.37 In 2008, Northwestern Memorial Hospital opened a 30‐bed hospitalist‐run SSU; for those patients, LOS decreased by 2 days.38 In 2010, Leykum and colleagues showed that a hospitalist‐run observation unit can decrease LOS from 2.4 days to 2.2 days.39 Careful selection of SSU patients is needed to obtain these results. Lucas and colleagues found that whether or not SSU patients required assistance of specialists was the strongest predictor of unsuccessful stays (>72 hours or inpatient conversion) in SSU.36
Whether SSU are run by hospital medicine or emergency medicine is decided at an institutional level. Location of SSU in a specifically designated area is crucial, as it allows physicians to round efficiently on patients and to work with staff trained in observation services. Development of admission criteria that include specific diagnoses which match hospitalists' scope of practice is also important (Table 1).32
| Evaluation of Diagnostic Syndromes | Treatment of Emergent Conditions |
|---|---|
| |
| Chest pain | Asthma |
| Abdominal pain | Congestive heart failure |
| Fever | Dehydration |
| Gastrointestinal bleed | Hypoglycemia or hyperglycemia |
| Syncope | Hypercalcemia |
| Dizziness | Atrial fibrillation |
| Headache | |
| Chest trauma | |
| Abdominal trauma | |
The protocol‐based and diagnosis‐specific nature of SSU may enhance quality of care through standardization. Future research may delineate the utility of SSU.
CHEST PAIN UNITS
In the United States, in 2004, approximately 6 million patients present annually to EDs with chest pain.40 Cost of care of patients unnecessarily admitted to coronary care units has been estimated to be nearly $3 billion annually.41 Still, as many as 3% of patients with acute myocardial infarction are discharged home.42 Chest pain units (CPU) were developed to facilitate evaluation of patients with chest pain, at low risk for acute coronary syndrome, without requiring inpatient admission. A number of studies have suggested that admission to a CPU is a safe and cost‐effective alternative to hospital admission.4348
CPU have traditionally been staffed by ED physicians and/or cardiologists. In a prepost study, Krantz and colleagues found that a CPU model, incorporating hospitalists at an academic public safety‐net hospital, decreased ED LOS with no difference in 30‐day cardiac event rate.49 Myers and colleagues created a hospitalist‐directed nonteaching service in an academic medical center to admit low‐risk chest pain patients. Patients admitted to the hospitalist service had a statistically significant lower median LOS (23 hours vs 33 hours) and approximately half the median hospital charges than those admitted to teaching services.50 At the same academic medical center, Bayley and colleagues showed that 91% of patients admitted for chest pain waited more than 3 hours for a bed. This adversely affected ED revenue by tying up beds, resulting in an estimated annual loss of $168,300 of hospital revenue. Creation of a hospitalist‐managed service for low‐acuity chest pain patients reduced hospital LOS by 7 hours.51 Somekh and colleagues demonstrated that a protocol‐driven, cardiologist‐run CPU results in a decreased LOS and readmission rate compared to usual care.52 In a non‐peer reviewed case study, Cox Health opened an 8‐bed, hospitalist‐led CPU in 2003. They decreased LOS from 72 to 18 hours, while increasing revenue by $2.5 million a year.53 These studies suggest that hospitalist‐run CPU can decrease LOS, increase revenue, and relieve ED overcrowding.
Development of a successful CPU depends upon clear inclusion/exclusion criteria; close collaboration among ED physicians, hospitalists, and cardiologists; the development of evidence‐based protocols, and the availability of stress testing.
ACTIVE BED MANAGEMENT
As of 2007, 90% of EDs were crowded beyond their capacity.2 ED crowding leads to ambulance diversion,54 which can delay care and increase mortality rates.55 One of the main causes of ED crowding is the boarding of admitted patients.56 Boarded, admitted patients have been shown to have decreased quality of care and patient satisfaction.35
Active bed management (ABM) by hospitalists can decrease ED diversion. Howell and colleagues instituted ABM where hospitalists, as active bed managers, facilitate placement of patients to their inpatient destinations to assist ED flow.57 This 24‐hour, hospitalist‐led, active bed management service decreased both ED LOS and ambulance diversion. The bed manager collaborated real‐time with medicine and ED attending physicians, nursing supervisors, and charge nurses to change patient care status, and assign and facilitate transfer of patients to appropriate units. These hospitalist bed managers were also empowered to activate additional resources when pre‐diversion rounds identified resource limitations and impending ED divert. They found overall ED LOS for admitted patients decreased by 98 minutes, while LOS for non‐admitted patients stayed the same. AMB decreased diversion due to critically ill and telemetry patients by 28% (786 hours), and diversion due to lower acuity patients by 6% (182 hours). This intervention proved cost‐effective. Three full‐time equivalent (FTE) hospitalists' salaries staff 1 active bed manager working 24/7. Nearly 1000 hours of diversion were avoided at an annual savings of $1086 per hour of diversion decreased.
ABM is a new frontier for hospitals in general, and hospitalists in particular. Chadaga and colleagues found that a hospital medicine‐ED team participating in active bed management, while caring for admitted patients boarded in the ED, can decrease ED diversion and improve patient flow. The percentage of patients transferred to a medicine floor and discharged within 8 hours was reduced by 67% (P < 0.01), while the number of discharges from the ED of admitted medicine patients increased by 61% (P < 0.001).58
To decrease initial investment, components of ABM (ED triage, bed assignment, discharge facilitation) can be instituted in parts. Hospital medicine groups with limited resources may only provide a triage service by phone for difficult ED cases. Bedside evaluations and collaboration with nursing staff to improve bed placement may be a next step, with floor and/or intensive care unit (ICU) rounds to facilitate early discharges as a final component.
OTHER AREAS
Preoperative Clinics
In 2005, SHM cited preoperative clinics as an important aspect of preoperative care.59 Sehgal and Wachter included preoperative clinics as an area for expanding the role of hospitalists in the United States.60 These clinics can decrease delays to surgery, LOS, and cancellations on the day of surgery.61 The Cleveland Clinic established the Internal Medicine Preoperative Assessment, Consultation, and Treatment (IMPACT) Center in 1997, and has decreased surgery delay rate by 49%.59 At Kaiser Bellflower Medical Center, a preoperative medicine service that provides preoperative screening decreased the number of surgical procedures cancelled on the day of surgery by more than half.62 Gates Hospitalists LLC's perioperative care decreased delay to surgery and lost operating room time.63 In order for a preoperative service to be successful, there must be buy‐in from hospitalists, surgeons, and primary care physicians, as well as adequate staffing and clinical support.59
Palliative Care
Palliative care has been identified by SHM as a core competency in hospital medicine.64 There are several key components in delivery of quality palliative care, including communication about prognosis, pain and symptom control, and hospice eligibility.65 Hospitalists are in a unique position to offer and improve palliative care for hospitalized patients. The majority of hospitalists report spending significant amounts of time caring for dying patients; thereby, hospitalists frequently provide end‐of‐life care.66, 67 Compared to community‐based physicians, patients cared for by hospitalists have higher odds of having documented family discussions regarding end‐of‐life care, and have fewer or no key symptoms (pain, anxiety, or dyspnea).66 In addition, hospitalists' availability improves response time when a patient's clinical status changes or deteriorates, leading to prompter delivery of symptom alleviation.65 Hospitalists are becoming more experienced with end‐of‐life care, as they are exposed to terminally ill patients on a daily basis. More experience leads to improved recognition of patients with limited prognosis, which leads to earlier discussions about goals of care and faster delivery of palliative care. Perhaps this could decrease LOS and be a future area of study.
Geographic Rounding
In the last 5 years, hospital administrators have promoted geographic rounding, where hospitalists see all their patients in 1 geographic location.69 The driving forces behind this include poor patient satisfaction with physician availability, large amounts of time spent by hospitalists in transit to and from patient locations, and frustrations regarding communication with nursing.70 Several groups have instituted this with success. Cleveland Clinic and Virtua Memorial Hospital have found improved patient satisfaction and decreased LOS.69, 70 O'Leary and colleagues found improved awareness of care plans by the entire team.71 Caution should be taken to assure proper physician‐to‐patient ratios, avoid physician isolation, and coordinate physician shifts with bed assignments.69 To address some of these issues, groups have used a hybrid model where a hospitalist is primarily located on one unit but can flex or overflow onto another unit.70 Steps to success with geographic rounding include buy‐in from the institution and nursing, assuring a safe physician‐to‐patient ratio, avoiding wasted beds, and facilitating multidisciplinary rounds.69
Flexible Staffing Models
In SHM's 2010 State of Hospital Medicine Report, 70% of hospitalist groups used a fixed shift‐based staffing model (ie, 7 days on/7 days off).72 Flexible staffing models in which physician coverage is adjusted to patient volume are growing in popularity. This model can be tailored for each institution by examining admission and patient volume trends to increase coverage during busy periods and decrease coverage during slower periods. Potential benefits include alleviating burn out, reducing LOS, and improving patient outcomes. Nursing data suggests that a higher patient‐to‐nursing ratio is associated with increased 30‐day mortality,73 and an ED study found that increasing physician coverage during the evening shift shortened ED LOS by 20%.74 To date, none of these endpoints have been studied for hospital medicine.
CONCLUSION
While many hospital medicine groups were started to provide acute inpatient medical care, most have found that their value to hospitals reaches beyond bedside care. With an epidemic of ED diversion and lack of access to hospital beds and services, optimizing throughput has become imperative for hospital systems. While hospital access can be improved with addition of new beds, improving throughput by decreasing LOS maximizes utilization of existing resources.
We have reviewed how hospitalists improve patient flow in acute inpatient medicine, surgical comanagement, short stay units, chest pain units, and active bed management. In each instance, the literature supports measures for decreasing LOS while maintaining or improving quality of care. Hinami and colleagues showed physician satisfaction with hospitalist‐provided patient care.75 Most studies have been limited by tracking upstream effects of improved efficiency. As there is now some evidence that decreasing LOS may increase readmissions,17 future studies should incorporate this metric into their outcomes. The effect of formal operations management principles on patient flow and bed efficiency is not well known and should be further examined.
In addition, we have touched on other areas (perioperative clinics, palliative care, geographic rounding, and flexible staffing models) where hospitalists may impact patient throughput. These areas represent excellent opportunities for future research.
Hospitalist participation in many of these areas is in its infancy. Hospital medicine programs interested in expanding their services, beyond acute inpatient care, have the opportunity to develop standards and continue research on the effect of hospital medicine‐led services on patient care and flow.
Acknowledgements
Disclosure: All authors disclose no relevant or financial conflicts of interest.
- SHM Benchmarks Committee. Maximizing throughput and improving patient flow. The Hospitalist, Supplement: How Hospitalists Add Value. Philadelphia, PA: Society of Hospital Medicine; 2005. Available online at http://www.the‐hospitalist.org/details/article/279433/Maximizing_Throughput_and_Improving_Patient_Flow.html. Accessed on July 2009.
- Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. Hospital‐Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press; 2007.
- , . Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008;51:1–5.
- , , , et al. The impact of emergency department crowding measures on time to antibiotics for patients with community‐acquired pneumonia. Ann Emerg Med. 2007;50:510–516.
- , , , , ; for the DELAYED‐ED Study Group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35:1477–1483.
- . Managing Patient Flow in Hospitals: Strategies and Solutions, 2nd ed. In: Beurhaus P, Rudolph M, Prenney B, et al, eds. Joint Commission Resources, Joint Commission Resources, Inc., 2009.
- , , , . California hospital leader's view of hospitalists: meeting needs of the present and the future. J Hosp Med. 2009;4(9):528–534.
- , . The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514–517.
- , , , et al. Trends in market demand for internal medicine 1999–2004: an analysis of physician job advertisements. J Gen Intern Med. 2006;21:1079–1085.
- , , , et al. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343–349.
- , , , et al. Reorganizing an academic medical service impact on cost, quality, patient satisfaction, and education. JAMA. 1998;279:1560–1565.
- , . The hospitalist movement 5 years later. JAMA. 2002;287:487–494.
- , , , , , . Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137(11):859–865.
- , , . Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004;10(8):561–568.
- , , , et al. Outcomes of care by hospitalists, general internists and family physicians. N Engl J Med. 2007;357(25):2589–2600.
- . Systematic review of outcomes and quality measures in adult patients cared for by hospitalists vs nonhospitalists. Mayo Clin Proc. 2009;84(3):248–254.
- , . Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152–159.
- , , , et al. The potential size of the hospitalist workforce in the United States. Am Med. 1999;106(4):441–445.
- , . Surgical co‐management: a natural evolution of hospitalist practice. J Hosp Med. 2008;3:394–397.
- , , , et al. The core competencies in hospital medicine: a framework for curriculum development. J Hosp Med. 2006;1(suppl 1):1–30.
- Society of Hospital Medicine. Co‐Management Task Force Page. Available at: http://www.hospitalmedicine.org/AM/Template.cfm? Section=Home165(7):796–801.
- , , , et al. Associations between the hospitalist model of care and quality‐of‐care‐related outcomes in patients undergoing hip fracture surgery. Mayo Clin Proc. 2006;81(1):28–31.
- . Effects of a hospitalist care model on mortality of elderly patients with hip fractures. J Hosp Med. 2007;2(4):219–225.
- , , , et al; for the Hospital‐Orthopedic Team Trial Investigators. Medical and surgical co‐management after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141(1):28–38.
- , , , et al. Hospitalist‐orthopedic co‐management of high‐risk patients undergoing lower extremity reconstruction surgery. Orthopedics. 2009;32(7):495.
- , , , et al. Pediatric hospitalist co‐management of spinal fusion surgery patients. J Hosp Med. 2007;2:23–29.
- . Just because you can, doesn't mean that you should: a call for the rational application of hospitalist co‐management. J Hosp Med. 2008;3:398–402.
- Society of Hospital Medicine. SHM White Paper: Co‐Management White Paper. Philadelphia, PA: 2010.
- American Medical Association, Council on Ethical and Judicial Affairs. CEJA Report 5–I‐99. Ethical Implications of Surgical Co‐Management. Available at: http://www.ama‐assn.org/resources/doc/code‐medical‐ethics/8043a.pdf. Accessed November 17, 2011.
- , , , et al. Hospitalist care and length of stay in patients requiring complex discharge planning and close clinical monitoring. Arch Intern Med. 2007;167:1869–1874.
- , , , et al. Hospitalist's perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111:247–254.
- , . Why perioperative medicine matters more than ever. Cleve Clin J Med. 2006;73(supp 1):S1.
- , , , et al. A national survey of observation units in the United States. Am J Emerg Med. 2003;12:529–533.
- Society of Hospital Medicine. SHM White Paper: Observation Unit White Paper. Philadelphia, PA: 2009.
- , , , et al. A hospitalist‐run short‐stay unit: features that predict length‐of‐stay and eventual admission to traditional inpatient services. J Hosp Med. 2009;4(5):276–284.
- , , , . Program description: a hospitalist‐run medical short‐stay unit in a teaching hospital. Can Med Assoc J. 2000:163(11):1477–1480.
- . Hospitalists can cut ED overcrowding. ACEP News. 2010.
- , , . Implementation of a hospitalist‐run observation unit and impact on length of stay (LOS): a brief report. J Hosp Med. 2010;5(9):E2–E5.
- , . National Hospital Ambulatory Medical Care survey: 2004 emergency department summary. Adv Data. 2006;23:1–29.
- , . Identification of chest pain patients appropriate for an emergency department observation unit. Emerg Med Clin North Am. 2001;19:35–66.
- , , . Stress testing for risk stratification of patients with low to moderate probability of acute cardiac ischemia. Emerg Med Clin North Am. 2001;19:87–103.
- , , , et al. An evaluation of a chest pain diagnostic protocol to exclude acute cardiac ischemia in the emergency department. Arch Intern Med. 1997;157:1085–1091.
- , , . The Chest Pain Evaluation Center at the University of Maryland Medical Center. Md Med J. 1994;43:1047–1052.
- , , , , . Cost effectiveness of mandatory stress testing in chest pain center patients. Ann Emerg Med. 1997;29:88–98.
- , , , et al. A rapid diagnostic and treatment center for patients with chest pain in the emergency department. Ann Emerg Med. 1995;25:1–8.
- , , , , . An emergency department‐based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results of a randomized study (ROMIO). J Am Coll Cardiol. 1996;28:25–33.
- , , , et al. Randomized controlled trial and economic evaluation of a chest pain observation unit compared with routine care. BMJ. 2004;328:254.
- , , , et al. A cooperative care model: cardiologists and hospitalists reduce length of stay in a chest pain observation unit. Crit Pathw Cardiol. 2005;4(2):55–58.
- , , , et al. Improving resource utilization in a teaching hospital: development of a nonteaching service for chest pain admissions. Acad Med. 2006;81(5):432–435.
- , , , et al. The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission. Ann Emerg Med. 2005;45(2):110–117.
- , , , , . Differences in diagnostic evaluation and clinical outcomes in the care of patients with chest pain based on admitting service: the benefits of a dedicated chest pain unit. J Nucl Cardiol. 2008;15(2):186–192.
- . Taking charge of observation units. Today's Hospitalist. July 2007.
- , , . Access block cause emergency department overcrowding and ambulance diversion in Perth, Western Australia. Emerg Med J. 2005;22:351–354.
- , , , . The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007;24:665–668.
- , . Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52:126–136.
- , , , , , . Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149:804–810.
- , , , et al. A hospitalist‐led emergency department team improves hospital bed efficiency. J Hosp Med. 2010;5(suppl 1):17–18.
- Society of Hospital Medicine. Perioperative care (a special supplement to The Hospitalist). Philadelphia, PA: Society of Hospital Medicine; 2005. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home136:591–596.
- Hospitalist Management Advisor. Hospitalist branch into preoperative medicine with preop assessments. Marblehead, MA: HCPro, 2006. Available at: http://www.hcpro.com/HOM‐57460–3615/Hospitalists‐branch‐into‐perioperative‐medicine‐with‐preop‐assessments.html. Accessed February 15, 2012.
- . The preoperative medicine service: an innovative practice at Kaiser Bellflower Medical Center. The Permanente Journal. 2002;6:13–16.
- . A preop evaluation service delivers unexpected benefits. Today's Hospitalist. January 2008.
- , , , , . The core competencies in hospital medicine: a framework for curriculum development. J Hosp Med. 2006;1:1–67.
- , , , , , . Common myths about caring for patients with terminal illness: opportunities to improve care in the hospital setting. J Hosp Med. 2007;2:357–365.
- . End‐of‐life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004;116:669–675.
- , , , . Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343–349.
- , . Palliative care and hospitalist: an opportunity for cross‐fertilization. Am J Med. 2001;111(suppl):10S–14S.
- . Giving hospitalists their space. ACP Hospitalist. February 2008.
- . Having problems findings your patients? Today's Hospitalists. June 2010.
- , , , et al. Impact of localizing physicians to hospital units on nurse–physician communication and agreement on the plan of care. J Gen Intern Med. 24(11):1223–1227.
- Medical Group Management Association and Society of Hospital Medicine (SHM). State of Hospital Medicine 2010 Report Based on 2009. Available online at http://www.mgma.com/store/Surveys‐and‐Benchmarking/State‐of‐Hospital‐Medicine‐2010‐Report‐Based‐on‐2009 ‐Data‐Print‐Edition/.
- , , , et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987–1993.
- , . Reduced length of stay in medical emergency department patients: a prospective controlled study on emergency physician staffing. Eur J Emerg Med. 2004;11(1):29–34.
- , , , . Provider expectations and experiences of comanagement. J Hosp Med. 2011;6(7):401–404.
- SHM Benchmarks Committee. Maximizing throughput and improving patient flow. The Hospitalist, Supplement: How Hospitalists Add Value. Philadelphia, PA: Society of Hospital Medicine; 2005. Available online at http://www.the‐hospitalist.org/details/article/279433/Maximizing_Throughput_and_Improving_Patient_Flow.html. Accessed on July 2009.
- Institute of Medicine, Committee on the Future of Emergency Care in the United States Health System. Hospital‐Based Emergency Care: At the Breaking Point. Washington, DC: National Academies Press; 2007.
- , . Emergency department crowding is associated with poor care for patients with severe pain. Ann Emerg Med. 2008;51:1–5.
- , , , et al. The impact of emergency department crowding measures on time to antibiotics for patients with community‐acquired pneumonia. Ann Emerg Med. 2007;50:510–516.
- , , , , ; for the DELAYED‐ED Study Group. Impact of delayed transfer of critically ill patients from the emergency department to the intensive care unit. Crit Care Med. 2007;35:1477–1483.
- . Managing Patient Flow in Hospitals: Strategies and Solutions, 2nd ed. In: Beurhaus P, Rudolph M, Prenney B, et al, eds. Joint Commission Resources, Joint Commission Resources, Inc., 2009.
- , , , . California hospital leader's view of hospitalists: meeting needs of the present and the future. J Hosp Med. 2009;4(9):528–534.
- , . The emerging role of “hospitalists” in the American health care system. N Engl J Med. 1996;335:514–517.
- , , , et al. Trends in market demand for internal medicine 1999–2004: an analysis of physician job advertisements. J Gen Intern Med. 2006;21:1079–1085.
- , , , et al. Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343–349.
- , , , et al. Reorganizing an academic medical service impact on cost, quality, patient satisfaction, and education. JAMA. 1998;279:1560–1565.
- , . The hospitalist movement 5 years later. JAMA. 2002;287:487–494.
- , , , , , . Implementation of a voluntary hospitalist service at a community teaching hospital: improved clinical efficiency and patient outcomes. Ann Intern Med. 2002;137(11):859–865.
- , , . Associations with reduced length of stay and costs on an academic hospitalist service. Am J Manag Care. 2004;10(8):561–568.
- , , , et al. Outcomes of care by hospitalists, general internists and family physicians. N Engl J Med. 2007;357(25):2589–2600.
- . Systematic review of outcomes and quality measures in adult patients cared for by hospitalists vs nonhospitalists. Mayo Clin Proc. 2009;84(3):248–254.
- , . Association of hospitalist care with medical utilization after discharge: evidence of cost shift from a cohort study. Ann Intern Med. 2011;155:152–159.
- , , , et al. The potential size of the hospitalist workforce in the United States. Am Med. 1999;106(4):441–445.
- , . Surgical co‐management: a natural evolution of hospitalist practice. J Hosp Med. 2008;3:394–397.
- , , , et al. The core competencies in hospital medicine: a framework for curriculum development. J Hosp Med. 2006;1(suppl 1):1–30.
- Society of Hospital Medicine. Co‐Management Task Force Page. Available at: http://www.hospitalmedicine.org/AM/Template.cfm? Section=Home165(7):796–801.
- , , , et al. Associations between the hospitalist model of care and quality‐of‐care‐related outcomes in patients undergoing hip fracture surgery. Mayo Clin Proc. 2006;81(1):28–31.
- . Effects of a hospitalist care model on mortality of elderly patients with hip fractures. J Hosp Med. 2007;2(4):219–225.
- , , , et al; for the Hospital‐Orthopedic Team Trial Investigators. Medical and surgical co‐management after elective hip and knee arthroplasty: a randomized, controlled trial. Ann Intern Med. 2004;141(1):28–38.
- , , , et al. Hospitalist‐orthopedic co‐management of high‐risk patients undergoing lower extremity reconstruction surgery. Orthopedics. 2009;32(7):495.
- , , , et al. Pediatric hospitalist co‐management of spinal fusion surgery patients. J Hosp Med. 2007;2:23–29.
- . Just because you can, doesn't mean that you should: a call for the rational application of hospitalist co‐management. J Hosp Med. 2008;3:398–402.
- Society of Hospital Medicine. SHM White Paper: Co‐Management White Paper. Philadelphia, PA: 2010.
- American Medical Association, Council on Ethical and Judicial Affairs. CEJA Report 5–I‐99. Ethical Implications of Surgical Co‐Management. Available at: http://www.ama‐assn.org/resources/doc/code‐medical‐ethics/8043a.pdf. Accessed November 17, 2011.
- , , , et al. Hospitalist care and length of stay in patients requiring complex discharge planning and close clinical monitoring. Arch Intern Med. 2007;167:1869–1874.
- , , , et al. Hospitalist's perceptions of their residency training needs: results of a national survey. Am J Med. 2001;111:247–254.
- , . Why perioperative medicine matters more than ever. Cleve Clin J Med. 2006;73(supp 1):S1.
- , , , et al. A national survey of observation units in the United States. Am J Emerg Med. 2003;12:529–533.
- Society of Hospital Medicine. SHM White Paper: Observation Unit White Paper. Philadelphia, PA: 2009.
- , , , et al. A hospitalist‐run short‐stay unit: features that predict length‐of‐stay and eventual admission to traditional inpatient services. J Hosp Med. 2009;4(5):276–284.
- , , , . Program description: a hospitalist‐run medical short‐stay unit in a teaching hospital. Can Med Assoc J. 2000:163(11):1477–1480.
- . Hospitalists can cut ED overcrowding. ACEP News. 2010.
- , , . Implementation of a hospitalist‐run observation unit and impact on length of stay (LOS): a brief report. J Hosp Med. 2010;5(9):E2–E5.
- , . National Hospital Ambulatory Medical Care survey: 2004 emergency department summary. Adv Data. 2006;23:1–29.
- , . Identification of chest pain patients appropriate for an emergency department observation unit. Emerg Med Clin North Am. 2001;19:35–66.
- , , . Stress testing for risk stratification of patients with low to moderate probability of acute cardiac ischemia. Emerg Med Clin North Am. 2001;19:87–103.
- , , , et al. An evaluation of a chest pain diagnostic protocol to exclude acute cardiac ischemia in the emergency department. Arch Intern Med. 1997;157:1085–1091.
- , , . The Chest Pain Evaluation Center at the University of Maryland Medical Center. Md Med J. 1994;43:1047–1052.
- , , , , . Cost effectiveness of mandatory stress testing in chest pain center patients. Ann Emerg Med. 1997;29:88–98.
- , , , et al. A rapid diagnostic and treatment center for patients with chest pain in the emergency department. Ann Emerg Med. 1995;25:1–8.
- , , , , . An emergency department‐based protocol for rapidly ruling out myocardial ischemia reduces hospital time and expense: results of a randomized study (ROMIO). J Am Coll Cardiol. 1996;28:25–33.
- , , , et al. Randomized controlled trial and economic evaluation of a chest pain observation unit compared with routine care. BMJ. 2004;328:254.
- , , , et al. A cooperative care model: cardiologists and hospitalists reduce length of stay in a chest pain observation unit. Crit Pathw Cardiol. 2005;4(2):55–58.
- , , , et al. Improving resource utilization in a teaching hospital: development of a nonteaching service for chest pain admissions. Acad Med. 2006;81(5):432–435.
- , , , et al. The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission. Ann Emerg Med. 2005;45(2):110–117.
- , , , , . Differences in diagnostic evaluation and clinical outcomes in the care of patients with chest pain based on admitting service: the benefits of a dedicated chest pain unit. J Nucl Cardiol. 2008;15(2):186–192.
- . Taking charge of observation units. Today's Hospitalist. July 2007.
- , , . Access block cause emergency department overcrowding and ambulance diversion in Perth, Western Australia. Emerg Med J. 2005;22:351–354.
- , , , . The relationship between distance to hospital and patient mortality in emergencies: an observational study. Emerg Med J. 2007;24:665–668.
- , . Systematic review of emergency department crowding: causes, effects, and solutions. Ann Emerg Med. 2008;52:126–136.
- , , , , , . Active bed management by hospitalists and emergency department throughput. Ann Intern Med. 2008;149:804–810.
- , , , et al. A hospitalist‐led emergency department team improves hospital bed efficiency. J Hosp Med. 2010;5(suppl 1):17–18.
- Society of Hospital Medicine. Perioperative care (a special supplement to The Hospitalist). Philadelphia, PA: Society of Hospital Medicine; 2005. Available at: http://www.hospitalmedicine.org/AM/Template.cfm?Section=Home136:591–596.
- Hospitalist Management Advisor. Hospitalist branch into preoperative medicine with preop assessments. Marblehead, MA: HCPro, 2006. Available at: http://www.hcpro.com/HOM‐57460–3615/Hospitalists‐branch‐into‐perioperative‐medicine‐with‐preop‐assessments.html. Accessed February 15, 2012.
- . The preoperative medicine service: an innovative practice at Kaiser Bellflower Medical Center. The Permanente Journal. 2002;6:13–16.
- . A preop evaluation service delivers unexpected benefits. Today's Hospitalist. January 2008.
- , , , , . The core competencies in hospital medicine: a framework for curriculum development. J Hosp Med. 2006;1:1–67.
- , , , , , . Common myths about caring for patients with terminal illness: opportunities to improve care in the hospital setting. J Hosp Med. 2007;2:357–365.
- . End‐of‐life care in a voluntary hospitalist model: effects on communication, processes of care, and patient symptoms. Am J Med. 2004;116:669–675.
- , , , . Hospitalists and the practice of inpatient medicine: results of a survey of the National Association of Inpatient Physicians. Ann Intern Med. 1999;130:343–349.
- , . Palliative care and hospitalist: an opportunity for cross‐fertilization. Am J Med. 2001;111(suppl):10S–14S.
- . Giving hospitalists their space. ACP Hospitalist. February 2008.
- . Having problems findings your patients? Today's Hospitalists. June 2010.
- , , , et al. Impact of localizing physicians to hospital units on nurse–physician communication and agreement on the plan of care. J Gen Intern Med. 24(11):1223–1227.
- Medical Group Management Association and Society of Hospital Medicine (SHM). State of Hospital Medicine 2010 Report Based on 2009. Available online at http://www.mgma.com/store/Surveys‐and‐Benchmarking/State‐of‐Hospital‐Medicine‐2010‐Report‐Based‐on‐2009 ‐Data‐Print‐Edition/.
- , , , et al. Hospital nurse staffing and patient mortality, nurse burnout, and job dissatisfaction. JAMA. 2002;288(16):1987–1993.
- , . Reduced length of stay in medical emergency department patients: a prospective controlled study on emergency physician staffing. Eur J Emerg Med. 2004;11(1):29–34.
- , , , . Provider expectations and experiences of comanagement. J Hosp Med. 2011;6(7):401–404.
In the Literature: Research You Need to Know
Clinical question: What is the current level of continuity of care, and what factors affect continuity of care in the hospital setting? Has this changed with increasing use of hospitalists and limits on residency duty hours?
Background: Outpatient continuity of care leads to lower costs, better quality of life, and less emergency room use. Recent changes in residency hours have increased hand-offs and decreased inpatient continuity, but to what extent is unknown.
Study design: Retrospective cohort of 5% of Medicare claims data (530,000 patients in all) from 1996 to 2006, including patients admitted for COPD, congestive heart failure, or pneumonia who were cared for by a general internist or family practitioner.
Setting: Nationwide in the U.S.
Synopsis: The authors defined patients as having a primary-care physician (PCP) if they had three billed visits with the PCP in the last year, hospitalists as those who derived at least 90% of their Medicare claims from inpatient billing, and other generalists as those who met criteria as a generalist but did not fit these categories. Inpatient continuity of care decreased to 59% of patients seeing a single physician in the hospital in 2006 from 71% in 1996, with an accompanying decrease in the length of stay of one full day. There were large variations by geographic region, population size, and hospital characteristics. Patients cared for by hospitalists had slightly better continuity of care than those cared for by nonhospitalist generalists, and those who were cared for by both hospitalists and nonhospitalist generalists had the worst continuity of care. Having a PCP was associated with increased discontinuity of care as an inpatient, perhaps because of individual members of a practice rounding on all of the practice’s inpatients.
Bottom line: Patients were 5% less likely per year between 1996 and 2006 to have a single physician be their primary caregiver in the hospital, but the rise of the hospitalist movement does not seem to be the cause.
Citation: Fletcher KE, Sharma G, Zhang D, Kuo YF, Goodwin JS. Trends in inpatient continuity of care for a cohort of Medicare patients 1996-2006. J Hosp Med. 2011;6:441-447.
For more physician reviews of HM-relevant literature, visit our website.
Clinical question: What is the current level of continuity of care, and what factors affect continuity of care in the hospital setting? Has this changed with increasing use of hospitalists and limits on residency duty hours?
Background: Outpatient continuity of care leads to lower costs, better quality of life, and less emergency room use. Recent changes in residency hours have increased hand-offs and decreased inpatient continuity, but to what extent is unknown.
Study design: Retrospective cohort of 5% of Medicare claims data (530,000 patients in all) from 1996 to 2006, including patients admitted for COPD, congestive heart failure, or pneumonia who were cared for by a general internist or family practitioner.
Setting: Nationwide in the U.S.
Synopsis: The authors defined patients as having a primary-care physician (PCP) if they had three billed visits with the PCP in the last year, hospitalists as those who derived at least 90% of their Medicare claims from inpatient billing, and other generalists as those who met criteria as a generalist but did not fit these categories. Inpatient continuity of care decreased to 59% of patients seeing a single physician in the hospital in 2006 from 71% in 1996, with an accompanying decrease in the length of stay of one full day. There were large variations by geographic region, population size, and hospital characteristics. Patients cared for by hospitalists had slightly better continuity of care than those cared for by nonhospitalist generalists, and those who were cared for by both hospitalists and nonhospitalist generalists had the worst continuity of care. Having a PCP was associated with increased discontinuity of care as an inpatient, perhaps because of individual members of a practice rounding on all of the practice’s inpatients.
Bottom line: Patients were 5% less likely per year between 1996 and 2006 to have a single physician be their primary caregiver in the hospital, but the rise of the hospitalist movement does not seem to be the cause.
Citation: Fletcher KE, Sharma G, Zhang D, Kuo YF, Goodwin JS. Trends in inpatient continuity of care for a cohort of Medicare patients 1996-2006. J Hosp Med. 2011;6:441-447.
For more physician reviews of HM-relevant literature, visit our website.
Clinical question: What is the current level of continuity of care, and what factors affect continuity of care in the hospital setting? Has this changed with increasing use of hospitalists and limits on residency duty hours?
Background: Outpatient continuity of care leads to lower costs, better quality of life, and less emergency room use. Recent changes in residency hours have increased hand-offs and decreased inpatient continuity, but to what extent is unknown.
Study design: Retrospective cohort of 5% of Medicare claims data (530,000 patients in all) from 1996 to 2006, including patients admitted for COPD, congestive heart failure, or pneumonia who were cared for by a general internist or family practitioner.
Setting: Nationwide in the U.S.
Synopsis: The authors defined patients as having a primary-care physician (PCP) if they had three billed visits with the PCP in the last year, hospitalists as those who derived at least 90% of their Medicare claims from inpatient billing, and other generalists as those who met criteria as a generalist but did not fit these categories. Inpatient continuity of care decreased to 59% of patients seeing a single physician in the hospital in 2006 from 71% in 1996, with an accompanying decrease in the length of stay of one full day. There were large variations by geographic region, population size, and hospital characteristics. Patients cared for by hospitalists had slightly better continuity of care than those cared for by nonhospitalist generalists, and those who were cared for by both hospitalists and nonhospitalist generalists had the worst continuity of care. Having a PCP was associated with increased discontinuity of care as an inpatient, perhaps because of individual members of a practice rounding on all of the practice’s inpatients.
Bottom line: Patients were 5% less likely per year between 1996 and 2006 to have a single physician be their primary caregiver in the hospital, but the rise of the hospitalist movement does not seem to be the cause.
Citation: Fletcher KE, Sharma G, Zhang D, Kuo YF, Goodwin JS. Trends in inpatient continuity of care for a cohort of Medicare patients 1996-2006. J Hosp Med. 2011;6:441-447.
For more physician reviews of HM-relevant literature, visit our website.