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Hospital Unit‐Based Leadership Models
Hospital‐based care has become more complex over time. Patients are sicker, with more chronic comorbid conditions requiring greater collaboration to provide coordinated patient care.[1, 2] Care coordination requires an interdisciplinary approach during hospitalization and especially during transitions of care.[3, 4] In addition, hospitals are tasked with managing and improving clinical workflow efficiencies, and implementing electronic health records (EHR)[5] that require healthcare professionals to learn new systems of care and technology. Payment models have also started to shift toward an incentive and penalty‐based structure in the form of value‐based purchasing, readmission penalties, hospital‐acquired conditions, and meaningful use.[4, 6]
In response to these pressures, hospitals are searching for ways to reliably deliver quality care that is safe, effective, patient centered, timely, efficient, and equitable.[7] Previous efforts to improve quality in the general medical inpatient setting have included redesign of the clinical work environment and new workflows through the use of checklists and whiteboards to enhance communication, patient‐centered bedside rounds, standardized protocols and handovers, and integrated clinical decision support using health information technology.[8, 9, 10, 11, 12, 13] Although each of these care coordination activities has potential value, integrating them at the unit level often remains a challenge. Some hospitals have addressed this challenge by establishing and supporting a unit‐based leadership model, where a medical director and nurse manager work together to assess and improve the quality, safety, efficiency, and patient experience‐based mission of the organization.[14, 15] However, there are few descriptions of this leadership model in the current literature. Herein, we present the unit‐based leadership model that has been developed and implemented at 6 hospitals.
MODELS OF UNIT‐BASED LEADERSHIP
The unit‐based leadership model is grounded on the idea that culture and clinical care are products of frontline structure, process, and relationships, and that leaders at the site of care can have the greatest influence on the local work environment.[16, 17] The objective is to influence care and culture at the bedside and the unit, where care is delivered and where alignment with organizational vision and mission must occur. The concept of the inpatient unit medical director is not new, and hospitals in the past have recruited physician leaders to become clinical champions for quality improvement and help establish a collaborative work environment for physicians and unit‐based staff.[18, 19, 20, 21, 22] These studies report on the challenges and benefits of incorporating a medical director to inpatient psychiatry or general care units, but do not provide specific details about the recruitment and responsibilities for unit‐based dyad partnerships, which are critical factors for success on multidisciplinary inpatient care units.
There are several logistical matters to consider when instituting a unit‐based leadership model. These include the composition of the leadership team, selection process of the leaders, the presence of trainees and permanent faculty, and whether the units are able to geographically cohort patients. Other considerations include a clear role description with established shared goals and expectations, and a compensation model that includes effort and incentives. In addition, there should be a clearly established reporting structure to senior leadership, and the unit leaders should be given opportunities for professional growth and development. Table 1 provides a summary overview of 6 hospitals' experiences to date.
| Structure | Hospital of the University of Pennsylvania | Northwestern Memorial Hospital | Emory University Hospital | University of Michigan Health System | Christiana Care Health System | St. Joseph Mercy Health System/Integrated Health Associates |
|---|---|---|---|---|---|---|
| ||||||
| Description of hospital(s) | Academic medical center, 784 beds, 40,000 annual admissions | Academic medical center, 897 beds, 53,000 annual admissions | Academic medical center, 579 beds, 24,000 annual admissions | Academic medical center, 839 beds, 45,000 annual admissions | Independent academic medical center, 1,100 beds, 53,000 annual admissions | Tertiary community hospital that is part of a larger health care system (Trinity Health), 579 beds, 33,000 annual admissions |
| Unit leadership model | Triad of medical director, nurse manager, and quality improvement specialist/project manager | Dyad of medical director and nurse manager | Dyad of medical director and nurse manager | Dyad of medical director and nurse manager | Dyad of medical director and nurse manager | Dyad of medical director and nurse manager |
| Percent effort time supported for unit medical director | 10% | 17% | 10% | 20% | 20% | 10% |
| Incentives built into unit leaders' performance in outcomes metrics | No | Yes | No | No | No | Yes |
| Professional development/leadership training | Quality improvement method: PDSA, Six Sigma, Lean Healthcare | Quality improvement method: Six Sigma | Situational leadership training with 1:1 mentoring | Quality improvement method: Lean Healthcare, service excellence program | Quality Improvement method: Six Sigma, Lean Healthcare | Quality improvement method: Six Sigma |
| Additional leadership development through Penn Medicine Leadership Academy and Wharton Executive Education | Additional leadership development through Northwestern's professional development center and simulation training center | Conflict resolution skill development | Attend patient and Family Centered Care conference | Additional leadership development through Christiana Care Learning Institute | Attend educational course on Crucial Conversations | |
| Personality profile with coaching | Additional leadership development through University of Michigan Health System's human resources group | |||||
| Outcomes metrics monitored | Patient satisfaction | Patient satisfaction | Patient satisfaction | Patient satisfaction | Patient satisfaction | Patient satisfaction |
| Efficiency of multidisciplinary rounds | Teamwork climate (survey) | Teamwork and implementation of structured interdisciplinary bedside rounds | Multidisciplinary rounds | Interdisciplinary rounds | Participation in interdisciplinary rounds | |
| RNMD work environment surveys | Adverse events | Unit‐based patient safety culture survey | Patient‐centered, bedside rounds | Readmission rates | ||
| Hospital‐acquired conditions (CAUTI, CLABSI, VAP, DVT, pressure ulcers) | Hospital‐acquired conditions (fall rates, pressure ulcers | Hospital‐acquired conditions (CAUTI, CLABSI, fall rates, pressure ulcers) | Hospital‐acquired conditions (CAUTI) | Hospital‐acquired conditions (fall rates, pressure ulcers) | Core measures | |
| Readmission rates | Readmission rates | Mortality | Readmission rates | Readmission rates | Medication reconciliation | |
| Core measures, patient safety indicators | Core measures | Length of stay | DVT prophylaxis | Hand hygiene | Discharge by 11 am | |
| Mortality (observed to expected, transfer, inpatient) | Hand hygiene | Glycemic control | Meeting attendance | Length of stay | Use of patient teach‐back | |
| Medication reconciliation | Restraint use | Communication with PCPs | ||||
| Home care, hospice, post‐acute care referral rates | ||||||
| Organizational leadership structure support for clinical unit partnership program | CMO, CNO, vice president of quality/patient safety, directors of medical and surgical nursing | Associate chair of medicine, director of medicine nursing; all medical directors are members of the department of medicine quality management committee | CMO, CNO, CEO, CQO | CMO, CNO | All teams report to and are supported by 3 overarching, system‐wide committees: (1) safety first, (2) think of yourself as a patient, (3) clinical excellence. Those committees, in turn, report up to the senior management quality/safety coordinating council. | Director of hospitalist program (reports to CMO); nursing director of acute care (reports to CNO) |
DISCUSSION
In reviewing our 6 organization's collective experiences, we identified several common themes and some notable differences across sites. The core of the leadership team was primarily composed of the medical director and nurse manager on the unit. Across all 6 organizations, medical directors had a portion of their effort supported for their leadership work on the unit. Leadership development training was provided at all of our sites, with particular emphasis on quality improvement (QI) methods such as Six‐Sigma, Lean, or Plan, Do, Study, Act (PDSA). Additional leadership development sessions were provided through the organization's human resources or affiliated university. Common outcome measures of interest include patient satisfaction, interdisciplinary practice, and collaboration on the unit, and some hospital‐acquired condition measures. Last, there is a direct reporting relationship to a chief or senior nurse or physician leader within each organization. These commonalities and variances are further detailed below.
Establishing the Unit‐Based Leadership Model
The composition of the unit‐based leadership model in our 6 organizations is predominantly a dyad partnership of medical directors and nurse managers. Although informal physician‐nurse collaborative practices have likely been in existence at many hospitals, formalizing this dyad partnership is an important step to fostering collaborative efforts to improve quality of care. It is also essential for hospital leadership to clearly articulate the need for this unit‐based leadership model. Whether the motivation for change is from a previously untenable practice environment, or part of an ongoing improvement program, the model should be presented in a manner that supports the organization's commitment to improve collaborative practices for better patient care. One of our 6 hospitals initiated this leadership model based on troubling relationships between nurses and physicians on some of their inpatient care units, which threatened to stall the organization's Magnet application. Implementation of the leadership model at the unit level yielded improvements in nursephysician interactions, patient satisfaction, and staff turnover.[15, 23] Another of the hospitals first evaluated why a previous attempt at this model did not deliver the intended outcomes, and redesigned the model based on its analysis.[14]
Across all of the organizations featured here, a common driver behind the adoption of the unit‐based leadership model was to bridge the divide between physician services and nursing and other allied health providers. We found that many of the physicians routinely had patients on multiple units, limiting the quantity and quality of collaborative practices between unit‐based staff and physician teams. The unit‐based dyad leaders are ideally positioned to build and foster a culture of collaboration, and our organizations have been inclusive to ensure the participation of a multidisciplinary group of providers, including representatives from pharmacy, environmental services, physical therapy, respiratory therapy, social work, case management, and nutrition at leadership meetings or in daily patient‐care discussions. In addition, 2 of the organizations have added quality improvement specialist/project managers to their teams to support the physiciannurse manager leaders on the unit.
Selection Process and Professional Development
The traditional approach to hiring a physician leader or a nurse manager has been an isolated process of drafting a job description for each position and hiring within their respective departments. For the dyad partnership to be successful, there should be established goals and expectations that require shared responsibilities between the 2 partners, which should guide the selection of these leaders. Other leadership attributes and essential character traits that should be modeled by the unit‐based leaders include good communication skills, respect among coworkers, and a collaborative approach to decision making and action. In addition, both physician leaders and nurse managers in these roles should have the ability to take a system's view, recognizing that within the complex network of healthcare providers and processes on their unit, these elements interact with each other, which lead to the outcomes achieved on their units.[24, 25] Table 2 lists some general shared responsibilities, highlighting specific activities that can be used to achieve the established outcomes. As the unit's dyad leadership works together to address these shared responsibilities, they should keep their sights focused on the overall strategic goals of the healthcare organization. Bohmer has defined 4 habits of the high‐value healthcare organization that in turn can be reflected through the inpatient unit leadership model to capture these activities at the local level: (1) planning care for specific patient populations, (2) microsystem design, (3) measurement and oversight, and (4) self‐study.[26] In determining specific shared responsibilities for each dyad partner, it is important for these leaders to understand the clinical microsystem of their unit such as their patient population, interdisciplinary care team, approach to process improvement, and performance patterns over time.[27]
| General Shared Responsibilities of Physician and Nurse Unit Directors | Examples of Specific Activities |
|---|---|
| |
| Serve as management partners to enhance culture of the unit | Co‐craft and deliver consistent leadership message |
| Co‐establish and enforce unit processes and protocols | |
| Co‐lead recruitment and retention efforts | |
| Co‐orient trainees and faculty rotating through unit | |
| Co‐educate on the management of common medical and surgical conditions | |
| Facilitate interstaff conflict resolution sessions | |
| Regular leadership meetings | |
| Actively manage unit processes and outcomes | Quality: improve core quality measure performance |
| Safety: improve culture of patient safety within the unit as measured by surveys and incident reporting systems | |
| Efficiency: reduce unnecessary length of stay and variability in resource use | |
| Patient experience: focus on improving patient‐family experience with targeted outcomes in patient experience metrics (eg, HCAHPS) | |
| Education: develop trainee and staff clinical and teamwork competencies | |
| Continuous process improvement initiatives (eg, PDSA cycles) | Improve the discharge transitions process, tailoring the process to each individual patient's identified risk factors |
| Focus improvement efforts on reduction in specific hospital acquired conditions such as CAUTI, VTE, CLABSI, pressure ulcers, falls | |
| Measure, analyze, reassess, and improve in all described areas of shared responsibilities | |
| Perform unit level chart reviews to evaluate readmissions and LOS and identify improvement opportunities | |
In our collective experience, the dyad leaders bring passion and commitment to improving care; however, many (the medical directors in particular) have minimal prior formal training in leadership, quality improvement, or hospital management. Recognizing that unit leaders require specialized knowledge and skills, each of our organizations has enrolled unit medical directors and nurse managers in leadership development courses or educational programs. Many healthcare organizations have become more grounded in a QI methodology including Six‐Sigma, Lean Healthcare, PDSA, and other scientifically based methods, and the unit‐based leaders should receive advanced training in the preferred methods of their institution. Additional training in quality improvement, patient safety, and physician leadership can also be obtained through supplemental coursework specifically designed to train hospital leaders, with some programs leading to a certification or additional credentials.[28]
Beyond such formal educational opportunities, hospitals should not overlook the opportunity to learn from and share experiences with the other dyad leadership units within the hospital. One of the organizations described here holds monthly meetings with all of the unit dyad leaders, and 2 other organizations conduct quarterly meetings to share experiences and best practices related to specific improvement initiatives in a learning network model. Those units with more experience in specific initiatives are asked to share their lessons learned with others, as well as support each other in their efforts to collectively meet the strategic goals of the hospital.
Time and Organizational Support
In addition to leadership development, hospitals and the clinical department leadership need to support the medical directors with dedicated time away from their usual clinical duties. Some organizations in this report are providing up to 20% effort for the medical director's unit‐based leadership work; however, there is some variation in practice with regard to physician effort across sites. The University of Pennsylvania has a smaller effort support at 10%; however, some of that effort differential may be offset through the allocation of the quality improvement specialist/project manager assigned to work with the medical director and nurse manager dyad. St. Joseph Mercy Hospital also has a lower allocation, as there is additional financial compensation for the role that is at risk and not included in this 10% allocation.
It is also important to assure that the medical directors have institutional support to carry out their work in partnership with their nursing leadership. The 6 health systems described here report that although most of the physicians have appointments within a physician group or clinical department, there is hospital leadership oversight from a chief medical, nursing, or operating officer. This organizational structure may be an important aspect of the model as the unit‐based leaders seek to align their efforts with that of the hospital. Further, this form of organizational oversight can ensure that the unit leaders will receive timely and essential unit‐ and hospital‐based performance measures to manage local improvement efforts. These measures may include some components of patient experiences as reported in the Hospital Consumer Assessment of Healthcare Providers and Systems survey, readmission rates, hospital‐acquired condition rates, length of stay, observed to expected mortality rates, and results of staff satisfaction and safety culture surveys. As highlighted by several studies and commentaries, our collective experiences also identified interdisciplinary teamwork, collaboration, and communication as desirable outcome measures through the unit‐based leadership structure.[21, 22, 24, 29, 30] The medical director and nurse manager dyads can prioritize their improvement efforts based on the data provided to them, and mobilize the appropriate group of multidisciplinary practitioners and support staff on the unit.
OTHER CONSIDERATIONS
Other infrastructure variables that may increase the effectiveness of the unit leadership dyad include unit‐based clinical services (geographic localization), engaging the frontline team members in the design and implementation of change innovations, a commitment to patient and family centered practices on the unit, and enhancing clinical workflow through the support of EHR functions such as concurrent documentation and provider order entry. Geographic localization, placing the fewest possible clinical service providers on the unit to work alongside unit‐based staff, allows for a cohesive interdisciplinary unit‐based team to develop under the dyad leadership, and has been shown to improve communication practices.[9, 31] Beyond geographic localization of patients, it is critical to ensure team members are committed to the changes in workflow by directly involving them through the design and implementation of new models of care taking place on the unit. This commitment starts from the top senior nurse and physician leaders in the organization, and extends to the unit‐based dyad partners, and down to each individual interdisciplinary team member on the unit.[1] Thus, it is critical to clarify roles and responsibilities and how team members on the unit will interact with each other. For some situations, conflict management training will be helpful to the unit‐based leaders to resolve issues. To appreciate potential barriers to successful rollout of this unit leadership model, a phased implementation of pilot units, followed by successive waves, should be considered. Many of the units that instituted unit‐based interdisciplinary team rounds solicited and implemented direct feedback from frontline team members in efforts to improve communication and be more patient centered. Conversely, there are also likely to be situations where the unit‐based leaders will be confronted with hindrances to their unit‐based collaborative improvement efforts. To help prepare the dyad leaders, many of our unit‐based leaders have received specific training on how to coach and conduct difficult conversations with individuals who have performance gaps or are perceived to be hindering the progress of the unit's work. These crucial negotiation skills are not innate among most managers and should be explicitly provided to new leaders across organizations.
The goals and merits of patient‐ and family‐centered care (PFCC) have been well described.[32, 33, 34] Organizational support to teach and disseminate PFCC practices throughout all settings of care may help the leadership dyads implement rounding strategies that engage all staff, patients, and family members throughout the hospital course and during the transitions out of the hospital.
Clinical workflow has become heavily dependent on the EHR systems. For those organizations that have yet to adopt a particular EHR system, the leadership dyads should be involved throughout the EHR design process to help ensure that the technological solutions will be built to assist the clinical workflow, and once the system has been built, the leadership dyad should monitor and enhance the interface between workflow and EHR system so that it can support the creation and advancement of interdisciplinary plans of care on the unit.
CONCLUSION
The care of the hospitalized patient has become more complex over time. Interdisciplinary teamwork needs to be improved at the unit level to achieve the strategic goals of the hospital. Although quality improvement is an organizational goal, change takes place locally. Physician leaders, in partnership with nurse managers, are needed now more than ever to take on this task to improve the hospital‐care experience for patients by functioning as the primary effector arms for changing the landscape of hospital‐based care. We have described characteristics of unit‐based leadership programs adopted across 6 organizations. Hospitalists with clinical experience as the principal providers of inpatient‐based care and quality improvement experience and training, have been key participants in the development and implementation of the local leadership models in each of these hospital systems. We hope the comparison of the various models featured in this article serves as a valuable reference to hospitals and healthcare organizations who are contemplating the incorporation of this model into their strategic plan.
- , , , et al. Organizational predictors of coordination in inpatient medicine [published online ahead of print February 26, 2014]. Health Care Manage Rev. doi: 10.1097/HMR.0000000000000004.
- . Trends in case‐mix in the medicare population. Paper presented at: American Hospital Association, Federation of American Hospitals, Association of American Medical Colleges; http://www.aha.org/content/00‐10/100715‐CMItrends.pdf. July 15, 2010.
- . A requirement to reduce readmissions: take care of the patient, not just the disease. JAMA. 2013;309(4):394–396.
- , . Value‐based purchasing—national programs to move from volume to value. N Engl J Med. 2012;367(4):292–295.
- Medicare and Medicaid programs; electronic health record incentive program. Final rule. Fed Regist. 2010;75(144):44313–44588.
- . The Center for Medicare and Medicaid innovation's blueprint for rapid‐cycle evaluation of new care and payment models. Health Aff (Millwood). 2013;32(4):807–812.
- Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.
- , , , , , . Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit. J Gen Intern Med. 2010;25(8):826–832.
- , , , et al. Impact of localizing physicians to hospital units on nurse‐physician communication and agreement on the plan of care. J Gen Intern Med. 2009;24(11):1223–1227.
- , , , . A review on systematic reviews of health information system studies. J Am Med Inform Assoc. 2010;17(6):637–645.
- , , , , . Patient whiteboards as a communication tool in the hospital setting: a survey of practices and recommendations. J Hosp Med. Apr 2010;5(4):234–239.
- , , . Development of a checklist for documenting team and collaborative behaviors during multidisciplinary bedside rounds. J Nurs Adm. 2013;43(5):280–285.
- , , , , . Assessment of teamwork during structured interdisciplinary rounds on medical units. J Hosp Med. 2012;7(9):679–683.
- , , , et al. Leadership at the front line: a clinical partnership model on general care inpatient units. Am J Med Qual. 2012;27(2):106–111.
- , . AHRQ health care innovations exchange: improvement projects led by unit‐based teams of nurse, physician, and quality leaders reduce infections, lower costs, improve patient satisfaction, and nurse‐physician communication. Available at: http://www.innovations.ahrq.gov/content.aspx?id=2719. Published April 14, 2010. Accessed November 26, 2011.
- , , , , , . Microsystems in health care: part 8. Developing people and improving work life: what front‐line staff told us. Jt Comm J Qual Saf. 2003;29(10):512–522.
- , , , et al. Microsystems in health care: part 5. How leaders are leading. Jt Comm J Qual Saf. 2003;29(6):297–308.
- , , . The academic dilemma of the inpatient unit director. Am J Psychiatry. 1989;146(1):73–76.
- , , , , . Improving and sustaining core measure performance through effective accountability of clinical microsystems in an academic medical center. Jt Comm J Qual Patient Saf. 2010;36(9):387–398.
- , , . Physician leadership and quality improvement in the acute child and adolescent psychiatric care setting. Child Adolesc Psychiatr Clin N Am. 2010;19(1):1–19; table of contents.
- , , , . Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. Am J Crit Care. 2005;14(1):71–77.
- , . Nurse‐physician leadership: insights into interprofessional collaboration. J Nurs Adm. 2013;43(12):653–659.
- The Advisory Board. University of Pennsylvania Health System pilots unit clinical leadership model to spur quality gains. Nurs Exec Watch. 2008;9(2):4–6.
- , . Physicians as leaders in improving health care: a new series in Annals of Internal Medicine. Ann Intern Med. 1998;128(4):289–292.
- . Understanding medical systems. Ann Intern Med. 1998;128(4):293–298.
- . The four habits of high‐value health care organizations. N Engl J Med. 2011;365(22):2045–2047.
- , , , et al. Microsystems in health care: Part 1. Learning from high‐performing front‐line clinical units. Jt Comm J Qual Improv. 2002;28(9):472–493.
- , , , et al. The quality and safety educators academy: fulfilling an unmet need for faculty development. Am J Med Qual. 2014;29(1):5–12.
- , , , . Cooperation: the foundation of improvement. Ann Intern Med. 1998;128(12 pt 1):1004–1009.
- , , , , , . Ten principles of good interdisciplinary team work. Hum Resour Health 2013;11(1):19.
- , , , et al. Impact of localizing general medical teams to a single nursing unit. J Hosp Med. 2012;7(7):551–556.
- , , , . Integrating patient‐ and family‐centered care with health policy: four proposed policy approaches. Qual Manag Health Care. 2013;22(2):137–145.
- , , . Incorporating patient‐ and family‐centered care into resident education: approaches, benefits, and challenges. J Grad Med Educ. 2011;3(2):272–278.
- Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2012.
Hospital‐based care has become more complex over time. Patients are sicker, with more chronic comorbid conditions requiring greater collaboration to provide coordinated patient care.[1, 2] Care coordination requires an interdisciplinary approach during hospitalization and especially during transitions of care.[3, 4] In addition, hospitals are tasked with managing and improving clinical workflow efficiencies, and implementing electronic health records (EHR)[5] that require healthcare professionals to learn new systems of care and technology. Payment models have also started to shift toward an incentive and penalty‐based structure in the form of value‐based purchasing, readmission penalties, hospital‐acquired conditions, and meaningful use.[4, 6]
In response to these pressures, hospitals are searching for ways to reliably deliver quality care that is safe, effective, patient centered, timely, efficient, and equitable.[7] Previous efforts to improve quality in the general medical inpatient setting have included redesign of the clinical work environment and new workflows through the use of checklists and whiteboards to enhance communication, patient‐centered bedside rounds, standardized protocols and handovers, and integrated clinical decision support using health information technology.[8, 9, 10, 11, 12, 13] Although each of these care coordination activities has potential value, integrating them at the unit level often remains a challenge. Some hospitals have addressed this challenge by establishing and supporting a unit‐based leadership model, where a medical director and nurse manager work together to assess and improve the quality, safety, efficiency, and patient experience‐based mission of the organization.[14, 15] However, there are few descriptions of this leadership model in the current literature. Herein, we present the unit‐based leadership model that has been developed and implemented at 6 hospitals.
MODELS OF UNIT‐BASED LEADERSHIP
The unit‐based leadership model is grounded on the idea that culture and clinical care are products of frontline structure, process, and relationships, and that leaders at the site of care can have the greatest influence on the local work environment.[16, 17] The objective is to influence care and culture at the bedside and the unit, where care is delivered and where alignment with organizational vision and mission must occur. The concept of the inpatient unit medical director is not new, and hospitals in the past have recruited physician leaders to become clinical champions for quality improvement and help establish a collaborative work environment for physicians and unit‐based staff.[18, 19, 20, 21, 22] These studies report on the challenges and benefits of incorporating a medical director to inpatient psychiatry or general care units, but do not provide specific details about the recruitment and responsibilities for unit‐based dyad partnerships, which are critical factors for success on multidisciplinary inpatient care units.
There are several logistical matters to consider when instituting a unit‐based leadership model. These include the composition of the leadership team, selection process of the leaders, the presence of trainees and permanent faculty, and whether the units are able to geographically cohort patients. Other considerations include a clear role description with established shared goals and expectations, and a compensation model that includes effort and incentives. In addition, there should be a clearly established reporting structure to senior leadership, and the unit leaders should be given opportunities for professional growth and development. Table 1 provides a summary overview of 6 hospitals' experiences to date.
| Structure | Hospital of the University of Pennsylvania | Northwestern Memorial Hospital | Emory University Hospital | University of Michigan Health System | Christiana Care Health System | St. Joseph Mercy Health System/Integrated Health Associates |
|---|---|---|---|---|---|---|
| ||||||
| Description of hospital(s) | Academic medical center, 784 beds, 40,000 annual admissions | Academic medical center, 897 beds, 53,000 annual admissions | Academic medical center, 579 beds, 24,000 annual admissions | Academic medical center, 839 beds, 45,000 annual admissions | Independent academic medical center, 1,100 beds, 53,000 annual admissions | Tertiary community hospital that is part of a larger health care system (Trinity Health), 579 beds, 33,000 annual admissions |
| Unit leadership model | Triad of medical director, nurse manager, and quality improvement specialist/project manager | Dyad of medical director and nurse manager | Dyad of medical director and nurse manager | Dyad of medical director and nurse manager | Dyad of medical director and nurse manager | Dyad of medical director and nurse manager |
| Percent effort time supported for unit medical director | 10% | 17% | 10% | 20% | 20% | 10% |
| Incentives built into unit leaders' performance in outcomes metrics | No | Yes | No | No | No | Yes |
| Professional development/leadership training | Quality improvement method: PDSA, Six Sigma, Lean Healthcare | Quality improvement method: Six Sigma | Situational leadership training with 1:1 mentoring | Quality improvement method: Lean Healthcare, service excellence program | Quality Improvement method: Six Sigma, Lean Healthcare | Quality improvement method: Six Sigma |
| Additional leadership development through Penn Medicine Leadership Academy and Wharton Executive Education | Additional leadership development through Northwestern's professional development center and simulation training center | Conflict resolution skill development | Attend patient and Family Centered Care conference | Additional leadership development through Christiana Care Learning Institute | Attend educational course on Crucial Conversations | |
| Personality profile with coaching | Additional leadership development through University of Michigan Health System's human resources group | |||||
| Outcomes metrics monitored | Patient satisfaction | Patient satisfaction | Patient satisfaction | Patient satisfaction | Patient satisfaction | Patient satisfaction |
| Efficiency of multidisciplinary rounds | Teamwork climate (survey) | Teamwork and implementation of structured interdisciplinary bedside rounds | Multidisciplinary rounds | Interdisciplinary rounds | Participation in interdisciplinary rounds | |
| RNMD work environment surveys | Adverse events | Unit‐based patient safety culture survey | Patient‐centered, bedside rounds | Readmission rates | ||
| Hospital‐acquired conditions (CAUTI, CLABSI, VAP, DVT, pressure ulcers) | Hospital‐acquired conditions (fall rates, pressure ulcers | Hospital‐acquired conditions (CAUTI, CLABSI, fall rates, pressure ulcers) | Hospital‐acquired conditions (CAUTI) | Hospital‐acquired conditions (fall rates, pressure ulcers) | Core measures | |
| Readmission rates | Readmission rates | Mortality | Readmission rates | Readmission rates | Medication reconciliation | |
| Core measures, patient safety indicators | Core measures | Length of stay | DVT prophylaxis | Hand hygiene | Discharge by 11 am | |
| Mortality (observed to expected, transfer, inpatient) | Hand hygiene | Glycemic control | Meeting attendance | Length of stay | Use of patient teach‐back | |
| Medication reconciliation | Restraint use | Communication with PCPs | ||||
| Home care, hospice, post‐acute care referral rates | ||||||
| Organizational leadership structure support for clinical unit partnership program | CMO, CNO, vice president of quality/patient safety, directors of medical and surgical nursing | Associate chair of medicine, director of medicine nursing; all medical directors are members of the department of medicine quality management committee | CMO, CNO, CEO, CQO | CMO, CNO | All teams report to and are supported by 3 overarching, system‐wide committees: (1) safety first, (2) think of yourself as a patient, (3) clinical excellence. Those committees, in turn, report up to the senior management quality/safety coordinating council. | Director of hospitalist program (reports to CMO); nursing director of acute care (reports to CNO) |
DISCUSSION
In reviewing our 6 organization's collective experiences, we identified several common themes and some notable differences across sites. The core of the leadership team was primarily composed of the medical director and nurse manager on the unit. Across all 6 organizations, medical directors had a portion of their effort supported for their leadership work on the unit. Leadership development training was provided at all of our sites, with particular emphasis on quality improvement (QI) methods such as Six‐Sigma, Lean, or Plan, Do, Study, Act (PDSA). Additional leadership development sessions were provided through the organization's human resources or affiliated university. Common outcome measures of interest include patient satisfaction, interdisciplinary practice, and collaboration on the unit, and some hospital‐acquired condition measures. Last, there is a direct reporting relationship to a chief or senior nurse or physician leader within each organization. These commonalities and variances are further detailed below.
Establishing the Unit‐Based Leadership Model
The composition of the unit‐based leadership model in our 6 organizations is predominantly a dyad partnership of medical directors and nurse managers. Although informal physician‐nurse collaborative practices have likely been in existence at many hospitals, formalizing this dyad partnership is an important step to fostering collaborative efforts to improve quality of care. It is also essential for hospital leadership to clearly articulate the need for this unit‐based leadership model. Whether the motivation for change is from a previously untenable practice environment, or part of an ongoing improvement program, the model should be presented in a manner that supports the organization's commitment to improve collaborative practices for better patient care. One of our 6 hospitals initiated this leadership model based on troubling relationships between nurses and physicians on some of their inpatient care units, which threatened to stall the organization's Magnet application. Implementation of the leadership model at the unit level yielded improvements in nursephysician interactions, patient satisfaction, and staff turnover.[15, 23] Another of the hospitals first evaluated why a previous attempt at this model did not deliver the intended outcomes, and redesigned the model based on its analysis.[14]
Across all of the organizations featured here, a common driver behind the adoption of the unit‐based leadership model was to bridge the divide between physician services and nursing and other allied health providers. We found that many of the physicians routinely had patients on multiple units, limiting the quantity and quality of collaborative practices between unit‐based staff and physician teams. The unit‐based dyad leaders are ideally positioned to build and foster a culture of collaboration, and our organizations have been inclusive to ensure the participation of a multidisciplinary group of providers, including representatives from pharmacy, environmental services, physical therapy, respiratory therapy, social work, case management, and nutrition at leadership meetings or in daily patient‐care discussions. In addition, 2 of the organizations have added quality improvement specialist/project managers to their teams to support the physiciannurse manager leaders on the unit.
Selection Process and Professional Development
The traditional approach to hiring a physician leader or a nurse manager has been an isolated process of drafting a job description for each position and hiring within their respective departments. For the dyad partnership to be successful, there should be established goals and expectations that require shared responsibilities between the 2 partners, which should guide the selection of these leaders. Other leadership attributes and essential character traits that should be modeled by the unit‐based leaders include good communication skills, respect among coworkers, and a collaborative approach to decision making and action. In addition, both physician leaders and nurse managers in these roles should have the ability to take a system's view, recognizing that within the complex network of healthcare providers and processes on their unit, these elements interact with each other, which lead to the outcomes achieved on their units.[24, 25] Table 2 lists some general shared responsibilities, highlighting specific activities that can be used to achieve the established outcomes. As the unit's dyad leadership works together to address these shared responsibilities, they should keep their sights focused on the overall strategic goals of the healthcare organization. Bohmer has defined 4 habits of the high‐value healthcare organization that in turn can be reflected through the inpatient unit leadership model to capture these activities at the local level: (1) planning care for specific patient populations, (2) microsystem design, (3) measurement and oversight, and (4) self‐study.[26] In determining specific shared responsibilities for each dyad partner, it is important for these leaders to understand the clinical microsystem of their unit such as their patient population, interdisciplinary care team, approach to process improvement, and performance patterns over time.[27]
| General Shared Responsibilities of Physician and Nurse Unit Directors | Examples of Specific Activities |
|---|---|
| |
| Serve as management partners to enhance culture of the unit | Co‐craft and deliver consistent leadership message |
| Co‐establish and enforce unit processes and protocols | |
| Co‐lead recruitment and retention efforts | |
| Co‐orient trainees and faculty rotating through unit | |
| Co‐educate on the management of common medical and surgical conditions | |
| Facilitate interstaff conflict resolution sessions | |
| Regular leadership meetings | |
| Actively manage unit processes and outcomes | Quality: improve core quality measure performance |
| Safety: improve culture of patient safety within the unit as measured by surveys and incident reporting systems | |
| Efficiency: reduce unnecessary length of stay and variability in resource use | |
| Patient experience: focus on improving patient‐family experience with targeted outcomes in patient experience metrics (eg, HCAHPS) | |
| Education: develop trainee and staff clinical and teamwork competencies | |
| Continuous process improvement initiatives (eg, PDSA cycles) | Improve the discharge transitions process, tailoring the process to each individual patient's identified risk factors |
| Focus improvement efforts on reduction in specific hospital acquired conditions such as CAUTI, VTE, CLABSI, pressure ulcers, falls | |
| Measure, analyze, reassess, and improve in all described areas of shared responsibilities | |
| Perform unit level chart reviews to evaluate readmissions and LOS and identify improvement opportunities | |
In our collective experience, the dyad leaders bring passion and commitment to improving care; however, many (the medical directors in particular) have minimal prior formal training in leadership, quality improvement, or hospital management. Recognizing that unit leaders require specialized knowledge and skills, each of our organizations has enrolled unit medical directors and nurse managers in leadership development courses or educational programs. Many healthcare organizations have become more grounded in a QI methodology including Six‐Sigma, Lean Healthcare, PDSA, and other scientifically based methods, and the unit‐based leaders should receive advanced training in the preferred methods of their institution. Additional training in quality improvement, patient safety, and physician leadership can also be obtained through supplemental coursework specifically designed to train hospital leaders, with some programs leading to a certification or additional credentials.[28]
Beyond such formal educational opportunities, hospitals should not overlook the opportunity to learn from and share experiences with the other dyad leadership units within the hospital. One of the organizations described here holds monthly meetings with all of the unit dyad leaders, and 2 other organizations conduct quarterly meetings to share experiences and best practices related to specific improvement initiatives in a learning network model. Those units with more experience in specific initiatives are asked to share their lessons learned with others, as well as support each other in their efforts to collectively meet the strategic goals of the hospital.
Time and Organizational Support
In addition to leadership development, hospitals and the clinical department leadership need to support the medical directors with dedicated time away from their usual clinical duties. Some organizations in this report are providing up to 20% effort for the medical director's unit‐based leadership work; however, there is some variation in practice with regard to physician effort across sites. The University of Pennsylvania has a smaller effort support at 10%; however, some of that effort differential may be offset through the allocation of the quality improvement specialist/project manager assigned to work with the medical director and nurse manager dyad. St. Joseph Mercy Hospital also has a lower allocation, as there is additional financial compensation for the role that is at risk and not included in this 10% allocation.
It is also important to assure that the medical directors have institutional support to carry out their work in partnership with their nursing leadership. The 6 health systems described here report that although most of the physicians have appointments within a physician group or clinical department, there is hospital leadership oversight from a chief medical, nursing, or operating officer. This organizational structure may be an important aspect of the model as the unit‐based leaders seek to align their efforts with that of the hospital. Further, this form of organizational oversight can ensure that the unit leaders will receive timely and essential unit‐ and hospital‐based performance measures to manage local improvement efforts. These measures may include some components of patient experiences as reported in the Hospital Consumer Assessment of Healthcare Providers and Systems survey, readmission rates, hospital‐acquired condition rates, length of stay, observed to expected mortality rates, and results of staff satisfaction and safety culture surveys. As highlighted by several studies and commentaries, our collective experiences also identified interdisciplinary teamwork, collaboration, and communication as desirable outcome measures through the unit‐based leadership structure.[21, 22, 24, 29, 30] The medical director and nurse manager dyads can prioritize their improvement efforts based on the data provided to them, and mobilize the appropriate group of multidisciplinary practitioners and support staff on the unit.
OTHER CONSIDERATIONS
Other infrastructure variables that may increase the effectiveness of the unit leadership dyad include unit‐based clinical services (geographic localization), engaging the frontline team members in the design and implementation of change innovations, a commitment to patient and family centered practices on the unit, and enhancing clinical workflow through the support of EHR functions such as concurrent documentation and provider order entry. Geographic localization, placing the fewest possible clinical service providers on the unit to work alongside unit‐based staff, allows for a cohesive interdisciplinary unit‐based team to develop under the dyad leadership, and has been shown to improve communication practices.[9, 31] Beyond geographic localization of patients, it is critical to ensure team members are committed to the changes in workflow by directly involving them through the design and implementation of new models of care taking place on the unit. This commitment starts from the top senior nurse and physician leaders in the organization, and extends to the unit‐based dyad partners, and down to each individual interdisciplinary team member on the unit.[1] Thus, it is critical to clarify roles and responsibilities and how team members on the unit will interact with each other. For some situations, conflict management training will be helpful to the unit‐based leaders to resolve issues. To appreciate potential barriers to successful rollout of this unit leadership model, a phased implementation of pilot units, followed by successive waves, should be considered. Many of the units that instituted unit‐based interdisciplinary team rounds solicited and implemented direct feedback from frontline team members in efforts to improve communication and be more patient centered. Conversely, there are also likely to be situations where the unit‐based leaders will be confronted with hindrances to their unit‐based collaborative improvement efforts. To help prepare the dyad leaders, many of our unit‐based leaders have received specific training on how to coach and conduct difficult conversations with individuals who have performance gaps or are perceived to be hindering the progress of the unit's work. These crucial negotiation skills are not innate among most managers and should be explicitly provided to new leaders across organizations.
The goals and merits of patient‐ and family‐centered care (PFCC) have been well described.[32, 33, 34] Organizational support to teach and disseminate PFCC practices throughout all settings of care may help the leadership dyads implement rounding strategies that engage all staff, patients, and family members throughout the hospital course and during the transitions out of the hospital.
Clinical workflow has become heavily dependent on the EHR systems. For those organizations that have yet to adopt a particular EHR system, the leadership dyads should be involved throughout the EHR design process to help ensure that the technological solutions will be built to assist the clinical workflow, and once the system has been built, the leadership dyad should monitor and enhance the interface between workflow and EHR system so that it can support the creation and advancement of interdisciplinary plans of care on the unit.
CONCLUSION
The care of the hospitalized patient has become more complex over time. Interdisciplinary teamwork needs to be improved at the unit level to achieve the strategic goals of the hospital. Although quality improvement is an organizational goal, change takes place locally. Physician leaders, in partnership with nurse managers, are needed now more than ever to take on this task to improve the hospital‐care experience for patients by functioning as the primary effector arms for changing the landscape of hospital‐based care. We have described characteristics of unit‐based leadership programs adopted across 6 organizations. Hospitalists with clinical experience as the principal providers of inpatient‐based care and quality improvement experience and training, have been key participants in the development and implementation of the local leadership models in each of these hospital systems. We hope the comparison of the various models featured in this article serves as a valuable reference to hospitals and healthcare organizations who are contemplating the incorporation of this model into their strategic plan.
Hospital‐based care has become more complex over time. Patients are sicker, with more chronic comorbid conditions requiring greater collaboration to provide coordinated patient care.[1, 2] Care coordination requires an interdisciplinary approach during hospitalization and especially during transitions of care.[3, 4] In addition, hospitals are tasked with managing and improving clinical workflow efficiencies, and implementing electronic health records (EHR)[5] that require healthcare professionals to learn new systems of care and technology. Payment models have also started to shift toward an incentive and penalty‐based structure in the form of value‐based purchasing, readmission penalties, hospital‐acquired conditions, and meaningful use.[4, 6]
In response to these pressures, hospitals are searching for ways to reliably deliver quality care that is safe, effective, patient centered, timely, efficient, and equitable.[7] Previous efforts to improve quality in the general medical inpatient setting have included redesign of the clinical work environment and new workflows through the use of checklists and whiteboards to enhance communication, patient‐centered bedside rounds, standardized protocols and handovers, and integrated clinical decision support using health information technology.[8, 9, 10, 11, 12, 13] Although each of these care coordination activities has potential value, integrating them at the unit level often remains a challenge. Some hospitals have addressed this challenge by establishing and supporting a unit‐based leadership model, where a medical director and nurse manager work together to assess and improve the quality, safety, efficiency, and patient experience‐based mission of the organization.[14, 15] However, there are few descriptions of this leadership model in the current literature. Herein, we present the unit‐based leadership model that has been developed and implemented at 6 hospitals.
MODELS OF UNIT‐BASED LEADERSHIP
The unit‐based leadership model is grounded on the idea that culture and clinical care are products of frontline structure, process, and relationships, and that leaders at the site of care can have the greatest influence on the local work environment.[16, 17] The objective is to influence care and culture at the bedside and the unit, where care is delivered and where alignment with organizational vision and mission must occur. The concept of the inpatient unit medical director is not new, and hospitals in the past have recruited physician leaders to become clinical champions for quality improvement and help establish a collaborative work environment for physicians and unit‐based staff.[18, 19, 20, 21, 22] These studies report on the challenges and benefits of incorporating a medical director to inpatient psychiatry or general care units, but do not provide specific details about the recruitment and responsibilities for unit‐based dyad partnerships, which are critical factors for success on multidisciplinary inpatient care units.
There are several logistical matters to consider when instituting a unit‐based leadership model. These include the composition of the leadership team, selection process of the leaders, the presence of trainees and permanent faculty, and whether the units are able to geographically cohort patients. Other considerations include a clear role description with established shared goals and expectations, and a compensation model that includes effort and incentives. In addition, there should be a clearly established reporting structure to senior leadership, and the unit leaders should be given opportunities for professional growth and development. Table 1 provides a summary overview of 6 hospitals' experiences to date.
| Structure | Hospital of the University of Pennsylvania | Northwestern Memorial Hospital | Emory University Hospital | University of Michigan Health System | Christiana Care Health System | St. Joseph Mercy Health System/Integrated Health Associates |
|---|---|---|---|---|---|---|
| ||||||
| Description of hospital(s) | Academic medical center, 784 beds, 40,000 annual admissions | Academic medical center, 897 beds, 53,000 annual admissions | Academic medical center, 579 beds, 24,000 annual admissions | Academic medical center, 839 beds, 45,000 annual admissions | Independent academic medical center, 1,100 beds, 53,000 annual admissions | Tertiary community hospital that is part of a larger health care system (Trinity Health), 579 beds, 33,000 annual admissions |
| Unit leadership model | Triad of medical director, nurse manager, and quality improvement specialist/project manager | Dyad of medical director and nurse manager | Dyad of medical director and nurse manager | Dyad of medical director and nurse manager | Dyad of medical director and nurse manager | Dyad of medical director and nurse manager |
| Percent effort time supported for unit medical director | 10% | 17% | 10% | 20% | 20% | 10% |
| Incentives built into unit leaders' performance in outcomes metrics | No | Yes | No | No | No | Yes |
| Professional development/leadership training | Quality improvement method: PDSA, Six Sigma, Lean Healthcare | Quality improvement method: Six Sigma | Situational leadership training with 1:1 mentoring | Quality improvement method: Lean Healthcare, service excellence program | Quality Improvement method: Six Sigma, Lean Healthcare | Quality improvement method: Six Sigma |
| Additional leadership development through Penn Medicine Leadership Academy and Wharton Executive Education | Additional leadership development through Northwestern's professional development center and simulation training center | Conflict resolution skill development | Attend patient and Family Centered Care conference | Additional leadership development through Christiana Care Learning Institute | Attend educational course on Crucial Conversations | |
| Personality profile with coaching | Additional leadership development through University of Michigan Health System's human resources group | |||||
| Outcomes metrics monitored | Patient satisfaction | Patient satisfaction | Patient satisfaction | Patient satisfaction | Patient satisfaction | Patient satisfaction |
| Efficiency of multidisciplinary rounds | Teamwork climate (survey) | Teamwork and implementation of structured interdisciplinary bedside rounds | Multidisciplinary rounds | Interdisciplinary rounds | Participation in interdisciplinary rounds | |
| RNMD work environment surveys | Adverse events | Unit‐based patient safety culture survey | Patient‐centered, bedside rounds | Readmission rates | ||
| Hospital‐acquired conditions (CAUTI, CLABSI, VAP, DVT, pressure ulcers) | Hospital‐acquired conditions (fall rates, pressure ulcers | Hospital‐acquired conditions (CAUTI, CLABSI, fall rates, pressure ulcers) | Hospital‐acquired conditions (CAUTI) | Hospital‐acquired conditions (fall rates, pressure ulcers) | Core measures | |
| Readmission rates | Readmission rates | Mortality | Readmission rates | Readmission rates | Medication reconciliation | |
| Core measures, patient safety indicators | Core measures | Length of stay | DVT prophylaxis | Hand hygiene | Discharge by 11 am | |
| Mortality (observed to expected, transfer, inpatient) | Hand hygiene | Glycemic control | Meeting attendance | Length of stay | Use of patient teach‐back | |
| Medication reconciliation | Restraint use | Communication with PCPs | ||||
| Home care, hospice, post‐acute care referral rates | ||||||
| Organizational leadership structure support for clinical unit partnership program | CMO, CNO, vice president of quality/patient safety, directors of medical and surgical nursing | Associate chair of medicine, director of medicine nursing; all medical directors are members of the department of medicine quality management committee | CMO, CNO, CEO, CQO | CMO, CNO | All teams report to and are supported by 3 overarching, system‐wide committees: (1) safety first, (2) think of yourself as a patient, (3) clinical excellence. Those committees, in turn, report up to the senior management quality/safety coordinating council. | Director of hospitalist program (reports to CMO); nursing director of acute care (reports to CNO) |
DISCUSSION
In reviewing our 6 organization's collective experiences, we identified several common themes and some notable differences across sites. The core of the leadership team was primarily composed of the medical director and nurse manager on the unit. Across all 6 organizations, medical directors had a portion of their effort supported for their leadership work on the unit. Leadership development training was provided at all of our sites, with particular emphasis on quality improvement (QI) methods such as Six‐Sigma, Lean, or Plan, Do, Study, Act (PDSA). Additional leadership development sessions were provided through the organization's human resources or affiliated university. Common outcome measures of interest include patient satisfaction, interdisciplinary practice, and collaboration on the unit, and some hospital‐acquired condition measures. Last, there is a direct reporting relationship to a chief or senior nurse or physician leader within each organization. These commonalities and variances are further detailed below.
Establishing the Unit‐Based Leadership Model
The composition of the unit‐based leadership model in our 6 organizations is predominantly a dyad partnership of medical directors and nurse managers. Although informal physician‐nurse collaborative practices have likely been in existence at many hospitals, formalizing this dyad partnership is an important step to fostering collaborative efforts to improve quality of care. It is also essential for hospital leadership to clearly articulate the need for this unit‐based leadership model. Whether the motivation for change is from a previously untenable practice environment, or part of an ongoing improvement program, the model should be presented in a manner that supports the organization's commitment to improve collaborative practices for better patient care. One of our 6 hospitals initiated this leadership model based on troubling relationships between nurses and physicians on some of their inpatient care units, which threatened to stall the organization's Magnet application. Implementation of the leadership model at the unit level yielded improvements in nursephysician interactions, patient satisfaction, and staff turnover.[15, 23] Another of the hospitals first evaluated why a previous attempt at this model did not deliver the intended outcomes, and redesigned the model based on its analysis.[14]
Across all of the organizations featured here, a common driver behind the adoption of the unit‐based leadership model was to bridge the divide between physician services and nursing and other allied health providers. We found that many of the physicians routinely had patients on multiple units, limiting the quantity and quality of collaborative practices between unit‐based staff and physician teams. The unit‐based dyad leaders are ideally positioned to build and foster a culture of collaboration, and our organizations have been inclusive to ensure the participation of a multidisciplinary group of providers, including representatives from pharmacy, environmental services, physical therapy, respiratory therapy, social work, case management, and nutrition at leadership meetings or in daily patient‐care discussions. In addition, 2 of the organizations have added quality improvement specialist/project managers to their teams to support the physiciannurse manager leaders on the unit.
Selection Process and Professional Development
The traditional approach to hiring a physician leader or a nurse manager has been an isolated process of drafting a job description for each position and hiring within their respective departments. For the dyad partnership to be successful, there should be established goals and expectations that require shared responsibilities between the 2 partners, which should guide the selection of these leaders. Other leadership attributes and essential character traits that should be modeled by the unit‐based leaders include good communication skills, respect among coworkers, and a collaborative approach to decision making and action. In addition, both physician leaders and nurse managers in these roles should have the ability to take a system's view, recognizing that within the complex network of healthcare providers and processes on their unit, these elements interact with each other, which lead to the outcomes achieved on their units.[24, 25] Table 2 lists some general shared responsibilities, highlighting specific activities that can be used to achieve the established outcomes. As the unit's dyad leadership works together to address these shared responsibilities, they should keep their sights focused on the overall strategic goals of the healthcare organization. Bohmer has defined 4 habits of the high‐value healthcare organization that in turn can be reflected through the inpatient unit leadership model to capture these activities at the local level: (1) planning care for specific patient populations, (2) microsystem design, (3) measurement and oversight, and (4) self‐study.[26] In determining specific shared responsibilities for each dyad partner, it is important for these leaders to understand the clinical microsystem of their unit such as their patient population, interdisciplinary care team, approach to process improvement, and performance patterns over time.[27]
| General Shared Responsibilities of Physician and Nurse Unit Directors | Examples of Specific Activities |
|---|---|
| |
| Serve as management partners to enhance culture of the unit | Co‐craft and deliver consistent leadership message |
| Co‐establish and enforce unit processes and protocols | |
| Co‐lead recruitment and retention efforts | |
| Co‐orient trainees and faculty rotating through unit | |
| Co‐educate on the management of common medical and surgical conditions | |
| Facilitate interstaff conflict resolution sessions | |
| Regular leadership meetings | |
| Actively manage unit processes and outcomes | Quality: improve core quality measure performance |
| Safety: improve culture of patient safety within the unit as measured by surveys and incident reporting systems | |
| Efficiency: reduce unnecessary length of stay and variability in resource use | |
| Patient experience: focus on improving patient‐family experience with targeted outcomes in patient experience metrics (eg, HCAHPS) | |
| Education: develop trainee and staff clinical and teamwork competencies | |
| Continuous process improvement initiatives (eg, PDSA cycles) | Improve the discharge transitions process, tailoring the process to each individual patient's identified risk factors |
| Focus improvement efforts on reduction in specific hospital acquired conditions such as CAUTI, VTE, CLABSI, pressure ulcers, falls | |
| Measure, analyze, reassess, and improve in all described areas of shared responsibilities | |
| Perform unit level chart reviews to evaluate readmissions and LOS and identify improvement opportunities | |
In our collective experience, the dyad leaders bring passion and commitment to improving care; however, many (the medical directors in particular) have minimal prior formal training in leadership, quality improvement, or hospital management. Recognizing that unit leaders require specialized knowledge and skills, each of our organizations has enrolled unit medical directors and nurse managers in leadership development courses or educational programs. Many healthcare organizations have become more grounded in a QI methodology including Six‐Sigma, Lean Healthcare, PDSA, and other scientifically based methods, and the unit‐based leaders should receive advanced training in the preferred methods of their institution. Additional training in quality improvement, patient safety, and physician leadership can also be obtained through supplemental coursework specifically designed to train hospital leaders, with some programs leading to a certification or additional credentials.[28]
Beyond such formal educational opportunities, hospitals should not overlook the opportunity to learn from and share experiences with the other dyad leadership units within the hospital. One of the organizations described here holds monthly meetings with all of the unit dyad leaders, and 2 other organizations conduct quarterly meetings to share experiences and best practices related to specific improvement initiatives in a learning network model. Those units with more experience in specific initiatives are asked to share their lessons learned with others, as well as support each other in their efforts to collectively meet the strategic goals of the hospital.
Time and Organizational Support
In addition to leadership development, hospitals and the clinical department leadership need to support the medical directors with dedicated time away from their usual clinical duties. Some organizations in this report are providing up to 20% effort for the medical director's unit‐based leadership work; however, there is some variation in practice with regard to physician effort across sites. The University of Pennsylvania has a smaller effort support at 10%; however, some of that effort differential may be offset through the allocation of the quality improvement specialist/project manager assigned to work with the medical director and nurse manager dyad. St. Joseph Mercy Hospital also has a lower allocation, as there is additional financial compensation for the role that is at risk and not included in this 10% allocation.
It is also important to assure that the medical directors have institutional support to carry out their work in partnership with their nursing leadership. The 6 health systems described here report that although most of the physicians have appointments within a physician group or clinical department, there is hospital leadership oversight from a chief medical, nursing, or operating officer. This organizational structure may be an important aspect of the model as the unit‐based leaders seek to align their efforts with that of the hospital. Further, this form of organizational oversight can ensure that the unit leaders will receive timely and essential unit‐ and hospital‐based performance measures to manage local improvement efforts. These measures may include some components of patient experiences as reported in the Hospital Consumer Assessment of Healthcare Providers and Systems survey, readmission rates, hospital‐acquired condition rates, length of stay, observed to expected mortality rates, and results of staff satisfaction and safety culture surveys. As highlighted by several studies and commentaries, our collective experiences also identified interdisciplinary teamwork, collaboration, and communication as desirable outcome measures through the unit‐based leadership structure.[21, 22, 24, 29, 30] The medical director and nurse manager dyads can prioritize their improvement efforts based on the data provided to them, and mobilize the appropriate group of multidisciplinary practitioners and support staff on the unit.
OTHER CONSIDERATIONS
Other infrastructure variables that may increase the effectiveness of the unit leadership dyad include unit‐based clinical services (geographic localization), engaging the frontline team members in the design and implementation of change innovations, a commitment to patient and family centered practices on the unit, and enhancing clinical workflow through the support of EHR functions such as concurrent documentation and provider order entry. Geographic localization, placing the fewest possible clinical service providers on the unit to work alongside unit‐based staff, allows for a cohesive interdisciplinary unit‐based team to develop under the dyad leadership, and has been shown to improve communication practices.[9, 31] Beyond geographic localization of patients, it is critical to ensure team members are committed to the changes in workflow by directly involving them through the design and implementation of new models of care taking place on the unit. This commitment starts from the top senior nurse and physician leaders in the organization, and extends to the unit‐based dyad partners, and down to each individual interdisciplinary team member on the unit.[1] Thus, it is critical to clarify roles and responsibilities and how team members on the unit will interact with each other. For some situations, conflict management training will be helpful to the unit‐based leaders to resolve issues. To appreciate potential barriers to successful rollout of this unit leadership model, a phased implementation of pilot units, followed by successive waves, should be considered. Many of the units that instituted unit‐based interdisciplinary team rounds solicited and implemented direct feedback from frontline team members in efforts to improve communication and be more patient centered. Conversely, there are also likely to be situations where the unit‐based leaders will be confronted with hindrances to their unit‐based collaborative improvement efforts. To help prepare the dyad leaders, many of our unit‐based leaders have received specific training on how to coach and conduct difficult conversations with individuals who have performance gaps or are perceived to be hindering the progress of the unit's work. These crucial negotiation skills are not innate among most managers and should be explicitly provided to new leaders across organizations.
The goals and merits of patient‐ and family‐centered care (PFCC) have been well described.[32, 33, 34] Organizational support to teach and disseminate PFCC practices throughout all settings of care may help the leadership dyads implement rounding strategies that engage all staff, patients, and family members throughout the hospital course and during the transitions out of the hospital.
Clinical workflow has become heavily dependent on the EHR systems. For those organizations that have yet to adopt a particular EHR system, the leadership dyads should be involved throughout the EHR design process to help ensure that the technological solutions will be built to assist the clinical workflow, and once the system has been built, the leadership dyad should monitor and enhance the interface between workflow and EHR system so that it can support the creation and advancement of interdisciplinary plans of care on the unit.
CONCLUSION
The care of the hospitalized patient has become more complex over time. Interdisciplinary teamwork needs to be improved at the unit level to achieve the strategic goals of the hospital. Although quality improvement is an organizational goal, change takes place locally. Physician leaders, in partnership with nurse managers, are needed now more than ever to take on this task to improve the hospital‐care experience for patients by functioning as the primary effector arms for changing the landscape of hospital‐based care. We have described characteristics of unit‐based leadership programs adopted across 6 organizations. Hospitalists with clinical experience as the principal providers of inpatient‐based care and quality improvement experience and training, have been key participants in the development and implementation of the local leadership models in each of these hospital systems. We hope the comparison of the various models featured in this article serves as a valuable reference to hospitals and healthcare organizations who are contemplating the incorporation of this model into their strategic plan.
- , , , et al. Organizational predictors of coordination in inpatient medicine [published online ahead of print February 26, 2014]. Health Care Manage Rev. doi: 10.1097/HMR.0000000000000004.
- . Trends in case‐mix in the medicare population. Paper presented at: American Hospital Association, Federation of American Hospitals, Association of American Medical Colleges; http://www.aha.org/content/00‐10/100715‐CMItrends.pdf. July 15, 2010.
- . A requirement to reduce readmissions: take care of the patient, not just the disease. JAMA. 2013;309(4):394–396.
- , . Value‐based purchasing—national programs to move from volume to value. N Engl J Med. 2012;367(4):292–295.
- Medicare and Medicaid programs; electronic health record incentive program. Final rule. Fed Regist. 2010;75(144):44313–44588.
- . The Center for Medicare and Medicaid innovation's blueprint for rapid‐cycle evaluation of new care and payment models. Health Aff (Millwood). 2013;32(4):807–812.
- Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academies Press; 2001.
- , , , , , . Improving teamwork: impact of structured interdisciplinary rounds on a medical teaching unit. J Gen Intern Med. 2010;25(8):826–832.
- , , , et al. Impact of localizing physicians to hospital units on nurse‐physician communication and agreement on the plan of care. J Gen Intern Med. 2009;24(11):1223–1227.
- , , , . A review on systematic reviews of health information system studies. J Am Med Inform Assoc. 2010;17(6):637–645.
- , , , , . Patient whiteboards as a communication tool in the hospital setting: a survey of practices and recommendations. J Hosp Med. Apr 2010;5(4):234–239.
- , , . Development of a checklist for documenting team and collaborative behaviors during multidisciplinary bedside rounds. J Nurs Adm. 2013;43(5):280–285.
- , , , , . Assessment of teamwork during structured interdisciplinary rounds on medical units. J Hosp Med. 2012;7(9):679–683.
- , , , et al. Leadership at the front line: a clinical partnership model on general care inpatient units. Am J Med Qual. 2012;27(2):106–111.
- , . AHRQ health care innovations exchange: improvement projects led by unit‐based teams of nurse, physician, and quality leaders reduce infections, lower costs, improve patient satisfaction, and nurse‐physician communication. Available at: http://www.innovations.ahrq.gov/content.aspx?id=2719. Published April 14, 2010. Accessed November 26, 2011.
- , , , , , . Microsystems in health care: part 8. Developing people and improving work life: what front‐line staff told us. Jt Comm J Qual Saf. 2003;29(10):512–522.
- , , , et al. Microsystems in health care: part 5. How leaders are leading. Jt Comm J Qual Saf. 2003;29(6):297–308.
- , , . The academic dilemma of the inpatient unit director. Am J Psychiatry. 1989;146(1):73–76.
- , , , , . Improving and sustaining core measure performance through effective accountability of clinical microsystems in an academic medical center. Jt Comm J Qual Patient Saf. 2010;36(9):387–398.
- , , . Physician leadership and quality improvement in the acute child and adolescent psychiatric care setting. Child Adolesc Psychiatr Clin N Am. 2010;19(1):1–19; table of contents.
- , , , . Effect of a multidisciplinary intervention on communication and collaboration among physicians and nurses. Am J Crit Care. 2005;14(1):71–77.
- , . Nurse‐physician leadership: insights into interprofessional collaboration. J Nurs Adm. 2013;43(12):653–659.
- The Advisory Board. University of Pennsylvania Health System pilots unit clinical leadership model to spur quality gains. Nurs Exec Watch. 2008;9(2):4–6.
- , . Physicians as leaders in improving health care: a new series in Annals of Internal Medicine. Ann Intern Med. 1998;128(4):289–292.
- . Understanding medical systems. Ann Intern Med. 1998;128(4):293–298.
- . The four habits of high‐value health care organizations. N Engl J Med. 2011;365(22):2045–2047.
- , , , et al. Microsystems in health care: Part 1. Learning from high‐performing front‐line clinical units. Jt Comm J Qual Improv. 2002;28(9):472–493.
- , , , et al. The quality and safety educators academy: fulfilling an unmet need for faculty development. Am J Med Qual. 2014;29(1):5–12.
- , , , . Cooperation: the foundation of improvement. Ann Intern Med. 1998;128(12 pt 1):1004–1009.
- , , , , , . Ten principles of good interdisciplinary team work. Hum Resour Health 2013;11(1):19.
- , , , et al. Impact of localizing general medical teams to a single nursing unit. J Hosp Med. 2012;7(7):551–556.
- , , , . Integrating patient‐ and family‐centered care with health policy: four proposed policy approaches. Qual Manag Health Care. 2013;22(2):137–145.
- , , . Incorporating patient‐ and family‐centered care into resident education: approaches, benefits, and challenges. J Grad Med Educ. 2011;3(2):272–278.
- Smith M, Saunders R, Stuckhardt L, McGinnis JM, eds. Best Care at Lower Cost: The Path to Continuously Learning Health Care in America. Washington, DC: National Academies Press; 2012.
- , , , et al. Organizational predictors of coordination in inpatient medicine [published online ahead of print February 26, 2014]. Health Care Manage Rev. doi: 10.1097/HMR.0000000000000004.
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Hospitalist Experiences Regarding PICCs
Peripherally inserted central catheters (PICCs) have become among the most common central venous catheters (CVCs) used in contemporary medical practice.[1] Although they were originally developed for delivery of parenteral nutrition, the use of PICCs has expanded to include chemotherapy administration, long‐term intravenous (IV) antibiotic treatment, and venous access when obtaining peripheral veins is difficult (eg, occluded peripheral veins, unusual venous anatomies).[2] Despite these roles, little is known about PICC use in hospitalized patients. This knowledge gap is important, as PICCs are placed in inpatient settings for a variety of reasons. Some of these reasons may not be appropriate, and inappropriate PICC use may worsen outcomes and increase healthcare costs.[3] In addition, PICCs are not innocuous and are frequently associated with important complications including thrombophlebitis, central‐lineassociated bloodstream infection and venous thromboembolism.[4, 5, 6] Therefore, understanding patterns and knowledge associated with PICC use is also an important patient safety concern.
As the main providers of inpatient care, hospitalists frequently order the insertion of PICCs and treat PICC‐related complications. Unfortunately, to date, no study has surveyed hospitalists regarding management or use of PICCs. Understanding hospitalist experiences, practice, opinions, and knowledge related to PICCs is therefore of significant interest when examining present‐day PICC use. To bridge this important knowledge gap and better understand these practices, we conducted a Web‐based survey of hospitalists in 5 healthcare systems in the state of Michigan.
METHODS
A convenience sample of hospitalists (N=227) was assembled from 5 large healthcare systems (representing 10 hospitals) that participate in the Hospital Medicine Safety (HMS) Consortium, a Blue Cross/Blue Shield of Michiganfunded statewide collaborative quality initiative. Individuals engaged in research, quality improvement, or leadership at HMS sites were invited to serve as site principal investigators (site PIs). Site PIs were responsible for obtaining regulatory approval at their parent facilities and disseminating the survey to providers in their group. Participation in the survey was solicited via e‐mail invitations from site PIs to hospitalists within their provider group. To encourage participation, a $10 electronic gift card was offered to respondents who successfully completed the survey. Reminder e‐mails were also sent each week by site PIs to augment participation. To enhance study recruitment, all responses were collected anonymously. The survey was administered between August 2012 and September 2012; data collection occurred for 5 weeks during this interval.
Survey questions were derived from our published, evidence‐based conceptual framework of PICC‐related complications. Briefly, this model identifies complications related to PICCs as arising from domains related to patient‐, provider‐, and device‐related characteristics based on existing evidence.[2] For our survey, questions were sourced from each of these domains so as to improve understanding of hospitalist experience, practice, opinions, and knowledge regarding PICC use. To ensure clarity of the survey questions, all questions were first pilot‐tested with a group of randomly selected hospitalist respondents at the University of Michigan Health System. Direct feedback obtained from these respondents was then used to iteratively improve each question. In order to generate holistic responses, questions were designed to generate a response reflective of the participants typical PICC use/subenario. We used SurveyMonkey to collect and manage survey data.
Statistical Analyses
Variation in hospitalist experience, reported practice, opinions, and knowledge regarding PICCs was assessed by hospitalist type (full time vs part time), years of practice (<1, 15, >5), and care‐delivery model (direct care vs learner‐based care). Bivariate comparisons were made using the 2 or Fisher exact tests as appropriate; 2‐sided with a P value <0.05 was considered statistically significant. All analyses were conducted using Stata version 11 (StataCorp, College Station, TX). Local institutional review board approval was obtained at each site participating in the survey.
RESULTS
A total of 227 surveys were administered and 144 responses collected, for a survey response rate of 63%. Each participating site had unique characteristics including size, number of hospitalists, and modality of PICC insertion (Table 1). Of the hospitalists who completed the survey, 81% held full‐time clinical positions and had been in practice an average of 5.6 years. Surveyed hospitalists reported caring for an average of 40.6 patients per week and ordering a mean of 2.9 (range, 015) PICCs per week of clinical service. Among survey respondents, 36% provided direct patient care, 34% provided care either directly or through mid‐level providers and housestaff, and 9% delivered care exclusively through mid‐level providers or housestaff (Table 2). As our survey was conducted anonymously, potential identifying information such as age, race, and sex of those responding was not collected.
| Survey Site | No. of Hospitals | No. of Inpatient Beds | No. of Annual Inpatient Encounters | No. of Hospitalists | Full‐Time Hospitalists, % | Avg. No. Weeks/Year on Service | Avg. Years of Experience | No. PICCs/Week, 2012 | Modality of PICC Insertion Available |
|---|---|---|---|---|---|---|---|---|---|
| |||||||||
| University of Michigan Health System | 1 | 900+ | 5,775 | 46 | 100 | 25 | 6 | 42 | Vascular access nurse |
| Ann Arbor VA Medical Center | 1 | 135 | 825 | 16 | 50 | 17.6 | 5.1 | 12 | Vascular access nurse |
| Spectrum Health System | 2 | 800 | 14,000 | 47 | 80 | 34 | 3.75 | 56 | Interventional radiology |
| Trinity Health System | 3 | 634 | 2,300 | 67 | 80 | 24 | 4 | 31 | Interventional radiology and hospitalists |
| Henry Ford Health System | 3 | 1,150 | 1,450 | 51 | 100 | 20.4 | 5.6 | 15 | Vascular access nurse |
| Characteristic | Total (N=144) |
|---|---|
| |
| Hospitalist type, n (%) | |
| Full time | 117 (81) |
| Part time | 19 (13) |
| Unknown | 8 (6) |
| Weeks/year on a clinical service, n (%) | |
| <20 | 24 (17) |
| 20 | 107 (74) |
| Unknown | 13 (9) |
| Mean (SD) | 25.5 (10.7) |
| Median | 26 |
| Type of patients treated, n (%) | |
| Adults only | 129 (90) |
| Adults and children | 7 (5) |
| Unknown | 8 (6) |
| Years in practice as a hospitalist, n (%) | |
| 5 | 81 (56) |
| >5 | 54 (38) |
| Unknown | 9 (6) |
| Model of care delivery, n (%) | |
| Direct | 52 (36) |
| Some midlevel or housestaff providers (<50% of all encounters) | 49 (34) |
| Mostly midlevel or housestaff providers (>50% of all encounters) | 22 (15) |
| Only midlevel or housestaff providers | 13 (9) |
| Unknown | 8 (6) |
| Location of practice | |
| Trinity Health System | 39 (27) |
| University of Michigan Health System | 37 (26) |
| Henry Ford Health System | 28 (19) |
| Spectrum Health System | 21 (15) |
| Ann Arbor VA Medical Center | 11 (8) |
| Unknown | 8 (6) |
Hospitalist Experiences and Practice Related to Peripherally Inserted Central Catheters
According to responding hospitalists, the most common indications for PICC placement were long‐term IV antibiotic treatment (64%), followed by inability to obtain peripheral venous access (24%). Hospitalists reported an average duration of PICC placement of 17 days (range, 342 days). A significant percentage of hospitalists (93%) stated that they had cared for patients where a PICC was placed only for use during hospitalization, with the most common reason for such insertion being difficulty in otherwise securing venous access (67%). Respondents also reported caring for patients who had both PICCs and peripheral IV catheters in place at the same time; 49% stated that they had experienced this <5 times, whereas 33% stated they had experienced this 510 times. Furthermore, 87% of respondents indicated having admitted a patient who specifically requested a PICC due to prior difficulties with venous access. More than half of surveyed hospitalists (63%) admitted to having been contacted by a PICC nurse enquiring as to whether their patient might benefit from PICC insertion.
The majority of hospitalists (66%) reported that they specified the number of lumens when ordering PICCs. Thirty‐eight percent indicated that this decision was based on type of medication, whereas 35% selected the lowest number of lumens possible. A power PICC (specialized PICCs that are designed to withstand high‐pressure contrast injections), was specifically requested for radiographic studies (56%), infusion of large volume of fluids (10%), or was the default PICC type at their facility (34%).
A majority (74%) of survey respondents also reported that once inserted, PICCs were always used to obtain blood for routine laboratory testing. Moreover, 41% indicated that PICCs were also always used to obtain blood for microbiological cultures. The 3 most frequently encountered PICC‐related complications reported by hospitalists in our survey were blockage of a PICC lumen, bloodstream infection, and venous thromboembolism (VTE; Table 3).
| Hospitalist Experiences With PICCs | Total (N=144) |
|---|---|
| |
| Primary indication for PICC placement* | |
| Long‐term IV antibiotics | 64 |
| Venous access in a patient with poor peripheral veins | 24 |
| Parenteral nutrition | 5 |
| Chemotherapy | 4 |
| Patient specifically requested a PICC | 1 |
| Unknown/other | 2 |
| PICC placed only for venous access, n (%) | |
| Yes | 135 (94) |
| No | 9 (6) |
| PICC placed only during hospitalization, n (%) | |
| Yes | 134 (93) |
| No | 10 (7) |
| Notified by a PICC nurse (or other provider) that patient may need or benefit from a PICC, n (%) | |
| Yes | 91 (63) |
| No | 53 (37) |
| How frequently PICCs are used to obtain blood for routine laboratory testing, n (%) | |
| Always | 106 (74) |
| Unknown/other | 38 (26) |
| How frequently PICCs are used to obtain blood for blood cultures, n (%) | |
| Always | 59 (41) |
| Unknown/other | 85 (59) |
| Hospitalist Opinions on PICCs | Total (N=144) |
| In your opinion, is it appropriate to place a vascular in a hospitalized patient if other forms of peripheral access cannot be obtained? n (%) | |
| Yes | 121 (84) |
| No | 21 (15) |
| Unknown | 2 (1) |
| In your opinion, should hospitalists be trained to insert PICCs? n (%) | |
| No | 57 (40) |
| Yes, this is an important skill set for hospitalists | 46 (32) |
| Unsure | 39 (27) |
| Unknown/other | 2 (1) |
| Do you think the increasing number of vascular nurses and PICC nursing teams has influenced the use of PICCs in hospitalized patients? n (%) | |
| Yes | 112 (78) |
| No | 30 (21) |
| Unknown | 2 (1) |
| What % of PICC insertions do you think may represent inappropriate use in your hospital? n (%) | |
| <10 | 53 (37) |
| 1025 | 68 (47) |
| 2550 | 18 (13) |
| >50 | 3 (2) |
| Unknown/other | 2 (1) |
Hospitalist Opinions Regarding Peripherally Inserted Central Catheters
Compared with CVCs, 69% of hospitalists felt that PICCs were safer and more efficient because they could stay in place longer and were less likely to cause infection. Most (65%) also agreed that PICCs were more convenient than CVCs because they were inserted by PICC teams. Additionally, 74% of hospitalists felt that their patients preferred PICCs because they minimize pain from routine peripheral IV changes and phlebotomy. A majority of respondents (84%) indicated that it was appropriate to place a PICC if other forms of peripheral venous access could not be obtained. However, when specifically questioned, 47% of hospitalists indicated that at least 10%25% of PICCs placed in their hospitals might represent inappropriate use. A majority (78%) agreed with the statement that the increase in numbers of vascular nurses had influenced use of PICCs in hospitalized patients, but most (45%) were neutral when asked if PICCs were more cost‐effective than traditional CVCs.
Hospitalist Knowledge Regarding Risk of Peripherally Inserted Central CatheterRelated Venous Thromboembolism and Bloodstream Infection
Although 65% of responding hospitalists disagreed with the statement that PICCs were less likely to lead to VTE, important knowledge gaps regarding PICCs and VTE were identified (Table 4). For instance, only 4% of hospitalists were correctly aware that the PICC‐tip position is checked to reduce risk of PICC‐related VTE, and only 12% knew that the site of PICC insertion has also been associated with VTE risk. Although 85% of respondents stated they would prescribe a therapeutic dose of an anticoagulant in the case of PICC‐associated VTE, deviations from the guideline‐recommended 3‐month treatment period were noted. For example, 6% of hospitalists reported treating with anticoagulation for 6 months, and 19% stated they would treat as long as the PICC remained in place, plus an additional period of time (eg, 24 weeks) after removal. With respect to bloodstream infection, 92% of responding hospitalists correctly identified PICC duration and prompt removal as factors promoting PICC‐related bloodstream infection and 78% accurately identified components of the catheter‐associated bloodstream infection bundle. When specifically asked about factors associated with risk of PICC‐related bloodstream infection, only half of respondents recognized the number of PICC lumens as being associated with this outcome.
| Total (N=144) | |
|---|---|
| |
| Why is the position of the PICC tip checked after bedside PICC insertion? n (%) | |
| To decrease the risk of arrhythmia related to right‐atrial positioning | 108 (75) |
| To minimize the risk of VTEa | 6 (4) |
| To ensure it is not accidentally placed into an artery | 16 (11) |
| For documentation purposes (to reduce the risk of lawsuits related to line‐insertion complications) | 6 (4) |
| Unsure/Unknown | 8 (6) |
| According to the 2012 ACCP Guidelines on VTE prevention, is pharmacologic prophylaxis for DVT recommended in patients who receive long‐term PICCs? n (%) | |
| No; no anticoagulant prophylaxis is recommended for patients who receive long‐term PICCsa | 107 (74) |
| Yes, but the choice and duration of anticoagulant is at the discretion of the provider | 23 (16) |
| Yes; aspirin is recommended for 3 months | 4 (3) |
| Yes; anticoagulation with warfarin or enoxaparin is recommended for 3 months | 3 (2) |
| Yes; anticoagulation with warfarin or enoxaparin is recommended for 6 months | 2 (1) |
| Unknown | 5 (4) |
| Assuming no contraindications exist, do you anticoagulate patients who develop a PICC‐associated DVT (with any therapeutic anticoagulant)? n (%) | |
| Yesa | 122 (85) |
| No | 16 (11) |
| Unknown | 6 (4) |
| How long do you usually prescribe anticoagulation for patients who develop PICC‐associated DVT? n (%) | |
| I don't prescribe anticoagulation | 12 (8) |
| 1 month | 4 (3) |
| 3 monthsa | 84 (58) |
| 6 months | 8 (6) |
| As long as the line remains in place; I stop anticoagulation once the PICC comes out | 3 (2) |
| As long as the line remains in place and for an additional specified period of time after line removal, such as 2 or 4 weeks | 27 (19) |
| Unknown | 6 (4) |
| As part of the treatment of PICC‐related DVT, do you routinely remove the PICC?b n (%) | |
| Yes | 102 (71) |
| No | 36 (25) |
| Unknown | 6 (4) |
Variation in Hospitalist Knowledge, Experience, or Opinions
We assessed whether any of our findings varied according to hospitalist type (full time versus part time), years of practice (<1, 15, >5), and model of care delivery (direct care vs learner‐based care). Our analyses suggested that part‐time hospitalists were more likely to select rarely when it came to finding patients with a PICC and a working peripheral IV at the same time (74% vs 45%, P=0.02). Interestingly, a higher percentage of those in practice <5 years indicated that 10%25% of PICCs represented inappropriate placement (58% vs 33%, P<0.01) and that vascular nurses had influenced the use of PICCs in hospitalized patients (88% vs 69%, P=0.01). Lastly, a higher percentage of hospitalists who provided direct patient care reported that PICCs were always used to obtain blood for microbiological culture (54% vs 37%, P=0.05).
DISCUSSION
In this survey of hospitalists practicing at 5 large healthcare systems in Michigan, we observed significant variation in experience, reported practice, opinions, and knowledge related to PICCs. Our findings highlight important concerns related to inpatient PICC use and suggest a need for greater scrutiny related to these devices in these settings.
The use of PICCs in hospitalized patients has risen dramatically over the past decade. Though such growth is multifactorial and relates in part to increasing inpatient volume and complexity, hospitalists have increasingly turned to PICCs as a convenient and reliable tool to obtain venous access.[7] Indeed, in our survey, PICCs that were only used during hospitalization were most likely to be placed for this very reason. Because PICCs are safer to insert than CVCs and the original evidence regarding PICC‐related VTE or bloodstream infection suggested low rates of these events,[8, 9, 10, 11, 12, 13, 14] many hospitalists may not perceive these devices as being associated with significant risks. In fact, some have suggested that hospitalists be specifically trained to insert these devices, given their safety compared with traditional CVCs.[7]
However, accumulating evidence suggests that PICCs are associated with important complications.[5, 15, 16] In studies examining risk of bloodstream infection, PICCs were associated with significant risk of this outcome.[6, 17, 18] Recently, the presence of a PICC was identified as an independent predictor of VTE in hospitalized patients.[19] Several studies and systematic reviews have repeatedly demonstrated these findings.[19, 20, 21, 22] A recent systematic review examining nonpharmacologic methods to prevent catheter‐related thrombosis specifically called for avoidance of PICC insertion to prevent thrombosis in hospitalized patients.[23] Despite this growing evidence base, the use of PICCs in the inpatient setting is likely to rise, and our survey highlights several practices that may contribute to adverse outcomes. For instance, hospitalists in our survey were unlikely to remove a PICC until a patient was discharged, irrespective of the need for this device. As each day with a PICC increases the risk of complications, such practice poses potential patient safety concerns. Similarly, many hospitalists believe that PICCs are safer than CVCs, a viewpoint that does not stand up to increasing scrutiny and highlights important knowledge gaps. The risk of PICC‐related complications appears not to be a stationary target, but rather a dynamic balance that is influenced by patient‐, provider‐, and device‐specific characteristics.[2] Increasing discretionary use (especially for patients with poor peripheral venous access), forgetting at times that a patient has a PICC, and the finding that up to 25% of PICCs placed in their hospitals may be unnecessary underscore concerns regarding the safety of current practice trends. Interestingly, the viewpoints of hospitalists in practice <5 years and those providing direct patient care were more likely to reflect concerns regarding inappropriate placement, influence of vascular nurses, and use of PICCs for blood culture. This finding may reflect that these nuances are more recent phenomena or perhaps most apparent when care is delivered directly.
Our study must be interpreted in the context of several limitations. First, as this was a survey‐based study of a small, convenience sample of hospitalists in a single state, recall, respondent, and systematic biases remain threats to our findings. However, all site PIs encouraged survey participation and (through local dialogue) none were aware of material differences between those who did or did not participate in the study. Similarly, Michigan is a diverse and relatively large state, and our results should be generalizable to other settings; however, national studies are necessary to confirm our findings. Second, our response rate may be perceived as low; however, our rates are in accordance with, and, in fact, superior to those of many existing physician surveys.[24] Finally, only 1 federal facility was included in this study; thus, this care‐delivery model is underrepresented, limiting generalization of findings to other such sites.
However, our study also has important strengths. First, this is the only survey that specifically examines hospitalist viewpoints when it comes to PICCs. As hospitalists frequently order and/or insert these devices, their perspectives are highly pertinent to discussions regarding current PICC use. Second, our survey highlights several instances that may be associated with preventable patient harm and identifies areas where interventions may be valuable. For example, forgetting the presence of a device, keeping PICCs in place throughout hospitalization, and rendering treatment for PICC‐related VTE not in accordance with accepted guidelines are remediable practices that may lead to poor outcomes. Interventions such as device‐reminder alerts, provider education regarding complications from PICCs, and systematic efforts to identify and remove unnecessary PICCs may mitigate these problems. Finally, our findings highlight the need for data repositories that track PICC use and hospitalist practice on a national scale. Given the risk and significance of the complications associated with these devices, understanding the epidemiology, use, and potential misuse of PICCs are important areas for hospitalist research.
In conclusion, our study of hospitalist experience, practice, opinions, and knowledge related to PICCs suggests important gaps between available evidence and current practice. There is growing need for the development of appropriateness criteria to guide vascular access in inpatient settings.[25, 26] Such criteria should consider not only type of venous access device, but granular details including rationale for venous access, nature of the infusate, optimal number of lumens, and safest gauge when recommending devices. Until such criteria and comparative studies become available, hospitals should consider instituting policies to monitor PICC use with specific attention to indication for insertion, duration of placement, and complications. These interventions represent a first and necessary step in improving patient safety when it comes to preventing PICC‐related complications.
Disclosures
The Blue Cross/Blue Shield of Michigan Foundation in Detroit funded this study through an investigator‐initiated research proposal (1931‐PIRAP). The funding source, however, played no role in study design, acquisition of data, data analysis, or reporting of these results. The authors report no conflicts of interest.
- , , , et al. Hospital‐wide survey of the use of central venous catheters. J Hosp Infect. 2011;77(4):304–308.
- , , , , . Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence. Am J Med. 2012;125(8):733–741.
- , , . The problem with peripherally inserted central catheters. JAMA. 2012;308(15):1527–1528.
- , , , et al. Reduction of peripherally inserted central catheter associated deep venous thrombosis [published online ahead of print August 1, 2012]. Chest. doi: 10.1378/chest.12–0923.
- , , . Complications associated with peripheral or central routes for central venous cannulation. Anaesthesia. 2012;67(1):65–71.
- , , , et al. Patient‐ and device‐specific risk factors for peripherally inserted central venous catheter‐related bloodstream infections. Infect Control Hosp Epidemiol. 2013;34(2):184–189.
- , . Peripherally inserted central catheter use in the hospitalized patient: is there a role for the hospitalist? J Hosp Med. 2009;4(6):E1–E4.
- , , , , , . Peripherally inserted central catheter (PICC)‐associated upper‐extremity deep venous thrombosis (UEDVT) in critical‐care setting. Chest. 2005;128(4 suppl S):193S–194S.
- , , , , , . Complications and cost associated with parenteral nutrition delivered to hospitalized patients through either subclavian or peripherally inserted central catheters. Clin Nutr. 2000;19(4):237–243.
- , . Risk of catheter‐related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest. 2005;128(2):489–495.
- , , , . Long‐term intravenous therapy with peripherally inserted silicone elastomer central venous catheters in patients with malignant diseases. Cancer. 1979;43(5):1937–1943.
- , , , , . Central vs peripheral venous catheters in critically ill patients. Chest. 1986;90(6):806–809.
- , , , , . Infectious complications among patients receiving home intravenous therapy with peripheral, central, or peripherally placed central venous catheters. Am J Med. 1991;91(3B):95S–100S.
- , , , , . Upper‐extremity deep venous thrombosis and pulmonary embolism: a prospective study. Chest. 1991;99(2):280–283.
- , , , et al. Risk factors for catheter‐related thrombosis (CRT) in cancer patients: a patient‐level data (IPD) meta‐analysis of clinical trials and prospective studies. J Thromb Haemost. 2011;9(2):312–319.
- , , , et al. Venous thrombosis associated with peripherally inserted central catheters: a retrospective analysis of the Cleveland Clinic experience. Clin Infect Dis. 2002;34(9):1179–1183.
- , , , et al. Peripherally inserted central venous catheter–associated bloodstream infections in hospitalized adult patients. Infect Control Hosp Epidemiol. 2011;32(2):125–130.
- , , . Peripherally inserted central catheter bloodstream infection surveillance rates in an acute care setting in Saudi Arabia. Ann Saudi Med. 2012;32(2):169–173.
- , , , et al. Derivation and validation of a simple model to identify venous thromboembolism risk in medical patients. Am J Med. 2011;124(10):947.e942–954.e942.
- , , , et al. Risk of symptomatic DVT associated with peripherally inserted central catheters. Chest. 2010;138(4):803–810.
- , , . The clinical significance of peripherally inserted central venous catheter‐related deep vein thrombosis. Neurocrit Care. 2011;15(3):454–460.
- , , , et al. Catheter‐associated bloodstream infection incidence and risk factors in adults with cancer: a prospective cohort study. J Hosp Infect. 2011;78(1):26–30.
- , , , . Nonpharmacologic interventions for prevention of catheter‐related thrombosis: a systematic review [published online ahead of print September 13, 2012]. J Crit Care. doi: 10.1016/j.jcrc.2012.07.007.
- , , . Why are response rates in clinician surveys declining? Can Fam Physician. 2012;58(4):e225–e228.
- , , , , , . Sensitivity and specificity of the RAND/UCLA Appropriateness Method to identify the overuse and underuse of coronary revascularization and hysterectomy. J Clin Epidemiol. 2001;54(10):1004–1010.
- , , , et al. Variations by specialty in physician ratings of the appropriateness and necessity of indications for procedures. Med Care. 1996;34(6):512–523.
Peripherally inserted central catheters (PICCs) have become among the most common central venous catheters (CVCs) used in contemporary medical practice.[1] Although they were originally developed for delivery of parenteral nutrition, the use of PICCs has expanded to include chemotherapy administration, long‐term intravenous (IV) antibiotic treatment, and venous access when obtaining peripheral veins is difficult (eg, occluded peripheral veins, unusual venous anatomies).[2] Despite these roles, little is known about PICC use in hospitalized patients. This knowledge gap is important, as PICCs are placed in inpatient settings for a variety of reasons. Some of these reasons may not be appropriate, and inappropriate PICC use may worsen outcomes and increase healthcare costs.[3] In addition, PICCs are not innocuous and are frequently associated with important complications including thrombophlebitis, central‐lineassociated bloodstream infection and venous thromboembolism.[4, 5, 6] Therefore, understanding patterns and knowledge associated with PICC use is also an important patient safety concern.
As the main providers of inpatient care, hospitalists frequently order the insertion of PICCs and treat PICC‐related complications. Unfortunately, to date, no study has surveyed hospitalists regarding management or use of PICCs. Understanding hospitalist experiences, practice, opinions, and knowledge related to PICCs is therefore of significant interest when examining present‐day PICC use. To bridge this important knowledge gap and better understand these practices, we conducted a Web‐based survey of hospitalists in 5 healthcare systems in the state of Michigan.
METHODS
A convenience sample of hospitalists (N=227) was assembled from 5 large healthcare systems (representing 10 hospitals) that participate in the Hospital Medicine Safety (HMS) Consortium, a Blue Cross/Blue Shield of Michiganfunded statewide collaborative quality initiative. Individuals engaged in research, quality improvement, or leadership at HMS sites were invited to serve as site principal investigators (site PIs). Site PIs were responsible for obtaining regulatory approval at their parent facilities and disseminating the survey to providers in their group. Participation in the survey was solicited via e‐mail invitations from site PIs to hospitalists within their provider group. To encourage participation, a $10 electronic gift card was offered to respondents who successfully completed the survey. Reminder e‐mails were also sent each week by site PIs to augment participation. To enhance study recruitment, all responses were collected anonymously. The survey was administered between August 2012 and September 2012; data collection occurred for 5 weeks during this interval.
Survey questions were derived from our published, evidence‐based conceptual framework of PICC‐related complications. Briefly, this model identifies complications related to PICCs as arising from domains related to patient‐, provider‐, and device‐related characteristics based on existing evidence.[2] For our survey, questions were sourced from each of these domains so as to improve understanding of hospitalist experience, practice, opinions, and knowledge regarding PICC use. To ensure clarity of the survey questions, all questions were first pilot‐tested with a group of randomly selected hospitalist respondents at the University of Michigan Health System. Direct feedback obtained from these respondents was then used to iteratively improve each question. In order to generate holistic responses, questions were designed to generate a response reflective of the participants typical PICC use/subenario. We used SurveyMonkey to collect and manage survey data.
Statistical Analyses
Variation in hospitalist experience, reported practice, opinions, and knowledge regarding PICCs was assessed by hospitalist type (full time vs part time), years of practice (<1, 15, >5), and care‐delivery model (direct care vs learner‐based care). Bivariate comparisons were made using the 2 or Fisher exact tests as appropriate; 2‐sided with a P value <0.05 was considered statistically significant. All analyses were conducted using Stata version 11 (StataCorp, College Station, TX). Local institutional review board approval was obtained at each site participating in the survey.
RESULTS
A total of 227 surveys were administered and 144 responses collected, for a survey response rate of 63%. Each participating site had unique characteristics including size, number of hospitalists, and modality of PICC insertion (Table 1). Of the hospitalists who completed the survey, 81% held full‐time clinical positions and had been in practice an average of 5.6 years. Surveyed hospitalists reported caring for an average of 40.6 patients per week and ordering a mean of 2.9 (range, 015) PICCs per week of clinical service. Among survey respondents, 36% provided direct patient care, 34% provided care either directly or through mid‐level providers and housestaff, and 9% delivered care exclusively through mid‐level providers or housestaff (Table 2). As our survey was conducted anonymously, potential identifying information such as age, race, and sex of those responding was not collected.
| Survey Site | No. of Hospitals | No. of Inpatient Beds | No. of Annual Inpatient Encounters | No. of Hospitalists | Full‐Time Hospitalists, % | Avg. No. Weeks/Year on Service | Avg. Years of Experience | No. PICCs/Week, 2012 | Modality of PICC Insertion Available |
|---|---|---|---|---|---|---|---|---|---|
| |||||||||
| University of Michigan Health System | 1 | 900+ | 5,775 | 46 | 100 | 25 | 6 | 42 | Vascular access nurse |
| Ann Arbor VA Medical Center | 1 | 135 | 825 | 16 | 50 | 17.6 | 5.1 | 12 | Vascular access nurse |
| Spectrum Health System | 2 | 800 | 14,000 | 47 | 80 | 34 | 3.75 | 56 | Interventional radiology |
| Trinity Health System | 3 | 634 | 2,300 | 67 | 80 | 24 | 4 | 31 | Interventional radiology and hospitalists |
| Henry Ford Health System | 3 | 1,150 | 1,450 | 51 | 100 | 20.4 | 5.6 | 15 | Vascular access nurse |
| Characteristic | Total (N=144) |
|---|---|
| |
| Hospitalist type, n (%) | |
| Full time | 117 (81) |
| Part time | 19 (13) |
| Unknown | 8 (6) |
| Weeks/year on a clinical service, n (%) | |
| <20 | 24 (17) |
| 20 | 107 (74) |
| Unknown | 13 (9) |
| Mean (SD) | 25.5 (10.7) |
| Median | 26 |
| Type of patients treated, n (%) | |
| Adults only | 129 (90) |
| Adults and children | 7 (5) |
| Unknown | 8 (6) |
| Years in practice as a hospitalist, n (%) | |
| 5 | 81 (56) |
| >5 | 54 (38) |
| Unknown | 9 (6) |
| Model of care delivery, n (%) | |
| Direct | 52 (36) |
| Some midlevel or housestaff providers (<50% of all encounters) | 49 (34) |
| Mostly midlevel or housestaff providers (>50% of all encounters) | 22 (15) |
| Only midlevel or housestaff providers | 13 (9) |
| Unknown | 8 (6) |
| Location of practice | |
| Trinity Health System | 39 (27) |
| University of Michigan Health System | 37 (26) |
| Henry Ford Health System | 28 (19) |
| Spectrum Health System | 21 (15) |
| Ann Arbor VA Medical Center | 11 (8) |
| Unknown | 8 (6) |
Hospitalist Experiences and Practice Related to Peripherally Inserted Central Catheters
According to responding hospitalists, the most common indications for PICC placement were long‐term IV antibiotic treatment (64%), followed by inability to obtain peripheral venous access (24%). Hospitalists reported an average duration of PICC placement of 17 days (range, 342 days). A significant percentage of hospitalists (93%) stated that they had cared for patients where a PICC was placed only for use during hospitalization, with the most common reason for such insertion being difficulty in otherwise securing venous access (67%). Respondents also reported caring for patients who had both PICCs and peripheral IV catheters in place at the same time; 49% stated that they had experienced this <5 times, whereas 33% stated they had experienced this 510 times. Furthermore, 87% of respondents indicated having admitted a patient who specifically requested a PICC due to prior difficulties with venous access. More than half of surveyed hospitalists (63%) admitted to having been contacted by a PICC nurse enquiring as to whether their patient might benefit from PICC insertion.
The majority of hospitalists (66%) reported that they specified the number of lumens when ordering PICCs. Thirty‐eight percent indicated that this decision was based on type of medication, whereas 35% selected the lowest number of lumens possible. A power PICC (specialized PICCs that are designed to withstand high‐pressure contrast injections), was specifically requested for radiographic studies (56%), infusion of large volume of fluids (10%), or was the default PICC type at their facility (34%).
A majority (74%) of survey respondents also reported that once inserted, PICCs were always used to obtain blood for routine laboratory testing. Moreover, 41% indicated that PICCs were also always used to obtain blood for microbiological cultures. The 3 most frequently encountered PICC‐related complications reported by hospitalists in our survey were blockage of a PICC lumen, bloodstream infection, and venous thromboembolism (VTE; Table 3).
| Hospitalist Experiences With PICCs | Total (N=144) |
|---|---|
| |
| Primary indication for PICC placement* | |
| Long‐term IV antibiotics | 64 |
| Venous access in a patient with poor peripheral veins | 24 |
| Parenteral nutrition | 5 |
| Chemotherapy | 4 |
| Patient specifically requested a PICC | 1 |
| Unknown/other | 2 |
| PICC placed only for venous access, n (%) | |
| Yes | 135 (94) |
| No | 9 (6) |
| PICC placed only during hospitalization, n (%) | |
| Yes | 134 (93) |
| No | 10 (7) |
| Notified by a PICC nurse (or other provider) that patient may need or benefit from a PICC, n (%) | |
| Yes | 91 (63) |
| No | 53 (37) |
| How frequently PICCs are used to obtain blood for routine laboratory testing, n (%) | |
| Always | 106 (74) |
| Unknown/other | 38 (26) |
| How frequently PICCs are used to obtain blood for blood cultures, n (%) | |
| Always | 59 (41) |
| Unknown/other | 85 (59) |
| Hospitalist Opinions on PICCs | Total (N=144) |
| In your opinion, is it appropriate to place a vascular in a hospitalized patient if other forms of peripheral access cannot be obtained? n (%) | |
| Yes | 121 (84) |
| No | 21 (15) |
| Unknown | 2 (1) |
| In your opinion, should hospitalists be trained to insert PICCs? n (%) | |
| No | 57 (40) |
| Yes, this is an important skill set for hospitalists | 46 (32) |
| Unsure | 39 (27) |
| Unknown/other | 2 (1) |
| Do you think the increasing number of vascular nurses and PICC nursing teams has influenced the use of PICCs in hospitalized patients? n (%) | |
| Yes | 112 (78) |
| No | 30 (21) |
| Unknown | 2 (1) |
| What % of PICC insertions do you think may represent inappropriate use in your hospital? n (%) | |
| <10 | 53 (37) |
| 1025 | 68 (47) |
| 2550 | 18 (13) |
| >50 | 3 (2) |
| Unknown/other | 2 (1) |
Hospitalist Opinions Regarding Peripherally Inserted Central Catheters
Compared with CVCs, 69% of hospitalists felt that PICCs were safer and more efficient because they could stay in place longer and were less likely to cause infection. Most (65%) also agreed that PICCs were more convenient than CVCs because they were inserted by PICC teams. Additionally, 74% of hospitalists felt that their patients preferred PICCs because they minimize pain from routine peripheral IV changes and phlebotomy. A majority of respondents (84%) indicated that it was appropriate to place a PICC if other forms of peripheral venous access could not be obtained. However, when specifically questioned, 47% of hospitalists indicated that at least 10%25% of PICCs placed in their hospitals might represent inappropriate use. A majority (78%) agreed with the statement that the increase in numbers of vascular nurses had influenced use of PICCs in hospitalized patients, but most (45%) were neutral when asked if PICCs were more cost‐effective than traditional CVCs.
Hospitalist Knowledge Regarding Risk of Peripherally Inserted Central CatheterRelated Venous Thromboembolism and Bloodstream Infection
Although 65% of responding hospitalists disagreed with the statement that PICCs were less likely to lead to VTE, important knowledge gaps regarding PICCs and VTE were identified (Table 4). For instance, only 4% of hospitalists were correctly aware that the PICC‐tip position is checked to reduce risk of PICC‐related VTE, and only 12% knew that the site of PICC insertion has also been associated with VTE risk. Although 85% of respondents stated they would prescribe a therapeutic dose of an anticoagulant in the case of PICC‐associated VTE, deviations from the guideline‐recommended 3‐month treatment period were noted. For example, 6% of hospitalists reported treating with anticoagulation for 6 months, and 19% stated they would treat as long as the PICC remained in place, plus an additional period of time (eg, 24 weeks) after removal. With respect to bloodstream infection, 92% of responding hospitalists correctly identified PICC duration and prompt removal as factors promoting PICC‐related bloodstream infection and 78% accurately identified components of the catheter‐associated bloodstream infection bundle. When specifically asked about factors associated with risk of PICC‐related bloodstream infection, only half of respondents recognized the number of PICC lumens as being associated with this outcome.
| Total (N=144) | |
|---|---|
| |
| Why is the position of the PICC tip checked after bedside PICC insertion? n (%) | |
| To decrease the risk of arrhythmia related to right‐atrial positioning | 108 (75) |
| To minimize the risk of VTEa | 6 (4) |
| To ensure it is not accidentally placed into an artery | 16 (11) |
| For documentation purposes (to reduce the risk of lawsuits related to line‐insertion complications) | 6 (4) |
| Unsure/Unknown | 8 (6) |
| According to the 2012 ACCP Guidelines on VTE prevention, is pharmacologic prophylaxis for DVT recommended in patients who receive long‐term PICCs? n (%) | |
| No; no anticoagulant prophylaxis is recommended for patients who receive long‐term PICCsa | 107 (74) |
| Yes, but the choice and duration of anticoagulant is at the discretion of the provider | 23 (16) |
| Yes; aspirin is recommended for 3 months | 4 (3) |
| Yes; anticoagulation with warfarin or enoxaparin is recommended for 3 months | 3 (2) |
| Yes; anticoagulation with warfarin or enoxaparin is recommended for 6 months | 2 (1) |
| Unknown | 5 (4) |
| Assuming no contraindications exist, do you anticoagulate patients who develop a PICC‐associated DVT (with any therapeutic anticoagulant)? n (%) | |
| Yesa | 122 (85) |
| No | 16 (11) |
| Unknown | 6 (4) |
| How long do you usually prescribe anticoagulation for patients who develop PICC‐associated DVT? n (%) | |
| I don't prescribe anticoagulation | 12 (8) |
| 1 month | 4 (3) |
| 3 monthsa | 84 (58) |
| 6 months | 8 (6) |
| As long as the line remains in place; I stop anticoagulation once the PICC comes out | 3 (2) |
| As long as the line remains in place and for an additional specified period of time after line removal, such as 2 or 4 weeks | 27 (19) |
| Unknown | 6 (4) |
| As part of the treatment of PICC‐related DVT, do you routinely remove the PICC?b n (%) | |
| Yes | 102 (71) |
| No | 36 (25) |
| Unknown | 6 (4) |
Variation in Hospitalist Knowledge, Experience, or Opinions
We assessed whether any of our findings varied according to hospitalist type (full time versus part time), years of practice (<1, 15, >5), and model of care delivery (direct care vs learner‐based care). Our analyses suggested that part‐time hospitalists were more likely to select rarely when it came to finding patients with a PICC and a working peripheral IV at the same time (74% vs 45%, P=0.02). Interestingly, a higher percentage of those in practice <5 years indicated that 10%25% of PICCs represented inappropriate placement (58% vs 33%, P<0.01) and that vascular nurses had influenced the use of PICCs in hospitalized patients (88% vs 69%, P=0.01). Lastly, a higher percentage of hospitalists who provided direct patient care reported that PICCs were always used to obtain blood for microbiological culture (54% vs 37%, P=0.05).
DISCUSSION
In this survey of hospitalists practicing at 5 large healthcare systems in Michigan, we observed significant variation in experience, reported practice, opinions, and knowledge related to PICCs. Our findings highlight important concerns related to inpatient PICC use and suggest a need for greater scrutiny related to these devices in these settings.
The use of PICCs in hospitalized patients has risen dramatically over the past decade. Though such growth is multifactorial and relates in part to increasing inpatient volume and complexity, hospitalists have increasingly turned to PICCs as a convenient and reliable tool to obtain venous access.[7] Indeed, in our survey, PICCs that were only used during hospitalization were most likely to be placed for this very reason. Because PICCs are safer to insert than CVCs and the original evidence regarding PICC‐related VTE or bloodstream infection suggested low rates of these events,[8, 9, 10, 11, 12, 13, 14] many hospitalists may not perceive these devices as being associated with significant risks. In fact, some have suggested that hospitalists be specifically trained to insert these devices, given their safety compared with traditional CVCs.[7]
However, accumulating evidence suggests that PICCs are associated with important complications.[5, 15, 16] In studies examining risk of bloodstream infection, PICCs were associated with significant risk of this outcome.[6, 17, 18] Recently, the presence of a PICC was identified as an independent predictor of VTE in hospitalized patients.[19] Several studies and systematic reviews have repeatedly demonstrated these findings.[19, 20, 21, 22] A recent systematic review examining nonpharmacologic methods to prevent catheter‐related thrombosis specifically called for avoidance of PICC insertion to prevent thrombosis in hospitalized patients.[23] Despite this growing evidence base, the use of PICCs in the inpatient setting is likely to rise, and our survey highlights several practices that may contribute to adverse outcomes. For instance, hospitalists in our survey were unlikely to remove a PICC until a patient was discharged, irrespective of the need for this device. As each day with a PICC increases the risk of complications, such practice poses potential patient safety concerns. Similarly, many hospitalists believe that PICCs are safer than CVCs, a viewpoint that does not stand up to increasing scrutiny and highlights important knowledge gaps. The risk of PICC‐related complications appears not to be a stationary target, but rather a dynamic balance that is influenced by patient‐, provider‐, and device‐specific characteristics.[2] Increasing discretionary use (especially for patients with poor peripheral venous access), forgetting at times that a patient has a PICC, and the finding that up to 25% of PICCs placed in their hospitals may be unnecessary underscore concerns regarding the safety of current practice trends. Interestingly, the viewpoints of hospitalists in practice <5 years and those providing direct patient care were more likely to reflect concerns regarding inappropriate placement, influence of vascular nurses, and use of PICCs for blood culture. This finding may reflect that these nuances are more recent phenomena or perhaps most apparent when care is delivered directly.
Our study must be interpreted in the context of several limitations. First, as this was a survey‐based study of a small, convenience sample of hospitalists in a single state, recall, respondent, and systematic biases remain threats to our findings. However, all site PIs encouraged survey participation and (through local dialogue) none were aware of material differences between those who did or did not participate in the study. Similarly, Michigan is a diverse and relatively large state, and our results should be generalizable to other settings; however, national studies are necessary to confirm our findings. Second, our response rate may be perceived as low; however, our rates are in accordance with, and, in fact, superior to those of many existing physician surveys.[24] Finally, only 1 federal facility was included in this study; thus, this care‐delivery model is underrepresented, limiting generalization of findings to other such sites.
However, our study also has important strengths. First, this is the only survey that specifically examines hospitalist viewpoints when it comes to PICCs. As hospitalists frequently order and/or insert these devices, their perspectives are highly pertinent to discussions regarding current PICC use. Second, our survey highlights several instances that may be associated with preventable patient harm and identifies areas where interventions may be valuable. For example, forgetting the presence of a device, keeping PICCs in place throughout hospitalization, and rendering treatment for PICC‐related VTE not in accordance with accepted guidelines are remediable practices that may lead to poor outcomes. Interventions such as device‐reminder alerts, provider education regarding complications from PICCs, and systematic efforts to identify and remove unnecessary PICCs may mitigate these problems. Finally, our findings highlight the need for data repositories that track PICC use and hospitalist practice on a national scale. Given the risk and significance of the complications associated with these devices, understanding the epidemiology, use, and potential misuse of PICCs are important areas for hospitalist research.
In conclusion, our study of hospitalist experience, practice, opinions, and knowledge related to PICCs suggests important gaps between available evidence and current practice. There is growing need for the development of appropriateness criteria to guide vascular access in inpatient settings.[25, 26] Such criteria should consider not only type of venous access device, but granular details including rationale for venous access, nature of the infusate, optimal number of lumens, and safest gauge when recommending devices. Until such criteria and comparative studies become available, hospitals should consider instituting policies to monitor PICC use with specific attention to indication for insertion, duration of placement, and complications. These interventions represent a first and necessary step in improving patient safety when it comes to preventing PICC‐related complications.
Disclosures
The Blue Cross/Blue Shield of Michigan Foundation in Detroit funded this study through an investigator‐initiated research proposal (1931‐PIRAP). The funding source, however, played no role in study design, acquisition of data, data analysis, or reporting of these results. The authors report no conflicts of interest.
Peripherally inserted central catheters (PICCs) have become among the most common central venous catheters (CVCs) used in contemporary medical practice.[1] Although they were originally developed for delivery of parenteral nutrition, the use of PICCs has expanded to include chemotherapy administration, long‐term intravenous (IV) antibiotic treatment, and venous access when obtaining peripheral veins is difficult (eg, occluded peripheral veins, unusual venous anatomies).[2] Despite these roles, little is known about PICC use in hospitalized patients. This knowledge gap is important, as PICCs are placed in inpatient settings for a variety of reasons. Some of these reasons may not be appropriate, and inappropriate PICC use may worsen outcomes and increase healthcare costs.[3] In addition, PICCs are not innocuous and are frequently associated with important complications including thrombophlebitis, central‐lineassociated bloodstream infection and venous thromboembolism.[4, 5, 6] Therefore, understanding patterns and knowledge associated with PICC use is also an important patient safety concern.
As the main providers of inpatient care, hospitalists frequently order the insertion of PICCs and treat PICC‐related complications. Unfortunately, to date, no study has surveyed hospitalists regarding management or use of PICCs. Understanding hospitalist experiences, practice, opinions, and knowledge related to PICCs is therefore of significant interest when examining present‐day PICC use. To bridge this important knowledge gap and better understand these practices, we conducted a Web‐based survey of hospitalists in 5 healthcare systems in the state of Michigan.
METHODS
A convenience sample of hospitalists (N=227) was assembled from 5 large healthcare systems (representing 10 hospitals) that participate in the Hospital Medicine Safety (HMS) Consortium, a Blue Cross/Blue Shield of Michiganfunded statewide collaborative quality initiative. Individuals engaged in research, quality improvement, or leadership at HMS sites were invited to serve as site principal investigators (site PIs). Site PIs were responsible for obtaining regulatory approval at their parent facilities and disseminating the survey to providers in their group. Participation in the survey was solicited via e‐mail invitations from site PIs to hospitalists within their provider group. To encourage participation, a $10 electronic gift card was offered to respondents who successfully completed the survey. Reminder e‐mails were also sent each week by site PIs to augment participation. To enhance study recruitment, all responses were collected anonymously. The survey was administered between August 2012 and September 2012; data collection occurred for 5 weeks during this interval.
Survey questions were derived from our published, evidence‐based conceptual framework of PICC‐related complications. Briefly, this model identifies complications related to PICCs as arising from domains related to patient‐, provider‐, and device‐related characteristics based on existing evidence.[2] For our survey, questions were sourced from each of these domains so as to improve understanding of hospitalist experience, practice, opinions, and knowledge regarding PICC use. To ensure clarity of the survey questions, all questions were first pilot‐tested with a group of randomly selected hospitalist respondents at the University of Michigan Health System. Direct feedback obtained from these respondents was then used to iteratively improve each question. In order to generate holistic responses, questions were designed to generate a response reflective of the participants typical PICC use/subenario. We used SurveyMonkey to collect and manage survey data.
Statistical Analyses
Variation in hospitalist experience, reported practice, opinions, and knowledge regarding PICCs was assessed by hospitalist type (full time vs part time), years of practice (<1, 15, >5), and care‐delivery model (direct care vs learner‐based care). Bivariate comparisons were made using the 2 or Fisher exact tests as appropriate; 2‐sided with a P value <0.05 was considered statistically significant. All analyses were conducted using Stata version 11 (StataCorp, College Station, TX). Local institutional review board approval was obtained at each site participating in the survey.
RESULTS
A total of 227 surveys were administered and 144 responses collected, for a survey response rate of 63%. Each participating site had unique characteristics including size, number of hospitalists, and modality of PICC insertion (Table 1). Of the hospitalists who completed the survey, 81% held full‐time clinical positions and had been in practice an average of 5.6 years. Surveyed hospitalists reported caring for an average of 40.6 patients per week and ordering a mean of 2.9 (range, 015) PICCs per week of clinical service. Among survey respondents, 36% provided direct patient care, 34% provided care either directly or through mid‐level providers and housestaff, and 9% delivered care exclusively through mid‐level providers or housestaff (Table 2). As our survey was conducted anonymously, potential identifying information such as age, race, and sex of those responding was not collected.
| Survey Site | No. of Hospitals | No. of Inpatient Beds | No. of Annual Inpatient Encounters | No. of Hospitalists | Full‐Time Hospitalists, % | Avg. No. Weeks/Year on Service | Avg. Years of Experience | No. PICCs/Week, 2012 | Modality of PICC Insertion Available |
|---|---|---|---|---|---|---|---|---|---|
| |||||||||
| University of Michigan Health System | 1 | 900+ | 5,775 | 46 | 100 | 25 | 6 | 42 | Vascular access nurse |
| Ann Arbor VA Medical Center | 1 | 135 | 825 | 16 | 50 | 17.6 | 5.1 | 12 | Vascular access nurse |
| Spectrum Health System | 2 | 800 | 14,000 | 47 | 80 | 34 | 3.75 | 56 | Interventional radiology |
| Trinity Health System | 3 | 634 | 2,300 | 67 | 80 | 24 | 4 | 31 | Interventional radiology and hospitalists |
| Henry Ford Health System | 3 | 1,150 | 1,450 | 51 | 100 | 20.4 | 5.6 | 15 | Vascular access nurse |
| Characteristic | Total (N=144) |
|---|---|
| |
| Hospitalist type, n (%) | |
| Full time | 117 (81) |
| Part time | 19 (13) |
| Unknown | 8 (6) |
| Weeks/year on a clinical service, n (%) | |
| <20 | 24 (17) |
| 20 | 107 (74) |
| Unknown | 13 (9) |
| Mean (SD) | 25.5 (10.7) |
| Median | 26 |
| Type of patients treated, n (%) | |
| Adults only | 129 (90) |
| Adults and children | 7 (5) |
| Unknown | 8 (6) |
| Years in practice as a hospitalist, n (%) | |
| 5 | 81 (56) |
| >5 | 54 (38) |
| Unknown | 9 (6) |
| Model of care delivery, n (%) | |
| Direct | 52 (36) |
| Some midlevel or housestaff providers (<50% of all encounters) | 49 (34) |
| Mostly midlevel or housestaff providers (>50% of all encounters) | 22 (15) |
| Only midlevel or housestaff providers | 13 (9) |
| Unknown | 8 (6) |
| Location of practice | |
| Trinity Health System | 39 (27) |
| University of Michigan Health System | 37 (26) |
| Henry Ford Health System | 28 (19) |
| Spectrum Health System | 21 (15) |
| Ann Arbor VA Medical Center | 11 (8) |
| Unknown | 8 (6) |
Hospitalist Experiences and Practice Related to Peripherally Inserted Central Catheters
According to responding hospitalists, the most common indications for PICC placement were long‐term IV antibiotic treatment (64%), followed by inability to obtain peripheral venous access (24%). Hospitalists reported an average duration of PICC placement of 17 days (range, 342 days). A significant percentage of hospitalists (93%) stated that they had cared for patients where a PICC was placed only for use during hospitalization, with the most common reason for such insertion being difficulty in otherwise securing venous access (67%). Respondents also reported caring for patients who had both PICCs and peripheral IV catheters in place at the same time; 49% stated that they had experienced this <5 times, whereas 33% stated they had experienced this 510 times. Furthermore, 87% of respondents indicated having admitted a patient who specifically requested a PICC due to prior difficulties with venous access. More than half of surveyed hospitalists (63%) admitted to having been contacted by a PICC nurse enquiring as to whether their patient might benefit from PICC insertion.
The majority of hospitalists (66%) reported that they specified the number of lumens when ordering PICCs. Thirty‐eight percent indicated that this decision was based on type of medication, whereas 35% selected the lowest number of lumens possible. A power PICC (specialized PICCs that are designed to withstand high‐pressure contrast injections), was specifically requested for radiographic studies (56%), infusion of large volume of fluids (10%), or was the default PICC type at their facility (34%).
A majority (74%) of survey respondents also reported that once inserted, PICCs were always used to obtain blood for routine laboratory testing. Moreover, 41% indicated that PICCs were also always used to obtain blood for microbiological cultures. The 3 most frequently encountered PICC‐related complications reported by hospitalists in our survey were blockage of a PICC lumen, bloodstream infection, and venous thromboembolism (VTE; Table 3).
| Hospitalist Experiences With PICCs | Total (N=144) |
|---|---|
| |
| Primary indication for PICC placement* | |
| Long‐term IV antibiotics | 64 |
| Venous access in a patient with poor peripheral veins | 24 |
| Parenteral nutrition | 5 |
| Chemotherapy | 4 |
| Patient specifically requested a PICC | 1 |
| Unknown/other | 2 |
| PICC placed only for venous access, n (%) | |
| Yes | 135 (94) |
| No | 9 (6) |
| PICC placed only during hospitalization, n (%) | |
| Yes | 134 (93) |
| No | 10 (7) |
| Notified by a PICC nurse (or other provider) that patient may need or benefit from a PICC, n (%) | |
| Yes | 91 (63) |
| No | 53 (37) |
| How frequently PICCs are used to obtain blood for routine laboratory testing, n (%) | |
| Always | 106 (74) |
| Unknown/other | 38 (26) |
| How frequently PICCs are used to obtain blood for blood cultures, n (%) | |
| Always | 59 (41) |
| Unknown/other | 85 (59) |
| Hospitalist Opinions on PICCs | Total (N=144) |
| In your opinion, is it appropriate to place a vascular in a hospitalized patient if other forms of peripheral access cannot be obtained? n (%) | |
| Yes | 121 (84) |
| No | 21 (15) |
| Unknown | 2 (1) |
| In your opinion, should hospitalists be trained to insert PICCs? n (%) | |
| No | 57 (40) |
| Yes, this is an important skill set for hospitalists | 46 (32) |
| Unsure | 39 (27) |
| Unknown/other | 2 (1) |
| Do you think the increasing number of vascular nurses and PICC nursing teams has influenced the use of PICCs in hospitalized patients? n (%) | |
| Yes | 112 (78) |
| No | 30 (21) |
| Unknown | 2 (1) |
| What % of PICC insertions do you think may represent inappropriate use in your hospital? n (%) | |
| <10 | 53 (37) |
| 1025 | 68 (47) |
| 2550 | 18 (13) |
| >50 | 3 (2) |
| Unknown/other | 2 (1) |
Hospitalist Opinions Regarding Peripherally Inserted Central Catheters
Compared with CVCs, 69% of hospitalists felt that PICCs were safer and more efficient because they could stay in place longer and were less likely to cause infection. Most (65%) also agreed that PICCs were more convenient than CVCs because they were inserted by PICC teams. Additionally, 74% of hospitalists felt that their patients preferred PICCs because they minimize pain from routine peripheral IV changes and phlebotomy. A majority of respondents (84%) indicated that it was appropriate to place a PICC if other forms of peripheral venous access could not be obtained. However, when specifically questioned, 47% of hospitalists indicated that at least 10%25% of PICCs placed in their hospitals might represent inappropriate use. A majority (78%) agreed with the statement that the increase in numbers of vascular nurses had influenced use of PICCs in hospitalized patients, but most (45%) were neutral when asked if PICCs were more cost‐effective than traditional CVCs.
Hospitalist Knowledge Regarding Risk of Peripherally Inserted Central CatheterRelated Venous Thromboembolism and Bloodstream Infection
Although 65% of responding hospitalists disagreed with the statement that PICCs were less likely to lead to VTE, important knowledge gaps regarding PICCs and VTE were identified (Table 4). For instance, only 4% of hospitalists were correctly aware that the PICC‐tip position is checked to reduce risk of PICC‐related VTE, and only 12% knew that the site of PICC insertion has also been associated with VTE risk. Although 85% of respondents stated they would prescribe a therapeutic dose of an anticoagulant in the case of PICC‐associated VTE, deviations from the guideline‐recommended 3‐month treatment period were noted. For example, 6% of hospitalists reported treating with anticoagulation for 6 months, and 19% stated they would treat as long as the PICC remained in place, plus an additional period of time (eg, 24 weeks) after removal. With respect to bloodstream infection, 92% of responding hospitalists correctly identified PICC duration and prompt removal as factors promoting PICC‐related bloodstream infection and 78% accurately identified components of the catheter‐associated bloodstream infection bundle. When specifically asked about factors associated with risk of PICC‐related bloodstream infection, only half of respondents recognized the number of PICC lumens as being associated with this outcome.
| Total (N=144) | |
|---|---|
| |
| Why is the position of the PICC tip checked after bedside PICC insertion? n (%) | |
| To decrease the risk of arrhythmia related to right‐atrial positioning | 108 (75) |
| To minimize the risk of VTEa | 6 (4) |
| To ensure it is not accidentally placed into an artery | 16 (11) |
| For documentation purposes (to reduce the risk of lawsuits related to line‐insertion complications) | 6 (4) |
| Unsure/Unknown | 8 (6) |
| According to the 2012 ACCP Guidelines on VTE prevention, is pharmacologic prophylaxis for DVT recommended in patients who receive long‐term PICCs? n (%) | |
| No; no anticoagulant prophylaxis is recommended for patients who receive long‐term PICCsa | 107 (74) |
| Yes, but the choice and duration of anticoagulant is at the discretion of the provider | 23 (16) |
| Yes; aspirin is recommended for 3 months | 4 (3) |
| Yes; anticoagulation with warfarin or enoxaparin is recommended for 3 months | 3 (2) |
| Yes; anticoagulation with warfarin or enoxaparin is recommended for 6 months | 2 (1) |
| Unknown | 5 (4) |
| Assuming no contraindications exist, do you anticoagulate patients who develop a PICC‐associated DVT (with any therapeutic anticoagulant)? n (%) | |
| Yesa | 122 (85) |
| No | 16 (11) |
| Unknown | 6 (4) |
| How long do you usually prescribe anticoagulation for patients who develop PICC‐associated DVT? n (%) | |
| I don't prescribe anticoagulation | 12 (8) |
| 1 month | 4 (3) |
| 3 monthsa | 84 (58) |
| 6 months | 8 (6) |
| As long as the line remains in place; I stop anticoagulation once the PICC comes out | 3 (2) |
| As long as the line remains in place and for an additional specified period of time after line removal, such as 2 or 4 weeks | 27 (19) |
| Unknown | 6 (4) |
| As part of the treatment of PICC‐related DVT, do you routinely remove the PICC?b n (%) | |
| Yes | 102 (71) |
| No | 36 (25) |
| Unknown | 6 (4) |
Variation in Hospitalist Knowledge, Experience, or Opinions
We assessed whether any of our findings varied according to hospitalist type (full time versus part time), years of practice (<1, 15, >5), and model of care delivery (direct care vs learner‐based care). Our analyses suggested that part‐time hospitalists were more likely to select rarely when it came to finding patients with a PICC and a working peripheral IV at the same time (74% vs 45%, P=0.02). Interestingly, a higher percentage of those in practice <5 years indicated that 10%25% of PICCs represented inappropriate placement (58% vs 33%, P<0.01) and that vascular nurses had influenced the use of PICCs in hospitalized patients (88% vs 69%, P=0.01). Lastly, a higher percentage of hospitalists who provided direct patient care reported that PICCs were always used to obtain blood for microbiological culture (54% vs 37%, P=0.05).
DISCUSSION
In this survey of hospitalists practicing at 5 large healthcare systems in Michigan, we observed significant variation in experience, reported practice, opinions, and knowledge related to PICCs. Our findings highlight important concerns related to inpatient PICC use and suggest a need for greater scrutiny related to these devices in these settings.
The use of PICCs in hospitalized patients has risen dramatically over the past decade. Though such growth is multifactorial and relates in part to increasing inpatient volume and complexity, hospitalists have increasingly turned to PICCs as a convenient and reliable tool to obtain venous access.[7] Indeed, in our survey, PICCs that were only used during hospitalization were most likely to be placed for this very reason. Because PICCs are safer to insert than CVCs and the original evidence regarding PICC‐related VTE or bloodstream infection suggested low rates of these events,[8, 9, 10, 11, 12, 13, 14] many hospitalists may not perceive these devices as being associated with significant risks. In fact, some have suggested that hospitalists be specifically trained to insert these devices, given their safety compared with traditional CVCs.[7]
However, accumulating evidence suggests that PICCs are associated with important complications.[5, 15, 16] In studies examining risk of bloodstream infection, PICCs were associated with significant risk of this outcome.[6, 17, 18] Recently, the presence of a PICC was identified as an independent predictor of VTE in hospitalized patients.[19] Several studies and systematic reviews have repeatedly demonstrated these findings.[19, 20, 21, 22] A recent systematic review examining nonpharmacologic methods to prevent catheter‐related thrombosis specifically called for avoidance of PICC insertion to prevent thrombosis in hospitalized patients.[23] Despite this growing evidence base, the use of PICCs in the inpatient setting is likely to rise, and our survey highlights several practices that may contribute to adverse outcomes. For instance, hospitalists in our survey were unlikely to remove a PICC until a patient was discharged, irrespective of the need for this device. As each day with a PICC increases the risk of complications, such practice poses potential patient safety concerns. Similarly, many hospitalists believe that PICCs are safer than CVCs, a viewpoint that does not stand up to increasing scrutiny and highlights important knowledge gaps. The risk of PICC‐related complications appears not to be a stationary target, but rather a dynamic balance that is influenced by patient‐, provider‐, and device‐specific characteristics.[2] Increasing discretionary use (especially for patients with poor peripheral venous access), forgetting at times that a patient has a PICC, and the finding that up to 25% of PICCs placed in their hospitals may be unnecessary underscore concerns regarding the safety of current practice trends. Interestingly, the viewpoints of hospitalists in practice <5 years and those providing direct patient care were more likely to reflect concerns regarding inappropriate placement, influence of vascular nurses, and use of PICCs for blood culture. This finding may reflect that these nuances are more recent phenomena or perhaps most apparent when care is delivered directly.
Our study must be interpreted in the context of several limitations. First, as this was a survey‐based study of a small, convenience sample of hospitalists in a single state, recall, respondent, and systematic biases remain threats to our findings. However, all site PIs encouraged survey participation and (through local dialogue) none were aware of material differences between those who did or did not participate in the study. Similarly, Michigan is a diverse and relatively large state, and our results should be generalizable to other settings; however, national studies are necessary to confirm our findings. Second, our response rate may be perceived as low; however, our rates are in accordance with, and, in fact, superior to those of many existing physician surveys.[24] Finally, only 1 federal facility was included in this study; thus, this care‐delivery model is underrepresented, limiting generalization of findings to other such sites.
However, our study also has important strengths. First, this is the only survey that specifically examines hospitalist viewpoints when it comes to PICCs. As hospitalists frequently order and/or insert these devices, their perspectives are highly pertinent to discussions regarding current PICC use. Second, our survey highlights several instances that may be associated with preventable patient harm and identifies areas where interventions may be valuable. For example, forgetting the presence of a device, keeping PICCs in place throughout hospitalization, and rendering treatment for PICC‐related VTE not in accordance with accepted guidelines are remediable practices that may lead to poor outcomes. Interventions such as device‐reminder alerts, provider education regarding complications from PICCs, and systematic efforts to identify and remove unnecessary PICCs may mitigate these problems. Finally, our findings highlight the need for data repositories that track PICC use and hospitalist practice on a national scale. Given the risk and significance of the complications associated with these devices, understanding the epidemiology, use, and potential misuse of PICCs are important areas for hospitalist research.
In conclusion, our study of hospitalist experience, practice, opinions, and knowledge related to PICCs suggests important gaps between available evidence and current practice. There is growing need for the development of appropriateness criteria to guide vascular access in inpatient settings.[25, 26] Such criteria should consider not only type of venous access device, but granular details including rationale for venous access, nature of the infusate, optimal number of lumens, and safest gauge when recommending devices. Until such criteria and comparative studies become available, hospitals should consider instituting policies to monitor PICC use with specific attention to indication for insertion, duration of placement, and complications. These interventions represent a first and necessary step in improving patient safety when it comes to preventing PICC‐related complications.
Disclosures
The Blue Cross/Blue Shield of Michigan Foundation in Detroit funded this study through an investigator‐initiated research proposal (1931‐PIRAP). The funding source, however, played no role in study design, acquisition of data, data analysis, or reporting of these results. The authors report no conflicts of interest.
- , , , et al. Hospital‐wide survey of the use of central venous catheters. J Hosp Infect. 2011;77(4):304–308.
- , , , , . Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence. Am J Med. 2012;125(8):733–741.
- , , . The problem with peripherally inserted central catheters. JAMA. 2012;308(15):1527–1528.
- , , , et al. Reduction of peripherally inserted central catheter associated deep venous thrombosis [published online ahead of print August 1, 2012]. Chest. doi: 10.1378/chest.12–0923.
- , , . Complications associated with peripheral or central routes for central venous cannulation. Anaesthesia. 2012;67(1):65–71.
- , , , et al. Patient‐ and device‐specific risk factors for peripherally inserted central venous catheter‐related bloodstream infections. Infect Control Hosp Epidemiol. 2013;34(2):184–189.
- , . Peripherally inserted central catheter use in the hospitalized patient: is there a role for the hospitalist? J Hosp Med. 2009;4(6):E1–E4.
- , , , , , . Peripherally inserted central catheter (PICC)‐associated upper‐extremity deep venous thrombosis (UEDVT) in critical‐care setting. Chest. 2005;128(4 suppl S):193S–194S.
- , , , , , . Complications and cost associated with parenteral nutrition delivered to hospitalized patients through either subclavian or peripherally inserted central catheters. Clin Nutr. 2000;19(4):237–243.
- , . Risk of catheter‐related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest. 2005;128(2):489–495.
- , , , . Long‐term intravenous therapy with peripherally inserted silicone elastomer central venous catheters in patients with malignant diseases. Cancer. 1979;43(5):1937–1943.
- , , , , . Central vs peripheral venous catheters in critically ill patients. Chest. 1986;90(6):806–809.
- , , , , . Infectious complications among patients receiving home intravenous therapy with peripheral, central, or peripherally placed central venous catheters. Am J Med. 1991;91(3B):95S–100S.
- , , , , . Upper‐extremity deep venous thrombosis and pulmonary embolism: a prospective study. Chest. 1991;99(2):280–283.
- , , , et al. Risk factors for catheter‐related thrombosis (CRT) in cancer patients: a patient‐level data (IPD) meta‐analysis of clinical trials and prospective studies. J Thromb Haemost. 2011;9(2):312–319.
- , , , et al. Venous thrombosis associated with peripherally inserted central catheters: a retrospective analysis of the Cleveland Clinic experience. Clin Infect Dis. 2002;34(9):1179–1183.
- , , , et al. Peripherally inserted central venous catheter–associated bloodstream infections in hospitalized adult patients. Infect Control Hosp Epidemiol. 2011;32(2):125–130.
- , , . Peripherally inserted central catheter bloodstream infection surveillance rates in an acute care setting in Saudi Arabia. Ann Saudi Med. 2012;32(2):169–173.
- , , , et al. Derivation and validation of a simple model to identify venous thromboembolism risk in medical patients. Am J Med. 2011;124(10):947.e942–954.e942.
- , , , et al. Risk of symptomatic DVT associated with peripherally inserted central catheters. Chest. 2010;138(4):803–810.
- , , . The clinical significance of peripherally inserted central venous catheter‐related deep vein thrombosis. Neurocrit Care. 2011;15(3):454–460.
- , , , et al. Catheter‐associated bloodstream infection incidence and risk factors in adults with cancer: a prospective cohort study. J Hosp Infect. 2011;78(1):26–30.
- , , , . Nonpharmacologic interventions for prevention of catheter‐related thrombosis: a systematic review [published online ahead of print September 13, 2012]. J Crit Care. doi: 10.1016/j.jcrc.2012.07.007.
- , , . Why are response rates in clinician surveys declining? Can Fam Physician. 2012;58(4):e225–e228.
- , , , , , . Sensitivity and specificity of the RAND/UCLA Appropriateness Method to identify the overuse and underuse of coronary revascularization and hysterectomy. J Clin Epidemiol. 2001;54(10):1004–1010.
- , , , et al. Variations by specialty in physician ratings of the appropriateness and necessity of indications for procedures. Med Care. 1996;34(6):512–523.
- , , , et al. Hospital‐wide survey of the use of central venous catheters. J Hosp Infect. 2011;77(4):304–308.
- , , , , . Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence. Am J Med. 2012;125(8):733–741.
- , , . The problem with peripherally inserted central catheters. JAMA. 2012;308(15):1527–1528.
- , , , et al. Reduction of peripherally inserted central catheter associated deep venous thrombosis [published online ahead of print August 1, 2012]. Chest. doi: 10.1378/chest.12–0923.
- , , . Complications associated with peripheral or central routes for central venous cannulation. Anaesthesia. 2012;67(1):65–71.
- , , , et al. Patient‐ and device‐specific risk factors for peripherally inserted central venous catheter‐related bloodstream infections. Infect Control Hosp Epidemiol. 2013;34(2):184–189.
- , . Peripherally inserted central catheter use in the hospitalized patient: is there a role for the hospitalist? J Hosp Med. 2009;4(6):E1–E4.
- , , , , , . Peripherally inserted central catheter (PICC)‐associated upper‐extremity deep venous thrombosis (UEDVT) in critical‐care setting. Chest. 2005;128(4 suppl S):193S–194S.
- , , , , , . Complications and cost associated with parenteral nutrition delivered to hospitalized patients through either subclavian or peripherally inserted central catheters. Clin Nutr. 2000;19(4):237–243.
- , . Risk of catheter‐related bloodstream infection with peripherally inserted central venous catheters used in hospitalized patients. Chest. 2005;128(2):489–495.
- , , , . Long‐term intravenous therapy with peripherally inserted silicone elastomer central venous catheters in patients with malignant diseases. Cancer. 1979;43(5):1937–1943.
- , , , , . Central vs peripheral venous catheters in critically ill patients. Chest. 1986;90(6):806–809.
- , , , , . Infectious complications among patients receiving home intravenous therapy with peripheral, central, or peripherally placed central venous catheters. Am J Med. 1991;91(3B):95S–100S.
- , , , , . Upper‐extremity deep venous thrombosis and pulmonary embolism: a prospective study. Chest. 1991;99(2):280–283.
- , , , et al. Risk factors for catheter‐related thrombosis (CRT) in cancer patients: a patient‐level data (IPD) meta‐analysis of clinical trials and prospective studies. J Thromb Haemost. 2011;9(2):312–319.
- , , , et al. Venous thrombosis associated with peripherally inserted central catheters: a retrospective analysis of the Cleveland Clinic experience. Clin Infect Dis. 2002;34(9):1179–1183.
- , , , et al. Peripherally inserted central venous catheter–associated bloodstream infections in hospitalized adult patients. Infect Control Hosp Epidemiol. 2011;32(2):125–130.
- , , . Peripherally inserted central catheter bloodstream infection surveillance rates in an acute care setting in Saudi Arabia. Ann Saudi Med. 2012;32(2):169–173.
- , , , et al. Derivation and validation of a simple model to identify venous thromboembolism risk in medical patients. Am J Med. 2011;124(10):947.e942–954.e942.
- , , , et al. Risk of symptomatic DVT associated with peripherally inserted central catheters. Chest. 2010;138(4):803–810.
- , , . The clinical significance of peripherally inserted central venous catheter‐related deep vein thrombosis. Neurocrit Care. 2011;15(3):454–460.
- , , , et al. Catheter‐associated bloodstream infection incidence and risk factors in adults with cancer: a prospective cohort study. J Hosp Infect. 2011;78(1):26–30.
- , , , . Nonpharmacologic interventions for prevention of catheter‐related thrombosis: a systematic review [published online ahead of print September 13, 2012]. J Crit Care. doi: 10.1016/j.jcrc.2012.07.007.
- , , . Why are response rates in clinician surveys declining? Can Fam Physician. 2012;58(4):e225–e228.
- , , , , , . Sensitivity and specificity of the RAND/UCLA Appropriateness Method to identify the overuse and underuse of coronary revascularization and hysterectomy. J Clin Epidemiol. 2001;54(10):1004–1010.
- , , , et al. Variations by specialty in physician ratings of the appropriateness and necessity of indications for procedures. Med Care. 1996;34(6):512–523.
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