Norra MacReady

Patient autonomy is one of the core principles of medicine in the U.S. All adult patients of sound mind are entitled to know the risks and benefits of the procedures they undergo—especially when surgery or transfusions are involved.

However, sometimes principles collide with practicalities. Hospitals would grind nearly to a halt if clinicians had to stop and inform patients of the remotest risks associated with even the most benign therapies like potassium supplementation or furosemide.

As a result, the vast majority of medical treatments are administered to hospitalized patients with no discussion of risks, benefits, and alternatives. Besides, most patients wouldn’t want to be informed of every single risk associated with those medications if the likelihood of an adverse event were relatively small. Or would they?

A team of investigators at Yale and Bridgeport Hospital in Bridgeport, Conn., led by medical resident Shweta Upadhyay, MD, examined patients’ preferences when it comes to providing informed consent for routine hospital procedures associated with varying degrees of risk.

These researchers submitted questionnaires to 210 patients admitted to the hospital between June and August 2006. The questionnaires described four hypothetical situations of escalating risk:

• Administration of a diuretic to relieve pulmonary congestion resulting from heart failure;
• Supplementation to replace mineral loss associated with diuretic use; and
• Administration of tissue plasminogen activator (TPA) to treat pulmonary emboli, with a 5% or 20% risk of cerebral hemorrhage and stroke.

In each case, patients were asked if they would want their physicians to begin treatment without asking their permission, ask their permission before beginning treatment no matter what, or obtain permission only if time and clinical circumstances permitted.

“We designed the questionnaire to step up from minimal risk to life-threatening intervention,” says Constantine Manthous, MD, associate clinical professor of medicine at the hospital and senior author of the study.

Surprisingly, the vast majority of patients—85%—wanted to participate in making even the most trivial decisions about their care. Of those answering the question about potassium supplementation, 92% wanted to be informed before receiving a diuretic.

Less surprisingly, 93% and 95% of patients, respectively, wanted their doctors to obtain their permission before administering TPA when the risk of hemorrhage was 5% and 20%. “We did not expect the patients to be interested at all in the mundane things,” Dr. Manthous says.

In general, patients younger than 65 were more likely to want to discuss the risks, but more of the older patients wanted to be informed if time allowed.

“Older patients (>65 years old) were more likely in some questions than younger (<65 years old) patients to allow their physicians to make unilateral decisions regarding their healthcare. This could be explained by the fact that those age 65 and older grew up at a time when physician paternalism was more prevalent in American medicine,” the authors write.

The findings “demonstrate a big change in what it means to be a patient from 30 to 40 years ago,” Dr. Manthous points out. “These data demonstrate that patients’ expectations are high: They want to be fully involved in even the most mundane aspects of their care. I doubt that most physicians realize just how involved their patients want to be.”

Often, the decision to disclose a treatment’s risks boils down to a judgment call, especially when the frequency and severity of those risks are low, John Banja, MD, and Jason Schneider, MD, both of Emory University in Atlanta, wrote in an editorial accompanying the study (“Ethical Challenges in Disclosing Risk”).

The ethical obligation to discuss risks increases when risk severity increases, even if the frequency of those risks remains low. However, hospitals have inconsistent policies for obtaining informed consent.

“Many hospitals, for example, would have staff simply tell patients that they needed diuretics or thrombolytics, even though in certain instances—and especially with thrombolytic agents—the risk of a significant adverse event could well exceed some reasonable disclosure threshold (which is often set at 1%),” Drs. Banja and Schneider write. If a patient is about to undergo a procedure like thrombolysis, in which the risk of cerebral hemorrhage may be as high as 20%, formal informed consent would “most certainly” be required. Failure to get it could be construed as a serious ethical breach.

Like Dr. Manthous, Dr. Schneider, assistant professor of general medicine at Emory University School of Medicine, was startled by the number of patients who took such an interest in even relatively innocuous treatments. “What was most eye-opening for me was the number of people who had so much interest in the intricacies of their medical care,” he says.

Good communication can help doctors strike a balance between fulfilling patients’ wishes for information and working efficiently, Dr. Schneider adds. “Quality can compensate for quantity; with well-tuned communication, you can make up for limited time,” he explains. Unfortunately, although communication has recently been added to the list of core competencies residents should master, “physicians don’t have the interpersonal communication skills they should have. It’s definitely an area where improvement is needed.”

Indeed, doctors could use their newfound expertise in communication to describe to patients the practical implications of listing every risk of every procedure. Right now, “patients probably don’t understand how bothersome and logistically problematic it would be” to make that disclosure, says Dr. Manthous. “I suspect their answers would be different if we explained that care would slow to a crawl.”

Norra MacReady is a medical writer based in California. TH

Norra MacReady is a medical writer based in California.

Patient autonomy is one of the core principles of medicine in the U.S. All adult patients of sound mind are entitled to know the risks and benefits of the procedures they undergo—especially when surgery or transfusions are involved.

However, sometimes principles collide with practicalities. Hospitals would grind nearly to a halt if clinicians had to stop and inform patients of the remotest risks associated with even the most benign therapies like potassium supplementation or furosemide.

As a result, the vast majority of medical treatments are administered to hospitalized patients with no discussion of risks, benefits, and alternatives. Besides, most patients wouldn’t want to be informed of every single risk associated with those medications if the likelihood of an adverse event were relatively small. Or would they?

A team of investigators at Yale and Bridgeport Hospital in Bridgeport, Conn., led by medical resident Shweta Upadhyay, MD, examined patients’ preferences when it comes to providing informed consent for routine hospital procedures associated with varying degrees of risk.

These researchers submitted questionnaires to 210 patients admitted to the hospital between June and August 2006. The questionnaires described four hypothetical situations of escalating risk:

• Administration of a diuretic to relieve pulmonary congestion resulting from heart failure;
• Supplementation to replace mineral loss associated with diuretic use; and
• Administration of tissue plasminogen activator (TPA) to treat pulmonary emboli, with a 5% or 20% risk of cerebral hemorrhage and stroke.

In each case, patients were asked if they would want their physicians to begin treatment without asking their permission, ask their permission before beginning treatment no matter what, or obtain permission only if time and clinical circumstances permitted.

“We designed the questionnaire to step up from minimal risk to life-threatening intervention,” says Constantine Manthous, MD, associate clinical professor of medicine at the hospital and senior author of the study.

Surprisingly, the vast majority of patients—85%—wanted to participate in making even the most trivial decisions about their care. Of those answering the question about potassium supplementation, 92% wanted to be informed before receiving a diuretic.

Less surprisingly, 93% and 95% of patients, respectively, wanted their doctors to obtain their permission before administering TPA when the risk of hemorrhage was 5% and 20%. “We did not expect the patients to be interested at all in the mundane things,” Dr. Manthous says.

In general, patients younger than 65 were more likely to want to discuss the risks, but more of the older patients wanted to be informed if time allowed.

“Older patients (>65 years old) were more likely in some questions than younger (<65 years old) patients to allow their physicians to make unilateral decisions regarding their healthcare. This could be explained by the fact that those age 65 and older grew up at a time when physician paternalism was more prevalent in American medicine,” the authors write.

The findings “demonstrate a big change in what it means to be a patient from 30 to 40 years ago,” Dr. Manthous points out. “These data demonstrate that patients’ expectations are high: They want to be fully involved in even the most mundane aspects of their care. I doubt that most physicians realize just how involved their patients want to be.”

Often, the decision to disclose a treatment’s risks boils down to a judgment call, especially when the frequency and severity of those risks are low, John Banja, MD, and Jason Schneider, MD, both of Emory University in Atlanta, wrote in an editorial accompanying the study (“Ethical Challenges in Disclosing Risk”).

The ethical obligation to discuss risks increases when risk severity increases, even if the frequency of those risks remains low. However, hospitals have inconsistent policies for obtaining informed consent.

“Many hospitals, for example, would have staff simply tell patients that they needed diuretics or thrombolytics, even though in certain instances—and especially with thrombolytic agents—the risk of a significant adverse event could well exceed some reasonable disclosure threshold (which is often set at 1%),” Drs. Banja and Schneider write. If a patient is about to undergo a procedure like thrombolysis, in which the risk of cerebral hemorrhage may be as high as 20%, formal informed consent would “most certainly” be required. Failure to get it could be construed as a serious ethical breach.

Like Dr. Manthous, Dr. Schneider, assistant professor of general medicine at Emory University School of Medicine, was startled by the number of patients who took such an interest in even relatively innocuous treatments. “What was most eye-opening for me was the number of people who had so much interest in the intricacies of their medical care,” he says.

Good communication can help doctors strike a balance between fulfilling patients’ wishes for information and working efficiently, Dr. Schneider adds. “Quality can compensate for quantity; with well-tuned communication, you can make up for limited time,” he explains. Unfortunately, although communication has recently been added to the list of core competencies residents should master, “physicians don’t have the interpersonal communication skills they should have. It’s definitely an area where improvement is needed.”

Indeed, doctors could use their newfound expertise in communication to describe to patients the practical implications of listing every risk of every procedure. Right now, “patients probably don’t understand how bothersome and logistically problematic it would be” to make that disclosure, says Dr. Manthous. “I suspect their answers would be different if we explained that care would slow to a crawl.”

Norra MacReady is a medical writer based in California. TH

Norra MacReady is a medical writer based in California.

Patient autonomy is one of the core principles of medicine in the U.S. All adult patients of sound mind are entitled to know the risks and benefits of the procedures they undergo—especially when surgery or transfusions are involved.

However, sometimes principles collide with practicalities. Hospitals would grind nearly to a halt if clinicians had to stop and inform patients of the remotest risks associated with even the most benign therapies like potassium supplementation or furosemide.

As a result, the vast majority of medical treatments are administered to hospitalized patients with no discussion of risks, benefits, and alternatives. Besides, most patients wouldn’t want to be informed of every single risk associated with those medications if the likelihood of an adverse event were relatively small. Or would they?

A team of investigators at Yale and Bridgeport Hospital in Bridgeport, Conn., led by medical resident Shweta Upadhyay, MD, examined patients’ preferences when it comes to providing informed consent for routine hospital procedures associated with varying degrees of risk.

These researchers submitted questionnaires to 210 patients admitted to the hospital between June and August 2006. The questionnaires described four hypothetical situations of escalating risk:

• Administration of a diuretic to relieve pulmonary congestion resulting from heart failure;
• Supplementation to replace mineral loss associated with diuretic use; and
• Administration of tissue plasminogen activator (TPA) to treat pulmonary emboli, with a 5% or 20% risk of cerebral hemorrhage and stroke.

In each case, patients were asked if they would want their physicians to begin treatment without asking their permission, ask their permission before beginning treatment no matter what, or obtain permission only if time and clinical circumstances permitted.

“We designed the questionnaire to step up from minimal risk to life-threatening intervention,” says Constantine Manthous, MD, associate clinical professor of medicine at the hospital and senior author of the study.

Surprisingly, the vast majority of patients—85%—wanted to participate in making even the most trivial decisions about their care. Of those answering the question about potassium supplementation, 92% wanted to be informed before receiving a diuretic.

Less surprisingly, 93% and 95% of patients, respectively, wanted their doctors to obtain their permission before administering TPA when the risk of hemorrhage was 5% and 20%. “We did not expect the patients to be interested at all in the mundane things,” Dr. Manthous says.

In general, patients younger than 65 were more likely to want to discuss the risks, but more of the older patients wanted to be informed if time allowed.

“Older patients (>65 years old) were more likely in some questions than younger (<65 years old) patients to allow their physicians to make unilateral decisions regarding their healthcare. This could be explained by the fact that those age 65 and older grew up at a time when physician paternalism was more prevalent in American medicine,” the authors write.

The findings “demonstrate a big change in what it means to be a patient from 30 to 40 years ago,” Dr. Manthous points out. “These data demonstrate that patients’ expectations are high: They want to be fully involved in even the most mundane aspects of their care. I doubt that most physicians realize just how involved their patients want to be.”

Often, the decision to disclose a treatment’s risks boils down to a judgment call, especially when the frequency and severity of those risks are low, John Banja, MD, and Jason Schneider, MD, both of Emory University in Atlanta, wrote in an editorial accompanying the study (“Ethical Challenges in Disclosing Risk”).

The ethical obligation to discuss risks increases when risk severity increases, even if the frequency of those risks remains low. However, hospitals have inconsistent policies for obtaining informed consent.

“Many hospitals, for example, would have staff simply tell patients that they needed diuretics or thrombolytics, even though in certain instances—and especially with thrombolytic agents—the risk of a significant adverse event could well exceed some reasonable disclosure threshold (which is often set at 1%),” Drs. Banja and Schneider write. If a patient is about to undergo a procedure like thrombolysis, in which the risk of cerebral hemorrhage may be as high as 20%, formal informed consent would “most certainly” be required. Failure to get it could be construed as a serious ethical breach.

Like Dr. Manthous, Dr. Schneider, assistant professor of general medicine at Emory University School of Medicine, was startled by the number of patients who took such an interest in even relatively innocuous treatments. “What was most eye-opening for me was the number of people who had so much interest in the intricacies of their medical care,” he says.

Good communication can help doctors strike a balance between fulfilling patients’ wishes for information and working efficiently, Dr. Schneider adds. “Quality can compensate for quantity; with well-tuned communication, you can make up for limited time,” he explains. Unfortunately, although communication has recently been added to the list of core competencies residents should master, “physicians don’t have the interpersonal communication skills they should have. It’s definitely an area where improvement is needed.”

Indeed, doctors could use their newfound expertise in communication to describe to patients the practical implications of listing every risk of every procedure. Right now, “patients probably don’t understand how bothersome and logistically problematic it would be” to make that disclosure, says Dr. Manthous. “I suspect their answers would be different if we explained that care would slow to a crawl.”

Norra MacReady is a medical writer based in California. TH

Norra MacReady is a medical writer based in California.

Dr. Sehgal

When it comes to communicating do-not-resuscitate (DNR) orders, hospitals rely on a bewildering array of paper documentation, electronic records, and colored wristbands that can easily be misinterpreted.

These are the findings reported in the November-December issue of the Journal of Hospital Medicine by Niraj Sehgal, MD, and Robert Wachter, MD. Dr. Wachter is associate chair of the department of medicine at the University of California, San Francisco. Dr. Sehgal is an assistant clinical professor of medicine at the school.

In a survey of 69 nursing executives representing hospitals in a consortium of academic medical centers, “More than 70% of respondents recalled situations when confusion around a DNR order led to problems in patient care,” the authors say.

Everyone has a “near-miss” story, says Dr. Sehgal.

In one budget-minded hospital where materials were recycled, someone forgot to remove a DNR sticker from a previous patient’s folder before the folder was assigned to someone else. Several nurses told of instances in which patients were resuscitated inappropriately because hospital staff members did not see DNR stickers in the patient’s chart, the patient was off the unit for a procedure without a complete chart, or the DNR order was buried under other materials.

Much of the problem stems from the lack of a standardized method for making a patient’s DNR wishes known, Dr. Sehgal explains.

For example, in 2004 Dr. Sehgal saw a newspaper report that BayCare Health hospitals, in and around Tampa, Fla., were covering yellow “Livestrong” bracelets issued by the Lance Armstrong Foundation and worn by some patients to support those living with cancer. BayCare uses yellow bracelets for DNR patients. Nearly 20% of Americans wear “Livestrong” bracelets, posing a challenge for any hospital that also uses yellow bracelets to indicate DNR.

The newspaper story was the impetus for this study, Dr. Sehgal recalls. “I saw that article and thought, ‘What a great metaphor for the need for standardization.’”

He and Dr. Wachter designed a brief survey and distributed it via an e-mail listserve to senior nursing staff members of the University HealthSystem Consortium, an alliance of 97 academic medical centers and their affiliated hospitals. Those institutions represent 90% of the nation’s nonprofit academic medical centers.

Of the 127 nursing executives who received survey announcements, 69 (54%) returned completed questionnaires. Of those, 39 (56%) reported that their hospitals documented patients’ DNR preferences only in the charts, while 11 (16%) used only electronic health records (EHRs). Seventeen (25%) augmented the paper charts or EHRs with color-coded wristbands in eight colors.

“We expected variability, but even so we were struck by how much variability existed in our findings,” Dr. Sehgal says.

Hospitals use wristbands in a rainbow of colors to convey many messages. Of the hospitals represented in this survey, 55% used them to warn of allergies, fall risks, and even same last names. The authors found “12 different indications were depicted by various colors, with variations in both the color choice for a given indication (e.g., red and yellow used for allergy wristbands at different hospitals) and across indications (e.g., red for allergy at one hospital and red for bleeding risk at another).”

Dr. Sehgal

A national, standardized system for conveying patients’ DNR wishes would seem logical, but no system is in place, Dr. Sehgal says. Hospitals cannot even agree on which method to use. While some use wristbands, others use notices or stickers incorporated into the chart. Still others use EHRs.

A few states, including Arizona, Pennsylvania, and Colorado have established statewide standards for using wristbands—but each state chose a different color. “I suspect that many physicians don’t know the meaning of many of the wristbands used in their hospitals, especially if those doctors rotate among different hospitals or hospital systems,” Dr. Sehgal says.

Developing a system for making a patient’s wishes known to hospital staff is one of two challenges reflected in this study, he adds. The second is to use what might be perfunctory questions about advance directives as an opening for a deeper discussion about the patient’s thoughts on end-of-life care. Right now, those questions are just another process measure hospitals must document. “It becomes just another box to check instead of a tool for opening a conversation about what the patient’s wishes are,” he says.

Hospitalists should embrace the opportunity to involve the patient, the patient’s family members, and the primary care provider in an ongoing discussion about the patient’s desires over the course of the hospital stay. “This can give patients a mechanism for thinking about what they’d want under certain circumstances,” Dr. Sehgal explains.

From this study’s findings emerge two take-home messages for hospitalists, he maintains. The first is to remember that “we in inpatient settings spend a lot of time taking care of patients, and we must be aware of what those patients’ wishes are with respect to DNR.” The second is to step back and take an even broader view by remaining alert to processes other than DNR that might benefit from a standardized approach. “Maybe we should think about that, particularly when there is the potential to significantly harm patients,” he says. TH

Norra MacReady is a medical writer based in California.

Dr. Sehgal

When it comes to communicating do-not-resuscitate (DNR) orders, hospitals rely on a bewildering array of paper documentation, electronic records, and colored wristbands that can easily be misinterpreted.

These are the findings reported in the November-December issue of the Journal of Hospital Medicine by Niraj Sehgal, MD, and Robert Wachter, MD. Dr. Wachter is associate chair of the department of medicine at the University of California, San Francisco. Dr. Sehgal is an assistant clinical professor of medicine at the school.

In a survey of 69 nursing executives representing hospitals in a consortium of academic medical centers, “More than 70% of respondents recalled situations when confusion around a DNR order led to problems in patient care,” the authors say.

Everyone has a “near-miss” story, says Dr. Sehgal.

In one budget-minded hospital where materials were recycled, someone forgot to remove a DNR sticker from a previous patient’s folder before the folder was assigned to someone else. Several nurses told of instances in which patients were resuscitated inappropriately because hospital staff members did not see DNR stickers in the patient’s chart, the patient was off the unit for a procedure without a complete chart, or the DNR order was buried under other materials.

Much of the problem stems from the lack of a standardized method for making a patient’s DNR wishes known, Dr. Sehgal explains.

For example, in 2004 Dr. Sehgal saw a newspaper report that BayCare Health hospitals, in and around Tampa, Fla., were covering yellow “Livestrong” bracelets issued by the Lance Armstrong Foundation and worn by some patients to support those living with cancer. BayCare uses yellow bracelets for DNR patients. Nearly 20% of Americans wear “Livestrong” bracelets, posing a challenge for any hospital that also uses yellow bracelets to indicate DNR.

The newspaper story was the impetus for this study, Dr. Sehgal recalls. “I saw that article and thought, ‘What a great metaphor for the need for standardization.’”

He and Dr. Wachter designed a brief survey and distributed it via an e-mail listserve to senior nursing staff members of the University HealthSystem Consortium, an alliance of 97 academic medical centers and their affiliated hospitals. Those institutions represent 90% of the nation’s nonprofit academic medical centers.

Of the 127 nursing executives who received survey announcements, 69 (54%) returned completed questionnaires. Of those, 39 (56%) reported that their hospitals documented patients’ DNR preferences only in the charts, while 11 (16%) used only electronic health records (EHRs). Seventeen (25%) augmented the paper charts or EHRs with color-coded wristbands in eight colors.

“We expected variability, but even so we were struck by how much variability existed in our findings,” Dr. Sehgal says.

Hospitals use wristbands in a rainbow of colors to convey many messages. Of the hospitals represented in this survey, 55% used them to warn of allergies, fall risks, and even same last names. The authors found “12 different indications were depicted by various colors, with variations in both the color choice for a given indication (e.g., red and yellow used for allergy wristbands at different hospitals) and across indications (e.g., red for allergy at one hospital and red for bleeding risk at another).”

Dr. Sehgal

A national, standardized system for conveying patients’ DNR wishes would seem logical, but no system is in place, Dr. Sehgal says. Hospitals cannot even agree on which method to use. While some use wristbands, others use notices or stickers incorporated into the chart. Still others use EHRs.

A few states, including Arizona, Pennsylvania, and Colorado have established statewide standards for using wristbands—but each state chose a different color. “I suspect that many physicians don’t know the meaning of many of the wristbands used in their hospitals, especially if those doctors rotate among different hospitals or hospital systems,” Dr. Sehgal says.

Developing a system for making a patient’s wishes known to hospital staff is one of two challenges reflected in this study, he adds. The second is to use what might be perfunctory questions about advance directives as an opening for a deeper discussion about the patient’s thoughts on end-of-life care. Right now, those questions are just another process measure hospitals must document. “It becomes just another box to check instead of a tool for opening a conversation about what the patient’s wishes are,” he says.

Hospitalists should embrace the opportunity to involve the patient, the patient’s family members, and the primary care provider in an ongoing discussion about the patient’s desires over the course of the hospital stay. “This can give patients a mechanism for thinking about what they’d want under certain circumstances,” Dr. Sehgal explains.

From this study’s findings emerge two take-home messages for hospitalists, he maintains. The first is to remember that “we in inpatient settings spend a lot of time taking care of patients, and we must be aware of what those patients’ wishes are with respect to DNR.” The second is to step back and take an even broader view by remaining alert to processes other than DNR that might benefit from a standardized approach. “Maybe we should think about that, particularly when there is the potential to significantly harm patients,” he says. TH

Norra MacReady is a medical writer based in California.

Dr. Sehgal

When it comes to communicating do-not-resuscitate (DNR) orders, hospitals rely on a bewildering array of paper documentation, electronic records, and colored wristbands that can easily be misinterpreted.

These are the findings reported in the November-December issue of the Journal of Hospital Medicine by Niraj Sehgal, MD, and Robert Wachter, MD. Dr. Wachter is associate chair of the department of medicine at the University of California, San Francisco. Dr. Sehgal is an assistant clinical professor of medicine at the school.

In a survey of 69 nursing executives representing hospitals in a consortium of academic medical centers, “More than 70% of respondents recalled situations when confusion around a DNR order led to problems in patient care,” the authors say.

Everyone has a “near-miss” story, says Dr. Sehgal.

In one budget-minded hospital where materials were recycled, someone forgot to remove a DNR sticker from a previous patient’s folder before the folder was assigned to someone else. Several nurses told of instances in which patients were resuscitated inappropriately because hospital staff members did not see DNR stickers in the patient’s chart, the patient was off the unit for a procedure without a complete chart, or the DNR order was buried under other materials.

Much of the problem stems from the lack of a standardized method for making a patient’s DNR wishes known, Dr. Sehgal explains.

For example, in 2004 Dr. Sehgal saw a newspaper report that BayCare Health hospitals, in and around Tampa, Fla., were covering yellow “Livestrong” bracelets issued by the Lance Armstrong Foundation and worn by some patients to support those living with cancer. BayCare uses yellow bracelets for DNR patients. Nearly 20% of Americans wear “Livestrong” bracelets, posing a challenge for any hospital that also uses yellow bracelets to indicate DNR.

The newspaper story was the impetus for this study, Dr. Sehgal recalls. “I saw that article and thought, ‘What a great metaphor for the need for standardization.’”

He and Dr. Wachter designed a brief survey and distributed it via an e-mail listserve to senior nursing staff members of the University HealthSystem Consortium, an alliance of 97 academic medical centers and their affiliated hospitals. Those institutions represent 90% of the nation’s nonprofit academic medical centers.

Of the 127 nursing executives who received survey announcements, 69 (54%) returned completed questionnaires. Of those, 39 (56%) reported that their hospitals documented patients’ DNR preferences only in the charts, while 11 (16%) used only electronic health records (EHRs). Seventeen (25%) augmented the paper charts or EHRs with color-coded wristbands in eight colors.

“We expected variability, but even so we were struck by how much variability existed in our findings,” Dr. Sehgal says.

Hospitals use wristbands in a rainbow of colors to convey many messages. Of the hospitals represented in this survey, 55% used them to warn of allergies, fall risks, and even same last names. The authors found “12 different indications were depicted by various colors, with variations in both the color choice for a given indication (e.g., red and yellow used for allergy wristbands at different hospitals) and across indications (e.g., red for allergy at one hospital and red for bleeding risk at another).”

Dr. Sehgal

A national, standardized system for conveying patients’ DNR wishes would seem logical, but no system is in place, Dr. Sehgal says. Hospitals cannot even agree on which method to use. While some use wristbands, others use notices or stickers incorporated into the chart. Still others use EHRs.

A few states, including Arizona, Pennsylvania, and Colorado have established statewide standards for using wristbands—but each state chose a different color. “I suspect that many physicians don’t know the meaning of many of the wristbands used in their hospitals, especially if those doctors rotate among different hospitals or hospital systems,” Dr. Sehgal says.

Developing a system for making a patient’s wishes known to hospital staff is one of two challenges reflected in this study, he adds. The second is to use what might be perfunctory questions about advance directives as an opening for a deeper discussion about the patient’s thoughts on end-of-life care. Right now, those questions are just another process measure hospitals must document. “It becomes just another box to check instead of a tool for opening a conversation about what the patient’s wishes are,” he says.

Hospitalists should embrace the opportunity to involve the patient, the patient’s family members, and the primary care provider in an ongoing discussion about the patient’s desires over the course of the hospital stay. “This can give patients a mechanism for thinking about what they’d want under certain circumstances,” Dr. Sehgal explains.

From this study’s findings emerge two take-home messages for hospitalists, he maintains. The first is to remember that “we in inpatient settings spend a lot of time taking care of patients, and we must be aware of what those patients’ wishes are with respect to DNR.” The second is to step back and take an even broader view by remaining alert to processes other than DNR that might benefit from a standardized approach. “Maybe we should think about that, particularly when there is the potential to significantly harm patients,” he says. TH

Norra MacReady is a medical writer based in California.

Dr. Jaffer

Drug-eluting stents (DES) are a medical success story: In the four years since they were approved, in-stent restenosis rates have gone from the 25%-30% associated with bare-metal stents to the single digits.

Thanks to this track record, the world market for stents has doubled to $5 billion—despite the fact patients with DES must take aspirin or clopidogrel to prevent thromboses.

It’s easy to forget not all questions concerning DES have been answered, despite their wide acceptance and good overall outcomes.

One concern is discontinuation of antiplatelet therapy for DES patients who require noncardiac surgery.

In the November-December 2007 Journal of Hospital Medicine, senior author Amir Jaffer, MD, and colleagues at the Cleveland Clinic in Ohio studied the relationship between a patient’s time on antiplatelet medication and the consequences of discontinuing those agents in preparation for surgery.

“This is a common clinical conundrum,” says Dr. Jaffer, director of the Cleveland Clinic’s Internal Medicine Preoperative Assessment Consultation and Treatment (IMPACT) Center. “We face this question almost every day in our practice relative to perioperative care.”

Patients slated for noncardiac surgery are seen first at the IMPACT center, where hospitalists conduct the preoperative evaluation.

Data show that patients with bare-metal stents run a high risk of stent thrombosis if they undergo noncardiac surgery within two to six weeks of stent placement.

But information on DES is hard to come by, “so we decided to try to get a handle on the safety of stopping these drugs,” says Dr. Jaffer.

The authors, led by Daniel J. Brotman, MD, studied all patients who had undergone DES placement and were evaluated for noncardiac surgery at the IMPACT Center from July 2003 to July 2005. They examined 30-day rates of postoperative myocardial infarction (MI), DES thrombosis, major bleeding, and all-cause mortality—all relative to how long the patient had been on and off antiplatelet therapy.

The type of surgery each patient underwent was classified by invasiveness and anticipated blood loss, according to the system developed by L. Reuven Pasternak, MD, vice dean, Bayview Campus, Johns Hopkins University in Baltimore, and his colleagues.1

The categories range from one, which includes cystoscopy, breast biopsy, and other minor procedures that involve little if any blood loss, to five, which encompasses highly invasive procedures with anticipated blood losses in excess of 1,500 cc, such as major vascular repair.

A total of 114 patients met the study criteria. Seventy-five (66%) of the patients were men, and the median age was 71.

The most common comorbidities were diabetes (in 41% of patients), a history of coronary bypass (34%), and chronic renal insufficiency (20%). Most patients (73%) received sirolimus (Rapamune) stents; 28% received paclitaxel (Onxol) stents; and 33% had more than one DES.

Of the patients studied, 69 (61%) underwent surgery more than 180 days after receiving their DES; 30 (26%) had their procedures within 91-180 days of receiving the stent; and 15 (13%) had their operations within 90 days of stenting.

The most common procedures were major orthopedic surgeries such as hip replacement (34.2% of patients), and ophthalmologic procedures like cataract removal (26.3%).

No procedures fell into category five, and only 6.1% fell into category four; the rest were in categories one to three.

In most cases (77%), antiplatelet therapy had been discontinued a median of 10 days before surgery, with patients remaining off the drugs a median of 14 days after surgery.

There were no deaths. The most serious complications were non-ST-elevation myocardial infarction (NSTEMI) in two patients, and retroperitoneal hemorrhage following kidney transplantation in a patient who had been taking aspirin and clopidogrel until a week before surgery.

These findings suggest that “transient termination of antiplatelet agents in the perioperative setting is not associated with high morbidity and mortality in patients with DES, even when patients have had their stents implanted in the previous three to six months,” the authors write.

The study has limitations, Dr. Jaffer warns. “This was a small study, and more than 50% of our patients had surgery more than six months after DES placement,’’ he says. “It is difficult to predict a true relationship between timing of stent placement and subsequent surgery.”

Also, about a third of the patients underwent minor procedures, and roughly one-fifth never discontinued antiplatelet medication.

There were “several issues that may have led to fairly reasonable outcomes, and which could also be related to why we saw a fairly low rate of thrombosis,” he says.

In part because of these remaining questions, he recommends hospitalists take the timing of stent placement into account when evaluating patients with DES for surgery.

If it has been six months or less since the stent was implanted, the risk of thrombosis is still high, and “we can’t accurately say if it’s safe to stop antiplatelet medication,’’ he says. “I would treat those patients cautiously, as the literature suggests they may have a high risk of adverse events.”

But if the patient needs urgent surgery and more than six months have elapsed, “it may be safer to discontinue clopidogrel and continue baby aspirin, or to continue both antiplatelet medications during surgery if an urgent procedure is needed within six months of receiving the DES” he says. TH

Norra MacReady is a medical writer based in California.

Reference

1. Pasternak LR. Preoperative assessment: guidelines and challenges. Acta Anaesthesiol Scand Suppl. 1997;111:318-320.

Dr. Jaffer

Drug-eluting stents (DES) are a medical success story: In the four years since they were approved, in-stent restenosis rates have gone from the 25%-30% associated with bare-metal stents to the single digits.

Thanks to this track record, the world market for stents has doubled to $5 billion—despite the fact patients with DES must take aspirin or clopidogrel to prevent thromboses.

It’s easy to forget not all questions concerning DES have been answered, despite their wide acceptance and good overall outcomes.

One concern is discontinuation of antiplatelet therapy for DES patients who require noncardiac surgery.

In the November-December 2007 Journal of Hospital Medicine, senior author Amir Jaffer, MD, and colleagues at the Cleveland Clinic in Ohio studied the relationship between a patient’s time on antiplatelet medication and the consequences of discontinuing those agents in preparation for surgery.

“This is a common clinical conundrum,” says Dr. Jaffer, director of the Cleveland Clinic’s Internal Medicine Preoperative Assessment Consultation and Treatment (IMPACT) Center. “We face this question almost every day in our practice relative to perioperative care.”

Patients slated for noncardiac surgery are seen first at the IMPACT center, where hospitalists conduct the preoperative evaluation.

Data show that patients with bare-metal stents run a high risk of stent thrombosis if they undergo noncardiac surgery within two to six weeks of stent placement.

But information on DES is hard to come by, “so we decided to try to get a handle on the safety of stopping these drugs,” says Dr. Jaffer.

The authors, led by Daniel J. Brotman, MD, studied all patients who had undergone DES placement and were evaluated for noncardiac surgery at the IMPACT Center from July 2003 to July 2005. They examined 30-day rates of postoperative myocardial infarction (MI), DES thrombosis, major bleeding, and all-cause mortality—all relative to how long the patient had been on and off antiplatelet therapy.

The type of surgery each patient underwent was classified by invasiveness and anticipated blood loss, according to the system developed by L. Reuven Pasternak, MD, vice dean, Bayview Campus, Johns Hopkins University in Baltimore, and his colleagues.1

The categories range from one, which includes cystoscopy, breast biopsy, and other minor procedures that involve little if any blood loss, to five, which encompasses highly invasive procedures with anticipated blood losses in excess of 1,500 cc, such as major vascular repair.

A total of 114 patients met the study criteria. Seventy-five (66%) of the patients were men, and the median age was 71.

The most common comorbidities were diabetes (in 41% of patients), a history of coronary bypass (34%), and chronic renal insufficiency (20%). Most patients (73%) received sirolimus (Rapamune) stents; 28% received paclitaxel (Onxol) stents; and 33% had more than one DES.

Of the patients studied, 69 (61%) underwent surgery more than 180 days after receiving their DES; 30 (26%) had their procedures within 91-180 days of receiving the stent; and 15 (13%) had their operations within 90 days of stenting.

The most common procedures were major orthopedic surgeries such as hip replacement (34.2% of patients), and ophthalmologic procedures like cataract removal (26.3%).

No procedures fell into category five, and only 6.1% fell into category four; the rest were in categories one to three.

In most cases (77%), antiplatelet therapy had been discontinued a median of 10 days before surgery, with patients remaining off the drugs a median of 14 days after surgery.

There were no deaths. The most serious complications were non-ST-elevation myocardial infarction (NSTEMI) in two patients, and retroperitoneal hemorrhage following kidney transplantation in a patient who had been taking aspirin and clopidogrel until a week before surgery.

These findings suggest that “transient termination of antiplatelet agents in the perioperative setting is not associated with high morbidity and mortality in patients with DES, even when patients have had their stents implanted in the previous three to six months,” the authors write.

The study has limitations, Dr. Jaffer warns. “This was a small study, and more than 50% of our patients had surgery more than six months after DES placement,’’ he says. “It is difficult to predict a true relationship between timing of stent placement and subsequent surgery.”

Also, about a third of the patients underwent minor procedures, and roughly one-fifth never discontinued antiplatelet medication.

There were “several issues that may have led to fairly reasonable outcomes, and which could also be related to why we saw a fairly low rate of thrombosis,” he says.

In part because of these remaining questions, he recommends hospitalists take the timing of stent placement into account when evaluating patients with DES for surgery.

If it has been six months or less since the stent was implanted, the risk of thrombosis is still high, and “we can’t accurately say if it’s safe to stop antiplatelet medication,’’ he says. “I would treat those patients cautiously, as the literature suggests they may have a high risk of adverse events.”

But if the patient needs urgent surgery and more than six months have elapsed, “it may be safer to discontinue clopidogrel and continue baby aspirin, or to continue both antiplatelet medications during surgery if an urgent procedure is needed within six months of receiving the DES” he says. TH

Norra MacReady is a medical writer based in California.

Reference

1. Pasternak LR. Preoperative assessment: guidelines and challenges. Acta Anaesthesiol Scand Suppl. 1997;111:318-320.

Dr. Jaffer

Drug-eluting stents (DES) are a medical success story: In the four years since they were approved, in-stent restenosis rates have gone from the 25%-30% associated with bare-metal stents to the single digits.

Thanks to this track record, the world market for stents has doubled to $5 billion—despite the fact patients with DES must take aspirin or clopidogrel to prevent thromboses.

It’s easy to forget not all questions concerning DES have been answered, despite their wide acceptance and good overall outcomes.

One concern is discontinuation of antiplatelet therapy for DES patients who require noncardiac surgery.

In the November-December 2007 Journal of Hospital Medicine, senior author Amir Jaffer, MD, and colleagues at the Cleveland Clinic in Ohio studied the relationship between a patient’s time on antiplatelet medication and the consequences of discontinuing those agents in preparation for surgery.

“This is a common clinical conundrum,” says Dr. Jaffer, director of the Cleveland Clinic’s Internal Medicine Preoperative Assessment Consultation and Treatment (IMPACT) Center. “We face this question almost every day in our practice relative to perioperative care.”

Patients slated for noncardiac surgery are seen first at the IMPACT center, where hospitalists conduct the preoperative evaluation.

Data show that patients with bare-metal stents run a high risk of stent thrombosis if they undergo noncardiac surgery within two to six weeks of stent placement.

But information on DES is hard to come by, “so we decided to try to get a handle on the safety of stopping these drugs,” says Dr. Jaffer.

The authors, led by Daniel J. Brotman, MD, studied all patients who had undergone DES placement and were evaluated for noncardiac surgery at the IMPACT Center from July 2003 to July 2005. They examined 30-day rates of postoperative myocardial infarction (MI), DES thrombosis, major bleeding, and all-cause mortality—all relative to how long the patient had been on and off antiplatelet therapy.

The type of surgery each patient underwent was classified by invasiveness and anticipated blood loss, according to the system developed by L. Reuven Pasternak, MD, vice dean, Bayview Campus, Johns Hopkins University in Baltimore, and his colleagues.1

The categories range from one, which includes cystoscopy, breast biopsy, and other minor procedures that involve little if any blood loss, to five, which encompasses highly invasive procedures with anticipated blood losses in excess of 1,500 cc, such as major vascular repair.

A total of 114 patients met the study criteria. Seventy-five (66%) of the patients were men, and the median age was 71.

The most common comorbidities were diabetes (in 41% of patients), a history of coronary bypass (34%), and chronic renal insufficiency (20%). Most patients (73%) received sirolimus (Rapamune) stents; 28% received paclitaxel (Onxol) stents; and 33% had more than one DES.

Of the patients studied, 69 (61%) underwent surgery more than 180 days after receiving their DES; 30 (26%) had their procedures within 91-180 days of receiving the stent; and 15 (13%) had their operations within 90 days of stenting.

The most common procedures were major orthopedic surgeries such as hip replacement (34.2% of patients), and ophthalmologic procedures like cataract removal (26.3%).

No procedures fell into category five, and only 6.1% fell into category four; the rest were in categories one to three.

In most cases (77%), antiplatelet therapy had been discontinued a median of 10 days before surgery, with patients remaining off the drugs a median of 14 days after surgery.

There were no deaths. The most serious complications were non-ST-elevation myocardial infarction (NSTEMI) in two patients, and retroperitoneal hemorrhage following kidney transplantation in a patient who had been taking aspirin and clopidogrel until a week before surgery.

These findings suggest that “transient termination of antiplatelet agents in the perioperative setting is not associated with high morbidity and mortality in patients with DES, even when patients have had their stents implanted in the previous three to six months,” the authors write.

The study has limitations, Dr. Jaffer warns. “This was a small study, and more than 50% of our patients had surgery more than six months after DES placement,’’ he says. “It is difficult to predict a true relationship between timing of stent placement and subsequent surgery.”

Also, about a third of the patients underwent minor procedures, and roughly one-fifth never discontinued antiplatelet medication.

There were “several issues that may have led to fairly reasonable outcomes, and which could also be related to why we saw a fairly low rate of thrombosis,” he says.

In part because of these remaining questions, he recommends hospitalists take the timing of stent placement into account when evaluating patients with DES for surgery.

If it has been six months or less since the stent was implanted, the risk of thrombosis is still high, and “we can’t accurately say if it’s safe to stop antiplatelet medication,’’ he says. “I would treat those patients cautiously, as the literature suggests they may have a high risk of adverse events.”

But if the patient needs urgent surgery and more than six months have elapsed, “it may be safer to discontinue clopidogrel and continue baby aspirin, or to continue both antiplatelet medications during surgery if an urgent procedure is needed within six months of receiving the DES” he says. TH

Norra MacReady is a medical writer based in California.

Reference

1. Pasternak LR. Preoperative assessment: guidelines and challenges. Acta Anaesthesiol Scand Suppl. 1997;111:318-320.

A significant percentage of patients do not remember or understand the instructions they receive before leaving the hospital, according to a study in this month’s Journal of Hospital Medicine.

“Anyone who’s taken care of patients or put together a discharge plan only to have things not work out knows how frustrating that can be,” says lead author Jonathan Flacker, MD.

Dr. Flacker

Dr. Flacker, assistant professor of medicine in the Division of Geriatric Medicine and Gerontology, Emory University School of Medicine, Atlanta, and coauthors Wansoo Park, PhD, and Addie Sims, MSW, surveyed a group of elderly patients shortly after discharge to determine their recall and comprehension of their pre-discharge instructions. Dr. Park is an assistant professor of social work at the University of Windsor in Ontario, Canada. Dr. Sims is director of Senior Services at Grady Health System in Atlanta.

They conducted telephone interviews with 269 patients 70 or older, or their caregivers, within 10 days of discharge from Grady Memorial Hospital in Atlanta. Most interviews were conducted within a mean of three days of discharge and lasted 20 to 30 minutes. No effort was made to determine the patients’ cognitive status or degree of health literacy.

The survey was an offshoot of Aging Atlanta, a project funded by the Robert Wood Johnson Foundation to study the overall care of older adults in the community. It asked 37 questions covering patients’ financial resources and activities of daily living as well as the nature of their discharge instructions.

The authors found the survey “feasible and easily administered,” but its results were somewhat discouraging. In 52% of the cases, respondents claimed no one spoke to them prior to discharge about caring for themselves at home. Almost as many (47%) says they were not given a phone number or the name of a person to call if they experienced problems at home. “Yet the number was on the discharge papers; 100% of the people received it,” says Dr. Flacker.

Also, 41% says they were not told what to do if they experienced problems at home. On a more positive note, only 13% of the patients had to call concerning problems, and 84% felt they had received enough help after returning home.

Of the 115 (43%) patients who said the received instructions prior to discharge, 103 (90%) remembered how they were delivered: verbally in 68 cases (63%), written in 11 cases (11%), and both ways in 24 cases (23%).

“Patients receiving instructions both verbally and in writing were more likely to report that they understood care instruction ‘very well’ versus ‘somewhat’ or ‘very little,’ ” the authors wrote. Of those who recalled being instructed on how to take their medication, 86% says they took their medicine correctly, compared with 62% who had no such recollection.

To those who can’t understand how someone might completely forget receiving discharge instructions, Dr. Flacker suggests thinking back to the first day of residency or medical school when “you’re handed a whole pile of stuff” while trying to acclimate to unfamiliar surroundings. “Add to that being uncomfortable, sick, and uncertain about the future, and a lot of what is said goes untransferred,” he says.

In an elderly population, cognitive status and poor health literacy are certainly important potential confounders, but “based on my experience, our results are not a whole lot different than those of other investigators who accounted for those factors,” says Dr. Flacker.

These findings suggest that merely transmitting information is not sufficient. Some follow-up is needed to ensure that patients understand the information as their healthcare providers intend, Dr. Flacker and his colleagues wrote. Anything less might violate the spirit of Joint Commission on Accreditation of Healthcare Organization (JCAHO) standards requiring the clear and routine provision of information to patients.

Because of this study, Grady has revised its discharge sheet so information concerning telephone numbers, medication, and other important details are displayed more prominently. The hospital has retrained its nurses to deliver the information more effectively. Follow-up studies will assess how these changes affect patient comprehension and outcomes.

If hospitalists perceive their responsibility to the patient ending not at hospital discharge, but when the patient resumes seeing his or her primary care physician, then “their job is to ensure that the patient understands the discharge instructions,” Dr. Flacker points out.

He suggests they have a social worker or other staff member call patients within a few days after discharge to see how they’re doing and nip any problems in the bud. Admittedly, “a lot depends on where you want to put your resources,” he says. Time and budgets can be stretched only so far. Nevertheless, he maintains, “Post discharge contact is a critically important piece of the process.” TH

Norra MacReady is a medical writer based in California.

A significant percentage of patients do not remember or understand the instructions they receive before leaving the hospital, according to a study in this month’s Journal of Hospital Medicine.

“Anyone who’s taken care of patients or put together a discharge plan only to have things not work out knows how frustrating that can be,” says lead author Jonathan Flacker, MD.

Dr. Flacker

Dr. Flacker, assistant professor of medicine in the Division of Geriatric Medicine and Gerontology, Emory University School of Medicine, Atlanta, and coauthors Wansoo Park, PhD, and Addie Sims, MSW, surveyed a group of elderly patients shortly after discharge to determine their recall and comprehension of their pre-discharge instructions. Dr. Park is an assistant professor of social work at the University of Windsor in Ontario, Canada. Dr. Sims is director of Senior Services at Grady Health System in Atlanta.

They conducted telephone interviews with 269 patients 70 or older, or their caregivers, within 10 days of discharge from Grady Memorial Hospital in Atlanta. Most interviews were conducted within a mean of three days of discharge and lasted 20 to 30 minutes. No effort was made to determine the patients’ cognitive status or degree of health literacy.

The survey was an offshoot of Aging Atlanta, a project funded by the Robert Wood Johnson Foundation to study the overall care of older adults in the community. It asked 37 questions covering patients’ financial resources and activities of daily living as well as the nature of their discharge instructions.

The authors found the survey “feasible and easily administered,” but its results were somewhat discouraging. In 52% of the cases, respondents claimed no one spoke to them prior to discharge about caring for themselves at home. Almost as many (47%) says they were not given a phone number or the name of a person to call if they experienced problems at home. “Yet the number was on the discharge papers; 100% of the people received it,” says Dr. Flacker.

Also, 41% says they were not told what to do if they experienced problems at home. On a more positive note, only 13% of the patients had to call concerning problems, and 84% felt they had received enough help after returning home.

Of the 115 (43%) patients who said the received instructions prior to discharge, 103 (90%) remembered how they were delivered: verbally in 68 cases (63%), written in 11 cases (11%), and both ways in 24 cases (23%).

“Patients receiving instructions both verbally and in writing were more likely to report that they understood care instruction ‘very well’ versus ‘somewhat’ or ‘very little,’ ” the authors wrote. Of those who recalled being instructed on how to take their medication, 86% says they took their medicine correctly, compared with 62% who had no such recollection.

To those who can’t understand how someone might completely forget receiving discharge instructions, Dr. Flacker suggests thinking back to the first day of residency or medical school when “you’re handed a whole pile of stuff” while trying to acclimate to unfamiliar surroundings. “Add to that being uncomfortable, sick, and uncertain about the future, and a lot of what is said goes untransferred,” he says.

In an elderly population, cognitive status and poor health literacy are certainly important potential confounders, but “based on my experience, our results are not a whole lot different than those of other investigators who accounted for those factors,” says Dr. Flacker.

These findings suggest that merely transmitting information is not sufficient. Some follow-up is needed to ensure that patients understand the information as their healthcare providers intend, Dr. Flacker and his colleagues wrote. Anything less might violate the spirit of Joint Commission on Accreditation of Healthcare Organization (JCAHO) standards requiring the clear and routine provision of information to patients.

Because of this study, Grady has revised its discharge sheet so information concerning telephone numbers, medication, and other important details are displayed more prominently. The hospital has retrained its nurses to deliver the information more effectively. Follow-up studies will assess how these changes affect patient comprehension and outcomes.

If hospitalists perceive their responsibility to the patient ending not at hospital discharge, but when the patient resumes seeing his or her primary care physician, then “their job is to ensure that the patient understands the discharge instructions,” Dr. Flacker points out.

He suggests they have a social worker or other staff member call patients within a few days after discharge to see how they’re doing and nip any problems in the bud. Admittedly, “a lot depends on where you want to put your resources,” he says. Time and budgets can be stretched only so far. Nevertheless, he maintains, “Post discharge contact is a critically important piece of the process.” TH

Norra MacReady is a medical writer based in California.

A significant percentage of patients do not remember or understand the instructions they receive before leaving the hospital, according to a study in this month’s Journal of Hospital Medicine.

“Anyone who’s taken care of patients or put together a discharge plan only to have things not work out knows how frustrating that can be,” says lead author Jonathan Flacker, MD.

Dr. Flacker

Dr. Flacker, assistant professor of medicine in the Division of Geriatric Medicine and Gerontology, Emory University School of Medicine, Atlanta, and coauthors Wansoo Park, PhD, and Addie Sims, MSW, surveyed a group of elderly patients shortly after discharge to determine their recall and comprehension of their pre-discharge instructions. Dr. Park is an assistant professor of social work at the University of Windsor in Ontario, Canada. Dr. Sims is director of Senior Services at Grady Health System in Atlanta.

They conducted telephone interviews with 269 patients 70 or older, or their caregivers, within 10 days of discharge from Grady Memorial Hospital in Atlanta. Most interviews were conducted within a mean of three days of discharge and lasted 20 to 30 minutes. No effort was made to determine the patients’ cognitive status or degree of health literacy.

The survey was an offshoot of Aging Atlanta, a project funded by the Robert Wood Johnson Foundation to study the overall care of older adults in the community. It asked 37 questions covering patients’ financial resources and activities of daily living as well as the nature of their discharge instructions.

The authors found the survey “feasible and easily administered,” but its results were somewhat discouraging. In 52% of the cases, respondents claimed no one spoke to them prior to discharge about caring for themselves at home. Almost as many (47%) says they were not given a phone number or the name of a person to call if they experienced problems at home. “Yet the number was on the discharge papers; 100% of the people received it,” says Dr. Flacker.

Also, 41% says they were not told what to do if they experienced problems at home. On a more positive note, only 13% of the patients had to call concerning problems, and 84% felt they had received enough help after returning home.

Of the 115 (43%) patients who said the received instructions prior to discharge, 103 (90%) remembered how they were delivered: verbally in 68 cases (63%), written in 11 cases (11%), and both ways in 24 cases (23%).

“Patients receiving instructions both verbally and in writing were more likely to report that they understood care instruction ‘very well’ versus ‘somewhat’ or ‘very little,’ ” the authors wrote. Of those who recalled being instructed on how to take their medication, 86% says they took their medicine correctly, compared with 62% who had no such recollection.

To those who can’t understand how someone might completely forget receiving discharge instructions, Dr. Flacker suggests thinking back to the first day of residency or medical school when “you’re handed a whole pile of stuff” while trying to acclimate to unfamiliar surroundings. “Add to that being uncomfortable, sick, and uncertain about the future, and a lot of what is said goes untransferred,” he says.

In an elderly population, cognitive status and poor health literacy are certainly important potential confounders, but “based on my experience, our results are not a whole lot different than those of other investigators who accounted for those factors,” says Dr. Flacker.

These findings suggest that merely transmitting information is not sufficient. Some follow-up is needed to ensure that patients understand the information as their healthcare providers intend, Dr. Flacker and his colleagues wrote. Anything less might violate the spirit of Joint Commission on Accreditation of Healthcare Organization (JCAHO) standards requiring the clear and routine provision of information to patients.

Because of this study, Grady has revised its discharge sheet so information concerning telephone numbers, medication, and other important details are displayed more prominently. The hospital has retrained its nurses to deliver the information more effectively. Follow-up studies will assess how these changes affect patient comprehension and outcomes.

If hospitalists perceive their responsibility to the patient ending not at hospital discharge, but when the patient resumes seeing his or her primary care physician, then “their job is to ensure that the patient understands the discharge instructions,” Dr. Flacker points out.

He suggests they have a social worker or other staff member call patients within a few days after discharge to see how they’re doing and nip any problems in the bud. Admittedly, “a lot depends on where you want to put your resources,” he says. Time and budgets can be stretched only so far. Nevertheless, he maintains, “Post discharge contact is a critically important piece of the process.” TH

Norra MacReady is a medical writer based in California.

Hospital discharge and transition, whether back into the community or to other levels of care, are burdened by a lack of standardization and can be executed poorly—making them treacherous periods for patients.

Indeed, 20% of discharges are complicated by adverse events within 30 days, often resulting in avoidable trips to the emergency department and rehospitalization. Nationwide, 25% of patients are readmitted within 90 days, often because the fragmented discharge process leaves them vulnerable to iatrogenic complications.

Yet few studies have examined the discharge process in depth. Until now, none have looked at it from the patient’s point of view, lead author Lee Strunin, PhD, and colleagues Meg Stone, MPH, and Brian Jack, MD, write in the September-October edition of the Journal of Hospital Medicine. They interviewed 21 low-income patients in an inner-city hospital in Boston to identify the factors most closely associated with the risk of readmission.

The patients had a mean age of 46, and all had been hospitalized at least once within the previous six months. Twenty of the 21 patients were in the hospital for the same primary problem they were admitted for on their previous stay. The interviews lasted 20 to 45 minutes with each patient and addressed the patient’s ability to obtain follow-up care, care after discharge, and social support.

In most cases, inability to understand discharge instructions was not a problem. All participants could describe those instructions as well as their medical condition, why they were admitted to the hospital, and the medications they were taking.

“For the participants in this study, difficult life circumstances posed a greater barrier to recuperation than lack of medical knowledge,” the investigators write. Patients complained of little or no support in such areas as child care, transportation to medical appointments, or attempts to overcome alcoholism or drug abuse. Many patients could not follow instructions to rest because they had to work or care for young children.

Half the patients reported psychological conditions such as depression and stress, which interfered with their ability to follow their treatment plan. For example, an 18-year-old black woman with diabetes told of how she would do well for a while, following diet and medication recommendations and monitoring her blood sugar regularly, only to become depressed and lose motivation. She was not receiving treatment for her depression. Another woman with polycystic kidney disease described pain that was sometimes so intense she had to delegate the housekeeping chores to her 5-year-old son.

Even though the patients in this study appeared to understand their illnesses and what to do (under ideal circumstances) after they went home, poor health literacy could be one explanation for these findings, senior author Dr. Jack tells The Hospitalist.

“We have data now that patients with low health literacy are less ready for discharge,” says Dr. Jack, associate professor of family medicine, Boston University Medical Center, and the department’s founding vice chair for academic affairs. He and his colleagues are developing patient-centered interventions to mitigate the discrepancies between people who are more or less health-literate. “To the degree that the middle-class population has higher health literacy, [outcomes after discharge] might vary,” he says.

These findings demonstrate the critical effect life circumstances outside the hospital have on a patient’s recovery, the authors say in the paper, adding that the patients’ experiences “clearly demonstrate the ways in which stresses make it difficult or impossible to attain sufficient rest to heal, maintain behavior change necessary to improve health, and follow instructions given by clinicians at the time of discharge.”

They further point out that interventions aimed at low-income patients should include social support and assistance with daily responsibilities.

“A focus on each patient’s life circumstance is critical,” Dr. Jack explains. For example, it isn’t sufficient simply to tell the patient when to come back for a stress test. Hospitals or caseworkers should also determine if “it is a day the patient can go, do they have a ride, daycare, do they know where the test is, which doctor will follow up the results, will they be seeing that doctor, and so on. There are now recent data suggesting that most tests ordered after discharge are never done.”

From this and other studies on the subject, it seems intuitive that providing these supports for at-risk patients should reduce rehospitalization rates. Is there any evidence this is the case?

“Not yet,” Dr. Jack says. “But stay tuned.” TH

Norra MacReady is a medical writer based in California.

Hospital discharge and transition, whether back into the community or to other levels of care, are burdened by a lack of standardization and can be executed poorly—making them treacherous periods for patients.

Indeed, 20% of discharges are complicated by adverse events within 30 days, often resulting in avoidable trips to the emergency department and rehospitalization. Nationwide, 25% of patients are readmitted within 90 days, often because the fragmented discharge process leaves them vulnerable to iatrogenic complications.

Yet few studies have examined the discharge process in depth. Until now, none have looked at it from the patient’s point of view, lead author Lee Strunin, PhD, and colleagues Meg Stone, MPH, and Brian Jack, MD, write in the September-October edition of the Journal of Hospital Medicine. They interviewed 21 low-income patients in an inner-city hospital in Boston to identify the factors most closely associated with the risk of readmission.

The patients had a mean age of 46, and all had been hospitalized at least once within the previous six months. Twenty of the 21 patients were in the hospital for the same primary problem they were admitted for on their previous stay. The interviews lasted 20 to 45 minutes with each patient and addressed the patient’s ability to obtain follow-up care, care after discharge, and social support.

In most cases, inability to understand discharge instructions was not a problem. All participants could describe those instructions as well as their medical condition, why they were admitted to the hospital, and the medications they were taking.

“For the participants in this study, difficult life circumstances posed a greater barrier to recuperation than lack of medical knowledge,” the investigators write. Patients complained of little or no support in such areas as child care, transportation to medical appointments, or attempts to overcome alcoholism or drug abuse. Many patients could not follow instructions to rest because they had to work or care for young children.

Half the patients reported psychological conditions such as depression and stress, which interfered with their ability to follow their treatment plan. For example, an 18-year-old black woman with diabetes told of how she would do well for a while, following diet and medication recommendations and monitoring her blood sugar regularly, only to become depressed and lose motivation. She was not receiving treatment for her depression. Another woman with polycystic kidney disease described pain that was sometimes so intense she had to delegate the housekeeping chores to her 5-year-old son.

Even though the patients in this study appeared to understand their illnesses and what to do (under ideal circumstances) after they went home, poor health literacy could be one explanation for these findings, senior author Dr. Jack tells The Hospitalist.

“We have data now that patients with low health literacy are less ready for discharge,” says Dr. Jack, associate professor of family medicine, Boston University Medical Center, and the department’s founding vice chair for academic affairs. He and his colleagues are developing patient-centered interventions to mitigate the discrepancies between people who are more or less health-literate. “To the degree that the middle-class population has higher health literacy, [outcomes after discharge] might vary,” he says.

These findings demonstrate the critical effect life circumstances outside the hospital have on a patient’s recovery, the authors say in the paper, adding that the patients’ experiences “clearly demonstrate the ways in which stresses make it difficult or impossible to attain sufficient rest to heal, maintain behavior change necessary to improve health, and follow instructions given by clinicians at the time of discharge.”

They further point out that interventions aimed at low-income patients should include social support and assistance with daily responsibilities.

“A focus on each patient’s life circumstance is critical,” Dr. Jack explains. For example, it isn’t sufficient simply to tell the patient when to come back for a stress test. Hospitals or caseworkers should also determine if “it is a day the patient can go, do they have a ride, daycare, do they know where the test is, which doctor will follow up the results, will they be seeing that doctor, and so on. There are now recent data suggesting that most tests ordered after discharge are never done.”

From this and other studies on the subject, it seems intuitive that providing these supports for at-risk patients should reduce rehospitalization rates. Is there any evidence this is the case?

“Not yet,” Dr. Jack says. “But stay tuned.” TH

Norra MacReady is a medical writer based in California.

Hospital discharge and transition, whether back into the community or to other levels of care, are burdened by a lack of standardization and can be executed poorly—making them treacherous periods for patients.

Indeed, 20% of discharges are complicated by adverse events within 30 days, often resulting in avoidable trips to the emergency department and rehospitalization. Nationwide, 25% of patients are readmitted within 90 days, often because the fragmented discharge process leaves them vulnerable to iatrogenic complications.

Yet few studies have examined the discharge process in depth. Until now, none have looked at it from the patient’s point of view, lead author Lee Strunin, PhD, and colleagues Meg Stone, MPH, and Brian Jack, MD, write in the September-October edition of the Journal of Hospital Medicine. They interviewed 21 low-income patients in an inner-city hospital in Boston to identify the factors most closely associated with the risk of readmission.

The patients had a mean age of 46, and all had been hospitalized at least once within the previous six months. Twenty of the 21 patients were in the hospital for the same primary problem they were admitted for on their previous stay. The interviews lasted 20 to 45 minutes with each patient and addressed the patient’s ability to obtain follow-up care, care after discharge, and social support.

In most cases, inability to understand discharge instructions was not a problem. All participants could describe those instructions as well as their medical condition, why they were admitted to the hospital, and the medications they were taking.

“For the participants in this study, difficult life circumstances posed a greater barrier to recuperation than lack of medical knowledge,” the investigators write. Patients complained of little or no support in such areas as child care, transportation to medical appointments, or attempts to overcome alcoholism or drug abuse. Many patients could not follow instructions to rest because they had to work or care for young children.

Half the patients reported psychological conditions such as depression and stress, which interfered with their ability to follow their treatment plan. For example, an 18-year-old black woman with diabetes told of how she would do well for a while, following diet and medication recommendations and monitoring her blood sugar regularly, only to become depressed and lose motivation. She was not receiving treatment for her depression. Another woman with polycystic kidney disease described pain that was sometimes so intense she had to delegate the housekeeping chores to her 5-year-old son.

Even though the patients in this study appeared to understand their illnesses and what to do (under ideal circumstances) after they went home, poor health literacy could be one explanation for these findings, senior author Dr. Jack tells The Hospitalist.

“We have data now that patients with low health literacy are less ready for discharge,” says Dr. Jack, associate professor of family medicine, Boston University Medical Center, and the department’s founding vice chair for academic affairs. He and his colleagues are developing patient-centered interventions to mitigate the discrepancies between people who are more or less health-literate. “To the degree that the middle-class population has higher health literacy, [outcomes after discharge] might vary,” he says.

These findings demonstrate the critical effect life circumstances outside the hospital have on a patient’s recovery, the authors say in the paper, adding that the patients’ experiences “clearly demonstrate the ways in which stresses make it difficult or impossible to attain sufficient rest to heal, maintain behavior change necessary to improve health, and follow instructions given by clinicians at the time of discharge.”

They further point out that interventions aimed at low-income patients should include social support and assistance with daily responsibilities.

“A focus on each patient’s life circumstance is critical,” Dr. Jack explains. For example, it isn’t sufficient simply to tell the patient when to come back for a stress test. Hospitals or caseworkers should also determine if “it is a day the patient can go, do they have a ride, daycare, do they know where the test is, which doctor will follow up the results, will they be seeing that doctor, and so on. There are now recent data suggesting that most tests ordered after discharge are never done.”

From this and other studies on the subject, it seems intuitive that providing these supports for at-risk patients should reduce rehospitalization rates. Is there any evidence this is the case?

“Not yet,” Dr. Jack says. “But stay tuned.” TH

Norra MacReady is a medical writer based in California.

Translate the following statement into plain English:*

“It is fruitless to become lachrymose over precipitately departed lacteal fluid.”1

If these words made you pause—even for a moment—you now have an inkling of what people of limited literacy confront when they deal with the healthcare system.

Health literacy is best defined as a patient’s ability to read, comprehend, and act on medical instructions and to make appropriate health-related decisions.2,3 It is closely related to, although not absolutely dependent upon, one’s overall level of literacy—and literacy problems are surprisingly widespread. According to the National Assessment of Adult Literacy (NAAL), a survey of more than 19,000 adults conducted in 2003 by the National Center for Educational Statistics and published in 2006, 36% of American adults have nothing more than basic or below basic literacy. People in these two categories might be able to sign their names, decipher a bus schedule, or read very simple instructions telling them what they can and cannot eat before a medical test, but they cannot read a juror information pamphlet, much less an informed consent form. Another recent survey suggested that about one-third of adults in public hospitals read at or below a sixth-grade level.4

Components of Health Literacy

Several components figure into a person’s ability to manage his health and engage the healthcare system. Literacy limitations can impair any or all of these factors, which include:

• Health promotion: reading and understanding product labels or articles in newspapers;
• Health protection: reading and understanding applications for insurance or following sanitary precautions in the workplace;
• Disease prevention and screening: obtaining information about flu shots and blood pressure maintenance;
• Ability to access care and navigate the system: determining the most appropriate healthcare provider to call when a problem arises or filling out forms correctly; and
• Routine care and maintenance: testing blood glucose and getting regular checkups.1

Health literacy is further complicated by the fact that it can fluctuate in the same individual at different times and under different circumstances. For example, you might have no trouble deciphering the sentence at the beginning of this article if you feel well and are reading it in your office, living room, study, or some other familiar and comfortable environment. Now imagine that you’re ill and sitting in a noisy, chaotic emergency department, with a sheaf of other forms and papers to plow through. Suddenly the statement above may not be as easy to interpret.

“We must leave behind the notion of ‘illiterates,’ ” says Lakshmi Halasyamani, MD, chair of the Hospital Quality and Patient Safety Committee for SHM. “A person may not normally have a literacy problem, but they may be overwhelmed by the medical terminology, or they simply may not feel well enough to comprehend immediately everything the doctor says to them.”

The changing nature of healthcare may exacerbate the problem. Thirty years ago, only 650 drugs were available, and the average hospital stay for a myocardial infarction was four to six weeks. Today, there are more than 10,000 prescription drugs alone, and the typical stay for a heart attack is two to four days. As healthcare grows increasingly fragmented and complex, doctors have less time than ever to explain things and answer questions for their patients. Nevertheless, patients are expected to shoulder an ever-greater portion of the responsibility for their care and to live with conditions like diabetes or congestive heart failure, which require aggressive and detailed management.5 This is a challenge for even the most highly educated person; for someone whose literacy skills are fragile, the task can seem hopeless.

In addition to its medical and emotional consequences, limited health literacy is estimated to cost U.S. society $50 to $73 billion per year.6

Who Is Most Likely to Have Literacy Problems?

In general, “the likelihood of low literacy increases in racial and ethnic minority groups, patients with language barriers, and those with low educational achievement,” says Benjamin Powers, MD, associate professor of general internal medicine at Duke University and a physician at the Durham Veterans Affairs Medical Center in North Carolina.

It’s no surprise that literacy overall, and health literacy specifically, correlate so closely with education and especially with the lack of a high school degree. What is perhaps more surprising is that educational achievement alone does not necessarily guarantee good health literacy.

“Even high school graduates may have trouble,” says Mark Williams, MD. In addition to being a professor of medicine and director of the hospital medicine unit at Emory University School of Medicine in Atlanta, Dr. Williams is the editor of the Journal of Hospital Medicine and has studied health literacy problems for years. “Some highly literate people may have problems reading or absorbing health-related information if they’re sick and not feeling well.”

These people are not illiterate in the conventional sense, but they may have inadequate functional health literacy skills, at least in certain settings.

Age is another risk factor. In one survey of Medicare enrollees, at least one-third of people age 65 or older had some degree of health illiteracy, Dr. Williams says. As with so many other skills, proficient reading requires regular practice, and people tend to read less as they age, so their literacy skills may decline. “It’s especially a problem for the ‘oldest old,’ people who are 75 years old or more,” he explains.

Language and cultural differences also enter into the equation. A patient may be well educated and able to articulate in her own language (perhaps even able to converse well in English under normal circumstances), but may be unfamiliar with medical terminology. Put her in a situation in which she feels ill, flustered, and disoriented, and her communication skills may deteriorate even more, says Dr. Halasyamani.

In short, health literacy consists of many components, including “an emotional overlay, information overload, and cultural overload. All of these factor into the patients’ ability to understand what we tell them,” says Barbara DeBuono, MD, MPH, senior medical advisor on U.S. Public Health and Policy at Pfizer Pharmaceuticals.

Issues Unique to Hospitalists

There are also a few issues unique to hospitalists and their patients, warns Dr. DeBuono, who is also on the board of the Partnership for Clear Health Communication (See “Ask Me 3,” at right.) “Hospitalists don’t necessarily have a long-term relationship with these patients, so they have to make a quick assessment of the patient’s ability to understand and absorb information. Then they have to determine the best way to communicate that information, and, when necessary, change their communication strategy to fit the circumstances.”

In addition, she says, “hospital patients usually are more complicated than patients seen in an office practice. They may have chronic conditions and several comorbidities, and the information and discharge instructions the physicians give them can be pretty complex.”

Indeed, “a patient may come in thinking she had no issues and leave the hospital with four or five complaints. We’ve rocked her world, and that can be overwhelming for even the most motivated person,” says Dr. Halasyamani, who cautions that any chronic illness that requires a significant amount of ongoing self-care, such as diabetes or heart failure, can tax a patient’s ability to completely understand her situation and coordinate her care effectively.

Fragmented Care

Patients with multiple and complex morbidities also are likely to be cared for by several physicians, who prescribe numerous drugs, tests, and procedures, and who don’t necessarily know what the other members of the care team are doing. Even highly sophisticated people can get the feeling that they’re caught in an ever-changing kaleidoscope of medical visits and jargon, in which the various fragments never coalesce into a comprehensible whole. As Dr. Powers and coauthor Hayden Bosworth, PhD, wrote in a recent editorial: “ … there may be specific physician and health system organizational factors that exacerbate or mitigate the impact of low literacy. Literacy may matter more for patients who are cared for in a chaotic and discontinuous system that is not organized around delivering high quality care in a multidisciplinary setting.”7

This is more than a subjective impression: There is evidence supporting the importance of coordinated care for people of limited literacy skills. Dr. Powers and Bosworth recently compared the impact of low literacy on blood pressure control in patients in the Veterans Affairs (VA) system and those who attended local community clinics.

“Although the prevalence of low literacy was high in both populations, there was a significant association with low literacy and poor blood pressure control in the community clinics but not the VA,” Dr. Powers tells The Hospitalist. “In other words, literacy seemed to be an important predictor of good blood pressure control in one healthcare setting but not in another.”

In hospitals, “the frequency of handoffs among doctors, nurses, caseworkers, and social workers may all contribute to the fragmented nature of a patient’s care,” warns Dr. Halasyamani. This may be exacerbated even further should the patient have the misfortune to be admitted during a transitional period, such as a weekend or the end of the month when staff members rotate.

Red Flags

Literacy limitations are easy to miss: Patients rarely announce that they can’t read forms or comprehend a clinician’s instructions. “Just asking, ‘Do you understand?’ rarely works, because the patient may just nod yes. Physicians need to assess the patient’s comprehension proactively,” says Dr. Williams.

Usually, the clues are subtle. “Most physicians do encounter such patients, but we’re not trained to detect literacy problems and respond appropriately,” says Sunil Kripalani, MD, MSc, who, like Dr. Williams, is an Emory University hospitalist with a special interest in patient literacy issues. Dr. Kripalani suggests looking for red flags, including:

• Vague or evasive answers to questions. For example, “the patient who is taking a host of medications but can’t name them or tell you what time of day he’s supposed to take them;”
• Few, if any, questions or discussions of concerns: “Patients with limited literacy are less prone to ask questions, and the questions they do ask may not be as deep as those asked by a patient with greater literacy skills. The patient may use very simple terminology and not integrate any of the concepts discussed during the appointment;” and
• Missed appointments and repeated crises and hospitalizations resulting from the patient’s inability to read appointment cards or manage his illness. “Limited literacy skills may be a contributor to the exacerbations that put the patient in the hospital,” says Dr. Kripalani.

A patient with few family or social connections is also cause for concern, adds Dr. Halasyamani: “Lack of social support means there’s not another set of eyes and ears taking in the information.” Yet another red flag to her is the patient who cannot describe his plans for pursuing his care at home.

When patients have their medications with them, Dr. Williams asks how they take them. Those who can read simply look at the label, but a patient with literacy problems must open the bottle and look at the pills to identify them.

Solutions

How can physicians ensure that these patients understand and can follow instructions? Perhaps the easiest and most effective way is the “teach-back” approach, in which you ask the patient to repeat or teach back to you what you’ve just explained to him. For example, you might have him show you how to use an asthma inhaler or how to measure his blood glucose. In this way, you can rapidly assess and correct any deficiencies in the patient’s understanding.

“I’ve seen it take less than 90 seconds for physicians to confirm patient understanding in the context of a clinical visit,” says Dr. Kripalani.

A related technique that might help save time is to resist the temptation to tell the patient too much in a single visit. “Don’t try to give the patient too much information,” he advises. “People can process and retain maybe three nuggets of information at a time, so tell the patient the three most important things and then confirm their understanding of those three things.”

Dr. DeBuono suggests using visual aids like pictures or cartoons to help get important points across. If written material is necessary, have it printed in large type, which might appear less daunting than a page covered in dense, tiny print.

Above all, never embarrass a patient by bluntly asking him if he can read. “Explore the issue sensitively and respectfully,” Dr. Williams says. “Ask if they ever struggle with written materials or what the best way is for them to learn.” Adds Dr. DeBuono, “just by being sensitive to the fact that the patient may not understand is half the game.” TH

Norra MacReady is a medical journalist based in Southern California.

*“There’s no use crying over spilt milk.”

References

1. Rudd RE. Literacy and implications for navigating health care. Harvard School of Public Health: Health Literacy Website. Slide 20. 2002. Available at www.hsph.harvard.edu/healthliteracy/slides/2002/2002_01.html. Last accessed December 1, 2006.
2. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002 Jul 24;288(4):475-482.
3. Paasche-Orlow MK, Schillinger D, Greene SM, et al. How health care systems can begin to address the challenge of limited literacy. J Gen Intern Med. 2006 Aug;21(8):884-887.
4. Marcus EN. The silent epidemic—the health effects of illiteracy. N Engl J Med. 2006 Jul 27;355(4):339-341. Erratum in N Engl J Med. 2006 Sept 7;355(10):1076.
5. Williams MV. Recognizing and overcoming inadequate health literacy, a barrier to care. Cleve Clin J Med. 2002 May;69(5):415-418.
6. Weiss BD. Health literacy: a manual for clinicians [American Medical Association Web site]. American Medical Association Foundation and the American Medical Association, 2003. Available at: www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf. Last accessed December 16, 2006.
7. Powers BJ, Bosworth HB. Revisiting literacy and adherence: future clinical and research directions. J Gen Intern Med. 2006;21:1341-1342.

Just asking, “Do you understand?” rarely works because the patient may just nod yes. Physicians need to assess the patient’s comprehension proactively.—Mark Williams, MD, professor of medicine and director of the hospital medicine unit at Emory University School of Medicine, Atlanta.

Translate the following statement into plain English:*

“It is fruitless to become lachrymose over precipitately departed lacteal fluid.”1

If these words made you pause—even for a moment—you now have an inkling of what people of limited literacy confront when they deal with the healthcare system.

Health literacy is best defined as a patient’s ability to read, comprehend, and act on medical instructions and to make appropriate health-related decisions.2,3 It is closely related to, although not absolutely dependent upon, one’s overall level of literacy—and literacy problems are surprisingly widespread. According to the National Assessment of Adult Literacy (NAAL), a survey of more than 19,000 adults conducted in 2003 by the National Center for Educational Statistics and published in 2006, 36% of American adults have nothing more than basic or below basic literacy. People in these two categories might be able to sign their names, decipher a bus schedule, or read very simple instructions telling them what they can and cannot eat before a medical test, but they cannot read a juror information pamphlet, much less an informed consent form. Another recent survey suggested that about one-third of adults in public hospitals read at or below a sixth-grade level.4

Components of Health Literacy

Several components figure into a person’s ability to manage his health and engage the healthcare system. Literacy limitations can impair any or all of these factors, which include:

• Health promotion: reading and understanding product labels or articles in newspapers;
• Health protection: reading and understanding applications for insurance or following sanitary precautions in the workplace;
• Disease prevention and screening: obtaining information about flu shots and blood pressure maintenance;
• Ability to access care and navigate the system: determining the most appropriate healthcare provider to call when a problem arises or filling out forms correctly; and
• Routine care and maintenance: testing blood glucose and getting regular checkups.1

Health literacy is further complicated by the fact that it can fluctuate in the same individual at different times and under different circumstances. For example, you might have no trouble deciphering the sentence at the beginning of this article if you feel well and are reading it in your office, living room, study, or some other familiar and comfortable environment. Now imagine that you’re ill and sitting in a noisy, chaotic emergency department, with a sheaf of other forms and papers to plow through. Suddenly the statement above may not be as easy to interpret.

“We must leave behind the notion of ‘illiterates,’ ” says Lakshmi Halasyamani, MD, chair of the Hospital Quality and Patient Safety Committee for SHM. “A person may not normally have a literacy problem, but they may be overwhelmed by the medical terminology, or they simply may not feel well enough to comprehend immediately everything the doctor says to them.”

The changing nature of healthcare may exacerbate the problem. Thirty years ago, only 650 drugs were available, and the average hospital stay for a myocardial infarction was four to six weeks. Today, there are more than 10,000 prescription drugs alone, and the typical stay for a heart attack is two to four days. As healthcare grows increasingly fragmented and complex, doctors have less time than ever to explain things and answer questions for their patients. Nevertheless, patients are expected to shoulder an ever-greater portion of the responsibility for their care and to live with conditions like diabetes or congestive heart failure, which require aggressive and detailed management.5 This is a challenge for even the most highly educated person; for someone whose literacy skills are fragile, the task can seem hopeless.

In addition to its medical and emotional consequences, limited health literacy is estimated to cost U.S. society $50 to $73 billion per year.6

Who Is Most Likely to Have Literacy Problems?

In general, “the likelihood of low literacy increases in racial and ethnic minority groups, patients with language barriers, and those with low educational achievement,” says Benjamin Powers, MD, associate professor of general internal medicine at Duke University and a physician at the Durham Veterans Affairs Medical Center in North Carolina.

It’s no surprise that literacy overall, and health literacy specifically, correlate so closely with education and especially with the lack of a high school degree. What is perhaps more surprising is that educational achievement alone does not necessarily guarantee good health literacy.

“Even high school graduates may have trouble,” says Mark Williams, MD. In addition to being a professor of medicine and director of the hospital medicine unit at Emory University School of Medicine in Atlanta, Dr. Williams is the editor of the Journal of Hospital Medicine and has studied health literacy problems for years. “Some highly literate people may have problems reading or absorbing health-related information if they’re sick and not feeling well.”

These people are not illiterate in the conventional sense, but they may have inadequate functional health literacy skills, at least in certain settings.

Age is another risk factor. In one survey of Medicare enrollees, at least one-third of people age 65 or older had some degree of health illiteracy, Dr. Williams says. As with so many other skills, proficient reading requires regular practice, and people tend to read less as they age, so their literacy skills may decline. “It’s especially a problem for the ‘oldest old,’ people who are 75 years old or more,” he explains.

Language and cultural differences also enter into the equation. A patient may be well educated and able to articulate in her own language (perhaps even able to converse well in English under normal circumstances), but may be unfamiliar with medical terminology. Put her in a situation in which she feels ill, flustered, and disoriented, and her communication skills may deteriorate even more, says Dr. Halasyamani.

In short, health literacy consists of many components, including “an emotional overlay, information overload, and cultural overload. All of these factor into the patients’ ability to understand what we tell them,” says Barbara DeBuono, MD, MPH, senior medical advisor on U.S. Public Health and Policy at Pfizer Pharmaceuticals.

Issues Unique to Hospitalists

There are also a few issues unique to hospitalists and their patients, warns Dr. DeBuono, who is also on the board of the Partnership for Clear Health Communication (See “Ask Me 3,” at right.) “Hospitalists don’t necessarily have a long-term relationship with these patients, so they have to make a quick assessment of the patient’s ability to understand and absorb information. Then they have to determine the best way to communicate that information, and, when necessary, change their communication strategy to fit the circumstances.”

In addition, she says, “hospital patients usually are more complicated than patients seen in an office practice. They may have chronic conditions and several comorbidities, and the information and discharge instructions the physicians give them can be pretty complex.”

Indeed, “a patient may come in thinking she had no issues and leave the hospital with four or five complaints. We’ve rocked her world, and that can be overwhelming for even the most motivated person,” says Dr. Halasyamani, who cautions that any chronic illness that requires a significant amount of ongoing self-care, such as diabetes or heart failure, can tax a patient’s ability to completely understand her situation and coordinate her care effectively.

Fragmented Care

Patients with multiple and complex morbidities also are likely to be cared for by several physicians, who prescribe numerous drugs, tests, and procedures, and who don’t necessarily know what the other members of the care team are doing. Even highly sophisticated people can get the feeling that they’re caught in an ever-changing kaleidoscope of medical visits and jargon, in which the various fragments never coalesce into a comprehensible whole. As Dr. Powers and coauthor Hayden Bosworth, PhD, wrote in a recent editorial: “ … there may be specific physician and health system organizational factors that exacerbate or mitigate the impact of low literacy. Literacy may matter more for patients who are cared for in a chaotic and discontinuous system that is not organized around delivering high quality care in a multidisciplinary setting.”7

This is more than a subjective impression: There is evidence supporting the importance of coordinated care for people of limited literacy skills. Dr. Powers and Bosworth recently compared the impact of low literacy on blood pressure control in patients in the Veterans Affairs (VA) system and those who attended local community clinics.

“Although the prevalence of low literacy was high in both populations, there was a significant association with low literacy and poor blood pressure control in the community clinics but not the VA,” Dr. Powers tells The Hospitalist. “In other words, literacy seemed to be an important predictor of good blood pressure control in one healthcare setting but not in another.”

In hospitals, “the frequency of handoffs among doctors, nurses, caseworkers, and social workers may all contribute to the fragmented nature of a patient’s care,” warns Dr. Halasyamani. This may be exacerbated even further should the patient have the misfortune to be admitted during a transitional period, such as a weekend or the end of the month when staff members rotate.

Red Flags

Literacy limitations are easy to miss: Patients rarely announce that they can’t read forms or comprehend a clinician’s instructions. “Just asking, ‘Do you understand?’ rarely works, because the patient may just nod yes. Physicians need to assess the patient’s comprehension proactively,” says Dr. Williams.

Usually, the clues are subtle. “Most physicians do encounter such patients, but we’re not trained to detect literacy problems and respond appropriately,” says Sunil Kripalani, MD, MSc, who, like Dr. Williams, is an Emory University hospitalist with a special interest in patient literacy issues. Dr. Kripalani suggests looking for red flags, including:

• Vague or evasive answers to questions. For example, “the patient who is taking a host of medications but can’t name them or tell you what time of day he’s supposed to take them;”
• Few, if any, questions or discussions of concerns: “Patients with limited literacy are less prone to ask questions, and the questions they do ask may not be as deep as those asked by a patient with greater literacy skills. The patient may use very simple terminology and not integrate any of the concepts discussed during the appointment;” and
• Missed appointments and repeated crises and hospitalizations resulting from the patient’s inability to read appointment cards or manage his illness. “Limited literacy skills may be a contributor to the exacerbations that put the patient in the hospital,” says Dr. Kripalani.

A patient with few family or social connections is also cause for concern, adds Dr. Halasyamani: “Lack of social support means there’s not another set of eyes and ears taking in the information.” Yet another red flag to her is the patient who cannot describe his plans for pursuing his care at home.

When patients have their medications with them, Dr. Williams asks how they take them. Those who can read simply look at the label, but a patient with literacy problems must open the bottle and look at the pills to identify them.

Solutions

How can physicians ensure that these patients understand and can follow instructions? Perhaps the easiest and most effective way is the “teach-back” approach, in which you ask the patient to repeat or teach back to you what you’ve just explained to him. For example, you might have him show you how to use an asthma inhaler or how to measure his blood glucose. In this way, you can rapidly assess and correct any deficiencies in the patient’s understanding.

“I’ve seen it take less than 90 seconds for physicians to confirm patient understanding in the context of a clinical visit,” says Dr. Kripalani.

A related technique that might help save time is to resist the temptation to tell the patient too much in a single visit. “Don’t try to give the patient too much information,” he advises. “People can process and retain maybe three nuggets of information at a time, so tell the patient the three most important things and then confirm their understanding of those three things.”

Dr. DeBuono suggests using visual aids like pictures or cartoons to help get important points across. If written material is necessary, have it printed in large type, which might appear less daunting than a page covered in dense, tiny print.

Above all, never embarrass a patient by bluntly asking him if he can read. “Explore the issue sensitively and respectfully,” Dr. Williams says. “Ask if they ever struggle with written materials or what the best way is for them to learn.” Adds Dr. DeBuono, “just by being sensitive to the fact that the patient may not understand is half the game.” TH

Norra MacReady is a medical journalist based in Southern California.

*“There’s no use crying over spilt milk.”

References

1. Rudd RE. Literacy and implications for navigating health care. Harvard School of Public Health: Health Literacy Website. Slide 20. 2002. Available at www.hsph.harvard.edu/healthliteracy/slides/2002/2002_01.html. Last accessed December 1, 2006.
2. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002 Jul 24;288(4):475-482.
3. Paasche-Orlow MK, Schillinger D, Greene SM, et al. How health care systems can begin to address the challenge of limited literacy. J Gen Intern Med. 2006 Aug;21(8):884-887.
4. Marcus EN. The silent epidemic—the health effects of illiteracy. N Engl J Med. 2006 Jul 27;355(4):339-341. Erratum in N Engl J Med. 2006 Sept 7;355(10):1076.
5. Williams MV. Recognizing and overcoming inadequate health literacy, a barrier to care. Cleve Clin J Med. 2002 May;69(5):415-418.
6. Weiss BD. Health literacy: a manual for clinicians [American Medical Association Web site]. American Medical Association Foundation and the American Medical Association, 2003. Available at: www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf. Last accessed December 16, 2006.
7. Powers BJ, Bosworth HB. Revisiting literacy and adherence: future clinical and research directions. J Gen Intern Med. 2006;21:1341-1342.

Just asking, “Do you understand?” rarely works because the patient may just nod yes. Physicians need to assess the patient’s comprehension proactively.—Mark Williams, MD, professor of medicine and director of the hospital medicine unit at Emory University School of Medicine, Atlanta.

Translate the following statement into plain English:*

“It is fruitless to become lachrymose over precipitately departed lacteal fluid.”1

If these words made you pause—even for a moment—you now have an inkling of what people of limited literacy confront when they deal with the healthcare system.

Health literacy is best defined as a patient’s ability to read, comprehend, and act on medical instructions and to make appropriate health-related decisions.2,3 It is closely related to, although not absolutely dependent upon, one’s overall level of literacy—and literacy problems are surprisingly widespread. According to the National Assessment of Adult Literacy (NAAL), a survey of more than 19,000 adults conducted in 2003 by the National Center for Educational Statistics and published in 2006, 36% of American adults have nothing more than basic or below basic literacy. People in these two categories might be able to sign their names, decipher a bus schedule, or read very simple instructions telling them what they can and cannot eat before a medical test, but they cannot read a juror information pamphlet, much less an informed consent form. Another recent survey suggested that about one-third of adults in public hospitals read at or below a sixth-grade level.4

Components of Health Literacy

Several components figure into a person’s ability to manage his health and engage the healthcare system. Literacy limitations can impair any or all of these factors, which include:

• Health promotion: reading and understanding product labels or articles in newspapers;
• Health protection: reading and understanding applications for insurance or following sanitary precautions in the workplace;
• Disease prevention and screening: obtaining information about flu shots and blood pressure maintenance;
• Ability to access care and navigate the system: determining the most appropriate healthcare provider to call when a problem arises or filling out forms correctly; and
• Routine care and maintenance: testing blood glucose and getting regular checkups.1

Health literacy is further complicated by the fact that it can fluctuate in the same individual at different times and under different circumstances. For example, you might have no trouble deciphering the sentence at the beginning of this article if you feel well and are reading it in your office, living room, study, or some other familiar and comfortable environment. Now imagine that you’re ill and sitting in a noisy, chaotic emergency department, with a sheaf of other forms and papers to plow through. Suddenly the statement above may not be as easy to interpret.

“We must leave behind the notion of ‘illiterates,’ ” says Lakshmi Halasyamani, MD, chair of the Hospital Quality and Patient Safety Committee for SHM. “A person may not normally have a literacy problem, but they may be overwhelmed by the medical terminology, or they simply may not feel well enough to comprehend immediately everything the doctor says to them.”

The changing nature of healthcare may exacerbate the problem. Thirty years ago, only 650 drugs were available, and the average hospital stay for a myocardial infarction was four to six weeks. Today, there are more than 10,000 prescription drugs alone, and the typical stay for a heart attack is two to four days. As healthcare grows increasingly fragmented and complex, doctors have less time than ever to explain things and answer questions for their patients. Nevertheless, patients are expected to shoulder an ever-greater portion of the responsibility for their care and to live with conditions like diabetes or congestive heart failure, which require aggressive and detailed management.5 This is a challenge for even the most highly educated person; for someone whose literacy skills are fragile, the task can seem hopeless.

In addition to its medical and emotional consequences, limited health literacy is estimated to cost U.S. society $50 to $73 billion per year.6

Who Is Most Likely to Have Literacy Problems?

In general, “the likelihood of low literacy increases in racial and ethnic minority groups, patients with language barriers, and those with low educational achievement,” says Benjamin Powers, MD, associate professor of general internal medicine at Duke University and a physician at the Durham Veterans Affairs Medical Center in North Carolina.

It’s no surprise that literacy overall, and health literacy specifically, correlate so closely with education and especially with the lack of a high school degree. What is perhaps more surprising is that educational achievement alone does not necessarily guarantee good health literacy.

“Even high school graduates may have trouble,” says Mark Williams, MD. In addition to being a professor of medicine and director of the hospital medicine unit at Emory University School of Medicine in Atlanta, Dr. Williams is the editor of the Journal of Hospital Medicine and has studied health literacy problems for years. “Some highly literate people may have problems reading or absorbing health-related information if they’re sick and not feeling well.”

These people are not illiterate in the conventional sense, but they may have inadequate functional health literacy skills, at least in certain settings.

Age is another risk factor. In one survey of Medicare enrollees, at least one-third of people age 65 or older had some degree of health illiteracy, Dr. Williams says. As with so many other skills, proficient reading requires regular practice, and people tend to read less as they age, so their literacy skills may decline. “It’s especially a problem for the ‘oldest old,’ people who are 75 years old or more,” he explains.

Language and cultural differences also enter into the equation. A patient may be well educated and able to articulate in her own language (perhaps even able to converse well in English under normal circumstances), but may be unfamiliar with medical terminology. Put her in a situation in which she feels ill, flustered, and disoriented, and her communication skills may deteriorate even more, says Dr. Halasyamani.

In short, health literacy consists of many components, including “an emotional overlay, information overload, and cultural overload. All of these factor into the patients’ ability to understand what we tell them,” says Barbara DeBuono, MD, MPH, senior medical advisor on U.S. Public Health and Policy at Pfizer Pharmaceuticals.

Issues Unique to Hospitalists

There are also a few issues unique to hospitalists and their patients, warns Dr. DeBuono, who is also on the board of the Partnership for Clear Health Communication (See “Ask Me 3,” at right.) “Hospitalists don’t necessarily have a long-term relationship with these patients, so they have to make a quick assessment of the patient’s ability to understand and absorb information. Then they have to determine the best way to communicate that information, and, when necessary, change their communication strategy to fit the circumstances.”

In addition, she says, “hospital patients usually are more complicated than patients seen in an office practice. They may have chronic conditions and several comorbidities, and the information and discharge instructions the physicians give them can be pretty complex.”

Indeed, “a patient may come in thinking she had no issues and leave the hospital with four or five complaints. We’ve rocked her world, and that can be overwhelming for even the most motivated person,” says Dr. Halasyamani, who cautions that any chronic illness that requires a significant amount of ongoing self-care, such as diabetes or heart failure, can tax a patient’s ability to completely understand her situation and coordinate her care effectively.

Fragmented Care

Patients with multiple and complex morbidities also are likely to be cared for by several physicians, who prescribe numerous drugs, tests, and procedures, and who don’t necessarily know what the other members of the care team are doing. Even highly sophisticated people can get the feeling that they’re caught in an ever-changing kaleidoscope of medical visits and jargon, in which the various fragments never coalesce into a comprehensible whole. As Dr. Powers and coauthor Hayden Bosworth, PhD, wrote in a recent editorial: “ … there may be specific physician and health system organizational factors that exacerbate or mitigate the impact of low literacy. Literacy may matter more for patients who are cared for in a chaotic and discontinuous system that is not organized around delivering high quality care in a multidisciplinary setting.”7

This is more than a subjective impression: There is evidence supporting the importance of coordinated care for people of limited literacy skills. Dr. Powers and Bosworth recently compared the impact of low literacy on blood pressure control in patients in the Veterans Affairs (VA) system and those who attended local community clinics.

“Although the prevalence of low literacy was high in both populations, there was a significant association with low literacy and poor blood pressure control in the community clinics but not the VA,” Dr. Powers tells The Hospitalist. “In other words, literacy seemed to be an important predictor of good blood pressure control in one healthcare setting but not in another.”

In hospitals, “the frequency of handoffs among doctors, nurses, caseworkers, and social workers may all contribute to the fragmented nature of a patient’s care,” warns Dr. Halasyamani. This may be exacerbated even further should the patient have the misfortune to be admitted during a transitional period, such as a weekend or the end of the month when staff members rotate.

Red Flags

Literacy limitations are easy to miss: Patients rarely announce that they can’t read forms or comprehend a clinician’s instructions. “Just asking, ‘Do you understand?’ rarely works, because the patient may just nod yes. Physicians need to assess the patient’s comprehension proactively,” says Dr. Williams.

Usually, the clues are subtle. “Most physicians do encounter such patients, but we’re not trained to detect literacy problems and respond appropriately,” says Sunil Kripalani, MD, MSc, who, like Dr. Williams, is an Emory University hospitalist with a special interest in patient literacy issues. Dr. Kripalani suggests looking for red flags, including:

• Vague or evasive answers to questions. For example, “the patient who is taking a host of medications but can’t name them or tell you what time of day he’s supposed to take them;”
• Few, if any, questions or discussions of concerns: “Patients with limited literacy are less prone to ask questions, and the questions they do ask may not be as deep as those asked by a patient with greater literacy skills. The patient may use very simple terminology and not integrate any of the concepts discussed during the appointment;” and
• Missed appointments and repeated crises and hospitalizations resulting from the patient’s inability to read appointment cards or manage his illness. “Limited literacy skills may be a contributor to the exacerbations that put the patient in the hospital,” says Dr. Kripalani.

A patient with few family or social connections is also cause for concern, adds Dr. Halasyamani: “Lack of social support means there’s not another set of eyes and ears taking in the information.” Yet another red flag to her is the patient who cannot describe his plans for pursuing his care at home.

When patients have their medications with them, Dr. Williams asks how they take them. Those who can read simply look at the label, but a patient with literacy problems must open the bottle and look at the pills to identify them.

Solutions

How can physicians ensure that these patients understand and can follow instructions? Perhaps the easiest and most effective way is the “teach-back” approach, in which you ask the patient to repeat or teach back to you what you’ve just explained to him. For example, you might have him show you how to use an asthma inhaler or how to measure his blood glucose. In this way, you can rapidly assess and correct any deficiencies in the patient’s understanding.

“I’ve seen it take less than 90 seconds for physicians to confirm patient understanding in the context of a clinical visit,” says Dr. Kripalani.

A related technique that might help save time is to resist the temptation to tell the patient too much in a single visit. “Don’t try to give the patient too much information,” he advises. “People can process and retain maybe three nuggets of information at a time, so tell the patient the three most important things and then confirm their understanding of those three things.”

Dr. DeBuono suggests using visual aids like pictures or cartoons to help get important points across. If written material is necessary, have it printed in large type, which might appear less daunting than a page covered in dense, tiny print.

Above all, never embarrass a patient by bluntly asking him if he can read. “Explore the issue sensitively and respectfully,” Dr. Williams says. “Ask if they ever struggle with written materials or what the best way is for them to learn.” Adds Dr. DeBuono, “just by being sensitive to the fact that the patient may not understand is half the game.” TH

Norra MacReady is a medical journalist based in Southern California.

*“There’s no use crying over spilt milk.”

References

1. Rudd RE. Literacy and implications for navigating health care. Harvard School of Public Health: Health Literacy Website. Slide 20. 2002. Available at www.hsph.harvard.edu/healthliteracy/slides/2002/2002_01.html. Last accessed December 1, 2006.
2. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes. JAMA. 2002 Jul 24;288(4):475-482.
3. Paasche-Orlow MK, Schillinger D, Greene SM, et al. How health care systems can begin to address the challenge of limited literacy. J Gen Intern Med. 2006 Aug;21(8):884-887.
4. Marcus EN. The silent epidemic—the health effects of illiteracy. N Engl J Med. 2006 Jul 27;355(4):339-341. Erratum in N Engl J Med. 2006 Sept 7;355(10):1076.
5. Williams MV. Recognizing and overcoming inadequate health literacy, a barrier to care. Cleve Clin J Med. 2002 May;69(5):415-418.
6. Weiss BD. Health literacy: a manual for clinicians [American Medical Association Web site]. American Medical Association Foundation and the American Medical Association, 2003. Available at: www.ama-assn.org/ama1/pub/upload/mm/367/healthlitclinicians.pdf. Last accessed December 16, 2006.
7. Powers BJ, Bosworth HB. Revisiting literacy and adherence: future clinical and research directions. J Gen Intern Med. 2006;21:1341-1342.

Just asking, “Do you understand?” rarely works because the patient may just nod yes. Physicians need to assess the patient’s comprehension proactively.—Mark Williams, MD, professor of medicine and director of the hospital medicine unit at Emory University School of Medicine, Atlanta.

The hospitalist movement is going Down Under: In a pilot program starting in January 2007, 20 hospitalists will begin working in 11 Australian hospitals as the country tries to adapt to the new realities of healthcare. The move reflects an ongoing debate in Australia concerning the best way to confront the challenges facing many developed nations in the 21st century: how to provide hospital care to an aging patient population that is growing sicker as medical costs skyrocket.

Current Concerns

Currently, Australia, like the United Kingdom and other Commonwealth countries, has a consultant-led medical system in which a specialist, or consultant, admits a patient and “owns” that individual for the duration of his or her hospital stay. The patient’s day-to-day care generally falls to a senior resident (or registrar) and a junior physician—both of whom consult with the supervising physician on rounds. In the meantime, little attention is paid to standardized indications and protocols for admission and discharge, and many observers complain about the lack of coordination and organization of care and patient flow.1

“In some cases, patient flow through our system can be disjointed, leading to delays in care and frustration from patients and staff,” says Katherine McGrath, MD, deputy director of General Health System Performance in New South Wales (NSW) Health, whose department is overseeing the pilot study. “We believe a new role, like that of the hospitalist, will fill the gap between the current non-clinical time requirements and patient needs.”

Others in Australia agree. “What we’re looking for is a senior presence in the hospital who can provide continuity of care,” says William Lancashire, MD, acting director of intensive care at Port Macquarie Base Hospital in Port Macquarie, NSW.

Rural care is another concern. Currently, 34% of all Australians and 70% of Australian aborigines live outside major urban centers and depend on “bush” hospitals when they become ill. Yet only 23% of medical specialists and 27% of general practitioners work in these remote areas.2 Hospitalists, with their expertise in general medicine and comfort with teamwork and coordination of care, are seen by some as an answer to the shortage of medical personnel in the bush. Some authors have suggested that physicians who work in these settings are already de facto hospitalists.3

The program is also an effort to improve quality of care, in response to studies reporting a troubling rate of medical errors and as many as 10,000 to 14,000 preventable deaths occurring within the Australian hospital system annually.4 When the Australian authorities first considered a hospitalist model and began studying programs in other countries, “we noted the rapid growth in hospitalist numbers and the positive contribution they have made to patient flow and patient safety,” says Dr. McGrath.

The Program

The participating hospitals are all located in the state of New South Wales: Westmead, Nepean, Bulli, Shellharbour, Shoalhaven, St. George, Sutherland, Fairfield, Manly, Mona Vale, and Hornsby. Depending on the institution, hospitalists may work in geriatrics, cardiology, renal, or emergency care.

In an address to the NSW state parliament, Minister for Health John Hatzistergos explains that hospitalists will coordinate care across departments to ensure that patients enjoy a smooth stay. They will also participate in hospital governance and organization, as well as staff education, giving them a say in developing policies and procedures. “The proposal is tantamount to patients having their own general practitioner in the hospital with them to ensure continued quality care,” he says.5

Many of the new hospitalists will probably come from the ranks of career medical officers (CMOs), general physicians recruited directly out of training to work in underserved rural and suburban hospitals. Most CMOs are concentrated in emergency or critical care, but they can be found across a wide range of specialties, including orthopedics, community medicine, and even sexual medicine.4 CMOs may also follow patients after they have been admitted by a specialist.

But even the CMO position is still relatively new, having been created only in the 1980s. “They’ve been an absolutely invaluable resource in non-metropolitan Australia, but we still don’t have a formal system for their ongoing training or certification,” Dr. Lancashire tells The Hospitalist. “We need to provide a clear certification and career structure for these individuals.”

Participation in the hospitalist program is voluntary, says Dr. McGrath. Successful candidates “will be skilled in care coordination, patient flow management, patient safety systems, negotiation, procedural skills relevant to their roles, and clinical specialty modules relevant to the areas of specialty in which they are now working, such as geriatrics and emergency care.” Training will be on the job, “with skills assessment and ‘up-skilling’ as necessary to meet the responsibilities of the role they are filling in the local service.”

Still, the program reflects a tweaking—rather than a full-fledged revamping—of the Australian system. “The hospitalists will work with the consultants, who know them and trust their judgment,” says Abd Malak, executive director of workforce development at Sydney West Area Health Service, which is recruiting hospitalists for Westmead and Nepean hospitals. This means that hospitalists will have the authority to change a patient’s medication or other treatments when they deem it necessary, without waiting for the admitting specialist to come on rounds—but the admitting physician will still bear the ultimate responsibility for the patient’s outcome.

“The hospitalists will answer to the specialist clinicians for their patient care as well as management for patient flow and care coordination,” explains Dr. McGrath.

This approach represents a philosophy that differs sharply from the hospitalist’s position in the United States, in which a hospitalist has full responsibility for the patient’s care as long as that patient is in the hospital. In the Australian model, hospitalists will function almost as middle managers, exercising authority up to a point, but ultimately reporting to a more senior physician. Those who favor this arrangement describe it as organizing a patient’s care, rather than taking it over.4

Not surprisingly, some doctors are taking a dim view of this policy. “I think it’s a mistake. It’s just like giving the specialist another registrar,” says Dr. Lancashire. At Port Macquarie Base Hospital, he is leading the effort to develop a hospitalist program that is closer to the U.S. model because it will give those physicians primary responsibility for their patients.

Challenges

Indeed, good communication among a patient’s various doctors, always an essential element of good care, will be especially critical in the Australian system, says John Nelson, MD, medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash. “The hospitalists and consultants should try to preserve a collegial culture in which they talk to each other regularly,” he says. “Otherwise, you could wind up with a situation like the one in some European countries where hospital doctors and office doctors seldom communicate and don’t even see themselves as peers.”

Dr. Nelson, who has consulted on the establishment of more than 150 hospitalist practices, also warns the Australians against taking a one-size-fits-all approach. “Each hospital has its own culture, so they should acknowledge that the experience will play out differently at each institution,” he says.

Many Aussies agree with Dr. Nelson. “We find that the outcomes are better when the hospitalists are in charge of patient care,” adds Peter Jamieson, MD, division chief, acute care family medicine at Calgary Health Region in Canada, which has a hospitalist practice of about 80 physicians serving five hospitals. “Hospitalists take a holistic view of the patients and their problems. For example, at discharge they can reconcile a patient’s medications and, in general, make sure the ball isn’t dropped. These are skills that specialists don’t focus on and by putting hospitalists in a secondary, supportive, or bedside role, I don’t think they will capture those benefits.”

Another challenge concerns the effect of a hospitalist program on primary care physicians who practice outside the hospital setting, such as family physicians. “Will they lift those doctors from the community to work in the hospital, or will they employ full-time hospitalists?” asks Dr. Jamieson. “A new program is easiest to administer when you have full-time people on rotation, but it robs the community of some primary care physicians. In Calgary, we have a mix, so as not to deplete the community of those doctors.”

More concrete challenges concern funding streams and convincing hospital and, in a single-payer system, governmental authorities that hospitalists are worth the investment. “Demonstrating value is the first step,” says Dr. Jamieson, who helped develop the hospitalist program in Calgary.

The timely sharing of records is also critical, so electronic medical records or sophisticated faxing systems should be in place as well. “The hospital should send the patient’s records to the office doctor by the end of the day on which that patient is discharged,” explains Dr. Nelson. “If it takes two weeks for the community doctor to get the records, that’s going to be a problem.”

In general, he advises Australian hospitalists to listen well but make their needs and interests clear. “I would tell them to be frank about what they are looking for and how they want their practices to go. I encourage them to develop an ongoing dialogue with North American hospitalists: we can learn from each other.” TH

Norra MacReady is a regular contributor to The Hospitalist.

References

1. Hillman K. The changing role of acute-care hospitals. Med J Aust. 1999 Apr 5;170(7):325-328.
2. Murray RB, Wronski I. When the tide goes out: health workforce in rural, remote and indigenous communities. Med J Aust. 2006 Jul 3;185(1):37-38.
3. Hore CT, Lancashire W, Roberts JB, et al. Integrated critical care: an approach to specialist cover for critical care in the rural setting. Med J Aust. 2003 Nov 3;179(9):95-97.
4. Egan JM, Webber MG, King MR, et al. The hospitalist: a third alternative. Med J Aust. 2000 Apr 3;172(7):335-338.
5. Hatzistergos J. Health care work force innovations. Address before the Parliament of New South Wales, published in NSW Legislative Council Hansard, August 31, 2006, page 1221. Available at: www.parliament.nsw.gov.au/prod/PARLMENT/hansArt.nsf/V3Key/LC20060831012. Last accessed October 10, 2006.

The hospitalist movement is going Down Under: In a pilot program starting in January 2007, 20 hospitalists will begin working in 11 Australian hospitals as the country tries to adapt to the new realities of healthcare. The move reflects an ongoing debate in Australia concerning the best way to confront the challenges facing many developed nations in the 21st century: how to provide hospital care to an aging patient population that is growing sicker as medical costs skyrocket.

Current Concerns

Currently, Australia, like the United Kingdom and other Commonwealth countries, has a consultant-led medical system in which a specialist, or consultant, admits a patient and “owns” that individual for the duration of his or her hospital stay. The patient’s day-to-day care generally falls to a senior resident (or registrar) and a junior physician—both of whom consult with the supervising physician on rounds. In the meantime, little attention is paid to standardized indications and protocols for admission and discharge, and many observers complain about the lack of coordination and organization of care and patient flow.1

“In some cases, patient flow through our system can be disjointed, leading to delays in care and frustration from patients and staff,” says Katherine McGrath, MD, deputy director of General Health System Performance in New South Wales (NSW) Health, whose department is overseeing the pilot study. “We believe a new role, like that of the hospitalist, will fill the gap between the current non-clinical time requirements and patient needs.”

Others in Australia agree. “What we’re looking for is a senior presence in the hospital who can provide continuity of care,” says William Lancashire, MD, acting director of intensive care at Port Macquarie Base Hospital in Port Macquarie, NSW.

Rural care is another concern. Currently, 34% of all Australians and 70% of Australian aborigines live outside major urban centers and depend on “bush” hospitals when they become ill. Yet only 23% of medical specialists and 27% of general practitioners work in these remote areas.2 Hospitalists, with their expertise in general medicine and comfort with teamwork and coordination of care, are seen by some as an answer to the shortage of medical personnel in the bush. Some authors have suggested that physicians who work in these settings are already de facto hospitalists.3

The program is also an effort to improve quality of care, in response to studies reporting a troubling rate of medical errors and as many as 10,000 to 14,000 preventable deaths occurring within the Australian hospital system annually.4 When the Australian authorities first considered a hospitalist model and began studying programs in other countries, “we noted the rapid growth in hospitalist numbers and the positive contribution they have made to patient flow and patient safety,” says Dr. McGrath.

The Program

The participating hospitals are all located in the state of New South Wales: Westmead, Nepean, Bulli, Shellharbour, Shoalhaven, St. George, Sutherland, Fairfield, Manly, Mona Vale, and Hornsby. Depending on the institution, hospitalists may work in geriatrics, cardiology, renal, or emergency care.

In an address to the NSW state parliament, Minister for Health John Hatzistergos explains that hospitalists will coordinate care across departments to ensure that patients enjoy a smooth stay. They will also participate in hospital governance and organization, as well as staff education, giving them a say in developing policies and procedures. “The proposal is tantamount to patients having their own general practitioner in the hospital with them to ensure continued quality care,” he says.5

Many of the new hospitalists will probably come from the ranks of career medical officers (CMOs), general physicians recruited directly out of training to work in underserved rural and suburban hospitals. Most CMOs are concentrated in emergency or critical care, but they can be found across a wide range of specialties, including orthopedics, community medicine, and even sexual medicine.4 CMOs may also follow patients after they have been admitted by a specialist.

But even the CMO position is still relatively new, having been created only in the 1980s. “They’ve been an absolutely invaluable resource in non-metropolitan Australia, but we still don’t have a formal system for their ongoing training or certification,” Dr. Lancashire tells The Hospitalist. “We need to provide a clear certification and career structure for these individuals.”

Participation in the hospitalist program is voluntary, says Dr. McGrath. Successful candidates “will be skilled in care coordination, patient flow management, patient safety systems, negotiation, procedural skills relevant to their roles, and clinical specialty modules relevant to the areas of specialty in which they are now working, such as geriatrics and emergency care.” Training will be on the job, “with skills assessment and ‘up-skilling’ as necessary to meet the responsibilities of the role they are filling in the local service.”

Still, the program reflects a tweaking—rather than a full-fledged revamping—of the Australian system. “The hospitalists will work with the consultants, who know them and trust their judgment,” says Abd Malak, executive director of workforce development at Sydney West Area Health Service, which is recruiting hospitalists for Westmead and Nepean hospitals. This means that hospitalists will have the authority to change a patient’s medication or other treatments when they deem it necessary, without waiting for the admitting specialist to come on rounds—but the admitting physician will still bear the ultimate responsibility for the patient’s outcome.

“The hospitalists will answer to the specialist clinicians for their patient care as well as management for patient flow and care coordination,” explains Dr. McGrath.

This approach represents a philosophy that differs sharply from the hospitalist’s position in the United States, in which a hospitalist has full responsibility for the patient’s care as long as that patient is in the hospital. In the Australian model, hospitalists will function almost as middle managers, exercising authority up to a point, but ultimately reporting to a more senior physician. Those who favor this arrangement describe it as organizing a patient’s care, rather than taking it over.4

Not surprisingly, some doctors are taking a dim view of this policy. “I think it’s a mistake. It’s just like giving the specialist another registrar,” says Dr. Lancashire. At Port Macquarie Base Hospital, he is leading the effort to develop a hospitalist program that is closer to the U.S. model because it will give those physicians primary responsibility for their patients.

Challenges

Indeed, good communication among a patient’s various doctors, always an essential element of good care, will be especially critical in the Australian system, says John Nelson, MD, medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash. “The hospitalists and consultants should try to preserve a collegial culture in which they talk to each other regularly,” he says. “Otherwise, you could wind up with a situation like the one in some European countries where hospital doctors and office doctors seldom communicate and don’t even see themselves as peers.”

Dr. Nelson, who has consulted on the establishment of more than 150 hospitalist practices, also warns the Australians against taking a one-size-fits-all approach. “Each hospital has its own culture, so they should acknowledge that the experience will play out differently at each institution,” he says.

Many Aussies agree with Dr. Nelson. “We find that the outcomes are better when the hospitalists are in charge of patient care,” adds Peter Jamieson, MD, division chief, acute care family medicine at Calgary Health Region in Canada, which has a hospitalist practice of about 80 physicians serving five hospitals. “Hospitalists take a holistic view of the patients and their problems. For example, at discharge they can reconcile a patient’s medications and, in general, make sure the ball isn’t dropped. These are skills that specialists don’t focus on and by putting hospitalists in a secondary, supportive, or bedside role, I don’t think they will capture those benefits.”

Another challenge concerns the effect of a hospitalist program on primary care physicians who practice outside the hospital setting, such as family physicians. “Will they lift those doctors from the community to work in the hospital, or will they employ full-time hospitalists?” asks Dr. Jamieson. “A new program is easiest to administer when you have full-time people on rotation, but it robs the community of some primary care physicians. In Calgary, we have a mix, so as not to deplete the community of those doctors.”

More concrete challenges concern funding streams and convincing hospital and, in a single-payer system, governmental authorities that hospitalists are worth the investment. “Demonstrating value is the first step,” says Dr. Jamieson, who helped develop the hospitalist program in Calgary.

The timely sharing of records is also critical, so electronic medical records or sophisticated faxing systems should be in place as well. “The hospital should send the patient’s records to the office doctor by the end of the day on which that patient is discharged,” explains Dr. Nelson. “If it takes two weeks for the community doctor to get the records, that’s going to be a problem.”

In general, he advises Australian hospitalists to listen well but make their needs and interests clear. “I would tell them to be frank about what they are looking for and how they want their practices to go. I encourage them to develop an ongoing dialogue with North American hospitalists: we can learn from each other.” TH

Norra MacReady is a regular contributor to The Hospitalist.

References

1. Hillman K. The changing role of acute-care hospitals. Med J Aust. 1999 Apr 5;170(7):325-328.
2. Murray RB, Wronski I. When the tide goes out: health workforce in rural, remote and indigenous communities. Med J Aust. 2006 Jul 3;185(1):37-38.
3. Hore CT, Lancashire W, Roberts JB, et al. Integrated critical care: an approach to specialist cover for critical care in the rural setting. Med J Aust. 2003 Nov 3;179(9):95-97.
4. Egan JM, Webber MG, King MR, et al. The hospitalist: a third alternative. Med J Aust. 2000 Apr 3;172(7):335-338.
5. Hatzistergos J. Health care work force innovations. Address before the Parliament of New South Wales, published in NSW Legislative Council Hansard, August 31, 2006, page 1221. Available at: www.parliament.nsw.gov.au/prod/PARLMENT/hansArt.nsf/V3Key/LC20060831012. Last accessed October 10, 2006.

The hospitalist movement is going Down Under: In a pilot program starting in January 2007, 20 hospitalists will begin working in 11 Australian hospitals as the country tries to adapt to the new realities of healthcare. The move reflects an ongoing debate in Australia concerning the best way to confront the challenges facing many developed nations in the 21st century: how to provide hospital care to an aging patient population that is growing sicker as medical costs skyrocket.

Current Concerns

Currently, Australia, like the United Kingdom and other Commonwealth countries, has a consultant-led medical system in which a specialist, or consultant, admits a patient and “owns” that individual for the duration of his or her hospital stay. The patient’s day-to-day care generally falls to a senior resident (or registrar) and a junior physician—both of whom consult with the supervising physician on rounds. In the meantime, little attention is paid to standardized indications and protocols for admission and discharge, and many observers complain about the lack of coordination and organization of care and patient flow.1

“In some cases, patient flow through our system can be disjointed, leading to delays in care and frustration from patients and staff,” says Katherine McGrath, MD, deputy director of General Health System Performance in New South Wales (NSW) Health, whose department is overseeing the pilot study. “We believe a new role, like that of the hospitalist, will fill the gap between the current non-clinical time requirements and patient needs.”

Others in Australia agree. “What we’re looking for is a senior presence in the hospital who can provide continuity of care,” says William Lancashire, MD, acting director of intensive care at Port Macquarie Base Hospital in Port Macquarie, NSW.

Rural care is another concern. Currently, 34% of all Australians and 70% of Australian aborigines live outside major urban centers and depend on “bush” hospitals when they become ill. Yet only 23% of medical specialists and 27% of general practitioners work in these remote areas.2 Hospitalists, with their expertise in general medicine and comfort with teamwork and coordination of care, are seen by some as an answer to the shortage of medical personnel in the bush. Some authors have suggested that physicians who work in these settings are already de facto hospitalists.3

The program is also an effort to improve quality of care, in response to studies reporting a troubling rate of medical errors and as many as 10,000 to 14,000 preventable deaths occurring within the Australian hospital system annually.4 When the Australian authorities first considered a hospitalist model and began studying programs in other countries, “we noted the rapid growth in hospitalist numbers and the positive contribution they have made to patient flow and patient safety,” says Dr. McGrath.

The Program

The participating hospitals are all located in the state of New South Wales: Westmead, Nepean, Bulli, Shellharbour, Shoalhaven, St. George, Sutherland, Fairfield, Manly, Mona Vale, and Hornsby. Depending on the institution, hospitalists may work in geriatrics, cardiology, renal, or emergency care.

In an address to the NSW state parliament, Minister for Health John Hatzistergos explains that hospitalists will coordinate care across departments to ensure that patients enjoy a smooth stay. They will also participate in hospital governance and organization, as well as staff education, giving them a say in developing policies and procedures. “The proposal is tantamount to patients having their own general practitioner in the hospital with them to ensure continued quality care,” he says.5

Many of the new hospitalists will probably come from the ranks of career medical officers (CMOs), general physicians recruited directly out of training to work in underserved rural and suburban hospitals. Most CMOs are concentrated in emergency or critical care, but they can be found across a wide range of specialties, including orthopedics, community medicine, and even sexual medicine.4 CMOs may also follow patients after they have been admitted by a specialist.

But even the CMO position is still relatively new, having been created only in the 1980s. “They’ve been an absolutely invaluable resource in non-metropolitan Australia, but we still don’t have a formal system for their ongoing training or certification,” Dr. Lancashire tells The Hospitalist. “We need to provide a clear certification and career structure for these individuals.”

Participation in the hospitalist program is voluntary, says Dr. McGrath. Successful candidates “will be skilled in care coordination, patient flow management, patient safety systems, negotiation, procedural skills relevant to their roles, and clinical specialty modules relevant to the areas of specialty in which they are now working, such as geriatrics and emergency care.” Training will be on the job, “with skills assessment and ‘up-skilling’ as necessary to meet the responsibilities of the role they are filling in the local service.”

Still, the program reflects a tweaking—rather than a full-fledged revamping—of the Australian system. “The hospitalists will work with the consultants, who know them and trust their judgment,” says Abd Malak, executive director of workforce development at Sydney West Area Health Service, which is recruiting hospitalists for Westmead and Nepean hospitals. This means that hospitalists will have the authority to change a patient’s medication or other treatments when they deem it necessary, without waiting for the admitting specialist to come on rounds—but the admitting physician will still bear the ultimate responsibility for the patient’s outcome.

“The hospitalists will answer to the specialist clinicians for their patient care as well as management for patient flow and care coordination,” explains Dr. McGrath.

This approach represents a philosophy that differs sharply from the hospitalist’s position in the United States, in which a hospitalist has full responsibility for the patient’s care as long as that patient is in the hospital. In the Australian model, hospitalists will function almost as middle managers, exercising authority up to a point, but ultimately reporting to a more senior physician. Those who favor this arrangement describe it as organizing a patient’s care, rather than taking it over.4

Not surprisingly, some doctors are taking a dim view of this policy. “I think it’s a mistake. It’s just like giving the specialist another registrar,” says Dr. Lancashire. At Port Macquarie Base Hospital, he is leading the effort to develop a hospitalist program that is closer to the U.S. model because it will give those physicians primary responsibility for their patients.

Challenges

Indeed, good communication among a patient’s various doctors, always an essential element of good care, will be especially critical in the Australian system, says John Nelson, MD, medical director of the hospitalist practice at Overlake Hospital in Bellevue, Wash. “The hospitalists and consultants should try to preserve a collegial culture in which they talk to each other regularly,” he says. “Otherwise, you could wind up with a situation like the one in some European countries where hospital doctors and office doctors seldom communicate and don’t even see themselves as peers.”

Dr. Nelson, who has consulted on the establishment of more than 150 hospitalist practices, also warns the Australians against taking a one-size-fits-all approach. “Each hospital has its own culture, so they should acknowledge that the experience will play out differently at each institution,” he says.

Many Aussies agree with Dr. Nelson. “We find that the outcomes are better when the hospitalists are in charge of patient care,” adds Peter Jamieson, MD, division chief, acute care family medicine at Calgary Health Region in Canada, which has a hospitalist practice of about 80 physicians serving five hospitals. “Hospitalists take a holistic view of the patients and their problems. For example, at discharge they can reconcile a patient’s medications and, in general, make sure the ball isn’t dropped. These are skills that specialists don’t focus on and by putting hospitalists in a secondary, supportive, or bedside role, I don’t think they will capture those benefits.”

Another challenge concerns the effect of a hospitalist program on primary care physicians who practice outside the hospital setting, such as family physicians. “Will they lift those doctors from the community to work in the hospital, or will they employ full-time hospitalists?” asks Dr. Jamieson. “A new program is easiest to administer when you have full-time people on rotation, but it robs the community of some primary care physicians. In Calgary, we have a mix, so as not to deplete the community of those doctors.”

More concrete challenges concern funding streams and convincing hospital and, in a single-payer system, governmental authorities that hospitalists are worth the investment. “Demonstrating value is the first step,” says Dr. Jamieson, who helped develop the hospitalist program in Calgary.

The timely sharing of records is also critical, so electronic medical records or sophisticated faxing systems should be in place as well. “The hospital should send the patient’s records to the office doctor by the end of the day on which that patient is discharged,” explains Dr. Nelson. “If it takes two weeks for the community doctor to get the records, that’s going to be a problem.”

In general, he advises Australian hospitalists to listen well but make their needs and interests clear. “I would tell them to be frank about what they are looking for and how they want their practices to go. I encourage them to develop an ongoing dialogue with North American hospitalists: we can learn from each other.” TH

Norra MacReady is a regular contributor to The Hospitalist.

References

1. Hillman K. The changing role of acute-care hospitals. Med J Aust. 1999 Apr 5;170(7):325-328.
2. Murray RB, Wronski I. When the tide goes out: health workforce in rural, remote and indigenous communities. Med J Aust. 2006 Jul 3;185(1):37-38.
3. Hore CT, Lancashire W, Roberts JB, et al. Integrated critical care: an approach to specialist cover for critical care in the rural setting. Med J Aust. 2003 Nov 3;179(9):95-97.
4. Egan JM, Webber MG, King MR, et al. The hospitalist: a third alternative. Med J Aust. 2000 Apr 3;172(7):335-338.
5. Hatzistergos J. Health care work force innovations. Address before the Parliament of New South Wales, published in NSW Legislative Council Hansard, August 31, 2006, page 1221. Available at: www.parliament.nsw.gov.au/prod/PARLMENT/hansArt.nsf/V3Key/LC20060831012. Last accessed October 10, 2006.

Machines hum and alarms beep. Televisions squawk and telephones ring; overhead pagers blare out names. Equipment travels on squeaking, groaning carts, and people shout their conversations so they can be heard above the din.

Welcome to the hospital.

Noise has been a problem in hospitals at least since the 19th century, when Florence Nightingale described it as a “cruel absence of care.” In the nearly 150 years since she wrote that statement, the problem has only gotten worse, reflecting the increasing reliance on technology and an older and sicker patient population.

A Growing Problem

The average level of daytime hospital noise has risen from 57 decibels in 1960 to 72 decibels in 2005. Night-time noise increased from 42 to 60 decibels in the same time period. These levels are well above World Health Organization recommendations of no more than 40 decibels during the day and 30 to 35 decibels at night.

“It’s like being about 100 meters from a busy highway,” says Ilene Busch-Vishniac, PhD, professor of mechanical engineering at Johns Hopkins University (Baltimore) and a co-investigator in an ongoing study on hospital noise.

Despite the longstanding complaints of patients and hospital staff, little formal documentation of the problem existed until three years ago, when Stephanie L. Reel, vice president and chief information officer for Johns Hopkins Medicine learned from nurses that the noise level in the pediatric intensive care unit was a major source of complaints. To assess the problem she turned to two acoustical engineers: Busch-Vishniac, and James E. West, PhD, research professor in electrical and computer engineering.

Over the next year, they and their associates measured the noise at five wards on several floors in the hospital, including the PICU. The average sound levels in all five units ranged from 50 to 60 decibels, with the PICU being the loudest.

These findings reflect the pattern of a general rise in the sound level in hospitals worldwide, the investigators wrote (Busch-Vishniac IJ, West JE, Barnhill C, et al. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am. 2005;118(6):3629-3645).

Since then, West and Busch-Vishniac have performed similar measurements in the emergency department and virtually all of the operating rooms at Johns Hopkins Hospital, with similar results. West recounts anecdotes of nurses retreating into the bathroom to have a quiet place to think, and taking patient records home so they can prepare them in peace.

Perhaps the biggest reason for concern is the potential impact on patient safety. “If instructions are misunderstood because of the high noise levels, it can lead to all sorts of safety problems,” adds West. “What’s most disturbing to me is that the noise level will continue to rise if something isn’t done about it.”

Sound Solutions:

Innovative Ways to Reduce Noise

Noise-abatement strategies need not be expensive or high-tech. “We asked, ‘what kinds of changes can we make without going through a lot of red tape?’” says Cmiel. Among the solutions that St. Mary’s came up with:

• Make people aware of the problem. Post signs reminding them to keep their voices down and close the doors to patients’ rooms;
• Hold training sessions on noise abatement for ancillary staff members including the cleaning crew.
• Put foam padding on the bottom of chart holders.
• Identify patients who don’t need nighttime care—and don’t disturb them.
• Replace paper towel rolls in or near patient rooms with quieter, folded-towel dispensers.
• Eliminate the use of overhead paging systems—at least during nighttime hours. Consider equipping doctors and nurses with tiny individual pagers that can be worn around the neck.*
• Lower the volume of telephone ringers and other equipment wherever possible.
• Gain the cooperation of other departments. The St. Mary’s team finally persuaded the surgical department to revise its schedule so it could stop ordering X-rays at 3 a.m.

At Montefiore Hospital in New York City, the Silent Hospitals Help Healing (SHHH) program is employing many of these techniques. Signs reading “SHHH” decorate the hallways, and patients, staff, and even visitors sport buttons showing a nurse holding a finger to her lips. Intercoms are turned down, and staff members are asked to keep their beepers on vibrate mode. Equipment is kept lubricated and in good repair to minimize squeaks and rattles.

It’s all paying off: Noise levels have decreased markedly since the program’s inception in March. Elodia Mercier, RN, the administrative nurse manager who developed the program, reports that patients tell her they are sleeping better, and the house staff finds the environment less stressful.—NM

For more information, contact Vocera Communications Inc. in Cupertino, Calif. (www.vocera.com).

None of this is a surprise to hospitalists. “I’ve discussed this with at least 30 employees in hospitals—especially nurses—and they all agree it’s a problem,” says Douglas Cutler, MD, regional medical director, Phoenix and Tucson, for IPC The Hospitalist Company.

Indeed, Dr. Cutler could hardly be heard during a telephone interview. In the background phones rang, announcements blared, and people talked and laughed loudly. He was calling from the nurses’ station, an area he estimated at about five feet square and which contained—at that moment—at least seven people.

“I think it’s a terrible problem, but so far it’s been pretty much ignored,” says Burke Kealey, MD, chief of professional services for hospital medicine at Regions Hospital in St. Paul, Minn.

Regions is now building a new hospital (see The Hospitalist March 2006, p. 30), and Dr. Kealey has raised the issue in design sessions, so far with little success. Money is tight, and noise-reducing materials and designs are seen as expendable. “It’s way down on the list of priorities,” he notes.

Worst Offenders

In the Johns Hopkins study, the air-conditioning and overhead paging systems were among the biggest culprits. Human speech was also at the top of the list.

Lakshmi Halasyamani, MD, chair of the Hospital Quality and Patient Safety Committee for SHM, recalls one instance in which she and a resident couldn’t talk to a patient because of a loud conversation about another patient that occurred in the hallway just outside the room. In fact, the incident made her take a new look at patient privacy and confidentiality issues. She now makes a point of including patients in all such conferences whenever possible.

These may be the worst offenders, but anything that hums, rattles, vibrates, squeaks, beeps, ticks, or otherwise makes itself heard contributes to the general racket. Even something as innocuous as placing a chart in its holder can be disruptive, says Cheryl Ann Cmiel, BAN, RN, a staff nurse on the surgical thoracic intermediate care nursing unit at St. Mary’s Hospital, a Mayo Clinic-affiliated hospital in Rochester, Minn.

Cmiel and another team member, Dawn Marie Gasser, ASN, RN, spent an informative—and sleepless—night in a patient room as part of a sleep-promotion study. She found a portable chest X-ray unit to be the biggest single problem, especially because the technician wheeled it in at 3:15 a.m. In general, the noise was loudest during shift changes (AJN. 2004;104(2):40-48).

Squeaky Wheels

Perhaps the best way to start a noise-reduction program is by asking patients what bothers them the most. “Staff members kind of filter out the noise, so we don’t hear it all the time,” Cmiel tells The Hospitalist.

The next step is to remain vigilant and use common sense. “As we move forward with team-based care, noise will become more of a problem,” says Dr. Halasyamani. At night, “we must remember that the patient’s goal is to sleep, unless they’re having an acute problem.”

Remind staff members to keep their voices down. On wards, keep all conversations patient-centered and include the patients in them whenever you can. If possible, designate certain areas away from patient rooms as areas for collegial staff chats.

Simply remembering to close a patient’s door can make a difference, adds Dr. Kealey. Whenever it’s appropriate, he also orders that a patient not have her vital signs checked or receive medication at night. If a patient requires particularly close watching or is at risk of wandering or falling, he recommends video monitors, centralized alarms that sound at the nurses’ station rather than the bedside, and low beds that minimize the risk of falls. He and his colleagues are also trying to emphasize to residents the importance of keeping the noise level down.

Administrators require data before they’ll consider major, system-wide changes, Dr. Cutler warns. Noise-reducing strategies that involve significant sums of money are viewed as a capital expense, “and [administrators] have to balance that against other capital expenses. If there was evidence that it affected patient outcomes, the trend would be for hospitals to improve [their efforts at noise control],” he explains.

Dr. Busch-Vishniac agrees that more research is needed. “That there aren’t more people working in this area is disturbing,” she observes. “We were really surprised at our findings. We thought it would be a quick fix and walk away.” TH

Norra MacReady is based in Southern California.

Machines hum and alarms beep. Televisions squawk and telephones ring; overhead pagers blare out names. Equipment travels on squeaking, groaning carts, and people shout their conversations so they can be heard above the din.

Welcome to the hospital.

Noise has been a problem in hospitals at least since the 19th century, when Florence Nightingale described it as a “cruel absence of care.” In the nearly 150 years since she wrote that statement, the problem has only gotten worse, reflecting the increasing reliance on technology and an older and sicker patient population.

A Growing Problem

The average level of daytime hospital noise has risen from 57 decibels in 1960 to 72 decibels in 2005. Night-time noise increased from 42 to 60 decibels in the same time period. These levels are well above World Health Organization recommendations of no more than 40 decibels during the day and 30 to 35 decibels at night.

“It’s like being about 100 meters from a busy highway,” says Ilene Busch-Vishniac, PhD, professor of mechanical engineering at Johns Hopkins University (Baltimore) and a co-investigator in an ongoing study on hospital noise.

Despite the longstanding complaints of patients and hospital staff, little formal documentation of the problem existed until three years ago, when Stephanie L. Reel, vice president and chief information officer for Johns Hopkins Medicine learned from nurses that the noise level in the pediatric intensive care unit was a major source of complaints. To assess the problem she turned to two acoustical engineers: Busch-Vishniac, and James E. West, PhD, research professor in electrical and computer engineering.

Over the next year, they and their associates measured the noise at five wards on several floors in the hospital, including the PICU. The average sound levels in all five units ranged from 50 to 60 decibels, with the PICU being the loudest.

These findings reflect the pattern of a general rise in the sound level in hospitals worldwide, the investigators wrote (Busch-Vishniac IJ, West JE, Barnhill C, et al. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am. 2005;118(6):3629-3645).

Since then, West and Busch-Vishniac have performed similar measurements in the emergency department and virtually all of the operating rooms at Johns Hopkins Hospital, with similar results. West recounts anecdotes of nurses retreating into the bathroom to have a quiet place to think, and taking patient records home so they can prepare them in peace.

Perhaps the biggest reason for concern is the potential impact on patient safety. “If instructions are misunderstood because of the high noise levels, it can lead to all sorts of safety problems,” adds West. “What’s most disturbing to me is that the noise level will continue to rise if something isn’t done about it.”

Sound Solutions:

Innovative Ways to Reduce Noise

Noise-abatement strategies need not be expensive or high-tech. “We asked, ‘what kinds of changes can we make without going through a lot of red tape?’” says Cmiel. Among the solutions that St. Mary’s came up with:

• Make people aware of the problem. Post signs reminding them to keep their voices down and close the doors to patients’ rooms;
• Hold training sessions on noise abatement for ancillary staff members including the cleaning crew.
• Put foam padding on the bottom of chart holders.
• Identify patients who don’t need nighttime care—and don’t disturb them.
• Replace paper towel rolls in or near patient rooms with quieter, folded-towel dispensers.
• Eliminate the use of overhead paging systems—at least during nighttime hours. Consider equipping doctors and nurses with tiny individual pagers that can be worn around the neck.*
• Lower the volume of telephone ringers and other equipment wherever possible.
• Gain the cooperation of other departments. The St. Mary’s team finally persuaded the surgical department to revise its schedule so it could stop ordering X-rays at 3 a.m.

At Montefiore Hospital in New York City, the Silent Hospitals Help Healing (SHHH) program is employing many of these techniques. Signs reading “SHHH” decorate the hallways, and patients, staff, and even visitors sport buttons showing a nurse holding a finger to her lips. Intercoms are turned down, and staff members are asked to keep their beepers on vibrate mode. Equipment is kept lubricated and in good repair to minimize squeaks and rattles.

It’s all paying off: Noise levels have decreased markedly since the program’s inception in March. Elodia Mercier, RN, the administrative nurse manager who developed the program, reports that patients tell her they are sleeping better, and the house staff finds the environment less stressful.—NM

For more information, contact Vocera Communications Inc. in Cupertino, Calif. (www.vocera.com).

None of this is a surprise to hospitalists. “I’ve discussed this with at least 30 employees in hospitals—especially nurses—and they all agree it’s a problem,” says Douglas Cutler, MD, regional medical director, Phoenix and Tucson, for IPC The Hospitalist Company.

Indeed, Dr. Cutler could hardly be heard during a telephone interview. In the background phones rang, announcements blared, and people talked and laughed loudly. He was calling from the nurses’ station, an area he estimated at about five feet square and which contained—at that moment—at least seven people.

“I think it’s a terrible problem, but so far it’s been pretty much ignored,” says Burke Kealey, MD, chief of professional services for hospital medicine at Regions Hospital in St. Paul, Minn.

Regions is now building a new hospital (see The Hospitalist March 2006, p. 30), and Dr. Kealey has raised the issue in design sessions, so far with little success. Money is tight, and noise-reducing materials and designs are seen as expendable. “It’s way down on the list of priorities,” he notes.

Worst Offenders

In the Johns Hopkins study, the air-conditioning and overhead paging systems were among the biggest culprits. Human speech was also at the top of the list.

Lakshmi Halasyamani, MD, chair of the Hospital Quality and Patient Safety Committee for SHM, recalls one instance in which she and a resident couldn’t talk to a patient because of a loud conversation about another patient that occurred in the hallway just outside the room. In fact, the incident made her take a new look at patient privacy and confidentiality issues. She now makes a point of including patients in all such conferences whenever possible.

These may be the worst offenders, but anything that hums, rattles, vibrates, squeaks, beeps, ticks, or otherwise makes itself heard contributes to the general racket. Even something as innocuous as placing a chart in its holder can be disruptive, says Cheryl Ann Cmiel, BAN, RN, a staff nurse on the surgical thoracic intermediate care nursing unit at St. Mary’s Hospital, a Mayo Clinic-affiliated hospital in Rochester, Minn.

Cmiel and another team member, Dawn Marie Gasser, ASN, RN, spent an informative—and sleepless—night in a patient room as part of a sleep-promotion study. She found a portable chest X-ray unit to be the biggest single problem, especially because the technician wheeled it in at 3:15 a.m. In general, the noise was loudest during shift changes (AJN. 2004;104(2):40-48).

Squeaky Wheels

Perhaps the best way to start a noise-reduction program is by asking patients what bothers them the most. “Staff members kind of filter out the noise, so we don’t hear it all the time,” Cmiel tells The Hospitalist.

The next step is to remain vigilant and use common sense. “As we move forward with team-based care, noise will become more of a problem,” says Dr. Halasyamani. At night, “we must remember that the patient’s goal is to sleep, unless they’re having an acute problem.”

Remind staff members to keep their voices down. On wards, keep all conversations patient-centered and include the patients in them whenever you can. If possible, designate certain areas away from patient rooms as areas for collegial staff chats.

Simply remembering to close a patient’s door can make a difference, adds Dr. Kealey. Whenever it’s appropriate, he also orders that a patient not have her vital signs checked or receive medication at night. If a patient requires particularly close watching or is at risk of wandering or falling, he recommends video monitors, centralized alarms that sound at the nurses’ station rather than the bedside, and low beds that minimize the risk of falls. He and his colleagues are also trying to emphasize to residents the importance of keeping the noise level down.

Administrators require data before they’ll consider major, system-wide changes, Dr. Cutler warns. Noise-reducing strategies that involve significant sums of money are viewed as a capital expense, “and [administrators] have to balance that against other capital expenses. If there was evidence that it affected patient outcomes, the trend would be for hospitals to improve [their efforts at noise control],” he explains.

Dr. Busch-Vishniac agrees that more research is needed. “That there aren’t more people working in this area is disturbing,” she observes. “We were really surprised at our findings. We thought it would be a quick fix and walk away.” TH

Norra MacReady is based in Southern California.

Machines hum and alarms beep. Televisions squawk and telephones ring; overhead pagers blare out names. Equipment travels on squeaking, groaning carts, and people shout their conversations so they can be heard above the din.

Welcome to the hospital.

Noise has been a problem in hospitals at least since the 19th century, when Florence Nightingale described it as a “cruel absence of care.” In the nearly 150 years since she wrote that statement, the problem has only gotten worse, reflecting the increasing reliance on technology and an older and sicker patient population.

A Growing Problem

The average level of daytime hospital noise has risen from 57 decibels in 1960 to 72 decibels in 2005. Night-time noise increased from 42 to 60 decibels in the same time period. These levels are well above World Health Organization recommendations of no more than 40 decibels during the day and 30 to 35 decibels at night.

“It’s like being about 100 meters from a busy highway,” says Ilene Busch-Vishniac, PhD, professor of mechanical engineering at Johns Hopkins University (Baltimore) and a co-investigator in an ongoing study on hospital noise.

Despite the longstanding complaints of patients and hospital staff, little formal documentation of the problem existed until three years ago, when Stephanie L. Reel, vice president and chief information officer for Johns Hopkins Medicine learned from nurses that the noise level in the pediatric intensive care unit was a major source of complaints. To assess the problem she turned to two acoustical engineers: Busch-Vishniac, and James E. West, PhD, research professor in electrical and computer engineering.

Over the next year, they and their associates measured the noise at five wards on several floors in the hospital, including the PICU. The average sound levels in all five units ranged from 50 to 60 decibels, with the PICU being the loudest.

These findings reflect the pattern of a general rise in the sound level in hospitals worldwide, the investigators wrote (Busch-Vishniac IJ, West JE, Barnhill C, et al. Noise levels in Johns Hopkins Hospital. J Acoust Soc Am. 2005;118(6):3629-3645).

Since then, West and Busch-Vishniac have performed similar measurements in the emergency department and virtually all of the operating rooms at Johns Hopkins Hospital, with similar results. West recounts anecdotes of nurses retreating into the bathroom to have a quiet place to think, and taking patient records home so they can prepare them in peace.

Perhaps the biggest reason for concern is the potential impact on patient safety. “If instructions are misunderstood because of the high noise levels, it can lead to all sorts of safety problems,” adds West. “What’s most disturbing to me is that the noise level will continue to rise if something isn’t done about it.”

Sound Solutions:

Innovative Ways to Reduce Noise

Noise-abatement strategies need not be expensive or high-tech. “We asked, ‘what kinds of changes can we make without going through a lot of red tape?’” says Cmiel. Among the solutions that St. Mary’s came up with:

• Make people aware of the problem. Post signs reminding them to keep their voices down and close the doors to patients’ rooms;
• Hold training sessions on noise abatement for ancillary staff members including the cleaning crew.
• Put foam padding on the bottom of chart holders.
• Identify patients who don’t need nighttime care—and don’t disturb them.
• Replace paper towel rolls in or near patient rooms with quieter, folded-towel dispensers.
• Eliminate the use of overhead paging systems—at least during nighttime hours. Consider equipping doctors and nurses with tiny individual pagers that can be worn around the neck.*
• Lower the volume of telephone ringers and other equipment wherever possible.
• Gain the cooperation of other departments. The St. Mary’s team finally persuaded the surgical department to revise its schedule so it could stop ordering X-rays at 3 a.m.

At Montefiore Hospital in New York City, the Silent Hospitals Help Healing (SHHH) program is employing many of these techniques. Signs reading “SHHH” decorate the hallways, and patients, staff, and even visitors sport buttons showing a nurse holding a finger to her lips. Intercoms are turned down, and staff members are asked to keep their beepers on vibrate mode. Equipment is kept lubricated and in good repair to minimize squeaks and rattles.

It’s all paying off: Noise levels have decreased markedly since the program’s inception in March. Elodia Mercier, RN, the administrative nurse manager who developed the program, reports that patients tell her they are sleeping better, and the house staff finds the environment less stressful.—NM

For more information, contact Vocera Communications Inc. in Cupertino, Calif. (www.vocera.com).

None of this is a surprise to hospitalists. “I’ve discussed this with at least 30 employees in hospitals—especially nurses—and they all agree it’s a problem,” says Douglas Cutler, MD, regional medical director, Phoenix and Tucson, for IPC The Hospitalist Company.

Indeed, Dr. Cutler could hardly be heard during a telephone interview. In the background phones rang, announcements blared, and people talked and laughed loudly. He was calling from the nurses’ station, an area he estimated at about five feet square and which contained—at that moment—at least seven people.

“I think it’s a terrible problem, but so far it’s been pretty much ignored,” says Burke Kealey, MD, chief of professional services for hospital medicine at Regions Hospital in St. Paul, Minn.

Regions is now building a new hospital (see The Hospitalist March 2006, p. 30), and Dr. Kealey has raised the issue in design sessions, so far with little success. Money is tight, and noise-reducing materials and designs are seen as expendable. “It’s way down on the list of priorities,” he notes.

Worst Offenders

In the Johns Hopkins study, the air-conditioning and overhead paging systems were among the biggest culprits. Human speech was also at the top of the list.

Lakshmi Halasyamani, MD, chair of the Hospital Quality and Patient Safety Committee for SHM, recalls one instance in which she and a resident couldn’t talk to a patient because of a loud conversation about another patient that occurred in the hallway just outside the room. In fact, the incident made her take a new look at patient privacy and confidentiality issues. She now makes a point of including patients in all such conferences whenever possible.

These may be the worst offenders, but anything that hums, rattles, vibrates, squeaks, beeps, ticks, or otherwise makes itself heard contributes to the general racket. Even something as innocuous as placing a chart in its holder can be disruptive, says Cheryl Ann Cmiel, BAN, RN, a staff nurse on the surgical thoracic intermediate care nursing unit at St. Mary’s Hospital, a Mayo Clinic-affiliated hospital in Rochester, Minn.

Cmiel and another team member, Dawn Marie Gasser, ASN, RN, spent an informative—and sleepless—night in a patient room as part of a sleep-promotion study. She found a portable chest X-ray unit to be the biggest single problem, especially because the technician wheeled it in at 3:15 a.m. In general, the noise was loudest during shift changes (AJN. 2004;104(2):40-48).

Squeaky Wheels

Perhaps the best way to start a noise-reduction program is by asking patients what bothers them the most. “Staff members kind of filter out the noise, so we don’t hear it all the time,” Cmiel tells The Hospitalist.

The next step is to remain vigilant and use common sense. “As we move forward with team-based care, noise will become more of a problem,” says Dr. Halasyamani. At night, “we must remember that the patient’s goal is to sleep, unless they’re having an acute problem.”

Remind staff members to keep their voices down. On wards, keep all conversations patient-centered and include the patients in them whenever you can. If possible, designate certain areas away from patient rooms as areas for collegial staff chats.

Simply remembering to close a patient’s door can make a difference, adds Dr. Kealey. Whenever it’s appropriate, he also orders that a patient not have her vital signs checked or receive medication at night. If a patient requires particularly close watching or is at risk of wandering or falling, he recommends video monitors, centralized alarms that sound at the nurses’ station rather than the bedside, and low beds that minimize the risk of falls. He and his colleagues are also trying to emphasize to residents the importance of keeping the noise level down.

Administrators require data before they’ll consider major, system-wide changes, Dr. Cutler warns. Noise-reducing strategies that involve significant sums of money are viewed as a capital expense, “and [administrators] have to balance that against other capital expenses. If there was evidence that it affected patient outcomes, the trend would be for hospitals to improve [their efforts at noise control],” he explains.

Dr. Busch-Vishniac agrees that more research is needed. “That there aren’t more people working in this area is disturbing,” she observes. “We were really surprised at our findings. We thought it would be a quick fix and walk away.” TH

Norra MacReady is based in Southern California.