Vague laws and debate over use of physical restraint complicate management of dangerous patients. Restraints have historically been over-used in psychiatry, even contributing to patients’ deaths. Still, many psychiatric facilities grapple with a reluctance to use restraint versus a need to protect patients from themselves and from harming others.

The law requires use of “least-restrictive interventions” to manage patients, but clinicians cannot agree on what this term means. This article offers tips to maximize patient safety when using restraints and advice on when to use them.

Psychotic man breaks neck jumping into window

Dane County (WI) Circuit Court

A 40-year-old man was hospitalized during a psychotic episode, in which he acted out aural hallucinations.

The man—who was previously diagnosed with schizophrenia—received a dose of haloperidol, and at least two guards escorted him to a room in the psychiatric unit. While left with a nurse, he tried to smash a window. The nurse hit a panic button to summon help, but the patient climbed on top of his bed and dove headfirst into a shatterproof glass. He fractured his neck and became quadriplegic.

In court, the patient’s attorney argued that the hospital was negligent in its failure to restrain him from harming himself. The patient died shortly after the trial from complications of quadriplegia.

• The jury’s verdict, $13 million, was reduced to approximately $7 million because of a statutory capitation.
  

Dr. Grant’s observations

The legal issue here is not simply whether the staff failed to prevent the patient from harming himself. Instead, the jury believed a reasonable person could have foreseen danger to the patient, thereby deeming the hospital negligent.

I’m not suggesting that all psychotic patients be restrained to prevent litigation. This case, however, illustrates the importance of assessing patients for dangerousness and intervening appropriately. Because the patient acted out his hallucinations and required two guards to escort him to his room, one could argue that one nurse could not adequately manage this patient.

When restraints are necessary, assess and document the patient’s behavior and the reasons that necessitate restraints. In this case, for example, record that medication alone did not sufficiently calm this patient.

One-on-one verbal and behavioral interventions can be effective alternatives to seclusion and restraint (Table 1).^1,2 Predictably, patients respond negatively to restraints, preferring medication instead.⁴ When less-restrictive, behavioral, or pharmacologic measures fail, consider restraints to protect aggressive, assaultive patients.

Table 1

Possible alternatives to restraints

Security personnel asphyxiate woman

Pima County (AZ) Superior Court

A 32-year-old woman with a history of psychiatric disorders was admitted to a county hospital’s psychiatric department. Several guards and security technicians held her face down on the floor for 15 to 30 minutes. The patient struggled to breathe, turned blue, then stopped breathing. She died of asphyxiation.

The estate sued both the county and the security technicians’ employer, claiming the guards were not properly trained on patient restraint.

• A $105,000 settlement with the county was reached; a confidential settlement was reached with the security employer.
  

Dr. Grant’s observations

This case shows how improper use of restraints may result in a successful lawsuit.

In 1998, the Hartford Courant ran a series of articles alleging that seclusion and restraint in a psychiatric setting led to 142 deaths across 10 years.⁵ State and federal legislation passed after the newspaper’s report has focused on protecting patients from improper use of restraints. Be aware of your state’s and hospital’s regulations. The guidelines in Table 2 reflect general policies for using restraints suggested by the Joint Commission on Accreditation of Health-care Organizations.⁶

Restraints should be used only by trained staff and for only as long as the patient is dangerous to self or others. Also assess patients who may be at increased risk for physical or psychological difficulties if restrained or secluded and consider alternate interventions. Generally, restraints should be avoided in patients with the following relative contraindications:

• pregnant
  
• history of breathing problems
  
• head or spinal injuries
  
• history of recent fractures or surgeries
  
• seizure disorder
  
• history of sexual or physical abuse.
  

Table 2

Guidelines for proper restraint use

Unmonitored suicidal man suffocates himself

Tarrant County (TX) District Court

A 26-year-old man in the suicide prevention unit of a community hospital suffocated himself using a vinyl pillowcase from his room and cellophane wrap from the hospital’s kitchen.

For more than 40 minutes before finding the patient dead, staff had not documented checking the patient’s room, which was required every 15 minutes. Paramedics documented the beginning of rigor mortis.

The estate claimed the hospital had not adequately monitored the patient despite clear indications of suicidality. In the days preceding his death, records showed a deteriorating condition related to problems with his companion, who had told him she was leaving the home they shared. He previously attempted suicide when she threatened to move out and had injured himself on similar occasions.

At the time of his death, four staff members were on duty; one claimed to have seen the patient 5 minutes before he was found. The estate contended that more than 1 hour would have been required for rigor mortis to develop.

• A settlement of $1.1 million was reached.
  

Dr. Grant’s observations

Immediately assess suicidal patients and their environment to reduce the risk of self-harm. One-on-one observation has been found to be most effective⁷ and should be required for patients with severe suicide risk. All suicidal patients should (at minimum) be visible to staff members at all times to maintain safety standards.⁷ Frequently document the patient’s location, activities, and behavior.

To ensure a safe environment for suicidal patients, identify and minimize risk factors associated with hospital settings.⁸ For example, access to cellophane wrap in this case should have been blocked. Ensure that suicidal patients cannot reach materials they could use to harm themselves such as pillowcases, drapery cords, ingestible cleaning supplies, shower curtains and rods, and breakable objects.

Vague laws and debate over use of physical restraint complicate management of dangerous patients. Restraints have historically been over-used in psychiatry, even contributing to patients’ deaths. Still, many psychiatric facilities grapple with a reluctance to use restraint versus a need to protect patients from themselves and from harming others.

The law requires use of “least-restrictive interventions” to manage patients, but clinicians cannot agree on what this term means. This article offers tips to maximize patient safety when using restraints and advice on when to use them.

Psychotic man breaks neck jumping into window

Dane County (WI) Circuit Court

A 40-year-old man was hospitalized during a psychotic episode, in which he acted out aural hallucinations.

The man—who was previously diagnosed with schizophrenia—received a dose of haloperidol, and at least two guards escorted him to a room in the psychiatric unit. While left with a nurse, he tried to smash a window. The nurse hit a panic button to summon help, but the patient climbed on top of his bed and dove headfirst into a shatterproof glass. He fractured his neck and became quadriplegic.

In court, the patient’s attorney argued that the hospital was negligent in its failure to restrain him from harming himself. The patient died shortly after the trial from complications of quadriplegia.

• The jury’s verdict, $13 million, was reduced to approximately $7 million because of a statutory capitation.
  

Dr. Grant’s observations

The legal issue here is not simply whether the staff failed to prevent the patient from harming himself. Instead, the jury believed a reasonable person could have foreseen danger to the patient, thereby deeming the hospital negligent.

I’m not suggesting that all psychotic patients be restrained to prevent litigation. This case, however, illustrates the importance of assessing patients for dangerousness and intervening appropriately. Because the patient acted out his hallucinations and required two guards to escort him to his room, one could argue that one nurse could not adequately manage this patient.

When restraints are necessary, assess and document the patient’s behavior and the reasons that necessitate restraints. In this case, for example, record that medication alone did not sufficiently calm this patient.

One-on-one verbal and behavioral interventions can be effective alternatives to seclusion and restraint (Table 1).^1,2 Predictably, patients respond negatively to restraints, preferring medication instead.⁴ When less-restrictive, behavioral, or pharmacologic measures fail, consider restraints to protect aggressive, assaultive patients.

Table 1

Possible alternatives to restraints

Security personnel asphyxiate woman

Pima County (AZ) Superior Court

A 32-year-old woman with a history of psychiatric disorders was admitted to a county hospital’s psychiatric department. Several guards and security technicians held her face down on the floor for 15 to 30 minutes. The patient struggled to breathe, turned blue, then stopped breathing. She died of asphyxiation.

The estate sued both the county and the security technicians’ employer, claiming the guards were not properly trained on patient restraint.

• A $105,000 settlement with the county was reached; a confidential settlement was reached with the security employer.
  

Dr. Grant’s observations

This case shows how improper use of restraints may result in a successful lawsuit.

In 1998, the Hartford Courant ran a series of articles alleging that seclusion and restraint in a psychiatric setting led to 142 deaths across 10 years.⁵ State and federal legislation passed after the newspaper’s report has focused on protecting patients from improper use of restraints. Be aware of your state’s and hospital’s regulations. The guidelines in Table 2 reflect general policies for using restraints suggested by the Joint Commission on Accreditation of Health-care Organizations.⁶

Restraints should be used only by trained staff and for only as long as the patient is dangerous to self or others. Also assess patients who may be at increased risk for physical or psychological difficulties if restrained or secluded and consider alternate interventions. Generally, restraints should be avoided in patients with the following relative contraindications:

• pregnant
  
• history of breathing problems
  
• head or spinal injuries
  
• history of recent fractures or surgeries
  
• seizure disorder
  
• history of sexual or physical abuse.
  

Table 2

Guidelines for proper restraint use

Unmonitored suicidal man suffocates himself

Tarrant County (TX) District Court

A 26-year-old man in the suicide prevention unit of a community hospital suffocated himself using a vinyl pillowcase from his room and cellophane wrap from the hospital’s kitchen.

For more than 40 minutes before finding the patient dead, staff had not documented checking the patient’s room, which was required every 15 minutes. Paramedics documented the beginning of rigor mortis.

The estate claimed the hospital had not adequately monitored the patient despite clear indications of suicidality. In the days preceding his death, records showed a deteriorating condition related to problems with his companion, who had told him she was leaving the home they shared. He previously attempted suicide when she threatened to move out and had injured himself on similar occasions.

At the time of his death, four staff members were on duty; one claimed to have seen the patient 5 minutes before he was found. The estate contended that more than 1 hour would have been required for rigor mortis to develop.

• A settlement of $1.1 million was reached.
  

Dr. Grant’s observations

Immediately assess suicidal patients and their environment to reduce the risk of self-harm. One-on-one observation has been found to be most effective⁷ and should be required for patients with severe suicide risk. All suicidal patients should (at minimum) be visible to staff members at all times to maintain safety standards.⁷ Frequently document the patient’s location, activities, and behavior.

To ensure a safe environment for suicidal patients, identify and minimize risk factors associated with hospital settings.⁸ For example, access to cellophane wrap in this case should have been blocked. Ensure that suicidal patients cannot reach materials they could use to harm themselves such as pillowcases, drapery cords, ingestible cleaning supplies, shower curtains and rods, and breakable objects.

Vague laws and debate over use of physical restraint complicate management of dangerous patients. Restraints have historically been over-used in psychiatry, even contributing to patients’ deaths. Still, many psychiatric facilities grapple with a reluctance to use restraint versus a need to protect patients from themselves and from harming others.

The law requires use of “least-restrictive interventions” to manage patients, but clinicians cannot agree on what this term means. This article offers tips to maximize patient safety when using restraints and advice on when to use them.

Psychotic man breaks neck jumping into window

Dane County (WI) Circuit Court

A 40-year-old man was hospitalized during a psychotic episode, in which he acted out aural hallucinations.

The man—who was previously diagnosed with schizophrenia—received a dose of haloperidol, and at least two guards escorted him to a room in the psychiatric unit. While left with a nurse, he tried to smash a window. The nurse hit a panic button to summon help, but the patient climbed on top of his bed and dove headfirst into a shatterproof glass. He fractured his neck and became quadriplegic.

In court, the patient’s attorney argued that the hospital was negligent in its failure to restrain him from harming himself. The patient died shortly after the trial from complications of quadriplegia.

• The jury’s verdict, $13 million, was reduced to approximately $7 million because of a statutory capitation.
  

Dr. Grant’s observations

The legal issue here is not simply whether the staff failed to prevent the patient from harming himself. Instead, the jury believed a reasonable person could have foreseen danger to the patient, thereby deeming the hospital negligent.

I’m not suggesting that all psychotic patients be restrained to prevent litigation. This case, however, illustrates the importance of assessing patients for dangerousness and intervening appropriately. Because the patient acted out his hallucinations and required two guards to escort him to his room, one could argue that one nurse could not adequately manage this patient.

When restraints are necessary, assess and document the patient’s behavior and the reasons that necessitate restraints. In this case, for example, record that medication alone did not sufficiently calm this patient.

One-on-one verbal and behavioral interventions can be effective alternatives to seclusion and restraint (Table 1).^1,2 Predictably, patients respond negatively to restraints, preferring medication instead.⁴ When less-restrictive, behavioral, or pharmacologic measures fail, consider restraints to protect aggressive, assaultive patients.

Table 1

Possible alternatives to restraints

Security personnel asphyxiate woman

Pima County (AZ) Superior Court

A 32-year-old woman with a history of psychiatric disorders was admitted to a county hospital’s psychiatric department. Several guards and security technicians held her face down on the floor for 15 to 30 minutes. The patient struggled to breathe, turned blue, then stopped breathing. She died of asphyxiation.

The estate sued both the county and the security technicians’ employer, claiming the guards were not properly trained on patient restraint.

• A $105,000 settlement with the county was reached; a confidential settlement was reached with the security employer.
  

Dr. Grant’s observations

This case shows how improper use of restraints may result in a successful lawsuit.

In 1998, the Hartford Courant ran a series of articles alleging that seclusion and restraint in a psychiatric setting led to 142 deaths across 10 years.⁵ State and federal legislation passed after the newspaper’s report has focused on protecting patients from improper use of restraints. Be aware of your state’s and hospital’s regulations. The guidelines in Table 2 reflect general policies for using restraints suggested by the Joint Commission on Accreditation of Health-care Organizations.⁶

Restraints should be used only by trained staff and for only as long as the patient is dangerous to self or others. Also assess patients who may be at increased risk for physical or psychological difficulties if restrained or secluded and consider alternate interventions. Generally, restraints should be avoided in patients with the following relative contraindications:

• pregnant
  
• history of breathing problems
  
• head or spinal injuries
  
• history of recent fractures or surgeries
  
• seizure disorder
  
• history of sexual or physical abuse.
  

Table 2

Guidelines for proper restraint use

Unmonitored suicidal man suffocates himself

Tarrant County (TX) District Court

A 26-year-old man in the suicide prevention unit of a community hospital suffocated himself using a vinyl pillowcase from his room and cellophane wrap from the hospital’s kitchen.

For more than 40 minutes before finding the patient dead, staff had not documented checking the patient’s room, which was required every 15 minutes. Paramedics documented the beginning of rigor mortis.

The estate claimed the hospital had not adequately monitored the patient despite clear indications of suicidality. In the days preceding his death, records showed a deteriorating condition related to problems with his companion, who had told him she was leaving the home they shared. He previously attempted suicide when she threatened to move out and had injured himself on similar occasions.

At the time of his death, four staff members were on duty; one claimed to have seen the patient 5 minutes before he was found. The estate contended that more than 1 hour would have been required for rigor mortis to develop.

• A settlement of $1.1 million was reached.
  

Dr. Grant’s observations

Immediately assess suicidal patients and their environment to reduce the risk of self-harm. One-on-one observation has been found to be most effective⁷ and should be required for patients with severe suicide risk. All suicidal patients should (at minimum) be visible to staff members at all times to maintain safety standards.⁷ Frequently document the patient’s location, activities, and behavior.

To ensure a safe environment for suicidal patients, identify and minimize risk factors associated with hospital settings.⁸ For example, access to cellophane wrap in this case should have been blocked. Ensure that suicidal patients cannot reach materials they could use to harm themselves such as pillowcases, drapery cords, ingestible cleaning supplies, shower curtains and rods, and breakable objects.

Hospital work in psychiatry has a long, proud tradition. The severely mentally ill were housed in asylums in the historical past. In fact the origin of the word “bedlam” is derived from the pronunciation of Bethlehem and came to be synonymous with chaos. Bethlehem was the name of an insane asylum in London. Some aspects of current psychiatric hospital care still feel like bedlam.

A typical day for an inpatient psychiatrist involves rounding individually after a team meeting with social workers, nurses, and other members of the treatment team to determine events and observations during the previous 24 hours. The primary reasons for admission to inpatient services are imminent risk to self or others (suicide or homicide), psychotic disorders with inability to function, or severe anxiety or depression with inability to function. Geriatric units often deal with behavioral dyscontrol secondary to dementing illnesses or other neurologic disorders.

PSYCH ADMISSIONS

Practically speaking, the vast majority of admissions result from concerns related to the safety of the patient or others. For inpatient psychiatry the focus is acute stabilization and safety. This focus on stabilization often involves collaborating with outpatient members of the patient’s treatment team, including case managers and outside psychiatrists and therapists. Involving family in obtaining the patient’s collateral history is vital. The goal is to develop a treatment plan to address support, reasons for suicide, access to means for suicide, and treat underlying psychiatric syndromes.

Nonadherence to medication is another primary reason for admission. Patients with bipolar disorder, depression, and schizophrenia often stop taking their medications. Some of this is related to the underlying illness, while some is related to difficulties associated with medication side-effect profiles. Often, psychotic patients may have a fairly dramatic change in control of their symptoms after restarting their previous medications.

PSYCHIATRISTS IN HOSPITALS

Primary hospital work is not uncommon in the United States. A common arrangement is for a single psychiatrist or small group of psychiatrists to primarily manage an inpatient practice and see outpatients in the afternoon, depending on the size of the hospital.

Many psychiatrists lack interest in inpatient work, however. This lack of interest is related to the severity of symptoms, legal interface, call, and challenges with coordinating inpatient care with an outpatient practice.

The advantages of a dedicated psychiatric hospital practice are the same as for other hospitalists: The hospitalist develops both efficiencies and best practices based on seeing severe and complex problems repeatedly. They may also have knowledge of the community resources for the severely ill, which private outpatient psychiatrists may not be familiar with.

Psychiatric hospital work is always interesting and a great opportunity to work with severely ill patients who can be helped dramatically. The treatment is team-focused and offers the chance to work closely with social work, nursing, occupational therapy, psychology, and the community. It also allows for experience working with lawyers and the court system on a regular basis. Additionally, there’s often an opportunity to develop expert witness skills in some settings.

Academically, inpatient work is critical to resident and medical student education. It provides a chance for developing physicians to see and understand the realities and suffering associated with mental illness and their medical basis.

Psychiatric hospital medicine is emotionally intense work. Burnout is a major concern.

Many patients are not in the hospital voluntarily and don’t have insight into their illness. Nonadherence to treatment is common and the factor behind many admissions. Behaviorally, patients may be out of control from psychosis or severe personality disorders. Many have traumatic psychosocial histories and lack social supports. A number face legal charges. The intensity of practice is also due to the pressures of time, shortages of services for the mentally ill as outpatients, and pressures from both managed care and regulatory agencies.

EVOLUTION OF THE SPECIALTY

The state of hospital psychiatry has changed greatly in the past 40 or 50 years. The introduction of the antipsychotics solely for schizophrenia means we can now treat those previously thought untreatable. With the discovery and application of other treatments for mental illness, a movement developed to end the institutionalization of the mentally ill and integrate them back into the community. Other societal forces include the patient rights movement that has led to changes in the law and a needed focus on the rights of the mentally ill—both for minimums of treatment provided and protection against unnecessary hospitalization. State and federal budgetary and managed care pressures have also contributed to the remarkable changes in hospital psychiatry.

This combination of changes from medical, legal, societal, and fiscal forces has slashed the number of available inpatient beds and lengths of stays. In 1970 there were 413,066 state and county psychiatric inpatient beds in the United States.1 By 2000 that number had decreased to 59,403. There has been a moderate increase in private and community psychiatric beds in response. However, even considering this increase, the total number of beds in 1970 was

524,878 and the total in 2000 was 215,221. There have been continued reductions in beds since then nationally. Along with this decrease in psychiatric beds has come a dramatic shift in average length of stay as well. The general average length of stay in the United States is less than one week for psychiatric hospitalization.

The hope with decreasing the number of beds has been that a focus on community-based treatment and programs to support those with severe mental illness would be available to meet the needs of the severely mentally ill. Unfortunately, though the intent and goals were laudable, those programs have not developed as hoped. Current challenges for the seriously mentally ill include lack of parity for mental illness for insurance, continued pressure on private psychiatric beds to fill in the gaps of services not met by the community along with continued cuts in state and federal funding for inpatient psychiatric care.

This decrease in beds combined with decreased average length of stay and an increase in population has led to more and more pressure on the limited psychiatric beds available. It’s not uncommon now for patients to remain in the emergency department for 24 hours or longer waiting for a psychiatric bed. Along with these pressures has come decreased availability of inpatient substance abuse treatment, the ubiquitous comorbidity. Managed care review of inpatient stays on an almost daily basis, and the ever-increasing demands of documentation to meet regulatory requirements have also increased pressures on hospital psychiatry.

TYPES OF PSYCH HOSPITALIST PROGRAMS

As a result of the trends mentioned above, a variety of psychiatric hospitalist practice settings now exist. They include private and community psychiatric hospitals, academic center hospitals, state hospitals, Veterans Affairs and military hospitals, and—the most rapidly growing sector—correctional psychiatry in state and federal prison systems.

Correctional settings, such as jails and prisons, have been estimated by the Bureau of Justice Statistics to have a prevalence of inmates with mental illness between 7% and 16%.2 The rate of mental illness in inmates is approximately two to three times that of the general population for major mental illnesses such as schizophrenia, bipolar disorder, and major depressive disorder. The mentally ill in prison are more likely to be homeless, medically ill, and chemically dependent than the general population, as well.

Mentally ill inmates serve longer prison sentences on average than their mentally healthy peers. Mentally ill inmates are involved more commonly in disciplinary problems in prison also.

Overall, approximately 60% of mentally ill inmates receive some sort of mental health treatment while in custody. Two-thirds of inmates receiving treatment are in facilities that do not specialize in mental health treatment. Of state prisons, 155 specialize in mental health treatment—out of more than 1,500 facilities surveyed.3 Twelve facilities have mental health treatment as their primary function. Fewer than 2% of state inmates were housed in a mental health unit providing 24-hour care.

Psychiatric hospitalists in specialized treatment correctional settings have the opportunity to perform assessments and provide treatment to a patient population with a prevalence and severity of psychopathology that is not commonly seen in community psychiatric inpatient or outpatient practice today.

CRYSTAL BALL

Inpatient psychiatry will continue to be important in the future. There are great challenges ahead but the need for dedicated hospital psychiatrists won’t go away and will probably increase. The pressures on the shrinking number of inpatient beds will continue to grow. The lack of outpatient services in general and intensive outpatient services available to transition patients to on discharge is frustrating. The continued de-emphasis on availability of substance abuse treatment continues to perplex. TH

Dr. Lineberry is medical director, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn. Dr. Shine is senior associate consultant, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn.

REFERENCES

1. Manderscheid RW, Atay JE, Hernandez-Cartagena MR, et al. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, U.S. Department of Health and Human Services. Mental Health, United States, 2002. Chapter 18. Highlights of organized mental health services in 2000 and major national and state trends. Available at www.mentalhealth.org/publications/allpubs/SMA04-3938/. Last accessed July 29, 2005.
2. Bureau of Justice Statistics, Department of Justice. Mental health and treatment of inmates and probationers. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf. Last accessed July 29, 2005.
3. Bureau of Justice Statistics, Department of Justice. Mental health treatment in state prisons. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtsp00.pdf. Last accessed July 29, 2005.

Hospital work in psychiatry has a long, proud tradition. The severely mentally ill were housed in asylums in the historical past. In fact the origin of the word “bedlam” is derived from the pronunciation of Bethlehem and came to be synonymous with chaos. Bethlehem was the name of an insane asylum in London. Some aspects of current psychiatric hospital care still feel like bedlam.

A typical day for an inpatient psychiatrist involves rounding individually after a team meeting with social workers, nurses, and other members of the treatment team to determine events and observations during the previous 24 hours. The primary reasons for admission to inpatient services are imminent risk to self or others (suicide or homicide), psychotic disorders with inability to function, or severe anxiety or depression with inability to function. Geriatric units often deal with behavioral dyscontrol secondary to dementing illnesses or other neurologic disorders.

PSYCH ADMISSIONS

Practically speaking, the vast majority of admissions result from concerns related to the safety of the patient or others. For inpatient psychiatry the focus is acute stabilization and safety. This focus on stabilization often involves collaborating with outpatient members of the patient’s treatment team, including case managers and outside psychiatrists and therapists. Involving family in obtaining the patient’s collateral history is vital. The goal is to develop a treatment plan to address support, reasons for suicide, access to means for suicide, and treat underlying psychiatric syndromes.

Nonadherence to medication is another primary reason for admission. Patients with bipolar disorder, depression, and schizophrenia often stop taking their medications. Some of this is related to the underlying illness, while some is related to difficulties associated with medication side-effect profiles. Often, psychotic patients may have a fairly dramatic change in control of their symptoms after restarting their previous medications.

PSYCHIATRISTS IN HOSPITALS

Primary hospital work is not uncommon in the United States. A common arrangement is for a single psychiatrist or small group of psychiatrists to primarily manage an inpatient practice and see outpatients in the afternoon, depending on the size of the hospital.

Many psychiatrists lack interest in inpatient work, however. This lack of interest is related to the severity of symptoms, legal interface, call, and challenges with coordinating inpatient care with an outpatient practice.

The advantages of a dedicated psychiatric hospital practice are the same as for other hospitalists: The hospitalist develops both efficiencies and best practices based on seeing severe and complex problems repeatedly. They may also have knowledge of the community resources for the severely ill, which private outpatient psychiatrists may not be familiar with.

Psychiatric hospital work is always interesting and a great opportunity to work with severely ill patients who can be helped dramatically. The treatment is team-focused and offers the chance to work closely with social work, nursing, occupational therapy, psychology, and the community. It also allows for experience working with lawyers and the court system on a regular basis. Additionally, there’s often an opportunity to develop expert witness skills in some settings.

Academically, inpatient work is critical to resident and medical student education. It provides a chance for developing physicians to see and understand the realities and suffering associated with mental illness and their medical basis.

Psychiatric hospital medicine is emotionally intense work. Burnout is a major concern.

Many patients are not in the hospital voluntarily and don’t have insight into their illness. Nonadherence to treatment is common and the factor behind many admissions. Behaviorally, patients may be out of control from psychosis or severe personality disorders. Many have traumatic psychosocial histories and lack social supports. A number face legal charges. The intensity of practice is also due to the pressures of time, shortages of services for the mentally ill as outpatients, and pressures from both managed care and regulatory agencies.

EVOLUTION OF THE SPECIALTY

The state of hospital psychiatry has changed greatly in the past 40 or 50 years. The introduction of the antipsychotics solely for schizophrenia means we can now treat those previously thought untreatable. With the discovery and application of other treatments for mental illness, a movement developed to end the institutionalization of the mentally ill and integrate them back into the community. Other societal forces include the patient rights movement that has led to changes in the law and a needed focus on the rights of the mentally ill—both for minimums of treatment provided and protection against unnecessary hospitalization. State and federal budgetary and managed care pressures have also contributed to the remarkable changes in hospital psychiatry.

This combination of changes from medical, legal, societal, and fiscal forces has slashed the number of available inpatient beds and lengths of stays. In 1970 there were 413,066 state and county psychiatric inpatient beds in the United States.1 By 2000 that number had decreased to 59,403. There has been a moderate increase in private and community psychiatric beds in response. However, even considering this increase, the total number of beds in 1970 was

524,878 and the total in 2000 was 215,221. There have been continued reductions in beds since then nationally. Along with this decrease in psychiatric beds has come a dramatic shift in average length of stay as well. The general average length of stay in the United States is less than one week for psychiatric hospitalization.

The hope with decreasing the number of beds has been that a focus on community-based treatment and programs to support those with severe mental illness would be available to meet the needs of the severely mentally ill. Unfortunately, though the intent and goals were laudable, those programs have not developed as hoped. Current challenges for the seriously mentally ill include lack of parity for mental illness for insurance, continued pressure on private psychiatric beds to fill in the gaps of services not met by the community along with continued cuts in state and federal funding for inpatient psychiatric care.

This decrease in beds combined with decreased average length of stay and an increase in population has led to more and more pressure on the limited psychiatric beds available. It’s not uncommon now for patients to remain in the emergency department for 24 hours or longer waiting for a psychiatric bed. Along with these pressures has come decreased availability of inpatient substance abuse treatment, the ubiquitous comorbidity. Managed care review of inpatient stays on an almost daily basis, and the ever-increasing demands of documentation to meet regulatory requirements have also increased pressures on hospital psychiatry.

TYPES OF PSYCH HOSPITALIST PROGRAMS

As a result of the trends mentioned above, a variety of psychiatric hospitalist practice settings now exist. They include private and community psychiatric hospitals, academic center hospitals, state hospitals, Veterans Affairs and military hospitals, and—the most rapidly growing sector—correctional psychiatry in state and federal prison systems.

Correctional settings, such as jails and prisons, have been estimated by the Bureau of Justice Statistics to have a prevalence of inmates with mental illness between 7% and 16%.2 The rate of mental illness in inmates is approximately two to three times that of the general population for major mental illnesses such as schizophrenia, bipolar disorder, and major depressive disorder. The mentally ill in prison are more likely to be homeless, medically ill, and chemically dependent than the general population, as well.

Mentally ill inmates serve longer prison sentences on average than their mentally healthy peers. Mentally ill inmates are involved more commonly in disciplinary problems in prison also.

Overall, approximately 60% of mentally ill inmates receive some sort of mental health treatment while in custody. Two-thirds of inmates receiving treatment are in facilities that do not specialize in mental health treatment. Of state prisons, 155 specialize in mental health treatment—out of more than 1,500 facilities surveyed.3 Twelve facilities have mental health treatment as their primary function. Fewer than 2% of state inmates were housed in a mental health unit providing 24-hour care.

Psychiatric hospitalists in specialized treatment correctional settings have the opportunity to perform assessments and provide treatment to a patient population with a prevalence and severity of psychopathology that is not commonly seen in community psychiatric inpatient or outpatient practice today.

CRYSTAL BALL

Inpatient psychiatry will continue to be important in the future. There are great challenges ahead but the need for dedicated hospital psychiatrists won’t go away and will probably increase. The pressures on the shrinking number of inpatient beds will continue to grow. The lack of outpatient services in general and intensive outpatient services available to transition patients to on discharge is frustrating. The continued de-emphasis on availability of substance abuse treatment continues to perplex. TH

Dr. Lineberry is medical director, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn. Dr. Shine is senior associate consultant, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn.

REFERENCES

1. Manderscheid RW, Atay JE, Hernandez-Cartagena MR, et al. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, U.S. Department of Health and Human Services. Mental Health, United States, 2002. Chapter 18. Highlights of organized mental health services in 2000 and major national and state trends. Available at www.mentalhealth.org/publications/allpubs/SMA04-3938/. Last accessed July 29, 2005.
2. Bureau of Justice Statistics, Department of Justice. Mental health and treatment of inmates and probationers. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf. Last accessed July 29, 2005.
3. Bureau of Justice Statistics, Department of Justice. Mental health treatment in state prisons. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtsp00.pdf. Last accessed July 29, 2005.

Hospital work in psychiatry has a long, proud tradition. The severely mentally ill were housed in asylums in the historical past. In fact the origin of the word “bedlam” is derived from the pronunciation of Bethlehem and came to be synonymous with chaos. Bethlehem was the name of an insane asylum in London. Some aspects of current psychiatric hospital care still feel like bedlam.

A typical day for an inpatient psychiatrist involves rounding individually after a team meeting with social workers, nurses, and other members of the treatment team to determine events and observations during the previous 24 hours. The primary reasons for admission to inpatient services are imminent risk to self or others (suicide or homicide), psychotic disorders with inability to function, or severe anxiety or depression with inability to function. Geriatric units often deal with behavioral dyscontrol secondary to dementing illnesses or other neurologic disorders.

PSYCH ADMISSIONS

Practically speaking, the vast majority of admissions result from concerns related to the safety of the patient or others. For inpatient psychiatry the focus is acute stabilization and safety. This focus on stabilization often involves collaborating with outpatient members of the patient’s treatment team, including case managers and outside psychiatrists and therapists. Involving family in obtaining the patient’s collateral history is vital. The goal is to develop a treatment plan to address support, reasons for suicide, access to means for suicide, and treat underlying psychiatric syndromes.

Nonadherence to medication is another primary reason for admission. Patients with bipolar disorder, depression, and schizophrenia often stop taking their medications. Some of this is related to the underlying illness, while some is related to difficulties associated with medication side-effect profiles. Often, psychotic patients may have a fairly dramatic change in control of their symptoms after restarting their previous medications.

PSYCHIATRISTS IN HOSPITALS

Primary hospital work is not uncommon in the United States. A common arrangement is for a single psychiatrist or small group of psychiatrists to primarily manage an inpatient practice and see outpatients in the afternoon, depending on the size of the hospital.

Many psychiatrists lack interest in inpatient work, however. This lack of interest is related to the severity of symptoms, legal interface, call, and challenges with coordinating inpatient care with an outpatient practice.

The advantages of a dedicated psychiatric hospital practice are the same as for other hospitalists: The hospitalist develops both efficiencies and best practices based on seeing severe and complex problems repeatedly. They may also have knowledge of the community resources for the severely ill, which private outpatient psychiatrists may not be familiar with.

Psychiatric hospital work is always interesting and a great opportunity to work with severely ill patients who can be helped dramatically. The treatment is team-focused and offers the chance to work closely with social work, nursing, occupational therapy, psychology, and the community. It also allows for experience working with lawyers and the court system on a regular basis. Additionally, there’s often an opportunity to develop expert witness skills in some settings.

Academically, inpatient work is critical to resident and medical student education. It provides a chance for developing physicians to see and understand the realities and suffering associated with mental illness and their medical basis.

Psychiatric hospital medicine is emotionally intense work. Burnout is a major concern.

Many patients are not in the hospital voluntarily and don’t have insight into their illness. Nonadherence to treatment is common and the factor behind many admissions. Behaviorally, patients may be out of control from psychosis or severe personality disorders. Many have traumatic psychosocial histories and lack social supports. A number face legal charges. The intensity of practice is also due to the pressures of time, shortages of services for the mentally ill as outpatients, and pressures from both managed care and regulatory agencies.

EVOLUTION OF THE SPECIALTY

The state of hospital psychiatry has changed greatly in the past 40 or 50 years. The introduction of the antipsychotics solely for schizophrenia means we can now treat those previously thought untreatable. With the discovery and application of other treatments for mental illness, a movement developed to end the institutionalization of the mentally ill and integrate them back into the community. Other societal forces include the patient rights movement that has led to changes in the law and a needed focus on the rights of the mentally ill—both for minimums of treatment provided and protection against unnecessary hospitalization. State and federal budgetary and managed care pressures have also contributed to the remarkable changes in hospital psychiatry.

This combination of changes from medical, legal, societal, and fiscal forces has slashed the number of available inpatient beds and lengths of stays. In 1970 there were 413,066 state and county psychiatric inpatient beds in the United States.1 By 2000 that number had decreased to 59,403. There has been a moderate increase in private and community psychiatric beds in response. However, even considering this increase, the total number of beds in 1970 was

524,878 and the total in 2000 was 215,221. There have been continued reductions in beds since then nationally. Along with this decrease in psychiatric beds has come a dramatic shift in average length of stay as well. The general average length of stay in the United States is less than one week for psychiatric hospitalization.

The hope with decreasing the number of beds has been that a focus on community-based treatment and programs to support those with severe mental illness would be available to meet the needs of the severely mentally ill. Unfortunately, though the intent and goals were laudable, those programs have not developed as hoped. Current challenges for the seriously mentally ill include lack of parity for mental illness for insurance, continued pressure on private psychiatric beds to fill in the gaps of services not met by the community along with continued cuts in state and federal funding for inpatient psychiatric care.

This decrease in beds combined with decreased average length of stay and an increase in population has led to more and more pressure on the limited psychiatric beds available. It’s not uncommon now for patients to remain in the emergency department for 24 hours or longer waiting for a psychiatric bed. Along with these pressures has come decreased availability of inpatient substance abuse treatment, the ubiquitous comorbidity. Managed care review of inpatient stays on an almost daily basis, and the ever-increasing demands of documentation to meet regulatory requirements have also increased pressures on hospital psychiatry.

TYPES OF PSYCH HOSPITALIST PROGRAMS

As a result of the trends mentioned above, a variety of psychiatric hospitalist practice settings now exist. They include private and community psychiatric hospitals, academic center hospitals, state hospitals, Veterans Affairs and military hospitals, and—the most rapidly growing sector—correctional psychiatry in state and federal prison systems.

Correctional settings, such as jails and prisons, have been estimated by the Bureau of Justice Statistics to have a prevalence of inmates with mental illness between 7% and 16%.2 The rate of mental illness in inmates is approximately two to three times that of the general population for major mental illnesses such as schizophrenia, bipolar disorder, and major depressive disorder. The mentally ill in prison are more likely to be homeless, medically ill, and chemically dependent than the general population, as well.

Mentally ill inmates serve longer prison sentences on average than their mentally healthy peers. Mentally ill inmates are involved more commonly in disciplinary problems in prison also.

Overall, approximately 60% of mentally ill inmates receive some sort of mental health treatment while in custody. Two-thirds of inmates receiving treatment are in facilities that do not specialize in mental health treatment. Of state prisons, 155 specialize in mental health treatment—out of more than 1,500 facilities surveyed.3 Twelve facilities have mental health treatment as their primary function. Fewer than 2% of state inmates were housed in a mental health unit providing 24-hour care.

Psychiatric hospitalists in specialized treatment correctional settings have the opportunity to perform assessments and provide treatment to a patient population with a prevalence and severity of psychopathology that is not commonly seen in community psychiatric inpatient or outpatient practice today.

CRYSTAL BALL

Inpatient psychiatry will continue to be important in the future. There are great challenges ahead but the need for dedicated hospital psychiatrists won’t go away and will probably increase. The pressures on the shrinking number of inpatient beds will continue to grow. The lack of outpatient services in general and intensive outpatient services available to transition patients to on discharge is frustrating. The continued de-emphasis on availability of substance abuse treatment continues to perplex. TH

Dr. Lineberry is medical director, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn. Dr. Shine is senior associate consultant, Psychiatric Acute Care Program, Mayo Psychiatry and Psychology Treatment Center, St. Mary’s Hospital, Rochester, Minn.

REFERENCES

1. Manderscheid RW, Atay JE, Hernandez-Cartagena MR, et al. Substance Abuse and Mental Health Services Administration, Center for Mental Health Services, U.S. Department of Health and Human Services. Mental Health, United States, 2002. Chapter 18. Highlights of organized mental health services in 2000 and major national and state trends. Available at www.mentalhealth.org/publications/allpubs/SMA04-3938/. Last accessed July 29, 2005.
2. Bureau of Justice Statistics, Department of Justice. Mental health and treatment of inmates and probationers. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtip.pdf. Last accessed July 29, 2005.
3. Bureau of Justice Statistics, Department of Justice. Mental health treatment in state prisons. Available at www.ojp.usdoj.gov/bjs/pub/pdf/mhtsp00.pdf. Last accessed July 29, 2005.

As a board-certified medical oncologist with certification in hospice medicine and palliative care and 32 years of experience dealing with some thorny issues, I offer to our readers the 10 commandments that each of us should expect when we shift from caregivers to care receivers.

In effect, we are all patients. It is just a matter of time before we are in a bed in a hospital or nursing home rather than standing around the bed providing care. So here it goes.

1. Acknowledge me as a person. I am not simply a “diagnosis,” an ICD code, or a billing rubric. Find out something about me as a person. I am very funny. I have interests and hobbies. Get to know me.
2. Provide me with a medical quarterback, a Marcus Welby to direct my care. Do not bombard me with seven subspecialists each of who use a tiny piece of my anatomy and each of whom has a catheter or a tube to put in some orifice.
3. I understand that I will often be visited by teams of providers. If I am really sick, nauseated, or in pain, let’s minimize the size of the herd around the bedside. It takes energy to confront a team.
4. Treat me as if you would a member of your family. We all know that tests are sometimes done unnecessarily and subspecialty consultations might not always be necessary. Target my management to get the most value from the test.
5. Ask me about my major concerns. What worries me, what torments me may not even be on your radar screen. (One of our patients was a gentleman with far-advanced cancer of the pancreas, unresectable disease, and no one bothered to ask him what his greatest concern was. It was to get out of the hospital, to be with his daughter at her wedding the following month. Once we knew that, every effort was made for aggressive hydration and nutrition so he could make that important date.)
6. Have some understanding of my insurance policy. What is covered, what is not, are there deductibles, are there copays? Why? (One of our head and neck cancer patients was advised to receive an off-label use of a relatively new agent. No one bothered to inquire that the patient did not have great insurance, and he was responsible for a $15,000 a month bill for a medication with a less than 10% chance of working.)
7. If I have a serious illness and my expected survival is less than six months, do not wait to bring up the issue of hospice care. (This is a wonderful program, and what I consistently hear as a clinician from families, “Why didn’t we know about this sooner?”)
8. Whom do I call, whom do I contact if I have a problem outside of the hospital? I will have seen umpteen clinicians, most of whose names I do not remember so what do I do if there is a problem at 2 o’clock in the morning?
9. Please be certain that none of my medications have to be refilled within three days of leaving the hospital. No, I am not kidding. Give me enough medications to get me through acute episodes whether this is an antibiotic, an antiemetic, or a sleeping medication.
10. Equally importantly, please be aware of the healing power of sleep. Most of us are sleep deprived under optimum circumstances and this becomes magnified under the rigors of our modern techno hospitals.

One final thought, have some understanding of my faith/belief system. A century ago, the Mayo brothers clearly recognized the importance of the mind-body connection. To paraphrase Drs. Will and Charlie Mayo, they made the comment that the spiritual dimension of healing cannot be overlooked. They also commented that the Beatitudes and the 23rd Psalm are of great comfort to many individuals.

So, there you have it, my 10 commandments. Honor them, honor me, honor my family, and honor our patients.

Dr. Creagan is the American Cancer Society professor of clinical oncology, John and Roma Rouse Professor of Humanism in Medicine, professor, Mayo Clinic College of Medicine, and past president, Mayo Clinic Staff, Rochester, Minn.

As a board-certified medical oncologist with certification in hospice medicine and palliative care and 32 years of experience dealing with some thorny issues, I offer to our readers the 10 commandments that each of us should expect when we shift from caregivers to care receivers.

In effect, we are all patients. It is just a matter of time before we are in a bed in a hospital or nursing home rather than standing around the bed providing care. So here it goes.

1. Acknowledge me as a person. I am not simply a “diagnosis,” an ICD code, or a billing rubric. Find out something about me as a person. I am very funny. I have interests and hobbies. Get to know me.
2. Provide me with a medical quarterback, a Marcus Welby to direct my care. Do not bombard me with seven subspecialists each of who use a tiny piece of my anatomy and each of whom has a catheter or a tube to put in some orifice.
3. I understand that I will often be visited by teams of providers. If I am really sick, nauseated, or in pain, let’s minimize the size of the herd around the bedside. It takes energy to confront a team.
4. Treat me as if you would a member of your family. We all know that tests are sometimes done unnecessarily and subspecialty consultations might not always be necessary. Target my management to get the most value from the test.
5. Ask me about my major concerns. What worries me, what torments me may not even be on your radar screen. (One of our patients was a gentleman with far-advanced cancer of the pancreas, unresectable disease, and no one bothered to ask him what his greatest concern was. It was to get out of the hospital, to be with his daughter at her wedding the following month. Once we knew that, every effort was made for aggressive hydration and nutrition so he could make that important date.)
6. Have some understanding of my insurance policy. What is covered, what is not, are there deductibles, are there copays? Why? (One of our head and neck cancer patients was advised to receive an off-label use of a relatively new agent. No one bothered to inquire that the patient did not have great insurance, and he was responsible for a $15,000 a month bill for a medication with a less than 10% chance of working.)
7. If I have a serious illness and my expected survival is less than six months, do not wait to bring up the issue of hospice care. (This is a wonderful program, and what I consistently hear as a clinician from families, “Why didn’t we know about this sooner?”)
8. Whom do I call, whom do I contact if I have a problem outside of the hospital? I will have seen umpteen clinicians, most of whose names I do not remember so what do I do if there is a problem at 2 o’clock in the morning?
9. Please be certain that none of my medications have to be refilled within three days of leaving the hospital. No, I am not kidding. Give me enough medications to get me through acute episodes whether this is an antibiotic, an antiemetic, or a sleeping medication.
10. Equally importantly, please be aware of the healing power of sleep. Most of us are sleep deprived under optimum circumstances and this becomes magnified under the rigors of our modern techno hospitals.

One final thought, have some understanding of my faith/belief system. A century ago, the Mayo brothers clearly recognized the importance of the mind-body connection. To paraphrase Drs. Will and Charlie Mayo, they made the comment that the spiritual dimension of healing cannot be overlooked. They also commented that the Beatitudes and the 23rd Psalm are of great comfort to many individuals.

So, there you have it, my 10 commandments. Honor them, honor me, honor my family, and honor our patients.

Dr. Creagan is the American Cancer Society professor of clinical oncology, John and Roma Rouse Professor of Humanism in Medicine, professor, Mayo Clinic College of Medicine, and past president, Mayo Clinic Staff, Rochester, Minn.

As a board-certified medical oncologist with certification in hospice medicine and palliative care and 32 years of experience dealing with some thorny issues, I offer to our readers the 10 commandments that each of us should expect when we shift from caregivers to care receivers.

In effect, we are all patients. It is just a matter of time before we are in a bed in a hospital or nursing home rather than standing around the bed providing care. So here it goes.

1. Acknowledge me as a person. I am not simply a “diagnosis,” an ICD code, or a billing rubric. Find out something about me as a person. I am very funny. I have interests and hobbies. Get to know me.
2. Provide me with a medical quarterback, a Marcus Welby to direct my care. Do not bombard me with seven subspecialists each of who use a tiny piece of my anatomy and each of whom has a catheter or a tube to put in some orifice.
3. I understand that I will often be visited by teams of providers. If I am really sick, nauseated, or in pain, let’s minimize the size of the herd around the bedside. It takes energy to confront a team.
4. Treat me as if you would a member of your family. We all know that tests are sometimes done unnecessarily and subspecialty consultations might not always be necessary. Target my management to get the most value from the test.
5. Ask me about my major concerns. What worries me, what torments me may not even be on your radar screen. (One of our patients was a gentleman with far-advanced cancer of the pancreas, unresectable disease, and no one bothered to ask him what his greatest concern was. It was to get out of the hospital, to be with his daughter at her wedding the following month. Once we knew that, every effort was made for aggressive hydration and nutrition so he could make that important date.)
6. Have some understanding of my insurance policy. What is covered, what is not, are there deductibles, are there copays? Why? (One of our head and neck cancer patients was advised to receive an off-label use of a relatively new agent. No one bothered to inquire that the patient did not have great insurance, and he was responsible for a $15,000 a month bill for a medication with a less than 10% chance of working.)
7. If I have a serious illness and my expected survival is less than six months, do not wait to bring up the issue of hospice care. (This is a wonderful program, and what I consistently hear as a clinician from families, “Why didn’t we know about this sooner?”)
8. Whom do I call, whom do I contact if I have a problem outside of the hospital? I will have seen umpteen clinicians, most of whose names I do not remember so what do I do if there is a problem at 2 o’clock in the morning?
9. Please be certain that none of my medications have to be refilled within three days of leaving the hospital. No, I am not kidding. Give me enough medications to get me through acute episodes whether this is an antibiotic, an antiemetic, or a sleeping medication.
10. Equally importantly, please be aware of the healing power of sleep. Most of us are sleep deprived under optimum circumstances and this becomes magnified under the rigors of our modern techno hospitals.

One final thought, have some understanding of my faith/belief system. A century ago, the Mayo brothers clearly recognized the importance of the mind-body connection. To paraphrase Drs. Will and Charlie Mayo, they made the comment that the spiritual dimension of healing cannot be overlooked. They also commented that the Beatitudes and the 23rd Psalm are of great comfort to many individuals.

So, there you have it, my 10 commandments. Honor them, honor me, honor my family, and honor our patients.

Dr. Creagan is the American Cancer Society professor of clinical oncology, John and Roma Rouse Professor of Humanism in Medicine, professor, Mayo Clinic College of Medicine, and past president, Mayo Clinic Staff, Rochester, Minn.

The forces of our universe are described and measured by a series of laws and equations known collectively as physics. Though we seem far removed from those halcyon (or Halcion) days of college physics, we exist in a universe still ruled by them. In this instance, our world is the hospital.

Strange vectors of force and difficult-to-fathom principles swirl, causing unanticipated changes in our environment. Using the laws of physics we can attempt to understand these forces.

NEWTON’S FIRST LAW: Newton’s first law is a statement about inertia. An object at rest stays at rest; an object in motion stays in motion unless compelled to change its state by the action of an external force. Byzantine bureaucracies maintain a significant amount of inertia. The expression “that’s the way we’ve always done it here” best summarizes this philosophy.

NEWTON’S SECOND LAW: Newton’s second law examines the force necessary to cause the acceleration of an object in relationship to its mass (F=MA). A moderate amount of force applied to a golf ball may send that object 250 yards—hook right, but the same force applied to a dump truck causes no significant motion.

In the hospital, we often see large expenditures of energy resulting in little movement. This is generally an administrative phenomenon.

NEWTON’S THIRD LAW: For every action there is an equal and opposite reaction. This is an important law in the hospital. The most recent example is the change in residents’ work hours. A seemingly simple issue, residents working too many hours leads to a legislative action and mandated hours. This specific alteration has had unintended consequences and affected numerous other systems. In the case of resident work hours the potential advantages in hours worked has led to a potentially adverse effect on such things as continuity and learning—and an increase in demand for hospitalists.

No system changes can occur without consequences, and the trick is to identify those changes before they occur. Luckily most systems have significant inertia, and only the greatest forces cause major change. It takes massive energy expenditure (i.e., government regulation or resident review boards) to solicit the forces adequate to overcome escape velocity and cause change.

Some forces can cause change not by their sheer energy level, but by their strategic placement. A small forceful tap may split a diamond. A call by a resident’s spouse can cause the downfall of a program. An off-hand comment by a colleague can lead to a disastrous malpractice settlement.

CENTRIFUGAL PSEUDOFORCE: A pseudoforce occurs when one moves in a uniform circular motion. Most of us have observed this phenomenon. When you run around in circles like the proverbial decapitated fowl, little is accomplished despite a sensation of energy expended.

A related principle is Brownian motion: Particles in a gas or fluid collide against each other and the walls of the container causing a random motion. At times the hospitalist’s day may feel that way: active movement but much of it nondirectional.

COPERNICAN PRINCIPLE: The idea, suggested by Copernicus was that the sun—not the earth—is the center of this universe. This is an essential point for hospitalists to remember. We spend hours rounding on our patients. We must always remember that the physician is not the center of the universe for the hospitalized patient. As the name suggests, when we “round” we are the satellite.

CAUSALITY PRINCIPLE: Cause must follow effect. This is a dangerous theory exemplified by the classic post-hoc, prompter hoc: Because I did something, something happened.

When applied to patients, the causality principle can mislead. The fever went down when the antibiotic was started. Coincidence or causality? We hired a hospitalist and our length of stay went down. Coincidence or causality?

THE THEORY OF RELATIVITY: Einstein’s famous equation E=mc2 represents his theory of relativity. This equation represents the relationship between an object’s mass and its energy. Mass is represented by the formula M=DV where D is density and V=volume.

In a hospital setting we see this formula used in a corollary to Einstein’s, called the Theory of Relatives. When entering a patient’s room, one is often confronted with a large number of relatives, spouses, siblings, and the dreaded estranged children. These situations almost always require an increased amount of energy expenditure in communication, consensus building, and time.

As the absolute number (or volume) of family members increases, concurrent with any increased density on the individual members’ part, energy expenditure increases dramatically. This follows the mass equation closely. In situations where the density of an individual family member increases beyond measurable levels, one can enter a Black Hole scenario (see illustration).

BLACK HOLES: A black hole is a region of space-time from which nothing can escape—even light.

A black hole is a region of such extreme density that all energy is sucked into its gravitational field. Once exposed to a black hole situation, the observer may note expected phenomena, including absence of light, loss of energy, extreme fatigue and malaise, and a sensation of hopelessness. This effect can be seen in committee rooms or on the wards.

The only known remedies for this condition are avoidance or going off-service.

THE GIBBS FREE ENERGY EQUATION: The Gibbs free energy equation, G=H-(TS), is a thermodynamic formula and a measure of the conservation of energy. Simply put, the energy of a system is related to the enthalpy (H) or positive creative energy input minus the product of time and entropy, the natural tendency of systems to fall apart.

This effect can be seen in the creation of hospitalist programs.

A hospitalist program is sometimes created by an energetic entrepreneur responding to a vacuum or potential space. A great design leads to a functional program (G). The hospitalist (H) must continually put energy into maintaining the system, otherwise over time (T) entropy (S) takes hold and the system deteriorates. A hospitalist program can’t rely on its initial successful design to survive.

PARTICLE WAVE DUALITY: Quanta are bundles of energy. We see these basic units in the hospital on a nonsubatomic level.

Our admissions seem to come in waves. Our daily workload seems to come in waves as well. Yet the essential quantum of hospital medicine is the patient. RVUs may be 1.33, and LOS 3.2 days, and FTEs 0.8, but I have yet to see a patient-and-a-half in a room.

CRITICAL MASS: Critical mass is the smallest amount of fissionable material necessary to maintain a nuclear chain reaction at a constant level. The term is also used to denote an amount or level needed for a specific result or new action to occur. Happily the hospitalist movement in America has reached that self-sustaining critical mass.

CONCLUSION: As Sir Isaac Newton sat under the proverbial tree and watched a ripe Granny Smith drop on his noggin, little did he know how profoundly he would affect the world of hospital medicine. What goes up must come down. The patient admitted must be discharged. And the editorial started must eventually finish. TH

Jamie Newman, MD, FACP, is physician editor of The Hopitalist, and senior associate consultant, Hospital Internal Medicine and associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

The forces of our universe are described and measured by a series of laws and equations known collectively as physics. Though we seem far removed from those halcyon (or Halcion) days of college physics, we exist in a universe still ruled by them. In this instance, our world is the hospital.

Strange vectors of force and difficult-to-fathom principles swirl, causing unanticipated changes in our environment. Using the laws of physics we can attempt to understand these forces.

NEWTON’S FIRST LAW: Newton’s first law is a statement about inertia. An object at rest stays at rest; an object in motion stays in motion unless compelled to change its state by the action of an external force. Byzantine bureaucracies maintain a significant amount of inertia. The expression “that’s the way we’ve always done it here” best summarizes this philosophy.

NEWTON’S SECOND LAW: Newton’s second law examines the force necessary to cause the acceleration of an object in relationship to its mass (F=MA). A moderate amount of force applied to a golf ball may send that object 250 yards—hook right, but the same force applied to a dump truck causes no significant motion.

In the hospital, we often see large expenditures of energy resulting in little movement. This is generally an administrative phenomenon.

NEWTON’S THIRD LAW: For every action there is an equal and opposite reaction. This is an important law in the hospital. The most recent example is the change in residents’ work hours. A seemingly simple issue, residents working too many hours leads to a legislative action and mandated hours. This specific alteration has had unintended consequences and affected numerous other systems. In the case of resident work hours the potential advantages in hours worked has led to a potentially adverse effect on such things as continuity and learning—and an increase in demand for hospitalists.

No system changes can occur without consequences, and the trick is to identify those changes before they occur. Luckily most systems have significant inertia, and only the greatest forces cause major change. It takes massive energy expenditure (i.e., government regulation or resident review boards) to solicit the forces adequate to overcome escape velocity and cause change.

Some forces can cause change not by their sheer energy level, but by their strategic placement. A small forceful tap may split a diamond. A call by a resident’s spouse can cause the downfall of a program. An off-hand comment by a colleague can lead to a disastrous malpractice settlement.

CENTRIFUGAL PSEUDOFORCE: A pseudoforce occurs when one moves in a uniform circular motion. Most of us have observed this phenomenon. When you run around in circles like the proverbial decapitated fowl, little is accomplished despite a sensation of energy expended.

A related principle is Brownian motion: Particles in a gas or fluid collide against each other and the walls of the container causing a random motion. At times the hospitalist’s day may feel that way: active movement but much of it nondirectional.

COPERNICAN PRINCIPLE: The idea, suggested by Copernicus was that the sun—not the earth—is the center of this universe. This is an essential point for hospitalists to remember. We spend hours rounding on our patients. We must always remember that the physician is not the center of the universe for the hospitalized patient. As the name suggests, when we “round” we are the satellite.

CAUSALITY PRINCIPLE: Cause must follow effect. This is a dangerous theory exemplified by the classic post-hoc, prompter hoc: Because I did something, something happened.

When applied to patients, the causality principle can mislead. The fever went down when the antibiotic was started. Coincidence or causality? We hired a hospitalist and our length of stay went down. Coincidence or causality?

THE THEORY OF RELATIVITY: Einstein’s famous equation E=mc2 represents his theory of relativity. This equation represents the relationship between an object’s mass and its energy. Mass is represented by the formula M=DV where D is density and V=volume.

In a hospital setting we see this formula used in a corollary to Einstein’s, called the Theory of Relatives. When entering a patient’s room, one is often confronted with a large number of relatives, spouses, siblings, and the dreaded estranged children. These situations almost always require an increased amount of energy expenditure in communication, consensus building, and time.

As the absolute number (or volume) of family members increases, concurrent with any increased density on the individual members’ part, energy expenditure increases dramatically. This follows the mass equation closely. In situations where the density of an individual family member increases beyond measurable levels, one can enter a Black Hole scenario (see illustration).

BLACK HOLES: A black hole is a region of space-time from which nothing can escape—even light.

A black hole is a region of such extreme density that all energy is sucked into its gravitational field. Once exposed to a black hole situation, the observer may note expected phenomena, including absence of light, loss of energy, extreme fatigue and malaise, and a sensation of hopelessness. This effect can be seen in committee rooms or on the wards.

The only known remedies for this condition are avoidance or going off-service.

THE GIBBS FREE ENERGY EQUATION: The Gibbs free energy equation, G=H-(TS), is a thermodynamic formula and a measure of the conservation of energy. Simply put, the energy of a system is related to the enthalpy (H) or positive creative energy input minus the product of time and entropy, the natural tendency of systems to fall apart.

This effect can be seen in the creation of hospitalist programs.

A hospitalist program is sometimes created by an energetic entrepreneur responding to a vacuum or potential space. A great design leads to a functional program (G). The hospitalist (H) must continually put energy into maintaining the system, otherwise over time (T) entropy (S) takes hold and the system deteriorates. A hospitalist program can’t rely on its initial successful design to survive.

PARTICLE WAVE DUALITY: Quanta are bundles of energy. We see these basic units in the hospital on a nonsubatomic level.

Our admissions seem to come in waves. Our daily workload seems to come in waves as well. Yet the essential quantum of hospital medicine is the patient. RVUs may be 1.33, and LOS 3.2 days, and FTEs 0.8, but I have yet to see a patient-and-a-half in a room.

CRITICAL MASS: Critical mass is the smallest amount of fissionable material necessary to maintain a nuclear chain reaction at a constant level. The term is also used to denote an amount or level needed for a specific result or new action to occur. Happily the hospitalist movement in America has reached that self-sustaining critical mass.

CONCLUSION: As Sir Isaac Newton sat under the proverbial tree and watched a ripe Granny Smith drop on his noggin, little did he know how profoundly he would affect the world of hospital medicine. What goes up must come down. The patient admitted must be discharged. And the editorial started must eventually finish. TH

Jamie Newman, MD, FACP, is physician editor of The Hopitalist, and senior associate consultant, Hospital Internal Medicine and associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

The forces of our universe are described and measured by a series of laws and equations known collectively as physics. Though we seem far removed from those halcyon (or Halcion) days of college physics, we exist in a universe still ruled by them. In this instance, our world is the hospital.

Strange vectors of force and difficult-to-fathom principles swirl, causing unanticipated changes in our environment. Using the laws of physics we can attempt to understand these forces.

NEWTON’S FIRST LAW: Newton’s first law is a statement about inertia. An object at rest stays at rest; an object in motion stays in motion unless compelled to change its state by the action of an external force. Byzantine bureaucracies maintain a significant amount of inertia. The expression “that’s the way we’ve always done it here” best summarizes this philosophy.

NEWTON’S SECOND LAW: Newton’s second law examines the force necessary to cause the acceleration of an object in relationship to its mass (F=MA). A moderate amount of force applied to a golf ball may send that object 250 yards—hook right, but the same force applied to a dump truck causes no significant motion.

In the hospital, we often see large expenditures of energy resulting in little movement. This is generally an administrative phenomenon.

NEWTON’S THIRD LAW: For every action there is an equal and opposite reaction. This is an important law in the hospital. The most recent example is the change in residents’ work hours. A seemingly simple issue, residents working too many hours leads to a legislative action and mandated hours. This specific alteration has had unintended consequences and affected numerous other systems. In the case of resident work hours the potential advantages in hours worked has led to a potentially adverse effect on such things as continuity and learning—and an increase in demand for hospitalists.

No system changes can occur without consequences, and the trick is to identify those changes before they occur. Luckily most systems have significant inertia, and only the greatest forces cause major change. It takes massive energy expenditure (i.e., government regulation or resident review boards) to solicit the forces adequate to overcome escape velocity and cause change.

Some forces can cause change not by their sheer energy level, but by their strategic placement. A small forceful tap may split a diamond. A call by a resident’s spouse can cause the downfall of a program. An off-hand comment by a colleague can lead to a disastrous malpractice settlement.

CENTRIFUGAL PSEUDOFORCE: A pseudoforce occurs when one moves in a uniform circular motion. Most of us have observed this phenomenon. When you run around in circles like the proverbial decapitated fowl, little is accomplished despite a sensation of energy expended.

A related principle is Brownian motion: Particles in a gas or fluid collide against each other and the walls of the container causing a random motion. At times the hospitalist’s day may feel that way: active movement but much of it nondirectional.

COPERNICAN PRINCIPLE: The idea, suggested by Copernicus was that the sun—not the earth—is the center of this universe. This is an essential point for hospitalists to remember. We spend hours rounding on our patients. We must always remember that the physician is not the center of the universe for the hospitalized patient. As the name suggests, when we “round” we are the satellite.

CAUSALITY PRINCIPLE: Cause must follow effect. This is a dangerous theory exemplified by the classic post-hoc, prompter hoc: Because I did something, something happened.

When applied to patients, the causality principle can mislead. The fever went down when the antibiotic was started. Coincidence or causality? We hired a hospitalist and our length of stay went down. Coincidence or causality?

THE THEORY OF RELATIVITY: Einstein’s famous equation E=mc2 represents his theory of relativity. This equation represents the relationship between an object’s mass and its energy. Mass is represented by the formula M=DV where D is density and V=volume.

In a hospital setting we see this formula used in a corollary to Einstein’s, called the Theory of Relatives. When entering a patient’s room, one is often confronted with a large number of relatives, spouses, siblings, and the dreaded estranged children. These situations almost always require an increased amount of energy expenditure in communication, consensus building, and time.

As the absolute number (or volume) of family members increases, concurrent with any increased density on the individual members’ part, energy expenditure increases dramatically. This follows the mass equation closely. In situations where the density of an individual family member increases beyond measurable levels, one can enter a Black Hole scenario (see illustration).

BLACK HOLES: A black hole is a region of space-time from which nothing can escape—even light.

A black hole is a region of such extreme density that all energy is sucked into its gravitational field. Once exposed to a black hole situation, the observer may note expected phenomena, including absence of light, loss of energy, extreme fatigue and malaise, and a sensation of hopelessness. This effect can be seen in committee rooms or on the wards.

The only known remedies for this condition are avoidance or going off-service.

THE GIBBS FREE ENERGY EQUATION: The Gibbs free energy equation, G=H-(TS), is a thermodynamic formula and a measure of the conservation of energy. Simply put, the energy of a system is related to the enthalpy (H) or positive creative energy input minus the product of time and entropy, the natural tendency of systems to fall apart.

This effect can be seen in the creation of hospitalist programs.

A hospitalist program is sometimes created by an energetic entrepreneur responding to a vacuum or potential space. A great design leads to a functional program (G). The hospitalist (H) must continually put energy into maintaining the system, otherwise over time (T) entropy (S) takes hold and the system deteriorates. A hospitalist program can’t rely on its initial successful design to survive.

PARTICLE WAVE DUALITY: Quanta are bundles of energy. We see these basic units in the hospital on a nonsubatomic level.

Our admissions seem to come in waves. Our daily workload seems to come in waves as well. Yet the essential quantum of hospital medicine is the patient. RVUs may be 1.33, and LOS 3.2 days, and FTEs 0.8, but I have yet to see a patient-and-a-half in a room.

CRITICAL MASS: Critical mass is the smallest amount of fissionable material necessary to maintain a nuclear chain reaction at a constant level. The term is also used to denote an amount or level needed for a specific result or new action to occur. Happily the hospitalist movement in America has reached that self-sustaining critical mass.

CONCLUSION: As Sir Isaac Newton sat under the proverbial tree and watched a ripe Granny Smith drop on his noggin, little did he know how profoundly he would affect the world of hospital medicine. What goes up must come down. The patient admitted must be discharged. And the editorial started must eventually finish. TH

Jamie Newman, MD, FACP, is physician editor of The Hopitalist, and senior associate consultant, Hospital Internal Medicine and associate professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

WORSENING OUTCOMES AND INCREASED RECURRENCE OF CLOSTRIDIUM DIFFICILE AFTER INITIAL TREATMENT WITH METRONIDAZOLE?

Pepin J, Alary ME, Valiquette L, et al. Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada. Clin Infect Dis. 2005;40:1591-1597; and Musher DM, Aslam S, Logan N, et al. Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis. 2005;40:1586-1590.

Information on treatment of colitis caused by Clostridium difficile began to appear in the late 1970s and early 1980s. Since that time there have been a paucity of novel therapies. It has been well-established that both metronidazole and vancomycin can effectively treat this entity. Traditionally metronidazole has been the first-line agent for C. difficile-associated diarrhea (CDAD). The reasons for this are three:

1. Randomized controlled trials have shown vancomycin and metronidazole to be equally efficacious;
2. The cost of oral vancomycin is substantially more than oral metronidazole; and
3. Many experts have cautioned that using vancomycin may contribute to the blooming number of bacteria that are resistant to vancomycin.

Indeed recommendations from the Centers for Disease Control and Prevention’s Healthcare Infection Control Practices Advisory Committee as well as the American Society for Health-System Pharmacists have supported using metronidazole as our initial agent of choice for CDAD (oral vancomycin is actually the only agent that is approved by the Food and Drug Administration for CDAD). Most of our earlier data claim initial response rates to be 88% or better and relapse rates to be somewhere between 5% and 12% when metronidazole is used.

Two new studies have been published raising a red flag on our current standard of practice. Musher, et al., designed a prospective, observational study in which they followed more 200 patients with CDAD that were initially treated with metronidazole. The patient pool came from a Veterans Affairs Medical Center. They all had a positive fecal ELISA for C. difficile toxin and were treated for seven or more days using at least 1.5 grams per day of metronidazole.

Records were reviewed six weeks prior to the diagnosis and then patients were followed for three months after cessation of therapy. Patients were assigned to four outcome groups:

1. Complete responders who did not have recurrence over four months;
2. Refractory-to-treatment where signs and symptoms of CDAD were present for 10 or more days;
3. Recurrence after initial clinical response with signs and symptoms of CDAD and a positive toxin; and
4. Clinical recurrence where there was an initial response but a recurrence of signs and symptoms of CDAD without a positive toxin (either the toxin was not present when tested or the test was not done).

Fifty percent were completely cured. Twenty-two percent were refractory to initial therapy. Twenty-eight percent had a recurrence of CDAD within the 90-day period. The mortality was 27%. This was higher among people who had failed to respond to initial therapy (31% versus 21%; p<.05).

Pepin, et al., retrospectively looked at more than 2,000 CDAD cases from one hospital between 1991 and 2004. To be included the patients needed either a positive toxin, endoscopic evidence of pseudomembranous colitis, or histopathologic evidence of pseudomembranous colitis on a biopsy specimen. Patients received at least 1 gram per day of metronidazole for 10 to 14 days. They were considered to have a recurrence if they had diarrhea within two months of the completion of therapy and either a positive toxin at that time or if the attending physician ordered a second course of antibiotics for C. difficile.

Between 1991 and 2002 the frequency of times that either therapy was changed to vancomycin or vancomycin was added to metronidazole was unchanged (9.6%). During 2003-2004 this more than doubled (25.7%). The number of patients experiencing recurrence over a two-month period comparing data from 1991-2002 to 2003- 2004 was staggering (20.8% versus 47.2%; p<.001). The authors noted that as patients aged the probabilities of recurrence increased.

They also found that a subgroup of patients with a white blood cell count over 20,000 cells/mm3 and an elevated creatinine had a high short-term mortality rate.

Why might we be seeing these results? Several theories exist. Patients are both older and sicker than they have been in the past. Our antibiotic choice is changing with an increase in using agents that provide a more broad-spectrum coverage. Immune responses vary with fewer antitoxin antibodies found in those patients with symptoms and/or recurrence. Metronidazole levels in stool decrease as inflammation and diarrhea resolve; this is not the case with vancomycin where fecal concentrations remain high throughout treatment.

A survey of infectious disease physicians found that they believe antibiotic failure is on the rise in this setting. Before we take this as true, consider the following:

1. We have no universally accepted clinical definition of what constitutes diarrhea for CDAD;
2. Previous studies did not look for recurrence as far out from initial treatment as these two did; and
3. These studies do not have the design to support arguments powerful enough to change our paradigm just yet.

The editorial comment acknowledged the Pepin, et al., report that patients with a high white blood cell count and worsening renal function are those that we should be particularly concerned about. The authors write that if the patient’s white blood cell count is increasing while on therapy that he changes his antibiotic choice to vancomycin. In addition, if someone has either ileus or fulminant CDAD he will use multiple antibiotics and consult the surgeons. At this time we have other agents being studied for CDAD, such as tinidazole. We now need a larger randomized prospective trial to better explore treatment outcomes in CDAD.

HYPERTONIC SALINE SOLUTION TO TREAT REFRACTORY CONGESTIVE HEART FAILURE

Paterna S, Di Pasquale P, Parrinello G, et al. Changes in brain natriuretic peptide levels and bioelectrical impedance measurements after treatment with high-dose furosemide and hypertonic saline solution versus high-dose furosemide alone in refractory congestive heart failure. J Am Coll Cardiol. 2005;45:1997–2003.

CHF continues to increase in prevalence and incidence, despite our advances with therapies using ACE inhibitors, beta-blockers, and aldosterone antagonists. Refractory CHF accounts for a considerable portion of admissions to hospitalists’ services. Loop diuretics are part of the standard of arsenal we employ in these patients. Unfortunately, many patients fail to respond to initial diuretic doses. In this situation we might begin a constant infusion of diuretic or recruit diuretics from other classes in hope of synergism. Another typical approach in treating advanced CHF is restriction of sodium intake.

Paterna, et al., previously published four studies using small volume hypertonic saline solution and high-dose furosemide in refractory CHF, in which they demonstrated the safety and tolerability of these measures. They now present the first randomized double-blinded trial using this intervention. Ninety-four patients were included with NYHA functional class IV CHF on standard medical therapy and high doses of diuretics for at least two weeks. They had to have a left ventricular ejection fraction of <35%, serum creatinine <2 mg/dL, reduced urinary volume (<500 mL/24 h), and a low natriuresis (<60 mEq/24 h). They could not be taking NSAIDs.

Patients received either intravenous furosemide (500 to 1000 mg) plus hypertonic saline solution bid or the IV furosemide bid alone. Treatment lasted four to six days. Body weights were followed. Brain natriuretic peptide plasma levels were measured on hospital days one and six, as well as 30 days after discharge.

The group receiving hypertonic saline solution had brow-raising results. They had a significant increase in daily diuresis and natriuresis (p<0.05), a difference in brain natriuretic peptide levels on days six and 30, a reduction in their length of stay, and a decrease in their hospital readmission rate.

This is a provocative study. At this time the mechanism responsible for the results is unclear. Paterna, et al., offer multiple explanations. One possibility is through the osmotic action of hypertonic saline solution. It may hasten the mobilization of extravascular fluid into the intravascular space and then this volume is quickly excreted. Also, hypertonic saline solution may increase renal blood flow and perfusion alternating the handling of sodium and natriuresis while also allowing the concentration of furosemide in the loop of Henle to attain a more desirable level.

Should these results hold true in other investigations and the inclusion criteria loosen (measuring patients urine volume and sodium concentration for 24 hours prior to admission may not be easy or practical) then we might have a very inexpensive new method for treating refractory CHF.

PERIOPERATIVE BETA-BLOCKERS: HELPFUL OR HARMFUL FOR MAJOR NONCARDIAC SURGERY?

Lindenauer P, Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353:349–361.

Among the most common reasons that hospitalists are consulted is the “perioperative evaluation.” This is with good reason because 50,000 patients each year have a perioperative myocardial infarction. A statement by the Agency for Health Care Research and Quality proclaims that we have “clear opportunities for safety improvement” in regard to using beta-blockers for patients with intermediate and high risk for perioperative cardiovascular complications. The American Heart Association and the American College of Cardiology recommend using these medications in patients with either risk factors for or known coronary artery disease when undergoing high-risk surgeries. Despite all of this the efficacy of the class has not been proven by large randomized clinical studies.

Using a large national registry of more than 300 U.S. hospitals, Lindenauer, et al., conducted a large observational study evaluating beta-blockade in the perioperative period in patients undergoing major noncardiac surgery. Looking at more than 700,000 patients, they found that 85% had no recorded contraindication to beta-blockers. Only 18% of eligible patients received beta-blockers (n=122, 338).

Patients were considered to have had a beta-blocker for prophylaxis if it was given within the first 48 hours of their hospitalization, though this may or may not have been the intended use (this information was not provided by the registry data base). Only in-hospital mortality was evaluated as postdischarge information was not available. All patients had a revised cardiac risk index configured. This index places risk on perioperative cardiac events by looking at the nature of the surgery as well as whether or not a history of congestive heart failure, ischemic heart disease, perioperative treatment with insulin, an elevated preoperative creatinine, and cerebrovascular disease are present. An increasing score means that major perioperative complications become more likely (scores range from 0–5).

Considering all patients, there was no risk reduction of in-hospital death for those receiving beta-blockers. If the revised cardiac risk index score was 0 or 1, the patients had an increase in the risk of death (43% and 13%, respectively). However, those patients whose scores were 2, 3, or 4 or higher had a reduction in the risk of death (from 10% to 43% as their score increased).

How are we to account for these results? In the high-risk patients we see benefit in treatment with beta-blockers. We suspect this drug class improves coronary filling time during diastole and/or prevents dangerous arrhythmias. In patients at low and intermediate risk, the results may be surprising. The study group did not have patient charts available. It is possible that these patients were given betablockers not for prophylaxis but in response to a postoperative ischemic event or infarction. If this misclassification took place, then the effectiveness of beta-blockers is underestimated and the suggestion that these drugs are harmful in this situation would be erroneous.

Given the data gleaned from this study and considering previous publications, we are justified—even obligated—in using betablockers in high-risk patients, without contraindications, who undergo major noncardiac surgery. Before using these drugs in patients at low or intermediate risk we need more information. Two large ongoing randomized trials (POISE and DECREASE–IV) should bring clarity to this issue. We expect results from these in the next four years.

A NEW CLINICAL ENTITY: THE HEPATOADRENAL SYNDROME

Marik PE, Gayowski T, Starzl TE, et al. The hepatoadrenal syndrome: a common yet unrecognized clinical condition. Crit Care Med. 2005;33:1254-1259.

It is not uncommon to see the temporary dysfunction of the hypothalamic-pituitary-adrenal axis while someone is critically ill. Many physicians who suspect this condition attempt to make a diagnosis using either a random total cortisol level or perform a cosyntropin stimulation test. End-stage liver disease and sepsis share some elements of their pathophysiology, such as endotoxemia and increased levels of mediators that influence inflammation.

A liver transplant intensive care unit has produced data on what they have coined the “hepatoadrenal syndrome.” Due to emerging evidence that severe liver disease is associated with adrenal insufficiency, this liver transplant intensive care unit began routinely testing all patients admitted to their unit for this condition. They presented their findings for 340 patients. This review will focus only on those patients with chronic liver failure and fulminant hepatic failure because transplant patients are often cared for by a multidisciplinary team. Patients were labeled as having adrenal insufficiency if the random total cortisol level was <20 micrograms (mcg)/dL in patients who were “highly stressed” (i.e., hypotension, respiratory failure). In all other patients a random total cortisol level of <15 mcg/dL or a 30-minute level <20 mcg/dL post-low-dose (1 mcg) cosyntropin established the diagnosis. Lipid profiles were also obtained from each patient. Those receiving glucocorticoids were excluded. It was left to the discretion of the treating physician whether or not to treat patients with steroids.

Eight patients (33%) with fulminant hepatic failure and 97 patients (66%) with chronic liver disease met their criteria for adrenal insufficiency. Of the patients with adrenal insufficiency the mortality rate was 46% for those not treated with glucocorticoids compared with 26% for those receiving glucocorticoid therapy. The HDL level was the only variable predictive of adrenal insufficiency (p<.0001).

The association between HDL levels and cortisol is as follows: The adrenal glands do not store cortisol. Cholesterol is a precursor for the synthesis of steroids—80% of cortisol arises from it. The lipoprotein of choice to use as substrate in steroid production is HDL. Because a major protein component of HDL is synthesized by the liver, those with liver disease have low levels of serum HDL.

Recently our current method of diagnosing adrenal insufficiency during acute illness has been challenged in the literature. Measuring free cortisol rather than total cortisol has been suggested as proteins that bind cortisol decrease in this setting while free cortisol levels actually rise. Similar to the picture we see in sepsis, there are low levels of these same proteins in liver disease.

At this time testing for free cortisol is not widely available nor do we have good information on what an “appropriate” free cortisol level should be during acute illness. Therefore, given the frequency in which Marik, et al., report encountering this condition and the effect that treatment had on mortality it seems as though this is a diagnosis worth consideration.

TREATMENT OPTIONS FOR ATRIAL FIBRILLATION

Wazni OM, Marrouche NF, Martin DO, et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation. JAMA. 2005;293(21):2634-2640.

Atrial fibrillation affects millions of people. This diagnosis has a significant mortality associated with it, causes strokes, and influences quality of life. Therapy has been less than satisfying. Both rate control and rhythm control have multiple potential adverse consequences. Pulmonary vein isolation is performed in the electrophysiology laboratory using an ablation catheter. The goal of this procedure is to completely disconnect the electrical activity between the pulmonary vein antrum and the left atrium. This is a potentially curable procedure for atrial fibrillation.

In a multicenter prospective randomized pilot study Wazni, et al., studied 70 patients with highly symptomatic atrial fibrillation. Patients were between 18 and 75 years old. They could not have undergone ablation in the past, had a history of open-heart surgery, been previously treated with antiarrhythmic drugs, or had a contraindication to long-term anticoagulation. Patients were randomized to antiarrhythmic therapy or pulmonary vein isolation. Those receiving medical treatment were given flecainide, propafenone, or sotalol. Amiodarone was used for patients who had failed at least two or more of these medications. Drugs were titrated to the maximum tolerable doses. The other arm of the group underwent pulmonary vein isolation. This group also received anticoagulation with warfarin beginning the day of the procedure, and this was continued for at least three months. Anticoagulation was extended beyond this time if atrial fibrillation recurred or the pulmonary vein was narrowed by 50% or more (as seen on a three-month post-procedure CT scan). Follow-up was at least one year. A loop event-recorder was worn for one month by all patients and event recorders were used for patients who were symptomatic beyond the first three months of therapy initiation.

After one year, symptomatic atrial fibrillation recurred in 63% of the antiarrhythmic group versus 13% in the pulmonary vein isolation group (p<.001). Fifty-four percent of those medically treated were hospitalized versus 9% of pulmonary vein isolation patients (p<.001). There were no thromboembolic events in either group. Bleeding rates were similar in both groups. For those who underwent pulmonary vein isolation 3% had mild pulmonary vein stenosis and 3% had moderate stenosis (all of which were asymptomatic). Five of the eight measures of quality of life were significantly improved in the pulmonary vein isolation arm versus those receiving antiarrhythmic drugs.

Recently data from multiple trials such as AFFIRM and RACE confirm that rhythm control does not confer significant benefits over rate-control for atrial fibrillation. In fact rate control seems to be a more attractive approach to many patients given the side-effect profile of the antiarrhythmia medications. This study was initiated prior to the release of the information gained from RACE and AFFIRM, thus no rate-control arm was included. This trial also differed from previous studies by using a younger population that was highly symptomatic in comparison with other recent studies using older patients who had recurrent persistent atrial fibrillation.

The biggest concerns about pulmonary vein isolation are the complication rates (death in 0.05% and stroke in 0.28%). We also don’t know if this procedure will translate into long-term cures. Until we have larger studies this should not be a first-line modality for treating all patients. Quite often we find patients where neither rate nor rhythm control is a particularly attractive option, especially in regard to long-term anticoagulation. Pulmonary vein isolation provides us with a new viable option for these people as well as something to consider for carefully selected highly symptomatic patients. TH

WORSENING OUTCOMES AND INCREASED RECURRENCE OF CLOSTRIDIUM DIFFICILE AFTER INITIAL TREATMENT WITH METRONIDAZOLE?

Pepin J, Alary ME, Valiquette L, et al. Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada. Clin Infect Dis. 2005;40:1591-1597; and Musher DM, Aslam S, Logan N, et al. Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis. 2005;40:1586-1590.

Information on treatment of colitis caused by Clostridium difficile began to appear in the late 1970s and early 1980s. Since that time there have been a paucity of novel therapies. It has been well-established that both metronidazole and vancomycin can effectively treat this entity. Traditionally metronidazole has been the first-line agent for C. difficile-associated diarrhea (CDAD). The reasons for this are three:

1. Randomized controlled trials have shown vancomycin and metronidazole to be equally efficacious;
2. The cost of oral vancomycin is substantially more than oral metronidazole; and
3. Many experts have cautioned that using vancomycin may contribute to the blooming number of bacteria that are resistant to vancomycin.

Indeed recommendations from the Centers for Disease Control and Prevention’s Healthcare Infection Control Practices Advisory Committee as well as the American Society for Health-System Pharmacists have supported using metronidazole as our initial agent of choice for CDAD (oral vancomycin is actually the only agent that is approved by the Food and Drug Administration for CDAD). Most of our earlier data claim initial response rates to be 88% or better and relapse rates to be somewhere between 5% and 12% when metronidazole is used.

Two new studies have been published raising a red flag on our current standard of practice. Musher, et al., designed a prospective, observational study in which they followed more 200 patients with CDAD that were initially treated with metronidazole. The patient pool came from a Veterans Affairs Medical Center. They all had a positive fecal ELISA for C. difficile toxin and were treated for seven or more days using at least 1.5 grams per day of metronidazole.

Records were reviewed six weeks prior to the diagnosis and then patients were followed for three months after cessation of therapy. Patients were assigned to four outcome groups:

1. Complete responders who did not have recurrence over four months;
2. Refractory-to-treatment where signs and symptoms of CDAD were present for 10 or more days;
3. Recurrence after initial clinical response with signs and symptoms of CDAD and a positive toxin; and
4. Clinical recurrence where there was an initial response but a recurrence of signs and symptoms of CDAD without a positive toxin (either the toxin was not present when tested or the test was not done).

Fifty percent were completely cured. Twenty-two percent were refractory to initial therapy. Twenty-eight percent had a recurrence of CDAD within the 90-day period. The mortality was 27%. This was higher among people who had failed to respond to initial therapy (31% versus 21%; p<.05).

Pepin, et al., retrospectively looked at more than 2,000 CDAD cases from one hospital between 1991 and 2004. To be included the patients needed either a positive toxin, endoscopic evidence of pseudomembranous colitis, or histopathologic evidence of pseudomembranous colitis on a biopsy specimen. Patients received at least 1 gram per day of metronidazole for 10 to 14 days. They were considered to have a recurrence if they had diarrhea within two months of the completion of therapy and either a positive toxin at that time or if the attending physician ordered a second course of antibiotics for C. difficile.

Between 1991 and 2002 the frequency of times that either therapy was changed to vancomycin or vancomycin was added to metronidazole was unchanged (9.6%). During 2003-2004 this more than doubled (25.7%). The number of patients experiencing recurrence over a two-month period comparing data from 1991-2002 to 2003- 2004 was staggering (20.8% versus 47.2%; p<.001). The authors noted that as patients aged the probabilities of recurrence increased.

They also found that a subgroup of patients with a white blood cell count over 20,000 cells/mm3 and an elevated creatinine had a high short-term mortality rate.

Why might we be seeing these results? Several theories exist. Patients are both older and sicker than they have been in the past. Our antibiotic choice is changing with an increase in using agents that provide a more broad-spectrum coverage. Immune responses vary with fewer antitoxin antibodies found in those patients with symptoms and/or recurrence. Metronidazole levels in stool decrease as inflammation and diarrhea resolve; this is not the case with vancomycin where fecal concentrations remain high throughout treatment.

A survey of infectious disease physicians found that they believe antibiotic failure is on the rise in this setting. Before we take this as true, consider the following:

1. We have no universally accepted clinical definition of what constitutes diarrhea for CDAD;
2. Previous studies did not look for recurrence as far out from initial treatment as these two did; and
3. These studies do not have the design to support arguments powerful enough to change our paradigm just yet.

The editorial comment acknowledged the Pepin, et al., report that patients with a high white blood cell count and worsening renal function are those that we should be particularly concerned about. The authors write that if the patient’s white blood cell count is increasing while on therapy that he changes his antibiotic choice to vancomycin. In addition, if someone has either ileus or fulminant CDAD he will use multiple antibiotics and consult the surgeons. At this time we have other agents being studied for CDAD, such as tinidazole. We now need a larger randomized prospective trial to better explore treatment outcomes in CDAD.

HYPERTONIC SALINE SOLUTION TO TREAT REFRACTORY CONGESTIVE HEART FAILURE

Paterna S, Di Pasquale P, Parrinello G, et al. Changes in brain natriuretic peptide levels and bioelectrical impedance measurements after treatment with high-dose furosemide and hypertonic saline solution versus high-dose furosemide alone in refractory congestive heart failure. J Am Coll Cardiol. 2005;45:1997–2003.

CHF continues to increase in prevalence and incidence, despite our advances with therapies using ACE inhibitors, beta-blockers, and aldosterone antagonists. Refractory CHF accounts for a considerable portion of admissions to hospitalists’ services. Loop diuretics are part of the standard of arsenal we employ in these patients. Unfortunately, many patients fail to respond to initial diuretic doses. In this situation we might begin a constant infusion of diuretic or recruit diuretics from other classes in hope of synergism. Another typical approach in treating advanced CHF is restriction of sodium intake.

Paterna, et al., previously published four studies using small volume hypertonic saline solution and high-dose furosemide in refractory CHF, in which they demonstrated the safety and tolerability of these measures. They now present the first randomized double-blinded trial using this intervention. Ninety-four patients were included with NYHA functional class IV CHF on standard medical therapy and high doses of diuretics for at least two weeks. They had to have a left ventricular ejection fraction of <35%, serum creatinine <2 mg/dL, reduced urinary volume (<500 mL/24 h), and a low natriuresis (<60 mEq/24 h). They could not be taking NSAIDs.

Patients received either intravenous furosemide (500 to 1000 mg) plus hypertonic saline solution bid or the IV furosemide bid alone. Treatment lasted four to six days. Body weights were followed. Brain natriuretic peptide plasma levels were measured on hospital days one and six, as well as 30 days after discharge.

The group receiving hypertonic saline solution had brow-raising results. They had a significant increase in daily diuresis and natriuresis (p<0.05), a difference in brain natriuretic peptide levels on days six and 30, a reduction in their length of stay, and a decrease in their hospital readmission rate.

This is a provocative study. At this time the mechanism responsible for the results is unclear. Paterna, et al., offer multiple explanations. One possibility is through the osmotic action of hypertonic saline solution. It may hasten the mobilization of extravascular fluid into the intravascular space and then this volume is quickly excreted. Also, hypertonic saline solution may increase renal blood flow and perfusion alternating the handling of sodium and natriuresis while also allowing the concentration of furosemide in the loop of Henle to attain a more desirable level.

Should these results hold true in other investigations and the inclusion criteria loosen (measuring patients urine volume and sodium concentration for 24 hours prior to admission may not be easy or practical) then we might have a very inexpensive new method for treating refractory CHF.

PERIOPERATIVE BETA-BLOCKERS: HELPFUL OR HARMFUL FOR MAJOR NONCARDIAC SURGERY?

Lindenauer P, Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353:349–361.

Among the most common reasons that hospitalists are consulted is the “perioperative evaluation.” This is with good reason because 50,000 patients each year have a perioperative myocardial infarction. A statement by the Agency for Health Care Research and Quality proclaims that we have “clear opportunities for safety improvement” in regard to using beta-blockers for patients with intermediate and high risk for perioperative cardiovascular complications. The American Heart Association and the American College of Cardiology recommend using these medications in patients with either risk factors for or known coronary artery disease when undergoing high-risk surgeries. Despite all of this the efficacy of the class has not been proven by large randomized clinical studies.

Using a large national registry of more than 300 U.S. hospitals, Lindenauer, et al., conducted a large observational study evaluating beta-blockade in the perioperative period in patients undergoing major noncardiac surgery. Looking at more than 700,000 patients, they found that 85% had no recorded contraindication to beta-blockers. Only 18% of eligible patients received beta-blockers (n=122, 338).

Patients were considered to have had a beta-blocker for prophylaxis if it was given within the first 48 hours of their hospitalization, though this may or may not have been the intended use (this information was not provided by the registry data base). Only in-hospital mortality was evaluated as postdischarge information was not available. All patients had a revised cardiac risk index configured. This index places risk on perioperative cardiac events by looking at the nature of the surgery as well as whether or not a history of congestive heart failure, ischemic heart disease, perioperative treatment with insulin, an elevated preoperative creatinine, and cerebrovascular disease are present. An increasing score means that major perioperative complications become more likely (scores range from 0–5).

Considering all patients, there was no risk reduction of in-hospital death for those receiving beta-blockers. If the revised cardiac risk index score was 0 or 1, the patients had an increase in the risk of death (43% and 13%, respectively). However, those patients whose scores were 2, 3, or 4 or higher had a reduction in the risk of death (from 10% to 43% as their score increased).

How are we to account for these results? In the high-risk patients we see benefit in treatment with beta-blockers. We suspect this drug class improves coronary filling time during diastole and/or prevents dangerous arrhythmias. In patients at low and intermediate risk, the results may be surprising. The study group did not have patient charts available. It is possible that these patients were given betablockers not for prophylaxis but in response to a postoperative ischemic event or infarction. If this misclassification took place, then the effectiveness of beta-blockers is underestimated and the suggestion that these drugs are harmful in this situation would be erroneous.

Given the data gleaned from this study and considering previous publications, we are justified—even obligated—in using betablockers in high-risk patients, without contraindications, who undergo major noncardiac surgery. Before using these drugs in patients at low or intermediate risk we need more information. Two large ongoing randomized trials (POISE and DECREASE–IV) should bring clarity to this issue. We expect results from these in the next four years.

A NEW CLINICAL ENTITY: THE HEPATOADRENAL SYNDROME

Marik PE, Gayowski T, Starzl TE, et al. The hepatoadrenal syndrome: a common yet unrecognized clinical condition. Crit Care Med. 2005;33:1254-1259.

It is not uncommon to see the temporary dysfunction of the hypothalamic-pituitary-adrenal axis while someone is critically ill. Many physicians who suspect this condition attempt to make a diagnosis using either a random total cortisol level or perform a cosyntropin stimulation test. End-stage liver disease and sepsis share some elements of their pathophysiology, such as endotoxemia and increased levels of mediators that influence inflammation.

A liver transplant intensive care unit has produced data on what they have coined the “hepatoadrenal syndrome.” Due to emerging evidence that severe liver disease is associated with adrenal insufficiency, this liver transplant intensive care unit began routinely testing all patients admitted to their unit for this condition. They presented their findings for 340 patients. This review will focus only on those patients with chronic liver failure and fulminant hepatic failure because transplant patients are often cared for by a multidisciplinary team. Patients were labeled as having adrenal insufficiency if the random total cortisol level was <20 micrograms (mcg)/dL in patients who were “highly stressed” (i.e., hypotension, respiratory failure). In all other patients a random total cortisol level of <15 mcg/dL or a 30-minute level <20 mcg/dL post-low-dose (1 mcg) cosyntropin established the diagnosis. Lipid profiles were also obtained from each patient. Those receiving glucocorticoids were excluded. It was left to the discretion of the treating physician whether or not to treat patients with steroids.

Eight patients (33%) with fulminant hepatic failure and 97 patients (66%) with chronic liver disease met their criteria for adrenal insufficiency. Of the patients with adrenal insufficiency the mortality rate was 46% for those not treated with glucocorticoids compared with 26% for those receiving glucocorticoid therapy. The HDL level was the only variable predictive of adrenal insufficiency (p<.0001).

The association between HDL levels and cortisol is as follows: The adrenal glands do not store cortisol. Cholesterol is a precursor for the synthesis of steroids—80% of cortisol arises from it. The lipoprotein of choice to use as substrate in steroid production is HDL. Because a major protein component of HDL is synthesized by the liver, those with liver disease have low levels of serum HDL.

Recently our current method of diagnosing adrenal insufficiency during acute illness has been challenged in the literature. Measuring free cortisol rather than total cortisol has been suggested as proteins that bind cortisol decrease in this setting while free cortisol levels actually rise. Similar to the picture we see in sepsis, there are low levels of these same proteins in liver disease.

At this time testing for free cortisol is not widely available nor do we have good information on what an “appropriate” free cortisol level should be during acute illness. Therefore, given the frequency in which Marik, et al., report encountering this condition and the effect that treatment had on mortality it seems as though this is a diagnosis worth consideration.

TREATMENT OPTIONS FOR ATRIAL FIBRILLATION

Wazni OM, Marrouche NF, Martin DO, et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation. JAMA. 2005;293(21):2634-2640.

Atrial fibrillation affects millions of people. This diagnosis has a significant mortality associated with it, causes strokes, and influences quality of life. Therapy has been less than satisfying. Both rate control and rhythm control have multiple potential adverse consequences. Pulmonary vein isolation is performed in the electrophysiology laboratory using an ablation catheter. The goal of this procedure is to completely disconnect the electrical activity between the pulmonary vein antrum and the left atrium. This is a potentially curable procedure for atrial fibrillation.

In a multicenter prospective randomized pilot study Wazni, et al., studied 70 patients with highly symptomatic atrial fibrillation. Patients were between 18 and 75 years old. They could not have undergone ablation in the past, had a history of open-heart surgery, been previously treated with antiarrhythmic drugs, or had a contraindication to long-term anticoagulation. Patients were randomized to antiarrhythmic therapy or pulmonary vein isolation. Those receiving medical treatment were given flecainide, propafenone, or sotalol. Amiodarone was used for patients who had failed at least two or more of these medications. Drugs were titrated to the maximum tolerable doses. The other arm of the group underwent pulmonary vein isolation. This group also received anticoagulation with warfarin beginning the day of the procedure, and this was continued for at least three months. Anticoagulation was extended beyond this time if atrial fibrillation recurred or the pulmonary vein was narrowed by 50% or more (as seen on a three-month post-procedure CT scan). Follow-up was at least one year. A loop event-recorder was worn for one month by all patients and event recorders were used for patients who were symptomatic beyond the first three months of therapy initiation.

After one year, symptomatic atrial fibrillation recurred in 63% of the antiarrhythmic group versus 13% in the pulmonary vein isolation group (p<.001). Fifty-four percent of those medically treated were hospitalized versus 9% of pulmonary vein isolation patients (p<.001). There were no thromboembolic events in either group. Bleeding rates were similar in both groups. For those who underwent pulmonary vein isolation 3% had mild pulmonary vein stenosis and 3% had moderate stenosis (all of which were asymptomatic). Five of the eight measures of quality of life were significantly improved in the pulmonary vein isolation arm versus those receiving antiarrhythmic drugs.

Recently data from multiple trials such as AFFIRM and RACE confirm that rhythm control does not confer significant benefits over rate-control for atrial fibrillation. In fact rate control seems to be a more attractive approach to many patients given the side-effect profile of the antiarrhythmia medications. This study was initiated prior to the release of the information gained from RACE and AFFIRM, thus no rate-control arm was included. This trial also differed from previous studies by using a younger population that was highly symptomatic in comparison with other recent studies using older patients who had recurrent persistent atrial fibrillation.

The biggest concerns about pulmonary vein isolation are the complication rates (death in 0.05% and stroke in 0.28%). We also don’t know if this procedure will translate into long-term cures. Until we have larger studies this should not be a first-line modality for treating all patients. Quite often we find patients where neither rate nor rhythm control is a particularly attractive option, especially in regard to long-term anticoagulation. Pulmonary vein isolation provides us with a new viable option for these people as well as something to consider for carefully selected highly symptomatic patients. TH

WORSENING OUTCOMES AND INCREASED RECURRENCE OF CLOSTRIDIUM DIFFICILE AFTER INITIAL TREATMENT WITH METRONIDAZOLE?

Pepin J, Alary ME, Valiquette L, et al. Increasing risk of relapse after treatment of Clostridium difficile colitis in Quebec, Canada. Clin Infect Dis. 2005;40:1591-1597; and Musher DM, Aslam S, Logan N, et al. Relatively poor outcome after treatment of Clostridium difficile colitis with metronidazole. Clin Infect Dis. 2005;40:1586-1590.

Information on treatment of colitis caused by Clostridium difficile began to appear in the late 1970s and early 1980s. Since that time there have been a paucity of novel therapies. It has been well-established that both metronidazole and vancomycin can effectively treat this entity. Traditionally metronidazole has been the first-line agent for C. difficile-associated diarrhea (CDAD). The reasons for this are three:

1. Randomized controlled trials have shown vancomycin and metronidazole to be equally efficacious;
2. The cost of oral vancomycin is substantially more than oral metronidazole; and
3. Many experts have cautioned that using vancomycin may contribute to the blooming number of bacteria that are resistant to vancomycin.

Indeed recommendations from the Centers for Disease Control and Prevention’s Healthcare Infection Control Practices Advisory Committee as well as the American Society for Health-System Pharmacists have supported using metronidazole as our initial agent of choice for CDAD (oral vancomycin is actually the only agent that is approved by the Food and Drug Administration for CDAD). Most of our earlier data claim initial response rates to be 88% or better and relapse rates to be somewhere between 5% and 12% when metronidazole is used.

Two new studies have been published raising a red flag on our current standard of practice. Musher, et al., designed a prospective, observational study in which they followed more 200 patients with CDAD that were initially treated with metronidazole. The patient pool came from a Veterans Affairs Medical Center. They all had a positive fecal ELISA for C. difficile toxin and were treated for seven or more days using at least 1.5 grams per day of metronidazole.

Records were reviewed six weeks prior to the diagnosis and then patients were followed for three months after cessation of therapy. Patients were assigned to four outcome groups:

1. Complete responders who did not have recurrence over four months;
2. Refractory-to-treatment where signs and symptoms of CDAD were present for 10 or more days;
3. Recurrence after initial clinical response with signs and symptoms of CDAD and a positive toxin; and
4. Clinical recurrence where there was an initial response but a recurrence of signs and symptoms of CDAD without a positive toxin (either the toxin was not present when tested or the test was not done).

Fifty percent were completely cured. Twenty-two percent were refractory to initial therapy. Twenty-eight percent had a recurrence of CDAD within the 90-day period. The mortality was 27%. This was higher among people who had failed to respond to initial therapy (31% versus 21%; p<.05).

Pepin, et al., retrospectively looked at more than 2,000 CDAD cases from one hospital between 1991 and 2004. To be included the patients needed either a positive toxin, endoscopic evidence of pseudomembranous colitis, or histopathologic evidence of pseudomembranous colitis on a biopsy specimen. Patients received at least 1 gram per day of metronidazole for 10 to 14 days. They were considered to have a recurrence if they had diarrhea within two months of the completion of therapy and either a positive toxin at that time or if the attending physician ordered a second course of antibiotics for C. difficile.

Between 1991 and 2002 the frequency of times that either therapy was changed to vancomycin or vancomycin was added to metronidazole was unchanged (9.6%). During 2003-2004 this more than doubled (25.7%). The number of patients experiencing recurrence over a two-month period comparing data from 1991-2002 to 2003- 2004 was staggering (20.8% versus 47.2%; p<.001). The authors noted that as patients aged the probabilities of recurrence increased.

They also found that a subgroup of patients with a white blood cell count over 20,000 cells/mm3 and an elevated creatinine had a high short-term mortality rate.

Why might we be seeing these results? Several theories exist. Patients are both older and sicker than they have been in the past. Our antibiotic choice is changing with an increase in using agents that provide a more broad-spectrum coverage. Immune responses vary with fewer antitoxin antibodies found in those patients with symptoms and/or recurrence. Metronidazole levels in stool decrease as inflammation and diarrhea resolve; this is not the case with vancomycin where fecal concentrations remain high throughout treatment.

A survey of infectious disease physicians found that they believe antibiotic failure is on the rise in this setting. Before we take this as true, consider the following:

1. We have no universally accepted clinical definition of what constitutes diarrhea for CDAD;
2. Previous studies did not look for recurrence as far out from initial treatment as these two did; and
3. These studies do not have the design to support arguments powerful enough to change our paradigm just yet.

The editorial comment acknowledged the Pepin, et al., report that patients with a high white blood cell count and worsening renal function are those that we should be particularly concerned about. The authors write that if the patient’s white blood cell count is increasing while on therapy that he changes his antibiotic choice to vancomycin. In addition, if someone has either ileus or fulminant CDAD he will use multiple antibiotics and consult the surgeons. At this time we have other agents being studied for CDAD, such as tinidazole. We now need a larger randomized prospective trial to better explore treatment outcomes in CDAD.

HYPERTONIC SALINE SOLUTION TO TREAT REFRACTORY CONGESTIVE HEART FAILURE

Paterna S, Di Pasquale P, Parrinello G, et al. Changes in brain natriuretic peptide levels and bioelectrical impedance measurements after treatment with high-dose furosemide and hypertonic saline solution versus high-dose furosemide alone in refractory congestive heart failure. J Am Coll Cardiol. 2005;45:1997–2003.

CHF continues to increase in prevalence and incidence, despite our advances with therapies using ACE inhibitors, beta-blockers, and aldosterone antagonists. Refractory CHF accounts for a considerable portion of admissions to hospitalists’ services. Loop diuretics are part of the standard of arsenal we employ in these patients. Unfortunately, many patients fail to respond to initial diuretic doses. In this situation we might begin a constant infusion of diuretic or recruit diuretics from other classes in hope of synergism. Another typical approach in treating advanced CHF is restriction of sodium intake.

Paterna, et al., previously published four studies using small volume hypertonic saline solution and high-dose furosemide in refractory CHF, in which they demonstrated the safety and tolerability of these measures. They now present the first randomized double-blinded trial using this intervention. Ninety-four patients were included with NYHA functional class IV CHF on standard medical therapy and high doses of diuretics for at least two weeks. They had to have a left ventricular ejection fraction of <35%, serum creatinine <2 mg/dL, reduced urinary volume (<500 mL/24 h), and a low natriuresis (<60 mEq/24 h). They could not be taking NSAIDs.

Patients received either intravenous furosemide (500 to 1000 mg) plus hypertonic saline solution bid or the IV furosemide bid alone. Treatment lasted four to six days. Body weights were followed. Brain natriuretic peptide plasma levels were measured on hospital days one and six, as well as 30 days after discharge.

The group receiving hypertonic saline solution had brow-raising results. They had a significant increase in daily diuresis and natriuresis (p<0.05), a difference in brain natriuretic peptide levels on days six and 30, a reduction in their length of stay, and a decrease in their hospital readmission rate.

This is a provocative study. At this time the mechanism responsible for the results is unclear. Paterna, et al., offer multiple explanations. One possibility is through the osmotic action of hypertonic saline solution. It may hasten the mobilization of extravascular fluid into the intravascular space and then this volume is quickly excreted. Also, hypertonic saline solution may increase renal blood flow and perfusion alternating the handling of sodium and natriuresis while also allowing the concentration of furosemide in the loop of Henle to attain a more desirable level.

Should these results hold true in other investigations and the inclusion criteria loosen (measuring patients urine volume and sodium concentration for 24 hours prior to admission may not be easy or practical) then we might have a very inexpensive new method for treating refractory CHF.

PERIOPERATIVE BETA-BLOCKERS: HELPFUL OR HARMFUL FOR MAJOR NONCARDIAC SURGERY?

Lindenauer P, Pekow P, Wang K, et al. Perioperative beta-blocker therapy and mortality after major noncardiac surgery. N Engl J Med. 2005;353:349–361.

Among the most common reasons that hospitalists are consulted is the “perioperative evaluation.” This is with good reason because 50,000 patients each year have a perioperative myocardial infarction. A statement by the Agency for Health Care Research and Quality proclaims that we have “clear opportunities for safety improvement” in regard to using beta-blockers for patients with intermediate and high risk for perioperative cardiovascular complications. The American Heart Association and the American College of Cardiology recommend using these medications in patients with either risk factors for or known coronary artery disease when undergoing high-risk surgeries. Despite all of this the efficacy of the class has not been proven by large randomized clinical studies.

Using a large national registry of more than 300 U.S. hospitals, Lindenauer, et al., conducted a large observational study evaluating beta-blockade in the perioperative period in patients undergoing major noncardiac surgery. Looking at more than 700,000 patients, they found that 85% had no recorded contraindication to beta-blockers. Only 18% of eligible patients received beta-blockers (n=122, 338).

Patients were considered to have had a beta-blocker for prophylaxis if it was given within the first 48 hours of their hospitalization, though this may or may not have been the intended use (this information was not provided by the registry data base). Only in-hospital mortality was evaluated as postdischarge information was not available. All patients had a revised cardiac risk index configured. This index places risk on perioperative cardiac events by looking at the nature of the surgery as well as whether or not a history of congestive heart failure, ischemic heart disease, perioperative treatment with insulin, an elevated preoperative creatinine, and cerebrovascular disease are present. An increasing score means that major perioperative complications become more likely (scores range from 0–5).

Considering all patients, there was no risk reduction of in-hospital death for those receiving beta-blockers. If the revised cardiac risk index score was 0 or 1, the patients had an increase in the risk of death (43% and 13%, respectively). However, those patients whose scores were 2, 3, or 4 or higher had a reduction in the risk of death (from 10% to 43% as their score increased).

How are we to account for these results? In the high-risk patients we see benefit in treatment with beta-blockers. We suspect this drug class improves coronary filling time during diastole and/or prevents dangerous arrhythmias. In patients at low and intermediate risk, the results may be surprising. The study group did not have patient charts available. It is possible that these patients were given betablockers not for prophylaxis but in response to a postoperative ischemic event or infarction. If this misclassification took place, then the effectiveness of beta-blockers is underestimated and the suggestion that these drugs are harmful in this situation would be erroneous.

Given the data gleaned from this study and considering previous publications, we are justified—even obligated—in using betablockers in high-risk patients, without contraindications, who undergo major noncardiac surgery. Before using these drugs in patients at low or intermediate risk we need more information. Two large ongoing randomized trials (POISE and DECREASE–IV) should bring clarity to this issue. We expect results from these in the next four years.

A NEW CLINICAL ENTITY: THE HEPATOADRENAL SYNDROME

Marik PE, Gayowski T, Starzl TE, et al. The hepatoadrenal syndrome: a common yet unrecognized clinical condition. Crit Care Med. 2005;33:1254-1259.

It is not uncommon to see the temporary dysfunction of the hypothalamic-pituitary-adrenal axis while someone is critically ill. Many physicians who suspect this condition attempt to make a diagnosis using either a random total cortisol level or perform a cosyntropin stimulation test. End-stage liver disease and sepsis share some elements of their pathophysiology, such as endotoxemia and increased levels of mediators that influence inflammation.

A liver transplant intensive care unit has produced data on what they have coined the “hepatoadrenal syndrome.” Due to emerging evidence that severe liver disease is associated with adrenal insufficiency, this liver transplant intensive care unit began routinely testing all patients admitted to their unit for this condition. They presented their findings for 340 patients. This review will focus only on those patients with chronic liver failure and fulminant hepatic failure because transplant patients are often cared for by a multidisciplinary team. Patients were labeled as having adrenal insufficiency if the random total cortisol level was <20 micrograms (mcg)/dL in patients who were “highly stressed” (i.e., hypotension, respiratory failure). In all other patients a random total cortisol level of <15 mcg/dL or a 30-minute level <20 mcg/dL post-low-dose (1 mcg) cosyntropin established the diagnosis. Lipid profiles were also obtained from each patient. Those receiving glucocorticoids were excluded. It was left to the discretion of the treating physician whether or not to treat patients with steroids.

Eight patients (33%) with fulminant hepatic failure and 97 patients (66%) with chronic liver disease met their criteria for adrenal insufficiency. Of the patients with adrenal insufficiency the mortality rate was 46% for those not treated with glucocorticoids compared with 26% for those receiving glucocorticoid therapy. The HDL level was the only variable predictive of adrenal insufficiency (p<.0001).

The association between HDL levels and cortisol is as follows: The adrenal glands do not store cortisol. Cholesterol is a precursor for the synthesis of steroids—80% of cortisol arises from it. The lipoprotein of choice to use as substrate in steroid production is HDL. Because a major protein component of HDL is synthesized by the liver, those with liver disease have low levels of serum HDL.

Recently our current method of diagnosing adrenal insufficiency during acute illness has been challenged in the literature. Measuring free cortisol rather than total cortisol has been suggested as proteins that bind cortisol decrease in this setting while free cortisol levels actually rise. Similar to the picture we see in sepsis, there are low levels of these same proteins in liver disease.

At this time testing for free cortisol is not widely available nor do we have good information on what an “appropriate” free cortisol level should be during acute illness. Therefore, given the frequency in which Marik, et al., report encountering this condition and the effect that treatment had on mortality it seems as though this is a diagnosis worth consideration.

TREATMENT OPTIONS FOR ATRIAL FIBRILLATION

Wazni OM, Marrouche NF, Martin DO, et al. Radiofrequency ablation vs antiarrhythmic drugs as first-line treatment of symptomatic atrial fibrillation. JAMA. 2005;293(21):2634-2640.

Atrial fibrillation affects millions of people. This diagnosis has a significant mortality associated with it, causes strokes, and influences quality of life. Therapy has been less than satisfying. Both rate control and rhythm control have multiple potential adverse consequences. Pulmonary vein isolation is performed in the electrophysiology laboratory using an ablation catheter. The goal of this procedure is to completely disconnect the electrical activity between the pulmonary vein antrum and the left atrium. This is a potentially curable procedure for atrial fibrillation.

In a multicenter prospective randomized pilot study Wazni, et al., studied 70 patients with highly symptomatic atrial fibrillation. Patients were between 18 and 75 years old. They could not have undergone ablation in the past, had a history of open-heart surgery, been previously treated with antiarrhythmic drugs, or had a contraindication to long-term anticoagulation. Patients were randomized to antiarrhythmic therapy or pulmonary vein isolation. Those receiving medical treatment were given flecainide, propafenone, or sotalol. Amiodarone was used for patients who had failed at least two or more of these medications. Drugs were titrated to the maximum tolerable doses. The other arm of the group underwent pulmonary vein isolation. This group also received anticoagulation with warfarin beginning the day of the procedure, and this was continued for at least three months. Anticoagulation was extended beyond this time if atrial fibrillation recurred or the pulmonary vein was narrowed by 50% or more (as seen on a three-month post-procedure CT scan). Follow-up was at least one year. A loop event-recorder was worn for one month by all patients and event recorders were used for patients who were symptomatic beyond the first three months of therapy initiation.

After one year, symptomatic atrial fibrillation recurred in 63% of the antiarrhythmic group versus 13% in the pulmonary vein isolation group (p<.001). Fifty-four percent of those medically treated were hospitalized versus 9% of pulmonary vein isolation patients (p<.001). There were no thromboembolic events in either group. Bleeding rates were similar in both groups. For those who underwent pulmonary vein isolation 3% had mild pulmonary vein stenosis and 3% had moderate stenosis (all of which were asymptomatic). Five of the eight measures of quality of life were significantly improved in the pulmonary vein isolation arm versus those receiving antiarrhythmic drugs.

Recently data from multiple trials such as AFFIRM and RACE confirm that rhythm control does not confer significant benefits over rate-control for atrial fibrillation. In fact rate control seems to be a more attractive approach to many patients given the side-effect profile of the antiarrhythmia medications. This study was initiated prior to the release of the information gained from RACE and AFFIRM, thus no rate-control arm was included. This trial also differed from previous studies by using a younger population that was highly symptomatic in comparison with other recent studies using older patients who had recurrent persistent atrial fibrillation.

The biggest concerns about pulmonary vein isolation are the complication rates (death in 0.05% and stroke in 0.28%). We also don’t know if this procedure will translate into long-term cures. Until we have larger studies this should not be a first-line modality for treating all patients. Quite often we find patients where neither rate nor rhythm control is a particularly attractive option, especially in regard to long-term anticoagulation. Pulmonary vein isolation provides us with a new viable option for these people as well as something to consider for carefully selected highly symptomatic patients. TH

Denver—The Pediatric Hospital Medicine 2005 conference, held July 28–31, got off to a rousing start with a networking reception that preceded the keynote lecture on Thursday evening, July 28. Dan Rauch, MD, cochair of the Ambulatory Pediatric Association (APA) Special Interest Group in Hospital Medicine, welcomed the 200+ attendees. He described the meeting as the result of tremendous cooperation among the APA, the American Academy of Pediatrics (AAP), and the SHM.

“It’s been a tremendous pleasure to work with all three organizations,” said Dr. Rauch. “We have been truly blessed with leaders who think that growth of the field is more important than individual turf battles. I highly recommend that everybody in the room become members of all three organizations.”

Dr. Rauch later told The Hospitalist that he was surprised by how many attendees actually weren’t members of any of the three organizations.

The mostly young pediatric hospitalists in attendance came from all over the United States and Canada. According to keynote speaker Larry Wellikson, MD, CEO of SHM, the median age of the typical hospitalist is 37, and fewer than 10% are 50 or older. Dr. Rauch said the typical pediatric hospitalist is even younger.

In fact, the pediatric hospitalist profession is still in its infancy, a point underscored by the panel discussion during Friday’s plenary session, “Future Directions.” The conversation centered on whether pediatric hospitalist medicine is truly a new subspecialty or simply a job type within general pediatrics. Most attendees seemed to agree that in practice it is a new subspecialty, but gaining acknowledgement of that fact from the professional organizations, academics, hospital administrators, insurers, general practice pediatricians, and even from some pediatric hospitalists themselves is the continuing challenge.

Professional advancement was a theme every speaker emphasized, beginning with Dr. Wellikson.

You are building and defining the hospital of the future.

—Larry Wellikson, MD, CEO of SHM, explaining that the legacy of this generation of hospitalists will be to define hospital medicine.

CREATING THE HOSPITAL OF THE FUTURE

“My life’s goals were to be dean of a med school when I was 40 and a United States senator at 50,” said Dr. Wellikson during his keynote address. He may not have achieved those particular goals, but, he revealed, “believe it or not, my life has been even better than that.”

Dr. Wellikson, who discussed the current status of hospital medicine, is a sought-after speaker and consultant who helps hospitals and physicians understand the current medical environment and create strategies to succeed in it.

“You are building and defining the hospital of the future,” Dr. Wellikson told participants, explaining that the legacy of this generation of hospitalists will be to define hospital medicine. “[Hospitalists] are going to be the most important part of the hospital of the future.

“Hospitals are changing,” he said, describing the hospital of the future as patient-centered with medical care driven by measurable data and practiced in teams. With emergency departments overcrowded and hospitals and ICUs running at capacity, he predicts that $20 billion per year will be spent on hospital construction over the next 10 years. He foresees primary care pediatricians giving up inpatient care.

“Hospitalist medicine is by far the fastest growing medical specialty in the country,” said Dr. Wellikson. Currently, there are approximately 11,295 hospitalists, and he predicts that there will be 30,000 by the end of the decade. Approximately 9% of hospitalists are pediatricians.

According to Dr. Wellikson, 30% of 4,895 community hospitals today have hospitalists on staff, with about eight hospitalists per hospital. The larger the hospital, the more likely it is to have hospitalists:

• 71% of hospitals with more than 500 beds have hospitalists on staff; and
• 50% of hospitals with more than 100 beds have hospitalists.

“We believe at SHM that in 15 years 25% of the CEOs will be hospitalists and 15% of CMOs will be hospitalists,” said Dr. Wellikson, “ ... and you’re not all going to be able to take time off to go get an MBA. We’re going to be in the business of educating you to be a leader, how to be a manager. ... If you will commit to creating the hospital of the future, [SHM] will commit to giving you the tools to do it.”

VALUE VERSUS COMPENSATION

During the keynote, Dr. Wellikson set the stage for a compensation discussion that continued throughout the conference, both during sessions and in networking conversations.

“One of the things that makes the compensation model so unfair for hospital medicine,” said Dr. Wellikson, “is that the way we pay for medical care in this country is so screwed up. We pay by the unit of the visit and by the unit of the procedure. And so it is much better to do something wrong and do it a lot than it is to sit down and spend an hour talking with a family. And God forbid that you’re asked to sit on a QI committee; that’s really down time. ... And God forbid that instead of earning a living and seeing patients for three days you’re wasting your time here in Denver trying to be a better doctor. Our system doesn’t reward that.”

Several attendees mentioned that their hospitals consider them loss leaders. “Don’t allow yourself to be called a loss leader,” said Linda Snelling, MD, in her Friday session on contract negotiation. “You’re a system sustainer. If you want this profession to be respected, you’ve got to be paid for it.” Dr. Snelling is chief of pediatric critical care and associate professor of pediatrics and surgery (anesthesiology) at Brown University, Providence, R.I.

“Hospitalists need to convince ourselves of the value we bring to our institutions and to our patients,” said Mark Joffe, MD, director of community pediatric medicine for the Children’s Hospital of Philadelphia.

Dr. Wellikson emphasized that hospitalists do add value to hospitals—whether it’s educating, whether it’s throughput, whether it’s 24/7, whether it’s improving the quality. He said that hospital administrators—the CMOs at your hospital—understand that. “The reason that leadership and that hospitalists are important is that hospitals see you as the solution to many hospital issues,” he said. “When anthrax was thought to be a public health problem, every hospital started a bioterrorism committee and put the hospitalist on it.

“Almost every place I go, they want more of you. You’re better for their bottom line,” he continued. “If they’re ever going to be a better hospital, they need more of you, and they need you motivated, and they need you seeing the right number of patients so that you have the time to do a better job.”

According to Dr. Wellikson, the expectations of hospitalists is that they will improve efficiency, save the hospital money, provide measurable quality improvement (creating standards and measuring compliance), collect data, do things no one else will (e.g., provide uncompensated care, serve on committees).

Dr. Snelling agreed. “The benefit of hospitalists is not in what you bill,” she said, “but in systems improvements, patient satisfaction, QI, initiatives to start or change a program, teaching, cost-savings, and value-added services you provide to the hospital. ... Start with value. Figure out what you want. Identify common ground. Bargaining is the last thing you do.”

Hospitalists create a seamless continuity from inpatient to outpatient, from the emergency department to the floor, from the ICU to the floor. They improve efficiency via throughput and early discharge. They help uncrowd the emergency department and open ICU beds. “We make other physicians’ lives better,” said Dr. Wellikson. “We do a lot of things for the generalists so that they can go and have a better life.”

There is a definite bright side to being a hospitalist right now. According to Dr. Wellikson there are many more jobs than hospitalists—a trend that he predicts will continue for at least for the next five years.

“Don’t let the fact that we have a totally screwed up healthcare system get you down,” he said. “You’re not replaceable. The service you provide, someone must provide. Your hospital has more wastage in durable goods than it spends on pediatric hospitalists. They will pay for expertise.”

Dr. Snelling advised, “Be direct and shameless about compensation. No surgeon works for free unless they want to; no hospitalist should work for free unless that’s your selected charity, and my favorite charity is not the hospital I work for.

“Continually self-promote,” she continued. “Make sure [the person determining your compensation] knows what your successes are. If you’re doing something that’s successful—you get praise, you get a grant, you get a nice letter from a parent—pass that on. Document your value. If you save your hospital a million bucks, why shouldn’t you get a hunk of that? The CEO’s job is to pay you as little as possible.”

One attendee interjected, “I feel uncomfortable with the idea that what I’m doing as a hospitalist is worth more than what my private-practice colleagues are doing. I don’t want to be offensive.”

To which Dr. Snelling replied, “We’re not talking about being elitist. ‘Mine’s bigger than yours.’ What you’re talking about is the differences between C care—the minimum standard—and A care—the hospitalist. ... Who in this room wants to go to an average doctor?”

Dr. Snelling’s bottom line: “My message is not to gouge the system; it’s about respect. In an ideal situation, everybody gains.”

SHOULD PEDIATRIC HOSPITAL MEDICINE BE A BOARD-CERTIFIED SPECIALTY?

“This is a specialty,” emphasized Dr. Snelling during the contract negotiation session.

On the other hand, during the “Future Directions” plenary panel Dr. Wellikson said, “It is almost not relevant whether there is board certification or no board certification.” He described board certification as a way to measure quality.

“Clearly we need to find a way to validate what we’re doing for our good as well as for the good of our patients,” said Doug Carlson, MD, director of the Pediatric Hospital Medicine Program at St. Louis Children’s Hospital and associate professor of pediatrics at Washington University, St. Louis.

Stephen Ludwig, MD, associate chair for medical education at the Children’s Hospital of Philadelphia presented the case for becoming a board-certified specialty. Some benefits: recognition, prestige, job security, and professional advancement.

“Is this just a job, or do you want to fit into—become a thread in—the fabric of organized medicine?” asked Dr. Ludwig. Most important, though, would be the impact on child health. “Is [board certification] good for children and their parents? Unless you can demonstrate that, it won’t happen.”

According to Dr. Ludwig, becoming a board-certified specialty requires a defined body of knowledge, scientific basis, a sufficient number of practitioners, viable academic training programs, sufficient number of trainees willing to go into those fellowship programs, a board exam, geographic diversity, creation of new knowledge (or at least the application of existing knowledge in new ways), the support of national societies and organizations, and the consent of other specialties, such as internal medicine and family practice. It also takes time—likely years.

Some questions pediatric hospitalists still need to consider: Can you fill a void? Is there sufficient novel material for creating a certifying exam? Are there enough people who would take this exam? How will physicians view maintenance of certification? Where will the naysayers come from? What will be the response from primary care general pediatricians? What will be the response from academic generalists/pediatricians? What will be the subspecialist response?

Dr. Ludwig expressed one concern succinctly: “You might ultimately decrease the number of practitioners willing to make the commitment.”

Dr. Wellikson concurred. “Those of you who are group leaders are constantly in a recruiting mode,” he said. “You need something to help you determine who is good and who is not, but adding three years may drive those who would have been great pediatric hospitalists to become great pediatric anesthesiologists.”

In the end, the group could not agree on an answer. “You have an amazing amount of excitement,” said Dr. Ludwig. “Temper your excitement with focus. You need to decide whether becoming another subspecialty is what you want.”

SOMETHING FOR EVERYONE

The conference offered a broad range of learning opportunities.

Those interested in research heard about opportunities to collaborate and learned how to share resources and develop research projects.

Educators—and aren’t all hospitalists involved in education at some level?—learned “Seven Simple Secrets to Successful Supervision” from Vinny Chiang, MD, chief of inpatient services at Children’s Hospital, Boston. He says the single most powerful question you can ask as an educator is, “What do you think?”

“The med student may say, ‘I think the kid is sick.’ The intern may say, ‘I think it’s rejection.’ The resident may say, ‘We need to distinguish between infection and rejection,’” said Dr. Chiang. By asking this question, he said, “You make that trainee an active participant.”

Evidence-based medicine and the use of pathways were also on the agenda. The discussions started with the basics, defining terms. According to Dr. Chiang, evidence-based medicine is, “the conscientious, explicit, and judicious use of current best evidence in making a clinical decision.” (See also “Evidence-Based Medicine for the Hospitalist,” p. 22.)

Pathways, developed from that best evidence, are tools that guide clinical care. “It’s the same as with calculators and PDAs,” said Stephen E. Muething, MD, associate director of clinical services at Cincinnati Children’s Hospital. “A pathway is a tool that allows a resident to spend their time identifying the 20% who shouldn’t be on the pathway and figuring out what to do for them.”

“Medicine can be systematized,” said Dr. Wellikson. “You can have best practices.”

Attendees expressed concerns that pathways may not leave room for a hospitalist’s judgment.

“There is no pathway that addresses 100% of patients,” said Dr. Muething. “A pathway should be defined as a guideline not a standard of care. From a medicallegal standpoint, you need to document why you deviated from a pathway. You still need to use clinical judgment. Don’t forget to think.”

One reason to use pathways, according to Dr. Muething, is that you can more rapidly identify what works and what doesn’t. “If everyone is doing it the same way,” he said, “then even if everyone is doing it wrong, you’ll be able to identify the problem and resolve it more quickly, improving outcome.”

Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.

—Erin Stiucky, MD

HOT TOPICS

Clinical topics were also on the agenda. On the final day of the conference, Erin R. Stucky, MD, director of graduate medical education, an associate clinical professor in the University of California at San Diego Department of Pediatrics, and a pediatric hospitalist at the Children’s

Hospital and Health Center San Diego, tackled “The Top Five in ’05,” discussing:

1. Bronchiolitis;
2. Emerging pathogens;
3. Venous thrombosis;
4. Fungal infections; and
5. Kawasaki disease (KD).

In a whirlwind review, she presented the latest research on each of these topics.

Bronchiolitis: Surveys reveal that there’s a lot of variability in how hospitalists currently manage bronchiolitis, beginning with whether or not viral testing is helpful. “Testing, do we care? Does more than RSV matter?” asked Dr. Stucky. Her literature review of studies on bronchiolitis reveals, “Actually knowing the viral type is probably not helpful. Think before you test. Prevention is key.”

She also mentioned the need for additional studies on the use of heliox and CPAP in treating the condition.

Emerging pathogens: Dr. Stucky rapidly reviewed West Nile virus, coronavirus, varicella, influenza, MRSA, and pneumococcus. Discussing West Nile, Dr. Stucky said that diagnosing children with the condition can be tricky, particularly because the “predictive value [of diagnostic tests] isn’t 100%,” making the history and exam crucial. Of particular note for pediatric hospitalists, she said, is that the virus can be transmitted in blood, in utero, and via breast milk.

When speaking about coronavirus, Dr. Stucky said, “Transspecies jump (from civets, raccoons, ferrets, mice) is a great concern.” For diagnostic purposes, “Consider travel and exposure to animals.”

On varicella, Dr. Stucky said, “Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.”

On influenza, the discussion focused upon the reality of the avian strain causing human disease and increasing resistance as farmers use prophylactic doses of antibiotics for their poultry. There is worldwide effect of both human and avian strains. “The hospitalist as leader: public speaking in anxious times and real crises” is critical, said Dr Stucky.

Venous thrombosis: Kids with venous thrombosis typically have at least one known risk factor, with diabetics at increased risk. Thrombolytics can help save a limb or an organ, but “long-term prophylaxis is controversial,” said Dr. Stucky.

Fungal infections: Truly eradicating a fungal infection is difficult, said Dr. Stucky, with recurrence common. There’s currently no empirical evidence to support combination therapy. More research is needed.

KD: “Treat early and often,” said Dr. Stucky. Treatment goals are to stop inflammation, inhibit thrombosis, and avoid stenosis. Because stenotic lesions progress, “long-term therapy and follow-up are needed.” Children with KD should avoid ibuprofen. They should receive the influenza vaccine, but defer measles and varicella vaccines for 11 months after intravenous immunoglobulin.

COMING SOON

The pediatric hospitalists who met in Denver left the conference energized, armed with new leadership skills and clinical knowledge, and asking for more. Organizers are now starting to plan for Pediatric Hospital Medicine 2007. The Hospitalist will keep you posted with information on the next conference as soon as it’s available, and we’ll publish half a dozen additional articles related to pediatric hospital medicine in the coming months.

Keri Losavio is a medical journalist with more than 10 years’ experience writing about healthcare issues.

PEDIATRIC SPECIAL SECTION

In The Literature

Systemic Steroid Use in Pediatric Sepsis Patients

Review by Julia Simmons, MD

Markovitz BP, Goodman DM, Watson RS, et al. A retrospective cohort study of prognostic factors associated with outcome in pediatric severe sepsis: what is the role of steroids? Pediatr Crit Care Med. 2005:6:270-274.

The use of systemic steroids in septic adults with relative adrenal insufficiency has recently been shown to decrease mortality. The use of systemic steroids in the septic pediatric population remains a topic of debate and research focus. The goal of this retrospective cohort study was to determine factors associated with mortality in pediatric patients with severe sepsis treated with systemic steroids.

The authors searched the Pediatric Health Information System for their data. This system is a database for 35 pediatric hospitals within the Child Heath Corporation of America, a children’s hospital consortium. The International Classification Disease Codes for infection were used to search the database for patients from birth through 17 with sepsis during a one-year period.

Severe sepsis was defined as one or more organ dysfunction secondary to an infectious etiology during which the patient required mechanical ventilation and vasoactive medications. The primary outcome variable was mortality. Other variables analyzed included duration of hospitalization, duration of mechanical ventilatory support and vasoactive medications. Predictor variable was the use of parenteral systemic steroids given at least one day during which the patient required artificial ventilation and vasoactive medications.

There were 6,693 participants in the study. Mean days of ventilation was 24.4 +/- 37.3, median 13. Mean number of days hospitalized was 46.8 +/- 51.3 with a median of 30. The mean number of days requiring cardiac supportive medications was 7.8 +/- 9.9 with a median of five. The use of systemic steroids (hydrocortisone, dexamethasone, or methylprednisolone) with increased age, decreased hospital volume, and a history of a hematological/oncological disease were associated with an increased mortality. Even after controlling for the variables, steroids were a strong predictor of mortality. The overall mortality rate in the study was 24%.

In summary, there was an increase in mortality associated with systemic steroid use in the severely septic pediatric patient. As noted by the authors, the study was limited because there was no stratification for disease severity. Further, the rationale for giving the steroids was not known. Overall, larger prospective studies with controlled protocols are necessary in order to make recommendations regarding the use of systemic steroids in septic pediatric patients. TH

Denver—The Pediatric Hospital Medicine 2005 conference, held July 28–31, got off to a rousing start with a networking reception that preceded the keynote lecture on Thursday evening, July 28. Dan Rauch, MD, cochair of the Ambulatory Pediatric Association (APA) Special Interest Group in Hospital Medicine, welcomed the 200+ attendees. He described the meeting as the result of tremendous cooperation among the APA, the American Academy of Pediatrics (AAP), and the SHM.

“It’s been a tremendous pleasure to work with all three organizations,” said Dr. Rauch. “We have been truly blessed with leaders who think that growth of the field is more important than individual turf battles. I highly recommend that everybody in the room become members of all three organizations.”

Dr. Rauch later told The Hospitalist that he was surprised by how many attendees actually weren’t members of any of the three organizations.

The mostly young pediatric hospitalists in attendance came from all over the United States and Canada. According to keynote speaker Larry Wellikson, MD, CEO of SHM, the median age of the typical hospitalist is 37, and fewer than 10% are 50 or older. Dr. Rauch said the typical pediatric hospitalist is even younger.

In fact, the pediatric hospitalist profession is still in its infancy, a point underscored by the panel discussion during Friday’s plenary session, “Future Directions.” The conversation centered on whether pediatric hospitalist medicine is truly a new subspecialty or simply a job type within general pediatrics. Most attendees seemed to agree that in practice it is a new subspecialty, but gaining acknowledgement of that fact from the professional organizations, academics, hospital administrators, insurers, general practice pediatricians, and even from some pediatric hospitalists themselves is the continuing challenge.

Professional advancement was a theme every speaker emphasized, beginning with Dr. Wellikson.

You are building and defining the hospital of the future.

—Larry Wellikson, MD, CEO of SHM, explaining that the legacy of this generation of hospitalists will be to define hospital medicine.

CREATING THE HOSPITAL OF THE FUTURE

“My life’s goals were to be dean of a med school when I was 40 and a United States senator at 50,” said Dr. Wellikson during his keynote address. He may not have achieved those particular goals, but, he revealed, “believe it or not, my life has been even better than that.”

Dr. Wellikson, who discussed the current status of hospital medicine, is a sought-after speaker and consultant who helps hospitals and physicians understand the current medical environment and create strategies to succeed in it.

“You are building and defining the hospital of the future,” Dr. Wellikson told participants, explaining that the legacy of this generation of hospitalists will be to define hospital medicine. “[Hospitalists] are going to be the most important part of the hospital of the future.

“Hospitals are changing,” he said, describing the hospital of the future as patient-centered with medical care driven by measurable data and practiced in teams. With emergency departments overcrowded and hospitals and ICUs running at capacity, he predicts that $20 billion per year will be spent on hospital construction over the next 10 years. He foresees primary care pediatricians giving up inpatient care.

“Hospitalist medicine is by far the fastest growing medical specialty in the country,” said Dr. Wellikson. Currently, there are approximately 11,295 hospitalists, and he predicts that there will be 30,000 by the end of the decade. Approximately 9% of hospitalists are pediatricians.

According to Dr. Wellikson, 30% of 4,895 community hospitals today have hospitalists on staff, with about eight hospitalists per hospital. The larger the hospital, the more likely it is to have hospitalists:

• 71% of hospitals with more than 500 beds have hospitalists on staff; and
• 50% of hospitals with more than 100 beds have hospitalists.

“We believe at SHM that in 15 years 25% of the CEOs will be hospitalists and 15% of CMOs will be hospitalists,” said Dr. Wellikson, “ ... and you’re not all going to be able to take time off to go get an MBA. We’re going to be in the business of educating you to be a leader, how to be a manager. ... If you will commit to creating the hospital of the future, [SHM] will commit to giving you the tools to do it.”

VALUE VERSUS COMPENSATION

During the keynote, Dr. Wellikson set the stage for a compensation discussion that continued throughout the conference, both during sessions and in networking conversations.

“One of the things that makes the compensation model so unfair for hospital medicine,” said Dr. Wellikson, “is that the way we pay for medical care in this country is so screwed up. We pay by the unit of the visit and by the unit of the procedure. And so it is much better to do something wrong and do it a lot than it is to sit down and spend an hour talking with a family. And God forbid that you’re asked to sit on a QI committee; that’s really down time. ... And God forbid that instead of earning a living and seeing patients for three days you’re wasting your time here in Denver trying to be a better doctor. Our system doesn’t reward that.”

Several attendees mentioned that their hospitals consider them loss leaders. “Don’t allow yourself to be called a loss leader,” said Linda Snelling, MD, in her Friday session on contract negotiation. “You’re a system sustainer. If you want this profession to be respected, you’ve got to be paid for it.” Dr. Snelling is chief of pediatric critical care and associate professor of pediatrics and surgery (anesthesiology) at Brown University, Providence, R.I.

“Hospitalists need to convince ourselves of the value we bring to our institutions and to our patients,” said Mark Joffe, MD, director of community pediatric medicine for the Children’s Hospital of Philadelphia.

Dr. Wellikson emphasized that hospitalists do add value to hospitals—whether it’s educating, whether it’s throughput, whether it’s 24/7, whether it’s improving the quality. He said that hospital administrators—the CMOs at your hospital—understand that. “The reason that leadership and that hospitalists are important is that hospitals see you as the solution to many hospital issues,” he said. “When anthrax was thought to be a public health problem, every hospital started a bioterrorism committee and put the hospitalist on it.

“Almost every place I go, they want more of you. You’re better for their bottom line,” he continued. “If they’re ever going to be a better hospital, they need more of you, and they need you motivated, and they need you seeing the right number of patients so that you have the time to do a better job.”

According to Dr. Wellikson, the expectations of hospitalists is that they will improve efficiency, save the hospital money, provide measurable quality improvement (creating standards and measuring compliance), collect data, do things no one else will (e.g., provide uncompensated care, serve on committees).

Dr. Snelling agreed. “The benefit of hospitalists is not in what you bill,” she said, “but in systems improvements, patient satisfaction, QI, initiatives to start or change a program, teaching, cost-savings, and value-added services you provide to the hospital. ... Start with value. Figure out what you want. Identify common ground. Bargaining is the last thing you do.”

Hospitalists create a seamless continuity from inpatient to outpatient, from the emergency department to the floor, from the ICU to the floor. They improve efficiency via throughput and early discharge. They help uncrowd the emergency department and open ICU beds. “We make other physicians’ lives better,” said Dr. Wellikson. “We do a lot of things for the generalists so that they can go and have a better life.”

There is a definite bright side to being a hospitalist right now. According to Dr. Wellikson there are many more jobs than hospitalists—a trend that he predicts will continue for at least for the next five years.

“Don’t let the fact that we have a totally screwed up healthcare system get you down,” he said. “You’re not replaceable. The service you provide, someone must provide. Your hospital has more wastage in durable goods than it spends on pediatric hospitalists. They will pay for expertise.”

Dr. Snelling advised, “Be direct and shameless about compensation. No surgeon works for free unless they want to; no hospitalist should work for free unless that’s your selected charity, and my favorite charity is not the hospital I work for.

“Continually self-promote,” she continued. “Make sure [the person determining your compensation] knows what your successes are. If you’re doing something that’s successful—you get praise, you get a grant, you get a nice letter from a parent—pass that on. Document your value. If you save your hospital a million bucks, why shouldn’t you get a hunk of that? The CEO’s job is to pay you as little as possible.”

One attendee interjected, “I feel uncomfortable with the idea that what I’m doing as a hospitalist is worth more than what my private-practice colleagues are doing. I don’t want to be offensive.”

To which Dr. Snelling replied, “We’re not talking about being elitist. ‘Mine’s bigger than yours.’ What you’re talking about is the differences between C care—the minimum standard—and A care—the hospitalist. ... Who in this room wants to go to an average doctor?”

Dr. Snelling’s bottom line: “My message is not to gouge the system; it’s about respect. In an ideal situation, everybody gains.”

SHOULD PEDIATRIC HOSPITAL MEDICINE BE A BOARD-CERTIFIED SPECIALTY?

“This is a specialty,” emphasized Dr. Snelling during the contract negotiation session.

On the other hand, during the “Future Directions” plenary panel Dr. Wellikson said, “It is almost not relevant whether there is board certification or no board certification.” He described board certification as a way to measure quality.

“Clearly we need to find a way to validate what we’re doing for our good as well as for the good of our patients,” said Doug Carlson, MD, director of the Pediatric Hospital Medicine Program at St. Louis Children’s Hospital and associate professor of pediatrics at Washington University, St. Louis.

Stephen Ludwig, MD, associate chair for medical education at the Children’s Hospital of Philadelphia presented the case for becoming a board-certified specialty. Some benefits: recognition, prestige, job security, and professional advancement.

“Is this just a job, or do you want to fit into—become a thread in—the fabric of organized medicine?” asked Dr. Ludwig. Most important, though, would be the impact on child health. “Is [board certification] good for children and their parents? Unless you can demonstrate that, it won’t happen.”

According to Dr. Ludwig, becoming a board-certified specialty requires a defined body of knowledge, scientific basis, a sufficient number of practitioners, viable academic training programs, sufficient number of trainees willing to go into those fellowship programs, a board exam, geographic diversity, creation of new knowledge (or at least the application of existing knowledge in new ways), the support of national societies and organizations, and the consent of other specialties, such as internal medicine and family practice. It also takes time—likely years.

Some questions pediatric hospitalists still need to consider: Can you fill a void? Is there sufficient novel material for creating a certifying exam? Are there enough people who would take this exam? How will physicians view maintenance of certification? Where will the naysayers come from? What will be the response from primary care general pediatricians? What will be the response from academic generalists/pediatricians? What will be the subspecialist response?

Dr. Ludwig expressed one concern succinctly: “You might ultimately decrease the number of practitioners willing to make the commitment.”

Dr. Wellikson concurred. “Those of you who are group leaders are constantly in a recruiting mode,” he said. “You need something to help you determine who is good and who is not, but adding three years may drive those who would have been great pediatric hospitalists to become great pediatric anesthesiologists.”

In the end, the group could not agree on an answer. “You have an amazing amount of excitement,” said Dr. Ludwig. “Temper your excitement with focus. You need to decide whether becoming another subspecialty is what you want.”

SOMETHING FOR EVERYONE

The conference offered a broad range of learning opportunities.

Those interested in research heard about opportunities to collaborate and learned how to share resources and develop research projects.

Educators—and aren’t all hospitalists involved in education at some level?—learned “Seven Simple Secrets to Successful Supervision” from Vinny Chiang, MD, chief of inpatient services at Children’s Hospital, Boston. He says the single most powerful question you can ask as an educator is, “What do you think?”

“The med student may say, ‘I think the kid is sick.’ The intern may say, ‘I think it’s rejection.’ The resident may say, ‘We need to distinguish between infection and rejection,’” said Dr. Chiang. By asking this question, he said, “You make that trainee an active participant.”

Evidence-based medicine and the use of pathways were also on the agenda. The discussions started with the basics, defining terms. According to Dr. Chiang, evidence-based medicine is, “the conscientious, explicit, and judicious use of current best evidence in making a clinical decision.” (See also “Evidence-Based Medicine for the Hospitalist,” p. 22.)

Pathways, developed from that best evidence, are tools that guide clinical care. “It’s the same as with calculators and PDAs,” said Stephen E. Muething, MD, associate director of clinical services at Cincinnati Children’s Hospital. “A pathway is a tool that allows a resident to spend their time identifying the 20% who shouldn’t be on the pathway and figuring out what to do for them.”

“Medicine can be systematized,” said Dr. Wellikson. “You can have best practices.”

Attendees expressed concerns that pathways may not leave room for a hospitalist’s judgment.

“There is no pathway that addresses 100% of patients,” said Dr. Muething. “A pathway should be defined as a guideline not a standard of care. From a medicallegal standpoint, you need to document why you deviated from a pathway. You still need to use clinical judgment. Don’t forget to think.”

One reason to use pathways, according to Dr. Muething, is that you can more rapidly identify what works and what doesn’t. “If everyone is doing it the same way,” he said, “then even if everyone is doing it wrong, you’ll be able to identify the problem and resolve it more quickly, improving outcome.”

Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.

—Erin Stiucky, MD

HOT TOPICS

Clinical topics were also on the agenda. On the final day of the conference, Erin R. Stucky, MD, director of graduate medical education, an associate clinical professor in the University of California at San Diego Department of Pediatrics, and a pediatric hospitalist at the Children’s

Hospital and Health Center San Diego, tackled “The Top Five in ’05,” discussing:

1. Bronchiolitis;
2. Emerging pathogens;
3. Venous thrombosis;
4. Fungal infections; and
5. Kawasaki disease (KD).

In a whirlwind review, she presented the latest research on each of these topics.

Bronchiolitis: Surveys reveal that there’s a lot of variability in how hospitalists currently manage bronchiolitis, beginning with whether or not viral testing is helpful. “Testing, do we care? Does more than RSV matter?” asked Dr. Stucky. Her literature review of studies on bronchiolitis reveals, “Actually knowing the viral type is probably not helpful. Think before you test. Prevention is key.”

She also mentioned the need for additional studies on the use of heliox and CPAP in treating the condition.

Emerging pathogens: Dr. Stucky rapidly reviewed West Nile virus, coronavirus, varicella, influenza, MRSA, and pneumococcus. Discussing West Nile, Dr. Stucky said that diagnosing children with the condition can be tricky, particularly because the “predictive value [of diagnostic tests] isn’t 100%,” making the history and exam crucial. Of particular note for pediatric hospitalists, she said, is that the virus can be transmitted in blood, in utero, and via breast milk.

When speaking about coronavirus, Dr. Stucky said, “Transspecies jump (from civets, raccoons, ferrets, mice) is a great concern.” For diagnostic purposes, “Consider travel and exposure to animals.”

On varicella, Dr. Stucky said, “Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.”

On influenza, the discussion focused upon the reality of the avian strain causing human disease and increasing resistance as farmers use prophylactic doses of antibiotics for their poultry. There is worldwide effect of both human and avian strains. “The hospitalist as leader: public speaking in anxious times and real crises” is critical, said Dr Stucky.

Venous thrombosis: Kids with venous thrombosis typically have at least one known risk factor, with diabetics at increased risk. Thrombolytics can help save a limb or an organ, but “long-term prophylaxis is controversial,” said Dr. Stucky.

Fungal infections: Truly eradicating a fungal infection is difficult, said Dr. Stucky, with recurrence common. There’s currently no empirical evidence to support combination therapy. More research is needed.

KD: “Treat early and often,” said Dr. Stucky. Treatment goals are to stop inflammation, inhibit thrombosis, and avoid stenosis. Because stenotic lesions progress, “long-term therapy and follow-up are needed.” Children with KD should avoid ibuprofen. They should receive the influenza vaccine, but defer measles and varicella vaccines for 11 months after intravenous immunoglobulin.

COMING SOON

The pediatric hospitalists who met in Denver left the conference energized, armed with new leadership skills and clinical knowledge, and asking for more. Organizers are now starting to plan for Pediatric Hospital Medicine 2007. The Hospitalist will keep you posted with information on the next conference as soon as it’s available, and we’ll publish half a dozen additional articles related to pediatric hospital medicine in the coming months.

Keri Losavio is a medical journalist with more than 10 years’ experience writing about healthcare issues.

PEDIATRIC SPECIAL SECTION

In The Literature

Systemic Steroid Use in Pediatric Sepsis Patients

Review by Julia Simmons, MD

Markovitz BP, Goodman DM, Watson RS, et al. A retrospective cohort study of prognostic factors associated with outcome in pediatric severe sepsis: what is the role of steroids? Pediatr Crit Care Med. 2005:6:270-274.

The use of systemic steroids in septic adults with relative adrenal insufficiency has recently been shown to decrease mortality. The use of systemic steroids in the septic pediatric population remains a topic of debate and research focus. The goal of this retrospective cohort study was to determine factors associated with mortality in pediatric patients with severe sepsis treated with systemic steroids.

The authors searched the Pediatric Health Information System for their data. This system is a database for 35 pediatric hospitals within the Child Heath Corporation of America, a children’s hospital consortium. The International Classification Disease Codes for infection were used to search the database for patients from birth through 17 with sepsis during a one-year period.

Severe sepsis was defined as one or more organ dysfunction secondary to an infectious etiology during which the patient required mechanical ventilation and vasoactive medications. The primary outcome variable was mortality. Other variables analyzed included duration of hospitalization, duration of mechanical ventilatory support and vasoactive medications. Predictor variable was the use of parenteral systemic steroids given at least one day during which the patient required artificial ventilation and vasoactive medications.

There were 6,693 participants in the study. Mean days of ventilation was 24.4 +/- 37.3, median 13. Mean number of days hospitalized was 46.8 +/- 51.3 with a median of 30. The mean number of days requiring cardiac supportive medications was 7.8 +/- 9.9 with a median of five. The use of systemic steroids (hydrocortisone, dexamethasone, or methylprednisolone) with increased age, decreased hospital volume, and a history of a hematological/oncological disease were associated with an increased mortality. Even after controlling for the variables, steroids were a strong predictor of mortality. The overall mortality rate in the study was 24%.

In summary, there was an increase in mortality associated with systemic steroid use in the severely septic pediatric patient. As noted by the authors, the study was limited because there was no stratification for disease severity. Further, the rationale for giving the steroids was not known. Overall, larger prospective studies with controlled protocols are necessary in order to make recommendations regarding the use of systemic steroids in septic pediatric patients. TH

Denver—The Pediatric Hospital Medicine 2005 conference, held July 28–31, got off to a rousing start with a networking reception that preceded the keynote lecture on Thursday evening, July 28. Dan Rauch, MD, cochair of the Ambulatory Pediatric Association (APA) Special Interest Group in Hospital Medicine, welcomed the 200+ attendees. He described the meeting as the result of tremendous cooperation among the APA, the American Academy of Pediatrics (AAP), and the SHM.

“It’s been a tremendous pleasure to work with all three organizations,” said Dr. Rauch. “We have been truly blessed with leaders who think that growth of the field is more important than individual turf battles. I highly recommend that everybody in the room become members of all three organizations.”

Dr. Rauch later told The Hospitalist that he was surprised by how many attendees actually weren’t members of any of the three organizations.

The mostly young pediatric hospitalists in attendance came from all over the United States and Canada. According to keynote speaker Larry Wellikson, MD, CEO of SHM, the median age of the typical hospitalist is 37, and fewer than 10% are 50 or older. Dr. Rauch said the typical pediatric hospitalist is even younger.

In fact, the pediatric hospitalist profession is still in its infancy, a point underscored by the panel discussion during Friday’s plenary session, “Future Directions.” The conversation centered on whether pediatric hospitalist medicine is truly a new subspecialty or simply a job type within general pediatrics. Most attendees seemed to agree that in practice it is a new subspecialty, but gaining acknowledgement of that fact from the professional organizations, academics, hospital administrators, insurers, general practice pediatricians, and even from some pediatric hospitalists themselves is the continuing challenge.

Professional advancement was a theme every speaker emphasized, beginning with Dr. Wellikson.

You are building and defining the hospital of the future.

—Larry Wellikson, MD, CEO of SHM, explaining that the legacy of this generation of hospitalists will be to define hospital medicine.

CREATING THE HOSPITAL OF THE FUTURE

“My life’s goals were to be dean of a med school when I was 40 and a United States senator at 50,” said Dr. Wellikson during his keynote address. He may not have achieved those particular goals, but, he revealed, “believe it or not, my life has been even better than that.”

Dr. Wellikson, who discussed the current status of hospital medicine, is a sought-after speaker and consultant who helps hospitals and physicians understand the current medical environment and create strategies to succeed in it.

“You are building and defining the hospital of the future,” Dr. Wellikson told participants, explaining that the legacy of this generation of hospitalists will be to define hospital medicine. “[Hospitalists] are going to be the most important part of the hospital of the future.

“Hospitals are changing,” he said, describing the hospital of the future as patient-centered with medical care driven by measurable data and practiced in teams. With emergency departments overcrowded and hospitals and ICUs running at capacity, he predicts that $20 billion per year will be spent on hospital construction over the next 10 years. He foresees primary care pediatricians giving up inpatient care.

“Hospitalist medicine is by far the fastest growing medical specialty in the country,” said Dr. Wellikson. Currently, there are approximately 11,295 hospitalists, and he predicts that there will be 30,000 by the end of the decade. Approximately 9% of hospitalists are pediatricians.

According to Dr. Wellikson, 30% of 4,895 community hospitals today have hospitalists on staff, with about eight hospitalists per hospital. The larger the hospital, the more likely it is to have hospitalists:

• 71% of hospitals with more than 500 beds have hospitalists on staff; and
• 50% of hospitals with more than 100 beds have hospitalists.

“We believe at SHM that in 15 years 25% of the CEOs will be hospitalists and 15% of CMOs will be hospitalists,” said Dr. Wellikson, “ ... and you’re not all going to be able to take time off to go get an MBA. We’re going to be in the business of educating you to be a leader, how to be a manager. ... If you will commit to creating the hospital of the future, [SHM] will commit to giving you the tools to do it.”

VALUE VERSUS COMPENSATION

During the keynote, Dr. Wellikson set the stage for a compensation discussion that continued throughout the conference, both during sessions and in networking conversations.

“One of the things that makes the compensation model so unfair for hospital medicine,” said Dr. Wellikson, “is that the way we pay for medical care in this country is so screwed up. We pay by the unit of the visit and by the unit of the procedure. And so it is much better to do something wrong and do it a lot than it is to sit down and spend an hour talking with a family. And God forbid that you’re asked to sit on a QI committee; that’s really down time. ... And God forbid that instead of earning a living and seeing patients for three days you’re wasting your time here in Denver trying to be a better doctor. Our system doesn’t reward that.”

Several attendees mentioned that their hospitals consider them loss leaders. “Don’t allow yourself to be called a loss leader,” said Linda Snelling, MD, in her Friday session on contract negotiation. “You’re a system sustainer. If you want this profession to be respected, you’ve got to be paid for it.” Dr. Snelling is chief of pediatric critical care and associate professor of pediatrics and surgery (anesthesiology) at Brown University, Providence, R.I.

“Hospitalists need to convince ourselves of the value we bring to our institutions and to our patients,” said Mark Joffe, MD, director of community pediatric medicine for the Children’s Hospital of Philadelphia.

Dr. Wellikson emphasized that hospitalists do add value to hospitals—whether it’s educating, whether it’s throughput, whether it’s 24/7, whether it’s improving the quality. He said that hospital administrators—the CMOs at your hospital—understand that. “The reason that leadership and that hospitalists are important is that hospitals see you as the solution to many hospital issues,” he said. “When anthrax was thought to be a public health problem, every hospital started a bioterrorism committee and put the hospitalist on it.

“Almost every place I go, they want more of you. You’re better for their bottom line,” he continued. “If they’re ever going to be a better hospital, they need more of you, and they need you motivated, and they need you seeing the right number of patients so that you have the time to do a better job.”

According to Dr. Wellikson, the expectations of hospitalists is that they will improve efficiency, save the hospital money, provide measurable quality improvement (creating standards and measuring compliance), collect data, do things no one else will (e.g., provide uncompensated care, serve on committees).

Dr. Snelling agreed. “The benefit of hospitalists is not in what you bill,” she said, “but in systems improvements, patient satisfaction, QI, initiatives to start or change a program, teaching, cost-savings, and value-added services you provide to the hospital. ... Start with value. Figure out what you want. Identify common ground. Bargaining is the last thing you do.”

Hospitalists create a seamless continuity from inpatient to outpatient, from the emergency department to the floor, from the ICU to the floor. They improve efficiency via throughput and early discharge. They help uncrowd the emergency department and open ICU beds. “We make other physicians’ lives better,” said Dr. Wellikson. “We do a lot of things for the generalists so that they can go and have a better life.”

There is a definite bright side to being a hospitalist right now. According to Dr. Wellikson there are many more jobs than hospitalists—a trend that he predicts will continue for at least for the next five years.

“Don’t let the fact that we have a totally screwed up healthcare system get you down,” he said. “You’re not replaceable. The service you provide, someone must provide. Your hospital has more wastage in durable goods than it spends on pediatric hospitalists. They will pay for expertise.”

Dr. Snelling advised, “Be direct and shameless about compensation. No surgeon works for free unless they want to; no hospitalist should work for free unless that’s your selected charity, and my favorite charity is not the hospital I work for.

“Continually self-promote,” she continued. “Make sure [the person determining your compensation] knows what your successes are. If you’re doing something that’s successful—you get praise, you get a grant, you get a nice letter from a parent—pass that on. Document your value. If you save your hospital a million bucks, why shouldn’t you get a hunk of that? The CEO’s job is to pay you as little as possible.”

One attendee interjected, “I feel uncomfortable with the idea that what I’m doing as a hospitalist is worth more than what my private-practice colleagues are doing. I don’t want to be offensive.”

To which Dr. Snelling replied, “We’re not talking about being elitist. ‘Mine’s bigger than yours.’ What you’re talking about is the differences between C care—the minimum standard—and A care—the hospitalist. ... Who in this room wants to go to an average doctor?”

Dr. Snelling’s bottom line: “My message is not to gouge the system; it’s about respect. In an ideal situation, everybody gains.”

SHOULD PEDIATRIC HOSPITAL MEDICINE BE A BOARD-CERTIFIED SPECIALTY?

“This is a specialty,” emphasized Dr. Snelling during the contract negotiation session.

On the other hand, during the “Future Directions” plenary panel Dr. Wellikson said, “It is almost not relevant whether there is board certification or no board certification.” He described board certification as a way to measure quality.

“Clearly we need to find a way to validate what we’re doing for our good as well as for the good of our patients,” said Doug Carlson, MD, director of the Pediatric Hospital Medicine Program at St. Louis Children’s Hospital and associate professor of pediatrics at Washington University, St. Louis.

Stephen Ludwig, MD, associate chair for medical education at the Children’s Hospital of Philadelphia presented the case for becoming a board-certified specialty. Some benefits: recognition, prestige, job security, and professional advancement.

“Is this just a job, or do you want to fit into—become a thread in—the fabric of organized medicine?” asked Dr. Ludwig. Most important, though, would be the impact on child health. “Is [board certification] good for children and their parents? Unless you can demonstrate that, it won’t happen.”

According to Dr. Ludwig, becoming a board-certified specialty requires a defined body of knowledge, scientific basis, a sufficient number of practitioners, viable academic training programs, sufficient number of trainees willing to go into those fellowship programs, a board exam, geographic diversity, creation of new knowledge (or at least the application of existing knowledge in new ways), the support of national societies and organizations, and the consent of other specialties, such as internal medicine and family practice. It also takes time—likely years.

Some questions pediatric hospitalists still need to consider: Can you fill a void? Is there sufficient novel material for creating a certifying exam? Are there enough people who would take this exam? How will physicians view maintenance of certification? Where will the naysayers come from? What will be the response from primary care general pediatricians? What will be the response from academic generalists/pediatricians? What will be the subspecialist response?

Dr. Ludwig expressed one concern succinctly: “You might ultimately decrease the number of practitioners willing to make the commitment.”

Dr. Wellikson concurred. “Those of you who are group leaders are constantly in a recruiting mode,” he said. “You need something to help you determine who is good and who is not, but adding three years may drive those who would have been great pediatric hospitalists to become great pediatric anesthesiologists.”

In the end, the group could not agree on an answer. “You have an amazing amount of excitement,” said Dr. Ludwig. “Temper your excitement with focus. You need to decide whether becoming another subspecialty is what you want.”

SOMETHING FOR EVERYONE

The conference offered a broad range of learning opportunities.

Those interested in research heard about opportunities to collaborate and learned how to share resources and develop research projects.

Educators—and aren’t all hospitalists involved in education at some level?—learned “Seven Simple Secrets to Successful Supervision” from Vinny Chiang, MD, chief of inpatient services at Children’s Hospital, Boston. He says the single most powerful question you can ask as an educator is, “What do you think?”

“The med student may say, ‘I think the kid is sick.’ The intern may say, ‘I think it’s rejection.’ The resident may say, ‘We need to distinguish between infection and rejection,’” said Dr. Chiang. By asking this question, he said, “You make that trainee an active participant.”

Evidence-based medicine and the use of pathways were also on the agenda. The discussions started with the basics, defining terms. According to Dr. Chiang, evidence-based medicine is, “the conscientious, explicit, and judicious use of current best evidence in making a clinical decision.” (See also “Evidence-Based Medicine for the Hospitalist,” p. 22.)

Pathways, developed from that best evidence, are tools that guide clinical care. “It’s the same as with calculators and PDAs,” said Stephen E. Muething, MD, associate director of clinical services at Cincinnati Children’s Hospital. “A pathway is a tool that allows a resident to spend their time identifying the 20% who shouldn’t be on the pathway and figuring out what to do for them.”

“Medicine can be systematized,” said Dr. Wellikson. “You can have best practices.”

Attendees expressed concerns that pathways may not leave room for a hospitalist’s judgment.

“There is no pathway that addresses 100% of patients,” said Dr. Muething. “A pathway should be defined as a guideline not a standard of care. From a medicallegal standpoint, you need to document why you deviated from a pathway. You still need to use clinical judgment. Don’t forget to think.”

One reason to use pathways, according to Dr. Muething, is that you can more rapidly identify what works and what doesn’t. “If everyone is doing it the same way,” he said, “then even if everyone is doing it wrong, you’ll be able to identify the problem and resolve it more quickly, improving outcome.”

Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.

—Erin Stiucky, MD

HOT TOPICS

Clinical topics were also on the agenda. On the final day of the conference, Erin R. Stucky, MD, director of graduate medical education, an associate clinical professor in the University of California at San Diego Department of Pediatrics, and a pediatric hospitalist at the Children’s

Hospital and Health Center San Diego, tackled “The Top Five in ’05,” discussing:

1. Bronchiolitis;
2. Emerging pathogens;
3. Venous thrombosis;
4. Fungal infections; and
5. Kawasaki disease (KD).

In a whirlwind review, she presented the latest research on each of these topics.

Bronchiolitis: Surveys reveal that there’s a lot of variability in how hospitalists currently manage bronchiolitis, beginning with whether or not viral testing is helpful. “Testing, do we care? Does more than RSV matter?” asked Dr. Stucky. Her literature review of studies on bronchiolitis reveals, “Actually knowing the viral type is probably not helpful. Think before you test. Prevention is key.”

She also mentioned the need for additional studies on the use of heliox and CPAP in treating the condition.

Emerging pathogens: Dr. Stucky rapidly reviewed West Nile virus, coronavirus, varicella, influenza, MRSA, and pneumococcus. Discussing West Nile, Dr. Stucky said that diagnosing children with the condition can be tricky, particularly because the “predictive value [of diagnostic tests] isn’t 100%,” making the history and exam crucial. Of particular note for pediatric hospitalists, she said, is that the virus can be transmitted in blood, in utero, and via breast milk.

When speaking about coronavirus, Dr. Stucky said, “Transspecies jump (from civets, raccoons, ferrets, mice) is a great concern.” For diagnostic purposes, “Consider travel and exposure to animals.”

On varicella, Dr. Stucky said, “Zoster can occur in immunized kids. Immunization does not preclude disease. We all know that breakthrough can happen.” The question is, “If a kid’s not immunized but exposed to a milder case, will he/she get the milder case? Case studies indicate that’s a possibility. Vaccine may not prevent but mute disease.”

On influenza, the discussion focused upon the reality of the avian strain causing human disease and increasing resistance as farmers use prophylactic doses of antibiotics for their poultry. There is worldwide effect of both human and avian strains. “The hospitalist as leader: public speaking in anxious times and real crises” is critical, said Dr Stucky.

Venous thrombosis: Kids with venous thrombosis typically have at least one known risk factor, with diabetics at increased risk. Thrombolytics can help save a limb or an organ, but “long-term prophylaxis is controversial,” said Dr. Stucky.

Fungal infections: Truly eradicating a fungal infection is difficult, said Dr. Stucky, with recurrence common. There’s currently no empirical evidence to support combination therapy. More research is needed.

KD: “Treat early and often,” said Dr. Stucky. Treatment goals are to stop inflammation, inhibit thrombosis, and avoid stenosis. Because stenotic lesions progress, “long-term therapy and follow-up are needed.” Children with KD should avoid ibuprofen. They should receive the influenza vaccine, but defer measles and varicella vaccines for 11 months after intravenous immunoglobulin.

COMING SOON

The pediatric hospitalists who met in Denver left the conference energized, armed with new leadership skills and clinical knowledge, and asking for more. Organizers are now starting to plan for Pediatric Hospital Medicine 2007. The Hospitalist will keep you posted with information on the next conference as soon as it’s available, and we’ll publish half a dozen additional articles related to pediatric hospital medicine in the coming months.

Keri Losavio is a medical journalist with more than 10 years’ experience writing about healthcare issues.

PEDIATRIC SPECIAL SECTION

In The Literature

Systemic Steroid Use in Pediatric Sepsis Patients

Review by Julia Simmons, MD

Markovitz BP, Goodman DM, Watson RS, et al. A retrospective cohort study of prognostic factors associated with outcome in pediatric severe sepsis: what is the role of steroids? Pediatr Crit Care Med. 2005:6:270-274.

The use of systemic steroids in septic adults with relative adrenal insufficiency has recently been shown to decrease mortality. The use of systemic steroids in the septic pediatric population remains a topic of debate and research focus. The goal of this retrospective cohort study was to determine factors associated with mortality in pediatric patients with severe sepsis treated with systemic steroids.

The authors searched the Pediatric Health Information System for their data. This system is a database for 35 pediatric hospitals within the Child Heath Corporation of America, a children’s hospital consortium. The International Classification Disease Codes for infection were used to search the database for patients from birth through 17 with sepsis during a one-year period.

Severe sepsis was defined as one or more organ dysfunction secondary to an infectious etiology during which the patient required mechanical ventilation and vasoactive medications. The primary outcome variable was mortality. Other variables analyzed included duration of hospitalization, duration of mechanical ventilatory support and vasoactive medications. Predictor variable was the use of parenteral systemic steroids given at least one day during which the patient required artificial ventilation and vasoactive medications.

There were 6,693 participants in the study. Mean days of ventilation was 24.4 +/- 37.3, median 13. Mean number of days hospitalized was 46.8 +/- 51.3 with a median of 30. The mean number of days requiring cardiac supportive medications was 7.8 +/- 9.9 with a median of five. The use of systemic steroids (hydrocortisone, dexamethasone, or methylprednisolone) with increased age, decreased hospital volume, and a history of a hematological/oncological disease were associated with an increased mortality. Even after controlling for the variables, steroids were a strong predictor of mortality. The overall mortality rate in the study was 24%.

In summary, there was an increase in mortality associated with systemic steroid use in the severely septic pediatric patient. As noted by the authors, the study was limited because there was no stratification for disease severity. Further, the rationale for giving the steroids was not known. Overall, larger prospective studies with controlled protocols are necessary in order to make recommendations regarding the use of systemic steroids in septic pediatric patients. TH

Although most hospitalists have internal medicine as their medical specialty, a new breed of practitioners is gaining popularity. Hospitalists from obstetrics, pediatrics, psychiatry, dermatology, orthopedic surgery, and other fields bring the knowledge and experience of their specialties to hospital-based positions. In doing so, they gain many benefits they didn’t have as private practitioners. It’s a win-win situation that has the trend toward hospital-based specialists growing and receiving praise from physicians, administrators, and patients alike.

According to SHM CEO Larry Wellikson, MD, the demand for specialist hospitalists “is driven by hospitals’ needs to have these specialists available to them on a regular basis.”

HOSPITAL-BASED CARE DELIVERS FOR OBSTETRICIANS

Addressing a problem in their communities is one reason specialists join hospital teams. “The introduction of a new hospital in our small community, which previously only had one, created a challenge for small OB/GYN groups who didn’t have enough personnel to cover calls at two facilities,” says obstetric hospitalist Duncan Neilson, MD, chief of women’s services for Legacy Health System in Portland, Ore.

The ultimate question, Dr. Neilson says, was how to provide adequate OB/GYN and high-risk services and back up the community without having to hire “a lot” of physicians. “We solved both problems with hospitalists,” he explains.

Keith Marton, MD, FACP, chief medical officer/senior vice president at Legacy, adds that a key driver for the move to obstetric hospitalists was the desire to mitigate the facility’s liability risk.

“We saw hospitalists as providing continuity, more predictable physician presence to work with nurses to improve delivery outcomes,” he explains. Another important driver, Dr. Marton emphasizes, was his facility’s neonatal intensive care unit and the need for the perinatal specialists there to work with obstetricians they know and trust.

“We have seen from other communities that you don’t go out and ask community obstetricians to fill this role,” he says, adding that hospitalists are a better option. “This would improve care, increase our volume and revenues, and decrease costs.”

Being a hospital-based obstetrician has both business and lifestyle advantages. “In a typical OB/GYN practice, physicians often have to be in two places at once,” says Dr. Neilson. “When you’re with a laboring patient, you can’t be with patients in your office. You feel torn.”

There is no such split in hospital-based practice. “You’re free to concentrate on the care of laboring patients,” he says.

This is appealing for practitioners who especially like handling labor and deliveries because that’s the focus of their work. At the same time overhead and malpractice insurance are managed by the hospital, enabling specialty hospitalists to provide the best possible care with the least amount of hassle.

As for lifestyle, “you come to the hospital in the morning, you work your shift, you go home, and you are done,” explains Dr. Neilson.

Patients also benefit from having obstetric hospitalists involved in their care. “Patient safety is improved. A physician is onsite 24 hours a day to address problems,” says Dr. Neilson, who notes that this situation enables patients to stay with their own practitioner while having access to the hospital-based labor expert.

Are there disadvantages to being or hiring a hospital-based obstetrician? “It’s kind of hard to think of any,” admits Dr. Neilson. He suggests that physicians who like the variety of handling obstetrics and gynecology “might not like being a hospital-based specialist.”

PSYCHIATRIC HOSPITALISTS ANALYZE NEW OPPORTUNITIES

Obstetricians aren’t the only specialists enjoying lives as hospitalists. A growing number of psychiatrists are finding new and exciting opportunities as hospital-based practitioners. (See “The Doctor Is In,” p. 30.) For example, Thomas O’Brien, MD, a psychiatric hospitalist at Swedish Medical Center in Seattle, was drawn to hospital-based practice by his love of this setting and for treating acutely ill patients.

“I can intervene earlier,” he says. “And, as a result, patients don’t spin out of control.”

Dr. O’Brien likes the challenge of the complex cases he encounters. But he also likes the flexibility he enjoys. “It’s a good arrangement for me,” he says. “On the nights you’re off, you’re really off.”

As with other specialties, hospitals enjoy the arrangement as well. “Hospitals are much happier having physician employees that they can train and support more fully because they know them better,” observes Dr. O’Brien. “They also like the consistency of a physician who knows the staff and can respond quickly to problems, as well as patient and family questions. The doctor is part of the family, rather than an outsider,” which benefits both the facility and the practitioner.

KIDS TAKE CENTER STAGE

Mary Ottolini, MD, MPH, medical director, Hospitalist Services, at Children’s National Medical Center in Washington, D.C., was a pediatric hospitalist even before the job had a name.

“I was providing inpatient pediatric care, and I really loved it,” she says. “About that time, the hospitalist movement started, and I finally could attach a name to what I was doing.”

Everyone loves the arrangement, says Dr. Ottolini. Attending and referring physicians have the security of knowing that their patients are being cared for by specialists 24 hours a day.

“This removes a lot of stress and burden from them,” she notes. At the same time, parents “feel that there is someone taking ultimate responsibility for their child and looking after the whole child.”

Even when the prognosis is poor, “it is good to be there for families and help them through a difficult time,” continues Dr. Ottolini, who adds that it “is gratifying to work with an excellent team of experts to help a gravely ill child.”

HOSPITAL NEED FOR DERMATOLOGY: MORE THAN SKIN DEEP?

The need for a dermatologic hospitalist seems questionable. “Traditionally, dermatologists came to the hospital so infrequently,” recalls Dr. Wellikson. “There were few dermatologic emergencies.”

Even Rokea el-Azhary, MD, a dermatologic hospitalist at the Mayo Clinic in Rochester, Minn., admits, “There are so many medications to treat dermatologic conditions on an outpatient basis. This has influenced a downward trend in hospital dermatology over the years.”

Nonetheless, Dr. el-Azhary and her colleagues keep busy addressing severe medication-related and other rashes. They’re able to provide fast relief, which is important for patients with painful, uncomfortable conditions.

“If someone comes into the hospital with fever and a rash, aches, pain, neuralgia, and skin that shows vasculitis, we can make a diagnosis quickly and promptly begin treatment,” she explains.

PASSING FAD OR GROWING TREND?

Ask hospital-based specialists or their administrators if they think this trend is here to stay, and they are emphatic that it is.

“I think the hospitalist movement in general is reminiscent of the era when hospitals began hiring emergency room physicians,” suggests Dr. Marton. “These hadn’t existed previously; then overnight they were a common part of the hospital staff.”

Dr. Wellikson agrees. “Traditionally, hospitals have not been in the business of hiring physicians,” he says. “But now they are in the position of assembling a team with physicians as part of that.”

With the growth of hospital medicine overall, the variety of hospitalists will increase as well. The specialties will continue to transition into hospitalist programs and grow. They’re also expected to include such areas as orthopedic surgery. Specifically, Dr. Marton suggests that the next hot specialty for hospitalists can be predicted by identifying fields where there are high volumes of potential shortages. Still, he notes, some specialties, such as plastic surgery and neurosurgery, are unlikely to become hospital-based.

Many experts are not surprised by the rise of hospital-based specialists. Dr. Neilson points out that, in 2003, Louis Weinstein, MD, chair of the department of obstetrics and gynecology, Jefferson Medical College, Philadelphia, said that only about 10 hospitals had obstetric hospitalists, but that he expected this number to increase to several hundred in a few years.

“Weinstein proposed the idea of ‘laborists’ as a solution to the problems many hospitals had getting community obstetricians to handle patients besides their own,” recalls Dr. Neilson (see also, “What is a Laborist?” p. 6). “In fact, he felt it would evolve to a point where these laborists would handle the majority of hospital deliveries.”

RESEARCH SAYS …

Practitioners and administrators state anecdotally that hospital-based specialists make a positive difference in patient care, and research is just beginning to support these claims. For example, one study showed that pediatric hospitalists improve critical care outcomes. The authors concluded that patients treated by pediatric hospitalists were discharged nearly a full day sooner and were almost three times more likely to survive that stay after the pediatric intensive care unit switched after-hours coverage from residents to hospitalists.1

Clearly, more studies are needed regarding the effect of specialist hospitalists on outcomes, patient satisfaction, costs, and other aspects of hospital care. However, such research is likely to become more common as hospital-based specialists continue to gain popularity.

According to physicians who are hospital-based specialists, these studies will show that their services not only improve outcomes, but have a positive effect on practitioner lifestyle, hospital quality improvement efforts, and patient satisfaction.

“I think a few years ago this was a trend,” says Dr. Ottolini. “Now it’s not at all unusual to see specialists working as hospitalists.” TH

Writer Joanne Kaldy, who is based in Maryland, has covered healthcare issues for more than 10 years.

REFERENCE

1. Ottolini M, Pollack M. Pediatric hospitalists improve critical care outcomes. Crit Care Med. 2003;31(3):986-987.

Although most hospitalists have internal medicine as their medical specialty, a new breed of practitioners is gaining popularity. Hospitalists from obstetrics, pediatrics, psychiatry, dermatology, orthopedic surgery, and other fields bring the knowledge and experience of their specialties to hospital-based positions. In doing so, they gain many benefits they didn’t have as private practitioners. It’s a win-win situation that has the trend toward hospital-based specialists growing and receiving praise from physicians, administrators, and patients alike.

According to SHM CEO Larry Wellikson, MD, the demand for specialist hospitalists “is driven by hospitals’ needs to have these specialists available to them on a regular basis.”

HOSPITAL-BASED CARE DELIVERS FOR OBSTETRICIANS

Addressing a problem in their communities is one reason specialists join hospital teams. “The introduction of a new hospital in our small community, which previously only had one, created a challenge for small OB/GYN groups who didn’t have enough personnel to cover calls at two facilities,” says obstetric hospitalist Duncan Neilson, MD, chief of women’s services for Legacy Health System in Portland, Ore.

The ultimate question, Dr. Neilson says, was how to provide adequate OB/GYN and high-risk services and back up the community without having to hire “a lot” of physicians. “We solved both problems with hospitalists,” he explains.

Keith Marton, MD, FACP, chief medical officer/senior vice president at Legacy, adds that a key driver for the move to obstetric hospitalists was the desire to mitigate the facility’s liability risk.

“We saw hospitalists as providing continuity, more predictable physician presence to work with nurses to improve delivery outcomes,” he explains. Another important driver, Dr. Marton emphasizes, was his facility’s neonatal intensive care unit and the need for the perinatal specialists there to work with obstetricians they know and trust.

“We have seen from other communities that you don’t go out and ask community obstetricians to fill this role,” he says, adding that hospitalists are a better option. “This would improve care, increase our volume and revenues, and decrease costs.”

Being a hospital-based obstetrician has both business and lifestyle advantages. “In a typical OB/GYN practice, physicians often have to be in two places at once,” says Dr. Neilson. “When you’re with a laboring patient, you can’t be with patients in your office. You feel torn.”

There is no such split in hospital-based practice. “You’re free to concentrate on the care of laboring patients,” he says.

This is appealing for practitioners who especially like handling labor and deliveries because that’s the focus of their work. At the same time overhead and malpractice insurance are managed by the hospital, enabling specialty hospitalists to provide the best possible care with the least amount of hassle.

As for lifestyle, “you come to the hospital in the morning, you work your shift, you go home, and you are done,” explains Dr. Neilson.

Patients also benefit from having obstetric hospitalists involved in their care. “Patient safety is improved. A physician is onsite 24 hours a day to address problems,” says Dr. Neilson, who notes that this situation enables patients to stay with their own practitioner while having access to the hospital-based labor expert.

Are there disadvantages to being or hiring a hospital-based obstetrician? “It’s kind of hard to think of any,” admits Dr. Neilson. He suggests that physicians who like the variety of handling obstetrics and gynecology “might not like being a hospital-based specialist.”

PSYCHIATRIC HOSPITALISTS ANALYZE NEW OPPORTUNITIES

Obstetricians aren’t the only specialists enjoying lives as hospitalists. A growing number of psychiatrists are finding new and exciting opportunities as hospital-based practitioners. (See “The Doctor Is In,” p. 30.) For example, Thomas O’Brien, MD, a psychiatric hospitalist at Swedish Medical Center in Seattle, was drawn to hospital-based practice by his love of this setting and for treating acutely ill patients.

“I can intervene earlier,” he says. “And, as a result, patients don’t spin out of control.”

Dr. O’Brien likes the challenge of the complex cases he encounters. But he also likes the flexibility he enjoys. “It’s a good arrangement for me,” he says. “On the nights you’re off, you’re really off.”

As with other specialties, hospitals enjoy the arrangement as well. “Hospitals are much happier having physician employees that they can train and support more fully because they know them better,” observes Dr. O’Brien. “They also like the consistency of a physician who knows the staff and can respond quickly to problems, as well as patient and family questions. The doctor is part of the family, rather than an outsider,” which benefits both the facility and the practitioner.

KIDS TAKE CENTER STAGE

Mary Ottolini, MD, MPH, medical director, Hospitalist Services, at Children’s National Medical Center in Washington, D.C., was a pediatric hospitalist even before the job had a name.

“I was providing inpatient pediatric care, and I really loved it,” she says. “About that time, the hospitalist movement started, and I finally could attach a name to what I was doing.”

Everyone loves the arrangement, says Dr. Ottolini. Attending and referring physicians have the security of knowing that their patients are being cared for by specialists 24 hours a day.

“This removes a lot of stress and burden from them,” she notes. At the same time, parents “feel that there is someone taking ultimate responsibility for their child and looking after the whole child.”

Even when the prognosis is poor, “it is good to be there for families and help them through a difficult time,” continues Dr. Ottolini, who adds that it “is gratifying to work with an excellent team of experts to help a gravely ill child.”

HOSPITAL NEED FOR DERMATOLOGY: MORE THAN SKIN DEEP?

The need for a dermatologic hospitalist seems questionable. “Traditionally, dermatologists came to the hospital so infrequently,” recalls Dr. Wellikson. “There were few dermatologic emergencies.”

Even Rokea el-Azhary, MD, a dermatologic hospitalist at the Mayo Clinic in Rochester, Minn., admits, “There are so many medications to treat dermatologic conditions on an outpatient basis. This has influenced a downward trend in hospital dermatology over the years.”

Nonetheless, Dr. el-Azhary and her colleagues keep busy addressing severe medication-related and other rashes. They’re able to provide fast relief, which is important for patients with painful, uncomfortable conditions.

“If someone comes into the hospital with fever and a rash, aches, pain, neuralgia, and skin that shows vasculitis, we can make a diagnosis quickly and promptly begin treatment,” she explains.

PASSING FAD OR GROWING TREND?

Ask hospital-based specialists or their administrators if they think this trend is here to stay, and they are emphatic that it is.

“I think the hospitalist movement in general is reminiscent of the era when hospitals began hiring emergency room physicians,” suggests Dr. Marton. “These hadn’t existed previously; then overnight they were a common part of the hospital staff.”

Dr. Wellikson agrees. “Traditionally, hospitals have not been in the business of hiring physicians,” he says. “But now they are in the position of assembling a team with physicians as part of that.”

With the growth of hospital medicine overall, the variety of hospitalists will increase as well. The specialties will continue to transition into hospitalist programs and grow. They’re also expected to include such areas as orthopedic surgery. Specifically, Dr. Marton suggests that the next hot specialty for hospitalists can be predicted by identifying fields where there are high volumes of potential shortages. Still, he notes, some specialties, such as plastic surgery and neurosurgery, are unlikely to become hospital-based.

Many experts are not surprised by the rise of hospital-based specialists. Dr. Neilson points out that, in 2003, Louis Weinstein, MD, chair of the department of obstetrics and gynecology, Jefferson Medical College, Philadelphia, said that only about 10 hospitals had obstetric hospitalists, but that he expected this number to increase to several hundred in a few years.

“Weinstein proposed the idea of ‘laborists’ as a solution to the problems many hospitals had getting community obstetricians to handle patients besides their own,” recalls Dr. Neilson (see also, “What is a Laborist?” p. 6). “In fact, he felt it would evolve to a point where these laborists would handle the majority of hospital deliveries.”

RESEARCH SAYS …

Practitioners and administrators state anecdotally that hospital-based specialists make a positive difference in patient care, and research is just beginning to support these claims. For example, one study showed that pediatric hospitalists improve critical care outcomes. The authors concluded that patients treated by pediatric hospitalists were discharged nearly a full day sooner and were almost three times more likely to survive that stay after the pediatric intensive care unit switched after-hours coverage from residents to hospitalists.1

Clearly, more studies are needed regarding the effect of specialist hospitalists on outcomes, patient satisfaction, costs, and other aspects of hospital care. However, such research is likely to become more common as hospital-based specialists continue to gain popularity.

According to physicians who are hospital-based specialists, these studies will show that their services not only improve outcomes, but have a positive effect on practitioner lifestyle, hospital quality improvement efforts, and patient satisfaction.

“I think a few years ago this was a trend,” says Dr. Ottolini. “Now it’s not at all unusual to see specialists working as hospitalists.” TH

Writer Joanne Kaldy, who is based in Maryland, has covered healthcare issues for more than 10 years.

REFERENCE

1. Ottolini M, Pollack M. Pediatric hospitalists improve critical care outcomes. Crit Care Med. 2003;31(3):986-987.

Although most hospitalists have internal medicine as their medical specialty, a new breed of practitioners is gaining popularity. Hospitalists from obstetrics, pediatrics, psychiatry, dermatology, orthopedic surgery, and other fields bring the knowledge and experience of their specialties to hospital-based positions. In doing so, they gain many benefits they didn’t have as private practitioners. It’s a win-win situation that has the trend toward hospital-based specialists growing and receiving praise from physicians, administrators, and patients alike.

According to SHM CEO Larry Wellikson, MD, the demand for specialist hospitalists “is driven by hospitals’ needs to have these specialists available to them on a regular basis.”

HOSPITAL-BASED CARE DELIVERS FOR OBSTETRICIANS

Addressing a problem in their communities is one reason specialists join hospital teams. “The introduction of a new hospital in our small community, which previously only had one, created a challenge for small OB/GYN groups who didn’t have enough personnel to cover calls at two facilities,” says obstetric hospitalist Duncan Neilson, MD, chief of women’s services for Legacy Health System in Portland, Ore.

The ultimate question, Dr. Neilson says, was how to provide adequate OB/GYN and high-risk services and back up the community without having to hire “a lot” of physicians. “We solved both problems with hospitalists,” he explains.

Keith Marton, MD, FACP, chief medical officer/senior vice president at Legacy, adds that a key driver for the move to obstetric hospitalists was the desire to mitigate the facility’s liability risk.

“We saw hospitalists as providing continuity, more predictable physician presence to work with nurses to improve delivery outcomes,” he explains. Another important driver, Dr. Marton emphasizes, was his facility’s neonatal intensive care unit and the need for the perinatal specialists there to work with obstetricians they know and trust.

“We have seen from other communities that you don’t go out and ask community obstetricians to fill this role,” he says, adding that hospitalists are a better option. “This would improve care, increase our volume and revenues, and decrease costs.”

Being a hospital-based obstetrician has both business and lifestyle advantages. “In a typical OB/GYN practice, physicians often have to be in two places at once,” says Dr. Neilson. “When you’re with a laboring patient, you can’t be with patients in your office. You feel torn.”

There is no such split in hospital-based practice. “You’re free to concentrate on the care of laboring patients,” he says.

This is appealing for practitioners who especially like handling labor and deliveries because that’s the focus of their work. At the same time overhead and malpractice insurance are managed by the hospital, enabling specialty hospitalists to provide the best possible care with the least amount of hassle.

As for lifestyle, “you come to the hospital in the morning, you work your shift, you go home, and you are done,” explains Dr. Neilson.

Patients also benefit from having obstetric hospitalists involved in their care. “Patient safety is improved. A physician is onsite 24 hours a day to address problems,” says Dr. Neilson, who notes that this situation enables patients to stay with their own practitioner while having access to the hospital-based labor expert.

Are there disadvantages to being or hiring a hospital-based obstetrician? “It’s kind of hard to think of any,” admits Dr. Neilson. He suggests that physicians who like the variety of handling obstetrics and gynecology “might not like being a hospital-based specialist.”

PSYCHIATRIC HOSPITALISTS ANALYZE NEW OPPORTUNITIES

Obstetricians aren’t the only specialists enjoying lives as hospitalists. A growing number of psychiatrists are finding new and exciting opportunities as hospital-based practitioners. (See “The Doctor Is In,” p. 30.) For example, Thomas O’Brien, MD, a psychiatric hospitalist at Swedish Medical Center in Seattle, was drawn to hospital-based practice by his love of this setting and for treating acutely ill patients.

“I can intervene earlier,” he says. “And, as a result, patients don’t spin out of control.”

Dr. O’Brien likes the challenge of the complex cases he encounters. But he also likes the flexibility he enjoys. “It’s a good arrangement for me,” he says. “On the nights you’re off, you’re really off.”

As with other specialties, hospitals enjoy the arrangement as well. “Hospitals are much happier having physician employees that they can train and support more fully because they know them better,” observes Dr. O’Brien. “They also like the consistency of a physician who knows the staff and can respond quickly to problems, as well as patient and family questions. The doctor is part of the family, rather than an outsider,” which benefits both the facility and the practitioner.

KIDS TAKE CENTER STAGE

Mary Ottolini, MD, MPH, medical director, Hospitalist Services, at Children’s National Medical Center in Washington, D.C., was a pediatric hospitalist even before the job had a name.

“I was providing inpatient pediatric care, and I really loved it,” she says. “About that time, the hospitalist movement started, and I finally could attach a name to what I was doing.”

Everyone loves the arrangement, says Dr. Ottolini. Attending and referring physicians have the security of knowing that their patients are being cared for by specialists 24 hours a day.

“This removes a lot of stress and burden from them,” she notes. At the same time, parents “feel that there is someone taking ultimate responsibility for their child and looking after the whole child.”

Even when the prognosis is poor, “it is good to be there for families and help them through a difficult time,” continues Dr. Ottolini, who adds that it “is gratifying to work with an excellent team of experts to help a gravely ill child.”

HOSPITAL NEED FOR DERMATOLOGY: MORE THAN SKIN DEEP?

The need for a dermatologic hospitalist seems questionable. “Traditionally, dermatologists came to the hospital so infrequently,” recalls Dr. Wellikson. “There were few dermatologic emergencies.”

Even Rokea el-Azhary, MD, a dermatologic hospitalist at the Mayo Clinic in Rochester, Minn., admits, “There are so many medications to treat dermatologic conditions on an outpatient basis. This has influenced a downward trend in hospital dermatology over the years.”

Nonetheless, Dr. el-Azhary and her colleagues keep busy addressing severe medication-related and other rashes. They’re able to provide fast relief, which is important for patients with painful, uncomfortable conditions.

“If someone comes into the hospital with fever and a rash, aches, pain, neuralgia, and skin that shows vasculitis, we can make a diagnosis quickly and promptly begin treatment,” she explains.

PASSING FAD OR GROWING TREND?

Ask hospital-based specialists or their administrators if they think this trend is here to stay, and they are emphatic that it is.

“I think the hospitalist movement in general is reminiscent of the era when hospitals began hiring emergency room physicians,” suggests Dr. Marton. “These hadn’t existed previously; then overnight they were a common part of the hospital staff.”

Dr. Wellikson agrees. “Traditionally, hospitals have not been in the business of hiring physicians,” he says. “But now they are in the position of assembling a team with physicians as part of that.”

With the growth of hospital medicine overall, the variety of hospitalists will increase as well. The specialties will continue to transition into hospitalist programs and grow. They’re also expected to include such areas as orthopedic surgery. Specifically, Dr. Marton suggests that the next hot specialty for hospitalists can be predicted by identifying fields where there are high volumes of potential shortages. Still, he notes, some specialties, such as plastic surgery and neurosurgery, are unlikely to become hospital-based.

Many experts are not surprised by the rise of hospital-based specialists. Dr. Neilson points out that, in 2003, Louis Weinstein, MD, chair of the department of obstetrics and gynecology, Jefferson Medical College, Philadelphia, said that only about 10 hospitals had obstetric hospitalists, but that he expected this number to increase to several hundred in a few years.

“Weinstein proposed the idea of ‘laborists’ as a solution to the problems many hospitals had getting community obstetricians to handle patients besides their own,” recalls Dr. Neilson (see also, “What is a Laborist?” p. 6). “In fact, he felt it would evolve to a point where these laborists would handle the majority of hospital deliveries.”

RESEARCH SAYS …

Practitioners and administrators state anecdotally that hospital-based specialists make a positive difference in patient care, and research is just beginning to support these claims. For example, one study showed that pediatric hospitalists improve critical care outcomes. The authors concluded that patients treated by pediatric hospitalists were discharged nearly a full day sooner and were almost three times more likely to survive that stay after the pediatric intensive care unit switched after-hours coverage from residents to hospitalists.1

Clearly, more studies are needed regarding the effect of specialist hospitalists on outcomes, patient satisfaction, costs, and other aspects of hospital care. However, such research is likely to become more common as hospital-based specialists continue to gain popularity.

According to physicians who are hospital-based specialists, these studies will show that their services not only improve outcomes, but have a positive effect on practitioner lifestyle, hospital quality improvement efforts, and patient satisfaction.

“I think a few years ago this was a trend,” says Dr. Ottolini. “Now it’s not at all unusual to see specialists working as hospitalists.” TH

Writer Joanne Kaldy, who is based in Maryland, has covered healthcare issues for more than 10 years.

REFERENCE

1. Ottolini M, Pollack M. Pediatric hospitalists improve critical care outcomes. Crit Care Med. 2003;31(3):986-987.