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Hospitalist NPs and PAs note progress
But remain underutilized
Nurse practitioners (NPs) and physician assistants (PAs) have become a more prominent part of the hospitalist workforce, and at many institutions, they account for a large proportion of patient care and have a powerful effect on a patient’s experience. But NP and PA roles in hospital medicine continue to evolve – and understanding what they do is still, at times, a work in progress.
One myth that persists regarding NPs and PAs is that, if you’ve seen one, you’ve seen them all.
At the 2018 Annual Conference of the Society of Hospital Medicine, Noam Shabani, MS, PA-C, lead physician assistant at Massachusetts General Hospital’s Hospital Medicine Unit, Boston, offered an example to help shatter this misperception.
Mr. Shabani described a 28-year-old woman who had a bachelor’s in biology with a premed track and spent 4 years as a paramedic before attending the physician assistant program at Duke University, Durham, N.C. As a new PA graduate, she was hired as a hospitalist at a community hospital in Kentucky.
Given this new PA’s clinical experience and formal education, there are certain skills she should bring to the table: the ability to develop a differential diagnosis and a good understanding of disease pathophysiology and the mechanisms of action of drugs. And because of her paramedic experience, she should be comfortable with making urgent clinical care decisions and should be proficient with electrocardiograms, as well as chest and abdominal x-rays.
But compared with a newly graduated NP with registered nurse (RN) floor experience, the PA is likely to be less familiar with hospital mechanics and systems, with leading goal of care discussions with patients and families, and with understanding nuances involved with transitions of care.
The subtle differences between NPs and PAs don’t end there. Because of the progressive policies and recently updated bylaws at the Kentucky hospital where the PA was hired, this health care professional can see patients and write notes independently without a physician signature. But because she practices in Kentucky, she is not allowed to prescribe Schedule II medications, per state law.
“This example demonstrates how nuanced and multi-layered the process of integrating NPs and PAs into hospitalist groups can be,” Mr. Shabani said.
Goals, roles, and expectations
Physician assistants and nurse practitioners have reported that their job descriptions, and the variety of roles they can play within HM teams, are becoming better understood by hospitalist physicians and administrators. However, they also have acknowledged that both PAs and NPs are still underutilized.
Tricia Marriott, PA-C, MPAS, an orthopedic service line administrator at Saint Mary’s Hospital in Waterbury, Conn., and an expert in NP and PA policy, has noticed growing enlightenment about PAs and NPs in her travels to conferences in recent years.
“I’m no longer explaining what a PA is and what an NP is, and the questions have become very sophisticated,” she said at HM18. “However, I spent the last two days in the exhibit hall, and some of the conversations I had with physicians are interesting in that the practice and utilization styles have not become sophisticated. So I think there is a lot of opportunity out there.”
Mr. Shabani said the hospitalist care provided by PAs and NPs sits “at the intersection” of state regulations, hospital bylaws, department utilization, and – of course – clinical experience and formal medical education.
“What this boils down to is first understanding these factors, followed by strategizing recruitment and training as a response,” he said.
Tracy Cardin, ACNP-BC, SFHM, associate director of clinical integration at Adfinitas Health in Hanover, Md., and a Society of Hospital Medicine board member, said that, even though she usually sees and hears about a 10%-15% productivity gap between physicians and PAs or NPs, there is no good reason that an experienced PA or NP should not be able to handle the same patient load as a physician hospitalist – if that’s the goal.
“Part of it is about communication of expectation,” she said, noting that organizations must provide the training to allows NPs and PAs to reach prescribed goals along with an adequate level of administrative support. “I think we shouldn’t accept those gaps in productivity.”
Nicolas Houghton, DNP, ACNP-BC, CFRN, nurse practitioner/physician assistant manager at the Cleveland Clinic, thinks that it is completely reasonable for health care organizations to have an expectation that, at the 3- to 5-year mark, NPs and PAs “are really going to be functioning at very high levels that may be nearly indistinguishable.”
Dr. Houghton and Mr. Shabani agreed that, while they had considerably different duties at the start of their careers, they now have clinical roles which mirror one another.
For example, they agreed on these basics: NPs must be a certified RN, while a PA can have any undergraduate degree with certain prerequisite courses such as biology and chemistry. All PAs are trained in general medicine, while NPs specialize in areas such as acute care, family medicine, geriatrics, and women’s health. NPs need 500 didactic hours and 500-700 clinical hours in their area of expertise, while physician assistants need 1,000 didactic and 2,000 clinical hours spread over many disciplines.
For NP’s, required clinical rotations depend on the specialty, while all PAs need to complete rotations in inpatient medicine, emergency medicine, primary care, surgery, psychiatry, pediatrics, and ob.gyn. Also, NPs can practice independently in 23 states and the District of Columbia, while PAs must have a supervising physician. About 10% of NPs work in hospital settings, and about 39% of PAs work in hospital settings, they said.
Dr. Houghton and Mr. Shabani emphasized that Medicare does recognize NP and PA services as physician services. The official language, in place since 1998, is that their services “are the type that are considered physician’s services if furnished by a doctor of medicine or osteopathy.”
Mr. Shabani said this remained a very relevant issue. “I can’t overstate how important this is,” he said.
Debunking myths
Several myths continue to persist about PAs and NPs, Ms. Marriott said. Some administrators and physicians believe that they can’t see new patients, that a physician must see every patient, that a physician cosignature means that a claim can be submitted under the physician’s name, that reimbursement for services provided by PAs and NPs “leaves 15% on the table,” and that patients won’t be happy being seen by a PA or an NP. All of those things are false, she said.
“We really need to improve people’s understanding in a lot of different places – it’s not just at the clinician level,” she said. “It goes all the way through the operations team, and the operations team has some very old-fashioned thinking about what PAs and NPs really are, which is – they believe – clinical support staff.”
But she suggested that the phrase “working at the top of one’s license” can be used too freely – individual experience and ability will encompass a range of practices, she said.
“I’m licensed to drive a car,” she said. “But you do not want me in the Daytona 500. I am not capable of driving a race car.”
She cautioned that nurse practitioner care must still involve an element of collaboration, according to the Medicaid benefit policy manual, even if they work in states that allow NPs to provide “independent” care. They must have documentation “indicating the relationships that they have with physicians to deal with issues outside their scope of practice,” the manual says.
“Don’t ask me how people prove it,” Ms. Marriott said. “Just know that, if someone were to audit you, then you would need to show what this looks like.”
Regarding the 15% myth, she showed a calculation: Data from the Medical Group Management Association show that median annual compensation for a physician is $134 an hour and that it’s approximately $52 an hour for a PA or NP. An admission history and physical that takes an hour can be reimbursed at $102 for a physician and at 85% of that – $87 – for a PA or NP. That leaves a deficit of $32 for the physician and a surplus of $35 for the PA or NP.
“If you properly deploy your PAs and NPs, you’re going to generate positive margins,” Ms. Marriott said.
Physicians often scurry about seeing all the patients that have already been seen by a PA, she said, because they think they must capture the extra 15% reimbursement. But that is unnecessary, she said.
“Go do another admission. You should see patients because of their clinical condition. My point is not that you go running around because you want to capture the extra 15% – because that provides no additional medically necessary care.”
Changing practice
Many institutions continue to be hamstrung by their own bylaws in the use of NPs and PAs. It’s true that a physician doesn’t have to see every patient, unless it’s required in a hospital’s rules, Ms. Marriott noted.
“Somebody step up, get on the bylaws committee, and say, ‘Let’s update these.’ ” she said.
As for patient satisfaction, access and convenience routinely rank higher on the patient priority lists than provider credentials. “The patient wants to get off the gurney in the ED and get to a room,” she said.
But changing hospital bylaws and practices is also about the responsible use of health care dollars, Ms. Marriott affirmed.
“More patients seen in a timely fashion, and quality metrics improvement: Those are all things that are really, really important,” she said. “As a result, [if bylaws and practice patterns are changed] the physicians are hopefully going to be happier, certainly the administration is going to be happier, and the patients are going to fare better.”
Scott Faust, MS, APRN, CNP, an acute care nurse practitioner at Health Partners in St. Paul, Minn., said that teamwork without egos is crucial to success for all providers on the hospital medicine team, especially at busier moments.
“Nobody wants to be in this alone,” he said. “I think the hospitalist teams that work well are the ones that check their titles at the door.”
PAs and NPs generally agree that, as long as all clinical staffers are working within their areas of skill without being overly concerned about specific titles and roles, hospitals and patients will benefit.
“I’ve had physicians at my organization say ‘We need to have an NP and PA set of educational requirements,’ and I said, ‘We have some already for physicians, right? Why aren’t we using that?’ ” Dr. Houghton said. “I think we should have the same expectations clinically. At the end of the day, the patient deserves the same outcomes and the same care, whether they’re being cared for by a physician, an NP, or a PA.”
Onboarding NPs and PAs
According to SHM’s Nurse Practitioner/Physician Assistant Committee, the integration of a new NP or PA hire, whether experienced or not, requires up-front organization and planning for the employee as he or she enters into a new practice.
To that end, the NP/PA Committee created a toolkit to aid health care organizations in their integration of NP and PA staffers into hospital medicine practice groups. The document includes resources for recruiting and interviewing NPs and PAs, information about orientation and onboarding, detailed descriptions of models of care to aid in the utilization of NPs and PAs, best practices for staff retention, insights on billing and reimbursement, and ideas for program evaluation.
Readers can download the Onboarding Toolkit in PDF format at shm.hospitalmedicine.org/acton/attachment/25526/f-040f/1/-/-/-/-/SHM_NPPA_OboardingToolkit.pdf.
But remain underutilized
But remain underutilized
Nurse practitioners (NPs) and physician assistants (PAs) have become a more prominent part of the hospitalist workforce, and at many institutions, they account for a large proportion of patient care and have a powerful effect on a patient’s experience. But NP and PA roles in hospital medicine continue to evolve – and understanding what they do is still, at times, a work in progress.
One myth that persists regarding NPs and PAs is that, if you’ve seen one, you’ve seen them all.
At the 2018 Annual Conference of the Society of Hospital Medicine, Noam Shabani, MS, PA-C, lead physician assistant at Massachusetts General Hospital’s Hospital Medicine Unit, Boston, offered an example to help shatter this misperception.
Mr. Shabani described a 28-year-old woman who had a bachelor’s in biology with a premed track and spent 4 years as a paramedic before attending the physician assistant program at Duke University, Durham, N.C. As a new PA graduate, she was hired as a hospitalist at a community hospital in Kentucky.
Given this new PA’s clinical experience and formal education, there are certain skills she should bring to the table: the ability to develop a differential diagnosis and a good understanding of disease pathophysiology and the mechanisms of action of drugs. And because of her paramedic experience, she should be comfortable with making urgent clinical care decisions and should be proficient with electrocardiograms, as well as chest and abdominal x-rays.
But compared with a newly graduated NP with registered nurse (RN) floor experience, the PA is likely to be less familiar with hospital mechanics and systems, with leading goal of care discussions with patients and families, and with understanding nuances involved with transitions of care.
The subtle differences between NPs and PAs don’t end there. Because of the progressive policies and recently updated bylaws at the Kentucky hospital where the PA was hired, this health care professional can see patients and write notes independently without a physician signature. But because she practices in Kentucky, she is not allowed to prescribe Schedule II medications, per state law.
“This example demonstrates how nuanced and multi-layered the process of integrating NPs and PAs into hospitalist groups can be,” Mr. Shabani said.
Goals, roles, and expectations
Physician assistants and nurse practitioners have reported that their job descriptions, and the variety of roles they can play within HM teams, are becoming better understood by hospitalist physicians and administrators. However, they also have acknowledged that both PAs and NPs are still underutilized.
Tricia Marriott, PA-C, MPAS, an orthopedic service line administrator at Saint Mary’s Hospital in Waterbury, Conn., and an expert in NP and PA policy, has noticed growing enlightenment about PAs and NPs in her travels to conferences in recent years.
“I’m no longer explaining what a PA is and what an NP is, and the questions have become very sophisticated,” she said at HM18. “However, I spent the last two days in the exhibit hall, and some of the conversations I had with physicians are interesting in that the practice and utilization styles have not become sophisticated. So I think there is a lot of opportunity out there.”
Mr. Shabani said the hospitalist care provided by PAs and NPs sits “at the intersection” of state regulations, hospital bylaws, department utilization, and – of course – clinical experience and formal medical education.
“What this boils down to is first understanding these factors, followed by strategizing recruitment and training as a response,” he said.
Tracy Cardin, ACNP-BC, SFHM, associate director of clinical integration at Adfinitas Health in Hanover, Md., and a Society of Hospital Medicine board member, said that, even though she usually sees and hears about a 10%-15% productivity gap between physicians and PAs or NPs, there is no good reason that an experienced PA or NP should not be able to handle the same patient load as a physician hospitalist – if that’s the goal.
“Part of it is about communication of expectation,” she said, noting that organizations must provide the training to allows NPs and PAs to reach prescribed goals along with an adequate level of administrative support. “I think we shouldn’t accept those gaps in productivity.”
Nicolas Houghton, DNP, ACNP-BC, CFRN, nurse practitioner/physician assistant manager at the Cleveland Clinic, thinks that it is completely reasonable for health care organizations to have an expectation that, at the 3- to 5-year mark, NPs and PAs “are really going to be functioning at very high levels that may be nearly indistinguishable.”
Dr. Houghton and Mr. Shabani agreed that, while they had considerably different duties at the start of their careers, they now have clinical roles which mirror one another.
For example, they agreed on these basics: NPs must be a certified RN, while a PA can have any undergraduate degree with certain prerequisite courses such as biology and chemistry. All PAs are trained in general medicine, while NPs specialize in areas such as acute care, family medicine, geriatrics, and women’s health. NPs need 500 didactic hours and 500-700 clinical hours in their area of expertise, while physician assistants need 1,000 didactic and 2,000 clinical hours spread over many disciplines.
For NP’s, required clinical rotations depend on the specialty, while all PAs need to complete rotations in inpatient medicine, emergency medicine, primary care, surgery, psychiatry, pediatrics, and ob.gyn. Also, NPs can practice independently in 23 states and the District of Columbia, while PAs must have a supervising physician. About 10% of NPs work in hospital settings, and about 39% of PAs work in hospital settings, they said.
Dr. Houghton and Mr. Shabani emphasized that Medicare does recognize NP and PA services as physician services. The official language, in place since 1998, is that their services “are the type that are considered physician’s services if furnished by a doctor of medicine or osteopathy.”
Mr. Shabani said this remained a very relevant issue. “I can’t overstate how important this is,” he said.
Debunking myths
Several myths continue to persist about PAs and NPs, Ms. Marriott said. Some administrators and physicians believe that they can’t see new patients, that a physician must see every patient, that a physician cosignature means that a claim can be submitted under the physician’s name, that reimbursement for services provided by PAs and NPs “leaves 15% on the table,” and that patients won’t be happy being seen by a PA or an NP. All of those things are false, she said.
“We really need to improve people’s understanding in a lot of different places – it’s not just at the clinician level,” she said. “It goes all the way through the operations team, and the operations team has some very old-fashioned thinking about what PAs and NPs really are, which is – they believe – clinical support staff.”
But she suggested that the phrase “working at the top of one’s license” can be used too freely – individual experience and ability will encompass a range of practices, she said.
“I’m licensed to drive a car,” she said. “But you do not want me in the Daytona 500. I am not capable of driving a race car.”
She cautioned that nurse practitioner care must still involve an element of collaboration, according to the Medicaid benefit policy manual, even if they work in states that allow NPs to provide “independent” care. They must have documentation “indicating the relationships that they have with physicians to deal with issues outside their scope of practice,” the manual says.
“Don’t ask me how people prove it,” Ms. Marriott said. “Just know that, if someone were to audit you, then you would need to show what this looks like.”
Regarding the 15% myth, she showed a calculation: Data from the Medical Group Management Association show that median annual compensation for a physician is $134 an hour and that it’s approximately $52 an hour for a PA or NP. An admission history and physical that takes an hour can be reimbursed at $102 for a physician and at 85% of that – $87 – for a PA or NP. That leaves a deficit of $32 for the physician and a surplus of $35 for the PA or NP.
“If you properly deploy your PAs and NPs, you’re going to generate positive margins,” Ms. Marriott said.
Physicians often scurry about seeing all the patients that have already been seen by a PA, she said, because they think they must capture the extra 15% reimbursement. But that is unnecessary, she said.
“Go do another admission. You should see patients because of their clinical condition. My point is not that you go running around because you want to capture the extra 15% – because that provides no additional medically necessary care.”
Changing practice
Many institutions continue to be hamstrung by their own bylaws in the use of NPs and PAs. It’s true that a physician doesn’t have to see every patient, unless it’s required in a hospital’s rules, Ms. Marriott noted.
“Somebody step up, get on the bylaws committee, and say, ‘Let’s update these.’ ” she said.
As for patient satisfaction, access and convenience routinely rank higher on the patient priority lists than provider credentials. “The patient wants to get off the gurney in the ED and get to a room,” she said.
But changing hospital bylaws and practices is also about the responsible use of health care dollars, Ms. Marriott affirmed.
“More patients seen in a timely fashion, and quality metrics improvement: Those are all things that are really, really important,” she said. “As a result, [if bylaws and practice patterns are changed] the physicians are hopefully going to be happier, certainly the administration is going to be happier, and the patients are going to fare better.”
Scott Faust, MS, APRN, CNP, an acute care nurse practitioner at Health Partners in St. Paul, Minn., said that teamwork without egos is crucial to success for all providers on the hospital medicine team, especially at busier moments.
“Nobody wants to be in this alone,” he said. “I think the hospitalist teams that work well are the ones that check their titles at the door.”
PAs and NPs generally agree that, as long as all clinical staffers are working within their areas of skill without being overly concerned about specific titles and roles, hospitals and patients will benefit.
“I’ve had physicians at my organization say ‘We need to have an NP and PA set of educational requirements,’ and I said, ‘We have some already for physicians, right? Why aren’t we using that?’ ” Dr. Houghton said. “I think we should have the same expectations clinically. At the end of the day, the patient deserves the same outcomes and the same care, whether they’re being cared for by a physician, an NP, or a PA.”
Onboarding NPs and PAs
According to SHM’s Nurse Practitioner/Physician Assistant Committee, the integration of a new NP or PA hire, whether experienced or not, requires up-front organization and planning for the employee as he or she enters into a new practice.
To that end, the NP/PA Committee created a toolkit to aid health care organizations in their integration of NP and PA staffers into hospital medicine practice groups. The document includes resources for recruiting and interviewing NPs and PAs, information about orientation and onboarding, detailed descriptions of models of care to aid in the utilization of NPs and PAs, best practices for staff retention, insights on billing and reimbursement, and ideas for program evaluation.
Readers can download the Onboarding Toolkit in PDF format at shm.hospitalmedicine.org/acton/attachment/25526/f-040f/1/-/-/-/-/SHM_NPPA_OboardingToolkit.pdf.
Nurse practitioners (NPs) and physician assistants (PAs) have become a more prominent part of the hospitalist workforce, and at many institutions, they account for a large proportion of patient care and have a powerful effect on a patient’s experience. But NP and PA roles in hospital medicine continue to evolve – and understanding what they do is still, at times, a work in progress.
One myth that persists regarding NPs and PAs is that, if you’ve seen one, you’ve seen them all.
At the 2018 Annual Conference of the Society of Hospital Medicine, Noam Shabani, MS, PA-C, lead physician assistant at Massachusetts General Hospital’s Hospital Medicine Unit, Boston, offered an example to help shatter this misperception.
Mr. Shabani described a 28-year-old woman who had a bachelor’s in biology with a premed track and spent 4 years as a paramedic before attending the physician assistant program at Duke University, Durham, N.C. As a new PA graduate, she was hired as a hospitalist at a community hospital in Kentucky.
Given this new PA’s clinical experience and formal education, there are certain skills she should bring to the table: the ability to develop a differential diagnosis and a good understanding of disease pathophysiology and the mechanisms of action of drugs. And because of her paramedic experience, she should be comfortable with making urgent clinical care decisions and should be proficient with electrocardiograms, as well as chest and abdominal x-rays.
But compared with a newly graduated NP with registered nurse (RN) floor experience, the PA is likely to be less familiar with hospital mechanics and systems, with leading goal of care discussions with patients and families, and with understanding nuances involved with transitions of care.
The subtle differences between NPs and PAs don’t end there. Because of the progressive policies and recently updated bylaws at the Kentucky hospital where the PA was hired, this health care professional can see patients and write notes independently without a physician signature. But because she practices in Kentucky, she is not allowed to prescribe Schedule II medications, per state law.
“This example demonstrates how nuanced and multi-layered the process of integrating NPs and PAs into hospitalist groups can be,” Mr. Shabani said.
Goals, roles, and expectations
Physician assistants and nurse practitioners have reported that their job descriptions, and the variety of roles they can play within HM teams, are becoming better understood by hospitalist physicians and administrators. However, they also have acknowledged that both PAs and NPs are still underutilized.
Tricia Marriott, PA-C, MPAS, an orthopedic service line administrator at Saint Mary’s Hospital in Waterbury, Conn., and an expert in NP and PA policy, has noticed growing enlightenment about PAs and NPs in her travels to conferences in recent years.
“I’m no longer explaining what a PA is and what an NP is, and the questions have become very sophisticated,” she said at HM18. “However, I spent the last two days in the exhibit hall, and some of the conversations I had with physicians are interesting in that the practice and utilization styles have not become sophisticated. So I think there is a lot of opportunity out there.”
Mr. Shabani said the hospitalist care provided by PAs and NPs sits “at the intersection” of state regulations, hospital bylaws, department utilization, and – of course – clinical experience and formal medical education.
“What this boils down to is first understanding these factors, followed by strategizing recruitment and training as a response,” he said.
Tracy Cardin, ACNP-BC, SFHM, associate director of clinical integration at Adfinitas Health in Hanover, Md., and a Society of Hospital Medicine board member, said that, even though she usually sees and hears about a 10%-15% productivity gap between physicians and PAs or NPs, there is no good reason that an experienced PA or NP should not be able to handle the same patient load as a physician hospitalist – if that’s the goal.
“Part of it is about communication of expectation,” she said, noting that organizations must provide the training to allows NPs and PAs to reach prescribed goals along with an adequate level of administrative support. “I think we shouldn’t accept those gaps in productivity.”
Nicolas Houghton, DNP, ACNP-BC, CFRN, nurse practitioner/physician assistant manager at the Cleveland Clinic, thinks that it is completely reasonable for health care organizations to have an expectation that, at the 3- to 5-year mark, NPs and PAs “are really going to be functioning at very high levels that may be nearly indistinguishable.”
Dr. Houghton and Mr. Shabani agreed that, while they had considerably different duties at the start of their careers, they now have clinical roles which mirror one another.
For example, they agreed on these basics: NPs must be a certified RN, while a PA can have any undergraduate degree with certain prerequisite courses such as biology and chemistry. All PAs are trained in general medicine, while NPs specialize in areas such as acute care, family medicine, geriatrics, and women’s health. NPs need 500 didactic hours and 500-700 clinical hours in their area of expertise, while physician assistants need 1,000 didactic and 2,000 clinical hours spread over many disciplines.
For NP’s, required clinical rotations depend on the specialty, while all PAs need to complete rotations in inpatient medicine, emergency medicine, primary care, surgery, psychiatry, pediatrics, and ob.gyn. Also, NPs can practice independently in 23 states and the District of Columbia, while PAs must have a supervising physician. About 10% of NPs work in hospital settings, and about 39% of PAs work in hospital settings, they said.
Dr. Houghton and Mr. Shabani emphasized that Medicare does recognize NP and PA services as physician services. The official language, in place since 1998, is that their services “are the type that are considered physician’s services if furnished by a doctor of medicine or osteopathy.”
Mr. Shabani said this remained a very relevant issue. “I can’t overstate how important this is,” he said.
Debunking myths
Several myths continue to persist about PAs and NPs, Ms. Marriott said. Some administrators and physicians believe that they can’t see new patients, that a physician must see every patient, that a physician cosignature means that a claim can be submitted under the physician’s name, that reimbursement for services provided by PAs and NPs “leaves 15% on the table,” and that patients won’t be happy being seen by a PA or an NP. All of those things are false, she said.
“We really need to improve people’s understanding in a lot of different places – it’s not just at the clinician level,” she said. “It goes all the way through the operations team, and the operations team has some very old-fashioned thinking about what PAs and NPs really are, which is – they believe – clinical support staff.”
But she suggested that the phrase “working at the top of one’s license” can be used too freely – individual experience and ability will encompass a range of practices, she said.
“I’m licensed to drive a car,” she said. “But you do not want me in the Daytona 500. I am not capable of driving a race car.”
She cautioned that nurse practitioner care must still involve an element of collaboration, according to the Medicaid benefit policy manual, even if they work in states that allow NPs to provide “independent” care. They must have documentation “indicating the relationships that they have with physicians to deal with issues outside their scope of practice,” the manual says.
“Don’t ask me how people prove it,” Ms. Marriott said. “Just know that, if someone were to audit you, then you would need to show what this looks like.”
Regarding the 15% myth, she showed a calculation: Data from the Medical Group Management Association show that median annual compensation for a physician is $134 an hour and that it’s approximately $52 an hour for a PA or NP. An admission history and physical that takes an hour can be reimbursed at $102 for a physician and at 85% of that – $87 – for a PA or NP. That leaves a deficit of $32 for the physician and a surplus of $35 for the PA or NP.
“If you properly deploy your PAs and NPs, you’re going to generate positive margins,” Ms. Marriott said.
Physicians often scurry about seeing all the patients that have already been seen by a PA, she said, because they think they must capture the extra 15% reimbursement. But that is unnecessary, she said.
“Go do another admission. You should see patients because of their clinical condition. My point is not that you go running around because you want to capture the extra 15% – because that provides no additional medically necessary care.”
Changing practice
Many institutions continue to be hamstrung by their own bylaws in the use of NPs and PAs. It’s true that a physician doesn’t have to see every patient, unless it’s required in a hospital’s rules, Ms. Marriott noted.
“Somebody step up, get on the bylaws committee, and say, ‘Let’s update these.’ ” she said.
As for patient satisfaction, access and convenience routinely rank higher on the patient priority lists than provider credentials. “The patient wants to get off the gurney in the ED and get to a room,” she said.
But changing hospital bylaws and practices is also about the responsible use of health care dollars, Ms. Marriott affirmed.
“More patients seen in a timely fashion, and quality metrics improvement: Those are all things that are really, really important,” she said. “As a result, [if bylaws and practice patterns are changed] the physicians are hopefully going to be happier, certainly the administration is going to be happier, and the patients are going to fare better.”
Scott Faust, MS, APRN, CNP, an acute care nurse practitioner at Health Partners in St. Paul, Minn., said that teamwork without egos is crucial to success for all providers on the hospital medicine team, especially at busier moments.
“Nobody wants to be in this alone,” he said. “I think the hospitalist teams that work well are the ones that check their titles at the door.”
PAs and NPs generally agree that, as long as all clinical staffers are working within their areas of skill without being overly concerned about specific titles and roles, hospitals and patients will benefit.
“I’ve had physicians at my organization say ‘We need to have an NP and PA set of educational requirements,’ and I said, ‘We have some already for physicians, right? Why aren’t we using that?’ ” Dr. Houghton said. “I think we should have the same expectations clinically. At the end of the day, the patient deserves the same outcomes and the same care, whether they’re being cared for by a physician, an NP, or a PA.”
Onboarding NPs and PAs
According to SHM’s Nurse Practitioner/Physician Assistant Committee, the integration of a new NP or PA hire, whether experienced or not, requires up-front organization and planning for the employee as he or she enters into a new practice.
To that end, the NP/PA Committee created a toolkit to aid health care organizations in their integration of NP and PA staffers into hospital medicine practice groups. The document includes resources for recruiting and interviewing NPs and PAs, information about orientation and onboarding, detailed descriptions of models of care to aid in the utilization of NPs and PAs, best practices for staff retention, insights on billing and reimbursement, and ideas for program evaluation.
Readers can download the Onboarding Toolkit in PDF format at shm.hospitalmedicine.org/acton/attachment/25526/f-040f/1/-/-/-/-/SHM_NPPA_OboardingToolkit.pdf.
EXPERT ANALYSIS FROM HM18
Making the referral and navigating care
Be familiar with local post-acute care resources
Presenter
Elisabeth Schainker, MD, MSc
Session title
Making the referral and navigating “A Whole New World” of care
Session summary
By describing different types of post-acute care clinical services, Dr. Schainker empowered the HM18 audience to rethink how to best identify patients and conditions appropriate for transitions of care, from short-term acute care environments to long-term acute care places, inpatient rehabs, or skilled nursing facilities.
With increasing numbers of pediatric patients with medical complexity, who are dependent on technology devices and complicated care needs, hospitalists need to be knowledgeable about the rules of engagement for prolonged or enhanced recoveries, families’ needs, and insurance qualifications. The role of the hospitalist is to make sure that things are in place for safe and successful discharges, keeping in mind patients’ complexity, resources available within family and community, and fair assessments of readmission risks.
Whether rehab needs pertain to pulmonary, medical, or post NICU stays – length of stay averaging 70-80 days – hospitalists still need to ensure that patients have a clear potential to do better and transition to home eventually. There are inadequate numbers of such pediatric post-acute care facilities, 36 hospitals to be precise. Franciscan Children’s, where Dr. Schainker practices, was beautifully represented in a short movie played during the session at the annual meeting of the Society of Hospital Medicine. The protagonists in the movie were children: Mae and Luke.
Key takeaways for HM
1. Knowledge: Post-acute care services facilitate safe discharges of complex medical patients that eventually get home.
2. Attitude: Hospitalists need to identify what would benefit their patients and counsel families, as well as make proper and timely referrals.
3. Behavior: Hospitalists should be familiar with local resources and engage with available providers of post-acute care services.
Dr. Giordano is a pediatric neurosurgery hospitalist at Columbia University Medical Center in New York.
Be familiar with local post-acute care resources
Be familiar with local post-acute care resources
Presenter
Elisabeth Schainker, MD, MSc
Session title
Making the referral and navigating “A Whole New World” of care
Session summary
By describing different types of post-acute care clinical services, Dr. Schainker empowered the HM18 audience to rethink how to best identify patients and conditions appropriate for transitions of care, from short-term acute care environments to long-term acute care places, inpatient rehabs, or skilled nursing facilities.
With increasing numbers of pediatric patients with medical complexity, who are dependent on technology devices and complicated care needs, hospitalists need to be knowledgeable about the rules of engagement for prolonged or enhanced recoveries, families’ needs, and insurance qualifications. The role of the hospitalist is to make sure that things are in place for safe and successful discharges, keeping in mind patients’ complexity, resources available within family and community, and fair assessments of readmission risks.
Whether rehab needs pertain to pulmonary, medical, or post NICU stays – length of stay averaging 70-80 days – hospitalists still need to ensure that patients have a clear potential to do better and transition to home eventually. There are inadequate numbers of such pediatric post-acute care facilities, 36 hospitals to be precise. Franciscan Children’s, where Dr. Schainker practices, was beautifully represented in a short movie played during the session at the annual meeting of the Society of Hospital Medicine. The protagonists in the movie were children: Mae and Luke.
Key takeaways for HM
1. Knowledge: Post-acute care services facilitate safe discharges of complex medical patients that eventually get home.
2. Attitude: Hospitalists need to identify what would benefit their patients and counsel families, as well as make proper and timely referrals.
3. Behavior: Hospitalists should be familiar with local resources and engage with available providers of post-acute care services.
Dr. Giordano is a pediatric neurosurgery hospitalist at Columbia University Medical Center in New York.
Presenter
Elisabeth Schainker, MD, MSc
Session title
Making the referral and navigating “A Whole New World” of care
Session summary
By describing different types of post-acute care clinical services, Dr. Schainker empowered the HM18 audience to rethink how to best identify patients and conditions appropriate for transitions of care, from short-term acute care environments to long-term acute care places, inpatient rehabs, or skilled nursing facilities.
With increasing numbers of pediatric patients with medical complexity, who are dependent on technology devices and complicated care needs, hospitalists need to be knowledgeable about the rules of engagement for prolonged or enhanced recoveries, families’ needs, and insurance qualifications. The role of the hospitalist is to make sure that things are in place for safe and successful discharges, keeping in mind patients’ complexity, resources available within family and community, and fair assessments of readmission risks.
Whether rehab needs pertain to pulmonary, medical, or post NICU stays – length of stay averaging 70-80 days – hospitalists still need to ensure that patients have a clear potential to do better and transition to home eventually. There are inadequate numbers of such pediatric post-acute care facilities, 36 hospitals to be precise. Franciscan Children’s, where Dr. Schainker practices, was beautifully represented in a short movie played during the session at the annual meeting of the Society of Hospital Medicine. The protagonists in the movie were children: Mae and Luke.
Key takeaways for HM
1. Knowledge: Post-acute care services facilitate safe discharges of complex medical patients that eventually get home.
2. Attitude: Hospitalists need to identify what would benefit their patients and counsel families, as well as make proper and timely referrals.
3. Behavior: Hospitalists should be familiar with local resources and engage with available providers of post-acute care services.
Dr. Giordano is a pediatric neurosurgery hospitalist at Columbia University Medical Center in New York.
HM18: ‘Things we do for no reason’
Be aware of low value care practices
Presenter
Leonard Feldman, MD, SFHM
Session summary
In the current climate of increasing national health care expenditures, the Journal of Hospital Medicine continues to expand its series “Things We Do for No Reason” to shed light on areas for improvement in the delivery of high-value care. Physicians, however, continue to practice low value care because of practice habits and lack of cost transparency. In keeping with the spirit of the journal’s series, three low-value practices were highlighted in this HM18 session, including the benefits of high-flow nasal cannula (HFNC) oxygen therapy, the value of serum albumin and prealbumin in malnutrition, and the use of nebulized versus inhaler albuterol.
HFNC oxygen therapy has become a widespread practice internationally, with large variations in implementation across all age ranges. In bronchiolitic infants, variations in time of implementation, duration of therapy, weaning policies, and outcome measures have yielded mixed results to date. Many studies are still underway, but current literature has not shown significant benefits of starting HFNC early in the illness process, and infants receiving HFNC have not had better outcomes than those who received standard therapy (low-flow nasal cannula).
Serum albumin and prealbumin are often cited as markers of malnutrition. In patients on tube feeds, such as those with cerebral palsy and complex medical conditions, current literature shows no benefit in the use of these lab markers for screening or for following to assess improvement. In addition, patients with eating disorders do not have significant correlation of their nutritive status with these markers. Therefore, the use of these labs for screening of malnutrition is of little if any value.
Finally, when comparing albuterol delivery systems, there has been no proof that nebulized albuterol is any better than metered dose inhalers (MDI) in its effect. As long as appropriate dosing of MDIs is done, the benefits are the same. In addition, side effects are fewer, and the length of stay in the ED is shorter. The more a family uses MDI inhalers, the better their technique. Studies have shown it takes approximately three attempts at using an MDI to get the technique correct, so inpatient MDI use would also decrease user error in the outpatient setting.
Key takeaways for HM
- Practice habits, lack of transparency of costs, and regional training lead to low value care practices.
- Early introduction of high-flow nasal cannula in hospitalization of an infant with bronchiolitis has not been shown to decrease length of stay or severity outcomes, according to currently available data.
- Serum albumin and prealbumin have little to no benefit in screening of malnutrition.
- Nebulized albuterol has not been proven to be more beneficial that MDI albuterol at appropriate doses.
- Repeat MDI administration has been shown to positively affect user administration techniques.
- MDI albuterol use has fewer side effects and decreased ED length of stay, compared with nebulized albuterol.
Dr. Schwenk is an associate professor of pediatrics at the University of Louisville (Ky.) and a pediatric hospitalist at Norton Children’s Hospital, Louisville.
Be aware of low value care practices
Be aware of low value care practices
Presenter
Leonard Feldman, MD, SFHM
Session summary
In the current climate of increasing national health care expenditures, the Journal of Hospital Medicine continues to expand its series “Things We Do for No Reason” to shed light on areas for improvement in the delivery of high-value care. Physicians, however, continue to practice low value care because of practice habits and lack of cost transparency. In keeping with the spirit of the journal’s series, three low-value practices were highlighted in this HM18 session, including the benefits of high-flow nasal cannula (HFNC) oxygen therapy, the value of serum albumin and prealbumin in malnutrition, and the use of nebulized versus inhaler albuterol.
HFNC oxygen therapy has become a widespread practice internationally, with large variations in implementation across all age ranges. In bronchiolitic infants, variations in time of implementation, duration of therapy, weaning policies, and outcome measures have yielded mixed results to date. Many studies are still underway, but current literature has not shown significant benefits of starting HFNC early in the illness process, and infants receiving HFNC have not had better outcomes than those who received standard therapy (low-flow nasal cannula).
Serum albumin and prealbumin are often cited as markers of malnutrition. In patients on tube feeds, such as those with cerebral palsy and complex medical conditions, current literature shows no benefit in the use of these lab markers for screening or for following to assess improvement. In addition, patients with eating disorders do not have significant correlation of their nutritive status with these markers. Therefore, the use of these labs for screening of malnutrition is of little if any value.
Finally, when comparing albuterol delivery systems, there has been no proof that nebulized albuterol is any better than metered dose inhalers (MDI) in its effect. As long as appropriate dosing of MDIs is done, the benefits are the same. In addition, side effects are fewer, and the length of stay in the ED is shorter. The more a family uses MDI inhalers, the better their technique. Studies have shown it takes approximately three attempts at using an MDI to get the technique correct, so inpatient MDI use would also decrease user error in the outpatient setting.
Key takeaways for HM
- Practice habits, lack of transparency of costs, and regional training lead to low value care practices.
- Early introduction of high-flow nasal cannula in hospitalization of an infant with bronchiolitis has not been shown to decrease length of stay or severity outcomes, according to currently available data.
- Serum albumin and prealbumin have little to no benefit in screening of malnutrition.
- Nebulized albuterol has not been proven to be more beneficial that MDI albuterol at appropriate doses.
- Repeat MDI administration has been shown to positively affect user administration techniques.
- MDI albuterol use has fewer side effects and decreased ED length of stay, compared with nebulized albuterol.
Dr. Schwenk is an associate professor of pediatrics at the University of Louisville (Ky.) and a pediatric hospitalist at Norton Children’s Hospital, Louisville.
Presenter
Leonard Feldman, MD, SFHM
Session summary
In the current climate of increasing national health care expenditures, the Journal of Hospital Medicine continues to expand its series “Things We Do for No Reason” to shed light on areas for improvement in the delivery of high-value care. Physicians, however, continue to practice low value care because of practice habits and lack of cost transparency. In keeping with the spirit of the journal’s series, three low-value practices were highlighted in this HM18 session, including the benefits of high-flow nasal cannula (HFNC) oxygen therapy, the value of serum albumin and prealbumin in malnutrition, and the use of nebulized versus inhaler albuterol.
HFNC oxygen therapy has become a widespread practice internationally, with large variations in implementation across all age ranges. In bronchiolitic infants, variations in time of implementation, duration of therapy, weaning policies, and outcome measures have yielded mixed results to date. Many studies are still underway, but current literature has not shown significant benefits of starting HFNC early in the illness process, and infants receiving HFNC have not had better outcomes than those who received standard therapy (low-flow nasal cannula).
Serum albumin and prealbumin are often cited as markers of malnutrition. In patients on tube feeds, such as those with cerebral palsy and complex medical conditions, current literature shows no benefit in the use of these lab markers for screening or for following to assess improvement. In addition, patients with eating disorders do not have significant correlation of their nutritive status with these markers. Therefore, the use of these labs for screening of malnutrition is of little if any value.
Finally, when comparing albuterol delivery systems, there has been no proof that nebulized albuterol is any better than metered dose inhalers (MDI) in its effect. As long as appropriate dosing of MDIs is done, the benefits are the same. In addition, side effects are fewer, and the length of stay in the ED is shorter. The more a family uses MDI inhalers, the better their technique. Studies have shown it takes approximately three attempts at using an MDI to get the technique correct, so inpatient MDI use would also decrease user error in the outpatient setting.
Key takeaways for HM
- Practice habits, lack of transparency of costs, and regional training lead to low value care practices.
- Early introduction of high-flow nasal cannula in hospitalization of an infant with bronchiolitis has not been shown to decrease length of stay or severity outcomes, according to currently available data.
- Serum albumin and prealbumin have little to no benefit in screening of malnutrition.
- Nebulized albuterol has not been proven to be more beneficial that MDI albuterol at appropriate doses.
- Repeat MDI administration has been shown to positively affect user administration techniques.
- MDI albuterol use has fewer side effects and decreased ED length of stay, compared with nebulized albuterol.
Dr. Schwenk is an associate professor of pediatrics at the University of Louisville (Ky.) and a pediatric hospitalist at Norton Children’s Hospital, Louisville.
Benefits, drawbacks when hospitalists expand roles
Hospitalists can’t ‘fill all the cracks’ in primary care
As vice chair of the hospital medicine service at Northwell Health, Nick Fitterman, MD, FACP, SFHM, oversees 16 HM groups at 15 hospitals in New York. He says the duties of his hospitalist staff, like those of most U.S. hospitalists, are similar to what they have traditionally been – clinical care on the wards, teaching, comanagement of surgery, quality improvement, committee work, and research. But he has noticed a trend of late: rapid expansion of the hospitalist’s role.
Speaking at an education session at HM18 in Orlando, Dr. Fitterman said the role of the hospitalist is growing to include tasks that might not be as common, but are becoming more familiar all the time: working at infusion centers, caring for patients in skilled nursing facilities, specializing in electronic health record use, colocating in psychiatric hospitals, even being deployed to natural disasters. His list went on, and it was much longer than the list of traditional hospitalist responsibilities.
“Where do we draw the line and say, ‘Wait a minute, our primary site is going to suffer if we continue to get spread this thin. Can we really do it all?” Dr. Fitterman said. As the number of hats hospitalists wear grows ever bigger, he said more thought must be placed into how expansion happens.
The preop clinic
Efren Manjarrez, MD, SFHM, former chief of hospital medicine at the University of Miami, told a cautionary tale about a preoperative clinic staffed by hospitalists that appeared to provide a financial benefit to a hospital – helping to avoid costly last-minute cancellations of surgeries – but that ultimately was shuttered. The hospital, he said, loses $8,000-$10,000 for each case that gets canceled on the same day.
“Think about that just for a minute,” Dr. Manjarrez said. “If 100 cases are canceled during the year at the last minute, that’s a lot of money.”
A preoperative clinic seemed like a worthwhile role for hospitalists – the program was started in Miami by the same doctor who initiated a similar program at Cleveland Clinic. “Surgical cases are what support the hospital [financially], and we’re here to help them along,” Dr. Manjarrez said. “The purpose of hospitalists is to make sure that patients are medically optimized.”
The preop program concept, used in U.S. medicine since the 1990s, was originally started by anesthesiologists, but they may not always be the best fit to staff such programs.
“Anesthesiologists do not manage all beta blockers,” Dr. Manjarrez said. “They don’t manage ACE inhibitors by mouth. They don’t manage all oral diabetes agents, and they sure as heck don’t manage pills that are anticoagulants. That’s the domain of internal medicine. And as patients have become more complex, that’s where hospitalists who [work in] preop clinics have stepped in.”
Studies have found that hospitalists staffing preop clinics have improved quality metrics and some clinical outcomes, including lowering cancellation rates and more appropriate use of beta blockers, he said.
In the Miami program described by Dr. Manjarrez, hospitalists in the preop clinic at first saw only patients who’d been financially cleared as able to pay. But ultimately, a tiered system was developed, and hospitalists saw only patients who were higher risk – those with COPD or stroke patients, for example – without regard to ability to pay.
“The hospital would have to make up any financial deficit at the very end,” Dr. Manjarrez said. This meant there were no longer efficient 5-minute encounters with patients. Instead, visits lasted about 45 minutes, so fewer patients were seen.
The program was successful, in that the same-day cancellation rate for surgeries dropped to less than 0.1% – fewer than 1 in 1,000 – with the preop clinic up and running, Dr. Manjarrez. Still, the hospital decided to end the program. “The hospital no longer wanted to reimburse us,” he said.
A takeaway from this experience for Dr. Manjarrez was that hospitalists need to do a better job of showing the financial benefits in their expanding roles, if they want them to endure.
“At the end of the day, hospitalists do provide value in preoperative clinics,” he said. “But unfortunately, we’re not doing a great job of publishing our data and showing our value.”
At-home care
At Brigham and Women’s Hospital in Boston, hospitalists have demonstrated good results with a program to provide care at home rather than in the hospital.
David Levine, MD, MPH, MA, clinician and investigator at Brigham and Women’s and an instructor in medicine at Harvard Medical School, said that the structure of inpatient care has generally not changed much over decades, despite advances in technology.
“We round on them once a day – if they’re lucky, twice,” he said. “The medicines have changed and imaging has changed, but we really haven’t changed the structure of how we take care of acutely ill adults for almost a hundred years.”
Hospitalizing patients brings unintended consequences. Twenty percent of older adults will become delirious during their stay, 1 out of 3 will lose a level of functional status in the hospital that they’ll never regain, and 1 out of 10 hospitalized patients will experience an adverse event, like an infection or a medication error.
Brigham and Women’s program of at-home care involves “admitting” patients to their homes after being treated in the emergency department. The goal is to reduce costs by 20%, while maintaining quality and safety and improving patients’ quality of life and experience.
Researchers are studying their results. They randomized patients, after the ED determined they required admission, either to admission to the hospital or to their home. The decision on whether to admit was made before the study investigators became involved with the patients, Dr. Levine said.
The program is also intended to improve access to hospitals. Brigham and Women’s is often over 100% capacity in the general medical ward.
Patients in the study needed to live within a 5-mile radius of either Brigham and Women’s Hospital, or Brigham and Women’s Faulkner Hospital, a nearby community hospital. A physician and a registered nurse form the core team; they assess patient needs and ratchet care either up or down, perhaps adding a home health aide or social worker.
The home care team takes advantage of technology: Portable equipment allows a basic metabolic panel to be performed on the spot – for example, a hemoglobin and hematocrit can be produced within 2 minutes. Also, portable ultrasounds and x-rays are used. Doctors keep a “tackle box” of urgent medications such as antibiotics and diuretics.
“We showed a direct cost reduction taking care of patients at home,” Dr. Levine said. There was also a reduction in utilization of care, and an increase in patient activity, with patients taking about 1,800 steps at home, compared with 180 in the hospital. There were no significant changes in safety, quality, or patient experience, he said.
Postdischarge clinics
Lauren Doctoroff, MD, FHM – a hospitalist at Beth Israel Deaconness Medical Center in Boston and assistant professor of medicine at Harvard Medical School – explained another hospitalist-staffed project meant to improve access to care: her center’s postdischarge clinic, which was started in 2009 but is no longer operating.
The clinic tackled the problem of what to do with patients when you discharge them, Dr. Doctoroff said, and its goal was to foster more cooperation between hospitalists and the faculty primary care practice, as well as to improve postdischarge access for patients from that practice.
A dedicated group of hospitalists staffed the clinics, handling medication reconciliation, symptom management, pending tests, and other services the patients were supposed to be getting after discharge, Dr. Doctoroff said.
“We greatly improved access so that when you came to see us you generally saw a hospitalist a week before you would have seen your primary care doctor,” she said. “And that was mostly because we created open access in a clinic that did not have open access. So if a doctor discharging a patient really thought that the patient needed to be seen after discharge, they would often see us.”
Hospitalists considering starting such a clinic have several key questions to consider, Dr. Doctoroff said.
“You need to focus on who the patient population is, the clinic structure, how you plan to staff the clinic, and what your outcomes are – mainly how you will measure performance,” she said.
Dr. Doctoroff said hospitalists are good for this role because “we’re very comfortable with patients who are complicated, and we are very adept at accessing information from the hospitalization. I think, as a hospitalist who spent 5 years seeing patients in a discharge clinic, it greatly enhances my understanding of patients and their challenges at discharge.”
The clinic was closed, she said, in part because it was largely an extension of primary care, and the patient volume wasn’t big enough to justify continuing it.
“Postdischarge clinics are, in a very narrow sense, a bit of a Band-Aid for a really dysfunctional primary care system,” Dr. Doctoroff said. “Ideally, if all you’re doing is providing a postdischarge physician visit, then you really want primary care to be able to do that in order to reengage with their patient. I think this is because postdischarge clinics are construed in a very narrow way to address the simple need to see a patient after discharge. And this may lead to the failure of these clinics, or make them easy to replace. Also, often what patients really need is more than just a physician visit, so a discharge clinic may need to be designed to provide an enhanced array of services.”
Dr. Fitterman said that these stories show that not all role expansion in hospital medicine is good role expansion. The experiences described by Dr. Manjarrez, Dr. Levine, and Dr. Doctoroff demonstrate the challenges hospitalists face as they attempt expansions into new roles, he said.
“We can’t be expected to fill all the cracks in primary care,” Dr. Fitterman said. “As a country we need to really prop up primary care. This all can’t come under the roof of hospital medicine. We need to be part of a patient-centered medical home – but we are not the patient-centered medical home.”
He said the experience with the preop clinic described by Dr. Manjarrez also shows the need for buy-in from hospital or health system administration.
“While most of us are employed by hospitals and want to help meet their needs, we have to be more cautious. We have to look, I think, with a more critical eye, for the value; it may not always be in the dollars coming back in,” he said. “It might be in cost avoidance, such as reducing readmissions, or reducing same-day cancellations in an OR. Unless the C-suite appreciates that value, such programs will be short-lived.”
Hospitalists can’t ‘fill all the cracks’ in primary care
Hospitalists can’t ‘fill all the cracks’ in primary care
As vice chair of the hospital medicine service at Northwell Health, Nick Fitterman, MD, FACP, SFHM, oversees 16 HM groups at 15 hospitals in New York. He says the duties of his hospitalist staff, like those of most U.S. hospitalists, are similar to what they have traditionally been – clinical care on the wards, teaching, comanagement of surgery, quality improvement, committee work, and research. But he has noticed a trend of late: rapid expansion of the hospitalist’s role.
Speaking at an education session at HM18 in Orlando, Dr. Fitterman said the role of the hospitalist is growing to include tasks that might not be as common, but are becoming more familiar all the time: working at infusion centers, caring for patients in skilled nursing facilities, specializing in electronic health record use, colocating in psychiatric hospitals, even being deployed to natural disasters. His list went on, and it was much longer than the list of traditional hospitalist responsibilities.
“Where do we draw the line and say, ‘Wait a minute, our primary site is going to suffer if we continue to get spread this thin. Can we really do it all?” Dr. Fitterman said. As the number of hats hospitalists wear grows ever bigger, he said more thought must be placed into how expansion happens.
The preop clinic
Efren Manjarrez, MD, SFHM, former chief of hospital medicine at the University of Miami, told a cautionary tale about a preoperative clinic staffed by hospitalists that appeared to provide a financial benefit to a hospital – helping to avoid costly last-minute cancellations of surgeries – but that ultimately was shuttered. The hospital, he said, loses $8,000-$10,000 for each case that gets canceled on the same day.
“Think about that just for a minute,” Dr. Manjarrez said. “If 100 cases are canceled during the year at the last minute, that’s a lot of money.”
A preoperative clinic seemed like a worthwhile role for hospitalists – the program was started in Miami by the same doctor who initiated a similar program at Cleveland Clinic. “Surgical cases are what support the hospital [financially], and we’re here to help them along,” Dr. Manjarrez said. “The purpose of hospitalists is to make sure that patients are medically optimized.”
The preop program concept, used in U.S. medicine since the 1990s, was originally started by anesthesiologists, but they may not always be the best fit to staff such programs.
“Anesthesiologists do not manage all beta blockers,” Dr. Manjarrez said. “They don’t manage ACE inhibitors by mouth. They don’t manage all oral diabetes agents, and they sure as heck don’t manage pills that are anticoagulants. That’s the domain of internal medicine. And as patients have become more complex, that’s where hospitalists who [work in] preop clinics have stepped in.”
Studies have found that hospitalists staffing preop clinics have improved quality metrics and some clinical outcomes, including lowering cancellation rates and more appropriate use of beta blockers, he said.
In the Miami program described by Dr. Manjarrez, hospitalists in the preop clinic at first saw only patients who’d been financially cleared as able to pay. But ultimately, a tiered system was developed, and hospitalists saw only patients who were higher risk – those with COPD or stroke patients, for example – without regard to ability to pay.
“The hospital would have to make up any financial deficit at the very end,” Dr. Manjarrez said. This meant there were no longer efficient 5-minute encounters with patients. Instead, visits lasted about 45 minutes, so fewer patients were seen.
The program was successful, in that the same-day cancellation rate for surgeries dropped to less than 0.1% – fewer than 1 in 1,000 – with the preop clinic up and running, Dr. Manjarrez. Still, the hospital decided to end the program. “The hospital no longer wanted to reimburse us,” he said.
A takeaway from this experience for Dr. Manjarrez was that hospitalists need to do a better job of showing the financial benefits in their expanding roles, if they want them to endure.
“At the end of the day, hospitalists do provide value in preoperative clinics,” he said. “But unfortunately, we’re not doing a great job of publishing our data and showing our value.”
At-home care
At Brigham and Women’s Hospital in Boston, hospitalists have demonstrated good results with a program to provide care at home rather than in the hospital.
David Levine, MD, MPH, MA, clinician and investigator at Brigham and Women’s and an instructor in medicine at Harvard Medical School, said that the structure of inpatient care has generally not changed much over decades, despite advances in technology.
“We round on them once a day – if they’re lucky, twice,” he said. “The medicines have changed and imaging has changed, but we really haven’t changed the structure of how we take care of acutely ill adults for almost a hundred years.”
Hospitalizing patients brings unintended consequences. Twenty percent of older adults will become delirious during their stay, 1 out of 3 will lose a level of functional status in the hospital that they’ll never regain, and 1 out of 10 hospitalized patients will experience an adverse event, like an infection or a medication error.
Brigham and Women’s program of at-home care involves “admitting” patients to their homes after being treated in the emergency department. The goal is to reduce costs by 20%, while maintaining quality and safety and improving patients’ quality of life and experience.
Researchers are studying their results. They randomized patients, after the ED determined they required admission, either to admission to the hospital or to their home. The decision on whether to admit was made before the study investigators became involved with the patients, Dr. Levine said.
The program is also intended to improve access to hospitals. Brigham and Women’s is often over 100% capacity in the general medical ward.
Patients in the study needed to live within a 5-mile radius of either Brigham and Women’s Hospital, or Brigham and Women’s Faulkner Hospital, a nearby community hospital. A physician and a registered nurse form the core team; they assess patient needs and ratchet care either up or down, perhaps adding a home health aide or social worker.
The home care team takes advantage of technology: Portable equipment allows a basic metabolic panel to be performed on the spot – for example, a hemoglobin and hematocrit can be produced within 2 minutes. Also, portable ultrasounds and x-rays are used. Doctors keep a “tackle box” of urgent medications such as antibiotics and diuretics.
“We showed a direct cost reduction taking care of patients at home,” Dr. Levine said. There was also a reduction in utilization of care, and an increase in patient activity, with patients taking about 1,800 steps at home, compared with 180 in the hospital. There were no significant changes in safety, quality, or patient experience, he said.
Postdischarge clinics
Lauren Doctoroff, MD, FHM – a hospitalist at Beth Israel Deaconness Medical Center in Boston and assistant professor of medicine at Harvard Medical School – explained another hospitalist-staffed project meant to improve access to care: her center’s postdischarge clinic, which was started in 2009 but is no longer operating.
The clinic tackled the problem of what to do with patients when you discharge them, Dr. Doctoroff said, and its goal was to foster more cooperation between hospitalists and the faculty primary care practice, as well as to improve postdischarge access for patients from that practice.
A dedicated group of hospitalists staffed the clinics, handling medication reconciliation, symptom management, pending tests, and other services the patients were supposed to be getting after discharge, Dr. Doctoroff said.
“We greatly improved access so that when you came to see us you generally saw a hospitalist a week before you would have seen your primary care doctor,” she said. “And that was mostly because we created open access in a clinic that did not have open access. So if a doctor discharging a patient really thought that the patient needed to be seen after discharge, they would often see us.”
Hospitalists considering starting such a clinic have several key questions to consider, Dr. Doctoroff said.
“You need to focus on who the patient population is, the clinic structure, how you plan to staff the clinic, and what your outcomes are – mainly how you will measure performance,” she said.
Dr. Doctoroff said hospitalists are good for this role because “we’re very comfortable with patients who are complicated, and we are very adept at accessing information from the hospitalization. I think, as a hospitalist who spent 5 years seeing patients in a discharge clinic, it greatly enhances my understanding of patients and their challenges at discharge.”
The clinic was closed, she said, in part because it was largely an extension of primary care, and the patient volume wasn’t big enough to justify continuing it.
“Postdischarge clinics are, in a very narrow sense, a bit of a Band-Aid for a really dysfunctional primary care system,” Dr. Doctoroff said. “Ideally, if all you’re doing is providing a postdischarge physician visit, then you really want primary care to be able to do that in order to reengage with their patient. I think this is because postdischarge clinics are construed in a very narrow way to address the simple need to see a patient after discharge. And this may lead to the failure of these clinics, or make them easy to replace. Also, often what patients really need is more than just a physician visit, so a discharge clinic may need to be designed to provide an enhanced array of services.”
Dr. Fitterman said that these stories show that not all role expansion in hospital medicine is good role expansion. The experiences described by Dr. Manjarrez, Dr. Levine, and Dr. Doctoroff demonstrate the challenges hospitalists face as they attempt expansions into new roles, he said.
“We can’t be expected to fill all the cracks in primary care,” Dr. Fitterman said. “As a country we need to really prop up primary care. This all can’t come under the roof of hospital medicine. We need to be part of a patient-centered medical home – but we are not the patient-centered medical home.”
He said the experience with the preop clinic described by Dr. Manjarrez also shows the need for buy-in from hospital or health system administration.
“While most of us are employed by hospitals and want to help meet their needs, we have to be more cautious. We have to look, I think, with a more critical eye, for the value; it may not always be in the dollars coming back in,” he said. “It might be in cost avoidance, such as reducing readmissions, or reducing same-day cancellations in an OR. Unless the C-suite appreciates that value, such programs will be short-lived.”
As vice chair of the hospital medicine service at Northwell Health, Nick Fitterman, MD, FACP, SFHM, oversees 16 HM groups at 15 hospitals in New York. He says the duties of his hospitalist staff, like those of most U.S. hospitalists, are similar to what they have traditionally been – clinical care on the wards, teaching, comanagement of surgery, quality improvement, committee work, and research. But he has noticed a trend of late: rapid expansion of the hospitalist’s role.
Speaking at an education session at HM18 in Orlando, Dr. Fitterman said the role of the hospitalist is growing to include tasks that might not be as common, but are becoming more familiar all the time: working at infusion centers, caring for patients in skilled nursing facilities, specializing in electronic health record use, colocating in psychiatric hospitals, even being deployed to natural disasters. His list went on, and it was much longer than the list of traditional hospitalist responsibilities.
“Where do we draw the line and say, ‘Wait a minute, our primary site is going to suffer if we continue to get spread this thin. Can we really do it all?” Dr. Fitterman said. As the number of hats hospitalists wear grows ever bigger, he said more thought must be placed into how expansion happens.
The preop clinic
Efren Manjarrez, MD, SFHM, former chief of hospital medicine at the University of Miami, told a cautionary tale about a preoperative clinic staffed by hospitalists that appeared to provide a financial benefit to a hospital – helping to avoid costly last-minute cancellations of surgeries – but that ultimately was shuttered. The hospital, he said, loses $8,000-$10,000 for each case that gets canceled on the same day.
“Think about that just for a minute,” Dr. Manjarrez said. “If 100 cases are canceled during the year at the last minute, that’s a lot of money.”
A preoperative clinic seemed like a worthwhile role for hospitalists – the program was started in Miami by the same doctor who initiated a similar program at Cleveland Clinic. “Surgical cases are what support the hospital [financially], and we’re here to help them along,” Dr. Manjarrez said. “The purpose of hospitalists is to make sure that patients are medically optimized.”
The preop program concept, used in U.S. medicine since the 1990s, was originally started by anesthesiologists, but they may not always be the best fit to staff such programs.
“Anesthesiologists do not manage all beta blockers,” Dr. Manjarrez said. “They don’t manage ACE inhibitors by mouth. They don’t manage all oral diabetes agents, and they sure as heck don’t manage pills that are anticoagulants. That’s the domain of internal medicine. And as patients have become more complex, that’s where hospitalists who [work in] preop clinics have stepped in.”
Studies have found that hospitalists staffing preop clinics have improved quality metrics and some clinical outcomes, including lowering cancellation rates and more appropriate use of beta blockers, he said.
In the Miami program described by Dr. Manjarrez, hospitalists in the preop clinic at first saw only patients who’d been financially cleared as able to pay. But ultimately, a tiered system was developed, and hospitalists saw only patients who were higher risk – those with COPD or stroke patients, for example – without regard to ability to pay.
“The hospital would have to make up any financial deficit at the very end,” Dr. Manjarrez said. This meant there were no longer efficient 5-minute encounters with patients. Instead, visits lasted about 45 minutes, so fewer patients were seen.
The program was successful, in that the same-day cancellation rate for surgeries dropped to less than 0.1% – fewer than 1 in 1,000 – with the preop clinic up and running, Dr. Manjarrez. Still, the hospital decided to end the program. “The hospital no longer wanted to reimburse us,” he said.
A takeaway from this experience for Dr. Manjarrez was that hospitalists need to do a better job of showing the financial benefits in their expanding roles, if they want them to endure.
“At the end of the day, hospitalists do provide value in preoperative clinics,” he said. “But unfortunately, we’re not doing a great job of publishing our data and showing our value.”
At-home care
At Brigham and Women’s Hospital in Boston, hospitalists have demonstrated good results with a program to provide care at home rather than in the hospital.
David Levine, MD, MPH, MA, clinician and investigator at Brigham and Women’s and an instructor in medicine at Harvard Medical School, said that the structure of inpatient care has generally not changed much over decades, despite advances in technology.
“We round on them once a day – if they’re lucky, twice,” he said. “The medicines have changed and imaging has changed, but we really haven’t changed the structure of how we take care of acutely ill adults for almost a hundred years.”
Hospitalizing patients brings unintended consequences. Twenty percent of older adults will become delirious during their stay, 1 out of 3 will lose a level of functional status in the hospital that they’ll never regain, and 1 out of 10 hospitalized patients will experience an adverse event, like an infection or a medication error.
Brigham and Women’s program of at-home care involves “admitting” patients to their homes after being treated in the emergency department. The goal is to reduce costs by 20%, while maintaining quality and safety and improving patients’ quality of life and experience.
Researchers are studying their results. They randomized patients, after the ED determined they required admission, either to admission to the hospital or to their home. The decision on whether to admit was made before the study investigators became involved with the patients, Dr. Levine said.
The program is also intended to improve access to hospitals. Brigham and Women’s is often over 100% capacity in the general medical ward.
Patients in the study needed to live within a 5-mile radius of either Brigham and Women’s Hospital, or Brigham and Women’s Faulkner Hospital, a nearby community hospital. A physician and a registered nurse form the core team; they assess patient needs and ratchet care either up or down, perhaps adding a home health aide or social worker.
The home care team takes advantage of technology: Portable equipment allows a basic metabolic panel to be performed on the spot – for example, a hemoglobin and hematocrit can be produced within 2 minutes. Also, portable ultrasounds and x-rays are used. Doctors keep a “tackle box” of urgent medications such as antibiotics and diuretics.
“We showed a direct cost reduction taking care of patients at home,” Dr. Levine said. There was also a reduction in utilization of care, and an increase in patient activity, with patients taking about 1,800 steps at home, compared with 180 in the hospital. There were no significant changes in safety, quality, or patient experience, he said.
Postdischarge clinics
Lauren Doctoroff, MD, FHM – a hospitalist at Beth Israel Deaconness Medical Center in Boston and assistant professor of medicine at Harvard Medical School – explained another hospitalist-staffed project meant to improve access to care: her center’s postdischarge clinic, which was started in 2009 but is no longer operating.
The clinic tackled the problem of what to do with patients when you discharge them, Dr. Doctoroff said, and its goal was to foster more cooperation between hospitalists and the faculty primary care practice, as well as to improve postdischarge access for patients from that practice.
A dedicated group of hospitalists staffed the clinics, handling medication reconciliation, symptom management, pending tests, and other services the patients were supposed to be getting after discharge, Dr. Doctoroff said.
“We greatly improved access so that when you came to see us you generally saw a hospitalist a week before you would have seen your primary care doctor,” she said. “And that was mostly because we created open access in a clinic that did not have open access. So if a doctor discharging a patient really thought that the patient needed to be seen after discharge, they would often see us.”
Hospitalists considering starting such a clinic have several key questions to consider, Dr. Doctoroff said.
“You need to focus on who the patient population is, the clinic structure, how you plan to staff the clinic, and what your outcomes are – mainly how you will measure performance,” she said.
Dr. Doctoroff said hospitalists are good for this role because “we’re very comfortable with patients who are complicated, and we are very adept at accessing information from the hospitalization. I think, as a hospitalist who spent 5 years seeing patients in a discharge clinic, it greatly enhances my understanding of patients and their challenges at discharge.”
The clinic was closed, she said, in part because it was largely an extension of primary care, and the patient volume wasn’t big enough to justify continuing it.
“Postdischarge clinics are, in a very narrow sense, a bit of a Band-Aid for a really dysfunctional primary care system,” Dr. Doctoroff said. “Ideally, if all you’re doing is providing a postdischarge physician visit, then you really want primary care to be able to do that in order to reengage with their patient. I think this is because postdischarge clinics are construed in a very narrow way to address the simple need to see a patient after discharge. And this may lead to the failure of these clinics, or make them easy to replace. Also, often what patients really need is more than just a physician visit, so a discharge clinic may need to be designed to provide an enhanced array of services.”
Dr. Fitterman said that these stories show that not all role expansion in hospital medicine is good role expansion. The experiences described by Dr. Manjarrez, Dr. Levine, and Dr. Doctoroff demonstrate the challenges hospitalists face as they attempt expansions into new roles, he said.
“We can’t be expected to fill all the cracks in primary care,” Dr. Fitterman said. “As a country we need to really prop up primary care. This all can’t come under the roof of hospital medicine. We need to be part of a patient-centered medical home – but we are not the patient-centered medical home.”
He said the experience with the preop clinic described by Dr. Manjarrez also shows the need for buy-in from hospital or health system administration.
“While most of us are employed by hospitals and want to help meet their needs, we have to be more cautious. We have to look, I think, with a more critical eye, for the value; it may not always be in the dollars coming back in,” he said. “It might be in cost avoidance, such as reducing readmissions, or reducing same-day cancellations in an OR. Unless the C-suite appreciates that value, such programs will be short-lived.”
Rethinking preop testing
ORLANDO – Michael Rothberg, MD, a nocturnist who works at Presbyterian Rust Medical Center in Albuquerque, often is torn when asked to routinely perform preoperative tests, such as ECGs, on patients.
On the one hand, Dr. Rothberg knows that for many patients there is almost certainly no benefit to some of the tests. On the other hand, surgeons expect the tests to be performed – so, for the sake of collegiality, patients often have tests ordered that hospitalists suspect are unnecessary.
This was a big part of why Dr. Rothberg decided to come a day early to HM18, held in early April in Orlando, to attend the pre-course “Essentials of Perioperative Medicine and Co-Management for the Hospitalist.” He was looking for expert guidance on which patients need what tests before surgery, and also how to better determine what preoperative tests are a waste of time and money for certain patients, so that he’ll be armed with useful information when he went back to his medical center.
“I can slap something on the surgeon’s desk and say, ‘Here’s why we’re not doing it,’ ” Dr. Rothberg said.
At the HM18 pre-course, experts gave guidance on the benefits of hospitalist involvement in perioperative care and offered points to consider when assessing cardiac and pulmonary risk before surgeries. Hospitalists then broke into groups to brainstorm techniques that could improve their perioperative work.
She noted how surgical safety checklists have been shown to improve morbidity and mortality, as seen with a checklist developed by the World Health Organization and in California, where an enhanced recovery program at 20 hospitals has been successful.
“I think the reason we see changes in each of those … from pre to post when they implement, is because people start to communicate and collaborate,” she said. “I think that’s the secret sauce, and you can take that back home with you.”
Assessing risk
As for preoperative testing, history is replete with examples of tests once considered crucial but that have proven to be unimportant for many patients, including preoperative carotid endarterectomy, preop ECG, preop coronary revasularization, and preop lab work.
“I was always listening for bruits years ago,” Dr. Grant said. “I’ve sort of stopped doing that now. You’ll hear it, you won’t know what to do with it. We used to take care of those things before surgery. We now know that’s not helpful for patients without symptoms.”
Dr. Cohn’s philosophy is to not suggest a delay without firm evidence that it is necessary. “I try not to interfere with surgery unless I feel that there is significant risk,” he said.
In workshop discussions at the HM18 pre-course, hospitalists considered their contributions to preoperative care and ways they might be able to contribute more effectively. Among their ideas were better communication with anesthesiology – regarded as severely lacking by many hospitalists in the session – as well as designating smaller perioperative teams to foster knowledge and greater trust with surgeons.
Aron Mednick, MD, FHM, director of the comanagement service at Tisch Hospital, NYU Langone Medical Center, New York, said his group talked about an “identify, mitigate, propose, and resolve” method – identifying services or conditions with a high rate of preoperative problems, finding data on how to solve them, and proposing ways to get hospitalists involved in the solution.
“We noted that a lot of people experience resistance with getting hospitalists involved in care early,” he said. “So one of the ways to do this is actually to identify problems and start above the surgeon, at the CMO and COO level, and then move down through department chairs and, basically, impose our existence on the care of the patient.”
ORLANDO – Michael Rothberg, MD, a nocturnist who works at Presbyterian Rust Medical Center in Albuquerque, often is torn when asked to routinely perform preoperative tests, such as ECGs, on patients.
On the one hand, Dr. Rothberg knows that for many patients there is almost certainly no benefit to some of the tests. On the other hand, surgeons expect the tests to be performed – so, for the sake of collegiality, patients often have tests ordered that hospitalists suspect are unnecessary.
This was a big part of why Dr. Rothberg decided to come a day early to HM18, held in early April in Orlando, to attend the pre-course “Essentials of Perioperative Medicine and Co-Management for the Hospitalist.” He was looking for expert guidance on which patients need what tests before surgery, and also how to better determine what preoperative tests are a waste of time and money for certain patients, so that he’ll be armed with useful information when he went back to his medical center.
“I can slap something on the surgeon’s desk and say, ‘Here’s why we’re not doing it,’ ” Dr. Rothberg said.
At the HM18 pre-course, experts gave guidance on the benefits of hospitalist involvement in perioperative care and offered points to consider when assessing cardiac and pulmonary risk before surgeries. Hospitalists then broke into groups to brainstorm techniques that could improve their perioperative work.
She noted how surgical safety checklists have been shown to improve morbidity and mortality, as seen with a checklist developed by the World Health Organization and in California, where an enhanced recovery program at 20 hospitals has been successful.
“I think the reason we see changes in each of those … from pre to post when they implement, is because people start to communicate and collaborate,” she said. “I think that’s the secret sauce, and you can take that back home with you.”
Assessing risk
As for preoperative testing, history is replete with examples of tests once considered crucial but that have proven to be unimportant for many patients, including preoperative carotid endarterectomy, preop ECG, preop coronary revasularization, and preop lab work.
“I was always listening for bruits years ago,” Dr. Grant said. “I’ve sort of stopped doing that now. You’ll hear it, you won’t know what to do with it. We used to take care of those things before surgery. We now know that’s not helpful for patients without symptoms.”
Dr. Cohn’s philosophy is to not suggest a delay without firm evidence that it is necessary. “I try not to interfere with surgery unless I feel that there is significant risk,” he said.
In workshop discussions at the HM18 pre-course, hospitalists considered their contributions to preoperative care and ways they might be able to contribute more effectively. Among their ideas were better communication with anesthesiology – regarded as severely lacking by many hospitalists in the session – as well as designating smaller perioperative teams to foster knowledge and greater trust with surgeons.
Aron Mednick, MD, FHM, director of the comanagement service at Tisch Hospital, NYU Langone Medical Center, New York, said his group talked about an “identify, mitigate, propose, and resolve” method – identifying services or conditions with a high rate of preoperative problems, finding data on how to solve them, and proposing ways to get hospitalists involved in the solution.
“We noted that a lot of people experience resistance with getting hospitalists involved in care early,” he said. “So one of the ways to do this is actually to identify problems and start above the surgeon, at the CMO and COO level, and then move down through department chairs and, basically, impose our existence on the care of the patient.”
ORLANDO – Michael Rothberg, MD, a nocturnist who works at Presbyterian Rust Medical Center in Albuquerque, often is torn when asked to routinely perform preoperative tests, such as ECGs, on patients.
On the one hand, Dr. Rothberg knows that for many patients there is almost certainly no benefit to some of the tests. On the other hand, surgeons expect the tests to be performed – so, for the sake of collegiality, patients often have tests ordered that hospitalists suspect are unnecessary.
This was a big part of why Dr. Rothberg decided to come a day early to HM18, held in early April in Orlando, to attend the pre-course “Essentials of Perioperative Medicine and Co-Management for the Hospitalist.” He was looking for expert guidance on which patients need what tests before surgery, and also how to better determine what preoperative tests are a waste of time and money for certain patients, so that he’ll be armed with useful information when he went back to his medical center.
“I can slap something on the surgeon’s desk and say, ‘Here’s why we’re not doing it,’ ” Dr. Rothberg said.
At the HM18 pre-course, experts gave guidance on the benefits of hospitalist involvement in perioperative care and offered points to consider when assessing cardiac and pulmonary risk before surgeries. Hospitalists then broke into groups to brainstorm techniques that could improve their perioperative work.
She noted how surgical safety checklists have been shown to improve morbidity and mortality, as seen with a checklist developed by the World Health Organization and in California, where an enhanced recovery program at 20 hospitals has been successful.
“I think the reason we see changes in each of those … from pre to post when they implement, is because people start to communicate and collaborate,” she said. “I think that’s the secret sauce, and you can take that back home with you.”
Assessing risk
As for preoperative testing, history is replete with examples of tests once considered crucial but that have proven to be unimportant for many patients, including preoperative carotid endarterectomy, preop ECG, preop coronary revasularization, and preop lab work.
“I was always listening for bruits years ago,” Dr. Grant said. “I’ve sort of stopped doing that now. You’ll hear it, you won’t know what to do with it. We used to take care of those things before surgery. We now know that’s not helpful for patients without symptoms.”
Dr. Cohn’s philosophy is to not suggest a delay without firm evidence that it is necessary. “I try not to interfere with surgery unless I feel that there is significant risk,” he said.
In workshop discussions at the HM18 pre-course, hospitalists considered their contributions to preoperative care and ways they might be able to contribute more effectively. Among their ideas were better communication with anesthesiology – regarded as severely lacking by many hospitalists in the session – as well as designating smaller perioperative teams to foster knowledge and greater trust with surgeons.
Aron Mednick, MD, FHM, director of the comanagement service at Tisch Hospital, NYU Langone Medical Center, New York, said his group talked about an “identify, mitigate, propose, and resolve” method – identifying services or conditions with a high rate of preoperative problems, finding data on how to solve them, and proposing ways to get hospitalists involved in the solution.
“We noted that a lot of people experience resistance with getting hospitalists involved in care early,” he said. “So one of the ways to do this is actually to identify problems and start above the surgeon, at the CMO and COO level, and then move down through department chairs and, basically, impose our existence on the care of the patient.”
REPORTING FROM HM18
Antibiotic stewardship in sepsis
ORLANDO – When is it rational to consider de-escalating, or even stopping, antibiotics for septic patients, and how will patients’ future health be affected by antibiotic use during critical illnesses?
According to Jennifer Hanrahan, DO, of Case Western Reserve University, Cleveland, locating the tipping point between optimal care for the individual patient in sepsis, and the importance of antibiotic stewardship is a balancing act. It’s a process guided by laboratory findings, by knowledge of local pathogens and patterns of antimicrobial resistance, and also by clinical judgment, she said at the annual meeting of the Society of Hospital Medicine.
By all means, begin antibiotics for patients with sepsis, Dr. Hanrahan, also medical director of infection prevention at MetroHealth Medical Center, Cleveland, told attendees at a pre-course at HM18. “Prompt initiation of antibiotics for sepsis is critical, and appropriate use of antibiotics decreases mortality.” However, she noted, de-escalation of antibiotics also decreases mortality.
“What is antibiotic stewardship? Most of us think of this as the microbial stewardship police calling to ask you, ‘Why are you using this antibiotic?’’ she said. “It’s really the right antibiotic, for the right diagnosis, for the appropriate duration.”
Of course, Dr. Hanrahan said, any medication is associated with potential adverse events, and antibiotics are no different. “Almost one-third of antibiotics given are either unnecessary or inappropriate,” she said.
Antimicrobial resistance is a very serious public health threat, Dr. Hanrahan affirmed. “Antibiotic use is the most important modifiable factor related to development of antibiotic resistance. With regard to multidrug resistant [MDR] gram negatives, we are running out of antibiotics” to treat these organisms, she said, noting that “Many antibiotics to treat MDRs are “astronomically expensive – and that’s a really big problem.”
It’s important to remember that, when antibiotics are prescribed, “You’re affecting the microbiome not just of that patient, but of those around them,” as resistance factors are potentially spread from one individual’s microbiome to their friends, family, and other contacts, Dr. Hanrahan said.
The later risk of sepsis has also shown to be elevated for individuals who have received high-risk antibiotics such as fluoroquinolones, third- and fourth-generation cephalosporins, beta-lactamase inhibitor formulations, vancomycin, and carbapenems – many of which are also used to treat sepsis. All of these antibiotics kill anaerobic bacteria, Dr. Hanrahan said, and “when you kill anaerobes you do a lot of bad things to people.”
Identifying the pathogens
There are already many frightening players in the antibiotic-resistant landscape. Among them are carbapenem-resistant Enterobacteriaceae, increasingly common in health care settings. Unfortunately, with methicillin-resistant Staphylococcus aureus (MRSA), “we’ve lost the battle,” Dr. Hanrahan said.
Acinetobacter is another increasing threat, she said, as is Candida auris, which has caused large outbreaks in Europe. Because it’s resistant to azole antifungals, once C. auris comes to U.S. hospitals, “You’re going to have a really big problem,” she said. Finally, multidrug resistant and extremely drug resistant Pseudomonas species are being encountered with increasing frequency.
And, of course, Clostridium difficile infections continue to ravage older populations. “One in 11 people aged 65 or older will die from C. diff infections,” said Dr. Hanrahan.
For all of these bacteria, she said, “I can’t tell you what antibiotics to use because you have to know what the organisms are in your hospital.” A good resource for tracking local resistance patterns is the information provided by the Centers for Disease Control and Prevention, including interactive maps showing health care–associated infections, as well as HealthMap ResistanceOpen, which maps antibiotic resistance alerts across the United States. The CDC also offers training on antibiotic stewardship; Dr. Hanrahan said the several hours she spent completing the training were well spent.
After a broad-spectrum antibiotic is initiated for sepsis, Dr. Hanrahan said that the next infectious disease–related steps should focus on identifying pathogens so antimicrobial therapy can be tailored or scaled back appropriately. In many cases, this will mean obtaining blood cultures – ideally, two sets from two separate sites. It’s no longer thought necessary to separate the blood draws by 20 minutes, or to try to time the draw during a febrile episode, she said.
What is important is to make sure that you’re not treating contamination or colonization – “Treat only clinically significant infections,” Dr. Hanrahan said. A common red herring, especially among elderly individuals coming from assisted living or in patients with indwelling urinary catheters, is a positive urine culture in the absence of signs or symptoms of urinary tract infection. Think twice about whether this truly represents a source of infection, she said. “Don’t treat asymptomatic bacteriuria.”
In order to avoid “chasing contamination,” do not obtain the blood culture samples from a venipuncture site. “Contamination is twice as likely when drawing from a venipuncture site,” Dr. Hanrahan noted. “When possible you should avoid this.”
It’s also important to remember that 10% of fever in hospitalized individuals is from a noninfectious source. “Take a careful history, and do a physical exam to help distinguish infections from other causes of fever,” said Dr. Hanrahan.
Additional investigations to consider in highly immunocompromised patients might include both mycobacterial and fungal cultures, although these studies are otherwise generally low yield. And, she said, “Don’t send catheter-tip cultures – it’s pointless, and it really doesn’t add much information.”
Good clinical judgment still goes a long way toward guiding therapy. “If a patient is stable and it’s not clear whether an antibiotic is needed, consider waiting and re-evaluating later,” Dr. Hanrahan said.
Generally, duration of treatment should also be clinically based. “Stop antibiotics as soon as possible, and remove catheters as soon as possible,” Dr. Hanrahan said, adding that few infections really warrant treatment for a fixed amount of time. These include meningitis, endocarditis, tuberculosis, and many cases of osteomyelitis.
Similarly, when a patient who had been ill now looks well, feels well, and is stable or improving, there’s usually no need for repeat blood cultures, Dr. Hanrahan said. Still, a cautious balance is where most clinicians will wind up.
“I learned a long time ago that I have to do the things that let me go home and sleep at night,” she concluded.
Dr. Hanrahan reported having been a consultant for Gilead, Astellas, and Cempra.
ORLANDO – When is it rational to consider de-escalating, or even stopping, antibiotics for septic patients, and how will patients’ future health be affected by antibiotic use during critical illnesses?
According to Jennifer Hanrahan, DO, of Case Western Reserve University, Cleveland, locating the tipping point between optimal care for the individual patient in sepsis, and the importance of antibiotic stewardship is a balancing act. It’s a process guided by laboratory findings, by knowledge of local pathogens and patterns of antimicrobial resistance, and also by clinical judgment, she said at the annual meeting of the Society of Hospital Medicine.
By all means, begin antibiotics for patients with sepsis, Dr. Hanrahan, also medical director of infection prevention at MetroHealth Medical Center, Cleveland, told attendees at a pre-course at HM18. “Prompt initiation of antibiotics for sepsis is critical, and appropriate use of antibiotics decreases mortality.” However, she noted, de-escalation of antibiotics also decreases mortality.
“What is antibiotic stewardship? Most of us think of this as the microbial stewardship police calling to ask you, ‘Why are you using this antibiotic?’’ she said. “It’s really the right antibiotic, for the right diagnosis, for the appropriate duration.”
Of course, Dr. Hanrahan said, any medication is associated with potential adverse events, and antibiotics are no different. “Almost one-third of antibiotics given are either unnecessary or inappropriate,” she said.
Antimicrobial resistance is a very serious public health threat, Dr. Hanrahan affirmed. “Antibiotic use is the most important modifiable factor related to development of antibiotic resistance. With regard to multidrug resistant [MDR] gram negatives, we are running out of antibiotics” to treat these organisms, she said, noting that “Many antibiotics to treat MDRs are “astronomically expensive – and that’s a really big problem.”
It’s important to remember that, when antibiotics are prescribed, “You’re affecting the microbiome not just of that patient, but of those around them,” as resistance factors are potentially spread from one individual’s microbiome to their friends, family, and other contacts, Dr. Hanrahan said.
The later risk of sepsis has also shown to be elevated for individuals who have received high-risk antibiotics such as fluoroquinolones, third- and fourth-generation cephalosporins, beta-lactamase inhibitor formulations, vancomycin, and carbapenems – many of which are also used to treat sepsis. All of these antibiotics kill anaerobic bacteria, Dr. Hanrahan said, and “when you kill anaerobes you do a lot of bad things to people.”
Identifying the pathogens
There are already many frightening players in the antibiotic-resistant landscape. Among them are carbapenem-resistant Enterobacteriaceae, increasingly common in health care settings. Unfortunately, with methicillin-resistant Staphylococcus aureus (MRSA), “we’ve lost the battle,” Dr. Hanrahan said.
Acinetobacter is another increasing threat, she said, as is Candida auris, which has caused large outbreaks in Europe. Because it’s resistant to azole antifungals, once C. auris comes to U.S. hospitals, “You’re going to have a really big problem,” she said. Finally, multidrug resistant and extremely drug resistant Pseudomonas species are being encountered with increasing frequency.
And, of course, Clostridium difficile infections continue to ravage older populations. “One in 11 people aged 65 or older will die from C. diff infections,” said Dr. Hanrahan.
For all of these bacteria, she said, “I can’t tell you what antibiotics to use because you have to know what the organisms are in your hospital.” A good resource for tracking local resistance patterns is the information provided by the Centers for Disease Control and Prevention, including interactive maps showing health care–associated infections, as well as HealthMap ResistanceOpen, which maps antibiotic resistance alerts across the United States. The CDC also offers training on antibiotic stewardship; Dr. Hanrahan said the several hours she spent completing the training were well spent.
After a broad-spectrum antibiotic is initiated for sepsis, Dr. Hanrahan said that the next infectious disease–related steps should focus on identifying pathogens so antimicrobial therapy can be tailored or scaled back appropriately. In many cases, this will mean obtaining blood cultures – ideally, two sets from two separate sites. It’s no longer thought necessary to separate the blood draws by 20 minutes, or to try to time the draw during a febrile episode, she said.
What is important is to make sure that you’re not treating contamination or colonization – “Treat only clinically significant infections,” Dr. Hanrahan said. A common red herring, especially among elderly individuals coming from assisted living or in patients with indwelling urinary catheters, is a positive urine culture in the absence of signs or symptoms of urinary tract infection. Think twice about whether this truly represents a source of infection, she said. “Don’t treat asymptomatic bacteriuria.”
In order to avoid “chasing contamination,” do not obtain the blood culture samples from a venipuncture site. “Contamination is twice as likely when drawing from a venipuncture site,” Dr. Hanrahan noted. “When possible you should avoid this.”
It’s also important to remember that 10% of fever in hospitalized individuals is from a noninfectious source. “Take a careful history, and do a physical exam to help distinguish infections from other causes of fever,” said Dr. Hanrahan.
Additional investigations to consider in highly immunocompromised patients might include both mycobacterial and fungal cultures, although these studies are otherwise generally low yield. And, she said, “Don’t send catheter-tip cultures – it’s pointless, and it really doesn’t add much information.”
Good clinical judgment still goes a long way toward guiding therapy. “If a patient is stable and it’s not clear whether an antibiotic is needed, consider waiting and re-evaluating later,” Dr. Hanrahan said.
Generally, duration of treatment should also be clinically based. “Stop antibiotics as soon as possible, and remove catheters as soon as possible,” Dr. Hanrahan said, adding that few infections really warrant treatment for a fixed amount of time. These include meningitis, endocarditis, tuberculosis, and many cases of osteomyelitis.
Similarly, when a patient who had been ill now looks well, feels well, and is stable or improving, there’s usually no need for repeat blood cultures, Dr. Hanrahan said. Still, a cautious balance is where most clinicians will wind up.
“I learned a long time ago that I have to do the things that let me go home and sleep at night,” she concluded.
Dr. Hanrahan reported having been a consultant for Gilead, Astellas, and Cempra.
ORLANDO – When is it rational to consider de-escalating, or even stopping, antibiotics for septic patients, and how will patients’ future health be affected by antibiotic use during critical illnesses?
According to Jennifer Hanrahan, DO, of Case Western Reserve University, Cleveland, locating the tipping point between optimal care for the individual patient in sepsis, and the importance of antibiotic stewardship is a balancing act. It’s a process guided by laboratory findings, by knowledge of local pathogens and patterns of antimicrobial resistance, and also by clinical judgment, she said at the annual meeting of the Society of Hospital Medicine.
By all means, begin antibiotics for patients with sepsis, Dr. Hanrahan, also medical director of infection prevention at MetroHealth Medical Center, Cleveland, told attendees at a pre-course at HM18. “Prompt initiation of antibiotics for sepsis is critical, and appropriate use of antibiotics decreases mortality.” However, she noted, de-escalation of antibiotics also decreases mortality.
“What is antibiotic stewardship? Most of us think of this as the microbial stewardship police calling to ask you, ‘Why are you using this antibiotic?’’ she said. “It’s really the right antibiotic, for the right diagnosis, for the appropriate duration.”
Of course, Dr. Hanrahan said, any medication is associated with potential adverse events, and antibiotics are no different. “Almost one-third of antibiotics given are either unnecessary or inappropriate,” she said.
Antimicrobial resistance is a very serious public health threat, Dr. Hanrahan affirmed. “Antibiotic use is the most important modifiable factor related to development of antibiotic resistance. With regard to multidrug resistant [MDR] gram negatives, we are running out of antibiotics” to treat these organisms, she said, noting that “Many antibiotics to treat MDRs are “astronomically expensive – and that’s a really big problem.”
It’s important to remember that, when antibiotics are prescribed, “You’re affecting the microbiome not just of that patient, but of those around them,” as resistance factors are potentially spread from one individual’s microbiome to their friends, family, and other contacts, Dr. Hanrahan said.
The later risk of sepsis has also shown to be elevated for individuals who have received high-risk antibiotics such as fluoroquinolones, third- and fourth-generation cephalosporins, beta-lactamase inhibitor formulations, vancomycin, and carbapenems – many of which are also used to treat sepsis. All of these antibiotics kill anaerobic bacteria, Dr. Hanrahan said, and “when you kill anaerobes you do a lot of bad things to people.”
Identifying the pathogens
There are already many frightening players in the antibiotic-resistant landscape. Among them are carbapenem-resistant Enterobacteriaceae, increasingly common in health care settings. Unfortunately, with methicillin-resistant Staphylococcus aureus (MRSA), “we’ve lost the battle,” Dr. Hanrahan said.
Acinetobacter is another increasing threat, she said, as is Candida auris, which has caused large outbreaks in Europe. Because it’s resistant to azole antifungals, once C. auris comes to U.S. hospitals, “You’re going to have a really big problem,” she said. Finally, multidrug resistant and extremely drug resistant Pseudomonas species are being encountered with increasing frequency.
And, of course, Clostridium difficile infections continue to ravage older populations. “One in 11 people aged 65 or older will die from C. diff infections,” said Dr. Hanrahan.
For all of these bacteria, she said, “I can’t tell you what antibiotics to use because you have to know what the organisms are in your hospital.” A good resource for tracking local resistance patterns is the information provided by the Centers for Disease Control and Prevention, including interactive maps showing health care–associated infections, as well as HealthMap ResistanceOpen, which maps antibiotic resistance alerts across the United States. The CDC also offers training on antibiotic stewardship; Dr. Hanrahan said the several hours she spent completing the training were well spent.
After a broad-spectrum antibiotic is initiated for sepsis, Dr. Hanrahan said that the next infectious disease–related steps should focus on identifying pathogens so antimicrobial therapy can be tailored or scaled back appropriately. In many cases, this will mean obtaining blood cultures – ideally, two sets from two separate sites. It’s no longer thought necessary to separate the blood draws by 20 minutes, or to try to time the draw during a febrile episode, she said.
What is important is to make sure that you’re not treating contamination or colonization – “Treat only clinically significant infections,” Dr. Hanrahan said. A common red herring, especially among elderly individuals coming from assisted living or in patients with indwelling urinary catheters, is a positive urine culture in the absence of signs or symptoms of urinary tract infection. Think twice about whether this truly represents a source of infection, she said. “Don’t treat asymptomatic bacteriuria.”
In order to avoid “chasing contamination,” do not obtain the blood culture samples from a venipuncture site. “Contamination is twice as likely when drawing from a venipuncture site,” Dr. Hanrahan noted. “When possible you should avoid this.”
It’s also important to remember that 10% of fever in hospitalized individuals is from a noninfectious source. “Take a careful history, and do a physical exam to help distinguish infections from other causes of fever,” said Dr. Hanrahan.
Additional investigations to consider in highly immunocompromised patients might include both mycobacterial and fungal cultures, although these studies are otherwise generally low yield. And, she said, “Don’t send catheter-tip cultures – it’s pointless, and it really doesn’t add much information.”
Good clinical judgment still goes a long way toward guiding therapy. “If a patient is stable and it’s not clear whether an antibiotic is needed, consider waiting and re-evaluating later,” Dr. Hanrahan said.
Generally, duration of treatment should also be clinically based. “Stop antibiotics as soon as possible, and remove catheters as soon as possible,” Dr. Hanrahan said, adding that few infections really warrant treatment for a fixed amount of time. These include meningitis, endocarditis, tuberculosis, and many cases of osteomyelitis.
Similarly, when a patient who had been ill now looks well, feels well, and is stable or improving, there’s usually no need for repeat blood cultures, Dr. Hanrahan said. Still, a cautious balance is where most clinicians will wind up.
“I learned a long time ago that I have to do the things that let me go home and sleep at night,” she concluded.
Dr. Hanrahan reported having been a consultant for Gilead, Astellas, and Cempra.
REPORTING FROM HM18
HM18: Tick-borne illnesses
Presenter
Andrew J. Hale, MD
University of Vermont Medical Center, Burlington
Session summary
With rising temperatures from climate change, tick territory – and therefore tick-borne illnesses – are being seen with increasing frequency.
Lyme disease manifests as early-localized, early-disseminated, and late disease. The diagnosis of Lyme can be challenging and the pretest probability is key (geographic distribution, time of year, consistent symptoms). Do not send serologies unless the pretest probability is high, since the sensitivity of the test is generally low.
Concerning early-localized disease, 20% of patients will not develop the classic “bullseye” erythema migrans rash. Only 25% of patients recall even getting a tick bite. Not everyone with a rash will have a classic appearance (prepare for heterogeneity).
Neurologic symptoms can appear early or late in Lyme disease (usually weeks to months, but sometimes in days). The manifestations can include lymphocytic meningitis (which can be hard to separate from viral meningitis), radiculopathies, and cranial nerve palsies.
Lyme carditis happens early in the disseminated phase with a variety of disease (palpitations, conduction abnormalities, pericarditis, myocarditis, left ventricular failure). For those who develop a high-grade atrioventricular block, a temporary pacer may be needed; a permanent pacemaker is unnecessary because patients often do well with a course of antibiotics.
Late Lyme develops months to years after infection. It often presents as arthritis of the knee, although other large joints such as the shoulders, ankles, and elbows can also be affected. Chronic neurologic effects such as peripheral neuropathy and encephalitis can also occur.
Treatment depends on how the disease manifests. If one has arthritis or mild carditis, 28 days of doxycycline is appropriate; for neurologic disease or “bad” carditis, give ceftriaxone for 28 days; for everything else, 14-21 days of doxycycline. Amoxicillin can be used for patients who cannot tolerate doxycycline.
Borrelia miyamotoi and B. mayonii are emerging infections. Compared with Lyme, B. miyamotoi will present with more joint pain and less rash. B. mayonii has a more diffuse rash, but is otherwise similar to Lyme. Serologies for Lyme for both will be negative, but they are treated the same as Lyme disease.
Anaplasma presents as a flu-like illness and can be difficult to distinguish from Lyme. Ehrlichia is similar, but has more headache and CNS findings. Diagnosis during the first week is best with a blood smear (looking for morulae) and polymerase chain reaction; in week 2, serology is a bit better; after 3 weeks, serologies are very sensitive. Treatment for both is doxycycline for 7-14 days. Rifampin is second-line treatment, but does not treat Lyme (both can happen simultaneously).
Babesia is found in the same distribution as Lyme disease. Incubation is 1-12 weeks. Mild disease consists of parasitemia of less than 4% while severe disease is greater than 4%. Being asplenic, having HIV, receiving tumor necrosis factor alpha blockers or rituximab increases risk for severe disease. A blood smear is sufficient to diagnose Babesia, but polymerase chain reaction is also available. Treatment is atovaquone and azithromycin for 7 days for mild disease; clindamycin and quinine for 7-10 days for severe. Exchange transfusion can also be done especially for those with high parasitemia or severe symptoms.
Powassan virus is seen in the northeastern United States and the Minnesota/Wisconsin region. It has a fatality rate of 10%. About 50% of patients have long-term neurologic sequelae. Heartland virus has symptoms similar to other tick-borne illnesses, but can be associated with nausea, headache, diarrhea, myalgias, arthralgias, and renal failure. Bourbon virus also behaves like most tick-borne illnesses, but patients can develop a rapid sepsis picture.
Key takeaways for HM
- Lyme disease can be seen in inpatient settings with cardiac, neurologic, and musculoskeletal manifestations.
- Several emerging tick-borne infections (tularemia, STARI [southern tick-associated rash illness]), relapsing fever (B. hermsii), B. miyamotoi, and B. mayonii should also be on clinicians’ radar.
- Ticks can also spread viruses that can have particularly deadly consequences such as Powassan, Heartland, and Bourbon.
- Climate change is good for ticks, but bad for humans.
Dr. Kim is assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.
Presenter
Andrew J. Hale, MD
University of Vermont Medical Center, Burlington
Session summary
With rising temperatures from climate change, tick territory – and therefore tick-borne illnesses – are being seen with increasing frequency.
Lyme disease manifests as early-localized, early-disseminated, and late disease. The diagnosis of Lyme can be challenging and the pretest probability is key (geographic distribution, time of year, consistent symptoms). Do not send serologies unless the pretest probability is high, since the sensitivity of the test is generally low.
Concerning early-localized disease, 20% of patients will not develop the classic “bullseye” erythema migrans rash. Only 25% of patients recall even getting a tick bite. Not everyone with a rash will have a classic appearance (prepare for heterogeneity).
Neurologic symptoms can appear early or late in Lyme disease (usually weeks to months, but sometimes in days). The manifestations can include lymphocytic meningitis (which can be hard to separate from viral meningitis), radiculopathies, and cranial nerve palsies.
Lyme carditis happens early in the disseminated phase with a variety of disease (palpitations, conduction abnormalities, pericarditis, myocarditis, left ventricular failure). For those who develop a high-grade atrioventricular block, a temporary pacer may be needed; a permanent pacemaker is unnecessary because patients often do well with a course of antibiotics.
Late Lyme develops months to years after infection. It often presents as arthritis of the knee, although other large joints such as the shoulders, ankles, and elbows can also be affected. Chronic neurologic effects such as peripheral neuropathy and encephalitis can also occur.
Treatment depends on how the disease manifests. If one has arthritis or mild carditis, 28 days of doxycycline is appropriate; for neurologic disease or “bad” carditis, give ceftriaxone for 28 days; for everything else, 14-21 days of doxycycline. Amoxicillin can be used for patients who cannot tolerate doxycycline.
Borrelia miyamotoi and B. mayonii are emerging infections. Compared with Lyme, B. miyamotoi will present with more joint pain and less rash. B. mayonii has a more diffuse rash, but is otherwise similar to Lyme. Serologies for Lyme for both will be negative, but they are treated the same as Lyme disease.
Anaplasma presents as a flu-like illness and can be difficult to distinguish from Lyme. Ehrlichia is similar, but has more headache and CNS findings. Diagnosis during the first week is best with a blood smear (looking for morulae) and polymerase chain reaction; in week 2, serology is a bit better; after 3 weeks, serologies are very sensitive. Treatment for both is doxycycline for 7-14 days. Rifampin is second-line treatment, but does not treat Lyme (both can happen simultaneously).
Babesia is found in the same distribution as Lyme disease. Incubation is 1-12 weeks. Mild disease consists of parasitemia of less than 4% while severe disease is greater than 4%. Being asplenic, having HIV, receiving tumor necrosis factor alpha blockers or rituximab increases risk for severe disease. A blood smear is sufficient to diagnose Babesia, but polymerase chain reaction is also available. Treatment is atovaquone and azithromycin for 7 days for mild disease; clindamycin and quinine for 7-10 days for severe. Exchange transfusion can also be done especially for those with high parasitemia or severe symptoms.
Powassan virus is seen in the northeastern United States and the Minnesota/Wisconsin region. It has a fatality rate of 10%. About 50% of patients have long-term neurologic sequelae. Heartland virus has symptoms similar to other tick-borne illnesses, but can be associated with nausea, headache, diarrhea, myalgias, arthralgias, and renal failure. Bourbon virus also behaves like most tick-borne illnesses, but patients can develop a rapid sepsis picture.
Key takeaways for HM
- Lyme disease can be seen in inpatient settings with cardiac, neurologic, and musculoskeletal manifestations.
- Several emerging tick-borne infections (tularemia, STARI [southern tick-associated rash illness]), relapsing fever (B. hermsii), B. miyamotoi, and B. mayonii should also be on clinicians’ radar.
- Ticks can also spread viruses that can have particularly deadly consequences such as Powassan, Heartland, and Bourbon.
- Climate change is good for ticks, but bad for humans.
Dr. Kim is assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.
Presenter
Andrew J. Hale, MD
University of Vermont Medical Center, Burlington
Session summary
With rising temperatures from climate change, tick territory – and therefore tick-borne illnesses – are being seen with increasing frequency.
Lyme disease manifests as early-localized, early-disseminated, and late disease. The diagnosis of Lyme can be challenging and the pretest probability is key (geographic distribution, time of year, consistent symptoms). Do not send serologies unless the pretest probability is high, since the sensitivity of the test is generally low.
Concerning early-localized disease, 20% of patients will not develop the classic “bullseye” erythema migrans rash. Only 25% of patients recall even getting a tick bite. Not everyone with a rash will have a classic appearance (prepare for heterogeneity).
Neurologic symptoms can appear early or late in Lyme disease (usually weeks to months, but sometimes in days). The manifestations can include lymphocytic meningitis (which can be hard to separate from viral meningitis), radiculopathies, and cranial nerve palsies.
Lyme carditis happens early in the disseminated phase with a variety of disease (palpitations, conduction abnormalities, pericarditis, myocarditis, left ventricular failure). For those who develop a high-grade atrioventricular block, a temporary pacer may be needed; a permanent pacemaker is unnecessary because patients often do well with a course of antibiotics.
Late Lyme develops months to years after infection. It often presents as arthritis of the knee, although other large joints such as the shoulders, ankles, and elbows can also be affected. Chronic neurologic effects such as peripheral neuropathy and encephalitis can also occur.
Treatment depends on how the disease manifests. If one has arthritis or mild carditis, 28 days of doxycycline is appropriate; for neurologic disease or “bad” carditis, give ceftriaxone for 28 days; for everything else, 14-21 days of doxycycline. Amoxicillin can be used for patients who cannot tolerate doxycycline.
Borrelia miyamotoi and B. mayonii are emerging infections. Compared with Lyme, B. miyamotoi will present with more joint pain and less rash. B. mayonii has a more diffuse rash, but is otherwise similar to Lyme. Serologies for Lyme for both will be negative, but they are treated the same as Lyme disease.
Anaplasma presents as a flu-like illness and can be difficult to distinguish from Lyme. Ehrlichia is similar, but has more headache and CNS findings. Diagnosis during the first week is best with a blood smear (looking for morulae) and polymerase chain reaction; in week 2, serology is a bit better; after 3 weeks, serologies are very sensitive. Treatment for both is doxycycline for 7-14 days. Rifampin is second-line treatment, but does not treat Lyme (both can happen simultaneously).
Babesia is found in the same distribution as Lyme disease. Incubation is 1-12 weeks. Mild disease consists of parasitemia of less than 4% while severe disease is greater than 4%. Being asplenic, having HIV, receiving tumor necrosis factor alpha blockers or rituximab increases risk for severe disease. A blood smear is sufficient to diagnose Babesia, but polymerase chain reaction is also available. Treatment is atovaquone and azithromycin for 7 days for mild disease; clindamycin and quinine for 7-10 days for severe. Exchange transfusion can also be done especially for those with high parasitemia or severe symptoms.
Powassan virus is seen in the northeastern United States and the Minnesota/Wisconsin region. It has a fatality rate of 10%. About 50% of patients have long-term neurologic sequelae. Heartland virus has symptoms similar to other tick-borne illnesses, but can be associated with nausea, headache, diarrhea, myalgias, arthralgias, and renal failure. Bourbon virus also behaves like most tick-borne illnesses, but patients can develop a rapid sepsis picture.
Key takeaways for HM
- Lyme disease can be seen in inpatient settings with cardiac, neurologic, and musculoskeletal manifestations.
- Several emerging tick-borne infections (tularemia, STARI [southern tick-associated rash illness]), relapsing fever (B. hermsii), B. miyamotoi, and B. mayonii should also be on clinicians’ radar.
- Ticks can also spread viruses that can have particularly deadly consequences such as Powassan, Heartland, and Bourbon.
- Climate change is good for ticks, but bad for humans.
Dr. Kim is assistant professor of medicine in the division of hospital medicine at Emory University, Atlanta.
From #MeToo to troponins: Updates in hospital medicine
How do you summarize a year’s worth of hospitalist-relevant research in an hour? If you’re Cynthia Cooper, MD, and Barbara Slawski, MD, MS, SFHM, you do it with teamwork, rigor, and style.
When the two physicians signed on for the 2018 “Update in Hospital Medicine” talk, they knew the bar was high. The updates talk is a perennial crowd favorite at the Society of Hospital Medicine annual conferences, and this year’s talk, which touched on topics from #MeToo to kidney injury, didn’t disappoint.
“One of the things that made the news a lot this last year is gender bias, so we thought we’d start out with that,” said Dr. Slawski, chief of the section of perioperative medicine at the Medical College of Wisconsin in Milwaukee.
In a retrospective observational study, the investigators looked at archived grand rounds video to see how often speakers with doctoral degrees were introduced by title, rather than by first name. Mixed-gender evaluators found that females were much more likely than were males to introduce either females or males by title (P less than .001).
“Have any of you ever had this experience? Me, too,” said Dr. Slawski, to wide and prolonged applause.
Females introducing males were almost twice as likely to use the speaker’s title as when males introduced females (95% vs. 49%; P less than .001). These revelations, said Dr. Slawski, present an “opportunity for improving professional interactions in an environment of mutual respect,” a comment that the room again greeted with a round of applause.
The inpatient syncope evaluation was made a little easier with another top study presented by Dr. Slawski. Using a large multinational database, investigators looked at a subgroup of patients with syncope who were admitted to the hospital. They found that fewer than 2% of patients with syncope were diagnosed with pulmonary embolus (PE) or deep venous thrombosis within 90 days of the index admission. For Dr. Slawski, this means clinicians may be able to relax their worry about thromboembolic events just a bit: “Although this diagnosis should be considered, not all patients need evaluation,” she said.
Dr. Slawski did point out that this observational, retrospective trial differed in many ways from the earlier-published PESIT trial that found a rate of 17% for PE among patients hospitalized for syncope.
Another common clinical dilemma – how to rule out MI in low-risk patients – was addressed in a meta-analysis looking at high-sensitivity troponin T levels in patients with negative ECGs.
In patients coming to the emergency department with a suspicion of acute coronary syndrome, investigators found just a 0.49% incidence of cardiac events in patients who had no ECG evidence of new ischemia and very-low high-sensitivity troponin T. The study looked at two proposed lower limits – less than .0005 mcg/L and less than .003 mcg/L.
Between these two levels, “Sensitivity and negative predictive values were about the same; no patients had mortality within 30 days if they met the criteria,” said Dr. Slawski. However, “You have to remember that sensitivity was below the preset consensus of 99%,” she said; the pooled sensitivity was 98.7%, with fairly high heterogeneity between studies. Also, she said, “If you’re going to use this strategy as your hospital, you have to remember that these values are specific to the assay” at your particular institution.
Dr. Cooper, a nephrologist who practices hospital medicine at Massachusetts General Hospital, Boston, ran through several kidney-related studies. Among these was a retrospective study of the use of IV contrast for computerized tomography (CT), examining the risk of acute kidney injury when patients who received IV contrast were compared both with those who had a CT without contrast and with those who did not have CT. Nearly 17,000 patients were included, with propensity matching used to limit confounding.
Both in this study and in a later meta-analysis, no significant differences were seen in acute kidney injury, the need for renal replacement therapy, or mortality after CT with contrast. However, Dr. Cooper said that as a nephrologist, “This doesn’t make physiological sense to me, so I’m not convinced,” she said. “Ultimately, we need to have a randomized, controlled trial, though it’s hard to imagine” just how such a study could be structured and conducted, she said.
“Influenza H3N2 has dominated outbreaks in the United States over the last few years,” and this fact contributed significantly to the severity of the past year’s influenza season, said Dr. Cooper. Not only does this strain “seem to have greater variability in how often it mutates,” but “it’s also less likely to grow in egg media – so it’s less likely to appear in the vaccine,” she said.
Antivirals are effective only if instituted promptly, meaning that many patients who are admitted to the hospital with influenza and pulmonary infiltrates are beyond this window. Building on what was known about the theoretical efficacy of both macrolides and NSAID medications, a group of researchers in Hong Kong conducted a randomized placebo-controlled trial to compare outcomes when 500 mg of clarithromycin and 200 mg of naproxen were added on days 1 and 2 of hospitalization.
When these two interventions were added to the usual regime of amoxicillin clavulanate, oseltamivir, and esomeprazole, hospital stay was 1 day shorter. Importantly, said Dr. Cooper, 30-day and 90-day mortality rates were shorter and there was a significant reduction in viral titer. This is a strategy Dr. Cooper plans to implement. “My expectation is just like this past year, next year will likely be a bad year for influenza,” she said.
How do you summarize a year’s worth of hospitalist-relevant research in an hour? If you’re Cynthia Cooper, MD, and Barbara Slawski, MD, MS, SFHM, you do it with teamwork, rigor, and style.
When the two physicians signed on for the 2018 “Update in Hospital Medicine” talk, they knew the bar was high. The updates talk is a perennial crowd favorite at the Society of Hospital Medicine annual conferences, and this year’s talk, which touched on topics from #MeToo to kidney injury, didn’t disappoint.
“One of the things that made the news a lot this last year is gender bias, so we thought we’d start out with that,” said Dr. Slawski, chief of the section of perioperative medicine at the Medical College of Wisconsin in Milwaukee.
In a retrospective observational study, the investigators looked at archived grand rounds video to see how often speakers with doctoral degrees were introduced by title, rather than by first name. Mixed-gender evaluators found that females were much more likely than were males to introduce either females or males by title (P less than .001).
“Have any of you ever had this experience? Me, too,” said Dr. Slawski, to wide and prolonged applause.
Females introducing males were almost twice as likely to use the speaker’s title as when males introduced females (95% vs. 49%; P less than .001). These revelations, said Dr. Slawski, present an “opportunity for improving professional interactions in an environment of mutual respect,” a comment that the room again greeted with a round of applause.
The inpatient syncope evaluation was made a little easier with another top study presented by Dr. Slawski. Using a large multinational database, investigators looked at a subgroup of patients with syncope who were admitted to the hospital. They found that fewer than 2% of patients with syncope were diagnosed with pulmonary embolus (PE) or deep venous thrombosis within 90 days of the index admission. For Dr. Slawski, this means clinicians may be able to relax their worry about thromboembolic events just a bit: “Although this diagnosis should be considered, not all patients need evaluation,” she said.
Dr. Slawski did point out that this observational, retrospective trial differed in many ways from the earlier-published PESIT trial that found a rate of 17% for PE among patients hospitalized for syncope.
Another common clinical dilemma – how to rule out MI in low-risk patients – was addressed in a meta-analysis looking at high-sensitivity troponin T levels in patients with negative ECGs.
In patients coming to the emergency department with a suspicion of acute coronary syndrome, investigators found just a 0.49% incidence of cardiac events in patients who had no ECG evidence of new ischemia and very-low high-sensitivity troponin T. The study looked at two proposed lower limits – less than .0005 mcg/L and less than .003 mcg/L.
Between these two levels, “Sensitivity and negative predictive values were about the same; no patients had mortality within 30 days if they met the criteria,” said Dr. Slawski. However, “You have to remember that sensitivity was below the preset consensus of 99%,” she said; the pooled sensitivity was 98.7%, with fairly high heterogeneity between studies. Also, she said, “If you’re going to use this strategy as your hospital, you have to remember that these values are specific to the assay” at your particular institution.
Dr. Cooper, a nephrologist who practices hospital medicine at Massachusetts General Hospital, Boston, ran through several kidney-related studies. Among these was a retrospective study of the use of IV contrast for computerized tomography (CT), examining the risk of acute kidney injury when patients who received IV contrast were compared both with those who had a CT without contrast and with those who did not have CT. Nearly 17,000 patients were included, with propensity matching used to limit confounding.
Both in this study and in a later meta-analysis, no significant differences were seen in acute kidney injury, the need for renal replacement therapy, or mortality after CT with contrast. However, Dr. Cooper said that as a nephrologist, “This doesn’t make physiological sense to me, so I’m not convinced,” she said. “Ultimately, we need to have a randomized, controlled trial, though it’s hard to imagine” just how such a study could be structured and conducted, she said.
“Influenza H3N2 has dominated outbreaks in the United States over the last few years,” and this fact contributed significantly to the severity of the past year’s influenza season, said Dr. Cooper. Not only does this strain “seem to have greater variability in how often it mutates,” but “it’s also less likely to grow in egg media – so it’s less likely to appear in the vaccine,” she said.
Antivirals are effective only if instituted promptly, meaning that many patients who are admitted to the hospital with influenza and pulmonary infiltrates are beyond this window. Building on what was known about the theoretical efficacy of both macrolides and NSAID medications, a group of researchers in Hong Kong conducted a randomized placebo-controlled trial to compare outcomes when 500 mg of clarithromycin and 200 mg of naproxen were added on days 1 and 2 of hospitalization.
When these two interventions were added to the usual regime of amoxicillin clavulanate, oseltamivir, and esomeprazole, hospital stay was 1 day shorter. Importantly, said Dr. Cooper, 30-day and 90-day mortality rates were shorter and there was a significant reduction in viral titer. This is a strategy Dr. Cooper plans to implement. “My expectation is just like this past year, next year will likely be a bad year for influenza,” she said.
How do you summarize a year’s worth of hospitalist-relevant research in an hour? If you’re Cynthia Cooper, MD, and Barbara Slawski, MD, MS, SFHM, you do it with teamwork, rigor, and style.
When the two physicians signed on for the 2018 “Update in Hospital Medicine” talk, they knew the bar was high. The updates talk is a perennial crowd favorite at the Society of Hospital Medicine annual conferences, and this year’s talk, which touched on topics from #MeToo to kidney injury, didn’t disappoint.
“One of the things that made the news a lot this last year is gender bias, so we thought we’d start out with that,” said Dr. Slawski, chief of the section of perioperative medicine at the Medical College of Wisconsin in Milwaukee.
In a retrospective observational study, the investigators looked at archived grand rounds video to see how often speakers with doctoral degrees were introduced by title, rather than by first name. Mixed-gender evaluators found that females were much more likely than were males to introduce either females or males by title (P less than .001).
“Have any of you ever had this experience? Me, too,” said Dr. Slawski, to wide and prolonged applause.
Females introducing males were almost twice as likely to use the speaker’s title as when males introduced females (95% vs. 49%; P less than .001). These revelations, said Dr. Slawski, present an “opportunity for improving professional interactions in an environment of mutual respect,” a comment that the room again greeted with a round of applause.
The inpatient syncope evaluation was made a little easier with another top study presented by Dr. Slawski. Using a large multinational database, investigators looked at a subgroup of patients with syncope who were admitted to the hospital. They found that fewer than 2% of patients with syncope were diagnosed with pulmonary embolus (PE) or deep venous thrombosis within 90 days of the index admission. For Dr. Slawski, this means clinicians may be able to relax their worry about thromboembolic events just a bit: “Although this diagnosis should be considered, not all patients need evaluation,” she said.
Dr. Slawski did point out that this observational, retrospective trial differed in many ways from the earlier-published PESIT trial that found a rate of 17% for PE among patients hospitalized for syncope.
Another common clinical dilemma – how to rule out MI in low-risk patients – was addressed in a meta-analysis looking at high-sensitivity troponin T levels in patients with negative ECGs.
In patients coming to the emergency department with a suspicion of acute coronary syndrome, investigators found just a 0.49% incidence of cardiac events in patients who had no ECG evidence of new ischemia and very-low high-sensitivity troponin T. The study looked at two proposed lower limits – less than .0005 mcg/L and less than .003 mcg/L.
Between these two levels, “Sensitivity and negative predictive values were about the same; no patients had mortality within 30 days if they met the criteria,” said Dr. Slawski. However, “You have to remember that sensitivity was below the preset consensus of 99%,” she said; the pooled sensitivity was 98.7%, with fairly high heterogeneity between studies. Also, she said, “If you’re going to use this strategy as your hospital, you have to remember that these values are specific to the assay” at your particular institution.
Dr. Cooper, a nephrologist who practices hospital medicine at Massachusetts General Hospital, Boston, ran through several kidney-related studies. Among these was a retrospective study of the use of IV contrast for computerized tomography (CT), examining the risk of acute kidney injury when patients who received IV contrast were compared both with those who had a CT without contrast and with those who did not have CT. Nearly 17,000 patients were included, with propensity matching used to limit confounding.
Both in this study and in a later meta-analysis, no significant differences were seen in acute kidney injury, the need for renal replacement therapy, or mortality after CT with contrast. However, Dr. Cooper said that as a nephrologist, “This doesn’t make physiological sense to me, so I’m not convinced,” she said. “Ultimately, we need to have a randomized, controlled trial, though it’s hard to imagine” just how such a study could be structured and conducted, she said.
“Influenza H3N2 has dominated outbreaks in the United States over the last few years,” and this fact contributed significantly to the severity of the past year’s influenza season, said Dr. Cooper. Not only does this strain “seem to have greater variability in how often it mutates,” but “it’s also less likely to grow in egg media – so it’s less likely to appear in the vaccine,” she said.
Antivirals are effective only if instituted promptly, meaning that many patients who are admitted to the hospital with influenza and pulmonary infiltrates are beyond this window. Building on what was known about the theoretical efficacy of both macrolides and NSAID medications, a group of researchers in Hong Kong conducted a randomized placebo-controlled trial to compare outcomes when 500 mg of clarithromycin and 200 mg of naproxen were added on days 1 and 2 of hospitalization.
When these two interventions were added to the usual regime of amoxicillin clavulanate, oseltamivir, and esomeprazole, hospital stay was 1 day shorter. Importantly, said Dr. Cooper, 30-day and 90-day mortality rates were shorter and there was a significant reduction in viral titer. This is a strategy Dr. Cooper plans to implement. “My expectation is just like this past year, next year will likely be a bad year for influenza,” she said.
Presenting the 2018 SHM Awards of Excellence winners
SHM’s Award of Excellence in Outstanding Service in Hospital Medicine
Dr. Flora Kisuule, MD, SFHM, is an assistant professor at Johns Hopkins School of Medicine and the vice chair for clinical operations for the department of medicine at Johns Hopkins Bayview Medical Center. While at Johns Hopkins University, both in Baltimore, she codeveloped a hospitalist fellowship program that she now directs, as well as a fellowship program specifically for nurse practitioners and physician assistants. Under her leadership as the associate director of the division of hospital medicine, she helped to bring Johns Hopkins Bayview hospitalists’ quality and mortality indicators into the top 5% nationwide and reduced hospital-acquired conditions at Hopkins Bayview to the best of the four regional Hopkins Health System hospitals.
Nationally, she has served on several SHM committees, facilitated at multiple SHM leadership courses, served as vice president of SHM’s Baltimore Chapter, and consulted on hospitalist programs around the country. Internationally, Dr. Kisuule has developed and mentored hospitalist programs in Saudi Arabia, the United Arab Emirates, and Central America. She is currently developing a training program in hospital medicine in Panama and is a Senior Fellow in Hospital Medicine.
SHM’s Award of Excellence in Teamwork in Quality Improvement
Since 2011, the Johns Hopkins Health System hospitals have conducted quality improvement projects to increase the value of care for their patients. Their amazing work catalyzed a grass-roots initiative involving faculty and residents at both Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center.
With a unification of the EHR across the health system, RedondaMiller, MD, MBA, president of Johns Hopkins Hospital, and Renee Demski, MSW, MBA, vice president of quality for Johns Hopkins Health System, created the Johns Hopkins Health System High-Value Care Committee to operationalize initiatives across all six hospitals and Johns Hopkins community physicians. The committee is under the leadership of Trushar Dungarani, DO, FHM, from Howard County General Hospital and Lenny Feldman, MD, SFHM, Amit Pahwa, MD, and Pamela Johnson, MD, from Johns Hopkins Hospital, and comprises provider representatives from each institution and other important contributors from various specialties, including Mike Borowitz, MD, PhD; Dr. Ken Lee, DrPH; Emily Pherson, PharmD; Amy Knight, MD; Tim Niessen, MD, MPH; Keisha Perrin, and Clare Rock.
Initiatives directed by the committee have included reducing inappropriate testing for Clostridium difficile, folate testing for anemia, and duplicative imaging exams, among others. In the 18 months since inception, the committee reduced charges to patients and payers by nearly $4 million and hospital costs by more than $200,000.
Members of this committee joined forces with like-minded institutions to create the High Value Practice Academic Alliance in 2016. Faculty leaders from more than 80 academic centers are now collaborating to increase health care value on a national scale through quality improvement projects, education, and dissemination.
SHM’s Award of Excellence in Teaching
Jennifer O’Toole, MD, MEd, is a med-peds hospitalist at the Cincinnati Children’s Hospital Medical Center and University of Cincinnati Medical Center. She serves as the director of the combined internal medicine and pediatrics residency program and is the director of education for the Children’s Hospital division of hospital medicine. In these roles, Dr. O’Toole has established an acute care track for her med-peds residents interested in careers in hospital medicine and a career development boot camp for early-career faculty members and fellows in the division of hospital medicine.
Perhaps Dr. O’Toole’s most instrumental role as an educator has been her involvement in influential educational programs nationally, including the I-PASS Handoff program. Implementation of I-PASS decreased medical errors by 23% and preventable adverse events by 30% in more than 10,000 patient admissions across nine North American hospitals. She has authored more than 30 peer-reviewed publications related to medical education and has presented more than 50 workshops at national meetings. After serving as a member of the planning committee for the Pediatric Hospital Medicine meeting, she is cochair for the 2018 meeting.
SHM’s Award of Clinical Excellence for Physicians
Rick Hilger, MD, SFHM, has been a hospitalist with HealthPartners Regions Hospital in St. Paul, Minnesota for 16 years. He is a national expert in the areas of readmission prevention and care delivery for high-utilizer patients. His work in this area was named Best Clinical Innovation at Hospital Medicine 2012. His collaborative approach to solving complex problems is demonstrated by the amount of time he has volunteered to help other organizations improve their care of high utilizers. Over 90 organizations and hospitals have reached out for assistance in starting their own committees, and Dr. Hilger has shared his time and care plan templates with each one. He was one of the first hospitalists asked to participate on a National Quality Forum committee and has improved hospital reimbursement by over 4 million dollars by developing an internal physician advisor program.
Dr. Hilger also has served on the SHM Annual Conference Committee and the Public Policy Committee, where he has worked with other committee members to advocate for policy changes related to observation status and readmission penalties.
SHM’s Award for Excellence in Humanitarian Services
Michelle Morse, MD, MPH, is a hospitalist and the assistant program director for the internal medicine residency at Brigham and Women’s Hospital in Boston. She is also the founding codirector of EqualHealth, an organization that aims to inspire and support the development of Haiti’s next generation of health care leaders. In 2015, Dr. Morse helped to found the Social Medicine Consortium, a global coalition of more than 450 people representing over 50 universities and organizations in 12 countries, which seeks to address the miseducation of health professionals.
In the aftermath of the 2010 earthquake in Haiti, Dr. Morse was compelled to collaborate with colleagues and friends to help build capacity of health care providers committed to social medicine, medical and nursing education, and social justice. She helped to open and operate a new 300-bed teaching hospital in rural Haiti and founded the first three residency training programs at the hospital. Since that time, the hospital has expanded to serve an area of 3 million people with an annual budget of $12 million.
SHM’s Award of Excellence in Research
Teryl Nuckols, MD, FHM, is a hospitalist and the director of general internal medicine at Cedars-Sinai Medical Center in Los Angeles. She also serves as associate professor of medicine at the University of California, Los Angeles, and a health services researcher at the RAND Corporation in Santa Monica.
Currently, she is principal investigator and coprincipal investigator on two projects funded by the Agency for Healthcare Research and Quality that are evaluating effects of the Medicare Hospital Readmissions Reduction Program. Dr. Nuckols was previously the principal investigator on two R01 research grants from the Agency for Healthcare Research and Quality and the recipient of a K08 Career Development Award. She has evaluated clinical practice guidelines on behalf of SHM as well as policy makers in California and Australia, and her work has led to more than 30 peer-reviewed publications in NEJM, Journal of Hospital Medicine, and JAMA Internal Medicine among others.
SHM’s Award of Clinical Excellence for NPs/PAs
Meredith K. Wold, PA-C, is the supervisor of advanced practice clinicians at HealthPartners Medical Group, which includes 20 nurse practitioners and physician assistants, at Regions Hospital in St. Paul, Minn. She is also the cofounder and co-curriculum director for the HealthPartners Hospital Medicine Physician Assistant Fellowship Program. Under her leadership, the fellowship program offers a clear curriculum that exposes key clinical scenarios and specialties crucial to hospital medicine, preparing new PAs to contribute immediately to team-based care upon completion of the fellowship.
To prevent burnout in a 7-on/7-off schedule, Ms. Wold thought creatively and developed a pooling and “draft” system to give some flexibility and breaks in the block schedule – almost like a fantasy football draft but with patient care shifts for noncontinuity services.
Excellence in Management in Hospital Medicine
Maria Lourdes Novelero, MA, MPA, is the associate chair for administration of the department of medicine at the University of California, San Francisco, and has also served as the administrator of the UCSF division of hospital medicine and its associated medical service from 2005 to 2016. In this role, she managed the department’s expansion from a 20-physician division to an 80-physician division. She also led the department’s pioneering efforts in quality, safety, and value.
Ms. Novelero created a structure to build and manage 10 different hospitalist-run services, including cancer, cardiology, neurosurgery, and liver transplant comanagement services; a procedure service; a palliative care service; and a large non–housestaff medicine service. She co-led a multidisciplinary effort to transform the discharge process, and established and cochaired the department of hospital medicine’s high value care committee, which catalyzed value improvement activities throughout UCSF. This committee’s work led to tangible value improvements, such as a 14% reduction in direct costs and a first-ever positive net margin for the medical service.
Ms. Novelero has more than 25 years of experience in management positions in the United States and Japan.
Certificate of Leadership in Hospital Medicine
Benji K. Mathews, MD, SFHM, CLHM, graduated from the Institute of Technology at the University of Minnesota and the University of Minnesota Medical School. He completed his internal medicine residency and chief residency through the University of Minnesota, Minneapolis. He joined HealthPartners as an academic hospitalist and holds the titles of section head of hospital medicine at Regions Hospital and director of point of care ultrasound (POCUS) for Hospital Medicine at HealthPartners. He is the president for the Minnesota Chapter of the Society of Hospital Medicine (SHM).
Dr. Mathews has a passion for medical education, care delivery, and quality. He is an assistant professor of medicine at the University of Minnesota. As such, he is core faculty for the internal medicine residency program and chair of the Clinical Competency Committee. Dr. Mathews is an active member of SHM as a member of SHM's annual meeting planning committee, organizing and setting the agenda for SHM's record breaking meetings for the last 4 years. Dr. Mathews also serves on SHM's Quality Improvement and Patient Safety Committee and is the chair of the Diagnostic Error Subcommittee. He has completed the Certificate of Leadership in Hospital Medicine (CLHM) with his area of focus on ultrasound in hospital medicine. His work in diagnostic error and POCUS has been well recognized with multiple workshops and presentations given locally and nationally. He is a Fellow in Diagnostic Safety through the Society to Improve Diagnosis in Medicine.
Dr. Mathews also has a passion for global health, rooted in his commitment to reducing health care disparities both locally and globally. He has worked with medical missions, NGOs, and orphanages in Nepal, India, Bolivia, Honduras, and Costa Rica. This led him to complete the global health course at the University of Minnesota.
SHM’s Junior Investigator Award
Christine D. Jones, MD, MS, is an assistant professor of medicine at the University of Colorado's Anschutz medical campus, Aurora, where she is the director of care transitions and director of scholarship for the division of hospital medicine.
Dr. Jones’ research is focused on improving care coordination between clinicians in different settings to improve outcomes for patients discharged with home health care. Her research is supported by a K08 career development award from the Agency for Healthcare Research and Quality. Her overall goal is to improve the quality of care transitions for hospitalized patients discharged to post-acute care settings, including home health care. Dr. Jones has presented at every SHM annual conference since she joined in 2013.
Chapter Excellence Awards
The Society of Hospital Medicine is proud to recognize outstanding SHM chapters at HM18 for the fifth annual Chapter Excellence Awards. Each year, chapters strive to demonstrate growth, sustenance, and innovation within their chapter activities, which are then applauded for their successes at SHM’s annual conference.
Platinum Chapters: Gulf States, Iowa, Maryland, Michigan, Minnesota, New Mexico, North Carolina Triangle, St. Louis.
Gold Chapters: Hampton Roads, Kentucky, North Jersey, Pacific Northwest.
Silver Chapters: Boston/Eastern Massachusetts, Houston, Los Angeles, Maine, NYC/Westchester, Rocky Mountain, San Francisco Bay Area, South Central PA, Southwest Florida, Wiregrass.
Outstanding Chapter of the Year
New Mexico. SHM’s New Mexico Chapter has been nominated to receive the Outstanding Chapter of the Year Award for 2017. Consistently, leadership and members go above and beyond the basic requirements to maintain status by creating and cultivating multiple innovative and dynamic opportunities for attendees to educate and network. The chapter participated in SHM’s pilot program to offer CME for chapters, bringing a CME-accredited educational presentation on the care of diverse patients. Their annual meeting this year featured a poster competition for residents, students, and early-career hospitalists; a didactic on antimicrobial stewardship; and a business meeting with elections, member benefits, and highlights of the chapter’s year, and chapter awards. The chapter initiated breakfast meetings with didactics on DACA and on burnout and wellness, and collaborated with the University of New Mexico, Albuquerque on a grand rounds series on physician wellness that was available via telecast to numerous hospitals and providers off site. The chapter hosted a book club, a networking session at HM17, and an informational meeting on SHM membership and the Fellows Program. They have supported the future of hospital medicine by having a table at the UNM School of Medicine’s student activities fair, a Resident of the Year Award, and a position on our council for a resident representative. They have collaborated with the sole internal medicine residency program in New Mexico so that residents in the hospitalist training track have membership in SHM, and they have expanded our juried poster competition to include students. The chapter’s level of originality is not only a benefit to the chapter, but SHM’s chapter program as a whole.
Rising Star Chapter
Kentucky. SHM’s Kentucky Chapter has been nominated to receive the Rising Star Chapter Award for 2017 for their innovation and growth. The chapter’s leadership was involved with the establishment of the Heartland Hospital Medicine Conference and hosted a hospital medicine career panel and bustling Research, Innovations, and Clinical Vignettes abstract and poster competition. Nearly 50 abstracts were submitted, and the top 40 were invited to present posters at the competition. These posters included a mix of attendings, advanced practice providers, residents, and students interested in participating in the local hospital medicine community. The chapter sponsored the first prize winner’s travel to attend Hospital Medicine 2018 and gave awards to best resident and best student posters. The Kentucky Chapter directly recruited 27 hospitalists to join SHM membership in 2017. The Kentucky Chapter is an active, enthusiastic chapter that is rapidly growing and thriving.
Student Hospitalist Scholarship Recipients
The Society of Hospital Medicine’s Physician in Training Committee launched a Student Hospitalist Scholar Grant program in 2015 for medical students to conduct mentored scholarly projects related to quality improvement and patient safety.
The program was expanded in 2017 and now includes both a summer and longitudinal program for students.
The committee is happy to announce the 4th year of scholar grant recipients to six students based on their ability and interest in hospital medicine, general qualifications, prior educational training, and promise for scholarly activity.
Summer Program
Ilana Scandariato
Cornell University, New York
Project: Understanding the experience of the long-term hospitalized patient with provider fragmentation: A qualitative study
Mentor: Ernie Esquivel, MD, FHM
Maximilian Hemmrich
University of Chicago
Project: Derivation and validation of a COPD readmission risk prediction tool
Mentor: Valerie Press, MD, MPH, SFHM
Sandeep Bala
University of Central Florida, Orlando
Project: The impact of plain language open medical notes on patient activation
Mentor: Marisha Burden, MD, SFHM
Longitudinal Program
Erin Rainosek
University of Texas, San Antonio
Project Title: Design thinking to improve patient experience
Mentor: Luci Leykum, MD, SFHM
Matthew Fallon
Creighton University, Omaha, Neb.
Project: Reducing the hospital readmission rate of congestive heart failure (CHF)
Mentor: Venkata Andukuri, MD, MPH, FHM
Philip Huang
University of Iowa, Iowa City
Project: Expanded patient regionalization to improve care efficiency
Mentor: Ethan Kuperman, MD, FHM
Resident Travel Grant Recipients
The Society of Hospital Medicine’s Physician in Training Committee launched a Resident Travel Grant Program in 2017 for residents to receive funding to attend SHM’s Annual Conference and be recognized for their scholarly work.
The Committee is pleased to announce the first year of Resident Travel Grant Recipients to 10 Residents based on their ability and interest in hospital medicine, research originality, and teaching value, and general qualifications.
Ashley M. Jenkins, MD
Cincinnati Children’s Hospital Medical Center
Poster 41 - Aren’t adults just big kids?: Standardizing care of adults in pediatric hospitals
Brian A. MacDonald Jr., MD, PhD
State University of New York at Buffalo
Poster 135 – Phosphatidylethanol level as a predictor of acute alcohol withdrawal
Christopher S. Bartlett, MD, MPH
University of New Mexico Health Sciences Center, Albuquerque
Poster 47 - Lessons learned from a resident-created experiential quality improvement and patient safety curriculum for medical and nursing students at the University of New Mexico
Christopher T. Su, MD, MPH
Montefiore Medical Center/Albert Einstein College of Medicine, New York
Poster 173 - Concurrent NSAID and warfarin use is associated with increased blood transfusions in hospitalized patients
Madeleine Ivrit Matthiesen, MD
Harvard Medical School/Massachusetts General Hospital Medicine–Pediatrics, Boston
Poster 69 - Resident perceptions of feedback and teaching
Neil Keshvani, MD
University of Texas Southwestern Medical Center, Dallas
Poster 237 - Improving respiratory rate measurement accuracy in the hospital: A quality improvement initiative
Peter N. Barish, MD
University of California, San Francisco
Poster 344 - Costs Related to potential overuse of respiratory viral panel PCRs in general medicine patients
Rachna Rawal, MD
Saint Louis University
Poster 259 - Empowering medicine residents to think before ordering daily labs: A quality improvement study
Yihan Chen, MD
University of California, Los Angeles, Medical Center
Poster 12 - Hospitalist-directed transfers improve emergency room length of stay
Zachary G. Jacobs, MD
University of California, San Francisco
Poster 233 - The prevalence of treating asymptomatic elevated blood pressure with intravenous antihypertensives on the general medicine wards: A potential target for a quality improvement inter-vention
Poster 96 - Factors Impacting time to antibiotic administration in patients with sepsis: A single-center study of electronic health record data
SHM’s Award of Excellence in Outstanding Service in Hospital Medicine
Dr. Flora Kisuule, MD, SFHM, is an assistant professor at Johns Hopkins School of Medicine and the vice chair for clinical operations for the department of medicine at Johns Hopkins Bayview Medical Center. While at Johns Hopkins University, both in Baltimore, she codeveloped a hospitalist fellowship program that she now directs, as well as a fellowship program specifically for nurse practitioners and physician assistants. Under her leadership as the associate director of the division of hospital medicine, she helped to bring Johns Hopkins Bayview hospitalists’ quality and mortality indicators into the top 5% nationwide and reduced hospital-acquired conditions at Hopkins Bayview to the best of the four regional Hopkins Health System hospitals.
Nationally, she has served on several SHM committees, facilitated at multiple SHM leadership courses, served as vice president of SHM’s Baltimore Chapter, and consulted on hospitalist programs around the country. Internationally, Dr. Kisuule has developed and mentored hospitalist programs in Saudi Arabia, the United Arab Emirates, and Central America. She is currently developing a training program in hospital medicine in Panama and is a Senior Fellow in Hospital Medicine.
SHM’s Award of Excellence in Teamwork in Quality Improvement
Since 2011, the Johns Hopkins Health System hospitals have conducted quality improvement projects to increase the value of care for their patients. Their amazing work catalyzed a grass-roots initiative involving faculty and residents at both Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center.
With a unification of the EHR across the health system, RedondaMiller, MD, MBA, president of Johns Hopkins Hospital, and Renee Demski, MSW, MBA, vice president of quality for Johns Hopkins Health System, created the Johns Hopkins Health System High-Value Care Committee to operationalize initiatives across all six hospitals and Johns Hopkins community physicians. The committee is under the leadership of Trushar Dungarani, DO, FHM, from Howard County General Hospital and Lenny Feldman, MD, SFHM, Amit Pahwa, MD, and Pamela Johnson, MD, from Johns Hopkins Hospital, and comprises provider representatives from each institution and other important contributors from various specialties, including Mike Borowitz, MD, PhD; Dr. Ken Lee, DrPH; Emily Pherson, PharmD; Amy Knight, MD; Tim Niessen, MD, MPH; Keisha Perrin, and Clare Rock.
Initiatives directed by the committee have included reducing inappropriate testing for Clostridium difficile, folate testing for anemia, and duplicative imaging exams, among others. In the 18 months since inception, the committee reduced charges to patients and payers by nearly $4 million and hospital costs by more than $200,000.
Members of this committee joined forces with like-minded institutions to create the High Value Practice Academic Alliance in 2016. Faculty leaders from more than 80 academic centers are now collaborating to increase health care value on a national scale through quality improvement projects, education, and dissemination.
SHM’s Award of Excellence in Teaching
Jennifer O’Toole, MD, MEd, is a med-peds hospitalist at the Cincinnati Children’s Hospital Medical Center and University of Cincinnati Medical Center. She serves as the director of the combined internal medicine and pediatrics residency program and is the director of education for the Children’s Hospital division of hospital medicine. In these roles, Dr. O’Toole has established an acute care track for her med-peds residents interested in careers in hospital medicine and a career development boot camp for early-career faculty members and fellows in the division of hospital medicine.
Perhaps Dr. O’Toole’s most instrumental role as an educator has been her involvement in influential educational programs nationally, including the I-PASS Handoff program. Implementation of I-PASS decreased medical errors by 23% and preventable adverse events by 30% in more than 10,000 patient admissions across nine North American hospitals. She has authored more than 30 peer-reviewed publications related to medical education and has presented more than 50 workshops at national meetings. After serving as a member of the planning committee for the Pediatric Hospital Medicine meeting, she is cochair for the 2018 meeting.
SHM’s Award of Clinical Excellence for Physicians
Rick Hilger, MD, SFHM, has been a hospitalist with HealthPartners Regions Hospital in St. Paul, Minnesota for 16 years. He is a national expert in the areas of readmission prevention and care delivery for high-utilizer patients. His work in this area was named Best Clinical Innovation at Hospital Medicine 2012. His collaborative approach to solving complex problems is demonstrated by the amount of time he has volunteered to help other organizations improve their care of high utilizers. Over 90 organizations and hospitals have reached out for assistance in starting their own committees, and Dr. Hilger has shared his time and care plan templates with each one. He was one of the first hospitalists asked to participate on a National Quality Forum committee and has improved hospital reimbursement by over 4 million dollars by developing an internal physician advisor program.
Dr. Hilger also has served on the SHM Annual Conference Committee and the Public Policy Committee, where he has worked with other committee members to advocate for policy changes related to observation status and readmission penalties.
SHM’s Award for Excellence in Humanitarian Services
Michelle Morse, MD, MPH, is a hospitalist and the assistant program director for the internal medicine residency at Brigham and Women’s Hospital in Boston. She is also the founding codirector of EqualHealth, an organization that aims to inspire and support the development of Haiti’s next generation of health care leaders. In 2015, Dr. Morse helped to found the Social Medicine Consortium, a global coalition of more than 450 people representing over 50 universities and organizations in 12 countries, which seeks to address the miseducation of health professionals.
In the aftermath of the 2010 earthquake in Haiti, Dr. Morse was compelled to collaborate with colleagues and friends to help build capacity of health care providers committed to social medicine, medical and nursing education, and social justice. She helped to open and operate a new 300-bed teaching hospital in rural Haiti and founded the first three residency training programs at the hospital. Since that time, the hospital has expanded to serve an area of 3 million people with an annual budget of $12 million.
SHM’s Award of Excellence in Research
Teryl Nuckols, MD, FHM, is a hospitalist and the director of general internal medicine at Cedars-Sinai Medical Center in Los Angeles. She also serves as associate professor of medicine at the University of California, Los Angeles, and a health services researcher at the RAND Corporation in Santa Monica.
Currently, she is principal investigator and coprincipal investigator on two projects funded by the Agency for Healthcare Research and Quality that are evaluating effects of the Medicare Hospital Readmissions Reduction Program. Dr. Nuckols was previously the principal investigator on two R01 research grants from the Agency for Healthcare Research and Quality and the recipient of a K08 Career Development Award. She has evaluated clinical practice guidelines on behalf of SHM as well as policy makers in California and Australia, and her work has led to more than 30 peer-reviewed publications in NEJM, Journal of Hospital Medicine, and JAMA Internal Medicine among others.
SHM’s Award of Clinical Excellence for NPs/PAs
Meredith K. Wold, PA-C, is the supervisor of advanced practice clinicians at HealthPartners Medical Group, which includes 20 nurse practitioners and physician assistants, at Regions Hospital in St. Paul, Minn. She is also the cofounder and co-curriculum director for the HealthPartners Hospital Medicine Physician Assistant Fellowship Program. Under her leadership, the fellowship program offers a clear curriculum that exposes key clinical scenarios and specialties crucial to hospital medicine, preparing new PAs to contribute immediately to team-based care upon completion of the fellowship.
To prevent burnout in a 7-on/7-off schedule, Ms. Wold thought creatively and developed a pooling and “draft” system to give some flexibility and breaks in the block schedule – almost like a fantasy football draft but with patient care shifts for noncontinuity services.
Excellence in Management in Hospital Medicine
Maria Lourdes Novelero, MA, MPA, is the associate chair for administration of the department of medicine at the University of California, San Francisco, and has also served as the administrator of the UCSF division of hospital medicine and its associated medical service from 2005 to 2016. In this role, she managed the department’s expansion from a 20-physician division to an 80-physician division. She also led the department’s pioneering efforts in quality, safety, and value.
Ms. Novelero created a structure to build and manage 10 different hospitalist-run services, including cancer, cardiology, neurosurgery, and liver transplant comanagement services; a procedure service; a palliative care service; and a large non–housestaff medicine service. She co-led a multidisciplinary effort to transform the discharge process, and established and cochaired the department of hospital medicine’s high value care committee, which catalyzed value improvement activities throughout UCSF. This committee’s work led to tangible value improvements, such as a 14% reduction in direct costs and a first-ever positive net margin for the medical service.
Ms. Novelero has more than 25 years of experience in management positions in the United States and Japan.
Certificate of Leadership in Hospital Medicine
Benji K. Mathews, MD, SFHM, CLHM, graduated from the Institute of Technology at the University of Minnesota and the University of Minnesota Medical School. He completed his internal medicine residency and chief residency through the University of Minnesota, Minneapolis. He joined HealthPartners as an academic hospitalist and holds the titles of section head of hospital medicine at Regions Hospital and director of point of care ultrasound (POCUS) for Hospital Medicine at HealthPartners. He is the president for the Minnesota Chapter of the Society of Hospital Medicine (SHM).
Dr. Mathews has a passion for medical education, care delivery, and quality. He is an assistant professor of medicine at the University of Minnesota. As such, he is core faculty for the internal medicine residency program and chair of the Clinical Competency Committee. Dr. Mathews is an active member of SHM as a member of SHM's annual meeting planning committee, organizing and setting the agenda for SHM's record breaking meetings for the last 4 years. Dr. Mathews also serves on SHM's Quality Improvement and Patient Safety Committee and is the chair of the Diagnostic Error Subcommittee. He has completed the Certificate of Leadership in Hospital Medicine (CLHM) with his area of focus on ultrasound in hospital medicine. His work in diagnostic error and POCUS has been well recognized with multiple workshops and presentations given locally and nationally. He is a Fellow in Diagnostic Safety through the Society to Improve Diagnosis in Medicine.
Dr. Mathews also has a passion for global health, rooted in his commitment to reducing health care disparities both locally and globally. He has worked with medical missions, NGOs, and orphanages in Nepal, India, Bolivia, Honduras, and Costa Rica. This led him to complete the global health course at the University of Minnesota.
SHM’s Junior Investigator Award
Christine D. Jones, MD, MS, is an assistant professor of medicine at the University of Colorado's Anschutz medical campus, Aurora, where she is the director of care transitions and director of scholarship for the division of hospital medicine.
Dr. Jones’ research is focused on improving care coordination between clinicians in different settings to improve outcomes for patients discharged with home health care. Her research is supported by a K08 career development award from the Agency for Healthcare Research and Quality. Her overall goal is to improve the quality of care transitions for hospitalized patients discharged to post-acute care settings, including home health care. Dr. Jones has presented at every SHM annual conference since she joined in 2013.
Chapter Excellence Awards
The Society of Hospital Medicine is proud to recognize outstanding SHM chapters at HM18 for the fifth annual Chapter Excellence Awards. Each year, chapters strive to demonstrate growth, sustenance, and innovation within their chapter activities, which are then applauded for their successes at SHM’s annual conference.
Platinum Chapters: Gulf States, Iowa, Maryland, Michigan, Minnesota, New Mexico, North Carolina Triangle, St. Louis.
Gold Chapters: Hampton Roads, Kentucky, North Jersey, Pacific Northwest.
Silver Chapters: Boston/Eastern Massachusetts, Houston, Los Angeles, Maine, NYC/Westchester, Rocky Mountain, San Francisco Bay Area, South Central PA, Southwest Florida, Wiregrass.
Outstanding Chapter of the Year
New Mexico. SHM’s New Mexico Chapter has been nominated to receive the Outstanding Chapter of the Year Award for 2017. Consistently, leadership and members go above and beyond the basic requirements to maintain status by creating and cultivating multiple innovative and dynamic opportunities for attendees to educate and network. The chapter participated in SHM’s pilot program to offer CME for chapters, bringing a CME-accredited educational presentation on the care of diverse patients. Their annual meeting this year featured a poster competition for residents, students, and early-career hospitalists; a didactic on antimicrobial stewardship; and a business meeting with elections, member benefits, and highlights of the chapter’s year, and chapter awards. The chapter initiated breakfast meetings with didactics on DACA and on burnout and wellness, and collaborated with the University of New Mexico, Albuquerque on a grand rounds series on physician wellness that was available via telecast to numerous hospitals and providers off site. The chapter hosted a book club, a networking session at HM17, and an informational meeting on SHM membership and the Fellows Program. They have supported the future of hospital medicine by having a table at the UNM School of Medicine’s student activities fair, a Resident of the Year Award, and a position on our council for a resident representative. They have collaborated with the sole internal medicine residency program in New Mexico so that residents in the hospitalist training track have membership in SHM, and they have expanded our juried poster competition to include students. The chapter’s level of originality is not only a benefit to the chapter, but SHM’s chapter program as a whole.
Rising Star Chapter
Kentucky. SHM’s Kentucky Chapter has been nominated to receive the Rising Star Chapter Award for 2017 for their innovation and growth. The chapter’s leadership was involved with the establishment of the Heartland Hospital Medicine Conference and hosted a hospital medicine career panel and bustling Research, Innovations, and Clinical Vignettes abstract and poster competition. Nearly 50 abstracts were submitted, and the top 40 were invited to present posters at the competition. These posters included a mix of attendings, advanced practice providers, residents, and students interested in participating in the local hospital medicine community. The chapter sponsored the first prize winner’s travel to attend Hospital Medicine 2018 and gave awards to best resident and best student posters. The Kentucky Chapter directly recruited 27 hospitalists to join SHM membership in 2017. The Kentucky Chapter is an active, enthusiastic chapter that is rapidly growing and thriving.
Student Hospitalist Scholarship Recipients
The Society of Hospital Medicine’s Physician in Training Committee launched a Student Hospitalist Scholar Grant program in 2015 for medical students to conduct mentored scholarly projects related to quality improvement and patient safety.
The program was expanded in 2017 and now includes both a summer and longitudinal program for students.
The committee is happy to announce the 4th year of scholar grant recipients to six students based on their ability and interest in hospital medicine, general qualifications, prior educational training, and promise for scholarly activity.
Summer Program
Ilana Scandariato
Cornell University, New York
Project: Understanding the experience of the long-term hospitalized patient with provider fragmentation: A qualitative study
Mentor: Ernie Esquivel, MD, FHM
Maximilian Hemmrich
University of Chicago
Project: Derivation and validation of a COPD readmission risk prediction tool
Mentor: Valerie Press, MD, MPH, SFHM
Sandeep Bala
University of Central Florida, Orlando
Project: The impact of plain language open medical notes on patient activation
Mentor: Marisha Burden, MD, SFHM
Longitudinal Program
Erin Rainosek
University of Texas, San Antonio
Project Title: Design thinking to improve patient experience
Mentor: Luci Leykum, MD, SFHM
Matthew Fallon
Creighton University, Omaha, Neb.
Project: Reducing the hospital readmission rate of congestive heart failure (CHF)
Mentor: Venkata Andukuri, MD, MPH, FHM
Philip Huang
University of Iowa, Iowa City
Project: Expanded patient regionalization to improve care efficiency
Mentor: Ethan Kuperman, MD, FHM
Resident Travel Grant Recipients
The Society of Hospital Medicine’s Physician in Training Committee launched a Resident Travel Grant Program in 2017 for residents to receive funding to attend SHM’s Annual Conference and be recognized for their scholarly work.
The Committee is pleased to announce the first year of Resident Travel Grant Recipients to 10 Residents based on their ability and interest in hospital medicine, research originality, and teaching value, and general qualifications.
Ashley M. Jenkins, MD
Cincinnati Children’s Hospital Medical Center
Poster 41 - Aren’t adults just big kids?: Standardizing care of adults in pediatric hospitals
Brian A. MacDonald Jr., MD, PhD
State University of New York at Buffalo
Poster 135 – Phosphatidylethanol level as a predictor of acute alcohol withdrawal
Christopher S. Bartlett, MD, MPH
University of New Mexico Health Sciences Center, Albuquerque
Poster 47 - Lessons learned from a resident-created experiential quality improvement and patient safety curriculum for medical and nursing students at the University of New Mexico
Christopher T. Su, MD, MPH
Montefiore Medical Center/Albert Einstein College of Medicine, New York
Poster 173 - Concurrent NSAID and warfarin use is associated with increased blood transfusions in hospitalized patients
Madeleine Ivrit Matthiesen, MD
Harvard Medical School/Massachusetts General Hospital Medicine–Pediatrics, Boston
Poster 69 - Resident perceptions of feedback and teaching
Neil Keshvani, MD
University of Texas Southwestern Medical Center, Dallas
Poster 237 - Improving respiratory rate measurement accuracy in the hospital: A quality improvement initiative
Peter N. Barish, MD
University of California, San Francisco
Poster 344 - Costs Related to potential overuse of respiratory viral panel PCRs in general medicine patients
Rachna Rawal, MD
Saint Louis University
Poster 259 - Empowering medicine residents to think before ordering daily labs: A quality improvement study
Yihan Chen, MD
University of California, Los Angeles, Medical Center
Poster 12 - Hospitalist-directed transfers improve emergency room length of stay
Zachary G. Jacobs, MD
University of California, San Francisco
Poster 233 - The prevalence of treating asymptomatic elevated blood pressure with intravenous antihypertensives on the general medicine wards: A potential target for a quality improvement inter-vention
Poster 96 - Factors Impacting time to antibiotic administration in patients with sepsis: A single-center study of electronic health record data
SHM’s Award of Excellence in Outstanding Service in Hospital Medicine
Dr. Flora Kisuule, MD, SFHM, is an assistant professor at Johns Hopkins School of Medicine and the vice chair for clinical operations for the department of medicine at Johns Hopkins Bayview Medical Center. While at Johns Hopkins University, both in Baltimore, she codeveloped a hospitalist fellowship program that she now directs, as well as a fellowship program specifically for nurse practitioners and physician assistants. Under her leadership as the associate director of the division of hospital medicine, she helped to bring Johns Hopkins Bayview hospitalists’ quality and mortality indicators into the top 5% nationwide and reduced hospital-acquired conditions at Hopkins Bayview to the best of the four regional Hopkins Health System hospitals.
Nationally, she has served on several SHM committees, facilitated at multiple SHM leadership courses, served as vice president of SHM’s Baltimore Chapter, and consulted on hospitalist programs around the country. Internationally, Dr. Kisuule has developed and mentored hospitalist programs in Saudi Arabia, the United Arab Emirates, and Central America. She is currently developing a training program in hospital medicine in Panama and is a Senior Fellow in Hospital Medicine.
SHM’s Award of Excellence in Teamwork in Quality Improvement
Since 2011, the Johns Hopkins Health System hospitals have conducted quality improvement projects to increase the value of care for their patients. Their amazing work catalyzed a grass-roots initiative involving faculty and residents at both Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center.
With a unification of the EHR across the health system, RedondaMiller, MD, MBA, president of Johns Hopkins Hospital, and Renee Demski, MSW, MBA, vice president of quality for Johns Hopkins Health System, created the Johns Hopkins Health System High-Value Care Committee to operationalize initiatives across all six hospitals and Johns Hopkins community physicians. The committee is under the leadership of Trushar Dungarani, DO, FHM, from Howard County General Hospital and Lenny Feldman, MD, SFHM, Amit Pahwa, MD, and Pamela Johnson, MD, from Johns Hopkins Hospital, and comprises provider representatives from each institution and other important contributors from various specialties, including Mike Borowitz, MD, PhD; Dr. Ken Lee, DrPH; Emily Pherson, PharmD; Amy Knight, MD; Tim Niessen, MD, MPH; Keisha Perrin, and Clare Rock.
Initiatives directed by the committee have included reducing inappropriate testing for Clostridium difficile, folate testing for anemia, and duplicative imaging exams, among others. In the 18 months since inception, the committee reduced charges to patients and payers by nearly $4 million and hospital costs by more than $200,000.
Members of this committee joined forces with like-minded institutions to create the High Value Practice Academic Alliance in 2016. Faculty leaders from more than 80 academic centers are now collaborating to increase health care value on a national scale through quality improvement projects, education, and dissemination.
SHM’s Award of Excellence in Teaching
Jennifer O’Toole, MD, MEd, is a med-peds hospitalist at the Cincinnati Children’s Hospital Medical Center and University of Cincinnati Medical Center. She serves as the director of the combined internal medicine and pediatrics residency program and is the director of education for the Children’s Hospital division of hospital medicine. In these roles, Dr. O’Toole has established an acute care track for her med-peds residents interested in careers in hospital medicine and a career development boot camp for early-career faculty members and fellows in the division of hospital medicine.
Perhaps Dr. O’Toole’s most instrumental role as an educator has been her involvement in influential educational programs nationally, including the I-PASS Handoff program. Implementation of I-PASS decreased medical errors by 23% and preventable adverse events by 30% in more than 10,000 patient admissions across nine North American hospitals. She has authored more than 30 peer-reviewed publications related to medical education and has presented more than 50 workshops at national meetings. After serving as a member of the planning committee for the Pediatric Hospital Medicine meeting, she is cochair for the 2018 meeting.
SHM’s Award of Clinical Excellence for Physicians
Rick Hilger, MD, SFHM, has been a hospitalist with HealthPartners Regions Hospital in St. Paul, Minnesota for 16 years. He is a national expert in the areas of readmission prevention and care delivery for high-utilizer patients. His work in this area was named Best Clinical Innovation at Hospital Medicine 2012. His collaborative approach to solving complex problems is demonstrated by the amount of time he has volunteered to help other organizations improve their care of high utilizers. Over 90 organizations and hospitals have reached out for assistance in starting their own committees, and Dr. Hilger has shared his time and care plan templates with each one. He was one of the first hospitalists asked to participate on a National Quality Forum committee and has improved hospital reimbursement by over 4 million dollars by developing an internal physician advisor program.
Dr. Hilger also has served on the SHM Annual Conference Committee and the Public Policy Committee, where he has worked with other committee members to advocate for policy changes related to observation status and readmission penalties.
SHM’s Award for Excellence in Humanitarian Services
Michelle Morse, MD, MPH, is a hospitalist and the assistant program director for the internal medicine residency at Brigham and Women’s Hospital in Boston. She is also the founding codirector of EqualHealth, an organization that aims to inspire and support the development of Haiti’s next generation of health care leaders. In 2015, Dr. Morse helped to found the Social Medicine Consortium, a global coalition of more than 450 people representing over 50 universities and organizations in 12 countries, which seeks to address the miseducation of health professionals.
In the aftermath of the 2010 earthquake in Haiti, Dr. Morse was compelled to collaborate with colleagues and friends to help build capacity of health care providers committed to social medicine, medical and nursing education, and social justice. She helped to open and operate a new 300-bed teaching hospital in rural Haiti and founded the first three residency training programs at the hospital. Since that time, the hospital has expanded to serve an area of 3 million people with an annual budget of $12 million.
SHM’s Award of Excellence in Research
Teryl Nuckols, MD, FHM, is a hospitalist and the director of general internal medicine at Cedars-Sinai Medical Center in Los Angeles. She also serves as associate professor of medicine at the University of California, Los Angeles, and a health services researcher at the RAND Corporation in Santa Monica.
Currently, she is principal investigator and coprincipal investigator on two projects funded by the Agency for Healthcare Research and Quality that are evaluating effects of the Medicare Hospital Readmissions Reduction Program. Dr. Nuckols was previously the principal investigator on two R01 research grants from the Agency for Healthcare Research and Quality and the recipient of a K08 Career Development Award. She has evaluated clinical practice guidelines on behalf of SHM as well as policy makers in California and Australia, and her work has led to more than 30 peer-reviewed publications in NEJM, Journal of Hospital Medicine, and JAMA Internal Medicine among others.
SHM’s Award of Clinical Excellence for NPs/PAs
Meredith K. Wold, PA-C, is the supervisor of advanced practice clinicians at HealthPartners Medical Group, which includes 20 nurse practitioners and physician assistants, at Regions Hospital in St. Paul, Minn. She is also the cofounder and co-curriculum director for the HealthPartners Hospital Medicine Physician Assistant Fellowship Program. Under her leadership, the fellowship program offers a clear curriculum that exposes key clinical scenarios and specialties crucial to hospital medicine, preparing new PAs to contribute immediately to team-based care upon completion of the fellowship.
To prevent burnout in a 7-on/7-off schedule, Ms. Wold thought creatively and developed a pooling and “draft” system to give some flexibility and breaks in the block schedule – almost like a fantasy football draft but with patient care shifts for noncontinuity services.
Excellence in Management in Hospital Medicine
Maria Lourdes Novelero, MA, MPA, is the associate chair for administration of the department of medicine at the University of California, San Francisco, and has also served as the administrator of the UCSF division of hospital medicine and its associated medical service from 2005 to 2016. In this role, she managed the department’s expansion from a 20-physician division to an 80-physician division. She also led the department’s pioneering efforts in quality, safety, and value.
Ms. Novelero created a structure to build and manage 10 different hospitalist-run services, including cancer, cardiology, neurosurgery, and liver transplant comanagement services; a procedure service; a palliative care service; and a large non–housestaff medicine service. She co-led a multidisciplinary effort to transform the discharge process, and established and cochaired the department of hospital medicine’s high value care committee, which catalyzed value improvement activities throughout UCSF. This committee’s work led to tangible value improvements, such as a 14% reduction in direct costs and a first-ever positive net margin for the medical service.
Ms. Novelero has more than 25 years of experience in management positions in the United States and Japan.
Certificate of Leadership in Hospital Medicine
Benji K. Mathews, MD, SFHM, CLHM, graduated from the Institute of Technology at the University of Minnesota and the University of Minnesota Medical School. He completed his internal medicine residency and chief residency through the University of Minnesota, Minneapolis. He joined HealthPartners as an academic hospitalist and holds the titles of section head of hospital medicine at Regions Hospital and director of point of care ultrasound (POCUS) for Hospital Medicine at HealthPartners. He is the president for the Minnesota Chapter of the Society of Hospital Medicine (SHM).
Dr. Mathews has a passion for medical education, care delivery, and quality. He is an assistant professor of medicine at the University of Minnesota. As such, he is core faculty for the internal medicine residency program and chair of the Clinical Competency Committee. Dr. Mathews is an active member of SHM as a member of SHM's annual meeting planning committee, organizing and setting the agenda for SHM's record breaking meetings for the last 4 years. Dr. Mathews also serves on SHM's Quality Improvement and Patient Safety Committee and is the chair of the Diagnostic Error Subcommittee. He has completed the Certificate of Leadership in Hospital Medicine (CLHM) with his area of focus on ultrasound in hospital medicine. His work in diagnostic error and POCUS has been well recognized with multiple workshops and presentations given locally and nationally. He is a Fellow in Diagnostic Safety through the Society to Improve Diagnosis in Medicine.
Dr. Mathews also has a passion for global health, rooted in his commitment to reducing health care disparities both locally and globally. He has worked with medical missions, NGOs, and orphanages in Nepal, India, Bolivia, Honduras, and Costa Rica. This led him to complete the global health course at the University of Minnesota.
SHM’s Junior Investigator Award
Christine D. Jones, MD, MS, is an assistant professor of medicine at the University of Colorado's Anschutz medical campus, Aurora, where she is the director of care transitions and director of scholarship for the division of hospital medicine.
Dr. Jones’ research is focused on improving care coordination between clinicians in different settings to improve outcomes for patients discharged with home health care. Her research is supported by a K08 career development award from the Agency for Healthcare Research and Quality. Her overall goal is to improve the quality of care transitions for hospitalized patients discharged to post-acute care settings, including home health care. Dr. Jones has presented at every SHM annual conference since she joined in 2013.
Chapter Excellence Awards
The Society of Hospital Medicine is proud to recognize outstanding SHM chapters at HM18 for the fifth annual Chapter Excellence Awards. Each year, chapters strive to demonstrate growth, sustenance, and innovation within their chapter activities, which are then applauded for their successes at SHM’s annual conference.
Platinum Chapters: Gulf States, Iowa, Maryland, Michigan, Minnesota, New Mexico, North Carolina Triangle, St. Louis.
Gold Chapters: Hampton Roads, Kentucky, North Jersey, Pacific Northwest.
Silver Chapters: Boston/Eastern Massachusetts, Houston, Los Angeles, Maine, NYC/Westchester, Rocky Mountain, San Francisco Bay Area, South Central PA, Southwest Florida, Wiregrass.
Outstanding Chapter of the Year
New Mexico. SHM’s New Mexico Chapter has been nominated to receive the Outstanding Chapter of the Year Award for 2017. Consistently, leadership and members go above and beyond the basic requirements to maintain status by creating and cultivating multiple innovative and dynamic opportunities for attendees to educate and network. The chapter participated in SHM’s pilot program to offer CME for chapters, bringing a CME-accredited educational presentation on the care of diverse patients. Their annual meeting this year featured a poster competition for residents, students, and early-career hospitalists; a didactic on antimicrobial stewardship; and a business meeting with elections, member benefits, and highlights of the chapter’s year, and chapter awards. The chapter initiated breakfast meetings with didactics on DACA and on burnout and wellness, and collaborated with the University of New Mexico, Albuquerque on a grand rounds series on physician wellness that was available via telecast to numerous hospitals and providers off site. The chapter hosted a book club, a networking session at HM17, and an informational meeting on SHM membership and the Fellows Program. They have supported the future of hospital medicine by having a table at the UNM School of Medicine’s student activities fair, a Resident of the Year Award, and a position on our council for a resident representative. They have collaborated with the sole internal medicine residency program in New Mexico so that residents in the hospitalist training track have membership in SHM, and they have expanded our juried poster competition to include students. The chapter’s level of originality is not only a benefit to the chapter, but SHM’s chapter program as a whole.
Rising Star Chapter
Kentucky. SHM’s Kentucky Chapter has been nominated to receive the Rising Star Chapter Award for 2017 for their innovation and growth. The chapter’s leadership was involved with the establishment of the Heartland Hospital Medicine Conference and hosted a hospital medicine career panel and bustling Research, Innovations, and Clinical Vignettes abstract and poster competition. Nearly 50 abstracts were submitted, and the top 40 were invited to present posters at the competition. These posters included a mix of attendings, advanced practice providers, residents, and students interested in participating in the local hospital medicine community. The chapter sponsored the first prize winner’s travel to attend Hospital Medicine 2018 and gave awards to best resident and best student posters. The Kentucky Chapter directly recruited 27 hospitalists to join SHM membership in 2017. The Kentucky Chapter is an active, enthusiastic chapter that is rapidly growing and thriving.
Student Hospitalist Scholarship Recipients
The Society of Hospital Medicine’s Physician in Training Committee launched a Student Hospitalist Scholar Grant program in 2015 for medical students to conduct mentored scholarly projects related to quality improvement and patient safety.
The program was expanded in 2017 and now includes both a summer and longitudinal program for students.
The committee is happy to announce the 4th year of scholar grant recipients to six students based on their ability and interest in hospital medicine, general qualifications, prior educational training, and promise for scholarly activity.
Summer Program
Ilana Scandariato
Cornell University, New York
Project: Understanding the experience of the long-term hospitalized patient with provider fragmentation: A qualitative study
Mentor: Ernie Esquivel, MD, FHM
Maximilian Hemmrich
University of Chicago
Project: Derivation and validation of a COPD readmission risk prediction tool
Mentor: Valerie Press, MD, MPH, SFHM
Sandeep Bala
University of Central Florida, Orlando
Project: The impact of plain language open medical notes on patient activation
Mentor: Marisha Burden, MD, SFHM
Longitudinal Program
Erin Rainosek
University of Texas, San Antonio
Project Title: Design thinking to improve patient experience
Mentor: Luci Leykum, MD, SFHM
Matthew Fallon
Creighton University, Omaha, Neb.
Project: Reducing the hospital readmission rate of congestive heart failure (CHF)
Mentor: Venkata Andukuri, MD, MPH, FHM
Philip Huang
University of Iowa, Iowa City
Project: Expanded patient regionalization to improve care efficiency
Mentor: Ethan Kuperman, MD, FHM
Resident Travel Grant Recipients
The Society of Hospital Medicine’s Physician in Training Committee launched a Resident Travel Grant Program in 2017 for residents to receive funding to attend SHM’s Annual Conference and be recognized for their scholarly work.
The Committee is pleased to announce the first year of Resident Travel Grant Recipients to 10 Residents based on their ability and interest in hospital medicine, research originality, and teaching value, and general qualifications.
Ashley M. Jenkins, MD
Cincinnati Children’s Hospital Medical Center
Poster 41 - Aren’t adults just big kids?: Standardizing care of adults in pediatric hospitals
Brian A. MacDonald Jr., MD, PhD
State University of New York at Buffalo
Poster 135 – Phosphatidylethanol level as a predictor of acute alcohol withdrawal
Christopher S. Bartlett, MD, MPH
University of New Mexico Health Sciences Center, Albuquerque
Poster 47 - Lessons learned from a resident-created experiential quality improvement and patient safety curriculum for medical and nursing students at the University of New Mexico
Christopher T. Su, MD, MPH
Montefiore Medical Center/Albert Einstein College of Medicine, New York
Poster 173 - Concurrent NSAID and warfarin use is associated with increased blood transfusions in hospitalized patients
Madeleine Ivrit Matthiesen, MD
Harvard Medical School/Massachusetts General Hospital Medicine–Pediatrics, Boston
Poster 69 - Resident perceptions of feedback and teaching
Neil Keshvani, MD
University of Texas Southwestern Medical Center, Dallas
Poster 237 - Improving respiratory rate measurement accuracy in the hospital: A quality improvement initiative
Peter N. Barish, MD
University of California, San Francisco
Poster 344 - Costs Related to potential overuse of respiratory viral panel PCRs in general medicine patients
Rachna Rawal, MD
Saint Louis University
Poster 259 - Empowering medicine residents to think before ordering daily labs: A quality improvement study
Yihan Chen, MD
University of California, Los Angeles, Medical Center
Poster 12 - Hospitalist-directed transfers improve emergency room length of stay
Zachary G. Jacobs, MD
University of California, San Francisco
Poster 233 - The prevalence of treating asymptomatic elevated blood pressure with intravenous antihypertensives on the general medicine wards: A potential target for a quality improvement inter-vention
Poster 96 - Factors Impacting time to antibiotic administration in patients with sepsis: A single-center study of electronic health record data
New for HM19: Call for content expanded to include speaker, topic proposals
The Call for Content for HM19 – open to both Society of Hospital Medicine members and nonmembers – is being expanded from solely workshop submissions to include speaker and topic proposals.
“The open call for workshops has been in place for a number of years,” said Dustin T. Smith, MD, FHM, an associate professor of medicine at Emory University in Atlanta. Dr. Smith is an HM18 assistant course director and will be the primary course director for HM19. “In the past, we used a targeted survey method to get speaker/topic suggestions for the didactic sessions. The change was made, in part, based on member and annual meeting feedback along with strong SHM leadership support and guidance.”
This change, for both workshops and sessions, will allow for more speaker diversity, as well as open the door for new presenters. “We really feel this ability to propose content and speakers will resonate with our members and nonmembers alike, giving them a voice in annual conference planning,” he continued. “Our overall goal is to create new and exciting meeting formats each year that spark interest and promote overall attendee learning.”
Dr. Smith hosted an informational presentation on the process as part of the MEDTalks session on Monday.
When asked about themes for next year’s conference, Dr. Smith stated, “I anticipate that some of the areas of focus will center around health policy, advocacy for patients, and the latest in hospital medicine.” The SHM Annual Meeting Committee is responsible for HM19’s didactic content, the foundation of which will be rooted in hot topics and subject areas in the field. Planning also will take into account momentum and feedback from HM18.
“We have a few innovative and exciting educational tracks at HM18, including The Great Debate and Seasoning Your Career. If they are successful, we hope to offer similar ones next year,” Dr. Smith explained. “Some already popular tracks such as Rapid Fire clinical topics and Clinical Updates will likely remain meeting staples, although their content will certainly change.
“I am a working member of a talented group of incredibly knowledgeable hospitalists who form the Annual Conference Committee for both HM18 and HM19. With amazing SHM leadership and staff liaison guidance and support, we will be planning content for the bulk of the educational portion of next year’s conference,” he noted.
Dr. Smith, an Atlanta native, is an academic hospitalist and assistant chief of medicine for education in the Medical Specialty Care Services Line at the Atlanta Veterans Affairs (VA) Medical Center. He graduated from Emory University in Atlanta and completed his residency at the University of California, San Francisco, with distinction.
“I was immersed in large hospital medicine programs full of terrific practicing hospitalists at both institutions,” Dr. Smith recalled. “It became apparent that, when I completed my training, I wanted to pursue an academic hospital medicine career in a large, urban setting. Being from Atlanta, I wanted to reconnect with Emory, so I accepted a position at the Atlanta VA Medical Center as a hospitalist.” (The Atlanta VA is an Emory academic affiliate.)
The recipient of numerous teaching awards, Dr. Smith is an associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory, is the chair of the Emory division of hospital medicine Education Council, and has been codirector of the annual Southern Hospital Medicine Conference since 2012. The Emory department of medicine has named him “Distinguished Physician” for his significant clinical contributions.
“I am lucky enough to have been surrounded by great mentors in hospital medicine, both during training and as early- and now mid-career faculty. Mentoring and professional development are really key elements to building a successful and sustainable career in hospital medicine,” he said. “Additionally, I am incredibly humbled and thankful to have the opportunity to care for veterans in my various clinical roles at the Atlanta VA.”
When asked about the field, Dr. Smith said, “In my opinion, hospital medicine is and has been vital for the successful operation of health care and the management of hospitalized patients for more than a decade now. Hospitalists not only provide top-notch care for inpatients but also play so many other important roles in medicine in areas such as quality improvement, practice management, comanagement, research, and education.”
The Call for Content for HM19 – open to both Society of Hospital Medicine members and nonmembers – is being expanded from solely workshop submissions to include speaker and topic proposals.
“The open call for workshops has been in place for a number of years,” said Dustin T. Smith, MD, FHM, an associate professor of medicine at Emory University in Atlanta. Dr. Smith is an HM18 assistant course director and will be the primary course director for HM19. “In the past, we used a targeted survey method to get speaker/topic suggestions for the didactic sessions. The change was made, in part, based on member and annual meeting feedback along with strong SHM leadership support and guidance.”
This change, for both workshops and sessions, will allow for more speaker diversity, as well as open the door for new presenters. “We really feel this ability to propose content and speakers will resonate with our members and nonmembers alike, giving them a voice in annual conference planning,” he continued. “Our overall goal is to create new and exciting meeting formats each year that spark interest and promote overall attendee learning.”
Dr. Smith hosted an informational presentation on the process as part of the MEDTalks session on Monday.
When asked about themes for next year’s conference, Dr. Smith stated, “I anticipate that some of the areas of focus will center around health policy, advocacy for patients, and the latest in hospital medicine.” The SHM Annual Meeting Committee is responsible for HM19’s didactic content, the foundation of which will be rooted in hot topics and subject areas in the field. Planning also will take into account momentum and feedback from HM18.
“We have a few innovative and exciting educational tracks at HM18, including The Great Debate and Seasoning Your Career. If they are successful, we hope to offer similar ones next year,” Dr. Smith explained. “Some already popular tracks such as Rapid Fire clinical topics and Clinical Updates will likely remain meeting staples, although their content will certainly change.
“I am a working member of a talented group of incredibly knowledgeable hospitalists who form the Annual Conference Committee for both HM18 and HM19. With amazing SHM leadership and staff liaison guidance and support, we will be planning content for the bulk of the educational portion of next year’s conference,” he noted.
Dr. Smith, an Atlanta native, is an academic hospitalist and assistant chief of medicine for education in the Medical Specialty Care Services Line at the Atlanta Veterans Affairs (VA) Medical Center. He graduated from Emory University in Atlanta and completed his residency at the University of California, San Francisco, with distinction.
“I was immersed in large hospital medicine programs full of terrific practicing hospitalists at both institutions,” Dr. Smith recalled. “It became apparent that, when I completed my training, I wanted to pursue an academic hospital medicine career in a large, urban setting. Being from Atlanta, I wanted to reconnect with Emory, so I accepted a position at the Atlanta VA Medical Center as a hospitalist.” (The Atlanta VA is an Emory academic affiliate.)
The recipient of numerous teaching awards, Dr. Smith is an associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory, is the chair of the Emory division of hospital medicine Education Council, and has been codirector of the annual Southern Hospital Medicine Conference since 2012. The Emory department of medicine has named him “Distinguished Physician” for his significant clinical contributions.
“I am lucky enough to have been surrounded by great mentors in hospital medicine, both during training and as early- and now mid-career faculty. Mentoring and professional development are really key elements to building a successful and sustainable career in hospital medicine,” he said. “Additionally, I am incredibly humbled and thankful to have the opportunity to care for veterans in my various clinical roles at the Atlanta VA.”
When asked about the field, Dr. Smith said, “In my opinion, hospital medicine is and has been vital for the successful operation of health care and the management of hospitalized patients for more than a decade now. Hospitalists not only provide top-notch care for inpatients but also play so many other important roles in medicine in areas such as quality improvement, practice management, comanagement, research, and education.”
The Call for Content for HM19 – open to both Society of Hospital Medicine members and nonmembers – is being expanded from solely workshop submissions to include speaker and topic proposals.
“The open call for workshops has been in place for a number of years,” said Dustin T. Smith, MD, FHM, an associate professor of medicine at Emory University in Atlanta. Dr. Smith is an HM18 assistant course director and will be the primary course director for HM19. “In the past, we used a targeted survey method to get speaker/topic suggestions for the didactic sessions. The change was made, in part, based on member and annual meeting feedback along with strong SHM leadership support and guidance.”
This change, for both workshops and sessions, will allow for more speaker diversity, as well as open the door for new presenters. “We really feel this ability to propose content and speakers will resonate with our members and nonmembers alike, giving them a voice in annual conference planning,” he continued. “Our overall goal is to create new and exciting meeting formats each year that spark interest and promote overall attendee learning.”
Dr. Smith hosted an informational presentation on the process as part of the MEDTalks session on Monday.
When asked about themes for next year’s conference, Dr. Smith stated, “I anticipate that some of the areas of focus will center around health policy, advocacy for patients, and the latest in hospital medicine.” The SHM Annual Meeting Committee is responsible for HM19’s didactic content, the foundation of which will be rooted in hot topics and subject areas in the field. Planning also will take into account momentum and feedback from HM18.
“We have a few innovative and exciting educational tracks at HM18, including The Great Debate and Seasoning Your Career. If they are successful, we hope to offer similar ones next year,” Dr. Smith explained. “Some already popular tracks such as Rapid Fire clinical topics and Clinical Updates will likely remain meeting staples, although their content will certainly change.
“I am a working member of a talented group of incredibly knowledgeable hospitalists who form the Annual Conference Committee for both HM18 and HM19. With amazing SHM leadership and staff liaison guidance and support, we will be planning content for the bulk of the educational portion of next year’s conference,” he noted.
Dr. Smith, an Atlanta native, is an academic hospitalist and assistant chief of medicine for education in the Medical Specialty Care Services Line at the Atlanta Veterans Affairs (VA) Medical Center. He graduated from Emory University in Atlanta and completed his residency at the University of California, San Francisco, with distinction.
“I was immersed in large hospital medicine programs full of terrific practicing hospitalists at both institutions,” Dr. Smith recalled. “It became apparent that, when I completed my training, I wanted to pursue an academic hospital medicine career in a large, urban setting. Being from Atlanta, I wanted to reconnect with Emory, so I accepted a position at the Atlanta VA Medical Center as a hospitalist.” (The Atlanta VA is an Emory academic affiliate.)
The recipient of numerous teaching awards, Dr. Smith is an associate program director for the J. Willis Hurst Internal Medicine Residency Program at Emory, is the chair of the Emory division of hospital medicine Education Council, and has been codirector of the annual Southern Hospital Medicine Conference since 2012. The Emory department of medicine has named him “Distinguished Physician” for his significant clinical contributions.
“I am lucky enough to have been surrounded by great mentors in hospital medicine, both during training and as early- and now mid-career faculty. Mentoring and professional development are really key elements to building a successful and sustainable career in hospital medicine,” he said. “Additionally, I am incredibly humbled and thankful to have the opportunity to care for veterans in my various clinical roles at the Atlanta VA.”
When asked about the field, Dr. Smith said, “In my opinion, hospital medicine is and has been vital for the successful operation of health care and the management of hospitalized patients for more than a decade now. Hospitalists not only provide top-notch care for inpatients but also play so many other important roles in medicine in areas such as quality improvement, practice management, comanagement, research, and education.”
