Thomas R. Collins

Dr. Jonathan Zenilman, chief of infectious diseases at Johns Hopkins Bayview Medical Center in Baltimore, discusses details of Bayview’s antibiotic stewardship program and the challenge of getting such programs funded.

Dr. Jonathan Zenilman, chief of infectious diseases at Johns Hopkins Bayview Medical Center in Baltimore, discusses details of Bayview’s antibiotic stewardship program and the challenge of getting such programs funded.

Dr. Jonathan Zenilman, chief of infectious diseases at Johns Hopkins Bayview Medical Center in Baltimore, discusses details of Bayview’s antibiotic stewardship program and the challenge of getting such programs funded.

The hospitalists at six Illinois hospitals, physicians who are provided by Best Practices Inpatient Care, were grappling with some issues that might sound familiar to hospitalists around the country. The issues revolved around the electronic health record (EHR).

First, “it’s a pain,” says Jeffry Kreamer, MD, chief executive officer of Best Practices. The Long Grove, Ill.-based practice also wanted EHRs to include notes that were standardized, not limited by a template.

The big issue, however, was job satisfaction.

“Our docs are very smart people. If they would have wanted to do a clerical-type job, they would have done a clerical-type job,” Dr. Kreamer says. “They want to be doctors. They don’t want to be keyboardists.

“It makes no sense to take your most experienced asset, which is our physician, and then deploy them for a clerical task which can be done for a much lower cost.”

That’s where medical scribes come in. Scribes work as assistants to physicians and are responsible for entering information into the medical record with physician oversight. Scribes have a history that goes back a decade in emergency medicine, a setting in which doctors traditionally spend much more time in face-to-face contact with patients than they do in documenting the encounter.

Although scribe use in the emergency medicine and hospital medicine settings is growing, with supporters praising programs for boosting volume and allowing physicians to focus on patient care, not all attempts at using the scribe model of care have worked well. Some suggest scribes are a crutch for cumbersome EHRs and excessive administrative work that most doctors would prefer not to deal with.

Dr. Kreamer, however, says the majority of his scribe programs are tapping into a growing segment of the medical industry. There are now more than 15,000 scribes represented by the American College of Medical Scribe Specialists, and the numbers are increasing along a steep curve. There are still far more scribes working in EDs than alongside hospitalists, but as their track record in the inpatient setting lengthens, the number of inpatient scribes is likely to continue to grow.

Dr. Kreamer sensed that scribes would work as well in the inpatient setting as in the ED—maybe even better. He got in touch with the head of ScribeAmerica, the company that provides most of the scribes that work in U.S. hospitals.

ScribeAmerica had been providing scribes to hospitals for use in the inpatient setting, but in a limited way. With Dr. Kreamer’s input, the company developed a more elaborate plan to provide medical scribes for hospitalist programs.

Dr. Kreamer says scribes save his groups’ hospitalists a little more than 10 minutes per chart, or about three hours of productivity per day on a typical 18-patient census. There’s also less physician fatigue, and documentation is better, he adds.

Michael Murphy, MD, an emergency medicine physician by training and co-founder of ScribeAmerica, was introduced to the scribe concept when he was an undergraduate in California. He was asked to start a scribe program by a friend who was a physician and an attorney.

“The overwhelming benefit that I saw was that, A) Physicians were super-happy when they had a scribe,” says Dr. Murphy, now CEO of ScribeAmerica. “B) The patients were happy. The docs sat down and did different things,” allowing more interaction.

“We saw that huge benefit and said, ‘Why don’t we start this on a national level?’”

In 2004, ScribeAmerica was launched. It expanded to 32 hospitals through 2009. Since then, its client base has exploded to 610 hospitals.

Success Story

An early adopter of hospital medicine scribes was Rochester General. Researchers there performed a 10-month study evaluating length of stay of patients who were admitted using a “patient-centered admission team,” (PCAT), which included a scribe, a physician, a clinical pharmacist, two nurses, and a patient care technician.¹ The team has a dedicated workspace near the ED and follows a standardized admission process—part of which involves the scribe entering history and exam findings into the system as the physician explains to the patient what he has found during the exam.

The process also involves the physician simultaneously completing orders while the pharmacist receives pertinent information from the patient, along with other pre-determined steps.

Researchers compared about 2,200 admissions done using this PCAT process and about 6,000 that didn’t use the process; results showed the average length of stay for the PCAT patients was 0.18 days less than the non-PCAT group.¹

An analysis of lllinois hospitals in Dr. Kreamer’s Best Practices group found the use of scribes led to a dramatic increase in the case mix index (CMI), a measure of the level of complexity of care that relates to the reimbursements hospitals receive. In the first year using scribes, the CMI increased by 0.26, helping to boost revenue by tens of thousands of dollars, Dr. Murphy says.

The reason for the increase is that when scribes document in real time, the accuracy and detail on the care provided increase, Dr. Murphy says. With fewer omissions and clearer notes, CMIs show a greater level of care complexity. At a tertiary hospital in the Midwest, the CMI was 1.1 but should have been 1.7, Dr. Murphy explains.

Our docs are very smart people. If they would have wanted to do a clerical-type job, they would have done a clerical-type job. They want to be doctors. They don’t want to be keyboardists. —Jeffry Kreamer, MD

“These physicians are so busy and don’t really have an incentive to document,” Dr. Murphy adds. “They’re just surprised and shocked that, how could they be so inefficient, but they are.”

Scribes are typically pre-professionals, he says, who eventually become the next generation of doctors, nurses, physician assistants, and nurse practitioners. They receive three to four weeks of a mix of online, classroom, and hands-on clinical training. They also have a monthly continuing scribe education requirement.

Their schedules tend to match the schedules of the physicians with whom they work. Some are paid hourly, and some are salaried, he says.

Since the first hospitalist program was added to ScribeAmerica’s rolls, the number has grown to 40 programs.

“What a lot of hospitalist programs are doing is they’re saying, ‘Look, you can’t document for three hours by yourself. We just can’t afford that, because that means we have to have two to three extra docs on staff just to allow you to do what you’re doing,’” Dr. Murphy says, noting that scribes allow hospitalists “to document in sequence while you’re seeing the patients.”

Imperfect Solution

The use of scribes has not been a slam-dunk for every hospitalist program that has considered them, though. At TeamHealth, the national management firm that provides both emergency physicians and hospitalists, medical scribes have been used for years in EDs, and to great effect, says Jasen Gundersen, MD, MBA, CPE, SFHM, president of the acute care service division.

TeamHealth uses scribes from PhysAssist, which it now owns, along with a few other scribe providers.

“If we can allow our providers to spend more time with their patients and less time on paperwork and documentation, we can not only allow them to see more patients but spend more quality time at the bedside and less at the computer screen,” Dr. Gundersen says.

But when TeamHealth ran numbers to explore scribes in its hospitalist programs, they found that it likely doesn’t make sense in most markets.

“We have investigated several programs and pilots but have not been able to demonstrate a significant uptick in productivity to justify the costs of the scribes,” Dr. Gundersen explains. “That does not mean that scribes is not a workable model; it just requires a better review and adjustment of workflow. Our ED colleagues have had more time to deal with these adjustments and are able to demonstrate the necessary productivity changes.”

Scribes also would mean a fundamental shift in the function of a typical TeamHealth hospitalist, he says. Most studies show that hospitalists can spend less than a quarter of their time on direct patient care, and Dr. Gundersen says TeamHealth is actively working on new pilots and programs for implementing scribes.

The overwhelming benefit that I saw was that, A) Physicians were super-happy when they had a scribe. B) The patients were happy. The docs sat down and did different things, allowing more interaction. —Michael Murphy, MD

“There is an appetite from our physicians looking for the efficiency that we just haven’t seen before,” he says. “I think that is where we are going to see the program’s success. It must be embraced and driven from the providers.

“We are also facing physician shortages in several markets. Scribes have the potential to extend the current provider workforce and improve quality of life for our doctors.”

A well-run scribe program, he says, has the potential “to bring the provider back to the bedside and with the patient where they belong.”

Shifting Savings?

Kendall Rogers, MD, CPE, FACP, SFHM, chair of SHM’s Health IT Committee and associate professor and chief of the hospital medicine division at the University of New Mexico Health Sciences Center in Albuquerque, says he checked with colleagues at SHM and did not get much feedback on the use of scribes. His own center, he says, has “not even considered scribes.”

“I have not given it a lot of thought, though my initial impressions are if the EHR was better designed, there would be no need for scribes,” he says. “My hope would be to put our efforts there first. I think scribes are merely a coping mechanism for poorly designed documentation processes within existing EHRs.”

There are also some broader concerns about the potential effect of scribes on EHRs. In a recent op-ed in the Journal of the American Medical Association, a Texas physician sounded concerns that the use of scribes could stunt the evolution of better EHRs, since scribes can be used as a kind of workaround, lessening the demands for EHR improvements.²

There is an appetite from our physicians looking for the efficiency that we just haven’t seen before. I think that is where we are going to see the program’s success. It must be embraced and driven from the providers.—Jasen Gundersen, MD, MBA, CPE, SFHM

“Use of medical scribes to relieve physicians from using EHRs may limit this process by increasing physician acceptance of and satisfaction with an inferior product,” wrote George Gellert, MD, MPH, MPA, regional medical informatics officer at CHRISTUS Santa Rosa Health System in San Antonio.

Dr. Gellert wrote that while The Joint Commission prohibits scribes from performing computerized physician order entry (CPOE), an “unintended functional creep” could arise.

“Even physicians who understand that prohibition may, under pressure of a busy practice, ask a scribe to enter verbal orders,” he wrote, adding that this is something that can’t be monitored by the Joint Commission.

Dr. Murphy says those concerns are unfounded. In a response letter not yet published, he wrote, “Can you honestly believe that the small minority of providers who find EHR acceptable due to scribes are what is preventing EHR companies from making improvements? No, it is as a result of system and technology limitations.”

On scribes being used beyond their scope, Dr. Murphy says there will always be “‘bad actors’ willing to act outside of accepted industry norms; however, that does not mean that TJC [The Joint Commission] does not have control over the industry.”

SHM has not taken a position on the value or potential value of scribes in the inpatient setting.

Tom Collins is a freelance writer in South Florida.

References

1. Bansal A, Bejerano RL, Cashimere CK, Polashenski WA, Jr. Reducing length of stay by using standardized admission process: retrospective analysis of 11,249 patients [abstract]. Society of Hospital Medicine Annual Meeting 2015. Accessed September 10, 2015.
2. Gellert GA, Ramirez R, Webster SL. The rise of the medical scribe industry: implications for the advancement of electronic health records JAMA. 2015;313(13):1315-1316.

The hospitalists at six Illinois hospitals, physicians who are provided by Best Practices Inpatient Care, were grappling with some issues that might sound familiar to hospitalists around the country. The issues revolved around the electronic health record (EHR).

First, “it’s a pain,” says Jeffry Kreamer, MD, chief executive officer of Best Practices. The Long Grove, Ill.-based practice also wanted EHRs to include notes that were standardized, not limited by a template.

The big issue, however, was job satisfaction.

“Our docs are very smart people. If they would have wanted to do a clerical-type job, they would have done a clerical-type job,” Dr. Kreamer says. “They want to be doctors. They don’t want to be keyboardists.

“It makes no sense to take your most experienced asset, which is our physician, and then deploy them for a clerical task which can be done for a much lower cost.”

That’s where medical scribes come in. Scribes work as assistants to physicians and are responsible for entering information into the medical record with physician oversight. Scribes have a history that goes back a decade in emergency medicine, a setting in which doctors traditionally spend much more time in face-to-face contact with patients than they do in documenting the encounter.

Although scribe use in the emergency medicine and hospital medicine settings is growing, with supporters praising programs for boosting volume and allowing physicians to focus on patient care, not all attempts at using the scribe model of care have worked well. Some suggest scribes are a crutch for cumbersome EHRs and excessive administrative work that most doctors would prefer not to deal with.

Dr. Kreamer, however, says the majority of his scribe programs are tapping into a growing segment of the medical industry. There are now more than 15,000 scribes represented by the American College of Medical Scribe Specialists, and the numbers are increasing along a steep curve. There are still far more scribes working in EDs than alongside hospitalists, but as their track record in the inpatient setting lengthens, the number of inpatient scribes is likely to continue to grow.

Dr. Kreamer sensed that scribes would work as well in the inpatient setting as in the ED—maybe even better. He got in touch with the head of ScribeAmerica, the company that provides most of the scribes that work in U.S. hospitals.

ScribeAmerica had been providing scribes to hospitals for use in the inpatient setting, but in a limited way. With Dr. Kreamer’s input, the company developed a more elaborate plan to provide medical scribes for hospitalist programs.

Dr. Kreamer says scribes save his groups’ hospitalists a little more than 10 minutes per chart, or about three hours of productivity per day on a typical 18-patient census. There’s also less physician fatigue, and documentation is better, he adds.

Michael Murphy, MD, an emergency medicine physician by training and co-founder of ScribeAmerica, was introduced to the scribe concept when he was an undergraduate in California. He was asked to start a scribe program by a friend who was a physician and an attorney.

“The overwhelming benefit that I saw was that, A) Physicians were super-happy when they had a scribe,” says Dr. Murphy, now CEO of ScribeAmerica. “B) The patients were happy. The docs sat down and did different things,” allowing more interaction.

“We saw that huge benefit and said, ‘Why don’t we start this on a national level?’”

In 2004, ScribeAmerica was launched. It expanded to 32 hospitals through 2009. Since then, its client base has exploded to 610 hospitals.

Success Story

An early adopter of hospital medicine scribes was Rochester General. Researchers there performed a 10-month study evaluating length of stay of patients who were admitted using a “patient-centered admission team,” (PCAT), which included a scribe, a physician, a clinical pharmacist, two nurses, and a patient care technician.¹ The team has a dedicated workspace near the ED and follows a standardized admission process—part of which involves the scribe entering history and exam findings into the system as the physician explains to the patient what he has found during the exam.

The process also involves the physician simultaneously completing orders while the pharmacist receives pertinent information from the patient, along with other pre-determined steps.

Researchers compared about 2,200 admissions done using this PCAT process and about 6,000 that didn’t use the process; results showed the average length of stay for the PCAT patients was 0.18 days less than the non-PCAT group.¹

An analysis of lllinois hospitals in Dr. Kreamer’s Best Practices group found the use of scribes led to a dramatic increase in the case mix index (CMI), a measure of the level of complexity of care that relates to the reimbursements hospitals receive. In the first year using scribes, the CMI increased by 0.26, helping to boost revenue by tens of thousands of dollars, Dr. Murphy says.

The reason for the increase is that when scribes document in real time, the accuracy and detail on the care provided increase, Dr. Murphy says. With fewer omissions and clearer notes, CMIs show a greater level of care complexity. At a tertiary hospital in the Midwest, the CMI was 1.1 but should have been 1.7, Dr. Murphy explains.

Our docs are very smart people. If they would have wanted to do a clerical-type job, they would have done a clerical-type job. They want to be doctors. They don’t want to be keyboardists. —Jeffry Kreamer, MD

“These physicians are so busy and don’t really have an incentive to document,” Dr. Murphy adds. “They’re just surprised and shocked that, how could they be so inefficient, but they are.”

Scribes are typically pre-professionals, he says, who eventually become the next generation of doctors, nurses, physician assistants, and nurse practitioners. They receive three to four weeks of a mix of online, classroom, and hands-on clinical training. They also have a monthly continuing scribe education requirement.

Their schedules tend to match the schedules of the physicians with whom they work. Some are paid hourly, and some are salaried, he says.

Since the first hospitalist program was added to ScribeAmerica’s rolls, the number has grown to 40 programs.

“What a lot of hospitalist programs are doing is they’re saying, ‘Look, you can’t document for three hours by yourself. We just can’t afford that, because that means we have to have two to three extra docs on staff just to allow you to do what you’re doing,’” Dr. Murphy says, noting that scribes allow hospitalists “to document in sequence while you’re seeing the patients.”

Imperfect Solution

The use of scribes has not been a slam-dunk for every hospitalist program that has considered them, though. At TeamHealth, the national management firm that provides both emergency physicians and hospitalists, medical scribes have been used for years in EDs, and to great effect, says Jasen Gundersen, MD, MBA, CPE, SFHM, president of the acute care service division.

TeamHealth uses scribes from PhysAssist, which it now owns, along with a few other scribe providers.

“If we can allow our providers to spend more time with their patients and less time on paperwork and documentation, we can not only allow them to see more patients but spend more quality time at the bedside and less at the computer screen,” Dr. Gundersen says.

But when TeamHealth ran numbers to explore scribes in its hospitalist programs, they found that it likely doesn’t make sense in most markets.

“We have investigated several programs and pilots but have not been able to demonstrate a significant uptick in productivity to justify the costs of the scribes,” Dr. Gundersen explains. “That does not mean that scribes is not a workable model; it just requires a better review and adjustment of workflow. Our ED colleagues have had more time to deal with these adjustments and are able to demonstrate the necessary productivity changes.”

Scribes also would mean a fundamental shift in the function of a typical TeamHealth hospitalist, he says. Most studies show that hospitalists can spend less than a quarter of their time on direct patient care, and Dr. Gundersen says TeamHealth is actively working on new pilots and programs for implementing scribes.

The overwhelming benefit that I saw was that, A) Physicians were super-happy when they had a scribe. B) The patients were happy. The docs sat down and did different things, allowing more interaction. —Michael Murphy, MD

“There is an appetite from our physicians looking for the efficiency that we just haven’t seen before,” he says. “I think that is where we are going to see the program’s success. It must be embraced and driven from the providers.

“We are also facing physician shortages in several markets. Scribes have the potential to extend the current provider workforce and improve quality of life for our doctors.”

A well-run scribe program, he says, has the potential “to bring the provider back to the bedside and with the patient where they belong.”

Shifting Savings?

Kendall Rogers, MD, CPE, FACP, SFHM, chair of SHM’s Health IT Committee and associate professor and chief of the hospital medicine division at the University of New Mexico Health Sciences Center in Albuquerque, says he checked with colleagues at SHM and did not get much feedback on the use of scribes. His own center, he says, has “not even considered scribes.”

“I have not given it a lot of thought, though my initial impressions are if the EHR was better designed, there would be no need for scribes,” he says. “My hope would be to put our efforts there first. I think scribes are merely a coping mechanism for poorly designed documentation processes within existing EHRs.”

There are also some broader concerns about the potential effect of scribes on EHRs. In a recent op-ed in the Journal of the American Medical Association, a Texas physician sounded concerns that the use of scribes could stunt the evolution of better EHRs, since scribes can be used as a kind of workaround, lessening the demands for EHR improvements.²

There is an appetite from our physicians looking for the efficiency that we just haven’t seen before. I think that is where we are going to see the program’s success. It must be embraced and driven from the providers.—Jasen Gundersen, MD, MBA, CPE, SFHM

“Use of medical scribes to relieve physicians from using EHRs may limit this process by increasing physician acceptance of and satisfaction with an inferior product,” wrote George Gellert, MD, MPH, MPA, regional medical informatics officer at CHRISTUS Santa Rosa Health System in San Antonio.

Dr. Gellert wrote that while The Joint Commission prohibits scribes from performing computerized physician order entry (CPOE), an “unintended functional creep” could arise.

“Even physicians who understand that prohibition may, under pressure of a busy practice, ask a scribe to enter verbal orders,” he wrote, adding that this is something that can’t be monitored by the Joint Commission.

Dr. Murphy says those concerns are unfounded. In a response letter not yet published, he wrote, “Can you honestly believe that the small minority of providers who find EHR acceptable due to scribes are what is preventing EHR companies from making improvements? No, it is as a result of system and technology limitations.”

On scribes being used beyond their scope, Dr. Murphy says there will always be “‘bad actors’ willing to act outside of accepted industry norms; however, that does not mean that TJC [The Joint Commission] does not have control over the industry.”

SHM has not taken a position on the value or potential value of scribes in the inpatient setting.

Tom Collins is a freelance writer in South Florida.

References

1. Bansal A, Bejerano RL, Cashimere CK, Polashenski WA, Jr. Reducing length of stay by using standardized admission process: retrospective analysis of 11,249 patients [abstract]. Society of Hospital Medicine Annual Meeting 2015. Accessed September 10, 2015.
2. Gellert GA, Ramirez R, Webster SL. The rise of the medical scribe industry: implications for the advancement of electronic health records JAMA. 2015;313(13):1315-1316.

The hospitalists at six Illinois hospitals, physicians who are provided by Best Practices Inpatient Care, were grappling with some issues that might sound familiar to hospitalists around the country. The issues revolved around the electronic health record (EHR).

First, “it’s a pain,” says Jeffry Kreamer, MD, chief executive officer of Best Practices. The Long Grove, Ill.-based practice also wanted EHRs to include notes that were standardized, not limited by a template.

The big issue, however, was job satisfaction.

“Our docs are very smart people. If they would have wanted to do a clerical-type job, they would have done a clerical-type job,” Dr. Kreamer says. “They want to be doctors. They don’t want to be keyboardists.

“It makes no sense to take your most experienced asset, which is our physician, and then deploy them for a clerical task which can be done for a much lower cost.”

That’s where medical scribes come in. Scribes work as assistants to physicians and are responsible for entering information into the medical record with physician oversight. Scribes have a history that goes back a decade in emergency medicine, a setting in which doctors traditionally spend much more time in face-to-face contact with patients than they do in documenting the encounter.

Although scribe use in the emergency medicine and hospital medicine settings is growing, with supporters praising programs for boosting volume and allowing physicians to focus on patient care, not all attempts at using the scribe model of care have worked well. Some suggest scribes are a crutch for cumbersome EHRs and excessive administrative work that most doctors would prefer not to deal with.

Dr. Kreamer, however, says the majority of his scribe programs are tapping into a growing segment of the medical industry. There are now more than 15,000 scribes represented by the American College of Medical Scribe Specialists, and the numbers are increasing along a steep curve. There are still far more scribes working in EDs than alongside hospitalists, but as their track record in the inpatient setting lengthens, the number of inpatient scribes is likely to continue to grow.

Dr. Kreamer sensed that scribes would work as well in the inpatient setting as in the ED—maybe even better. He got in touch with the head of ScribeAmerica, the company that provides most of the scribes that work in U.S. hospitals.

ScribeAmerica had been providing scribes to hospitals for use in the inpatient setting, but in a limited way. With Dr. Kreamer’s input, the company developed a more elaborate plan to provide medical scribes for hospitalist programs.

Dr. Kreamer says scribes save his groups’ hospitalists a little more than 10 minutes per chart, or about three hours of productivity per day on a typical 18-patient census. There’s also less physician fatigue, and documentation is better, he adds.

Michael Murphy, MD, an emergency medicine physician by training and co-founder of ScribeAmerica, was introduced to the scribe concept when he was an undergraduate in California. He was asked to start a scribe program by a friend who was a physician and an attorney.

“The overwhelming benefit that I saw was that, A) Physicians were super-happy when they had a scribe,” says Dr. Murphy, now CEO of ScribeAmerica. “B) The patients were happy. The docs sat down and did different things,” allowing more interaction.

“We saw that huge benefit and said, ‘Why don’t we start this on a national level?’”

In 2004, ScribeAmerica was launched. It expanded to 32 hospitals through 2009. Since then, its client base has exploded to 610 hospitals.

Success Story

An early adopter of hospital medicine scribes was Rochester General. Researchers there performed a 10-month study evaluating length of stay of patients who were admitted using a “patient-centered admission team,” (PCAT), which included a scribe, a physician, a clinical pharmacist, two nurses, and a patient care technician.¹ The team has a dedicated workspace near the ED and follows a standardized admission process—part of which involves the scribe entering history and exam findings into the system as the physician explains to the patient what he has found during the exam.

The process also involves the physician simultaneously completing orders while the pharmacist receives pertinent information from the patient, along with other pre-determined steps.

Researchers compared about 2,200 admissions done using this PCAT process and about 6,000 that didn’t use the process; results showed the average length of stay for the PCAT patients was 0.18 days less than the non-PCAT group.¹

An analysis of lllinois hospitals in Dr. Kreamer’s Best Practices group found the use of scribes led to a dramatic increase in the case mix index (CMI), a measure of the level of complexity of care that relates to the reimbursements hospitals receive. In the first year using scribes, the CMI increased by 0.26, helping to boost revenue by tens of thousands of dollars, Dr. Murphy says.

The reason for the increase is that when scribes document in real time, the accuracy and detail on the care provided increase, Dr. Murphy says. With fewer omissions and clearer notes, CMIs show a greater level of care complexity. At a tertiary hospital in the Midwest, the CMI was 1.1 but should have been 1.7, Dr. Murphy explains.

Our docs are very smart people. If they would have wanted to do a clerical-type job, they would have done a clerical-type job. They want to be doctors. They don’t want to be keyboardists. —Jeffry Kreamer, MD

“These physicians are so busy and don’t really have an incentive to document,” Dr. Murphy adds. “They’re just surprised and shocked that, how could they be so inefficient, but they are.”

Scribes are typically pre-professionals, he says, who eventually become the next generation of doctors, nurses, physician assistants, and nurse practitioners. They receive three to four weeks of a mix of online, classroom, and hands-on clinical training. They also have a monthly continuing scribe education requirement.

Their schedules tend to match the schedules of the physicians with whom they work. Some are paid hourly, and some are salaried, he says.

Since the first hospitalist program was added to ScribeAmerica’s rolls, the number has grown to 40 programs.

“What a lot of hospitalist programs are doing is they’re saying, ‘Look, you can’t document for three hours by yourself. We just can’t afford that, because that means we have to have two to three extra docs on staff just to allow you to do what you’re doing,’” Dr. Murphy says, noting that scribes allow hospitalists “to document in sequence while you’re seeing the patients.”

Imperfect Solution

The use of scribes has not been a slam-dunk for every hospitalist program that has considered them, though. At TeamHealth, the national management firm that provides both emergency physicians and hospitalists, medical scribes have been used for years in EDs, and to great effect, says Jasen Gundersen, MD, MBA, CPE, SFHM, president of the acute care service division.

TeamHealth uses scribes from PhysAssist, which it now owns, along with a few other scribe providers.

“If we can allow our providers to spend more time with their patients and less time on paperwork and documentation, we can not only allow them to see more patients but spend more quality time at the bedside and less at the computer screen,” Dr. Gundersen says.

But when TeamHealth ran numbers to explore scribes in its hospitalist programs, they found that it likely doesn’t make sense in most markets.

“We have investigated several programs and pilots but have not been able to demonstrate a significant uptick in productivity to justify the costs of the scribes,” Dr. Gundersen explains. “That does not mean that scribes is not a workable model; it just requires a better review and adjustment of workflow. Our ED colleagues have had more time to deal with these adjustments and are able to demonstrate the necessary productivity changes.”

Scribes also would mean a fundamental shift in the function of a typical TeamHealth hospitalist, he says. Most studies show that hospitalists can spend less than a quarter of their time on direct patient care, and Dr. Gundersen says TeamHealth is actively working on new pilots and programs for implementing scribes.

The overwhelming benefit that I saw was that, A) Physicians were super-happy when they had a scribe. B) The patients were happy. The docs sat down and did different things, allowing more interaction. —Michael Murphy, MD

“There is an appetite from our physicians looking for the efficiency that we just haven’t seen before,” he says. “I think that is where we are going to see the program’s success. It must be embraced and driven from the providers.

“We are also facing physician shortages in several markets. Scribes have the potential to extend the current provider workforce and improve quality of life for our doctors.”

A well-run scribe program, he says, has the potential “to bring the provider back to the bedside and with the patient where they belong.”

Shifting Savings?

Kendall Rogers, MD, CPE, FACP, SFHM, chair of SHM’s Health IT Committee and associate professor and chief of the hospital medicine division at the University of New Mexico Health Sciences Center in Albuquerque, says he checked with colleagues at SHM and did not get much feedback on the use of scribes. His own center, he says, has “not even considered scribes.”

“I have not given it a lot of thought, though my initial impressions are if the EHR was better designed, there would be no need for scribes,” he says. “My hope would be to put our efforts there first. I think scribes are merely a coping mechanism for poorly designed documentation processes within existing EHRs.”

There are also some broader concerns about the potential effect of scribes on EHRs. In a recent op-ed in the Journal of the American Medical Association, a Texas physician sounded concerns that the use of scribes could stunt the evolution of better EHRs, since scribes can be used as a kind of workaround, lessening the demands for EHR improvements.²

There is an appetite from our physicians looking for the efficiency that we just haven’t seen before. I think that is where we are going to see the program’s success. It must be embraced and driven from the providers.—Jasen Gundersen, MD, MBA, CPE, SFHM

“Use of medical scribes to relieve physicians from using EHRs may limit this process by increasing physician acceptance of and satisfaction with an inferior product,” wrote George Gellert, MD, MPH, MPA, regional medical informatics officer at CHRISTUS Santa Rosa Health System in San Antonio.

Dr. Gellert wrote that while The Joint Commission prohibits scribes from performing computerized physician order entry (CPOE), an “unintended functional creep” could arise.

“Even physicians who understand that prohibition may, under pressure of a busy practice, ask a scribe to enter verbal orders,” he wrote, adding that this is something that can’t be monitored by the Joint Commission.

Dr. Murphy says those concerns are unfounded. In a response letter not yet published, he wrote, “Can you honestly believe that the small minority of providers who find EHR acceptable due to scribes are what is preventing EHR companies from making improvements? No, it is as a result of system and technology limitations.”

On scribes being used beyond their scope, Dr. Murphy says there will always be “‘bad actors’ willing to act outside of accepted industry norms; however, that does not mean that TJC [The Joint Commission] does not have control over the industry.”

SHM has not taken a position on the value or potential value of scribes in the inpatient setting.

Tom Collins is a freelance writer in South Florida.

References

1. Bansal A, Bejerano RL, Cashimere CK, Polashenski WA, Jr. Reducing length of stay by using standardized admission process: retrospective analysis of 11,249 patients [abstract]. Society of Hospital Medicine Annual Meeting 2015. Accessed September 10, 2015.
2. Gellert GA, Ramirez R, Webster SL. The rise of the medical scribe industry: implications for the advancement of electronic health records JAMA. 2015;313(13):1315-1316.

Robert Coben, MD, academic coordinator for the Gastrointestinal Fellowship Program at Thomas Jefferson University Hospital in Philadelphia, says that when patients get admitted with chest pain for reasons other than a heart-related problem, he is frequently called on to do an endoscopy right away.

But that’s usually not the best starting point, he says.

“I would say the best test would be to just place the patient on a high-dose proton pump inhibitor once or twice a day first, to see if those symptoms resolve,” he says. “Many times we’re called in to do an upper endoscopy. … And many times that’s not really indicated unless they’re

having other alarm symptoms such as dysphagia, odynophagia, and weight loss.”

“Many times we’re called in to do an upper endoscopy … And many times that’s not really indicated unless they’re having other alarm symptoms such as dysphagia, odynophagia, and weight loss.” —Robert Coben, MD

Marcelo Vela, MD, gastroenterologist and hepatologist at the Mayo Clinic in Scottsdale, Ariz., and an associate editor with Clinical Gastroenterology and Hepatology, adds that it’s okay to start a patient with non-cardiac chest pain on PPIs when they have concomitant, typical symptoms of gastroesophageal reflux disease (GERD)—heartburn and acid regurgitation. But in patients without such symptoms, further testing is needed to confirm GERD, he says (Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308–328, Table 1).

This evaluation is usually done in the outpatient setting, he says.

Dr. Vela suggests more care might be needed in the prescribing of PPIs. He says he frequently sees patients who have been hospitalized and put on a PPI without a clear reason.

“They get admitted for various reasons—DVT [deep vein thrombosis], pneumonia, whatever, and then in the hospital, they get started on a proton pump inhibitor for unclear reasons. And then they leave and they stay on it,” Dr. Vela says.

When he asks why, patients just say, “On my last hospitalization, they put me on it,” he says.

“I think you should only leave the hospital on a PPI with a very clear indication—either you found an ulcer or the patient clearly has GERD” or some other reason, he says. “They’re fairly benign medications, but if there’s no indication for it, there’s no benefit.”

Robert Coben, MD, academic coordinator for the Gastrointestinal Fellowship Program at Thomas Jefferson University Hospital in Philadelphia, says that when patients get admitted with chest pain for reasons other than a heart-related problem, he is frequently called on to do an endoscopy right away.

But that’s usually not the best starting point, he says.

“I would say the best test would be to just place the patient on a high-dose proton pump inhibitor once or twice a day first, to see if those symptoms resolve,” he says. “Many times we’re called in to do an upper endoscopy. … And many times that’s not really indicated unless they’re

having other alarm symptoms such as dysphagia, odynophagia, and weight loss.”

“Many times we’re called in to do an upper endoscopy … And many times that’s not really indicated unless they’re having other alarm symptoms such as dysphagia, odynophagia, and weight loss.” —Robert Coben, MD

Marcelo Vela, MD, gastroenterologist and hepatologist at the Mayo Clinic in Scottsdale, Ariz., and an associate editor with Clinical Gastroenterology and Hepatology, adds that it’s okay to start a patient with non-cardiac chest pain on PPIs when they have concomitant, typical symptoms of gastroesophageal reflux disease (GERD)—heartburn and acid regurgitation. But in patients without such symptoms, further testing is needed to confirm GERD, he says (Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308–328, Table 1).

This evaluation is usually done in the outpatient setting, he says.

Dr. Vela suggests more care might be needed in the prescribing of PPIs. He says he frequently sees patients who have been hospitalized and put on a PPI without a clear reason.

“They get admitted for various reasons—DVT [deep vein thrombosis], pneumonia, whatever, and then in the hospital, they get started on a proton pump inhibitor for unclear reasons. And then they leave and they stay on it,” Dr. Vela says.

When he asks why, patients just say, “On my last hospitalization, they put me on it,” he says.

“I think you should only leave the hospital on a PPI with a very clear indication—either you found an ulcer or the patient clearly has GERD” or some other reason, he says. “They’re fairly benign medications, but if there’s no indication for it, there’s no benefit.”

Robert Coben, MD, academic coordinator for the Gastrointestinal Fellowship Program at Thomas Jefferson University Hospital in Philadelphia, says that when patients get admitted with chest pain for reasons other than a heart-related problem, he is frequently called on to do an endoscopy right away.

But that’s usually not the best starting point, he says.

“I would say the best test would be to just place the patient on a high-dose proton pump inhibitor once or twice a day first, to see if those symptoms resolve,” he says. “Many times we’re called in to do an upper endoscopy. … And many times that’s not really indicated unless they’re

having other alarm symptoms such as dysphagia, odynophagia, and weight loss.”

“Many times we’re called in to do an upper endoscopy … And many times that’s not really indicated unless they’re having other alarm symptoms such as dysphagia, odynophagia, and weight loss.” —Robert Coben, MD

Marcelo Vela, MD, gastroenterologist and hepatologist at the Mayo Clinic in Scottsdale, Ariz., and an associate editor with Clinical Gastroenterology and Hepatology, adds that it’s okay to start a patient with non-cardiac chest pain on PPIs when they have concomitant, typical symptoms of gastroesophageal reflux disease (GERD)—heartburn and acid regurgitation. But in patients without such symptoms, further testing is needed to confirm GERD, he says (Katz PO, Gerson LB, Vela MF. Guidelines for the diagnosis and management of gastroesophageal reflux disease. Am J Gastroenterol. 2013;108(3):308–328, Table 1).

This evaluation is usually done in the outpatient setting, he says.

Dr. Vela suggests more care might be needed in the prescribing of PPIs. He says he frequently sees patients who have been hospitalized and put on a PPI without a clear reason.

“They get admitted for various reasons—DVT [deep vein thrombosis], pneumonia, whatever, and then in the hospital, they get started on a proton pump inhibitor for unclear reasons. And then they leave and they stay on it,” Dr. Vela says.

When he asks why, patients just say, “On my last hospitalization, they put me on it,” he says.

“I think you should only leave the hospital on a PPI with a very clear indication—either you found an ulcer or the patient clearly has GERD” or some other reason, he says. “They’re fairly benign medications, but if there’s no indication for it, there’s no benefit.”

So many symptoms that are staples of gastroenterology—chest pain, nausea, diarrhea—are mainstay causes for hospitalization that it might be worth fine-tuning how well you handle patients with gastroenterology disorders.

The Hospitalist asked several gastroenterologists for their guidance on better care and their suggestions for correcting some common mistakes that they encounter. Here are their tips:

1 Fluid resuscitation is crucial for pancreatitis patients.

It’s very important to rehydrate these patients within the first 24 hours, because those who remain underhydrated can have a worse prognosis, says Robert Coben, MD, academic coordinator for the Gastroentestinal Fellowship Program at Thomas Jefferson University Hospital in Philadelphia. On occasion, physicians are reluctant to give extra fluids to these patients, he says, particularly if they have heart failure or suffer kidney problems. A 70-kg patient should be receiving about 200 cc per hour, he notes.

“Sometimes we’ll walk in the room and they’re getting 80 cc an hour,” Dr. Coben says.

“These patients…need to be flooded with fluids,” says Rajeev Jain, MD, chief of gastroenterology at Presbyterian Hospital of Dallas, partner at Texas Digestive Disease Consultants, and chair of the Practice Management and Economics Committee of the American Gastroenterological Association. “We’re talking sometimes liters and liters of IV normal saline or lactated Ringer’s (solution) in a 24-hour period.”¹

Marcelo Vela, MD, a gastroenterologist and hepatologist at the Mayo Clinic in Scottsdale, Ariz., and an associate editor with Clinical Gastroenterology and Hepatology, says Ringer’s solution is a better choice than normal saline.²

“If you’re going to start IV fluids on somebody who’s coming in with acute pancreatitis, Ringer’s solution has been shown to be superior to saline in randomized controlled trials,” Dr. Vela says. “It reduces systemic inflammation.”

2 Gastrointestinal bleeding decisions

When inpatients have gastrointestinal bleeding, the hospitalist often has to assess its severity and make the call on whether a patient needs the ICU.

“The most important thing for that is obviously the vital signs,” says John Pandolfino, MD, chief of the division of medicine–gastroenterology and hepatology at Northwestern University Feinberg School of Medicine in Chicago. “If people are tachycardic and they’re not responding to hydration and blood transfusion, that usually means it’s a pretty active bleed and they need to go to the intensive care unit. If you have somebody who’s GI bleeding and they’re coagulopathic (i.e., they’re on anti-coagulation because they have a valve and they need anti-coagulation or they have cancer or bad cardiovascular disease), those are the people that you should have a low threshold for sending to the intensive care unit with a GI bleed; those are the people who are at a very high mortality [risk].”

He added that those with an ulcer, with a visible vessel, are at a high-risk of a rebleed and should spend some time in the ICU.

“Those people should be evaluated in the intensive care unit for at least 24 hours, maybe even 72 hours,” Dr. Pandolfino says, “and they should have IV PPI [proton pump inhibitor] therapy.”

3 Endoscopy has very low yield for diagnosis of reflux.

“Endoscopy has good yield for mucosa abnormalities on inspection of the esophageal mucosa, but it does not give you a diagnosis of reflux, especially on patients who have already been treated with a PPI,” says Prakash Gyawali, MD, MRCP, professor of gastroenterology at Washington University in St. Louis, Mo. “So, usually, in those settings, obtaining a consult or trying to decide exactly what you’re looking for to explain the symptoms has better yield than an endoscopy.”

Sometimes a pH study is needed, but that has to be planned, because patients may have to be taken off of a PPI in advance. That means those studies are not easy to set up in the hospital and might best be arranged by the gastroenterologist, Dr. Gyawali says.

4 In cases of acute diarrhea, order a stool sample right away.

That will help guide care from the gastroenterologist, if and when the gastroenterologist is called in, Dr. Pandolfino says.

“One of the things that is frustrating for the gastroenterologist is that we get called initially, but really the hospitalist should be getting stool studies, and they should have at least a very good idea of what they need from us,” he says. “Because, really, endoscopy is not usually needed very often in diagnosis of acute diarrhea.”

Broad-range stool studies, a good history and physical, and examining labs for a possible chronic inflammatory process or anemia are good ways to begin to assess patients with diarrhea, he says. Clostridium difficile colitis has to be considered as well, Dr. Pandolfino says.

Endoscopy is more helpful in evaluating acute diarrhea in those with bloody diarrhea suspected of having inflammatory bowel disease or an infectious diarrhea but on whom cultures have come back negative. For those with compromised immune systems, endoscopy could be done earlier, as well.

“So for us, I think we really need to get into the picture a little bit after the patient has been brought into the hospital and the stool study is negative, unless they’re an immune-compromised patient,” Dr. Pandolfino says.

5 When—and how—to test the stool.

If a patient develops diarrhea while already in the hospital, the only stool test needed is C. diff.

“They shouldn’t be developing a viral diarrhea, they shouldn’t be developing an infectious diarrhea—let’s say, from E. coli or Salmonella—unless they literally developed it a couple hours after getting in,” Dr. Jain says. “It should either be C. diff or a side effect of some medication. … We don’t need to spend the extra money, which is of low-value care to send for OVA and parasites, or bacterial pathogens and so forth.”

Dr. Jain says he thinks such testing is being done more appropriately of late.

“But I still will see multiple stool tests sent on somebody who’s been in the hospital for a week and then develops diarrhea,” he explains.

6 Gastroenterologists do not need to be consulted for every C. diff infection.

“I think that we really should get involved when patients are either not responding or when they’re very ill,” Dr. Pandolfino says.

Hospitalists should consider whether patients are on antibiotics or a PPI and whether or not they need to stay on those medications. Also, medications that slow motility (i.e., loperamide) should be avoided, if possible.

“We don’t want it to linger,” Dr. Pandolfino says. “One of the basic mechanisms of how we get rid of pathogens is to expel them with diarrhea.

“But you certainly don’t want the patient to be uncomfortable to the point where they’re having 20 to 30 bowel movements a day.”

In non-severe patients who have some diarrhea, abdominal pain, nausea, and vomiting—but are able to keep food down—the specialists might not have to be called in, and patients can just be treated with oral metronidazole or oral vancomycin fairly simply, he says.

For those who seem severely ill with a dilating colon, are in nearly a septic state, and have very severe diarrhea, the gastroenterologist should probably be called in, he says.

“Even if they have underlying heart failure, if they’re volume-depleted, they need that volume. Sometimes you’ll see that it takes eight hours to get two units of blood in. That’s inadequate.” —Rajeev Jain, MD

7 For patients with a possible GI bleed and black stools, do an exam before calling in the gastroenterologist.

The exam should determine what the stool color is and whether it is heme-positive, and the patient’s blood count should be evaluated, Dr. Coben says.

Frequently, “the consultant’s the one who ends up doing the rectal exam and checking that,” he says. “Sometimes we find that [the patient is] really not bleeding,” and it was just a case of a hospitalist taking the patient’s word that they were bleeding.

Being on iron therapy or taking Pepto-Bismol can turn the stool black, and the stool might not really be black; colors can sometimes be open to interpretation.

But he cautions that colon cancer could be the cause for a GI bleed.

“We’ve had it happen a few times where this occurred,” he says. “The patient was discharged, and they really didn’t get proper follow-up, and it ended up that they had a colon cancer. It kind of delayed that diagnosis. So I think you have to be aware of [the fact that], especially in somebody over the age of 40 or 50, if they have an iron-deficiency, anemia, or heme-positive stool, the first thing you really need to exclude is a colon cancer.”

8 Minimize CT scans in early evaluation and management of acute pancreatitis patients.

“The reason for that is they tend to be intravascularly volume-depleted,” Dr. Jain says. “So [with] the IV contrast, there’s an increased risk of developing kidney failure. It’s also been associated with increased risk of necrotizing pancreatitis.”

Dr. Jain notes that when he is consulted on this kind of patient, he will order a sonogram. If it doesn’t show gallstones, and there’s no clear reason for the pancreatitis, he will want a CT scan, but he will wait a few days until the patient is fluid-resuscitated.

Dr. Jain says that this is a problem more often seen in the ED—where 90% of patients with acute pancreatitis have already gotten the CT scan—and less so among hospitalists, but it’s still worth the reminder.

A CT scan right away is justified to rule out something such as a perforation, but not in the case of classic symptoms of acute pancreatitis, he adds.

9 Actively bleeding patients?

It’s smart to give patients a unit of packed red blood cells more quickly if they’re actively bleeding. Even over just one hour is OK, Dr. Jain says.

“Even if they have underlying heart failure, if they’re volume-depleted, they need that volume,” Dr. Jain explains. “Sometimes you’ll see that it takes eight hours to get two units of blood in. That’s inadequate.”

Another point worth a reminder, he says: Two large-bore peripheral IV’s are “much, much better” than a central or PICC line to deliver IV fluid resuscitation.

“Sometimes hospitalists order barium studies because these can be done the same day, whereas with endoscopy, patients need to be put on a schedule and have to be NPO [nothing by mouth] overnight.” —Prakash Gyawali, MD, MRCP

10 Don’t be too quick to order barium studies, especially in patients with dysphagia.

“The problem with that is it takes much longer to do an endoscopy if barium is put in the esophagus, because we usually wait until the barium clears,” Dr. Gyawali says. “And inpatient evaluation of new-onset dysphagia should be endoscopy first, and not barium, because biopsies need to be taken to rule out eosinophilic esophagitis.

“Sometimes hospitalists order barium studies because these can be done the same day, whereas with endoscopy, patients need to be put on a schedule and have to be NPO [nothing by mouth] overnight.”

11 Gastric-emptying studies should be outpatient.

Gastric-emptying studies are often better done when patients are not in a hospital, experts say, because they might be on medications that would interfere with the study.

“A common issue, not just among hospitalists but also gastroenterologists, is that patients may be on a bunch of medicines that would affect stomach-emptying while they are in-house for some other problem,” Dr. Gyawali says. “A lot of times, these patients with pain may get narcotics. They may be on medicines to prevent them from throwing up. … And all of these will slow down gastric emptying.”

With an abnormal test result, “you are left to decide whether that is a real abnormality or whether the medicines the patients were on impacted the abnormality.”

If emptying was significantly prolonged, the test may have some value, “but then it probably will need to be corroborated with symptoms and with endoscopic findings.”

Thomas Collins is a freelance writer in South Florida.

References

1. Warndorf MG, Kurtzman JT, Bartel MJ, et al. Early fluid resuscitation reduces morbidity among patients with acute pancreatitis. Clin Gastroenterol Hepatol. 2011;9(8):705-709.
2. Wu BU, Hwang JQ, Gardner TH, et al. Lactated Ringer’s solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol. 2011;9(8):710-717.

So many symptoms that are staples of gastroenterology—chest pain, nausea, diarrhea—are mainstay causes for hospitalization that it might be worth fine-tuning how well you handle patients with gastroenterology disorders.

The Hospitalist asked several gastroenterologists for their guidance on better care and their suggestions for correcting some common mistakes that they encounter. Here are their tips:

1 Fluid resuscitation is crucial for pancreatitis patients.

It’s very important to rehydrate these patients within the first 24 hours, because those who remain underhydrated can have a worse prognosis, says Robert Coben, MD, academic coordinator for the Gastroentestinal Fellowship Program at Thomas Jefferson University Hospital in Philadelphia. On occasion, physicians are reluctant to give extra fluids to these patients, he says, particularly if they have heart failure or suffer kidney problems. A 70-kg patient should be receiving about 200 cc per hour, he notes.

“Sometimes we’ll walk in the room and they’re getting 80 cc an hour,” Dr. Coben says.

“These patients…need to be flooded with fluids,” says Rajeev Jain, MD, chief of gastroenterology at Presbyterian Hospital of Dallas, partner at Texas Digestive Disease Consultants, and chair of the Practice Management and Economics Committee of the American Gastroenterological Association. “We’re talking sometimes liters and liters of IV normal saline or lactated Ringer’s (solution) in a 24-hour period.”¹

Marcelo Vela, MD, a gastroenterologist and hepatologist at the Mayo Clinic in Scottsdale, Ariz., and an associate editor with Clinical Gastroenterology and Hepatology, says Ringer’s solution is a better choice than normal saline.²

“If you’re going to start IV fluids on somebody who’s coming in with acute pancreatitis, Ringer’s solution has been shown to be superior to saline in randomized controlled trials,” Dr. Vela says. “It reduces systemic inflammation.”

2 Gastrointestinal bleeding decisions

When inpatients have gastrointestinal bleeding, the hospitalist often has to assess its severity and make the call on whether a patient needs the ICU.

“The most important thing for that is obviously the vital signs,” says John Pandolfino, MD, chief of the division of medicine–gastroenterology and hepatology at Northwestern University Feinberg School of Medicine in Chicago. “If people are tachycardic and they’re not responding to hydration and blood transfusion, that usually means it’s a pretty active bleed and they need to go to the intensive care unit. If you have somebody who’s GI bleeding and they’re coagulopathic (i.e., they’re on anti-coagulation because they have a valve and they need anti-coagulation or they have cancer or bad cardiovascular disease), those are the people that you should have a low threshold for sending to the intensive care unit with a GI bleed; those are the people who are at a very high mortality [risk].”

He added that those with an ulcer, with a visible vessel, are at a high-risk of a rebleed and should spend some time in the ICU.

“Those people should be evaluated in the intensive care unit for at least 24 hours, maybe even 72 hours,” Dr. Pandolfino says, “and they should have IV PPI [proton pump inhibitor] therapy.”

3 Endoscopy has very low yield for diagnosis of reflux.

“Endoscopy has good yield for mucosa abnormalities on inspection of the esophageal mucosa, but it does not give you a diagnosis of reflux, especially on patients who have already been treated with a PPI,” says Prakash Gyawali, MD, MRCP, professor of gastroenterology at Washington University in St. Louis, Mo. “So, usually, in those settings, obtaining a consult or trying to decide exactly what you’re looking for to explain the symptoms has better yield than an endoscopy.”

Sometimes a pH study is needed, but that has to be planned, because patients may have to be taken off of a PPI in advance. That means those studies are not easy to set up in the hospital and might best be arranged by the gastroenterologist, Dr. Gyawali says.

4 In cases of acute diarrhea, order a stool sample right away.

That will help guide care from the gastroenterologist, if and when the gastroenterologist is called in, Dr. Pandolfino says.

“One of the things that is frustrating for the gastroenterologist is that we get called initially, but really the hospitalist should be getting stool studies, and they should have at least a very good idea of what they need from us,” he says. “Because, really, endoscopy is not usually needed very often in diagnosis of acute diarrhea.”

Broad-range stool studies, a good history and physical, and examining labs for a possible chronic inflammatory process or anemia are good ways to begin to assess patients with diarrhea, he says. Clostridium difficile colitis has to be considered as well, Dr. Pandolfino says.

Endoscopy is more helpful in evaluating acute diarrhea in those with bloody diarrhea suspected of having inflammatory bowel disease or an infectious diarrhea but on whom cultures have come back negative. For those with compromised immune systems, endoscopy could be done earlier, as well.

“So for us, I think we really need to get into the picture a little bit after the patient has been brought into the hospital and the stool study is negative, unless they’re an immune-compromised patient,” Dr. Pandolfino says.

5 When—and how—to test the stool.

If a patient develops diarrhea while already in the hospital, the only stool test needed is C. diff.

“They shouldn’t be developing a viral diarrhea, they shouldn’t be developing an infectious diarrhea—let’s say, from E. coli or Salmonella—unless they literally developed it a couple hours after getting in,” Dr. Jain says. “It should either be C. diff or a side effect of some medication. … We don’t need to spend the extra money, which is of low-value care to send for OVA and parasites, or bacterial pathogens and so forth.”

Dr. Jain says he thinks such testing is being done more appropriately of late.

“But I still will see multiple stool tests sent on somebody who’s been in the hospital for a week and then develops diarrhea,” he explains.

6 Gastroenterologists do not need to be consulted for every C. diff infection.

“I think that we really should get involved when patients are either not responding or when they’re very ill,” Dr. Pandolfino says.

Hospitalists should consider whether patients are on antibiotics or a PPI and whether or not they need to stay on those medications. Also, medications that slow motility (i.e., loperamide) should be avoided, if possible.

“We don’t want it to linger,” Dr. Pandolfino says. “One of the basic mechanisms of how we get rid of pathogens is to expel them with diarrhea.

“But you certainly don’t want the patient to be uncomfortable to the point where they’re having 20 to 30 bowel movements a day.”

In non-severe patients who have some diarrhea, abdominal pain, nausea, and vomiting—but are able to keep food down—the specialists might not have to be called in, and patients can just be treated with oral metronidazole or oral vancomycin fairly simply, he says.

For those who seem severely ill with a dilating colon, are in nearly a septic state, and have very severe diarrhea, the gastroenterologist should probably be called in, he says.

“Even if they have underlying heart failure, if they’re volume-depleted, they need that volume. Sometimes you’ll see that it takes eight hours to get two units of blood in. That’s inadequate.” —Rajeev Jain, MD

7 For patients with a possible GI bleed and black stools, do an exam before calling in the gastroenterologist.

The exam should determine what the stool color is and whether it is heme-positive, and the patient’s blood count should be evaluated, Dr. Coben says.

Frequently, “the consultant’s the one who ends up doing the rectal exam and checking that,” he says. “Sometimes we find that [the patient is] really not bleeding,” and it was just a case of a hospitalist taking the patient’s word that they were bleeding.

Being on iron therapy or taking Pepto-Bismol can turn the stool black, and the stool might not really be black; colors can sometimes be open to interpretation.

But he cautions that colon cancer could be the cause for a GI bleed.

“We’ve had it happen a few times where this occurred,” he says. “The patient was discharged, and they really didn’t get proper follow-up, and it ended up that they had a colon cancer. It kind of delayed that diagnosis. So I think you have to be aware of [the fact that], especially in somebody over the age of 40 or 50, if they have an iron-deficiency, anemia, or heme-positive stool, the first thing you really need to exclude is a colon cancer.”

8 Minimize CT scans in early evaluation and management of acute pancreatitis patients.

“The reason for that is they tend to be intravascularly volume-depleted,” Dr. Jain says. “So [with] the IV contrast, there’s an increased risk of developing kidney failure. It’s also been associated with increased risk of necrotizing pancreatitis.”

Dr. Jain notes that when he is consulted on this kind of patient, he will order a sonogram. If it doesn’t show gallstones, and there’s no clear reason for the pancreatitis, he will want a CT scan, but he will wait a few days until the patient is fluid-resuscitated.

Dr. Jain says that this is a problem more often seen in the ED—where 90% of patients with acute pancreatitis have already gotten the CT scan—and less so among hospitalists, but it’s still worth the reminder.

A CT scan right away is justified to rule out something such as a perforation, but not in the case of classic symptoms of acute pancreatitis, he adds.

9 Actively bleeding patients?

It’s smart to give patients a unit of packed red blood cells more quickly if they’re actively bleeding. Even over just one hour is OK, Dr. Jain says.

“Even if they have underlying heart failure, if they’re volume-depleted, they need that volume,” Dr. Jain explains. “Sometimes you’ll see that it takes eight hours to get two units of blood in. That’s inadequate.”

Another point worth a reminder, he says: Two large-bore peripheral IV’s are “much, much better” than a central or PICC line to deliver IV fluid resuscitation.

“Sometimes hospitalists order barium studies because these can be done the same day, whereas with endoscopy, patients need to be put on a schedule and have to be NPO [nothing by mouth] overnight.” —Prakash Gyawali, MD, MRCP

10 Don’t be too quick to order barium studies, especially in patients with dysphagia.

“The problem with that is it takes much longer to do an endoscopy if barium is put in the esophagus, because we usually wait until the barium clears,” Dr. Gyawali says. “And inpatient evaluation of new-onset dysphagia should be endoscopy first, and not barium, because biopsies need to be taken to rule out eosinophilic esophagitis.

“Sometimes hospitalists order barium studies because these can be done the same day, whereas with endoscopy, patients need to be put on a schedule and have to be NPO [nothing by mouth] overnight.”

11 Gastric-emptying studies should be outpatient.

Gastric-emptying studies are often better done when patients are not in a hospital, experts say, because they might be on medications that would interfere with the study.

“A common issue, not just among hospitalists but also gastroenterologists, is that patients may be on a bunch of medicines that would affect stomach-emptying while they are in-house for some other problem,” Dr. Gyawali says. “A lot of times, these patients with pain may get narcotics. They may be on medicines to prevent them from throwing up. … And all of these will slow down gastric emptying.”

With an abnormal test result, “you are left to decide whether that is a real abnormality or whether the medicines the patients were on impacted the abnormality.”

If emptying was significantly prolonged, the test may have some value, “but then it probably will need to be corroborated with symptoms and with endoscopic findings.”

Thomas Collins is a freelance writer in South Florida.

References

1. Warndorf MG, Kurtzman JT, Bartel MJ, et al. Early fluid resuscitation reduces morbidity among patients with acute pancreatitis. Clin Gastroenterol Hepatol. 2011;9(8):705-709.
2. Wu BU, Hwang JQ, Gardner TH, et al. Lactated Ringer’s solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol. 2011;9(8):710-717.

So many symptoms that are staples of gastroenterology—chest pain, nausea, diarrhea—are mainstay causes for hospitalization that it might be worth fine-tuning how well you handle patients with gastroenterology disorders.

The Hospitalist asked several gastroenterologists for their guidance on better care and their suggestions for correcting some common mistakes that they encounter. Here are their tips:

1 Fluid resuscitation is crucial for pancreatitis patients.

It’s very important to rehydrate these patients within the first 24 hours, because those who remain underhydrated can have a worse prognosis, says Robert Coben, MD, academic coordinator for the Gastroentestinal Fellowship Program at Thomas Jefferson University Hospital in Philadelphia. On occasion, physicians are reluctant to give extra fluids to these patients, he says, particularly if they have heart failure or suffer kidney problems. A 70-kg patient should be receiving about 200 cc per hour, he notes.

“Sometimes we’ll walk in the room and they’re getting 80 cc an hour,” Dr. Coben says.

“These patients…need to be flooded with fluids,” says Rajeev Jain, MD, chief of gastroenterology at Presbyterian Hospital of Dallas, partner at Texas Digestive Disease Consultants, and chair of the Practice Management and Economics Committee of the American Gastroenterological Association. “We’re talking sometimes liters and liters of IV normal saline or lactated Ringer’s (solution) in a 24-hour period.”¹

Marcelo Vela, MD, a gastroenterologist and hepatologist at the Mayo Clinic in Scottsdale, Ariz., and an associate editor with Clinical Gastroenterology and Hepatology, says Ringer’s solution is a better choice than normal saline.²

“If you’re going to start IV fluids on somebody who’s coming in with acute pancreatitis, Ringer’s solution has been shown to be superior to saline in randomized controlled trials,” Dr. Vela says. “It reduces systemic inflammation.”

2 Gastrointestinal bleeding decisions

When inpatients have gastrointestinal bleeding, the hospitalist often has to assess its severity and make the call on whether a patient needs the ICU.

“The most important thing for that is obviously the vital signs,” says John Pandolfino, MD, chief of the division of medicine–gastroenterology and hepatology at Northwestern University Feinberg School of Medicine in Chicago. “If people are tachycardic and they’re not responding to hydration and blood transfusion, that usually means it’s a pretty active bleed and they need to go to the intensive care unit. If you have somebody who’s GI bleeding and they’re coagulopathic (i.e., they’re on anti-coagulation because they have a valve and they need anti-coagulation or they have cancer or bad cardiovascular disease), those are the people that you should have a low threshold for sending to the intensive care unit with a GI bleed; those are the people who are at a very high mortality [risk].”

He added that those with an ulcer, with a visible vessel, are at a high-risk of a rebleed and should spend some time in the ICU.

“Those people should be evaluated in the intensive care unit for at least 24 hours, maybe even 72 hours,” Dr. Pandolfino says, “and they should have IV PPI [proton pump inhibitor] therapy.”

3 Endoscopy has very low yield for diagnosis of reflux.

“Endoscopy has good yield for mucosa abnormalities on inspection of the esophageal mucosa, but it does not give you a diagnosis of reflux, especially on patients who have already been treated with a PPI,” says Prakash Gyawali, MD, MRCP, professor of gastroenterology at Washington University in St. Louis, Mo. “So, usually, in those settings, obtaining a consult or trying to decide exactly what you’re looking for to explain the symptoms has better yield than an endoscopy.”

Sometimes a pH study is needed, but that has to be planned, because patients may have to be taken off of a PPI in advance. That means those studies are not easy to set up in the hospital and might best be arranged by the gastroenterologist, Dr. Gyawali says.

4 In cases of acute diarrhea, order a stool sample right away.

That will help guide care from the gastroenterologist, if and when the gastroenterologist is called in, Dr. Pandolfino says.

“One of the things that is frustrating for the gastroenterologist is that we get called initially, but really the hospitalist should be getting stool studies, and they should have at least a very good idea of what they need from us,” he says. “Because, really, endoscopy is not usually needed very often in diagnosis of acute diarrhea.”

Broad-range stool studies, a good history and physical, and examining labs for a possible chronic inflammatory process or anemia are good ways to begin to assess patients with diarrhea, he says. Clostridium difficile colitis has to be considered as well, Dr. Pandolfino says.

Endoscopy is more helpful in evaluating acute diarrhea in those with bloody diarrhea suspected of having inflammatory bowel disease or an infectious diarrhea but on whom cultures have come back negative. For those with compromised immune systems, endoscopy could be done earlier, as well.

“So for us, I think we really need to get into the picture a little bit after the patient has been brought into the hospital and the stool study is negative, unless they’re an immune-compromised patient,” Dr. Pandolfino says.

5 When—and how—to test the stool.

If a patient develops diarrhea while already in the hospital, the only stool test needed is C. diff.

“They shouldn’t be developing a viral diarrhea, they shouldn’t be developing an infectious diarrhea—let’s say, from E. coli or Salmonella—unless they literally developed it a couple hours after getting in,” Dr. Jain says. “It should either be C. diff or a side effect of some medication. … We don’t need to spend the extra money, which is of low-value care to send for OVA and parasites, or bacterial pathogens and so forth.”

Dr. Jain says he thinks such testing is being done more appropriately of late.

“But I still will see multiple stool tests sent on somebody who’s been in the hospital for a week and then develops diarrhea,” he explains.

6 Gastroenterologists do not need to be consulted for every C. diff infection.

“I think that we really should get involved when patients are either not responding or when they’re very ill,” Dr. Pandolfino says.

Hospitalists should consider whether patients are on antibiotics or a PPI and whether or not they need to stay on those medications. Also, medications that slow motility (i.e., loperamide) should be avoided, if possible.

“We don’t want it to linger,” Dr. Pandolfino says. “One of the basic mechanisms of how we get rid of pathogens is to expel them with diarrhea.

“But you certainly don’t want the patient to be uncomfortable to the point where they’re having 20 to 30 bowel movements a day.”

In non-severe patients who have some diarrhea, abdominal pain, nausea, and vomiting—but are able to keep food down—the specialists might not have to be called in, and patients can just be treated with oral metronidazole or oral vancomycin fairly simply, he says.

For those who seem severely ill with a dilating colon, are in nearly a septic state, and have very severe diarrhea, the gastroenterologist should probably be called in, he says.

“Even if they have underlying heart failure, if they’re volume-depleted, they need that volume. Sometimes you’ll see that it takes eight hours to get two units of blood in. That’s inadequate.” —Rajeev Jain, MD

7 For patients with a possible GI bleed and black stools, do an exam before calling in the gastroenterologist.

The exam should determine what the stool color is and whether it is heme-positive, and the patient’s blood count should be evaluated, Dr. Coben says.

Frequently, “the consultant’s the one who ends up doing the rectal exam and checking that,” he says. “Sometimes we find that [the patient is] really not bleeding,” and it was just a case of a hospitalist taking the patient’s word that they were bleeding.

Being on iron therapy or taking Pepto-Bismol can turn the stool black, and the stool might not really be black; colors can sometimes be open to interpretation.

But he cautions that colon cancer could be the cause for a GI bleed.

“We’ve had it happen a few times where this occurred,” he says. “The patient was discharged, and they really didn’t get proper follow-up, and it ended up that they had a colon cancer. It kind of delayed that diagnosis. So I think you have to be aware of [the fact that], especially in somebody over the age of 40 or 50, if they have an iron-deficiency, anemia, or heme-positive stool, the first thing you really need to exclude is a colon cancer.”

8 Minimize CT scans in early evaluation and management of acute pancreatitis patients.

“The reason for that is they tend to be intravascularly volume-depleted,” Dr. Jain says. “So [with] the IV contrast, there’s an increased risk of developing kidney failure. It’s also been associated with increased risk of necrotizing pancreatitis.”

Dr. Jain notes that when he is consulted on this kind of patient, he will order a sonogram. If it doesn’t show gallstones, and there’s no clear reason for the pancreatitis, he will want a CT scan, but he will wait a few days until the patient is fluid-resuscitated.

Dr. Jain says that this is a problem more often seen in the ED—where 90% of patients with acute pancreatitis have already gotten the CT scan—and less so among hospitalists, but it’s still worth the reminder.

A CT scan right away is justified to rule out something such as a perforation, but not in the case of classic symptoms of acute pancreatitis, he adds.

9 Actively bleeding patients?

It’s smart to give patients a unit of packed red blood cells more quickly if they’re actively bleeding. Even over just one hour is OK, Dr. Jain says.

“Even if they have underlying heart failure, if they’re volume-depleted, they need that volume,” Dr. Jain explains. “Sometimes you’ll see that it takes eight hours to get two units of blood in. That’s inadequate.”

Another point worth a reminder, he says: Two large-bore peripheral IV’s are “much, much better” than a central or PICC line to deliver IV fluid resuscitation.

“Sometimes hospitalists order barium studies because these can be done the same day, whereas with endoscopy, patients need to be put on a schedule and have to be NPO [nothing by mouth] overnight.” —Prakash Gyawali, MD, MRCP

10 Don’t be too quick to order barium studies, especially in patients with dysphagia.

“The problem with that is it takes much longer to do an endoscopy if barium is put in the esophagus, because we usually wait until the barium clears,” Dr. Gyawali says. “And inpatient evaluation of new-onset dysphagia should be endoscopy first, and not barium, because biopsies need to be taken to rule out eosinophilic esophagitis.

“Sometimes hospitalists order barium studies because these can be done the same day, whereas with endoscopy, patients need to be put on a schedule and have to be NPO [nothing by mouth] overnight.”

11 Gastric-emptying studies should be outpatient.

Gastric-emptying studies are often better done when patients are not in a hospital, experts say, because they might be on medications that would interfere with the study.

“A common issue, not just among hospitalists but also gastroenterologists, is that patients may be on a bunch of medicines that would affect stomach-emptying while they are in-house for some other problem,” Dr. Gyawali says. “A lot of times, these patients with pain may get narcotics. They may be on medicines to prevent them from throwing up. … And all of these will slow down gastric emptying.”

With an abnormal test result, “you are left to decide whether that is a real abnormality or whether the medicines the patients were on impacted the abnormality.”

If emptying was significantly prolonged, the test may have some value, “but then it probably will need to be corroborated with symptoms and with endoscopic findings.”

Thomas Collins is a freelance writer in South Florida.

References

1. Warndorf MG, Kurtzman JT, Bartel MJ, et al. Early fluid resuscitation reduces morbidity among patients with acute pancreatitis. Clin Gastroenterol Hepatol. 2011;9(8):705-709.
2. Wu BU, Hwang JQ, Gardner TH, et al. Lactated Ringer’s solution reduces systemic inflammation compared with saline in patients with acute pancreatitis. Clin Gastroenterol Hepatol. 2011;9(8):710-717.

ROBERT COBEN, MD, Program director of the gastroenterology fellowship program at Thomas Jefferson University Hospital in Philadelphia, discusses GI bleeds and colon cancer.

ROBERT COBEN, MD, Program director of the gastroenterology fellowship program at Thomas Jefferson University Hospital in Philadelphia, discusses GI bleeds and colon cancer.

ROBERT COBEN, MD, Program director of the gastroenterology fellowship program at Thomas Jefferson University Hospital in Philadelphia, discusses GI bleeds and colon cancer.

John Pandolfino, MD, chief of gastroenterology and hepatology at Northwestern University’s Feinberg School of Medicine in Chicago, talks about best practices for colonoscopies and treating C. diff infections.

John Pandolfino, MD, chief of gastroenterology and hepatology at Northwestern University’s Feinberg School of Medicine in Chicago, talks about best practices for colonoscopies and treating C. diff infections.

John Pandolfino, MD, chief of gastroenterology and hepatology at Northwestern University’s Feinberg School of Medicine in Chicago, talks about best practices for colonoscopies and treating C. diff infections.

Jeffrey Greenwald, MD, a hospitalist at Massacusetts General Hospital with 15 years of experience in hospital medicine, discusses his view of the spectrum of endocrine disorders and how hospitalists should approach the question of when to call in an endocrine specialist.

Jeffrey Greenwald, MD, a hospitalist at Massacusetts General Hospital with 15 years of experience in hospital medicine, discusses his view of the spectrum of endocrine disorders and how hospitalists should approach the question of when to call in an endocrine specialist.

Jeffrey Greenwald, MD, a hospitalist at Massacusetts General Hospital with 15 years of experience in hospital medicine, discusses his view of the spectrum of endocrine disorders and how hospitalists should approach the question of when to call in an endocrine specialist.

Diabetes is as prevalent in hospitals today as lab coats and heart monitors. More than 8% of the population—almost 26 million people—and nearly 27% (11 million) of Americans 65 or older have diabetes, according to American Diabetes Association (ADA) statistics. That makes diabetes one of the most common conditions hospitalists face day in and day out.

Other endocrine disorders also pose a challenge to hospitalists because they may be relatively uncommon, endocrinologists say.

The Hospitalist spoke to several endocrinologists and veteran hospitalists, mining their backgrounds and observations for tips on caring for hospitalized patients with endocrine disorders. Here are nine things they think hospitalists need to know:

1. Realize the far-reaching impact of good care for diabetic patients.

Part of the reason this is important is the numbers of patients with the disease who will be hospitalized and come under the care of a hospitalist.

“They’re coming in for a host of medical conditions, not the least of which is that diabetes is a comorbid factor that goes along with it,” says John Anderson, MD, the ADA’s immediate past president of medicine and science and an internist and diabetician at The Frist Clinic in Nashville, Tenn. “For those who are critically ill—those having bypass, those having stroke—diabetes is overrepresented even more once they get inside the hospital and in the intensive care unit.”

Job No. 1, controlling blood sugar, can have broad implications, he says.

“We know that control of their glucose through the hospital stay actually makes a difference in long-term outcomes, particularly things like surgery, coronary bypass grafting, that type of thing,” he says, noting that the standard of care is to try to keep glucose under 200. “A lot of studies have been done that demonstrate that really poor control of glucose in the hospital, regardless of the disease entity they’re in with, can lead to worsening long-term outcomes. It’s really imperative that you control the blood sugar.^1,2

“A lot of studies have been done that demonstrate that really poor control of glucose in the hospital, regardless of the disease entity they’re in with, can lead to worsening long-term outcomes. It’s really imperative that you control the blood sugar.^1,2 However, if you control it so tightly that these patients are dropping their blood sugar and having significant hypoglycemia problems in the hospital, that’s not good either.”

—John Anderson, MD, past president, American Diabetes Association, internist and diabetician, The Frist Clinic, Nashville, Tenn.

“However, the other part of this is…that if you control it so tightly that these patients are dropping their blood sugar and having significant hypoglycemia problems in the hospital, that’s not good either.”

2. You probably shouldn’t be testing for thyroid-stimulating hormone (TSH) level by itself in an acutely ill inpatient.

Simply put, the results probably won’t be useful, says Tamara Wexler, MD, PhD, an endocrinologist attending at Massachusetts General Hospital in Boston.

“TSH alone, for some reason, seems to be often measured,” she says, but “it’s extremely rarely indicated during acute hospitalization.”

TSH is “notoriously spurious” in inpatients, she adds, because the stress of an illness can make the test difficult to interpret.

“Many endocrine hormone levels are affected by stress, for example, and thus are better measured in an outpatient setting than in an acute hospitalized illness because of the impact of the illness on interpreting the test results,” she says.

Euthyroid sick syndrome—or “sick euthyroid”—is a term used for abnormalities in thyroid tests in patients with systemic illnesses that are nonthyroidal.

In cases in which thyroid dysfunction is strongly suspected, TSH should be measured in conjunction with other levels, such as a free thyroxine (free T4) level, Dr. Wexler says.

3. Don’t forget to watch potassium in patients with diabetic ketoacidosis (DKA).

A patient with a normal level of potassium, or even a high one, at baseline can encounter a problem with plummeting levels, says Bruce Mitchell, MD, director of hospital medicine services at Emory Hospital Midtown and assistant professor of hospital medicine at Emory University in Atlanta.

“Once you start insulin and correcting the hyperosmolality, the potassium shifts,” says Dr. Mitchell, who has a particular interest in endocrinology, “so it can become abnormally low fairly quickly.

“You start the insulin and fluids; then all of a sudden that person’s potassium is drastically abnormal and they’re coding,” he says. “It’s important to make sure your hospital’s diabetic ketoacidosis protocol includes frequent potassium checks.”

4. Be sure to wait long enough before rechecking TSH after a medication change.

It takes several weeks before thyroid medication dose changes start to show their effects, says Jeffrey Greenwald, MD, a hospitalist at Massachusetts General with expertise in endocrinology. Guidelines published in 2012 by the American Association of Clinical Endocrinologists and the American Thyroid Association recommend rechecking TSH within four to eight weeks.³

“It bears reminding that [for] patients who have recently changed their thyroid medication dose, you need to wait several weeks before you recheck their TSH. That’s another reason why the TSH can be somewhat difficult to interpret. There’s a tendency that I have seen, too, if the TSH is high and they’re on thyroid replacement, to want to adjust the dose while they’re in the hospital, which is probably not the time to do it.”—Jeffrey Greenwald, MD, hospitalist, Massachusetts General, Boston

“It bears reminding that [for] patients who have recently changed their thyroid medication dose, you need to wait several weeks before you recheck their TSH,” he says. “That’s another reason why the TSH can be somewhat difficult to interpret.

“There’s a tendency that I have seen, too, if the TSH is high and they’re on thyroid replacement, to want to adjust the dose while they’re in the hospital, which is probably not the time to do it.”

5. When administering insulin, factor in soon-to-arrive meals and give prandial insulin as needed.

If patients with diabetes are receiving insulin in the hospital, even if their glucose is in the normal range, they will need insulin if they’re about to have a carb-loaded breakfast, says Jose Florez, MD, PhD, an endocrinologist at Massachusetts General and associate professor of medicine at Harvard Medical School in Boston.

“A person with a glucose of 98 who is about to eat pancakes needs standing short-acting insulin regardless of the fingerstick,” Dr. Florez says. “A person with a glucose of 250 who is about to eat needs both the correction insulin and the amount needed to handle the impending carbohydrate load.”

“The person not only needs to correct what the glucose is at the moment, but they also need to account for the impending carbohydrate intake,” he says.

Dr. Anderson says he always cautions those caring for hospitalized diabetic patients against using the “sliding-scale philosophy”—marked by set amounts of long-acting insulin and set amounts of carbohydrate intake—because it’s overly formulaic for that setting.

“It leads to really variable glucoses,” he says, “and usually not good control.”

6. Giving isotonic fluids to someone who has fixed water retention or hypertonic urine can worsen the problem.

This can stem from an incomplete or incorrect evaluation of hyponatremia, which is a common problem in hospitalized patients. When hyponatremia is present, the first order of business should be to exclude pseudohyponatremia and confirm that it’s hypotonic hyponatremia.

After confirmation, the volume status should be assessed. One useful way to do this is to measure urine creatinine, urine sodium, and urine osmolality (osm), Dr. Florez says. If a patient has water retention or hypertonic urine from syndrome of inappropriate diuretic hormone secretion (SIADH), hypothyroidism, or glucocorticoid deficiency, the hospitalist needs to act accordingly.

“If the urine osm is high, higher than the serum osm, and is fixed at that level for some reason…giving that person isotonic fluids will lead to additional water retention and make the situation worse,” he says. “It’s very important to assess the volume status and establish the cause. And then, if you’re going to give fluids, be mindful of what the urine might look like. Do not give fluids that are hypotonic with respect to what the urine is making, unless you are completely convinced that the person is dry and therefore needs volume.”

“Once you start insulin and correcting the hyperosmolality, the potassium shifts, so it can become abnormally low fairly quickly. You start the insulin and fluids; then all of a sudden that person’s potassium is drastically abnormal and they’re coding. It’s important to make sure your hospital’s diabetic ketoacidosis protocol includes frequent potassium checks.”—Bruce Mitchell, MD, director of hospital medicine services, Emory Hospital Midtown, assistant professor of hospital medicine, Emory University, Atlanta.

7. Encourage patients to check their own glucose and administer their own insulin while still in the hospital.

“We often deal with patients who start insulin treatment for diabetes during an admission or who seem not to be doing very well giving insulin at home,” Dr. Wexler says. “Many patients can benefit from supervised insulin injections and glucose testing.”

Going through the process while in the hospital with supervision can be a good refresher, she says.

“You don’t have to necessarily order specific diabetic teaching,” she adds, noting that not all hospitals have diabetic educators available at all times.

A patient might be waiting for diabetic teaching before discharge, but this might be one way to speed the process, Dr. Wexler says. She suggests teaching by example.

8. Patients on steroids every day are at risk for adrenal insufficiency.

Even if they aren’t on corticosteroids when they present, hospitalists should think of these patients as “at risk for adrenal insufficiency and potentially immunocompromised,” Dr. Greenwald says. “The bigger issue in most cases is the adrenal insufficiency.”

That means their bodies can’t mount an appropriate response to stress.

“And without that appropriate response of additional stress hormone the body would normally make, they may not be able, for example, to maintain their blood pressure,” he says. “This can be extremely dangerous.”

Inhaled steroids, and topical steroids if they are applied to broken skin, can have a kind of stealth effect.

“That’s something to keep in mind,” Dr. Wexler says, noting the connection between blood pressure management and endocrine conditions.

9. Thyroid hormone might not be as well absorbed under certain conditions.

With calcium or iron supplementation, thyroid hormones might present a problem, Dr. Wexler says. For patients at home taking thyroid hormone appropriately (an hour or two separated from calcium or iron supplementation), there “should be no issue,” she says. “But if they are administered at the same time at the hospital, patients may not absorb the full dose.”

Tom Collins is a freelance writer in South Florida.

Misinterpreting Thyroid Function Tests Can Lead You Down the Wrong Path, Expert Warns

Thyroid function tests in hospitalized patients can sometimes be a case of a mistake begetting a mistake.⁴ Don’t fall into the trap, endocrinologists say.³

Consider a patient presenting with new atrial fibrillation. One of the triggers for the condition is hyperthyroidism, so it’s common to do a thyroid function test.

“Say the TSH [thyroid-stimulating hormone] is up because the patient is recovering from an acute illness,”

Dr. Florez says. “All of a sudden you were looking for hyperthyroidism, but now you have a high TSH, so that initiates a workup for hypothyroidism.” But that is not the proper course, because a high TSH is not uncommon in a person getting over an illness.

Once the TSH comes back high, you’ve ruled out hyperthyroidism as the reason for the atrial fibrillation.

The matter should be considered settled, he said. “No reason to get all excited about pursuing a hypothyroidism diagnosis,” Dr. Florez says. If thereis any concern, the thyroid function tests could be repeated in the outpatient setting when the patient is no longer acutely ill.

Misdirected concerns about hypothyroidism should also be avoided.

For example, a patient presents with altered mental status, which can be brought about by myxedema coma, or profound hypothyroidism.

If the TSH comes back low—eliminating hypothyroidism as a problem—a hospitalist should not embark on a hyperthyroidism diagnosis, Dr. Florez says. It’s probably just sick euthyroid causing the abnormal TSH level.

“What you need to do is work on the reasons for altered mental status,” he says. “You’ve already exonerated myxedema coma. Move on, and then have the thyroid test pursued as an outpatient to ensure it normalizes.”

—Thomas R. Collins

Slow Down

Because diabetes is such a common disease among hospitalized patients, it might be easy to gloss over, but it’s important to regard each inpatient as an individual and not go on auto-pilot, diabetes experts say.

“Not every type 2 or type 1 patient is alike. They all have different insulin requirements. Some patients are on oral meds with type 2 diabetes, some are on one insulin shot a day, [and] some are on several insulin injections a day,” Dr. Anderson says. “It’s managing that glucose in that individual and trying to optimize their therapy.”

Plenty of factors in the hospital might get in the way of that optimal care, he adds. Is a patient NPO (nothing by mouth) before a surgery? Feeling too nauseous to follow the appropriate eating schedule? Has a meal been delivered late by the meal service?

“The hospital introduces an incredible layer of complexity to the care of the patient with type 2 diabetes,” Dr. Anderson says. “That’s why it’s really important for everybody who takes care of people with diabetes in the hospital to be pretty savvy about this.”

Hospitalists shouldn’t be lulled into complacency just because diabetes is usually non-life-threatening. Often, patients with diabetes are admitted for a completely different condition.

“And by the time [providers] get to diabetes as an issue, they may just say ‘diabetes, sliding scale, check A1C as a reflex,’ and then not take the time to think about what is this person’s regimen,” Dr. Florez says.

All the details about that person’s eating status and insulin requirements should be tended to carefully.

“I don’t think diabetes is rocket science,” Dr. Florez says. “But it does require attention.

I think it’s not so much [hospitalists’] level of expertise as it is the time and the pressures and the stresses. They have to actually slow down and give the diabetes some thought.”

—Thomas R. Collins

References

1. Omar AS, Salama A, Allam M, et al. Association of time in blood glucose range with outcomes following cardiac surgery. BMC Anesthesiol. 2015;15(1):14.
2. Han HS, Kang SB. Relations between long-term glycemic control and postoperative wound and infectious complications after total knee arthroplasty in type 2 diabetics. Clin Orthop Surg. 2013;5(2):118–123.
3. Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012;18(6):988-1028.
4. Supit EJ, Peiris AN. Interpretation of laboratory thyroid function tests for the primary care physician. South Med J. 2002;95(5):481-485.

Diabetes is as prevalent in hospitals today as lab coats and heart monitors. More than 8% of the population—almost 26 million people—and nearly 27% (11 million) of Americans 65 or older have diabetes, according to American Diabetes Association (ADA) statistics. That makes diabetes one of the most common conditions hospitalists face day in and day out.

Other endocrine disorders also pose a challenge to hospitalists because they may be relatively uncommon, endocrinologists say.

The Hospitalist spoke to several endocrinologists and veteran hospitalists, mining their backgrounds and observations for tips on caring for hospitalized patients with endocrine disorders. Here are nine things they think hospitalists need to know:

1. Realize the far-reaching impact of good care for diabetic patients.

Part of the reason this is important is the numbers of patients with the disease who will be hospitalized and come under the care of a hospitalist.

“They’re coming in for a host of medical conditions, not the least of which is that diabetes is a comorbid factor that goes along with it,” says John Anderson, MD, the ADA’s immediate past president of medicine and science and an internist and diabetician at The Frist Clinic in Nashville, Tenn. “For those who are critically ill—those having bypass, those having stroke—diabetes is overrepresented even more once they get inside the hospital and in the intensive care unit.”

Job No. 1, controlling blood sugar, can have broad implications, he says.

“We know that control of their glucose through the hospital stay actually makes a difference in long-term outcomes, particularly things like surgery, coronary bypass grafting, that type of thing,” he says, noting that the standard of care is to try to keep glucose under 200. “A lot of studies have been done that demonstrate that really poor control of glucose in the hospital, regardless of the disease entity they’re in with, can lead to worsening long-term outcomes. It’s really imperative that you control the blood sugar.^1,2

“A lot of studies have been done that demonstrate that really poor control of glucose in the hospital, regardless of the disease entity they’re in with, can lead to worsening long-term outcomes. It’s really imperative that you control the blood sugar.^1,2 However, if you control it so tightly that these patients are dropping their blood sugar and having significant hypoglycemia problems in the hospital, that’s not good either.”

—John Anderson, MD, past president, American Diabetes Association, internist and diabetician, The Frist Clinic, Nashville, Tenn.

“However, the other part of this is…that if you control it so tightly that these patients are dropping their blood sugar and having significant hypoglycemia problems in the hospital, that’s not good either.”

2. You probably shouldn’t be testing for thyroid-stimulating hormone (TSH) level by itself in an acutely ill inpatient.

Simply put, the results probably won’t be useful, says Tamara Wexler, MD, PhD, an endocrinologist attending at Massachusetts General Hospital in Boston.

“TSH alone, for some reason, seems to be often measured,” she says, but “it’s extremely rarely indicated during acute hospitalization.”

TSH is “notoriously spurious” in inpatients, she adds, because the stress of an illness can make the test difficult to interpret.

“Many endocrine hormone levels are affected by stress, for example, and thus are better measured in an outpatient setting than in an acute hospitalized illness because of the impact of the illness on interpreting the test results,” she says.

Euthyroid sick syndrome—or “sick euthyroid”—is a term used for abnormalities in thyroid tests in patients with systemic illnesses that are nonthyroidal.

In cases in which thyroid dysfunction is strongly suspected, TSH should be measured in conjunction with other levels, such as a free thyroxine (free T4) level, Dr. Wexler says.

3. Don’t forget to watch potassium in patients with diabetic ketoacidosis (DKA).

A patient with a normal level of potassium, or even a high one, at baseline can encounter a problem with plummeting levels, says Bruce Mitchell, MD, director of hospital medicine services at Emory Hospital Midtown and assistant professor of hospital medicine at Emory University in Atlanta.

“Once you start insulin and correcting the hyperosmolality, the potassium shifts,” says Dr. Mitchell, who has a particular interest in endocrinology, “so it can become abnormally low fairly quickly.

“You start the insulin and fluids; then all of a sudden that person’s potassium is drastically abnormal and they’re coding,” he says. “It’s important to make sure your hospital’s diabetic ketoacidosis protocol includes frequent potassium checks.”

4. Be sure to wait long enough before rechecking TSH after a medication change.

It takes several weeks before thyroid medication dose changes start to show their effects, says Jeffrey Greenwald, MD, a hospitalist at Massachusetts General with expertise in endocrinology. Guidelines published in 2012 by the American Association of Clinical Endocrinologists and the American Thyroid Association recommend rechecking TSH within four to eight weeks.³

“It bears reminding that [for] patients who have recently changed their thyroid medication dose, you need to wait several weeks before you recheck their TSH. That’s another reason why the TSH can be somewhat difficult to interpret. There’s a tendency that I have seen, too, if the TSH is high and they’re on thyroid replacement, to want to adjust the dose while they’re in the hospital, which is probably not the time to do it.”—Jeffrey Greenwald, MD, hospitalist, Massachusetts General, Boston

“It bears reminding that [for] patients who have recently changed their thyroid medication dose, you need to wait several weeks before you recheck their TSH,” he says. “That’s another reason why the TSH can be somewhat difficult to interpret.

“There’s a tendency that I have seen, too, if the TSH is high and they’re on thyroid replacement, to want to adjust the dose while they’re in the hospital, which is probably not the time to do it.”

5. When administering insulin, factor in soon-to-arrive meals and give prandial insulin as needed.

If patients with diabetes are receiving insulin in the hospital, even if their glucose is in the normal range, they will need insulin if they’re about to have a carb-loaded breakfast, says Jose Florez, MD, PhD, an endocrinologist at Massachusetts General and associate professor of medicine at Harvard Medical School in Boston.

“A person with a glucose of 98 who is about to eat pancakes needs standing short-acting insulin regardless of the fingerstick,” Dr. Florez says. “A person with a glucose of 250 who is about to eat needs both the correction insulin and the amount needed to handle the impending carbohydrate load.”

“The person not only needs to correct what the glucose is at the moment, but they also need to account for the impending carbohydrate intake,” he says.

Dr. Anderson says he always cautions those caring for hospitalized diabetic patients against using the “sliding-scale philosophy”—marked by set amounts of long-acting insulin and set amounts of carbohydrate intake—because it’s overly formulaic for that setting.

“It leads to really variable glucoses,” he says, “and usually not good control.”

6. Giving isotonic fluids to someone who has fixed water retention or hypertonic urine can worsen the problem.

This can stem from an incomplete or incorrect evaluation of hyponatremia, which is a common problem in hospitalized patients. When hyponatremia is present, the first order of business should be to exclude pseudohyponatremia and confirm that it’s hypotonic hyponatremia.

After confirmation, the volume status should be assessed. One useful way to do this is to measure urine creatinine, urine sodium, and urine osmolality (osm), Dr. Florez says. If a patient has water retention or hypertonic urine from syndrome of inappropriate diuretic hormone secretion (SIADH), hypothyroidism, or glucocorticoid deficiency, the hospitalist needs to act accordingly.

“If the urine osm is high, higher than the serum osm, and is fixed at that level for some reason…giving that person isotonic fluids will lead to additional water retention and make the situation worse,” he says. “It’s very important to assess the volume status and establish the cause. And then, if you’re going to give fluids, be mindful of what the urine might look like. Do not give fluids that are hypotonic with respect to what the urine is making, unless you are completely convinced that the person is dry and therefore needs volume.”

“Once you start insulin and correcting the hyperosmolality, the potassium shifts, so it can become abnormally low fairly quickly. You start the insulin and fluids; then all of a sudden that person’s potassium is drastically abnormal and they’re coding. It’s important to make sure your hospital’s diabetic ketoacidosis protocol includes frequent potassium checks.”—Bruce Mitchell, MD, director of hospital medicine services, Emory Hospital Midtown, assistant professor of hospital medicine, Emory University, Atlanta.

7. Encourage patients to check their own glucose and administer their own insulin while still in the hospital.

“We often deal with patients who start insulin treatment for diabetes during an admission or who seem not to be doing very well giving insulin at home,” Dr. Wexler says. “Many patients can benefit from supervised insulin injections and glucose testing.”

Going through the process while in the hospital with supervision can be a good refresher, she says.

“You don’t have to necessarily order specific diabetic teaching,” she adds, noting that not all hospitals have diabetic educators available at all times.

A patient might be waiting for diabetic teaching before discharge, but this might be one way to speed the process, Dr. Wexler says. She suggests teaching by example.

8. Patients on steroids every day are at risk for adrenal insufficiency.

Even if they aren’t on corticosteroids when they present, hospitalists should think of these patients as “at risk for adrenal insufficiency and potentially immunocompromised,” Dr. Greenwald says. “The bigger issue in most cases is the adrenal insufficiency.”

That means their bodies can’t mount an appropriate response to stress.

“And without that appropriate response of additional stress hormone the body would normally make, they may not be able, for example, to maintain their blood pressure,” he says. “This can be extremely dangerous.”

Inhaled steroids, and topical steroids if they are applied to broken skin, can have a kind of stealth effect.

“That’s something to keep in mind,” Dr. Wexler says, noting the connection between blood pressure management and endocrine conditions.

9. Thyroid hormone might not be as well absorbed under certain conditions.

With calcium or iron supplementation, thyroid hormones might present a problem, Dr. Wexler says. For patients at home taking thyroid hormone appropriately (an hour or two separated from calcium or iron supplementation), there “should be no issue,” she says. “But if they are administered at the same time at the hospital, patients may not absorb the full dose.”

Tom Collins is a freelance writer in South Florida.

Misinterpreting Thyroid Function Tests Can Lead You Down the Wrong Path, Expert Warns

Thyroid function tests in hospitalized patients can sometimes be a case of a mistake begetting a mistake.⁴ Don’t fall into the trap, endocrinologists say.³

Consider a patient presenting with new atrial fibrillation. One of the triggers for the condition is hyperthyroidism, so it’s common to do a thyroid function test.

“Say the TSH [thyroid-stimulating hormone] is up because the patient is recovering from an acute illness,”

Dr. Florez says. “All of a sudden you were looking for hyperthyroidism, but now you have a high TSH, so that initiates a workup for hypothyroidism.” But that is not the proper course, because a high TSH is not uncommon in a person getting over an illness.

Once the TSH comes back high, you’ve ruled out hyperthyroidism as the reason for the atrial fibrillation.

The matter should be considered settled, he said. “No reason to get all excited about pursuing a hypothyroidism diagnosis,” Dr. Florez says. If thereis any concern, the thyroid function tests could be repeated in the outpatient setting when the patient is no longer acutely ill.

Misdirected concerns about hypothyroidism should also be avoided.

For example, a patient presents with altered mental status, which can be brought about by myxedema coma, or profound hypothyroidism.

If the TSH comes back low—eliminating hypothyroidism as a problem—a hospitalist should not embark on a hyperthyroidism diagnosis, Dr. Florez says. It’s probably just sick euthyroid causing the abnormal TSH level.

“What you need to do is work on the reasons for altered mental status,” he says. “You’ve already exonerated myxedema coma. Move on, and then have the thyroid test pursued as an outpatient to ensure it normalizes.”

—Thomas R. Collins

Slow Down

Because diabetes is such a common disease among hospitalized patients, it might be easy to gloss over, but it’s important to regard each inpatient as an individual and not go on auto-pilot, diabetes experts say.

“Not every type 2 or type 1 patient is alike. They all have different insulin requirements. Some patients are on oral meds with type 2 diabetes, some are on one insulin shot a day, [and] some are on several insulin injections a day,” Dr. Anderson says. “It’s managing that glucose in that individual and trying to optimize their therapy.”

Plenty of factors in the hospital might get in the way of that optimal care, he adds. Is a patient NPO (nothing by mouth) before a surgery? Feeling too nauseous to follow the appropriate eating schedule? Has a meal been delivered late by the meal service?

“The hospital introduces an incredible layer of complexity to the care of the patient with type 2 diabetes,” Dr. Anderson says. “That’s why it’s really important for everybody who takes care of people with diabetes in the hospital to be pretty savvy about this.”

Hospitalists shouldn’t be lulled into complacency just because diabetes is usually non-life-threatening. Often, patients with diabetes are admitted for a completely different condition.

“And by the time [providers] get to diabetes as an issue, they may just say ‘diabetes, sliding scale, check A1C as a reflex,’ and then not take the time to think about what is this person’s regimen,” Dr. Florez says.

All the details about that person’s eating status and insulin requirements should be tended to carefully.

“I don’t think diabetes is rocket science,” Dr. Florez says. “But it does require attention.

I think it’s not so much [hospitalists’] level of expertise as it is the time and the pressures and the stresses. They have to actually slow down and give the diabetes some thought.”

—Thomas R. Collins

References

1. Omar AS, Salama A, Allam M, et al. Association of time in blood glucose range with outcomes following cardiac surgery. BMC Anesthesiol. 2015;15(1):14.
2. Han HS, Kang SB. Relations between long-term glycemic control and postoperative wound and infectious complications after total knee arthroplasty in type 2 diabetics. Clin Orthop Surg. 2013;5(2):118–123.
3. Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012;18(6):988-1028.
4. Supit EJ, Peiris AN. Interpretation of laboratory thyroid function tests for the primary care physician. South Med J. 2002;95(5):481-485.

Diabetes is as prevalent in hospitals today as lab coats and heart monitors. More than 8% of the population—almost 26 million people—and nearly 27% (11 million) of Americans 65 or older have diabetes, according to American Diabetes Association (ADA) statistics. That makes diabetes one of the most common conditions hospitalists face day in and day out.

Other endocrine disorders also pose a challenge to hospitalists because they may be relatively uncommon, endocrinologists say.

The Hospitalist spoke to several endocrinologists and veteran hospitalists, mining their backgrounds and observations for tips on caring for hospitalized patients with endocrine disorders. Here are nine things they think hospitalists need to know:

1. Realize the far-reaching impact of good care for diabetic patients.

Part of the reason this is important is the numbers of patients with the disease who will be hospitalized and come under the care of a hospitalist.

“They’re coming in for a host of medical conditions, not the least of which is that diabetes is a comorbid factor that goes along with it,” says John Anderson, MD, the ADA’s immediate past president of medicine and science and an internist and diabetician at The Frist Clinic in Nashville, Tenn. “For those who are critically ill—those having bypass, those having stroke—diabetes is overrepresented even more once they get inside the hospital and in the intensive care unit.”

Job No. 1, controlling blood sugar, can have broad implications, he says.

“We know that control of their glucose through the hospital stay actually makes a difference in long-term outcomes, particularly things like surgery, coronary bypass grafting, that type of thing,” he says, noting that the standard of care is to try to keep glucose under 200. “A lot of studies have been done that demonstrate that really poor control of glucose in the hospital, regardless of the disease entity they’re in with, can lead to worsening long-term outcomes. It’s really imperative that you control the blood sugar.^1,2

“A lot of studies have been done that demonstrate that really poor control of glucose in the hospital, regardless of the disease entity they’re in with, can lead to worsening long-term outcomes. It’s really imperative that you control the blood sugar.^1,2 However, if you control it so tightly that these patients are dropping their blood sugar and having significant hypoglycemia problems in the hospital, that’s not good either.”

—John Anderson, MD, past president, American Diabetes Association, internist and diabetician, The Frist Clinic, Nashville, Tenn.

“However, the other part of this is…that if you control it so tightly that these patients are dropping their blood sugar and having significant hypoglycemia problems in the hospital, that’s not good either.”

2. You probably shouldn’t be testing for thyroid-stimulating hormone (TSH) level by itself in an acutely ill inpatient.

Simply put, the results probably won’t be useful, says Tamara Wexler, MD, PhD, an endocrinologist attending at Massachusetts General Hospital in Boston.

“TSH alone, for some reason, seems to be often measured,” she says, but “it’s extremely rarely indicated during acute hospitalization.”

TSH is “notoriously spurious” in inpatients, she adds, because the stress of an illness can make the test difficult to interpret.

“Many endocrine hormone levels are affected by stress, for example, and thus are better measured in an outpatient setting than in an acute hospitalized illness because of the impact of the illness on interpreting the test results,” she says.

Euthyroid sick syndrome—or “sick euthyroid”—is a term used for abnormalities in thyroid tests in patients with systemic illnesses that are nonthyroidal.

In cases in which thyroid dysfunction is strongly suspected, TSH should be measured in conjunction with other levels, such as a free thyroxine (free T4) level, Dr. Wexler says.

3. Don’t forget to watch potassium in patients with diabetic ketoacidosis (DKA).

A patient with a normal level of potassium, or even a high one, at baseline can encounter a problem with plummeting levels, says Bruce Mitchell, MD, director of hospital medicine services at Emory Hospital Midtown and assistant professor of hospital medicine at Emory University in Atlanta.

“Once you start insulin and correcting the hyperosmolality, the potassium shifts,” says Dr. Mitchell, who has a particular interest in endocrinology, “so it can become abnormally low fairly quickly.

“You start the insulin and fluids; then all of a sudden that person’s potassium is drastically abnormal and they’re coding,” he says. “It’s important to make sure your hospital’s diabetic ketoacidosis protocol includes frequent potassium checks.”

4. Be sure to wait long enough before rechecking TSH after a medication change.

It takes several weeks before thyroid medication dose changes start to show their effects, says Jeffrey Greenwald, MD, a hospitalist at Massachusetts General with expertise in endocrinology. Guidelines published in 2012 by the American Association of Clinical Endocrinologists and the American Thyroid Association recommend rechecking TSH within four to eight weeks.³

“It bears reminding that [for] patients who have recently changed their thyroid medication dose, you need to wait several weeks before you recheck their TSH. That’s another reason why the TSH can be somewhat difficult to interpret. There’s a tendency that I have seen, too, if the TSH is high and they’re on thyroid replacement, to want to adjust the dose while they’re in the hospital, which is probably not the time to do it.”—Jeffrey Greenwald, MD, hospitalist, Massachusetts General, Boston

“It bears reminding that [for] patients who have recently changed their thyroid medication dose, you need to wait several weeks before you recheck their TSH,” he says. “That’s another reason why the TSH can be somewhat difficult to interpret.

“There’s a tendency that I have seen, too, if the TSH is high and they’re on thyroid replacement, to want to adjust the dose while they’re in the hospital, which is probably not the time to do it.”

5. When administering insulin, factor in soon-to-arrive meals and give prandial insulin as needed.

If patients with diabetes are receiving insulin in the hospital, even if their glucose is in the normal range, they will need insulin if they’re about to have a carb-loaded breakfast, says Jose Florez, MD, PhD, an endocrinologist at Massachusetts General and associate professor of medicine at Harvard Medical School in Boston.

“A person with a glucose of 98 who is about to eat pancakes needs standing short-acting insulin regardless of the fingerstick,” Dr. Florez says. “A person with a glucose of 250 who is about to eat needs both the correction insulin and the amount needed to handle the impending carbohydrate load.”

“The person not only needs to correct what the glucose is at the moment, but they also need to account for the impending carbohydrate intake,” he says.

Dr. Anderson says he always cautions those caring for hospitalized diabetic patients against using the “sliding-scale philosophy”—marked by set amounts of long-acting insulin and set amounts of carbohydrate intake—because it’s overly formulaic for that setting.

“It leads to really variable glucoses,” he says, “and usually not good control.”

6. Giving isotonic fluids to someone who has fixed water retention or hypertonic urine can worsen the problem.

This can stem from an incomplete or incorrect evaluation of hyponatremia, which is a common problem in hospitalized patients. When hyponatremia is present, the first order of business should be to exclude pseudohyponatremia and confirm that it’s hypotonic hyponatremia.

After confirmation, the volume status should be assessed. One useful way to do this is to measure urine creatinine, urine sodium, and urine osmolality (osm), Dr. Florez says. If a patient has water retention or hypertonic urine from syndrome of inappropriate diuretic hormone secretion (SIADH), hypothyroidism, or glucocorticoid deficiency, the hospitalist needs to act accordingly.

“If the urine osm is high, higher than the serum osm, and is fixed at that level for some reason…giving that person isotonic fluids will lead to additional water retention and make the situation worse,” he says. “It’s very important to assess the volume status and establish the cause. And then, if you’re going to give fluids, be mindful of what the urine might look like. Do not give fluids that are hypotonic with respect to what the urine is making, unless you are completely convinced that the person is dry and therefore needs volume.”

“Once you start insulin and correcting the hyperosmolality, the potassium shifts, so it can become abnormally low fairly quickly. You start the insulin and fluids; then all of a sudden that person’s potassium is drastically abnormal and they’re coding. It’s important to make sure your hospital’s diabetic ketoacidosis protocol includes frequent potassium checks.”—Bruce Mitchell, MD, director of hospital medicine services, Emory Hospital Midtown, assistant professor of hospital medicine, Emory University, Atlanta.

7. Encourage patients to check their own glucose and administer their own insulin while still in the hospital.

“We often deal with patients who start insulin treatment for diabetes during an admission or who seem not to be doing very well giving insulin at home,” Dr. Wexler says. “Many patients can benefit from supervised insulin injections and glucose testing.”

Going through the process while in the hospital with supervision can be a good refresher, she says.

“You don’t have to necessarily order specific diabetic teaching,” she adds, noting that not all hospitals have diabetic educators available at all times.

A patient might be waiting for diabetic teaching before discharge, but this might be one way to speed the process, Dr. Wexler says. She suggests teaching by example.

8. Patients on steroids every day are at risk for adrenal insufficiency.

Even if they aren’t on corticosteroids when they present, hospitalists should think of these patients as “at risk for adrenal insufficiency and potentially immunocompromised,” Dr. Greenwald says. “The bigger issue in most cases is the adrenal insufficiency.”

That means their bodies can’t mount an appropriate response to stress.

“And without that appropriate response of additional stress hormone the body would normally make, they may not be able, for example, to maintain their blood pressure,” he says. “This can be extremely dangerous.”

Inhaled steroids, and topical steroids if they are applied to broken skin, can have a kind of stealth effect.

“That’s something to keep in mind,” Dr. Wexler says, noting the connection between blood pressure management and endocrine conditions.

9. Thyroid hormone might not be as well absorbed under certain conditions.

With calcium or iron supplementation, thyroid hormones might present a problem, Dr. Wexler says. For patients at home taking thyroid hormone appropriately (an hour or two separated from calcium or iron supplementation), there “should be no issue,” she says. “But if they are administered at the same time at the hospital, patients may not absorb the full dose.”

Tom Collins is a freelance writer in South Florida.

Misinterpreting Thyroid Function Tests Can Lead You Down the Wrong Path, Expert Warns

Thyroid function tests in hospitalized patients can sometimes be a case of a mistake begetting a mistake.⁴ Don’t fall into the trap, endocrinologists say.³

Consider a patient presenting with new atrial fibrillation. One of the triggers for the condition is hyperthyroidism, so it’s common to do a thyroid function test.

“Say the TSH [thyroid-stimulating hormone] is up because the patient is recovering from an acute illness,”

Dr. Florez says. “All of a sudden you were looking for hyperthyroidism, but now you have a high TSH, so that initiates a workup for hypothyroidism.” But that is not the proper course, because a high TSH is not uncommon in a person getting over an illness.

Once the TSH comes back high, you’ve ruled out hyperthyroidism as the reason for the atrial fibrillation.

The matter should be considered settled, he said. “No reason to get all excited about pursuing a hypothyroidism diagnosis,” Dr. Florez says. If thereis any concern, the thyroid function tests could be repeated in the outpatient setting when the patient is no longer acutely ill.

Misdirected concerns about hypothyroidism should also be avoided.

For example, a patient presents with altered mental status, which can be brought about by myxedema coma, or profound hypothyroidism.

If the TSH comes back low—eliminating hypothyroidism as a problem—a hospitalist should not embark on a hyperthyroidism diagnosis, Dr. Florez says. It’s probably just sick euthyroid causing the abnormal TSH level.

“What you need to do is work on the reasons for altered mental status,” he says. “You’ve already exonerated myxedema coma. Move on, and then have the thyroid test pursued as an outpatient to ensure it normalizes.”

—Thomas R. Collins

Slow Down

Because diabetes is such a common disease among hospitalized patients, it might be easy to gloss over, but it’s important to regard each inpatient as an individual and not go on auto-pilot, diabetes experts say.

“Not every type 2 or type 1 patient is alike. They all have different insulin requirements. Some patients are on oral meds with type 2 diabetes, some are on one insulin shot a day, [and] some are on several insulin injections a day,” Dr. Anderson says. “It’s managing that glucose in that individual and trying to optimize their therapy.”

Plenty of factors in the hospital might get in the way of that optimal care, he adds. Is a patient NPO (nothing by mouth) before a surgery? Feeling too nauseous to follow the appropriate eating schedule? Has a meal been delivered late by the meal service?

“The hospital introduces an incredible layer of complexity to the care of the patient with type 2 diabetes,” Dr. Anderson says. “That’s why it’s really important for everybody who takes care of people with diabetes in the hospital to be pretty savvy about this.”

Hospitalists shouldn’t be lulled into complacency just because diabetes is usually non-life-threatening. Often, patients with diabetes are admitted for a completely different condition.

“And by the time [providers] get to diabetes as an issue, they may just say ‘diabetes, sliding scale, check A1C as a reflex,’ and then not take the time to think about what is this person’s regimen,” Dr. Florez says.

All the details about that person’s eating status and insulin requirements should be tended to carefully.

“I don’t think diabetes is rocket science,” Dr. Florez says. “But it does require attention.

I think it’s not so much [hospitalists’] level of expertise as it is the time and the pressures and the stresses. They have to actually slow down and give the diabetes some thought.”

—Thomas R. Collins

References

1. Omar AS, Salama A, Allam M, et al. Association of time in blood glucose range with outcomes following cardiac surgery. BMC Anesthesiol. 2015;15(1):14.
2. Han HS, Kang SB. Relations between long-term glycemic control and postoperative wound and infectious complications after total knee arthroplasty in type 2 diabetics. Clin Orthop Surg. 2013;5(2):118–123.
3. Garber JR, Cobin RH, Gharib H, et al. Clinical practice guidelines for hypothyroidism in adults: cosponsored by the American Association of Clinical Endocrinologists and the American Thyroid Association. Endocr Pract. 2012;18(6):988-1028.
4. Supit EJ, Peiris AN. Interpretation of laboratory thyroid function tests for the primary care physician. South Med J. 2002;95(5):481-485.

DAVID PRESSEL, MD, PHD, FHM, medical director of inpatient services at Nemours Children’s Health System, talks about the nature of violence in hospitals and a training program he has helped put into place at his center.

DAVID PRESSEL, MD, PHD, FHM, medical director of inpatient services at Nemours Children’s Health System, talks about the nature of violence in hospitals and a training program he has helped put into place at his center.

DAVID PRESSEL, MD, PHD, FHM, medical director of inpatient services at Nemours Children’s Health System, talks about the nature of violence in hospitals and a training program he has helped put into place at his center.

Hospitalists could hardly be faulted for wondering: Am I safe? After all, the inpatient setting can be a tense place, and it’s where hospitalists work day in and day out.

David Pressel, MD, PhD, FHM, a pediatric hospitalist and medical director of inpatient services at Nemours Children’s Health System, which has locations in Delaware, New Jersey, Pennsylvania, and Florida, says it’s no wonder violence can erupt in the hospital setting.

“Violence is an issue in hospitals that is a reflection of our society, unfortunately,” says Dr. Pressel, a member of Team Hospitalist. “And it happens because these are very stressful places where people’s behavior can get outside the norm given the stress of the problems.”

Dr. Pressel, in collaboration with many others, has developed a workplace violence prevention program at Nemours aimed at de-escalating situations to avoid physical violence. The program teaches providers how to respond when something violent does happen. It’s a tiered training regimen that involves more training for those most involved in handling violent situations.

Dr. Pressel is no stranger to violence himself. Although he is a pediatric hospitalist and his patients are younger, some adolescent patients can have the physical presence of adults and pose just as serious a threat. He said that before the training program was put into place about a year ago, an episode of violence every month or two would require a patient to be placed in restraints.

“Staff has been hurt,” he explains. “I’ve been bitten twice by a patient. I have a scar on my arm that will be with me for life from one episode.”

A Slow, Disheartening, Upward Trend

Whether violence in hospitals and medical facilities is really a growing problem—or whether awareness of the issue is simply greater given these recent, high profile incidents—is not entirely known.

But according to the latest figures available from the Bureau of Labor Statistics (BLS), provided by the Occupational Safety and Health Administration (OSHA), violent incidents in hospitals did appear to be on the rise through 2013. The number of hospital assaults rose from 5,030 in 2011 to 5,500 in 2012 to 5,660 in 2013.

The number of assaults rose across all private sector industries over that span, but the percentage of those assaults that occurred in hospitals grew greater during that time—an indication that hospitals might be getting more violent at a faster pace than other workplaces. In 2011, according to BLS data, 21.4% of all assaults in private sector industries occurred in hospitals. That number rose to 21.8% in 2012 and to 22.1% in 2013.

According to the 2014 Healthcare Crime Survey, published by the International Association for Healthcare Security and Safety (IAHSS)—an organization of hospital security officials and administrators—violent crime at U.S. facilities rose from two incidents per 100 beds in 2012 to 2.5 incidents per 100 beds in 2013. That category includes murder, rape, aggravated assault, and robbery.

Assaults rose from 10.7 incidents per 100 beds in 2012 to 11.1 incidents per 100 beds in 2013.

BLS data also show that more injuries in hospitals are due to assaults compared with the private sector overall. In 2011, 2.6% of all private sector injuries were due to assault; in 2012, the number rose to 2.8%; and, in 2013, it was 2.8%. In hospitals in 2011, 8.6% of all injuries resulted from assaults. That percentage rose to 9.5% in 2012 and to 9.8% in 2013.

“BLS data show that nonfatal injuries due to violence are greater in the healthcare/social assistance setting than in other workplaces,” an OSHA spokesperson says. “Assaults represent a serious safety and health hazard within healthcare, and data indicate that hospitals comprise a large percentage of workplace assaults.”

Incident Prevention

Programs aimed at preventing violence can reduce these incidents.

“How well prepared hospital workers are in dealing with violent situations depends on the workplace violence prevention program implemented at a facility,” the OSHA spokesperson says. “Some states have passed legislation that specifically requires workplace violence prevention programs in the healthcare setting.”

These programs should address management commitment and employee participation, worksite analysis, hazard prevention and control, safety and health training, and recordkeeping and program evaluation. These elements should be assessed regularly, with changes made to respond to changing conditions, OSHA says.

A large number of OSHA inspections in the healthcare setting occur because of complaints regarding lack of protections against workplace violence. In 2014, the agency did 35 inspections in response to such complaints; 25 of those were in a healthcare setting, with 12 specifically at hospitals. As a result, five citations were issued, all of which were in healthcare, including two at hospitals.

Last year, Brookdale University Hospital and Medical Center in Brooklyn, N.Y., was fined $78,000 after an OSHA inspection found 40 incidents of workplace violence between Feb. 7 and April 12. They included employees who were threatened or verbally or physically assaulted by patients and visitors or while breaking up fights between patients. In the worst attack, a nurse sustained severe brain injuries.

The bulk of the hospital’s fines came as a result of a willful violation—an intentional or voluntary disregard for laws meant to protect workers against hospital violence.

While data from IAHSS and the BLS show an increase in hospital violence, those national figures aren’t as important as what is happening at your own facility, says David LaRose, MS, CHPA, CPP, the president of IAHSS and director of safety, security, and emergency management at Lakeland Regional Medical Center in Florida.

“You have to do a vulnerability assessment, and you specifically have to look at your demographic,” he says. “You specifically have to look at what is the history and the culture of the facility” to determine a hospital’s specific risk factors.

Although it’s crucial that a hospital track its own statistics on violence, that’s not to say that incidents elsewhere are irrelevant.

“You also want to look at what’s happening in the real world,” he says. “Somebody else’s unfortunate (occurrence) is a learning experience for my system, so we can try to be proactively preventing that.”

Educate, Recognize, React

At Nemours, Dr. Pressel didn’t develop the training in response to a perceived rise in incidents there. It was apparent, he says, that deficiencies in readiness needed to be addressed.

In the Nemours program, every staff member with some level of patient care responsibility gets basic training in aggressive child emergencies: identifying these situations, responding appropriately, and keeping safe. This group includes doctors, nurses, and nurse’s aids. The training involves actually playing out scenarios of violence, with staff members attempting to subdue a would-be attacker.

Depending on the job, each worker receives extra training that is specific to the role he or she would play in handling violent scenarios.

The training is designed to help individuals respond to such situations with “the same alacrity and acuity as they would respond to a Code Blue,” Dr. Pressel says. “Drop what you’re doing and run. These events are dangerous. That’s what they teach people. They’re dangerous and they’re scary and they’re chaotic, just like a Code Blue. That’s how people need to treat it.”

The goal is to de-escalate a situation, verbally or physically, without more aggressive means. But if that doesn’t work, physical restraints, medication, or both are used.

Throughout the medical field, training in this area is scarce, Dr. Pressel says. In nursing school and medical school, “for the most part, it’s zero,” he says.

“If you’re in a psychiatric facility, these events happen,” he adds. “And then you get a lot of enhanced training.” But, he notes, “I had no formal training until I became tasked with dealing with this.”

Since the program was implemented at Nemours, it seems to have worked.

“We have had many of these episodes that have been resolved by verbal de-escalation, as opposed to physical restraints or medication,” he says.

His hospital has also made other changes. The facility used to have multiple entrances and exits that were unsecured, and anybody could walk into any unit “with no challenge whatsoever.” Now, everyone entering has to pass hospital personnel. And, to get into a patient unit, visitors have to check in and be issued a photo ID. Also, in response to an incident in 2013, the hospital now has “constables” who are trained and licensed to carry firearms, Dr. Pressel says.

Above all, he notes, is personal safety. If you yourself are hurt, you won’t be able to help anyone else.

“That’s absolutely the first thing that people hear, the last thing that people hear, and it’s repeated over and over again,” he says.

Both Dr. Pressel and LaRose say that even with the drumbeat of high profile incidents, they haven’t heard from colleagues that health professionals are concerned about people losing interest in entering the field or are feeling burned out because of safety concerns. Being prepared is the key, and the level of preparedness varies by facility, LaRose says. The IAHSS provides security and healthcare safety guidelines at iahss.org.

“We recognize that we are in an occupation that tends to be on the receiving end of more aggression and more violence than the average worker,” LaRose says. “Therefore, how proactively does the organization or the institution take that knowledge and provide the tools and the training to the staff?

“What can we do as a team to increase our sense of security and safety and make this a great place to continue your career?”

Tom Collins is a freelance writer in South Florida.

Hospitalists could hardly be faulted for wondering: Am I safe? After all, the inpatient setting can be a tense place, and it’s where hospitalists work day in and day out.

David Pressel, MD, PhD, FHM, a pediatric hospitalist and medical director of inpatient services at Nemours Children’s Health System, which has locations in Delaware, New Jersey, Pennsylvania, and Florida, says it’s no wonder violence can erupt in the hospital setting.

“Violence is an issue in hospitals that is a reflection of our society, unfortunately,” says Dr. Pressel, a member of Team Hospitalist. “And it happens because these are very stressful places where people’s behavior can get outside the norm given the stress of the problems.”

Dr. Pressel, in collaboration with many others, has developed a workplace violence prevention program at Nemours aimed at de-escalating situations to avoid physical violence. The program teaches providers how to respond when something violent does happen. It’s a tiered training regimen that involves more training for those most involved in handling violent situations.

Dr. Pressel is no stranger to violence himself. Although he is a pediatric hospitalist and his patients are younger, some adolescent patients can have the physical presence of adults and pose just as serious a threat. He said that before the training program was put into place about a year ago, an episode of violence every month or two would require a patient to be placed in restraints.

“Staff has been hurt,” he explains. “I’ve been bitten twice by a patient. I have a scar on my arm that will be with me for life from one episode.”

A Slow, Disheartening, Upward Trend

Whether violence in hospitals and medical facilities is really a growing problem—or whether awareness of the issue is simply greater given these recent, high profile incidents—is not entirely known.

But according to the latest figures available from the Bureau of Labor Statistics (BLS), provided by the Occupational Safety and Health Administration (OSHA), violent incidents in hospitals did appear to be on the rise through 2013. The number of hospital assaults rose from 5,030 in 2011 to 5,500 in 2012 to 5,660 in 2013.

The number of assaults rose across all private sector industries over that span, but the percentage of those assaults that occurred in hospitals grew greater during that time—an indication that hospitals might be getting more violent at a faster pace than other workplaces. In 2011, according to BLS data, 21.4% of all assaults in private sector industries occurred in hospitals. That number rose to 21.8% in 2012 and to 22.1% in 2013.

According to the 2014 Healthcare Crime Survey, published by the International Association for Healthcare Security and Safety (IAHSS)—an organization of hospital security officials and administrators—violent crime at U.S. facilities rose from two incidents per 100 beds in 2012 to 2.5 incidents per 100 beds in 2013. That category includes murder, rape, aggravated assault, and robbery.

Assaults rose from 10.7 incidents per 100 beds in 2012 to 11.1 incidents per 100 beds in 2013.

BLS data also show that more injuries in hospitals are due to assaults compared with the private sector overall. In 2011, 2.6% of all private sector injuries were due to assault; in 2012, the number rose to 2.8%; and, in 2013, it was 2.8%. In hospitals in 2011, 8.6% of all injuries resulted from assaults. That percentage rose to 9.5% in 2012 and to 9.8% in 2013.

“BLS data show that nonfatal injuries due to violence are greater in the healthcare/social assistance setting than in other workplaces,” an OSHA spokesperson says. “Assaults represent a serious safety and health hazard within healthcare, and data indicate that hospitals comprise a large percentage of workplace assaults.”

Incident Prevention

Programs aimed at preventing violence can reduce these incidents.

“How well prepared hospital workers are in dealing with violent situations depends on the workplace violence prevention program implemented at a facility,” the OSHA spokesperson says. “Some states have passed legislation that specifically requires workplace violence prevention programs in the healthcare setting.”

These programs should address management commitment and employee participation, worksite analysis, hazard prevention and control, safety and health training, and recordkeeping and program evaluation. These elements should be assessed regularly, with changes made to respond to changing conditions, OSHA says.

A large number of OSHA inspections in the healthcare setting occur because of complaints regarding lack of protections against workplace violence. In 2014, the agency did 35 inspections in response to such complaints; 25 of those were in a healthcare setting, with 12 specifically at hospitals. As a result, five citations were issued, all of which were in healthcare, including two at hospitals.

Last year, Brookdale University Hospital and Medical Center in Brooklyn, N.Y., was fined $78,000 after an OSHA inspection found 40 incidents of workplace violence between Feb. 7 and April 12. They included employees who were threatened or verbally or physically assaulted by patients and visitors or while breaking up fights between patients. In the worst attack, a nurse sustained severe brain injuries.

The bulk of the hospital’s fines came as a result of a willful violation—an intentional or voluntary disregard for laws meant to protect workers against hospital violence.

While data from IAHSS and the BLS show an increase in hospital violence, those national figures aren’t as important as what is happening at your own facility, says David LaRose, MS, CHPA, CPP, the president of IAHSS and director of safety, security, and emergency management at Lakeland Regional Medical Center in Florida.

“You have to do a vulnerability assessment, and you specifically have to look at your demographic,” he says. “You specifically have to look at what is the history and the culture of the facility” to determine a hospital’s specific risk factors.

Although it’s crucial that a hospital track its own statistics on violence, that’s not to say that incidents elsewhere are irrelevant.

“You also want to look at what’s happening in the real world,” he says. “Somebody else’s unfortunate (occurrence) is a learning experience for my system, so we can try to be proactively preventing that.”

Educate, Recognize, React

At Nemours, Dr. Pressel didn’t develop the training in response to a perceived rise in incidents there. It was apparent, he says, that deficiencies in readiness needed to be addressed.

In the Nemours program, every staff member with some level of patient care responsibility gets basic training in aggressive child emergencies: identifying these situations, responding appropriately, and keeping safe. This group includes doctors, nurses, and nurse’s aids. The training involves actually playing out scenarios of violence, with staff members attempting to subdue a would-be attacker.

Depending on the job, each worker receives extra training that is specific to the role he or she would play in handling violent scenarios.

The training is designed to help individuals respond to such situations with “the same alacrity and acuity as they would respond to a Code Blue,” Dr. Pressel says. “Drop what you’re doing and run. These events are dangerous. That’s what they teach people. They’re dangerous and they’re scary and they’re chaotic, just like a Code Blue. That’s how people need to treat it.”

The goal is to de-escalate a situation, verbally or physically, without more aggressive means. But if that doesn’t work, physical restraints, medication, or both are used.

Throughout the medical field, training in this area is scarce, Dr. Pressel says. In nursing school and medical school, “for the most part, it’s zero,” he says.

“If you’re in a psychiatric facility, these events happen,” he adds. “And then you get a lot of enhanced training.” But, he notes, “I had no formal training until I became tasked with dealing with this.”

Since the program was implemented at Nemours, it seems to have worked.

“We have had many of these episodes that have been resolved by verbal de-escalation, as opposed to physical restraints or medication,” he says.

His hospital has also made other changes. The facility used to have multiple entrances and exits that were unsecured, and anybody could walk into any unit “with no challenge whatsoever.” Now, everyone entering has to pass hospital personnel. And, to get into a patient unit, visitors have to check in and be issued a photo ID. Also, in response to an incident in 2013, the hospital now has “constables” who are trained and licensed to carry firearms, Dr. Pressel says.

Above all, he notes, is personal safety. If you yourself are hurt, you won’t be able to help anyone else.

“That’s absolutely the first thing that people hear, the last thing that people hear, and it’s repeated over and over again,” he says.

Both Dr. Pressel and LaRose say that even with the drumbeat of high profile incidents, they haven’t heard from colleagues that health professionals are concerned about people losing interest in entering the field or are feeling burned out because of safety concerns. Being prepared is the key, and the level of preparedness varies by facility, LaRose says. The IAHSS provides security and healthcare safety guidelines at iahss.org.

“We recognize that we are in an occupation that tends to be on the receiving end of more aggression and more violence than the average worker,” LaRose says. “Therefore, how proactively does the organization or the institution take that knowledge and provide the tools and the training to the staff?

“What can we do as a team to increase our sense of security and safety and make this a great place to continue your career?”

Tom Collins is a freelance writer in South Florida.

Hospitalists could hardly be faulted for wondering: Am I safe? After all, the inpatient setting can be a tense place, and it’s where hospitalists work day in and day out.

David Pressel, MD, PhD, FHM, a pediatric hospitalist and medical director of inpatient services at Nemours Children’s Health System, which has locations in Delaware, New Jersey, Pennsylvania, and Florida, says it’s no wonder violence can erupt in the hospital setting.

“Violence is an issue in hospitals that is a reflection of our society, unfortunately,” says Dr. Pressel, a member of Team Hospitalist. “And it happens because these are very stressful places where people’s behavior can get outside the norm given the stress of the problems.”

Dr. Pressel, in collaboration with many others, has developed a workplace violence prevention program at Nemours aimed at de-escalating situations to avoid physical violence. The program teaches providers how to respond when something violent does happen. It’s a tiered training regimen that involves more training for those most involved in handling violent situations.

Dr. Pressel is no stranger to violence himself. Although he is a pediatric hospitalist and his patients are younger, some adolescent patients can have the physical presence of adults and pose just as serious a threat. He said that before the training program was put into place about a year ago, an episode of violence every month or two would require a patient to be placed in restraints.

“Staff has been hurt,” he explains. “I’ve been bitten twice by a patient. I have a scar on my arm that will be with me for life from one episode.”

A Slow, Disheartening, Upward Trend

Whether violence in hospitals and medical facilities is really a growing problem—or whether awareness of the issue is simply greater given these recent, high profile incidents—is not entirely known.

But according to the latest figures available from the Bureau of Labor Statistics (BLS), provided by the Occupational Safety and Health Administration (OSHA), violent incidents in hospitals did appear to be on the rise through 2013. The number of hospital assaults rose from 5,030 in 2011 to 5,500 in 2012 to 5,660 in 2013.

The number of assaults rose across all private sector industries over that span, but the percentage of those assaults that occurred in hospitals grew greater during that time—an indication that hospitals might be getting more violent at a faster pace than other workplaces. In 2011, according to BLS data, 21.4% of all assaults in private sector industries occurred in hospitals. That number rose to 21.8% in 2012 and to 22.1% in 2013.

According to the 2014 Healthcare Crime Survey, published by the International Association for Healthcare Security and Safety (IAHSS)—an organization of hospital security officials and administrators—violent crime at U.S. facilities rose from two incidents per 100 beds in 2012 to 2.5 incidents per 100 beds in 2013. That category includes murder, rape, aggravated assault, and robbery.

Assaults rose from 10.7 incidents per 100 beds in 2012 to 11.1 incidents per 100 beds in 2013.

BLS data also show that more injuries in hospitals are due to assaults compared with the private sector overall. In 2011, 2.6% of all private sector injuries were due to assault; in 2012, the number rose to 2.8%; and, in 2013, it was 2.8%. In hospitals in 2011, 8.6% of all injuries resulted from assaults. That percentage rose to 9.5% in 2012 and to 9.8% in 2013.

“BLS data show that nonfatal injuries due to violence are greater in the healthcare/social assistance setting than in other workplaces,” an OSHA spokesperson says. “Assaults represent a serious safety and health hazard within healthcare, and data indicate that hospitals comprise a large percentage of workplace assaults.”

Incident Prevention

Programs aimed at preventing violence can reduce these incidents.

“How well prepared hospital workers are in dealing with violent situations depends on the workplace violence prevention program implemented at a facility,” the OSHA spokesperson says. “Some states have passed legislation that specifically requires workplace violence prevention programs in the healthcare setting.”

These programs should address management commitment and employee participation, worksite analysis, hazard prevention and control, safety and health training, and recordkeeping and program evaluation. These elements should be assessed regularly, with changes made to respond to changing conditions, OSHA says.

A large number of OSHA inspections in the healthcare setting occur because of complaints regarding lack of protections against workplace violence. In 2014, the agency did 35 inspections in response to such complaints; 25 of those were in a healthcare setting, with 12 specifically at hospitals. As a result, five citations were issued, all of which were in healthcare, including two at hospitals.

Last year, Brookdale University Hospital and Medical Center in Brooklyn, N.Y., was fined $78,000 after an OSHA inspection found 40 incidents of workplace violence between Feb. 7 and April 12. They included employees who were threatened or verbally or physically assaulted by patients and visitors or while breaking up fights between patients. In the worst attack, a nurse sustained severe brain injuries.

The bulk of the hospital’s fines came as a result of a willful violation—an intentional or voluntary disregard for laws meant to protect workers against hospital violence.

While data from IAHSS and the BLS show an increase in hospital violence, those national figures aren’t as important as what is happening at your own facility, says David LaRose, MS, CHPA, CPP, the president of IAHSS and director of safety, security, and emergency management at Lakeland Regional Medical Center in Florida.

“You have to do a vulnerability assessment, and you specifically have to look at your demographic,” he says. “You specifically have to look at what is the history and the culture of the facility” to determine a hospital’s specific risk factors.

Although it’s crucial that a hospital track its own statistics on violence, that’s not to say that incidents elsewhere are irrelevant.

“You also want to look at what’s happening in the real world,” he says. “Somebody else’s unfortunate (occurrence) is a learning experience for my system, so we can try to be proactively preventing that.”

Educate, Recognize, React

At Nemours, Dr. Pressel didn’t develop the training in response to a perceived rise in incidents there. It was apparent, he says, that deficiencies in readiness needed to be addressed.

In the Nemours program, every staff member with some level of patient care responsibility gets basic training in aggressive child emergencies: identifying these situations, responding appropriately, and keeping safe. This group includes doctors, nurses, and nurse’s aids. The training involves actually playing out scenarios of violence, with staff members attempting to subdue a would-be attacker.

Depending on the job, each worker receives extra training that is specific to the role he or she would play in handling violent scenarios.

The training is designed to help individuals respond to such situations with “the same alacrity and acuity as they would respond to a Code Blue,” Dr. Pressel says. “Drop what you’re doing and run. These events are dangerous. That’s what they teach people. They’re dangerous and they’re scary and they’re chaotic, just like a Code Blue. That’s how people need to treat it.”

The goal is to de-escalate a situation, verbally or physically, without more aggressive means. But if that doesn’t work, physical restraints, medication, or both are used.

Throughout the medical field, training in this area is scarce, Dr. Pressel says. In nursing school and medical school, “for the most part, it’s zero,” he says.

“If you’re in a psychiatric facility, these events happen,” he adds. “And then you get a lot of enhanced training.” But, he notes, “I had no formal training until I became tasked with dealing with this.”

Since the program was implemented at Nemours, it seems to have worked.

“We have had many of these episodes that have been resolved by verbal de-escalation, as opposed to physical restraints or medication,” he says.

His hospital has also made other changes. The facility used to have multiple entrances and exits that were unsecured, and anybody could walk into any unit “with no challenge whatsoever.” Now, everyone entering has to pass hospital personnel. And, to get into a patient unit, visitors have to check in and be issued a photo ID. Also, in response to an incident in 2013, the hospital now has “constables” who are trained and licensed to carry firearms, Dr. Pressel says.

Above all, he notes, is personal safety. If you yourself are hurt, you won’t be able to help anyone else.

“That’s absolutely the first thing that people hear, the last thing that people hear, and it’s repeated over and over again,” he says.

Both Dr. Pressel and LaRose say that even with the drumbeat of high profile incidents, they haven’t heard from colleagues that health professionals are concerned about people losing interest in entering the field or are feeling burned out because of safety concerns. Being prepared is the key, and the level of preparedness varies by facility, LaRose says. The IAHSS provides security and healthcare safety guidelines at iahss.org.

“We recognize that we are in an occupation that tends to be on the receiving end of more aggression and more violence than the average worker,” LaRose says. “Therefore, how proactively does the organization or the institution take that knowledge and provide the tools and the training to the staff?

“What can we do as a team to increase our sense of security and safety and make this a great place to continue your career?”

Tom Collins is a freelance writer in South Florida.