On general medical wards, effective interprofessional communication is essential for high-quality patient care. Hospitals increasingly adopt secure text-messaging systems for healthcare team members to communicate with physicians in lieu of paging.^1-3 Text messages facilitate bidirectional communication^4,5 and increase perceived efficiency^6-8 and are thus preferred over paging by nurses and trainees. However, this novel technology unintentionally causes high volumes of interruptions.^9,10 Compared to paging, sending text messages and calling smartphones are more convenient and encourage communication of issues in real time, regardless of urgency.¹¹ Interrupting messages are often perceived as nonurgent by physicians.^6,12 In particular, 73%-93% of pages or messages sent to physicians are found to be nonurgent.^13-17

Pages, text messages, or calls not only interrupt day-to-day tasks on the ward^{6,7,10,11,17,18} but also educational sessions,^18-21 which are essential to the clinical teaching unit (CTU). Interruptions reduce learning and retention²² and are disruptive to the medical learning climate.^18-20,23

Internal medicine CTUs at our large urban academic hospital network utilize a smartphone-based text messaging tool for interdisciplinary communication. Nonurgent interruptions are frequent during educational seminars, which occur at our institution between 8 AM and 9 AM and 12 PM and 1 PM on weekdays.^10,11,19 In a preliminary analysis at one hospital site, an average of three text messages (range 1-11), 2 calls (range 0-8), and 3 emails (range 0-13) interrupted each educational session. Physicians and nurses can disagree on the urgency of messages or calls for the purposes of patient care and workflow.^6,11,12,24 Nurses have expressed a desire for guidance regarding what constitutes an urgent clinical communication.⁶

This project aimed to reduce nonurgent text message interruptions during educational rounds. We hypothesized that improved decision support around clinical prioritization and reminders about educational hours could reduce unnecessary interruptions.

This study was approved by the institution’s Research Ethics Board and conducted across 8 general medical CTU teams at an academic hospital network (Sites 1 and 2). Each CTU team provides 24-hour coverage of approximately 20–28 patients. The most responsible resident from each team carries an institution-provided smartphone, which receives secure texts, phone calls, and emails from nurses, social workers, physiotherapists, speech language pathologists, dieticians, pharmacists, and other physicians. Close collaboration with the platform developer permitted changes to be made to the system when needed. Prior to our interventions, a nurse could send a text message as either an “immediate interrupt” or a “delayed interrupt” message. Messages sent via the “delayed interrupt” option would be added to a queue and would eventually lead to an interrupting message if not replied to after a defined period. Direct phone calls were reserved for especially urgent or emergent communications.

Meetings were held with physicians and nursing managers at Site 1 (August 2014) and Site 2 (January 2015) to establish consensus on the communication process and determine clinical scenarios, regardless of time of day, that warrant a phone call, an “immediate interrupt” text, or a “delayed interrupt” text. In March 2015, resident feedback led to the addition of a third option to the sender interface. This option allowed messages to be sent as “For Your Information (FYI)” only, which would not lead to an interruption. “FYI” messages (for example, to notify that an ambulance had been booked for a patient), were instead placed in an electronic message board that could be viewed by the resident through the application. This change relied upon interdisciplinary trust and a commitment from residents to ensure that “FYI” messages were reviewed regularly.

Sequential interventions over a 36-month period were associated with reduced nonurgent text message interruptions during educational hours. A clinical communication process was formally defined to accurately match message urgency with communication modality. A “noninterrupt” option allowed nonurgent text messages to be posted to an electronic message board, rather than causing real-time interruption, thereby reducing the overall volume of interrupting text messages. Modifying the interface to alert potential senders to protected educational hours was associated with reductions in educational interruptions. Through a blinded analysis of the text message content between 2014 and 2016, we determined that nonurgent educational interruptions were significantly reduced, and the number of urgent communications remained constant. Reduced nonurgent interruptions have the potential to improve the learning climate on the medical teaching unit during protected educational hours.

At baseline, 82% of the sampled text messages sent during educational hours across both sites were considered nonurgent. The estimated proportion of urgent messages varies in the literature (5%-34%)^13-18 possibly due to center-specific methods of defining and measuring urgent messages. For example, different assessor training backgrounds, different numbers of assessors, and varying institutional policies are described.^13-17 We considered an urgent message to require a response or action within 1 hour or to represent an established “critical lab value” as per the institution. The high proportion of nonurgent interruptions found in this study and other works demonstrates the widespread nature of this problem within inpatient hospital settings; this phenomenon could potentially lead to unintended consequences on efficiency and medical education.

Few other initiatives have aimed to reduce interruptions to medical trainees during educational sessions. At one center, replacing numeric pagers with alphanumeric pagers decreased the need to return pages during educational sessions but did not decrease the overall number of pages.²¹ Another center implemented an inbox tool that reduced daytime nonurgent numeric pages.¹⁵ Similar to our center’s previous experience,¹¹ the total number of communications increased with the creation of the inbox tool.¹⁵ Unexpectedly, the introduction of an “FYI” option for senders in March 2015 did not increase the total number of messages.

Increasing use of text messages for communication between physicians and allied health professions has resulted in higher volumes of interruptions compared with conventional paging.^6,7,9 Excessive interruptions create a “crisis mode” work climate,¹⁰ which could compromise patient safety^25-27 and hamper trainees’ attainment of educational objectives.^18-20,23 During educational sessions, audible text, phone call, and email interruptions disrupt all learners in addition to the resident receiving the message. The creation of the “FYI” message option in March 2015 was associated with reduced overall daily interruptions, which may improve efficiency in residents’ clinical duties^17,18 and minimize multi-tasking that could lead to errors.²⁸ However, adding a real-time notification during educational hours (March 2016, modified June 2016) exerted the greatest impact specifically on educational interruptions. Engaging physicians in the creation and ongoing modification of instant-messaging interfaces can help customize technology to meet the needs of users.^15,29 Our work provides a strategy for improving communication between nurses and physicians in a teaching hospital setting, by achieving consensus on levels of urgency of different messages, providing a non-interrupting message option, and providing nurses with real-time information about educational hours.

Potential unintended consequences of the interventions require consideration. Discouraging interruptions may have reduced urgent patient care communications but were mitigated by enabling senders to ignore/override interruption warnings. We did not observe an increase in the number of overall calls to team devices, “Code Blues,” or critical care team consultations. However, we found that a very small (2%) but important group of “FYI” messages should have been sent as urgent interrupting messages, thereby underscoring the necessity for continuous feedback to senders on the clinical communication process.

Our study has limitations. Although educational interruptions can cause fragmented learning at our institution,¹⁹ the impact of reduced interruptions on the quality of educational sessions can only be inferred because we did not formally assess resident or staff physician perceptions on this outcome during the interventions. Moreover, we were unable to quantify interruptions received through personal smartphones, a frequent method of physician-physician communication.³⁰ Phone calls are the most intrusive of interruptions but were not the focus of interventions. Future work must consider documenting perceived appropriateness of calls in real time, similar to previous studies assessing paging urgency.^13,14,18 Biased ranking of message urgency was minimized by utilizing 3 independent adjudicators blinded to message date throughout the adjudication process and by applying established communication guidelines where available. Nevertheless, retrospective assessment of message urgency could be limited by a lack of clinical context, which may have been more apparent to the original sender and the recipient. Finally, at our center, a close relationship with the communication platform programmer made sequential modifications possible, while other institutions may have limited ability to make such changes. A different approach may be useful in some cases, such as modifying academic teaching times to limit interruptions.²³

In a large academic center, a high number of interrupting smartphone messages cause unnecessary distractions and reduce learning during educational hours. “Nonurgent” educational interruptions were reduced through successive improvement cycles, and ultimately by modifying the program interface to alert senders of educational hours. Further reduction in interruptions and sustainability may be achieved by studying phone call interruptions and by formalizing audit and feedback of sender’s adherence to standardized clinical communication methods.

Dr. Wu is supported by an award from the Mak Pak Chiu and Mak-Soo Lai Hing Chair in General Internal Medicine, University of Toronto. The authors would like to acknowledge Jason Uppal for his ongoing contribution to the improvement of clinical text message communications at our institution.

Disclosures

The authors have nothing to disclose.

On general medical wards, effective interprofessional communication is essential for high-quality patient care. Hospitals increasingly adopt secure text-messaging systems for healthcare team members to communicate with physicians in lieu of paging.^1-3 Text messages facilitate bidirectional communication^4,5 and increase perceived efficiency^6-8 and are thus preferred over paging by nurses and trainees. However, this novel technology unintentionally causes high volumes of interruptions.^9,10 Compared to paging, sending text messages and calling smartphones are more convenient and encourage communication of issues in real time, regardless of urgency.¹¹ Interrupting messages are often perceived as nonurgent by physicians.^6,12 In particular, 73%-93% of pages or messages sent to physicians are found to be nonurgent.^13-17

Pages, text messages, or calls not only interrupt day-to-day tasks on the ward^{6,7,10,11,17,18} but also educational sessions,^18-21 which are essential to the clinical teaching unit (CTU). Interruptions reduce learning and retention²² and are disruptive to the medical learning climate.^18-20,23

Internal medicine CTUs at our large urban academic hospital network utilize a smartphone-based text messaging tool for interdisciplinary communication. Nonurgent interruptions are frequent during educational seminars, which occur at our institution between 8 AM and 9 AM and 12 PM and 1 PM on weekdays.^10,11,19 In a preliminary analysis at one hospital site, an average of three text messages (range 1-11), 2 calls (range 0-8), and 3 emails (range 0-13) interrupted each educational session. Physicians and nurses can disagree on the urgency of messages or calls for the purposes of patient care and workflow.^6,11,12,24 Nurses have expressed a desire for guidance regarding what constitutes an urgent clinical communication.⁶

This project aimed to reduce nonurgent text message interruptions during educational rounds. We hypothesized that improved decision support around clinical prioritization and reminders about educational hours could reduce unnecessary interruptions.

This study was approved by the institution’s Research Ethics Board and conducted across 8 general medical CTU teams at an academic hospital network (Sites 1 and 2). Each CTU team provides 24-hour coverage of approximately 20–28 patients. The most responsible resident from each team carries an institution-provided smartphone, which receives secure texts, phone calls, and emails from nurses, social workers, physiotherapists, speech language pathologists, dieticians, pharmacists, and other physicians. Close collaboration with the platform developer permitted changes to be made to the system when needed. Prior to our interventions, a nurse could send a text message as either an “immediate interrupt” or a “delayed interrupt” message. Messages sent via the “delayed interrupt” option would be added to a queue and would eventually lead to an interrupting message if not replied to after a defined period. Direct phone calls were reserved for especially urgent or emergent communications.

Meetings were held with physicians and nursing managers at Site 1 (August 2014) and Site 2 (January 2015) to establish consensus on the communication process and determine clinical scenarios, regardless of time of day, that warrant a phone call, an “immediate interrupt” text, or a “delayed interrupt” text. In March 2015, resident feedback led to the addition of a third option to the sender interface. This option allowed messages to be sent as “For Your Information (FYI)” only, which would not lead to an interruption. “FYI” messages (for example, to notify that an ambulance had been booked for a patient), were instead placed in an electronic message board that could be viewed by the resident through the application. This change relied upon interdisciplinary trust and a commitment from residents to ensure that “FYI” messages were reviewed regularly.

Sequential interventions over a 36-month period were associated with reduced nonurgent text message interruptions during educational hours. A clinical communication process was formally defined to accurately match message urgency with communication modality. A “noninterrupt” option allowed nonurgent text messages to be posted to an electronic message board, rather than causing real-time interruption, thereby reducing the overall volume of interrupting text messages. Modifying the interface to alert potential senders to protected educational hours was associated with reductions in educational interruptions. Through a blinded analysis of the text message content between 2014 and 2016, we determined that nonurgent educational interruptions were significantly reduced, and the number of urgent communications remained constant. Reduced nonurgent interruptions have the potential to improve the learning climate on the medical teaching unit during protected educational hours.

At baseline, 82% of the sampled text messages sent during educational hours across both sites were considered nonurgent. The estimated proportion of urgent messages varies in the literature (5%-34%)^13-18 possibly due to center-specific methods of defining and measuring urgent messages. For example, different assessor training backgrounds, different numbers of assessors, and varying institutional policies are described.^13-17 We considered an urgent message to require a response or action within 1 hour or to represent an established “critical lab value” as per the institution. The high proportion of nonurgent interruptions found in this study and other works demonstrates the widespread nature of this problem within inpatient hospital settings; this phenomenon could potentially lead to unintended consequences on efficiency and medical education.

Few other initiatives have aimed to reduce interruptions to medical trainees during educational sessions. At one center, replacing numeric pagers with alphanumeric pagers decreased the need to return pages during educational sessions but did not decrease the overall number of pages.²¹ Another center implemented an inbox tool that reduced daytime nonurgent numeric pages.¹⁵ Similar to our center’s previous experience,¹¹ the total number of communications increased with the creation of the inbox tool.¹⁵ Unexpectedly, the introduction of an “FYI” option for senders in March 2015 did not increase the total number of messages.

Increasing use of text messages for communication between physicians and allied health professions has resulted in higher volumes of interruptions compared with conventional paging.^6,7,9 Excessive interruptions create a “crisis mode” work climate,¹⁰ which could compromise patient safety^25-27 and hamper trainees’ attainment of educational objectives.^18-20,23 During educational sessions, audible text, phone call, and email interruptions disrupt all learners in addition to the resident receiving the message. The creation of the “FYI” message option in March 2015 was associated with reduced overall daily interruptions, which may improve efficiency in residents’ clinical duties^17,18 and minimize multi-tasking that could lead to errors.²⁸ However, adding a real-time notification during educational hours (March 2016, modified June 2016) exerted the greatest impact specifically on educational interruptions. Engaging physicians in the creation and ongoing modification of instant-messaging interfaces can help customize technology to meet the needs of users.^15,29 Our work provides a strategy for improving communication between nurses and physicians in a teaching hospital setting, by achieving consensus on levels of urgency of different messages, providing a non-interrupting message option, and providing nurses with real-time information about educational hours.

Potential unintended consequences of the interventions require consideration. Discouraging interruptions may have reduced urgent patient care communications but were mitigated by enabling senders to ignore/override interruption warnings. We did not observe an increase in the number of overall calls to team devices, “Code Blues,” or critical care team consultations. However, we found that a very small (2%) but important group of “FYI” messages should have been sent as urgent interrupting messages, thereby underscoring the necessity for continuous feedback to senders on the clinical communication process.

Our study has limitations. Although educational interruptions can cause fragmented learning at our institution,¹⁹ the impact of reduced interruptions on the quality of educational sessions can only be inferred because we did not formally assess resident or staff physician perceptions on this outcome during the interventions. Moreover, we were unable to quantify interruptions received through personal smartphones, a frequent method of physician-physician communication.³⁰ Phone calls are the most intrusive of interruptions but were not the focus of interventions. Future work must consider documenting perceived appropriateness of calls in real time, similar to previous studies assessing paging urgency.^13,14,18 Biased ranking of message urgency was minimized by utilizing 3 independent adjudicators blinded to message date throughout the adjudication process and by applying established communication guidelines where available. Nevertheless, retrospective assessment of message urgency could be limited by a lack of clinical context, which may have been more apparent to the original sender and the recipient. Finally, at our center, a close relationship with the communication platform programmer made sequential modifications possible, while other institutions may have limited ability to make such changes. A different approach may be useful in some cases, such as modifying academic teaching times to limit interruptions.²³

In a large academic center, a high number of interrupting smartphone messages cause unnecessary distractions and reduce learning during educational hours. “Nonurgent” educational interruptions were reduced through successive improvement cycles, and ultimately by modifying the program interface to alert senders of educational hours. Further reduction in interruptions and sustainability may be achieved by studying phone call interruptions and by formalizing audit and feedback of sender’s adherence to standardized clinical communication methods.

Dr. Wu is supported by an award from the Mak Pak Chiu and Mak-Soo Lai Hing Chair in General Internal Medicine, University of Toronto. The authors would like to acknowledge Jason Uppal for his ongoing contribution to the improvement of clinical text message communications at our institution.

Disclosures

The authors have nothing to disclose.

On general medical wards, effective interprofessional communication is essential for high-quality patient care. Hospitals increasingly adopt secure text-messaging systems for healthcare team members to communicate with physicians in lieu of paging.^1-3 Text messages facilitate bidirectional communication^4,5 and increase perceived efficiency^6-8 and are thus preferred over paging by nurses and trainees. However, this novel technology unintentionally causes high volumes of interruptions.^9,10 Compared to paging, sending text messages and calling smartphones are more convenient and encourage communication of issues in real time, regardless of urgency.¹¹ Interrupting messages are often perceived as nonurgent by physicians.^6,12 In particular, 73%-93% of pages or messages sent to physicians are found to be nonurgent.^13-17

Pages, text messages, or calls not only interrupt day-to-day tasks on the ward^{6,7,10,11,17,18} but also educational sessions,^18-21 which are essential to the clinical teaching unit (CTU). Interruptions reduce learning and retention²² and are disruptive to the medical learning climate.^18-20,23

Internal medicine CTUs at our large urban academic hospital network utilize a smartphone-based text messaging tool for interdisciplinary communication. Nonurgent interruptions are frequent during educational seminars, which occur at our institution between 8 AM and 9 AM and 12 PM and 1 PM on weekdays.^10,11,19 In a preliminary analysis at one hospital site, an average of three text messages (range 1-11), 2 calls (range 0-8), and 3 emails (range 0-13) interrupted each educational session. Physicians and nurses can disagree on the urgency of messages or calls for the purposes of patient care and workflow.^6,11,12,24 Nurses have expressed a desire for guidance regarding what constitutes an urgent clinical communication.⁶

This project aimed to reduce nonurgent text message interruptions during educational rounds. We hypothesized that improved decision support around clinical prioritization and reminders about educational hours could reduce unnecessary interruptions.

This study was approved by the institution’s Research Ethics Board and conducted across 8 general medical CTU teams at an academic hospital network (Sites 1 and 2). Each CTU team provides 24-hour coverage of approximately 20–28 patients. The most responsible resident from each team carries an institution-provided smartphone, which receives secure texts, phone calls, and emails from nurses, social workers, physiotherapists, speech language pathologists, dieticians, pharmacists, and other physicians. Close collaboration with the platform developer permitted changes to be made to the system when needed. Prior to our interventions, a nurse could send a text message as either an “immediate interrupt” or a “delayed interrupt” message. Messages sent via the “delayed interrupt” option would be added to a queue and would eventually lead to an interrupting message if not replied to after a defined period. Direct phone calls were reserved for especially urgent or emergent communications.

Meetings were held with physicians and nursing managers at Site 1 (August 2014) and Site 2 (January 2015) to establish consensus on the communication process and determine clinical scenarios, regardless of time of day, that warrant a phone call, an “immediate interrupt” text, or a “delayed interrupt” text. In March 2015, resident feedback led to the addition of a third option to the sender interface. This option allowed messages to be sent as “For Your Information (FYI)” only, which would not lead to an interruption. “FYI” messages (for example, to notify that an ambulance had been booked for a patient), were instead placed in an electronic message board that could be viewed by the resident through the application. This change relied upon interdisciplinary trust and a commitment from residents to ensure that “FYI” messages were reviewed regularly.

Sequential interventions over a 36-month period were associated with reduced nonurgent text message interruptions during educational hours. A clinical communication process was formally defined to accurately match message urgency with communication modality. A “noninterrupt” option allowed nonurgent text messages to be posted to an electronic message board, rather than causing real-time interruption, thereby reducing the overall volume of interrupting text messages. Modifying the interface to alert potential senders to protected educational hours was associated with reductions in educational interruptions. Through a blinded analysis of the text message content between 2014 and 2016, we determined that nonurgent educational interruptions were significantly reduced, and the number of urgent communications remained constant. Reduced nonurgent interruptions have the potential to improve the learning climate on the medical teaching unit during protected educational hours.

At baseline, 82% of the sampled text messages sent during educational hours across both sites were considered nonurgent. The estimated proportion of urgent messages varies in the literature (5%-34%)^13-18 possibly due to center-specific methods of defining and measuring urgent messages. For example, different assessor training backgrounds, different numbers of assessors, and varying institutional policies are described.^13-17 We considered an urgent message to require a response or action within 1 hour or to represent an established “critical lab value” as per the institution. The high proportion of nonurgent interruptions found in this study and other works demonstrates the widespread nature of this problem within inpatient hospital settings; this phenomenon could potentially lead to unintended consequences on efficiency and medical education.

Few other initiatives have aimed to reduce interruptions to medical trainees during educational sessions. At one center, replacing numeric pagers with alphanumeric pagers decreased the need to return pages during educational sessions but did not decrease the overall number of pages.²¹ Another center implemented an inbox tool that reduced daytime nonurgent numeric pages.¹⁵ Similar to our center’s previous experience,¹¹ the total number of communications increased with the creation of the inbox tool.¹⁵ Unexpectedly, the introduction of an “FYI” option for senders in March 2015 did not increase the total number of messages.

Increasing use of text messages for communication between physicians and allied health professions has resulted in higher volumes of interruptions compared with conventional paging.^6,7,9 Excessive interruptions create a “crisis mode” work climate,¹⁰ which could compromise patient safety^25-27 and hamper trainees’ attainment of educational objectives.^18-20,23 During educational sessions, audible text, phone call, and email interruptions disrupt all learners in addition to the resident receiving the message. The creation of the “FYI” message option in March 2015 was associated with reduced overall daily interruptions, which may improve efficiency in residents’ clinical duties^17,18 and minimize multi-tasking that could lead to errors.²⁸ However, adding a real-time notification during educational hours (March 2016, modified June 2016) exerted the greatest impact specifically on educational interruptions. Engaging physicians in the creation and ongoing modification of instant-messaging interfaces can help customize technology to meet the needs of users.^15,29 Our work provides a strategy for improving communication between nurses and physicians in a teaching hospital setting, by achieving consensus on levels of urgency of different messages, providing a non-interrupting message option, and providing nurses with real-time information about educational hours.

Potential unintended consequences of the interventions require consideration. Discouraging interruptions may have reduced urgent patient care communications but were mitigated by enabling senders to ignore/override interruption warnings. We did not observe an increase in the number of overall calls to team devices, “Code Blues,” or critical care team consultations. However, we found that a very small (2%) but important group of “FYI” messages should have been sent as urgent interrupting messages, thereby underscoring the necessity for continuous feedback to senders on the clinical communication process.

Our study has limitations. Although educational interruptions can cause fragmented learning at our institution,¹⁹ the impact of reduced interruptions on the quality of educational sessions can only be inferred because we did not formally assess resident or staff physician perceptions on this outcome during the interventions. Moreover, we were unable to quantify interruptions received through personal smartphones, a frequent method of physician-physician communication.³⁰ Phone calls are the most intrusive of interruptions but were not the focus of interventions. Future work must consider documenting perceived appropriateness of calls in real time, similar to previous studies assessing paging urgency.^13,14,18 Biased ranking of message urgency was minimized by utilizing 3 independent adjudicators blinded to message date throughout the adjudication process and by applying established communication guidelines where available. Nevertheless, retrospective assessment of message urgency could be limited by a lack of clinical context, which may have been more apparent to the original sender and the recipient. Finally, at our center, a close relationship with the communication platform programmer made sequential modifications possible, while other institutions may have limited ability to make such changes. A different approach may be useful in some cases, such as modifying academic teaching times to limit interruptions.²³

In a large academic center, a high number of interrupting smartphone messages cause unnecessary distractions and reduce learning during educational hours. “Nonurgent” educational interruptions were reduced through successive improvement cycles, and ultimately by modifying the program interface to alert senders of educational hours. Further reduction in interruptions and sustainability may be achieved by studying phone call interruptions and by formalizing audit and feedback of sender’s adherence to standardized clinical communication methods.

Dr. Wu is supported by an award from the Mak Pak Chiu and Mak-Soo Lai Hing Chair in General Internal Medicine, University of Toronto. The authors would like to acknowledge Jason Uppal for his ongoing contribution to the improvement of clinical text message communications at our institution.

Disclosures

The authors have nothing to disclose.

Hospital medicine has become the fastest growing medicine subspecialty, though no standardized hospitalist-focused educational program is required to become a practicing adult medicine hospitalist.¹ Historically, adult hospitalists have had little additional training beyond residency, yet, as residency training adapts to duty hour restrictions, patient caps, and increasing attending oversight, it is not clear if traditional rotations and curricula provide adequate preparation for independent practice as an adult hospitalist.^2-5 Several types of training and educational programs have emerged to fill this potential gap. These include hospital medicine fellowships, residency pathways, early career faculty development programs (eg, Society of Hospital Medicine/ Society of General Internal Medicine sponsored Academic Hospitalist Academy), and hospitalist-focused resident rotations.^6-10 These activities are intended to ensure that residents and early career physicians gain the skills and competencies required to effectively practice hospital medicine.

Hospital medicine fellowships, residency pathways, and faculty development have been described previously.^6-8 However, the prevalence and characteristics of hospital medicine-focused resident rotations are unknown, and these rotations are rarely publicized beyond local residency programs. Our study aims to determine the prevalence, purpose, and function of hospitalist-focused rotations within residency programs and explore the role these rotations have in preparing residents for a career in hospital medicine.

Study Design, Setting, and Participants

We conducted a cross-sectional study involving the largest 100 Accreditation Council for Graduate Medical Education (ACGME) internal medicine residency programs. We chose the largest programs as we hypothesized that these programs would be most likely to have the infrastructure to support hospital medicine focused rotations compared to smaller programs. The UCSF Committee on Human Research approved this study.

Survey Development

We developed a study-specific survey (the Hospitalist Elective National Survey [HENS]) to assess the prevalence, structure, curricular goals, and perceived benefits of distinct hospitalist rotations as defined by individual resident programs. The survey prompted respondents to consider a “hospitalist-focused” rotation as one that is different from a traditional inpatient “ward” rotation and whose emphasis is on hospitalist-specific training, clinical skills, or career development. The 18-question survey (Appendix 1) included fixed choice, multiple choice, and open-ended responses.

Data Collection

Using publicly available data from the ACGME website (www.acgme.org), we identified the largest 100 medicine programs based on the total number of residents. This included programs with 81 or more residents. An electronic survey was e-mailed to the leadership of each program. In May 2015, surveys were sent to Residency Program Directors (PD), and if they did not respond after 2 attempts, then Associate Program Directors (APD) were contacted twice. If both these leaders did not respond, then the survey was sent to residency program administrators or Hospital Medicine Division Chiefs. Only one survey was completed per site.

Data Analysis

We used descriptive statistics to summarize quantitative data. Responses to open-ended qualitative questions about the goals, strengths, and design of rotations were analyzed using thematic analysis.¹¹ During analysis, we iteratively developed and refined codes that identified important concepts that emerged from the data. Two members of the research team trained in qualitative data analysis coded these data independently (SL & JH).

Eighty-two residency program leaders (53 PD, 19 APD, 10 chiefs/admin) responded to the survey (82% total response rate). Among all responders, the prevalence of hospitalist-focused rotations was 50% (41/82). Of these 41 rotations, 85% (35/41) were elective rotations and 15% (6/41) were mandatory rotations. Hospitalist rotations ranged in existence from 1 to 15 years with a mean duration of 4.78 years (S.D. 3.5).

Of the 41 programs that did not have a hospital medicine-focused rotation, the key barriers identified were a lack of a well-defined model (29%), low faculty interest (15%), low resident interest (12%), and lack of funding (5%). Despite these barriers, 9 of these 41 programs (22%) stated they planned to start a rotation in the future – of which, 3 programs (7%) planned to start a rotation within the year.

The Hospital Elective National Survey provides insight into a growing component of hospitalist-focused training and preparation. Fifty percent of ACGME residency programs surveyed in this study had a hospitalist-focused rotation. Rotation characteristics were heterogeneous, perhaps reflecting both the homegrown nature of their development and the lack of national study or data to guide what constitutes an “ideal” rotation. Common functions of rotations included providing career mentorship and allowing for trainees to get experience “being a hospitalist.” Other key elements of the rotations included providing additional clinical autonomy and teaching material outside of traditional residency curricula such as quality improvement, patient safety, billing, and healthcare finances.

Prior research has explored other training for hospitalists such as fellowships, pathways, and faculty development.^6-8 A hospital medicine fellowship provides extensive training but without a practice requirement in adult medicine (as now exists in pediatric hospital medicine), the impact of fellowship training may be limited by its scale.^12,13 Longitudinal hospitalist residency pathways provide comprehensive skill development and often require an early career commitment from trainees.⁷ Faculty development can be another tool to foster career growth, though requires local investment from hospitalist groups that may not have the resources or experience to support this.⁸ Our study has highlighted that hospitalist-focused rotations within residency programs can train physicians for a career in hospital medicine. Hospitalist and residency leaders should consider that these rotations might be the only hospital medicine-focused training that new hospitalists will have. Given the variable nature of these rotations nationally, developing standards around core hospitalist competencies within these rotations should be a key component to career preparation and a goal for the field at large.^14,15

Our study has limitations. The survey focused only on internal medicine as it is the most common training background of hospitalists; however, the field has grown to include other specialties including pediatrics, neurology, family medicine, and surgery. In addition, the survey reviewed the largest ACGME Internal Medicine programs to best evaluate prevalence and content—it may be that some smaller programs have rotations with different characteristics that we have not captured. Lastly, the survey reviewed the rotations through the lens of residency program leadership and not trainees. A future survey of trainees or early career hospitalists who participated in these rotations could provide a better understanding of their achievements and effectiveness.

We anticipate that the demand for hospitalist-focused training will continue to grow as more residents in training seek to enter the specialty. Hospitalist and residency program leaders have an opportunity within residency training programs to build new or further develop existing hospital medicine-focused rotations. The HENS survey demonstrates that hospitalist-focused rotations are prevalent in residency education and have the potential to play an important role in hospitalist training.

Disclosure

The authors declare no conflicts of interest in relation to this manuscript.

Hospital medicine has become the fastest growing medicine subspecialty, though no standardized hospitalist-focused educational program is required to become a practicing adult medicine hospitalist.¹ Historically, adult hospitalists have had little additional training beyond residency, yet, as residency training adapts to duty hour restrictions, patient caps, and increasing attending oversight, it is not clear if traditional rotations and curricula provide adequate preparation for independent practice as an adult hospitalist.^2-5 Several types of training and educational programs have emerged to fill this potential gap. These include hospital medicine fellowships, residency pathways, early career faculty development programs (eg, Society of Hospital Medicine/ Society of General Internal Medicine sponsored Academic Hospitalist Academy), and hospitalist-focused resident rotations.^6-10 These activities are intended to ensure that residents and early career physicians gain the skills and competencies required to effectively practice hospital medicine.

Hospital medicine fellowships, residency pathways, and faculty development have been described previously.^6-8 However, the prevalence and characteristics of hospital medicine-focused resident rotations are unknown, and these rotations are rarely publicized beyond local residency programs. Our study aims to determine the prevalence, purpose, and function of hospitalist-focused rotations within residency programs and explore the role these rotations have in preparing residents for a career in hospital medicine.

Study Design, Setting, and Participants

We conducted a cross-sectional study involving the largest 100 Accreditation Council for Graduate Medical Education (ACGME) internal medicine residency programs. We chose the largest programs as we hypothesized that these programs would be most likely to have the infrastructure to support hospital medicine focused rotations compared to smaller programs. The UCSF Committee on Human Research approved this study.

Survey Development

We developed a study-specific survey (the Hospitalist Elective National Survey [HENS]) to assess the prevalence, structure, curricular goals, and perceived benefits of distinct hospitalist rotations as defined by individual resident programs. The survey prompted respondents to consider a “hospitalist-focused” rotation as one that is different from a traditional inpatient “ward” rotation and whose emphasis is on hospitalist-specific training, clinical skills, or career development. The 18-question survey (Appendix 1) included fixed choice, multiple choice, and open-ended responses.

Data Collection

Using publicly available data from the ACGME website (www.acgme.org), we identified the largest 100 medicine programs based on the total number of residents. This included programs with 81 or more residents. An electronic survey was e-mailed to the leadership of each program. In May 2015, surveys were sent to Residency Program Directors (PD), and if they did not respond after 2 attempts, then Associate Program Directors (APD) were contacted twice. If both these leaders did not respond, then the survey was sent to residency program administrators or Hospital Medicine Division Chiefs. Only one survey was completed per site.

Data Analysis

We used descriptive statistics to summarize quantitative data. Responses to open-ended qualitative questions about the goals, strengths, and design of rotations were analyzed using thematic analysis.¹¹ During analysis, we iteratively developed and refined codes that identified important concepts that emerged from the data. Two members of the research team trained in qualitative data analysis coded these data independently (SL & JH).

Eighty-two residency program leaders (53 PD, 19 APD, 10 chiefs/admin) responded to the survey (82% total response rate). Among all responders, the prevalence of hospitalist-focused rotations was 50% (41/82). Of these 41 rotations, 85% (35/41) were elective rotations and 15% (6/41) were mandatory rotations. Hospitalist rotations ranged in existence from 1 to 15 years with a mean duration of 4.78 years (S.D. 3.5).

Of the 41 programs that did not have a hospital medicine-focused rotation, the key barriers identified were a lack of a well-defined model (29%), low faculty interest (15%), low resident interest (12%), and lack of funding (5%). Despite these barriers, 9 of these 41 programs (22%) stated they planned to start a rotation in the future – of which, 3 programs (7%) planned to start a rotation within the year.

The Hospital Elective National Survey provides insight into a growing component of hospitalist-focused training and preparation. Fifty percent of ACGME residency programs surveyed in this study had a hospitalist-focused rotation. Rotation characteristics were heterogeneous, perhaps reflecting both the homegrown nature of their development and the lack of national study or data to guide what constitutes an “ideal” rotation. Common functions of rotations included providing career mentorship and allowing for trainees to get experience “being a hospitalist.” Other key elements of the rotations included providing additional clinical autonomy and teaching material outside of traditional residency curricula such as quality improvement, patient safety, billing, and healthcare finances.

Prior research has explored other training for hospitalists such as fellowships, pathways, and faculty development.^6-8 A hospital medicine fellowship provides extensive training but without a practice requirement in adult medicine (as now exists in pediatric hospital medicine), the impact of fellowship training may be limited by its scale.^12,13 Longitudinal hospitalist residency pathways provide comprehensive skill development and often require an early career commitment from trainees.⁷ Faculty development can be another tool to foster career growth, though requires local investment from hospitalist groups that may not have the resources or experience to support this.⁸ Our study has highlighted that hospitalist-focused rotations within residency programs can train physicians for a career in hospital medicine. Hospitalist and residency leaders should consider that these rotations might be the only hospital medicine-focused training that new hospitalists will have. Given the variable nature of these rotations nationally, developing standards around core hospitalist competencies within these rotations should be a key component to career preparation and a goal for the field at large.^14,15

Our study has limitations. The survey focused only on internal medicine as it is the most common training background of hospitalists; however, the field has grown to include other specialties including pediatrics, neurology, family medicine, and surgery. In addition, the survey reviewed the largest ACGME Internal Medicine programs to best evaluate prevalence and content—it may be that some smaller programs have rotations with different characteristics that we have not captured. Lastly, the survey reviewed the rotations through the lens of residency program leadership and not trainees. A future survey of trainees or early career hospitalists who participated in these rotations could provide a better understanding of their achievements and effectiveness.

We anticipate that the demand for hospitalist-focused training will continue to grow as more residents in training seek to enter the specialty. Hospitalist and residency program leaders have an opportunity within residency training programs to build new or further develop existing hospital medicine-focused rotations. The HENS survey demonstrates that hospitalist-focused rotations are prevalent in residency education and have the potential to play an important role in hospitalist training.

Disclosure

The authors declare no conflicts of interest in relation to this manuscript.

Hospital medicine has become the fastest growing medicine subspecialty, though no standardized hospitalist-focused educational program is required to become a practicing adult medicine hospitalist.¹ Historically, adult hospitalists have had little additional training beyond residency, yet, as residency training adapts to duty hour restrictions, patient caps, and increasing attending oversight, it is not clear if traditional rotations and curricula provide adequate preparation for independent practice as an adult hospitalist.^2-5 Several types of training and educational programs have emerged to fill this potential gap. These include hospital medicine fellowships, residency pathways, early career faculty development programs (eg, Society of Hospital Medicine/ Society of General Internal Medicine sponsored Academic Hospitalist Academy), and hospitalist-focused resident rotations.^6-10 These activities are intended to ensure that residents and early career physicians gain the skills and competencies required to effectively practice hospital medicine.

Hospital medicine fellowships, residency pathways, and faculty development have been described previously.^6-8 However, the prevalence and characteristics of hospital medicine-focused resident rotations are unknown, and these rotations are rarely publicized beyond local residency programs. Our study aims to determine the prevalence, purpose, and function of hospitalist-focused rotations within residency programs and explore the role these rotations have in preparing residents for a career in hospital medicine.

Study Design, Setting, and Participants

We conducted a cross-sectional study involving the largest 100 Accreditation Council for Graduate Medical Education (ACGME) internal medicine residency programs. We chose the largest programs as we hypothesized that these programs would be most likely to have the infrastructure to support hospital medicine focused rotations compared to smaller programs. The UCSF Committee on Human Research approved this study.

Survey Development

We developed a study-specific survey (the Hospitalist Elective National Survey [HENS]) to assess the prevalence, structure, curricular goals, and perceived benefits of distinct hospitalist rotations as defined by individual resident programs. The survey prompted respondents to consider a “hospitalist-focused” rotation as one that is different from a traditional inpatient “ward” rotation and whose emphasis is on hospitalist-specific training, clinical skills, or career development. The 18-question survey (Appendix 1) included fixed choice, multiple choice, and open-ended responses.

Data Collection

Using publicly available data from the ACGME website (www.acgme.org), we identified the largest 100 medicine programs based on the total number of residents. This included programs with 81 or more residents. An electronic survey was e-mailed to the leadership of each program. In May 2015, surveys were sent to Residency Program Directors (PD), and if they did not respond after 2 attempts, then Associate Program Directors (APD) were contacted twice. If both these leaders did not respond, then the survey was sent to residency program administrators or Hospital Medicine Division Chiefs. Only one survey was completed per site.

Data Analysis

We used descriptive statistics to summarize quantitative data. Responses to open-ended qualitative questions about the goals, strengths, and design of rotations were analyzed using thematic analysis.¹¹ During analysis, we iteratively developed and refined codes that identified important concepts that emerged from the data. Two members of the research team trained in qualitative data analysis coded these data independently (SL & JH).

Eighty-two residency program leaders (53 PD, 19 APD, 10 chiefs/admin) responded to the survey (82% total response rate). Among all responders, the prevalence of hospitalist-focused rotations was 50% (41/82). Of these 41 rotations, 85% (35/41) were elective rotations and 15% (6/41) were mandatory rotations. Hospitalist rotations ranged in existence from 1 to 15 years with a mean duration of 4.78 years (S.D. 3.5).

Of the 41 programs that did not have a hospital medicine-focused rotation, the key barriers identified were a lack of a well-defined model (29%), low faculty interest (15%), low resident interest (12%), and lack of funding (5%). Despite these barriers, 9 of these 41 programs (22%) stated they planned to start a rotation in the future – of which, 3 programs (7%) planned to start a rotation within the year.

The Hospital Elective National Survey provides insight into a growing component of hospitalist-focused training and preparation. Fifty percent of ACGME residency programs surveyed in this study had a hospitalist-focused rotation. Rotation characteristics were heterogeneous, perhaps reflecting both the homegrown nature of their development and the lack of national study or data to guide what constitutes an “ideal” rotation. Common functions of rotations included providing career mentorship and allowing for trainees to get experience “being a hospitalist.” Other key elements of the rotations included providing additional clinical autonomy and teaching material outside of traditional residency curricula such as quality improvement, patient safety, billing, and healthcare finances.

Prior research has explored other training for hospitalists such as fellowships, pathways, and faculty development.^6-8 A hospital medicine fellowship provides extensive training but without a practice requirement in adult medicine (as now exists in pediatric hospital medicine), the impact of fellowship training may be limited by its scale.^12,13 Longitudinal hospitalist residency pathways provide comprehensive skill development and often require an early career commitment from trainees.⁷ Faculty development can be another tool to foster career growth, though requires local investment from hospitalist groups that may not have the resources or experience to support this.⁸ Our study has highlighted that hospitalist-focused rotations within residency programs can train physicians for a career in hospital medicine. Hospitalist and residency leaders should consider that these rotations might be the only hospital medicine-focused training that new hospitalists will have. Given the variable nature of these rotations nationally, developing standards around core hospitalist competencies within these rotations should be a key component to career preparation and a goal for the field at large.^14,15

Our study has limitations. The survey focused only on internal medicine as it is the most common training background of hospitalists; however, the field has grown to include other specialties including pediatrics, neurology, family medicine, and surgery. In addition, the survey reviewed the largest ACGME Internal Medicine programs to best evaluate prevalence and content—it may be that some smaller programs have rotations with different characteristics that we have not captured. Lastly, the survey reviewed the rotations through the lens of residency program leadership and not trainees. A future survey of trainees or early career hospitalists who participated in these rotations could provide a better understanding of their achievements and effectiveness.

We anticipate that the demand for hospitalist-focused training will continue to grow as more residents in training seek to enter the specialty. Hospitalist and residency program leaders have an opportunity within residency training programs to build new or further develop existing hospital medicine-focused rotations. The HENS survey demonstrates that hospitalist-focused rotations are prevalent in residency education and have the potential to play an important role in hospitalist training.

Disclosure

The authors declare no conflicts of interest in relation to this manuscript.

Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. Prandoni P et al. New England Journal of Medicine, 2016;375(16):1524-31.¹

Background

Pulmonary embolism (PE), a potentially fatal disease, is rarely considered as a likely cause of syncope. To determine the prevalence of PE among patients presenting with their first episode of syncope, the authors performed a systematic workup for pulmonary embolism in adult patients admitted for syncope at 11 hospitals in Italy.

Findings

Of the 2584 patients who presented to the emergency department (ED) with syncope during the study, 560 patients were admitted and met the inclusion criteria. A modified Wells Score was applied, and a D-dimer was measured on every hospitalized patient. Those with a high pretest probability, a Wells Score of 4.0 or higher, or a positive D-dimer underwent further testing for pulmonary embolism by a CT scan, a ventilation perfusion scan, or an autopsy. Ninety-seven of the 560 patients admitted to the hospital for syncope were found to have a PE (17%). One in 4 patients (25%) with no clear cause for syncope was found to have a PE, and 1 in 4 patients with PE had no tachycardia, tachypnea, hypotension, or clinical signs of DVT.

Cautions

Nearly 72% of the patients with common explanations for syncope, such as vasovagal, drug-induced, or volume depletion, were discharged from the ED and not included in the study. The authors focused on the prevalence of PE. The causation between PE and syncope is not clear in each of the patients. Of the patients’ diagnosis by a CT, only 67% of the PEs were found to be in a main pulmonary artery or lobar artery. The other 33% were segmental or subsegmental. Of those diagnosed by a ventilation perfusion scan, 50% of the patients had 25% or more of the area of both lungs involved. The other 50% involved less than 25% of the area of both lungs. Also, it is important to note that 75% of the patients admitted to the hospital in this study were 70 years of age or older.

Implications

After common diagnoses are ruled out, it is important to consider pulmonary embolism in patients hospitalized with syncope. Providers should calculate a Wells Score and measure a D-dimer to guide the decision making.

Assessing the Risks Associated with MRI in Patients with a Pacemaker or Defibrillator. Russo RJ et al. New England Journal of Medicine, 2017;376(8):755-64.²

Background

Magnetic resonance imaging (MRI) in patients with implantable cardiac devices is considered a safety risk due to the potential of cardiac lead heating and subsequent myocardial injury or alterations of the pacing properties. Although manufacturers have developed “MRI-conditional” devices designed to reduce these risks, still 2 million people in the United States and 6 million people worldwide have “non–MRI-conditional” devices. The authors evaluated the event rates in patients with “non-MRI-conditional” devices undergoing an MRI.

Findings

The authors prospectively followed up 1500 adults with cardiac devices placed since 2001 who received nonthoracic MRIs according to a specific protocol available in the supplemental materials published with this article in the New England Journal of Medicine. Of the 1000 patients with pacemakers only, they observed 5 atrial arrhythmias and 6 electrical resets. Of the 500 patients with implantable cardioverter defibrillators (ICDs), they observed 1 atrial arrhythmia and 1 generator failure (although this case had deviated from the protocol). All of the atrial arrhythmias were self-terminating. No deaths, lead failure requiring an immediate replacement, a loss of capture, or ventricular arrhythmias were observed.

Cautions

Patients who were pacing dependent were excluded. No devices implanted before 2001 were included in the study, and the MRIs performed were only 1.5 Tesla (a lower field strength than the also available 3 Tesla MRIs).

Implications

It is safe to proceed with 1.5 Tesla nonthoracic MRIs in patients, following the protocol outlined in this article, with non–MRI conditional cardiac devices implanted since 2001.

Culture If Spikes? Indications and Yield of Blood Cultures in Hospitalized Medical Patients. Linsenmeyer K et al. Journal of Hospital Medicine, 2016;11(5):336-40.³

Background

Blood cultures are frequently drawn for the evaluation of an inpatient fever. This “culture if spikes” approach may lead to unnecessary testing and false positive results. In this study, the authors evaluated rates of true positive and false positive blood cultures in the setting of an inpatient fever.

Findings

The patients hospitalized on the general medicine or cardiology floors at a Veterans Affairs teaching hospital were prospectively followed over 7 months. A total of 576 blood cultures were ordered among 323 unique patients. The patients were older (average age of 70 years) and predominantly male (94%). The true-positive rate for cultures, determined by a consensus among the microbiology and infectious disease departments based on a review of clinical and laboratory data, was 3.6% compared with a false-positive rate of 2.3%. The clinical characteristics associated with a higher likelihood of a true positive included: the indication for a culture as a follow-up from a previous culture (likelihood ratio [LR] 3.4), a working diagnosis of bacteremia or endocarditis (LR 3.7), and the constellation of fever and leukocytosis in a patient who has not been on antibiotics (LR 5.6).

Cautions

This study was performed at a single center with patients in the medicine and cardiology services, and thus, the data is representative of clinical practice patterns specific to that site.

Implications

Reflexive ordering of blood cultures for inpatient fever is of a low yield with a false-positive rate that approximates the true positive rate. A large number of patients are tested unnecessarily, and for those with positive tests, physicians are as likely to be misled as they are certain to truly identify a pathogen. The positive predictive value of blood cultures is improved when drawn on patients who are not on antibiotics and when the patient has a specific diagnosis, such as pneumonia, previous bacteremia, or suspected endocarditis.

Incidence of and Risk Factors for Chronic Opioid Use among Opioid-Naive Patients in the Postoperative Period. Sun EC et al. JAMA Internal Medicine, 2016;176(9):1286-93.⁴

Background

Each day in the United States, 650,000 opioid prescriptions are filled, and 78 people suffer an opiate-related death. Opioids are frequently prescribed for inpatient management of postoperative pain. In this study, authors compared the development of chronic opioid use between patients who had undergone surgery and those who had not.

Findings

This was a retrospective analysis of a nationwide insurance claims database. A total of 641,941 opioid-naive patients underwent 1 of 11 designated surgeries in the study period and were compared with 18,011,137 opioid-naive patients who did not undergo surgery. Chronic opioid use was defined as the filling of 10 or more prescriptions or receiving more than a 120-day supply between 90 and 365 days postoperatively (or following the assigned faux surgical date in those not having surgery). This was observed in a small proportion of the surgical patients (less than 0.5%). However, several procedures were associated with the increased odds of postoperative chronic opioid use, including a simple mastectomy (Odds ratio [OR] 2.65), a cesarean delivery (OR 1.28), an open appendectomy (OR 1.69), an open and laparoscopic cholecystectomy (ORs 3.60 and 1.62, respectively), and a total hip and total knee arthroplasty (ORs 2.52 and 5.10, respectively). Also, male sex, age greater than 50 years, preoperative benzodiazepines or antidepressants, and a history of drug abuse were associated with increased odds.

Cautions

This study was limited by the claims-based data and that the nonsurgical population was inherently different from the surgical population in ways that could lead to confounding.

Implications

In perioperative care, there is a need to focus on multimodal approaches to pain and to implement opioid reducing and sparing strategies that might include options such as acetaminophen, NSAIDs, neuropathic pain medications, and Lidocaine patches. Moreover, at discharge, careful consideration should be given to the quantity and duration of the postoperative opioids.

Rapid Rule-out of Acute Myocardial Infarction with a Single High-Sensitivity Cardiac Troponin T Measurement below the Limit of Detection: A Collaborative Meta-Analysis. Pickering JW et al. Annals of Internal Medicine, 2017;166:715-24.⁵

Background

High-sensitivity cardiac troponin testing (hs-cTnT) is now available in the United States. Studies have found that these can play a significant role in a rapid rule-out of acute myocardial infarction (AMI).

Findings

In this meta-analysis, the authors identified 11 studies with 9241 participants that prospectively evaluated patients presenting to the emergency department (ED) with chest pain, underwent an ECG, and had hs-cTnT drawn. A total of 30% of the patients were classified as low risk with negative hs-cTnT and negative ECG (defined as no ST changes or T-wave inversions indicative of ischemia). Among the low risk patients, only 14 of the 2825 (0.5%) had AMI according to the Global Task Forces definition.⁶ Seven of these were in patients with hs-cTnT drawn within 3 hours of a chest pain onset. The pooled negative predictive value was 99.0% (CI 93.8%–99.8%).

Cautions

The heterogeneity between the studies in this meta-analysis, especially in the exclusion criteria, warrants careful consideration when being implemented in new settings. A more sensitive test will result in more positive troponins due to different limits of detection. Thus, medical teams and institutions need to plan accordingly. Caution should be taken for any patient presenting within 3 hours of a chest pain onset.

Implications

Rapid rule-out protocols—which include clinical evaluation, a negative ECG, and a negative high-sensitivity cardiac troponin—identify a large proportion of low-risk patients who are unlikely to have a true AMI.

Prevalence and Localization of Pulmonary Embolism in Unexplained Acute Exacerbations of COPD: A Systematic Review and Meta-analysis. Aleva FE et al. Chest, 2017;151(3):544-54.⁷

Background

Acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) are frequent. In up to 30%, no clear trigger is found. Previous studies suggested that 1 in 4 of these patients may have a pulmonary embolus (PE).⁷ This study reviewed the literature and meta-data to describe the prevalence, the embolism location, and the clinical predictors of PE among patients with unexplained AE-COPD.

Findings

A systematic review of the literature and meta-analysis identified 7 studies with 880 patients. In the pooled analysis, 16% had PE (range: 3%–29%). Of the 120 patients with PE, two-thirds were in lobar or larger arteries and one-third in segmental or smaller. Pleuritic chest pain and signs of cardiac compromise (hypotension, syncope, and right-sided heart failure) were associated with PE.

Cautions

This study was heterogeneous leading to a broad confidence interval for prevalence ranging from 8%–25%. Given the frequency of AE-COPD with no identified trigger, physicians need to attend to risks of repeat radiation exposure when considering an evaluation for PE.

Implications

One in 6 patients with unexplained AE-COPD was found to have PE; the odds were greater in those with pleuritic chest pain or signs of cardiac compromise. In patients with AE-COPD with an unclear trigger, the providers should consider an evaluation for PE by using a clinical prediction rule and/or a D-dimer.

Sitting at Patients’ Bedsides May Improve Patients’ Perceptions of Physician Communication Skills. Merel SE et al. Journal of Hospital Medicine, 2016;11(12):865-8.⁹

Background

Sitting at a patient’s bedside in the inpatient setting is considered a best practice, yet it has not been widely adopted. The authors conducted a cluster-randomized trial of physicians on a single 28-bed hospitalist only run unit where physicians were assigned to sitting or standing for the first 3 days of a 7-day workweek assignment. New admissions or transfers to the unit were considered eligible for the study.

Findings

Sixteen hospitalists saw on an average 13 patients daily during the study (a total of 159 patients were included in the analysis after 52 patients were excluded or declined to participate). The hospitalists were 69% female, and 81% had been in practice 3 years or less. The average time spent in the patient’s room was 12:00 minutes while seated and 12:10 minutes while standing. There was no difference in the patients’ perception of the amount of time spent—the patients overestimated this by 4 minutes in both groups. Sitting was associated with higher ratings for “listening carefully” and “explaining things in a way that was easy to understand.” There was no difference in ratings on the physicians interrupting the patient when talking or in treating patients with courtesy and respect.

Cautions

The study had a small sample size, was limited to English-speaking patients, and was a single-site study. It involved only attending-level physicians and did not involve nonphysician team members. The physicians were not blinded and were aware that the interactions were monitored, perhaps creating a Hawthorne effect. The analysis did not control for other factors such as the severity of the illness, the number of consultants used, or the degree of health literacy.

Implications

This study supports an important best practice highlighted in etiquette-based medicine ¹⁰: sitting at the bedside provided a benefit in the patient’s perception of communication by physicians without a negative effect on the physician’s workflow.

The Duration of Antibiotic Treatment in Community-Acquired Pneumonia: A Multi-Center Randomized Clinical Trial. Uranga A et al. JAMA Intern Medicine, 2016;176(9):1257-65.¹¹

Background

The optimal duration of treatment for community-acquired pneumonia (CAP) is unclear; a growing body of evidence suggests shorter and longer durations may be equivalent.

Findings

At 4 hospitals in Spain, 312 adults with a mean age of 65 years and a diagnosis of CAP (non-ICU) were randomized to a short (5 days) versus a long (provider discretion) course of antibiotics. In the short-course group, the antibiotics were stopped after 5 days if the body temperature had been 37.8^o C or less for 48 hours, and no more than 1 sign of clinical instability was present (SBP < 90 mmHg, HR >100/min, RR > 24/min, O2Sat < 90%). The median number of antibiotic days was 5 for the short-course group and 10 for the long-course group (P < .01). There was no difference in the resolution of pneumonia symptoms at 10 days or 30 days or in 30-day mortality. There were no differences in in-hospital side effects. However, 30-day readmissions were higher in the long-course group compared with the short-course group (6.6% vs 1.4%; P = .02). The results were similar across all of the Pneumonia Severity Index (PSI) classes.

Cautions

Most of the patients were not severely ill (~60% PSI I-III), the level of comorbid disease was low, and nearly 80% of the patients received fluoroquinolone. There was a significant cross over with 30% of patients assigned to the short-course group receiving antibiotics for more than 5 days.

Implications

Inpatient providers should aim to treat patients with community-acquired pneumonia (regardless of the severity of the illness) for 5 days. At day 5, if the patient is afebrile and has no signs of clinical instability, clinicians should be comfortable stopping antibiotics.

Is the Era of Intravenous Proton Pump Inhibitors Coming to an End in Patients with Bleeding Peptic Ulcers? A Meta-Analysis of the Published Literature. Jian Z et al. British Journal of Clinical Pharmacology, 2016;82(3):880-9.¹²

Background

Guidelines recommend intravenous proton pump inhibitors (PPI) after an endoscopy for patients with a bleeding peptic ulcer. Yet, acid suppression with oral PPI is deemed equivalent to the intravenous route.

Findings

This systematic review and meta-analysis identified 7 randomized controlled trials involving 859 patients. After an endoscopy, the patients were randomized to receive either oral or intravenous PPI. Most of the patients had “high-risk” peptic ulcers (active bleeding, a visible vessel, an adherent clot). The PPI dose and frequency varied between the studies. Re-bleeding rates were no different between the oral and intravenous route at 72 hours (2.4% vs 5.1%; P = .26), 7 days (5.6% vs 6.8%; P =.68), or 30 days (7.9% vs 8.8%; P = .62). There was also no difference in 30-day mortality (2.1% vs 2.4%; P = .88), and the length of stay was the same in both groups. Side effects were not reported.

Cautions

This systematic review and meta-analysis included multiple heterogeneous small studies of moderate quality. A large number of patients were excluded, increasing the risk of a selection bias.

Implications

There is no clear indication for intravenous PPI in the treatment of bleeding peptic ulcers following an endoscopy. Converting to oral PPI is equivalent to intravenous and is a safe, effective, and cost-saving option for patients with bleeding peptic ulcers.

Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. Prandoni P et al. New England Journal of Medicine, 2016;375(16):1524-31.¹

Background

Pulmonary embolism (PE), a potentially fatal disease, is rarely considered as a likely cause of syncope. To determine the prevalence of PE among patients presenting with their first episode of syncope, the authors performed a systematic workup for pulmonary embolism in adult patients admitted for syncope at 11 hospitals in Italy.

Findings

Of the 2584 patients who presented to the emergency department (ED) with syncope during the study, 560 patients were admitted and met the inclusion criteria. A modified Wells Score was applied, and a D-dimer was measured on every hospitalized patient. Those with a high pretest probability, a Wells Score of 4.0 or higher, or a positive D-dimer underwent further testing for pulmonary embolism by a CT scan, a ventilation perfusion scan, or an autopsy. Ninety-seven of the 560 patients admitted to the hospital for syncope were found to have a PE (17%). One in 4 patients (25%) with no clear cause for syncope was found to have a PE, and 1 in 4 patients with PE had no tachycardia, tachypnea, hypotension, or clinical signs of DVT.

Cautions

Nearly 72% of the patients with common explanations for syncope, such as vasovagal, drug-induced, or volume depletion, were discharged from the ED and not included in the study. The authors focused on the prevalence of PE. The causation between PE and syncope is not clear in each of the patients. Of the patients’ diagnosis by a CT, only 67% of the PEs were found to be in a main pulmonary artery or lobar artery. The other 33% were segmental or subsegmental. Of those diagnosed by a ventilation perfusion scan, 50% of the patients had 25% or more of the area of both lungs involved. The other 50% involved less than 25% of the area of both lungs. Also, it is important to note that 75% of the patients admitted to the hospital in this study were 70 years of age or older.

Implications

After common diagnoses are ruled out, it is important to consider pulmonary embolism in patients hospitalized with syncope. Providers should calculate a Wells Score and measure a D-dimer to guide the decision making.

Assessing the Risks Associated with MRI in Patients with a Pacemaker or Defibrillator. Russo RJ et al. New England Journal of Medicine, 2017;376(8):755-64.²

Background

Magnetic resonance imaging (MRI) in patients with implantable cardiac devices is considered a safety risk due to the potential of cardiac lead heating and subsequent myocardial injury or alterations of the pacing properties. Although manufacturers have developed “MRI-conditional” devices designed to reduce these risks, still 2 million people in the United States and 6 million people worldwide have “non–MRI-conditional” devices. The authors evaluated the event rates in patients with “non-MRI-conditional” devices undergoing an MRI.

Findings

The authors prospectively followed up 1500 adults with cardiac devices placed since 2001 who received nonthoracic MRIs according to a specific protocol available in the supplemental materials published with this article in the New England Journal of Medicine. Of the 1000 patients with pacemakers only, they observed 5 atrial arrhythmias and 6 electrical resets. Of the 500 patients with implantable cardioverter defibrillators (ICDs), they observed 1 atrial arrhythmia and 1 generator failure (although this case had deviated from the protocol). All of the atrial arrhythmias were self-terminating. No deaths, lead failure requiring an immediate replacement, a loss of capture, or ventricular arrhythmias were observed.

Cautions

Patients who were pacing dependent were excluded. No devices implanted before 2001 were included in the study, and the MRIs performed were only 1.5 Tesla (a lower field strength than the also available 3 Tesla MRIs).

Implications

It is safe to proceed with 1.5 Tesla nonthoracic MRIs in patients, following the protocol outlined in this article, with non–MRI conditional cardiac devices implanted since 2001.

Culture If Spikes? Indications and Yield of Blood Cultures in Hospitalized Medical Patients. Linsenmeyer K et al. Journal of Hospital Medicine, 2016;11(5):336-40.³

Background

Blood cultures are frequently drawn for the evaluation of an inpatient fever. This “culture if spikes” approach may lead to unnecessary testing and false positive results. In this study, the authors evaluated rates of true positive and false positive blood cultures in the setting of an inpatient fever.

Findings

The patients hospitalized on the general medicine or cardiology floors at a Veterans Affairs teaching hospital were prospectively followed over 7 months. A total of 576 blood cultures were ordered among 323 unique patients. The patients were older (average age of 70 years) and predominantly male (94%). The true-positive rate for cultures, determined by a consensus among the microbiology and infectious disease departments based on a review of clinical and laboratory data, was 3.6% compared with a false-positive rate of 2.3%. The clinical characteristics associated with a higher likelihood of a true positive included: the indication for a culture as a follow-up from a previous culture (likelihood ratio [LR] 3.4), a working diagnosis of bacteremia or endocarditis (LR 3.7), and the constellation of fever and leukocytosis in a patient who has not been on antibiotics (LR 5.6).

Cautions

This study was performed at a single center with patients in the medicine and cardiology services, and thus, the data is representative of clinical practice patterns specific to that site.

Implications

Reflexive ordering of blood cultures for inpatient fever is of a low yield with a false-positive rate that approximates the true positive rate. A large number of patients are tested unnecessarily, and for those with positive tests, physicians are as likely to be misled as they are certain to truly identify a pathogen. The positive predictive value of blood cultures is improved when drawn on patients who are not on antibiotics and when the patient has a specific diagnosis, such as pneumonia, previous bacteremia, or suspected endocarditis.

Incidence of and Risk Factors for Chronic Opioid Use among Opioid-Naive Patients in the Postoperative Period. Sun EC et al. JAMA Internal Medicine, 2016;176(9):1286-93.⁴

Background

Each day in the United States, 650,000 opioid prescriptions are filled, and 78 people suffer an opiate-related death. Opioids are frequently prescribed for inpatient management of postoperative pain. In this study, authors compared the development of chronic opioid use between patients who had undergone surgery and those who had not.

Findings

This was a retrospective analysis of a nationwide insurance claims database. A total of 641,941 opioid-naive patients underwent 1 of 11 designated surgeries in the study period and were compared with 18,011,137 opioid-naive patients who did not undergo surgery. Chronic opioid use was defined as the filling of 10 or more prescriptions or receiving more than a 120-day supply between 90 and 365 days postoperatively (or following the assigned faux surgical date in those not having surgery). This was observed in a small proportion of the surgical patients (less than 0.5%). However, several procedures were associated with the increased odds of postoperative chronic opioid use, including a simple mastectomy (Odds ratio [OR] 2.65), a cesarean delivery (OR 1.28), an open appendectomy (OR 1.69), an open and laparoscopic cholecystectomy (ORs 3.60 and 1.62, respectively), and a total hip and total knee arthroplasty (ORs 2.52 and 5.10, respectively). Also, male sex, age greater than 50 years, preoperative benzodiazepines or antidepressants, and a history of drug abuse were associated with increased odds.

Cautions

This study was limited by the claims-based data and that the nonsurgical population was inherently different from the surgical population in ways that could lead to confounding.

Implications

In perioperative care, there is a need to focus on multimodal approaches to pain and to implement opioid reducing and sparing strategies that might include options such as acetaminophen, NSAIDs, neuropathic pain medications, and Lidocaine patches. Moreover, at discharge, careful consideration should be given to the quantity and duration of the postoperative opioids.

Rapid Rule-out of Acute Myocardial Infarction with a Single High-Sensitivity Cardiac Troponin T Measurement below the Limit of Detection: A Collaborative Meta-Analysis. Pickering JW et al. Annals of Internal Medicine, 2017;166:715-24.⁵

Background

High-sensitivity cardiac troponin testing (hs-cTnT) is now available in the United States. Studies have found that these can play a significant role in a rapid rule-out of acute myocardial infarction (AMI).

Findings

In this meta-analysis, the authors identified 11 studies with 9241 participants that prospectively evaluated patients presenting to the emergency department (ED) with chest pain, underwent an ECG, and had hs-cTnT drawn. A total of 30% of the patients were classified as low risk with negative hs-cTnT and negative ECG (defined as no ST changes or T-wave inversions indicative of ischemia). Among the low risk patients, only 14 of the 2825 (0.5%) had AMI according to the Global Task Forces definition.⁶ Seven of these were in patients with hs-cTnT drawn within 3 hours of a chest pain onset. The pooled negative predictive value was 99.0% (CI 93.8%–99.8%).

Cautions

The heterogeneity between the studies in this meta-analysis, especially in the exclusion criteria, warrants careful consideration when being implemented in new settings. A more sensitive test will result in more positive troponins due to different limits of detection. Thus, medical teams and institutions need to plan accordingly. Caution should be taken for any patient presenting within 3 hours of a chest pain onset.

Implications

Rapid rule-out protocols—which include clinical evaluation, a negative ECG, and a negative high-sensitivity cardiac troponin—identify a large proportion of low-risk patients who are unlikely to have a true AMI.

Prevalence and Localization of Pulmonary Embolism in Unexplained Acute Exacerbations of COPD: A Systematic Review and Meta-analysis. Aleva FE et al. Chest, 2017;151(3):544-54.⁷

Background

Acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) are frequent. In up to 30%, no clear trigger is found. Previous studies suggested that 1 in 4 of these patients may have a pulmonary embolus (PE).⁷ This study reviewed the literature and meta-data to describe the prevalence, the embolism location, and the clinical predictors of PE among patients with unexplained AE-COPD.

Findings

A systematic review of the literature and meta-analysis identified 7 studies with 880 patients. In the pooled analysis, 16% had PE (range: 3%–29%). Of the 120 patients with PE, two-thirds were in lobar or larger arteries and one-third in segmental or smaller. Pleuritic chest pain and signs of cardiac compromise (hypotension, syncope, and right-sided heart failure) were associated with PE.

Cautions

This study was heterogeneous leading to a broad confidence interval for prevalence ranging from 8%–25%. Given the frequency of AE-COPD with no identified trigger, physicians need to attend to risks of repeat radiation exposure when considering an evaluation for PE.

Implications

One in 6 patients with unexplained AE-COPD was found to have PE; the odds were greater in those with pleuritic chest pain or signs of cardiac compromise. In patients with AE-COPD with an unclear trigger, the providers should consider an evaluation for PE by using a clinical prediction rule and/or a D-dimer.

Sitting at Patients’ Bedsides May Improve Patients’ Perceptions of Physician Communication Skills. Merel SE et al. Journal of Hospital Medicine, 2016;11(12):865-8.⁹

Background

Sitting at a patient’s bedside in the inpatient setting is considered a best practice, yet it has not been widely adopted. The authors conducted a cluster-randomized trial of physicians on a single 28-bed hospitalist only run unit where physicians were assigned to sitting or standing for the first 3 days of a 7-day workweek assignment. New admissions or transfers to the unit were considered eligible for the study.

Findings

Sixteen hospitalists saw on an average 13 patients daily during the study (a total of 159 patients were included in the analysis after 52 patients were excluded or declined to participate). The hospitalists were 69% female, and 81% had been in practice 3 years or less. The average time spent in the patient’s room was 12:00 minutes while seated and 12:10 minutes while standing. There was no difference in the patients’ perception of the amount of time spent—the patients overestimated this by 4 minutes in both groups. Sitting was associated with higher ratings for “listening carefully” and “explaining things in a way that was easy to understand.” There was no difference in ratings on the physicians interrupting the patient when talking or in treating patients with courtesy and respect.

Cautions

The study had a small sample size, was limited to English-speaking patients, and was a single-site study. It involved only attending-level physicians and did not involve nonphysician team members. The physicians were not blinded and were aware that the interactions were monitored, perhaps creating a Hawthorne effect. The analysis did not control for other factors such as the severity of the illness, the number of consultants used, or the degree of health literacy.

Implications

This study supports an important best practice highlighted in etiquette-based medicine ¹⁰: sitting at the bedside provided a benefit in the patient’s perception of communication by physicians without a negative effect on the physician’s workflow.

The Duration of Antibiotic Treatment in Community-Acquired Pneumonia: A Multi-Center Randomized Clinical Trial. Uranga A et al. JAMA Intern Medicine, 2016;176(9):1257-65.¹¹

Background

The optimal duration of treatment for community-acquired pneumonia (CAP) is unclear; a growing body of evidence suggests shorter and longer durations may be equivalent.

Findings

At 4 hospitals in Spain, 312 adults with a mean age of 65 years and a diagnosis of CAP (non-ICU) were randomized to a short (5 days) versus a long (provider discretion) course of antibiotics. In the short-course group, the antibiotics were stopped after 5 days if the body temperature had been 37.8^o C or less for 48 hours, and no more than 1 sign of clinical instability was present (SBP < 90 mmHg, HR >100/min, RR > 24/min, O2Sat < 90%). The median number of antibiotic days was 5 for the short-course group and 10 for the long-course group (P < .01). There was no difference in the resolution of pneumonia symptoms at 10 days or 30 days or in 30-day mortality. There were no differences in in-hospital side effects. However, 30-day readmissions were higher in the long-course group compared with the short-course group (6.6% vs 1.4%; P = .02). The results were similar across all of the Pneumonia Severity Index (PSI) classes.

Cautions

Most of the patients were not severely ill (~60% PSI I-III), the level of comorbid disease was low, and nearly 80% of the patients received fluoroquinolone. There was a significant cross over with 30% of patients assigned to the short-course group receiving antibiotics for more than 5 days.

Implications

Inpatient providers should aim to treat patients with community-acquired pneumonia (regardless of the severity of the illness) for 5 days. At day 5, if the patient is afebrile and has no signs of clinical instability, clinicians should be comfortable stopping antibiotics.

Is the Era of Intravenous Proton Pump Inhibitors Coming to an End in Patients with Bleeding Peptic Ulcers? A Meta-Analysis of the Published Literature. Jian Z et al. British Journal of Clinical Pharmacology, 2016;82(3):880-9.¹²

Background

Guidelines recommend intravenous proton pump inhibitors (PPI) after an endoscopy for patients with a bleeding peptic ulcer. Yet, acid suppression with oral PPI is deemed equivalent to the intravenous route.

Findings

This systematic review and meta-analysis identified 7 randomized controlled trials involving 859 patients. After an endoscopy, the patients were randomized to receive either oral or intravenous PPI. Most of the patients had “high-risk” peptic ulcers (active bleeding, a visible vessel, an adherent clot). The PPI dose and frequency varied between the studies. Re-bleeding rates were no different between the oral and intravenous route at 72 hours (2.4% vs 5.1%; P = .26), 7 days (5.6% vs 6.8%; P =.68), or 30 days (7.9% vs 8.8%; P = .62). There was also no difference in 30-day mortality (2.1% vs 2.4%; P = .88), and the length of stay was the same in both groups. Side effects were not reported.

Cautions

This systematic review and meta-analysis included multiple heterogeneous small studies of moderate quality. A large number of patients were excluded, increasing the risk of a selection bias.

Implications

There is no clear indication for intravenous PPI in the treatment of bleeding peptic ulcers following an endoscopy. Converting to oral PPI is equivalent to intravenous and is a safe, effective, and cost-saving option for patients with bleeding peptic ulcers.

Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope. Prandoni P et al. New England Journal of Medicine, 2016;375(16):1524-31.¹

Background

Pulmonary embolism (PE), a potentially fatal disease, is rarely considered as a likely cause of syncope. To determine the prevalence of PE among patients presenting with their first episode of syncope, the authors performed a systematic workup for pulmonary embolism in adult patients admitted for syncope at 11 hospitals in Italy.

Findings

Of the 2584 patients who presented to the emergency department (ED) with syncope during the study, 560 patients were admitted and met the inclusion criteria. A modified Wells Score was applied, and a D-dimer was measured on every hospitalized patient. Those with a high pretest probability, a Wells Score of 4.0 or higher, or a positive D-dimer underwent further testing for pulmonary embolism by a CT scan, a ventilation perfusion scan, or an autopsy. Ninety-seven of the 560 patients admitted to the hospital for syncope were found to have a PE (17%). One in 4 patients (25%) with no clear cause for syncope was found to have a PE, and 1 in 4 patients with PE had no tachycardia, tachypnea, hypotension, or clinical signs of DVT.

Cautions

Nearly 72% of the patients with common explanations for syncope, such as vasovagal, drug-induced, or volume depletion, were discharged from the ED and not included in the study. The authors focused on the prevalence of PE. The causation between PE and syncope is not clear in each of the patients. Of the patients’ diagnosis by a CT, only 67% of the PEs were found to be in a main pulmonary artery or lobar artery. The other 33% were segmental or subsegmental. Of those diagnosed by a ventilation perfusion scan, 50% of the patients had 25% or more of the area of both lungs involved. The other 50% involved less than 25% of the area of both lungs. Also, it is important to note that 75% of the patients admitted to the hospital in this study were 70 years of age or older.

Implications

After common diagnoses are ruled out, it is important to consider pulmonary embolism in patients hospitalized with syncope. Providers should calculate a Wells Score and measure a D-dimer to guide the decision making.

Assessing the Risks Associated with MRI in Patients with a Pacemaker or Defibrillator. Russo RJ et al. New England Journal of Medicine, 2017;376(8):755-64.²

Background

Magnetic resonance imaging (MRI) in patients with implantable cardiac devices is considered a safety risk due to the potential of cardiac lead heating and subsequent myocardial injury or alterations of the pacing properties. Although manufacturers have developed “MRI-conditional” devices designed to reduce these risks, still 2 million people in the United States and 6 million people worldwide have “non–MRI-conditional” devices. The authors evaluated the event rates in patients with “non-MRI-conditional” devices undergoing an MRI.

Findings

The authors prospectively followed up 1500 adults with cardiac devices placed since 2001 who received nonthoracic MRIs according to a specific protocol available in the supplemental materials published with this article in the New England Journal of Medicine. Of the 1000 patients with pacemakers only, they observed 5 atrial arrhythmias and 6 electrical resets. Of the 500 patients with implantable cardioverter defibrillators (ICDs), they observed 1 atrial arrhythmia and 1 generator failure (although this case had deviated from the protocol). All of the atrial arrhythmias were self-terminating. No deaths, lead failure requiring an immediate replacement, a loss of capture, or ventricular arrhythmias were observed.

Cautions

Patients who were pacing dependent were excluded. No devices implanted before 2001 were included in the study, and the MRIs performed were only 1.5 Tesla (a lower field strength than the also available 3 Tesla MRIs).

Implications

It is safe to proceed with 1.5 Tesla nonthoracic MRIs in patients, following the protocol outlined in this article, with non–MRI conditional cardiac devices implanted since 2001.

Culture If Spikes? Indications and Yield of Blood Cultures in Hospitalized Medical Patients. Linsenmeyer K et al. Journal of Hospital Medicine, 2016;11(5):336-40.³

Background

Blood cultures are frequently drawn for the evaluation of an inpatient fever. This “culture if spikes” approach may lead to unnecessary testing and false positive results. In this study, the authors evaluated rates of true positive and false positive blood cultures in the setting of an inpatient fever.

Findings

The patients hospitalized on the general medicine or cardiology floors at a Veterans Affairs teaching hospital were prospectively followed over 7 months. A total of 576 blood cultures were ordered among 323 unique patients. The patients were older (average age of 70 years) and predominantly male (94%). The true-positive rate for cultures, determined by a consensus among the microbiology and infectious disease departments based on a review of clinical and laboratory data, was 3.6% compared with a false-positive rate of 2.3%. The clinical characteristics associated with a higher likelihood of a true positive included: the indication for a culture as a follow-up from a previous culture (likelihood ratio [LR] 3.4), a working diagnosis of bacteremia or endocarditis (LR 3.7), and the constellation of fever and leukocytosis in a patient who has not been on antibiotics (LR 5.6).

Cautions

This study was performed at a single center with patients in the medicine and cardiology services, and thus, the data is representative of clinical practice patterns specific to that site.

Implications

Reflexive ordering of blood cultures for inpatient fever is of a low yield with a false-positive rate that approximates the true positive rate. A large number of patients are tested unnecessarily, and for those with positive tests, physicians are as likely to be misled as they are certain to truly identify a pathogen. The positive predictive value of blood cultures is improved when drawn on patients who are not on antibiotics and when the patient has a specific diagnosis, such as pneumonia, previous bacteremia, or suspected endocarditis.

Incidence of and Risk Factors for Chronic Opioid Use among Opioid-Naive Patients in the Postoperative Period. Sun EC et al. JAMA Internal Medicine, 2016;176(9):1286-93.⁴

Background

Each day in the United States, 650,000 opioid prescriptions are filled, and 78 people suffer an opiate-related death. Opioids are frequently prescribed for inpatient management of postoperative pain. In this study, authors compared the development of chronic opioid use between patients who had undergone surgery and those who had not.

Findings

This was a retrospective analysis of a nationwide insurance claims database. A total of 641,941 opioid-naive patients underwent 1 of 11 designated surgeries in the study period and were compared with 18,011,137 opioid-naive patients who did not undergo surgery. Chronic opioid use was defined as the filling of 10 or more prescriptions or receiving more than a 120-day supply between 90 and 365 days postoperatively (or following the assigned faux surgical date in those not having surgery). This was observed in a small proportion of the surgical patients (less than 0.5%). However, several procedures were associated with the increased odds of postoperative chronic opioid use, including a simple mastectomy (Odds ratio [OR] 2.65), a cesarean delivery (OR 1.28), an open appendectomy (OR 1.69), an open and laparoscopic cholecystectomy (ORs 3.60 and 1.62, respectively), and a total hip and total knee arthroplasty (ORs 2.52 and 5.10, respectively). Also, male sex, age greater than 50 years, preoperative benzodiazepines or antidepressants, and a history of drug abuse were associated with increased odds.

Cautions

This study was limited by the claims-based data and that the nonsurgical population was inherently different from the surgical population in ways that could lead to confounding.

Implications

In perioperative care, there is a need to focus on multimodal approaches to pain and to implement opioid reducing and sparing strategies that might include options such as acetaminophen, NSAIDs, neuropathic pain medications, and Lidocaine patches. Moreover, at discharge, careful consideration should be given to the quantity and duration of the postoperative opioids.

Rapid Rule-out of Acute Myocardial Infarction with a Single High-Sensitivity Cardiac Troponin T Measurement below the Limit of Detection: A Collaborative Meta-Analysis. Pickering JW et al. Annals of Internal Medicine, 2017;166:715-24.⁵

Background

High-sensitivity cardiac troponin testing (hs-cTnT) is now available in the United States. Studies have found that these can play a significant role in a rapid rule-out of acute myocardial infarction (AMI).

Findings

In this meta-analysis, the authors identified 11 studies with 9241 participants that prospectively evaluated patients presenting to the emergency department (ED) with chest pain, underwent an ECG, and had hs-cTnT drawn. A total of 30% of the patients were classified as low risk with negative hs-cTnT and negative ECG (defined as no ST changes or T-wave inversions indicative of ischemia). Among the low risk patients, only 14 of the 2825 (0.5%) had AMI according to the Global Task Forces definition.⁶ Seven of these were in patients with hs-cTnT drawn within 3 hours of a chest pain onset. The pooled negative predictive value was 99.0% (CI 93.8%–99.8%).

Cautions

The heterogeneity between the studies in this meta-analysis, especially in the exclusion criteria, warrants careful consideration when being implemented in new settings. A more sensitive test will result in more positive troponins due to different limits of detection. Thus, medical teams and institutions need to plan accordingly. Caution should be taken for any patient presenting within 3 hours of a chest pain onset.

Implications

Rapid rule-out protocols—which include clinical evaluation, a negative ECG, and a negative high-sensitivity cardiac troponin—identify a large proportion of low-risk patients who are unlikely to have a true AMI.

Prevalence and Localization of Pulmonary Embolism in Unexplained Acute Exacerbations of COPD: A Systematic Review and Meta-analysis. Aleva FE et al. Chest, 2017;151(3):544-54.⁷

Background

Acute exacerbations of chronic obstructive pulmonary disease (AE-COPD) are frequent. In up to 30%, no clear trigger is found. Previous studies suggested that 1 in 4 of these patients may have a pulmonary embolus (PE).⁷ This study reviewed the literature and meta-data to describe the prevalence, the embolism location, and the clinical predictors of PE among patients with unexplained AE-COPD.

Findings

A systematic review of the literature and meta-analysis identified 7 studies with 880 patients. In the pooled analysis, 16% had PE (range: 3%–29%). Of the 120 patients with PE, two-thirds were in lobar or larger arteries and one-third in segmental or smaller. Pleuritic chest pain and signs of cardiac compromise (hypotension, syncope, and right-sided heart failure) were associated with PE.

Cautions

This study was heterogeneous leading to a broad confidence interval for prevalence ranging from 8%–25%. Given the frequency of AE-COPD with no identified trigger, physicians need to attend to risks of repeat radiation exposure when considering an evaluation for PE.

Implications

One in 6 patients with unexplained AE-COPD was found to have PE; the odds were greater in those with pleuritic chest pain or signs of cardiac compromise. In patients with AE-COPD with an unclear trigger, the providers should consider an evaluation for PE by using a clinical prediction rule and/or a D-dimer.

Sitting at Patients’ Bedsides May Improve Patients’ Perceptions of Physician Communication Skills. Merel SE et al. Journal of Hospital Medicine, 2016;11(12):865-8.⁹

Background

Sitting at a patient’s bedside in the inpatient setting is considered a best practice, yet it has not been widely adopted. The authors conducted a cluster-randomized trial of physicians on a single 28-bed hospitalist only run unit where physicians were assigned to sitting or standing for the first 3 days of a 7-day workweek assignment. New admissions or transfers to the unit were considered eligible for the study.

Findings

Sixteen hospitalists saw on an average 13 patients daily during the study (a total of 159 patients were included in the analysis after 52 patients were excluded or declined to participate). The hospitalists were 69% female, and 81% had been in practice 3 years or less. The average time spent in the patient’s room was 12:00 minutes while seated and 12:10 minutes while standing. There was no difference in the patients’ perception of the amount of time spent—the patients overestimated this by 4 minutes in both groups. Sitting was associated with higher ratings for “listening carefully” and “explaining things in a way that was easy to understand.” There was no difference in ratings on the physicians interrupting the patient when talking or in treating patients with courtesy and respect.

Cautions

The study had a small sample size, was limited to English-speaking patients, and was a single-site study. It involved only attending-level physicians and did not involve nonphysician team members. The physicians were not blinded and were aware that the interactions were monitored, perhaps creating a Hawthorne effect. The analysis did not control for other factors such as the severity of the illness, the number of consultants used, or the degree of health literacy.

Implications

This study supports an important best practice highlighted in etiquette-based medicine ¹⁰: sitting at the bedside provided a benefit in the patient’s perception of communication by physicians without a negative effect on the physician’s workflow.

The Duration of Antibiotic Treatment in Community-Acquired Pneumonia: A Multi-Center Randomized Clinical Trial. Uranga A et al. JAMA Intern Medicine, 2016;176(9):1257-65.¹¹

Background

The optimal duration of treatment for community-acquired pneumonia (CAP) is unclear; a growing body of evidence suggests shorter and longer durations may be equivalent.

Findings

At 4 hospitals in Spain, 312 adults with a mean age of 65 years and a diagnosis of CAP (non-ICU) were randomized to a short (5 days) versus a long (provider discretion) course of antibiotics. In the short-course group, the antibiotics were stopped after 5 days if the body temperature had been 37.8^o C or less for 48 hours, and no more than 1 sign of clinical instability was present (SBP < 90 mmHg, HR >100/min, RR > 24/min, O2Sat < 90%). The median number of antibiotic days was 5 for the short-course group and 10 for the long-course group (P < .01). There was no difference in the resolution of pneumonia symptoms at 10 days or 30 days or in 30-day mortality. There were no differences in in-hospital side effects. However, 30-day readmissions were higher in the long-course group compared with the short-course group (6.6% vs 1.4%; P = .02). The results were similar across all of the Pneumonia Severity Index (PSI) classes.

Cautions

Most of the patients were not severely ill (~60% PSI I-III), the level of comorbid disease was low, and nearly 80% of the patients received fluoroquinolone. There was a significant cross over with 30% of patients assigned to the short-course group receiving antibiotics for more than 5 days.

Implications

Inpatient providers should aim to treat patients with community-acquired pneumonia (regardless of the severity of the illness) for 5 days. At day 5, if the patient is afebrile and has no signs of clinical instability, clinicians should be comfortable stopping antibiotics.

Is the Era of Intravenous Proton Pump Inhibitors Coming to an End in Patients with Bleeding Peptic Ulcers? A Meta-Analysis of the Published Literature. Jian Z et al. British Journal of Clinical Pharmacology, 2016;82(3):880-9.¹²

Background

Guidelines recommend intravenous proton pump inhibitors (PPI) after an endoscopy for patients with a bleeding peptic ulcer. Yet, acid suppression with oral PPI is deemed equivalent to the intravenous route.

Findings

This systematic review and meta-analysis identified 7 randomized controlled trials involving 859 patients. After an endoscopy, the patients were randomized to receive either oral or intravenous PPI. Most of the patients had “high-risk” peptic ulcers (active bleeding, a visible vessel, an adherent clot). The PPI dose and frequency varied between the studies. Re-bleeding rates were no different between the oral and intravenous route at 72 hours (2.4% vs 5.1%; P = .26), 7 days (5.6% vs 6.8%; P =.68), or 30 days (7.9% vs 8.8%; P = .62). There was also no difference in 30-day mortality (2.1% vs 2.4%; P = .88), and the length of stay was the same in both groups. Side effects were not reported.

Cautions

This systematic review and meta-analysis included multiple heterogeneous small studies of moderate quality. A large number of patients were excluded, increasing the risk of a selection bias.

Implications

There is no clear indication for intravenous PPI in the treatment of bleeding peptic ulcers following an endoscopy. Converting to oral PPI is equivalent to intravenous and is a safe, effective, and cost-saving option for patients with bleeding peptic ulcers.

The 2015 National Academy of Sciences (NAS; formerly the Institute of Medicine [IOM]) report, Improving Diagnosis in Health Care, attributes up to 10% of patient deaths and 17% of hospital adverse events to diagnostic errors,¹ one cause of which is absent or delayed follow-up of laboratory test results.² Poor communication or follow-up of laboratory tests with abnormal results has been cited repeatedly as a threat to patient safety.^1,3,4 In a survey of internists, 83% reported at least one unacceptably delayed laboratory test result during the previous 2 months.⁵

Care transitions magnify the risk of missed test results.^6,7 Up to 16% of all emergency department (ED) and 23% of all hospitalized patients will have pending laboratory test results at release or discharge.⁶ The percentage of tests that received follow-up ranged from 1% to 75% for tests done in the ED and from 20% to 69% for tests ordered on inpatients. In one study, 41% of all surveyed medical inpatients had at least one test result pending at discharge (TPAD). When further studied, over 40% of the results were abnormal and 9% required action, but the responsible physicians were unaware of 62% of the test results.⁸ Many examples of morbidity from such failure have been reported. One of many described by El-Kareh et al., for example, is that of an 81-year-old man on total parenteral nutrition who was treated for suspected line infection and discharged without antibiotics, but whose blood cultures grew Klebsiella pneumoniae after his discharge.⁹ Another example, presented on the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network, reported a patient admitted for a urinary tract infection and then discharged from the hospital on trimethoprim–sulfamethoxazole. He returned to the hospital 11 days later with severe sepsis. Upon review, the urine culture results from his previous admission, which were returned 2 days after his discharge, indicated that the infectious agent was not sensitive to trimethoprim–sulfamethoxazole. The results had not been reviewed by hospital clinicians or forwarded to the patient’s physician, so the patient continued on the ineffective treatment. His second hospital admission lasted 7 days, but he made a complete recovery with the correct antibiotic.¹⁰

Several barriers impede the follow-up of TPAD. First, who should receive test results or who is responsible for addressing them may be unclear. Second, even if responsibility is clear, communication between the provider who ordered the test and the provider responsible for follow-up may be suboptimal.¹¹ Finally, providers who need to follow up on abnormal results may not appreciate the urgency or significance of pending results.

The hospitalist model of care increases efficiency during hospitalization but further complicates care coordination.¹² The hospitalist who orders a test may not be on duty at discharge or when test results are finalized. Primary care providers may have little contact with their patients during their admission.¹² Effective communication between providers is key to ensuring appropriate follow-up care, but primary care physicians and hospital physicians communicate directly in 20% or fewer admissions.¹³ The hospital discharge summary is the primary method of communication with the next provider, but 65%–84% of all discharge summaries lack information on TPAD.^13,14

In this work, we sought to identify and evaluate interventions aimed at improving documentation, communication, and follow-up of TPAD. This review was conducted through the Laboratory Medicine Best Practices (LMBP™) initiative, which is sponsored by the Centers for Disease Control and Prevention’s (CDC’s) Division of Laboratory Systems (https://wwwn.cdc.gov/labbestpractices/). The LMBP™ was initiated as the CDC’s response to the IOM report To Err is Human: Building a Safer Health System.¹⁵

We applied the first four phases of the LMBP™-developed A-6 Cycle methodology to evaluate quality improvement practices as described below.¹⁶ Our report follows the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines.¹⁷

Asking the Question

The full review, which is available from the corresponding author, assessed the evidence that the interventions improved (1) the timeliness of follow-up of TPAD or reduced adverse health events; (2) discharge planning, documentation, or communication with the outpatient care provider regarding TPAD; and (3) health outcomes. In this article, we present the impact of interventions to improve the documentation, communication, and follow-up of TPAD. The review protocol, which is also available from the corresponding author, was developed with the input of a panel of experts (Appendix A) in laboratory medicine, systematic reviews, informatics, and patient safety. The analytic framework (Appendix B) describes the scope of the review. The inclusion criteria for papers reporting on interventions to improve communication of TPAD are the following:

• Population: Patients who were admitted to an inpatient facility or who visited an ED (including patients released from the ED) and who had one or more TPADs.
• Interventions: Practices that explicitly aimed to improve the documentation, communication, or follow-up of TPAD, alone or as part of a broader quality improvement effort.
• Comparators: Standard practice, pre-intervention practice, or any other valid comparator.
• Outcomes: Documentation completeness, physician awareness of pending tests, or follow-up of TPAD.

Acquire the Evidence

A professional librarian conducted literature searches in PubMed, CINAHL, Cochrane, and EMBASE using terms that captured relevant health care settings, transition of patient care, laboratory tests, communication, and pending or missed tests (Appendix C). Citations were also identified by expert panel members and by manual searches of bibliographies of relevant studies. We included studies published in English in 2005 or later. We sought unpublished studies through expert panelists and queries to relevant professional organizations.

Appraise the Studies

Two independent reviewers evaluated each retrieved citation for inclusion. We excluded articles that (1) did not explicitly address laboratory TPAD; (2) were letters, editorials, commentaries, or abstracts; (3) did not address transition between settings; (4) did not include an intervention; (5) were case reports or case series; or (6) were not published in English. A team member abstracted predetermined data elements (Appendix D) from each included study, and a senior scientist reviewed the abstraction. Two senior scientists independently scored the quality of the eligible studies on the A-6 domains of study characteristics, practice description, outcome measures, and results and findings; studies scored below 4 points on a 10-point scale were excluded. Based on this appraisal, studies were classified as good, fair, or poor; poor studies were excluded.

Analyze the Evidence

We synthesized the evidence by intervention type and outcome. The strength of the evidence that each intervention improved the desired outcome was rated in accordance with the A-6 methodology as high, moderate, suggestive, or insufficient based on the number of studies, the study ratings, and the consistency and magnitude of the effect size.

Education to Improve Discharge Summaries

Electronic Tools for Preparation of Discharge Summaries

Two studies ^21,22 investigated tools to aid preparation of discharge summaries. Kantor et al.,²¹ rated fair, evaluated an EMR-generated list of TPAD, and O’Leary et al.,²² rated good, evaluated an electronic discharge summary template. The EMR-generated list resulted in an absolute increase of 25% in the proportion of TPAD documented and of 18% in the percentage of discharge summaries with complete information on TPAD. An electronic discharge summary template increased the percentage of discharge summaries with complete information on TPAD by 32.4%.²² O’Leary et al.²² was the only study that reported a negative effect of an intervention. The authors found a 10% (P = .04) reduction in the documentation of clinically significant laboratory results after implementation of the electronic discharge summary.

Electronic Notifications to Physicians

One good study, El-Kareh et al.,²³ and one fair study, Dalal et al.,²⁴ examined the impact of electronic notification of pending laboratory tests or test results to physicians. El-Kareh et al.²³ also provided evidence on improved follow-up of test results. Physicians in intervention clusters were three times more likely (OR 3.2 95% CI 1.3-8.4) to have documented follow-up of test results than those in control clusters.²³ The absolute increase in awareness of TPAD was 20%,^23,24 among primary care physicians and 12%²³ or 38%²⁴ among inpatient attending physicians in the intervention clusters.

Notification of Patients or Parents

One study evaluated the impact of online parental access to the results of laboratory tests ordered during a child’s ED visit.²⁵ The intervention indirectly increased physician awareness of the test results: 36 parents (12% of enrolled families) reported informing their physician of the test results. Therapy changed for seven children (5% of 141 whose parents retrieved the child’s test results and completed the follow-up survey).

Evidence Summary

We identified four interventions aimed at improving follow-up of TPAD and found suggestive evidence indicating that individual education for preparers of discharge summaries improved the quality of discharge summary documentation of TPAD; however, this type of evidence is below the level of evidence required by the LMBP™ to issue a recommendation. Site variations in the type and timing of interventions,²⁰ small sample size,¹⁸ short follow-up,^18,19 lack of detail on educational content,^18-20 and differences in evaluated interventions limited the evidence quality. The long-term impact of educational interventions is also a concern. Oluma et al., for example, found that the benefits of education interventions were not sustained over time.²⁶

Two studies^21,22 evaluated aids to completing discharge summaries. The aids, which include a list of TPADs²¹ and an electronic template,²² resulted in a substantial increase in the completeness of the documentation of TPAD. Because of the differences in the interventions and the limited number of studies obtained, the evidence was rated as suggestive.

Suggestive evidence that automated e-mail notifications increased awareness of TPAD results by inpatient attending physicians and primary care providers was found. A limitation of this evidence is that both studies^23,24 retrieved were conducted at the same institution; thus, the findings may not be generalizable to other institutions. Only one paper²⁵ examined the impact of patient or parental access to laboratory tests results on the primary care physician’s awareness and follow-up of TPAD; as such, we consider the available evidence insufficient to evaluate the intervention.

Limitations

The evidence regarding interventions to improve follow-up of TPAD is limited. The interventions evaluated varied considerably in design and implementation. Most studies were conducted at a single medical center. Few studies had concurrent controls, and even fewer were randomized trials. Some studies included multiple interventions, thereby rendering the isolation of the impact of any single intervention difficult to accomplish.

Comparison to Other Literature

We found no other reviews of interventions to improve follow-up of TPAD. A review of interventions to improve information transfer found that computer-generated discharge summaries improved the timeliness and, less consistently, completeness of the summary.¹³ The authors of this review¹³ recommended computer-generated structured summaries that highlight the most pertinent information for follow-up care, as supported by a recent qualitative exploration of care coordination between hospitalists and primary care physicians.²⁷

Successful follow-up of TPAD during care transition is a multistep process requiring identification and documentation of TPAD, notification of person responsible for follow-up, and their recognition and execution of the appropriate follow-up actions. We found suggestive evidence that individual education and tools, such as automated templates or abstraction, can improve documentation of TPADs and that automated alerts to the physician responsible for follow-up can improve awareness of TPAD results. The interventions were distinct; evidence from one intervention and outcome should be applied cautiously to other interventions and outcomes.

None of the interventions completely resolved the problems of documentation, awareness, or follow-up of TPAD. New interventions should consider the barriers to coordination identified by Jones et al.²⁷ and Callen et al.⁷ Both studies identified a lack of systems, policies, and practices to support communication across different settings, including lack of access or difficulty navigating electronic medical records at other institutions; unclear or varied accountability for follow-up care; and inconsistent receipt of discharge documents after initial follow-up visit. These systemic problems were exacerbated by a lack of personal relationships between the community physicians, hospital, and ED clinicians, and between acute care clinicians and patients. In EDs, high patient throughput and short length of stay were found to contribute to these barriers. Although laboratories have a responsibility, required by CLIA regulations, to ensure the accurate and complete transmission of test reports,²⁸ none of the interventions appeared to include laboratorians as stakeholders during the design, implementation, or evaluation of the interventions. Incorporating laboratory personnel and processes into the design of follow-up solutions may increase their effectiveness.

Medical informatics tools have the potential to improve patient safety during care transitions. Unfortunately, the evidence regarding informatics interventions to improve follow-up of TPAD was limited by both the number and the quality of the published studies. In addition, better-designed studies in this area are needed. Studies of interventions to improve follow-up of TPAD need to include well-chosen comparator populations and single, well-defined interventions. Evaluation of the interventions would be strengthened if the studies measured both the targeted outcome of the intervention, such as physician awareness of TPAD, and its impact on patient outcomes. Evaluation of the generalizability of the interventions would be strengthened by multi-site studies and, where appropriate, application of the same intervention to multiple study populations. As failure to communicate or follow up on abnormal laboratory tests is a critical threat to patient safety, more research and interventions to address this problem are urgently needed.

Acknowledgments

The authors appreciate the thoughtful insights offered by the following expert panel members: Joanne Callen, PhD; Julie Gayken, MT; Eric Poon, MD; Meera Viswanathan, PhD; and David West, PhD. The authors thank Dr. Jennifer Taylor for her review of the draft manuscript.

Funding

This work was funded by contract number 200-2014-F-61251 from the Centers for Disease Control and Prevention, Division of Laboratory Systems. Dr. Singh was additionally supported by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (CIN 13-413).

Disclaimer

The findings and conclusions in this study are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the Department of Veterans Affairs.

Disclosures

Drs. Whitehead, Graber, and Meleth, Ms. Kennedy, and Mr. Epner received funding for their work on this manuscript (Contract No. 200-2014-F-61251) from the Centers for Disease Control and Prevention. Dr. Graber receives honoraria from several institutions for presentations on diagnostic errors and has a grant from the Macy Foundation to develop a curriculum on diagnostic errors. Unrelated to this publication, Mr. Epner receives payment as a board member of Silicon BioDevices, as a consultant to Kaiser Foundation Health Plan of Colorado, for lectures from Sysmex, Inc., and for meeting expenses from Abbott Laboratories. He has stock or stock options in Silicon BioDevices, Inc. and Viewics, Inc. No other authors have any financial conflicts to report.

The 2015 National Academy of Sciences (NAS; formerly the Institute of Medicine [IOM]) report, Improving Diagnosis in Health Care, attributes up to 10% of patient deaths and 17% of hospital adverse events to diagnostic errors,¹ one cause of which is absent or delayed follow-up of laboratory test results.² Poor communication or follow-up of laboratory tests with abnormal results has been cited repeatedly as a threat to patient safety.^1,3,4 In a survey of internists, 83% reported at least one unacceptably delayed laboratory test result during the previous 2 months.⁵

Care transitions magnify the risk of missed test results.^6,7 Up to 16% of all emergency department (ED) and 23% of all hospitalized patients will have pending laboratory test results at release or discharge.⁶ The percentage of tests that received follow-up ranged from 1% to 75% for tests done in the ED and from 20% to 69% for tests ordered on inpatients. In one study, 41% of all surveyed medical inpatients had at least one test result pending at discharge (TPAD). When further studied, over 40% of the results were abnormal and 9% required action, but the responsible physicians were unaware of 62% of the test results.⁸ Many examples of morbidity from such failure have been reported. One of many described by El-Kareh et al., for example, is that of an 81-year-old man on total parenteral nutrition who was treated for suspected line infection and discharged without antibiotics, but whose blood cultures grew Klebsiella pneumoniae after his discharge.⁹ Another example, presented on the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network, reported a patient admitted for a urinary tract infection and then discharged from the hospital on trimethoprim–sulfamethoxazole. He returned to the hospital 11 days later with severe sepsis. Upon review, the urine culture results from his previous admission, which were returned 2 days after his discharge, indicated that the infectious agent was not sensitive to trimethoprim–sulfamethoxazole. The results had not been reviewed by hospital clinicians or forwarded to the patient’s physician, so the patient continued on the ineffective treatment. His second hospital admission lasted 7 days, but he made a complete recovery with the correct antibiotic.¹⁰

Several barriers impede the follow-up of TPAD. First, who should receive test results or who is responsible for addressing them may be unclear. Second, even if responsibility is clear, communication between the provider who ordered the test and the provider responsible for follow-up may be suboptimal.¹¹ Finally, providers who need to follow up on abnormal results may not appreciate the urgency or significance of pending results.

The hospitalist model of care increases efficiency during hospitalization but further complicates care coordination.¹² The hospitalist who orders a test may not be on duty at discharge or when test results are finalized. Primary care providers may have little contact with their patients during their admission.¹² Effective communication between providers is key to ensuring appropriate follow-up care, but primary care physicians and hospital physicians communicate directly in 20% or fewer admissions.¹³ The hospital discharge summary is the primary method of communication with the next provider, but 65%–84% of all discharge summaries lack information on TPAD.^13,14

In this work, we sought to identify and evaluate interventions aimed at improving documentation, communication, and follow-up of TPAD. This review was conducted through the Laboratory Medicine Best Practices (LMBP™) initiative, which is sponsored by the Centers for Disease Control and Prevention’s (CDC’s) Division of Laboratory Systems (https://wwwn.cdc.gov/labbestpractices/). The LMBP™ was initiated as the CDC’s response to the IOM report To Err is Human: Building a Safer Health System.¹⁵

We applied the first four phases of the LMBP™-developed A-6 Cycle methodology to evaluate quality improvement practices as described below.¹⁶ Our report follows the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines.¹⁷

Asking the Question

The full review, which is available from the corresponding author, assessed the evidence that the interventions improved (1) the timeliness of follow-up of TPAD or reduced adverse health events; (2) discharge planning, documentation, or communication with the outpatient care provider regarding TPAD; and (3) health outcomes. In this article, we present the impact of interventions to improve the documentation, communication, and follow-up of TPAD. The review protocol, which is also available from the corresponding author, was developed with the input of a panel of experts (Appendix A) in laboratory medicine, systematic reviews, informatics, and patient safety. The analytic framework (Appendix B) describes the scope of the review. The inclusion criteria for papers reporting on interventions to improve communication of TPAD are the following:

• Population: Patients who were admitted to an inpatient facility or who visited an ED (including patients released from the ED) and who had one or more TPADs.
• Interventions: Practices that explicitly aimed to improve the documentation, communication, or follow-up of TPAD, alone or as part of a broader quality improvement effort.
• Comparators: Standard practice, pre-intervention practice, or any other valid comparator.
• Outcomes: Documentation completeness, physician awareness of pending tests, or follow-up of TPAD.

Acquire the Evidence

A professional librarian conducted literature searches in PubMed, CINAHL, Cochrane, and EMBASE using terms that captured relevant health care settings, transition of patient care, laboratory tests, communication, and pending or missed tests (Appendix C). Citations were also identified by expert panel members and by manual searches of bibliographies of relevant studies. We included studies published in English in 2005 or later. We sought unpublished studies through expert panelists and queries to relevant professional organizations.

Appraise the Studies

Two independent reviewers evaluated each retrieved citation for inclusion. We excluded articles that (1) did not explicitly address laboratory TPAD; (2) were letters, editorials, commentaries, or abstracts; (3) did not address transition between settings; (4) did not include an intervention; (5) were case reports or case series; or (6) were not published in English. A team member abstracted predetermined data elements (Appendix D) from each included study, and a senior scientist reviewed the abstraction. Two senior scientists independently scored the quality of the eligible studies on the A-6 domains of study characteristics, practice description, outcome measures, and results and findings; studies scored below 4 points on a 10-point scale were excluded. Based on this appraisal, studies were classified as good, fair, or poor; poor studies were excluded.

Analyze the Evidence

We synthesized the evidence by intervention type and outcome. The strength of the evidence that each intervention improved the desired outcome was rated in accordance with the A-6 methodology as high, moderate, suggestive, or insufficient based on the number of studies, the study ratings, and the consistency and magnitude of the effect size.

Education to Improve Discharge Summaries

Electronic Tools for Preparation of Discharge Summaries

Two studies ^21,22 investigated tools to aid preparation of discharge summaries. Kantor et al.,²¹ rated fair, evaluated an EMR-generated list of TPAD, and O’Leary et al.,²² rated good, evaluated an electronic discharge summary template. The EMR-generated list resulted in an absolute increase of 25% in the proportion of TPAD documented and of 18% in the percentage of discharge summaries with complete information on TPAD. An electronic discharge summary template increased the percentage of discharge summaries with complete information on TPAD by 32.4%.²² O’Leary et al.²² was the only study that reported a negative effect of an intervention. The authors found a 10% (P = .04) reduction in the documentation of clinically significant laboratory results after implementation of the electronic discharge summary.

Electronic Notifications to Physicians

One good study, El-Kareh et al.,²³ and one fair study, Dalal et al.,²⁴ examined the impact of electronic notification of pending laboratory tests or test results to physicians. El-Kareh et al.²³ also provided evidence on improved follow-up of test results. Physicians in intervention clusters were three times more likely (OR 3.2 95% CI 1.3-8.4) to have documented follow-up of test results than those in control clusters.²³ The absolute increase in awareness of TPAD was 20%,^23,24 among primary care physicians and 12%²³ or 38%²⁴ among inpatient attending physicians in the intervention clusters.

Notification of Patients or Parents

One study evaluated the impact of online parental access to the results of laboratory tests ordered during a child’s ED visit.²⁵ The intervention indirectly increased physician awareness of the test results: 36 parents (12% of enrolled families) reported informing their physician of the test results. Therapy changed for seven children (5% of 141 whose parents retrieved the child’s test results and completed the follow-up survey).

Evidence Summary

We identified four interventions aimed at improving follow-up of TPAD and found suggestive evidence indicating that individual education for preparers of discharge summaries improved the quality of discharge summary documentation of TPAD; however, this type of evidence is below the level of evidence required by the LMBP™ to issue a recommendation. Site variations in the type and timing of interventions,²⁰ small sample size,¹⁸ short follow-up,^18,19 lack of detail on educational content,^18-20 and differences in evaluated interventions limited the evidence quality. The long-term impact of educational interventions is also a concern. Oluma et al., for example, found that the benefits of education interventions were not sustained over time.²⁶

Two studies^21,22 evaluated aids to completing discharge summaries. The aids, which include a list of TPADs²¹ and an electronic template,²² resulted in a substantial increase in the completeness of the documentation of TPAD. Because of the differences in the interventions and the limited number of studies obtained, the evidence was rated as suggestive.

Suggestive evidence that automated e-mail notifications increased awareness of TPAD results by inpatient attending physicians and primary care providers was found. A limitation of this evidence is that both studies^23,24 retrieved were conducted at the same institution; thus, the findings may not be generalizable to other institutions. Only one paper²⁵ examined the impact of patient or parental access to laboratory tests results on the primary care physician’s awareness and follow-up of TPAD; as such, we consider the available evidence insufficient to evaluate the intervention.

Limitations

The evidence regarding interventions to improve follow-up of TPAD is limited. The interventions evaluated varied considerably in design and implementation. Most studies were conducted at a single medical center. Few studies had concurrent controls, and even fewer were randomized trials. Some studies included multiple interventions, thereby rendering the isolation of the impact of any single intervention difficult to accomplish.

Comparison to Other Literature

We found no other reviews of interventions to improve follow-up of TPAD. A review of interventions to improve information transfer found that computer-generated discharge summaries improved the timeliness and, less consistently, completeness of the summary.¹³ The authors of this review¹³ recommended computer-generated structured summaries that highlight the most pertinent information for follow-up care, as supported by a recent qualitative exploration of care coordination between hospitalists and primary care physicians.²⁷

Successful follow-up of TPAD during care transition is a multistep process requiring identification and documentation of TPAD, notification of person responsible for follow-up, and their recognition and execution of the appropriate follow-up actions. We found suggestive evidence that individual education and tools, such as automated templates or abstraction, can improve documentation of TPADs and that automated alerts to the physician responsible for follow-up can improve awareness of TPAD results. The interventions were distinct; evidence from one intervention and outcome should be applied cautiously to other interventions and outcomes.

None of the interventions completely resolved the problems of documentation, awareness, or follow-up of TPAD. New interventions should consider the barriers to coordination identified by Jones et al.²⁷ and Callen et al.⁷ Both studies identified a lack of systems, policies, and practices to support communication across different settings, including lack of access or difficulty navigating electronic medical records at other institutions; unclear or varied accountability for follow-up care; and inconsistent receipt of discharge documents after initial follow-up visit. These systemic problems were exacerbated by a lack of personal relationships between the community physicians, hospital, and ED clinicians, and between acute care clinicians and patients. In EDs, high patient throughput and short length of stay were found to contribute to these barriers. Although laboratories have a responsibility, required by CLIA regulations, to ensure the accurate and complete transmission of test reports,²⁸ none of the interventions appeared to include laboratorians as stakeholders during the design, implementation, or evaluation of the interventions. Incorporating laboratory personnel and processes into the design of follow-up solutions may increase their effectiveness.

Medical informatics tools have the potential to improve patient safety during care transitions. Unfortunately, the evidence regarding informatics interventions to improve follow-up of TPAD was limited by both the number and the quality of the published studies. In addition, better-designed studies in this area are needed. Studies of interventions to improve follow-up of TPAD need to include well-chosen comparator populations and single, well-defined interventions. Evaluation of the interventions would be strengthened if the studies measured both the targeted outcome of the intervention, such as physician awareness of TPAD, and its impact on patient outcomes. Evaluation of the generalizability of the interventions would be strengthened by multi-site studies and, where appropriate, application of the same intervention to multiple study populations. As failure to communicate or follow up on abnormal laboratory tests is a critical threat to patient safety, more research and interventions to address this problem are urgently needed.

Acknowledgments

The authors appreciate the thoughtful insights offered by the following expert panel members: Joanne Callen, PhD; Julie Gayken, MT; Eric Poon, MD; Meera Viswanathan, PhD; and David West, PhD. The authors thank Dr. Jennifer Taylor for her review of the draft manuscript.

Funding

This work was funded by contract number 200-2014-F-61251 from the Centers for Disease Control and Prevention, Division of Laboratory Systems. Dr. Singh was additionally supported by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (CIN 13-413).

Disclaimer

The findings and conclusions in this study are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the Department of Veterans Affairs.

Disclosures

Drs. Whitehead, Graber, and Meleth, Ms. Kennedy, and Mr. Epner received funding for their work on this manuscript (Contract No. 200-2014-F-61251) from the Centers for Disease Control and Prevention. Dr. Graber receives honoraria from several institutions for presentations on diagnostic errors and has a grant from the Macy Foundation to develop a curriculum on diagnostic errors. Unrelated to this publication, Mr. Epner receives payment as a board member of Silicon BioDevices, as a consultant to Kaiser Foundation Health Plan of Colorado, for lectures from Sysmex, Inc., and for meeting expenses from Abbott Laboratories. He has stock or stock options in Silicon BioDevices, Inc. and Viewics, Inc. No other authors have any financial conflicts to report.

The 2015 National Academy of Sciences (NAS; formerly the Institute of Medicine [IOM]) report, Improving Diagnosis in Health Care, attributes up to 10% of patient deaths and 17% of hospital adverse events to diagnostic errors,¹ one cause of which is absent or delayed follow-up of laboratory test results.² Poor communication or follow-up of laboratory tests with abnormal results has been cited repeatedly as a threat to patient safety.^1,3,4 In a survey of internists, 83% reported at least one unacceptably delayed laboratory test result during the previous 2 months.⁵

Care transitions magnify the risk of missed test results.^6,7 Up to 16% of all emergency department (ED) and 23% of all hospitalized patients will have pending laboratory test results at release or discharge.⁶ The percentage of tests that received follow-up ranged from 1% to 75% for tests done in the ED and from 20% to 69% for tests ordered on inpatients. In one study, 41% of all surveyed medical inpatients had at least one test result pending at discharge (TPAD). When further studied, over 40% of the results were abnormal and 9% required action, but the responsible physicians were unaware of 62% of the test results.⁸ Many examples of morbidity from such failure have been reported. One of many described by El-Kareh et al., for example, is that of an 81-year-old man on total parenteral nutrition who was treated for suspected line infection and discharged without antibiotics, but whose blood cultures grew Klebsiella pneumoniae after his discharge.⁹ Another example, presented on the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network, reported a patient admitted for a urinary tract infection and then discharged from the hospital on trimethoprim–sulfamethoxazole. He returned to the hospital 11 days later with severe sepsis. Upon review, the urine culture results from his previous admission, which were returned 2 days after his discharge, indicated that the infectious agent was not sensitive to trimethoprim–sulfamethoxazole. The results had not been reviewed by hospital clinicians or forwarded to the patient’s physician, so the patient continued on the ineffective treatment. His second hospital admission lasted 7 days, but he made a complete recovery with the correct antibiotic.¹⁰

Several barriers impede the follow-up of TPAD. First, who should receive test results or who is responsible for addressing them may be unclear. Second, even if responsibility is clear, communication between the provider who ordered the test and the provider responsible for follow-up may be suboptimal.¹¹ Finally, providers who need to follow up on abnormal results may not appreciate the urgency or significance of pending results.

The hospitalist model of care increases efficiency during hospitalization but further complicates care coordination.¹² The hospitalist who orders a test may not be on duty at discharge or when test results are finalized. Primary care providers may have little contact with their patients during their admission.¹² Effective communication between providers is key to ensuring appropriate follow-up care, but primary care physicians and hospital physicians communicate directly in 20% or fewer admissions.¹³ The hospital discharge summary is the primary method of communication with the next provider, but 65%–84% of all discharge summaries lack information on TPAD.^13,14

In this work, we sought to identify and evaluate interventions aimed at improving documentation, communication, and follow-up of TPAD. This review was conducted through the Laboratory Medicine Best Practices (LMBP™) initiative, which is sponsored by the Centers for Disease Control and Prevention’s (CDC’s) Division of Laboratory Systems (https://wwwn.cdc.gov/labbestpractices/). The LMBP™ was initiated as the CDC’s response to the IOM report To Err is Human: Building a Safer Health System.¹⁵

We applied the first four phases of the LMBP™-developed A-6 Cycle methodology to evaluate quality improvement practices as described below.¹⁶ Our report follows the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines.¹⁷

Asking the Question

The full review, which is available from the corresponding author, assessed the evidence that the interventions improved (1) the timeliness of follow-up of TPAD or reduced adverse health events; (2) discharge planning, documentation, or communication with the outpatient care provider regarding TPAD; and (3) health outcomes. In this article, we present the impact of interventions to improve the documentation, communication, and follow-up of TPAD. The review protocol, which is also available from the corresponding author, was developed with the input of a panel of experts (Appendix A) in laboratory medicine, systematic reviews, informatics, and patient safety. The analytic framework (Appendix B) describes the scope of the review. The inclusion criteria for papers reporting on interventions to improve communication of TPAD are the following:

• Population: Patients who were admitted to an inpatient facility or who visited an ED (including patients released from the ED) and who had one or more TPADs.
• Interventions: Practices that explicitly aimed to improve the documentation, communication, or follow-up of TPAD, alone or as part of a broader quality improvement effort.
• Comparators: Standard practice, pre-intervention practice, or any other valid comparator.
• Outcomes: Documentation completeness, physician awareness of pending tests, or follow-up of TPAD.

Acquire the Evidence

A professional librarian conducted literature searches in PubMed, CINAHL, Cochrane, and EMBASE using terms that captured relevant health care settings, transition of patient care, laboratory tests, communication, and pending or missed tests (Appendix C). Citations were also identified by expert panel members and by manual searches of bibliographies of relevant studies. We included studies published in English in 2005 or later. We sought unpublished studies through expert panelists and queries to relevant professional organizations.

Appraise the Studies

Two independent reviewers evaluated each retrieved citation for inclusion. We excluded articles that (1) did not explicitly address laboratory TPAD; (2) were letters, editorials, commentaries, or abstracts; (3) did not address transition between settings; (4) did not include an intervention; (5) were case reports or case series; or (6) were not published in English. A team member abstracted predetermined data elements (Appendix D) from each included study, and a senior scientist reviewed the abstraction. Two senior scientists independently scored the quality of the eligible studies on the A-6 domains of study characteristics, practice description, outcome measures, and results and findings; studies scored below 4 points on a 10-point scale were excluded. Based on this appraisal, studies were classified as good, fair, or poor; poor studies were excluded.

Analyze the Evidence

We synthesized the evidence by intervention type and outcome. The strength of the evidence that each intervention improved the desired outcome was rated in accordance with the A-6 methodology as high, moderate, suggestive, or insufficient based on the number of studies, the study ratings, and the consistency and magnitude of the effect size.

Education to Improve Discharge Summaries

Electronic Tools for Preparation of Discharge Summaries

Two studies ^21,22 investigated tools to aid preparation of discharge summaries. Kantor et al.,²¹ rated fair, evaluated an EMR-generated list of TPAD, and O’Leary et al.,²² rated good, evaluated an electronic discharge summary template. The EMR-generated list resulted in an absolute increase of 25% in the proportion of TPAD documented and of 18% in the percentage of discharge summaries with complete information on TPAD. An electronic discharge summary template increased the percentage of discharge summaries with complete information on TPAD by 32.4%.²² O’Leary et al.²² was the only study that reported a negative effect of an intervention. The authors found a 10% (P = .04) reduction in the documentation of clinically significant laboratory results after implementation of the electronic discharge summary.

Electronic Notifications to Physicians

One good study, El-Kareh et al.,²³ and one fair study, Dalal et al.,²⁴ examined the impact of electronic notification of pending laboratory tests or test results to physicians. El-Kareh et al.²³ also provided evidence on improved follow-up of test results. Physicians in intervention clusters were three times more likely (OR 3.2 95% CI 1.3-8.4) to have documented follow-up of test results than those in control clusters.²³ The absolute increase in awareness of TPAD was 20%,^23,24 among primary care physicians and 12%²³ or 38%²⁴ among inpatient attending physicians in the intervention clusters.

Notification of Patients or Parents

One study evaluated the impact of online parental access to the results of laboratory tests ordered during a child’s ED visit.²⁵ The intervention indirectly increased physician awareness of the test results: 36 parents (12% of enrolled families) reported informing their physician of the test results. Therapy changed for seven children (5% of 141 whose parents retrieved the child’s test results and completed the follow-up survey).

Evidence Summary

We identified four interventions aimed at improving follow-up of TPAD and found suggestive evidence indicating that individual education for preparers of discharge summaries improved the quality of discharge summary documentation of TPAD; however, this type of evidence is below the level of evidence required by the LMBP™ to issue a recommendation. Site variations in the type and timing of interventions,²⁰ small sample size,¹⁸ short follow-up,^18,19 lack of detail on educational content,^18-20 and differences in evaluated interventions limited the evidence quality. The long-term impact of educational interventions is also a concern. Oluma et al., for example, found that the benefits of education interventions were not sustained over time.²⁶

Two studies^21,22 evaluated aids to completing discharge summaries. The aids, which include a list of TPADs²¹ and an electronic template,²² resulted in a substantial increase in the completeness of the documentation of TPAD. Because of the differences in the interventions and the limited number of studies obtained, the evidence was rated as suggestive.

Suggestive evidence that automated e-mail notifications increased awareness of TPAD results by inpatient attending physicians and primary care providers was found. A limitation of this evidence is that both studies^23,24 retrieved were conducted at the same institution; thus, the findings may not be generalizable to other institutions. Only one paper²⁵ examined the impact of patient or parental access to laboratory tests results on the primary care physician’s awareness and follow-up of TPAD; as such, we consider the available evidence insufficient to evaluate the intervention.

Limitations

The evidence regarding interventions to improve follow-up of TPAD is limited. The interventions evaluated varied considerably in design and implementation. Most studies were conducted at a single medical center. Few studies had concurrent controls, and even fewer were randomized trials. Some studies included multiple interventions, thereby rendering the isolation of the impact of any single intervention difficult to accomplish.

Comparison to Other Literature

We found no other reviews of interventions to improve follow-up of TPAD. A review of interventions to improve information transfer found that computer-generated discharge summaries improved the timeliness and, less consistently, completeness of the summary.¹³ The authors of this review¹³ recommended computer-generated structured summaries that highlight the most pertinent information for follow-up care, as supported by a recent qualitative exploration of care coordination between hospitalists and primary care physicians.²⁷

Successful follow-up of TPAD during care transition is a multistep process requiring identification and documentation of TPAD, notification of person responsible for follow-up, and their recognition and execution of the appropriate follow-up actions. We found suggestive evidence that individual education and tools, such as automated templates or abstraction, can improve documentation of TPADs and that automated alerts to the physician responsible for follow-up can improve awareness of TPAD results. The interventions were distinct; evidence from one intervention and outcome should be applied cautiously to other interventions and outcomes.

None of the interventions completely resolved the problems of documentation, awareness, or follow-up of TPAD. New interventions should consider the barriers to coordination identified by Jones et al.²⁷ and Callen et al.⁷ Both studies identified a lack of systems, policies, and practices to support communication across different settings, including lack of access or difficulty navigating electronic medical records at other institutions; unclear or varied accountability for follow-up care; and inconsistent receipt of discharge documents after initial follow-up visit. These systemic problems were exacerbated by a lack of personal relationships between the community physicians, hospital, and ED clinicians, and between acute care clinicians and patients. In EDs, high patient throughput and short length of stay were found to contribute to these barriers. Although laboratories have a responsibility, required by CLIA regulations, to ensure the accurate and complete transmission of test reports,²⁸ none of the interventions appeared to include laboratorians as stakeholders during the design, implementation, or evaluation of the interventions. Incorporating laboratory personnel and processes into the design of follow-up solutions may increase their effectiveness.

Medical informatics tools have the potential to improve patient safety during care transitions. Unfortunately, the evidence regarding informatics interventions to improve follow-up of TPAD was limited by both the number and the quality of the published studies. In addition, better-designed studies in this area are needed. Studies of interventions to improve follow-up of TPAD need to include well-chosen comparator populations and single, well-defined interventions. Evaluation of the interventions would be strengthened if the studies measured both the targeted outcome of the intervention, such as physician awareness of TPAD, and its impact on patient outcomes. Evaluation of the generalizability of the interventions would be strengthened by multi-site studies and, where appropriate, application of the same intervention to multiple study populations. As failure to communicate or follow up on abnormal laboratory tests is a critical threat to patient safety, more research and interventions to address this problem are urgently needed.

Acknowledgments

The authors appreciate the thoughtful insights offered by the following expert panel members: Joanne Callen, PhD; Julie Gayken, MT; Eric Poon, MD; Meera Viswanathan, PhD; and David West, PhD. The authors thank Dr. Jennifer Taylor for her review of the draft manuscript.

Funding

This work was funded by contract number 200-2014-F-61251 from the Centers for Disease Control and Prevention, Division of Laboratory Systems. Dr. Singh was additionally supported by the Houston VA HSR&D Center for Innovations in Quality, Effectiveness, and Safety (CIN 13-413).

Disclaimer

The findings and conclusions in this study are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention or the Department of Veterans Affairs.

Disclosures

Drs. Whitehead, Graber, and Meleth, Ms. Kennedy, and Mr. Epner received funding for their work on this manuscript (Contract No. 200-2014-F-61251) from the Centers for Disease Control and Prevention. Dr. Graber receives honoraria from several institutions for presentations on diagnostic errors and has a grant from the Macy Foundation to develop a curriculum on diagnostic errors. Unrelated to this publication, Mr. Epner receives payment as a board member of Silicon BioDevices, as a consultant to Kaiser Foundation Health Plan of Colorado, for lectures from Sysmex, Inc., and for meeting expenses from Abbott Laboratories. He has stock or stock options in Silicon BioDevices, Inc. and Viewics, Inc. No other authors have any financial conflicts to report.

The “Things We Do for No Reason” series reviews practices which have become common parts of hospital care but which may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. https://www.choosingwisely.org/

CASE PRESENTATION

A 12-month-old female is admitted for acute bronchiolitis with increased work of breathing and decreased oral intake. She is mildly dehydrated upon exam with a sodium level of 139 mEq/L and is given a 20 mL/kg bolus of 0.9% saline. Given the patient’s poor oral intake, the admitting intern orders maintenance intravenous (IV) fluids and asks her senior resident which IV fluid should be used. The medical student on the team wonders if a different IV fluid would be selected for a 2-week-old with a similar presentation.

Maintenance IV fluids are continuously infused to preserve extracellular volume and electrolyte balance when fluids cannot be taken orally. In contrast, resuscitation IV fluids are given as a bolus to patients in states of hypoperfusion to restore extracellular volume. The given IV fluid concentration can be categorized as approximately equal to (isotonic) or less than (hypotonic) the plasma sodium concentration. Refer to Table 1 for the electrolyte composition of commonly used IV fluids. Dextrose is rapidly metabolized upon infusion and does not affect tonicity.

Why You Might Think Hypotonic Maintenance IV Fluids Are The Right Choice

A 1957 publication by Holliday and Segar laid the foundation for maintenance IV fluid and electrolyte requirements in children and was the initial catalyst for the use of hypotonic maintenance IV fluids.¹ This manuscript contended that hypotonic IV fluids could supply the water and sodium needed to meet maintenance dietary requirements. This claim led to the predominant use of hypotonic maintenance IV fluids in children. By contrast, isotonic IV fluids have been avoided given the apprehension over electrolytes exceeding maintenance needs.

Concerns about the unintended consequences of fluid overload – edema, hypernatremia, and hypertension secondary to increased sodium load – have led some to avoid isotonic IV fluids.² When presented with common clinical scenarios of patients at risk for excess antidiuretic hormone (ADH; also known as arginine vasopressin), pediatric residents chose hypotonic (instead of isotonic) IV fluids 78% of the time.³

Why Isotonic Maintenance IV Fluids Are Usually The Right Choice For Children

General recommendations for hypotonic IV fluids are primarily based on theoretical calculations from the fluid and electrolyte requirements of healthy individuals, and studies have not validated the use of hypotonic IV fluids in clinical practice.¹ Acutely ill patients are at risk for excessive levels of ADH from numerous causes (see Table 2).² As a result, nearly every hospitalized patient is at risk for excess ADH release, thus making them vulnerable to the development of hyponatremia. The syndrome of inappropriate secretion of ADH (SIADH) occurs when nonosmotic/nonhemodynamic stimuli trigger ADH release, which leads to excessive free-water retention and resultant hyponatremia. Schwartz and Bartter reported the first two cases of SIADH in 1957 when hyponatremia developed in the setting of bronchogenic carcinoma.⁴ Although the publication by Holliday and Seger did acknowledge the potential for water intoxication, it was written before this report and before the effects of ADH on the sodium levels of hospitalized patients were clearly understood.² SIADH is now recognized as one of the most common causes of hyponatremia in hospitalized patients.^{5, 6}

Numerous studies have demonstrated that patients who receive hypotonic IV fluids have a significantly higher risk of developing hyponatremia than patients who receive isotonic IV fluids.^7,8 An infrequent, yet serious, complication of iatrogenic hyponatremia is hyponatremic encephalopathy, which carries a high rate of morbidity or mortality.⁹ The prevention of hyponatremia is essential as the early symptoms of hyponatremic encephalopathy are nonspecific and can be easily missed.²

More than 15 prospective randomized controlled trials (RCTs) involving over 2,000 children have demonstrated that isotonic IV fluids are more effective in preventing hospital-acquired hyponatremia than hypotonic IV fluids and are not associated with the development of fluid overload or hypernatremia. A 2014 metaanalysis comprising 10 RCTs and involving over 800 children found that when compared with isotonic IV fluids, hypotonic IV fluids present a relative risk of 2.37 for sodium levels to drop below 135 mEq/L and a relative risk of 6.1 for levels to drop below 130 mEq/L. The numbers needed to treat (NNT) with isotonic IV fluids to prevent hyponatremia in each group were 6 and 17, respectively.⁷ A Cochrane review published in 2014 presented comparable findings, demonstrating that hypotonic IV fluids had a 34% risk of causing hyponatremia; by comparison, isotonic IV fluids had a 17% risk of causing hyponatremia and a NNT of six to prevent hyponatremia.⁸ In a large RCT conducted in 2015 with 676 pediatric patients, McNabb et al. found that when compared with patients receiving isotonic IV fluids, those receiving hypotonic IV fluids had a higher incidence of developing hyponatremia (10.9% versus 3.8%) with a NNT of 15 to prevent hyponatremia with the use of isotonic fluids.¹⁰ Published trials have likely been underpowered to detect a difference in the infrequent adverse hyponatremia outcomes of seizures and mortality.

On the basis of these data, patient safety alerts have recommended the avoidance of hypotonic IV fluids in the United Kingdom (UK) and Australia, and the 2015 UK guidelines for children now recommend isotonic IV fluids for maintenance needs.¹¹ Although many of the aforementioned studies included predominantly critically ill or surgical pediatric patients, the risk of hyponatremia with hypotonic IV fluids seems similarly increased in nonsurgical and noncritically ill pediatric patients.¹⁰

For patients at risk for excess ADH release, some have supported the use of hypotonic IV fluids at a lower than maintenance rate to theoretically decrease the risk of hyponatremia, but this practice has not been effective in preventing hyponatremia.^2,12 Unless a patient is in a fluid overload state, such as in congestive heart failure, cirrhosis, or renal failure; isotonic maintenance IV fluids should not result in fluid overload.³ Available evidence for guiding maintenance IV fluid choice in neonates or young infants is limited. Nevertheless, given the aforementioned reasons, we generally recommend the prescription of isotonic IV fluids for most in this population.

Which Isotonic IV Fluid Should Be Used?

The sodium concentration (154 mmol/L) of 0.9% saline, an isotonic IV fluid, is approximately equal to the tonicity of the aqueous phase of plasma. The majority of studies evaluating the risk of hyponatremia with maintenance IV fluids have used 0.9% saline as the studied isotonic IV fluid. Plasma-Lyte and Ringer’s lactate are low-chloride, buffered/balanced solutions. Plasma-Lyte ([Na] = 140 mmol/L) has been demonstrated to be effective in preventing hyponatremia. Ringers’ lactate is slightly hypotonic ([Na] = 130 mmol/L), and its administration is associated with a decrease in serum sodium.¹³ A resultant dilutional and hyperchloremic metabolic acidosis is more likely to develop with the use of large volumes of 0.9% saline in resuscitation than with the use of balanced solutions.² Whether the prolonged use of 0.9% saline maintenance IV fluids can lead to this same side effect remains unknown given insufficient evidence.² Retrospective studies using balanced solutions have shown an association with decreased rates of acute kidney injury (AKI) and mortality when compared with 0.9% saline. However, a RCT with over 2,000 adult ICU patients showed no change in rates of AKI in those that received Plasma-Lyte compared with those who received 0.9% saline.¹⁴

Two recent, single-center, prospective studies compared the use of Ringer’s lactate or Plasma-Lyte for resuscitation with that of 0.9% saline. One study was comprised of 15,802 critically ill adults, and the other was comprised of 13,347 noncritically adults. Both studies showed that balanced solutions decreased the rate of major adverse kidney events (defined as a composite of death from any cause, new renal-replacement therapy, or persistent renal injury) within 30 days.^15,16 Available published pediatric studies indicate that 0.9% saline is an effective maintenance IV fluid for the prevention of hyponatremia that is not associated with hypernatremia or fluid overload. Further pediatric studies comparing 0.9% saline with balanced solutions are needed.

When Should We Use Hypotonic IV Fluids?

Hypotonic IV fluids may be needed for patients with hypernatremia and a free-water deficit or a renal-concentrating defect with ongoing urinary free-water losses.² Special care should be taken when choosing maintenance IV fluids for patients with renal disease, liver disease, or heart failure given that these groups have been excluded from some studies.¹² These patients may be at risk for increased salt and fluid retention with any IV fluid, and fluid rates need to be restricted. The fluid intake of patients with hyponatremia secondary to SIADH needs close management; these patients benefit from total fluid restriction instead of standard maintenance IV fluid rates.²

What We Should Do Instead?

Maintenance IV fluids should only be used when necessary and should be stopped as soon as they are no longer required, especially in light of the recent shortages in 0.9% saline.¹⁷ Similar to all medications, maintenance IV fluids should be individualized to the patient’s needs on the basis of the indication for IV fluids and the patient’s comorbidities.² Consideration should be given to checking the patient’s electrolyte levels to monitor response to IV fluids, especially during the first 24 hours of admission when risk of hyponatremia is highest. Isotonic IV fluids with 5% dextrose should be used as the maintenance IV fluid in the majority of hospitalized children given its proven benefit in decreasing the rate of hospital-acquired hyponatremia.^7,8 Hypotonic IV fluids should be avoided as the default maintenance IV fluid and should only be utilized under specific circumstances.

• When needed, maintenance IV fluids should always be tailored to each individual patient.
• For most acutely ill hospitalized children, isotonic IV fluids should be the maintenance IV fluid of choice.
• Consider monitoring electrolytes to determine the effects of maintenance IV fluids.

Enteral maintenance fluids should be used first-line if possible. Although hypotonic IV fluids have historically been the maintenance IV fluid of choice, this class of IV fluids should be avoided for most hospitalized children to decrease the significant risk of iatrogenic hyponatremia, which can be severe and have catastrophic complications. When necessary, isotonic IV fluids should be used for the majority of hospitalized children given that these fluids present a significantly decreased risk for causing hyponatremia. Returning to our case presentation, to decrease the risk of hyponatremia, the senior resident should recommend starting isotonic IV fluids in the 12-month-old and theoretical 2-week-old until oral intake can be maintained.

Do you think this is a low-value practice? Is this truly a “Thing We Do for No Reason”? Let us know what you do in your practice and propose ideas for other “Things We Do for No Reason” topics. Please join in the conversation online at Twitter (#TWDFNR)/Facebook and don’t forget to “Like It” on Facebook or retweet it on Twitter.

Disclosure

The authors have no relevant conflicts of interest to report. No payment or services from a 3rd party were received for any aspect of this submitted work. The authors have no financial relationships with entities in the biomedical arena that could be perceived to influence, or that give the appearance of potentially influencing, what was written in this submitted work.

The “Things We Do for No Reason” series reviews practices which have become common parts of hospital care but which may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. https://www.choosingwisely.org/

CASE PRESENTATION

A 12-month-old female is admitted for acute bronchiolitis with increased work of breathing and decreased oral intake. She is mildly dehydrated upon exam with a sodium level of 139 mEq/L and is given a 20 mL/kg bolus of 0.9% saline. Given the patient’s poor oral intake, the admitting intern orders maintenance intravenous (IV) fluids and asks her senior resident which IV fluid should be used. The medical student on the team wonders if a different IV fluid would be selected for a 2-week-old with a similar presentation.

Maintenance IV fluids are continuously infused to preserve extracellular volume and electrolyte balance when fluids cannot be taken orally. In contrast, resuscitation IV fluids are given as a bolus to patients in states of hypoperfusion to restore extracellular volume. The given IV fluid concentration can be categorized as approximately equal to (isotonic) or less than (hypotonic) the plasma sodium concentration. Refer to Table 1 for the electrolyte composition of commonly used IV fluids. Dextrose is rapidly metabolized upon infusion and does not affect tonicity.

Why You Might Think Hypotonic Maintenance IV Fluids Are The Right Choice

A 1957 publication by Holliday and Segar laid the foundation for maintenance IV fluid and electrolyte requirements in children and was the initial catalyst for the use of hypotonic maintenance IV fluids.¹ This manuscript contended that hypotonic IV fluids could supply the water and sodium needed to meet maintenance dietary requirements. This claim led to the predominant use of hypotonic maintenance IV fluids in children. By contrast, isotonic IV fluids have been avoided given the apprehension over electrolytes exceeding maintenance needs.

Concerns about the unintended consequences of fluid overload – edema, hypernatremia, and hypertension secondary to increased sodium load – have led some to avoid isotonic IV fluids.² When presented with common clinical scenarios of patients at risk for excess antidiuretic hormone (ADH; also known as arginine vasopressin), pediatric residents chose hypotonic (instead of isotonic) IV fluids 78% of the time.³

Why Isotonic Maintenance IV Fluids Are Usually The Right Choice For Children

General recommendations for hypotonic IV fluids are primarily based on theoretical calculations from the fluid and electrolyte requirements of healthy individuals, and studies have not validated the use of hypotonic IV fluids in clinical practice.¹ Acutely ill patients are at risk for excessive levels of ADH from numerous causes (see Table 2).² As a result, nearly every hospitalized patient is at risk for excess ADH release, thus making them vulnerable to the development of hyponatremia. The syndrome of inappropriate secretion of ADH (SIADH) occurs when nonosmotic/nonhemodynamic stimuli trigger ADH release, which leads to excessive free-water retention and resultant hyponatremia. Schwartz and Bartter reported the first two cases of SIADH in 1957 when hyponatremia developed in the setting of bronchogenic carcinoma.⁴ Although the publication by Holliday and Seger did acknowledge the potential for water intoxication, it was written before this report and before the effects of ADH on the sodium levels of hospitalized patients were clearly understood.² SIADH is now recognized as one of the most common causes of hyponatremia in hospitalized patients.^{5, 6}

Numerous studies have demonstrated that patients who receive hypotonic IV fluids have a significantly higher risk of developing hyponatremia than patients who receive isotonic IV fluids.^7,8 An infrequent, yet serious, complication of iatrogenic hyponatremia is hyponatremic encephalopathy, which carries a high rate of morbidity or mortality.⁹ The prevention of hyponatremia is essential as the early symptoms of hyponatremic encephalopathy are nonspecific and can be easily missed.²

More than 15 prospective randomized controlled trials (RCTs) involving over 2,000 children have demonstrated that isotonic IV fluids are more effective in preventing hospital-acquired hyponatremia than hypotonic IV fluids and are not associated with the development of fluid overload or hypernatremia. A 2014 metaanalysis comprising 10 RCTs and involving over 800 children found that when compared with isotonic IV fluids, hypotonic IV fluids present a relative risk of 2.37 for sodium levels to drop below 135 mEq/L and a relative risk of 6.1 for levels to drop below 130 mEq/L. The numbers needed to treat (NNT) with isotonic IV fluids to prevent hyponatremia in each group were 6 and 17, respectively.⁷ A Cochrane review published in 2014 presented comparable findings, demonstrating that hypotonic IV fluids had a 34% risk of causing hyponatremia; by comparison, isotonic IV fluids had a 17% risk of causing hyponatremia and a NNT of six to prevent hyponatremia.⁸ In a large RCT conducted in 2015 with 676 pediatric patients, McNabb et al. found that when compared with patients receiving isotonic IV fluids, those receiving hypotonic IV fluids had a higher incidence of developing hyponatremia (10.9% versus 3.8%) with a NNT of 15 to prevent hyponatremia with the use of isotonic fluids.¹⁰ Published trials have likely been underpowered to detect a difference in the infrequent adverse hyponatremia outcomes of seizures and mortality.

On the basis of these data, patient safety alerts have recommended the avoidance of hypotonic IV fluids in the United Kingdom (UK) and Australia, and the 2015 UK guidelines for children now recommend isotonic IV fluids for maintenance needs.¹¹ Although many of the aforementioned studies included predominantly critically ill or surgical pediatric patients, the risk of hyponatremia with hypotonic IV fluids seems similarly increased in nonsurgical and noncritically ill pediatric patients.¹⁰

For patients at risk for excess ADH release, some have supported the use of hypotonic IV fluids at a lower than maintenance rate to theoretically decrease the risk of hyponatremia, but this practice has not been effective in preventing hyponatremia.^2,12 Unless a patient is in a fluid overload state, such as in congestive heart failure, cirrhosis, or renal failure; isotonic maintenance IV fluids should not result in fluid overload.³ Available evidence for guiding maintenance IV fluid choice in neonates or young infants is limited. Nevertheless, given the aforementioned reasons, we generally recommend the prescription of isotonic IV fluids for most in this population.

Which Isotonic IV Fluid Should Be Used?

The sodium concentration (154 mmol/L) of 0.9% saline, an isotonic IV fluid, is approximately equal to the tonicity of the aqueous phase of plasma. The majority of studies evaluating the risk of hyponatremia with maintenance IV fluids have used 0.9% saline as the studied isotonic IV fluid. Plasma-Lyte and Ringer’s lactate are low-chloride, buffered/balanced solutions. Plasma-Lyte ([Na] = 140 mmol/L) has been demonstrated to be effective in preventing hyponatremia. Ringers’ lactate is slightly hypotonic ([Na] = 130 mmol/L), and its administration is associated with a decrease in serum sodium.¹³ A resultant dilutional and hyperchloremic metabolic acidosis is more likely to develop with the use of large volumes of 0.9% saline in resuscitation than with the use of balanced solutions.² Whether the prolonged use of 0.9% saline maintenance IV fluids can lead to this same side effect remains unknown given insufficient evidence.² Retrospective studies using balanced solutions have shown an association with decreased rates of acute kidney injury (AKI) and mortality when compared with 0.9% saline. However, a RCT with over 2,000 adult ICU patients showed no change in rates of AKI in those that received Plasma-Lyte compared with those who received 0.9% saline.¹⁴

Two recent, single-center, prospective studies compared the use of Ringer’s lactate or Plasma-Lyte for resuscitation with that of 0.9% saline. One study was comprised of 15,802 critically ill adults, and the other was comprised of 13,347 noncritically adults. Both studies showed that balanced solutions decreased the rate of major adverse kidney events (defined as a composite of death from any cause, new renal-replacement therapy, or persistent renal injury) within 30 days.^15,16 Available published pediatric studies indicate that 0.9% saline is an effective maintenance IV fluid for the prevention of hyponatremia that is not associated with hypernatremia or fluid overload. Further pediatric studies comparing 0.9% saline with balanced solutions are needed.

When Should We Use Hypotonic IV Fluids?

Hypotonic IV fluids may be needed for patients with hypernatremia and a free-water deficit or a renal-concentrating defect with ongoing urinary free-water losses.² Special care should be taken when choosing maintenance IV fluids for patients with renal disease, liver disease, or heart failure given that these groups have been excluded from some studies.¹² These patients may be at risk for increased salt and fluid retention with any IV fluid, and fluid rates need to be restricted. The fluid intake of patients with hyponatremia secondary to SIADH needs close management; these patients benefit from total fluid restriction instead of standard maintenance IV fluid rates.²

What We Should Do Instead?

Maintenance IV fluids should only be used when necessary and should be stopped as soon as they are no longer required, especially in light of the recent shortages in 0.9% saline.¹⁷ Similar to all medications, maintenance IV fluids should be individualized to the patient’s needs on the basis of the indication for IV fluids and the patient’s comorbidities.² Consideration should be given to checking the patient’s electrolyte levels to monitor response to IV fluids, especially during the first 24 hours of admission when risk of hyponatremia is highest. Isotonic IV fluids with 5% dextrose should be used as the maintenance IV fluid in the majority of hospitalized children given its proven benefit in decreasing the rate of hospital-acquired hyponatremia.^7,8 Hypotonic IV fluids should be avoided as the default maintenance IV fluid and should only be utilized under specific circumstances.

• When needed, maintenance IV fluids should always be tailored to each individual patient.
• For most acutely ill hospitalized children, isotonic IV fluids should be the maintenance IV fluid of choice.
• Consider monitoring electrolytes to determine the effects of maintenance IV fluids.

Enteral maintenance fluids should be used first-line if possible. Although hypotonic IV fluids have historically been the maintenance IV fluid of choice, this class of IV fluids should be avoided for most hospitalized children to decrease the significant risk of iatrogenic hyponatremia, which can be severe and have catastrophic complications. When necessary, isotonic IV fluids should be used for the majority of hospitalized children given that these fluids present a significantly decreased risk for causing hyponatremia. Returning to our case presentation, to decrease the risk of hyponatremia, the senior resident should recommend starting isotonic IV fluids in the 12-month-old and theoretical 2-week-old until oral intake can be maintained.

Do you think this is a low-value practice? Is this truly a “Thing We Do for No Reason”? Let us know what you do in your practice and propose ideas for other “Things We Do for No Reason” topics. Please join in the conversation online at Twitter (#TWDFNR)/Facebook and don’t forget to “Like It” on Facebook or retweet it on Twitter.

Disclosure

The authors have no relevant conflicts of interest to report. No payment or services from a 3rd party were received for any aspect of this submitted work. The authors have no financial relationships with entities in the biomedical arena that could be perceived to influence, or that give the appearance of potentially influencing, what was written in this submitted work.

The “Things We Do for No Reason” series reviews practices which have become common parts of hospital care but which may provide little value to our patients. Practices reviewed in the TWDFNR series do not represent “black and white” conclusions or clinical practice standards, but are meant as a starting place for research and active discussions among hospitalists and patients. We invite you to be part of that discussion. https://www.choosingwisely.org/

CASE PRESENTATION

A 12-month-old female is admitted for acute bronchiolitis with increased work of breathing and decreased oral intake. She is mildly dehydrated upon exam with a sodium level of 139 mEq/L and is given a 20 mL/kg bolus of 0.9% saline. Given the patient’s poor oral intake, the admitting intern orders maintenance intravenous (IV) fluids and asks her senior resident which IV fluid should be used. The medical student on the team wonders if a different IV fluid would be selected for a 2-week-old with a similar presentation.

Maintenance IV fluids are continuously infused to preserve extracellular volume and electrolyte balance when fluids cannot be taken orally. In contrast, resuscitation IV fluids are given as a bolus to patients in states of hypoperfusion to restore extracellular volume. The given IV fluid concentration can be categorized as approximately equal to (isotonic) or less than (hypotonic) the plasma sodium concentration. Refer to Table 1 for the electrolyte composition of commonly used IV fluids. Dextrose is rapidly metabolized upon infusion and does not affect tonicity.

Why You Might Think Hypotonic Maintenance IV Fluids Are The Right Choice

A 1957 publication by Holliday and Segar laid the foundation for maintenance IV fluid and electrolyte requirements in children and was the initial catalyst for the use of hypotonic maintenance IV fluids.¹ This manuscript contended that hypotonic IV fluids could supply the water and sodium needed to meet maintenance dietary requirements. This claim led to the predominant use of hypotonic maintenance IV fluids in children. By contrast, isotonic IV fluids have been avoided given the apprehension over electrolytes exceeding maintenance needs.

Concerns about the unintended consequences of fluid overload – edema, hypernatremia, and hypertension secondary to increased sodium load – have led some to avoid isotonic IV fluids.² When presented with common clinical scenarios of patients at risk for excess antidiuretic hormone (ADH; also known as arginine vasopressin), pediatric residents chose hypotonic (instead of isotonic) IV fluids 78% of the time.³

Why Isotonic Maintenance IV Fluids Are Usually The Right Choice For Children

General recommendations for hypotonic IV fluids are primarily based on theoretical calculations from the fluid and electrolyte requirements of healthy individuals, and studies have not validated the use of hypotonic IV fluids in clinical practice.¹ Acutely ill patients are at risk for excessive levels of ADH from numerous causes (see Table 2).² As a result, nearly every hospitalized patient is at risk for excess ADH release, thus making them vulnerable to the development of hyponatremia. The syndrome of inappropriate secretion of ADH (SIADH) occurs when nonosmotic/nonhemodynamic stimuli trigger ADH release, which leads to excessive free-water retention and resultant hyponatremia. Schwartz and Bartter reported the first two cases of SIADH in 1957 when hyponatremia developed in the setting of bronchogenic carcinoma.⁴ Although the publication by Holliday and Seger did acknowledge the potential for water intoxication, it was written before this report and before the effects of ADH on the sodium levels of hospitalized patients were clearly understood.² SIADH is now recognized as one of the most common causes of hyponatremia in hospitalized patients.^{5, 6}

Numerous studies have demonstrated that patients who receive hypotonic IV fluids have a significantly higher risk of developing hyponatremia than patients who receive isotonic IV fluids.^7,8 An infrequent, yet serious, complication of iatrogenic hyponatremia is hyponatremic encephalopathy, which carries a high rate of morbidity or mortality.⁹ The prevention of hyponatremia is essential as the early symptoms of hyponatremic encephalopathy are nonspecific and can be easily missed.²

More than 15 prospective randomized controlled trials (RCTs) involving over 2,000 children have demonstrated that isotonic IV fluids are more effective in preventing hospital-acquired hyponatremia than hypotonic IV fluids and are not associated with the development of fluid overload or hypernatremia. A 2014 metaanalysis comprising 10 RCTs and involving over 800 children found that when compared with isotonic IV fluids, hypotonic IV fluids present a relative risk of 2.37 for sodium levels to drop below 135 mEq/L and a relative risk of 6.1 for levels to drop below 130 mEq/L. The numbers needed to treat (NNT) with isotonic IV fluids to prevent hyponatremia in each group were 6 and 17, respectively.⁷ A Cochrane review published in 2014 presented comparable findings, demonstrating that hypotonic IV fluids had a 34% risk of causing hyponatremia; by comparison, isotonic IV fluids had a 17% risk of causing hyponatremia and a NNT of six to prevent hyponatremia.⁸ In a large RCT conducted in 2015 with 676 pediatric patients, McNabb et al. found that when compared with patients receiving isotonic IV fluids, those receiving hypotonic IV fluids had a higher incidence of developing hyponatremia (10.9% versus 3.8%) with a NNT of 15 to prevent hyponatremia with the use of isotonic fluids.¹⁰ Published trials have likely been underpowered to detect a difference in the infrequent adverse hyponatremia outcomes of seizures and mortality.

On the basis of these data, patient safety alerts have recommended the avoidance of hypotonic IV fluids in the United Kingdom (UK) and Australia, and the 2015 UK guidelines for children now recommend isotonic IV fluids for maintenance needs.¹¹ Although many of the aforementioned studies included predominantly critically ill or surgical pediatric patients, the risk of hyponatremia with hypotonic IV fluids seems similarly increased in nonsurgical and noncritically ill pediatric patients.¹⁰

For patients at risk for excess ADH release, some have supported the use of hypotonic IV fluids at a lower than maintenance rate to theoretically decrease the risk of hyponatremia, but this practice has not been effective in preventing hyponatremia.^2,12 Unless a patient is in a fluid overload state, such as in congestive heart failure, cirrhosis, or renal failure; isotonic maintenance IV fluids should not result in fluid overload.³ Available evidence for guiding maintenance IV fluid choice in neonates or young infants is limited. Nevertheless, given the aforementioned reasons, we generally recommend the prescription of isotonic IV fluids for most in this population.

Which Isotonic IV Fluid Should Be Used?

The sodium concentration (154 mmol/L) of 0.9% saline, an isotonic IV fluid, is approximately equal to the tonicity of the aqueous phase of plasma. The majority of studies evaluating the risk of hyponatremia with maintenance IV fluids have used 0.9% saline as the studied isotonic IV fluid. Plasma-Lyte and Ringer’s lactate are low-chloride, buffered/balanced solutions. Plasma-Lyte ([Na] = 140 mmol/L) has been demonstrated to be effective in preventing hyponatremia. Ringers’ lactate is slightly hypotonic ([Na] = 130 mmol/L), and its administration is associated with a decrease in serum sodium.¹³ A resultant dilutional and hyperchloremic metabolic acidosis is more likely to develop with the use of large volumes of 0.9% saline in resuscitation than with the use of balanced solutions.² Whether the prolonged use of 0.9% saline maintenance IV fluids can lead to this same side effect remains unknown given insufficient evidence.² Retrospective studies using balanced solutions have shown an association with decreased rates of acute kidney injury (AKI) and mortality when compared with 0.9% saline. However, a RCT with over 2,000 adult ICU patients showed no change in rates of AKI in those that received Plasma-Lyte compared with those who received 0.9% saline.¹⁴

Two recent, single-center, prospective studies compared the use of Ringer’s lactate or Plasma-Lyte for resuscitation with that of 0.9% saline. One study was comprised of 15,802 critically ill adults, and the other was comprised of 13,347 noncritically adults. Both studies showed that balanced solutions decreased the rate of major adverse kidney events (defined as a composite of death from any cause, new renal-replacement therapy, or persistent renal injury) within 30 days.^15,16 Available published pediatric studies indicate that 0.9% saline is an effective maintenance IV fluid for the prevention of hyponatremia that is not associated with hypernatremia or fluid overload. Further pediatric studies comparing 0.9% saline with balanced solutions are needed.

When Should We Use Hypotonic IV Fluids?

Hypotonic IV fluids may be needed for patients with hypernatremia and a free-water deficit or a renal-concentrating defect with ongoing urinary free-water losses.² Special care should be taken when choosing maintenance IV fluids for patients with renal disease, liver disease, or heart failure given that these groups have been excluded from some studies.¹² These patients may be at risk for increased salt and fluid retention with any IV fluid, and fluid rates need to be restricted. The fluid intake of patients with hyponatremia secondary to SIADH needs close management; these patients benefit from total fluid restriction instead of standard maintenance IV fluid rates.²

What We Should Do Instead?

Maintenance IV fluids should only be used when necessary and should be stopped as soon as they are no longer required, especially in light of the recent shortages in 0.9% saline.¹⁷ Similar to all medications, maintenance IV fluids should be individualized to the patient’s needs on the basis of the indication for IV fluids and the patient’s comorbidities.² Consideration should be given to checking the patient’s electrolyte levels to monitor response to IV fluids, especially during the first 24 hours of admission when risk of hyponatremia is highest. Isotonic IV fluids with 5% dextrose should be used as the maintenance IV fluid in the majority of hospitalized children given its proven benefit in decreasing the rate of hospital-acquired hyponatremia.^7,8 Hypotonic IV fluids should be avoided as the default maintenance IV fluid and should only be utilized under specific circumstances.

• When needed, maintenance IV fluids should always be tailored to each individual patient.
• For most acutely ill hospitalized children, isotonic IV fluids should be the maintenance IV fluid of choice.
• Consider monitoring electrolytes to determine the effects of maintenance IV fluids.

Enteral maintenance fluids should be used first-line if possible. Although hypotonic IV fluids have historically been the maintenance IV fluid of choice, this class of IV fluids should be avoided for most hospitalized children to decrease the significant risk of iatrogenic hyponatremia, which can be severe and have catastrophic complications. When necessary, isotonic IV fluids should be used for the majority of hospitalized children given that these fluids present a significantly decreased risk for causing hyponatremia. Returning to our case presentation, to decrease the risk of hyponatremia, the senior resident should recommend starting isotonic IV fluids in the 12-month-old and theoretical 2-week-old until oral intake can be maintained.

Do you think this is a low-value practice? Is this truly a “Thing We Do for No Reason”? Let us know what you do in your practice and propose ideas for other “Things We Do for No Reason” topics. Please join in the conversation online at Twitter (#TWDFNR)/Facebook and don’t forget to “Like It” on Facebook or retweet it on Twitter.

Disclosure

The authors have no relevant conflicts of interest to report. No payment or services from a 3rd party were received for any aspect of this submitted work. The authors have no financial relationships with entities in the biomedical arena that could be perceived to influence, or that give the appearance of potentially influencing, what was written in this submitted work.

Once upon a time, discharges were easy to categorize: good, bad, or ugly. Good discharges allowed the patient to leave before noon, while bad discharges allowed the patient to leave without follow-up appointments. The worst discharges were defined by the two ugly cousins of acute care re-escalation: return emergency department (ED) visits and readmissions. Recently, however, much of this conventional wisdom has been turned on its head. For example, pre-noon discharges and provider-scheduled follow-up appointments may lead to unintended negative consequences and futility.^1,2 In contrast, weekend discharges, which were often viewed to be unsafe, may reduce lengths of stay without compromising care even in high-risk patients.³

Having obfuscated the line between good and bad, we can now turn our attention to the ugly. Comparing return ED visits with readmissions, hospitalists may be forgiven for judging the latter cousin as uglier – and not just for reimbursement reasons. Readmitted patients are sicker, more vulnerable, and have poorer outcomes. In our healthcare system’s resultant quest to eliminate readmissions, return ED visits that do not end in readmission are generally either ignored or grouped with readmissions. Ignoring these treat-and-discharge ED visits is problematic because of their incidence, which rivals that of ED visits ending in readmission.⁴ On the other hand, grouping these visits with readmissions only makes sense if the two are considered to be equally ugly outcomes. Is this a valid assumption to make?

In this issue of the Journal of Hospital Medicine, Venkatesh et al⁵ tackle that question by studying Medicare beneficiaries hospitalized for acute myocardial infarction, heart failure, or pneumonia over a 1-year period. The authors differentiate 30-day treat-and-discharge ED visit rates from 30-day readmission rates before risk-standardizing these rates based on visit codes and hospital characteristics. Similar to the results of prior studies, the authors observe an 8%–9% overall incidence of treat-and-discharge ED visits within 30 days of hospital discharge.⁶ Mapping treat-and-discharge ED visit rates versus readmission rates for each hospital, the authors detect modest but noticeable inverse correlations between the two. Among hospitals discharging heart failure patients, for example, every 10% increase in postdischarge ED visit rates corresponds to a roughly 2% decrease in readmission rates.

The authors are correct to tread cautiously with their interpretation of this correlation. Dispositions for ED patients exist on a continuum, so hospitals with higher propensities to discharge patients from EDs (whether directly or from observation units) will inherently have lower admission rates. The authors hint at a causal relationship nonetheless, suggesting that ED providers may be able to intervene on high-risk patients earlier before Readmission Road becomes a one-way street. Proving this hypothesis will require careful research that controls for patient, disease, and ED factors as well as their complex interactions in the post-discharge timeline. That being said, most analyses of outpatient follow-up visits (except for heart failure patients) have failed to find any anti-readmission correlation analogous to that identified by Venkatesh et al. What powers do ED providers have that outpatient providers lack? Many, admittedly: stat phlebotomy services, on-demand consultations, and observation units. Additionally, while ED visits invariably require a patient’s presence in person, 25% of provider-scheduled posthospitalization outpatient visits end in no-shows.² Whether patient-triggered follow-up through rapid access clinics or even urgent care centers can replicate ED functionality in recently discharged patients is unknown and warrants further study.

Venkatesh et al⁵ also find that reasons for postdischarge ED visits bear only a slight resemblance to reasons for index hospitalizations. For example, of all ED visits by patients recovering from hospitalizations for pneumonia, only 20% involve respiratory or pulmonary complaints. What explains the other 80%? Some variability may be attributable to the study’s use of visit codes instead of chart reviews or stakeholder interviews; in surveys of patients and ED physicians during these postdischarge visits, the two groups may have very different perceptions of why the encounter is occurring and whether it is preventable.⁷ Regardless of who is “right,” the heterogeneity of reasons that prompt care re-escalation lends further credence to the existence of a distinct posthospitalization syndrome:⁸ in the immediate postdischarge interval, patients experience many transient but real physiological risks for which they may identify the ED as their best recourse.

Whether the ED actually provides secondary prophylaxis against the posthospitalization syndrome is highly debatable, and Venkatesh et al wisely refrain from assigning a positive or negative valence to treat-and-discharge ED visits. Ultimately, postdischarge ED visits are neither inherently good nor bad (nor ugly, for that matter). Their unique nature is attracting newfound appreciation, and their potential ability to prevent readmission merits further research. If hospitals with high postdischarge ED visit rates can deliver high-quality care while truly arresting or reversing readmission-bound trajectories, then the strategies employed by these hospitals should inspire emulation, innovation, and dissemination.

Disclosures

The authors have nothing to disclose.

Once upon a time, discharges were easy to categorize: good, bad, or ugly. Good discharges allowed the patient to leave before noon, while bad discharges allowed the patient to leave without follow-up appointments. The worst discharges were defined by the two ugly cousins of acute care re-escalation: return emergency department (ED) visits and readmissions. Recently, however, much of this conventional wisdom has been turned on its head. For example, pre-noon discharges and provider-scheduled follow-up appointments may lead to unintended negative consequences and futility.^1,2 In contrast, weekend discharges, which were often viewed to be unsafe, may reduce lengths of stay without compromising care even in high-risk patients.³

Having obfuscated the line between good and bad, we can now turn our attention to the ugly. Comparing return ED visits with readmissions, hospitalists may be forgiven for judging the latter cousin as uglier – and not just for reimbursement reasons. Readmitted patients are sicker, more vulnerable, and have poorer outcomes. In our healthcare system’s resultant quest to eliminate readmissions, return ED visits that do not end in readmission are generally either ignored or grouped with readmissions. Ignoring these treat-and-discharge ED visits is problematic because of their incidence, which rivals that of ED visits ending in readmission.⁴ On the other hand, grouping these visits with readmissions only makes sense if the two are considered to be equally ugly outcomes. Is this a valid assumption to make?

In this issue of the Journal of Hospital Medicine, Venkatesh et al⁵ tackle that question by studying Medicare beneficiaries hospitalized for acute myocardial infarction, heart failure, or pneumonia over a 1-year period. The authors differentiate 30-day treat-and-discharge ED visit rates from 30-day readmission rates before risk-standardizing these rates based on visit codes and hospital characteristics. Similar to the results of prior studies, the authors observe an 8%–9% overall incidence of treat-and-discharge ED visits within 30 days of hospital discharge.⁶ Mapping treat-and-discharge ED visit rates versus readmission rates for each hospital, the authors detect modest but noticeable inverse correlations between the two. Among hospitals discharging heart failure patients, for example, every 10% increase in postdischarge ED visit rates corresponds to a roughly 2% decrease in readmission rates.

The authors are correct to tread cautiously with their interpretation of this correlation. Dispositions for ED patients exist on a continuum, so hospitals with higher propensities to discharge patients from EDs (whether directly or from observation units) will inherently have lower admission rates. The authors hint at a causal relationship nonetheless, suggesting that ED providers may be able to intervene on high-risk patients earlier before Readmission Road becomes a one-way street. Proving this hypothesis will require careful research that controls for patient, disease, and ED factors as well as their complex interactions in the post-discharge timeline. That being said, most analyses of outpatient follow-up visits (except for heart failure patients) have failed to find any anti-readmission correlation analogous to that identified by Venkatesh et al. What powers do ED providers have that outpatient providers lack? Many, admittedly: stat phlebotomy services, on-demand consultations, and observation units. Additionally, while ED visits invariably require a patient’s presence in person, 25% of provider-scheduled posthospitalization outpatient visits end in no-shows.² Whether patient-triggered follow-up through rapid access clinics or even urgent care centers can replicate ED functionality in recently discharged patients is unknown and warrants further study.

Venkatesh et al⁵ also find that reasons for postdischarge ED visits bear only a slight resemblance to reasons for index hospitalizations. For example, of all ED visits by patients recovering from hospitalizations for pneumonia, only 20% involve respiratory or pulmonary complaints. What explains the other 80%? Some variability may be attributable to the study’s use of visit codes instead of chart reviews or stakeholder interviews; in surveys of patients and ED physicians during these postdischarge visits, the two groups may have very different perceptions of why the encounter is occurring and whether it is preventable.⁷ Regardless of who is “right,” the heterogeneity of reasons that prompt care re-escalation lends further credence to the existence of a distinct posthospitalization syndrome:⁸ in the immediate postdischarge interval, patients experience many transient but real physiological risks for which they may identify the ED as their best recourse.

Whether the ED actually provides secondary prophylaxis against the posthospitalization syndrome is highly debatable, and Venkatesh et al wisely refrain from assigning a positive or negative valence to treat-and-discharge ED visits. Ultimately, postdischarge ED visits are neither inherently good nor bad (nor ugly, for that matter). Their unique nature is attracting newfound appreciation, and their potential ability to prevent readmission merits further research. If hospitals with high postdischarge ED visit rates can deliver high-quality care while truly arresting or reversing readmission-bound trajectories, then the strategies employed by these hospitals should inspire emulation, innovation, and dissemination.

Disclosures

The authors have nothing to disclose.

Once upon a time, discharges were easy to categorize: good, bad, or ugly. Good discharges allowed the patient to leave before noon, while bad discharges allowed the patient to leave without follow-up appointments. The worst discharges were defined by the two ugly cousins of acute care re-escalation: return emergency department (ED) visits and readmissions. Recently, however, much of this conventional wisdom has been turned on its head. For example, pre-noon discharges and provider-scheduled follow-up appointments may lead to unintended negative consequences and futility.^1,2 In contrast, weekend discharges, which were often viewed to be unsafe, may reduce lengths of stay without compromising care even in high-risk patients.³

Having obfuscated the line between good and bad, we can now turn our attention to the ugly. Comparing return ED visits with readmissions, hospitalists may be forgiven for judging the latter cousin as uglier – and not just for reimbursement reasons. Readmitted patients are sicker, more vulnerable, and have poorer outcomes. In our healthcare system’s resultant quest to eliminate readmissions, return ED visits that do not end in readmission are generally either ignored or grouped with readmissions. Ignoring these treat-and-discharge ED visits is problematic because of their incidence, which rivals that of ED visits ending in readmission.⁴ On the other hand, grouping these visits with readmissions only makes sense if the two are considered to be equally ugly outcomes. Is this a valid assumption to make?

In this issue of the Journal of Hospital Medicine, Venkatesh et al⁵ tackle that question by studying Medicare beneficiaries hospitalized for acute myocardial infarction, heart failure, or pneumonia over a 1-year period. The authors differentiate 30-day treat-and-discharge ED visit rates from 30-day readmission rates before risk-standardizing these rates based on visit codes and hospital characteristics. Similar to the results of prior studies, the authors observe an 8%–9% overall incidence of treat-and-discharge ED visits within 30 days of hospital discharge.⁶ Mapping treat-and-discharge ED visit rates versus readmission rates for each hospital, the authors detect modest but noticeable inverse correlations between the two. Among hospitals discharging heart failure patients, for example, every 10% increase in postdischarge ED visit rates corresponds to a roughly 2% decrease in readmission rates.

The authors are correct to tread cautiously with their interpretation of this correlation. Dispositions for ED patients exist on a continuum, so hospitals with higher propensities to discharge patients from EDs (whether directly or from observation units) will inherently have lower admission rates. The authors hint at a causal relationship nonetheless, suggesting that ED providers may be able to intervene on high-risk patients earlier before Readmission Road becomes a one-way street. Proving this hypothesis will require careful research that controls for patient, disease, and ED factors as well as their complex interactions in the post-discharge timeline. That being said, most analyses of outpatient follow-up visits (except for heart failure patients) have failed to find any anti-readmission correlation analogous to that identified by Venkatesh et al. What powers do ED providers have that outpatient providers lack? Many, admittedly: stat phlebotomy services, on-demand consultations, and observation units. Additionally, while ED visits invariably require a patient’s presence in person, 25% of provider-scheduled posthospitalization outpatient visits end in no-shows.² Whether patient-triggered follow-up through rapid access clinics or even urgent care centers can replicate ED functionality in recently discharged patients is unknown and warrants further study.

Venkatesh et al⁵ also find that reasons for postdischarge ED visits bear only a slight resemblance to reasons for index hospitalizations. For example, of all ED visits by patients recovering from hospitalizations for pneumonia, only 20% involve respiratory or pulmonary complaints. What explains the other 80%? Some variability may be attributable to the study’s use of visit codes instead of chart reviews or stakeholder interviews; in surveys of patients and ED physicians during these postdischarge visits, the two groups may have very different perceptions of why the encounter is occurring and whether it is preventable.⁷ Regardless of who is “right,” the heterogeneity of reasons that prompt care re-escalation lends further credence to the existence of a distinct posthospitalization syndrome:⁸ in the immediate postdischarge interval, patients experience many transient but real physiological risks for which they may identify the ED as their best recourse.

Whether the ED actually provides secondary prophylaxis against the posthospitalization syndrome is highly debatable, and Venkatesh et al wisely refrain from assigning a positive or negative valence to treat-and-discharge ED visits. Ultimately, postdischarge ED visits are neither inherently good nor bad (nor ugly, for that matter). Their unique nature is attracting newfound appreciation, and their potential ability to prevent readmission merits further research. If hospitals with high postdischarge ED visit rates can deliver high-quality care while truly arresting or reversing readmission-bound trajectories, then the strategies employed by these hospitals should inspire emulation, innovation, and dissemination.

Disclosures

The authors have nothing to disclose.

A 68-year-old woman presented to the emergency department with altered mental status. On the morning prior to admission, she was fully alert and oriented. Over the course of the day, she became more confused and somnolent, and by the evening, she was unarousable to voice. She had not fallen and had no head trauma.

Altered mental status may arise from metabolic (eg, hyponatremia), infectious (eg, urinary tract infection), structural (eg, subdural hematoma), or toxin-related (eg, adverse medication effect) processes. Any of these categories of encephalopathy can develop gradually over the course of a day.

One year prior, the patient was admitted for a similar episode of altered mental status. Asterixis and elevated transaminases prompted an abdominal ultrasound, which revealed a nodular liver and ascites. Paracentesis revealed a high serum-ascites albumin gradient. The diagnosis of cirrhosis was made based on these findings. Testing for viral hepatitis, autoimmune hepatitis, hemochromatosis, and Wilson’s disease were negative. Although steatosis was not detected on ultrasound, nonalcoholic fatty liver disease (NAFLD) was suspected based on the patient’s risk factors of hypertension and type 2 diabetes mellitus. She had four additional presentations of altered mental status with asterixis; each episode resolved with lactulose.

Other medical history included end-stage renal disease (ESRD) requiring hemodialysis. Her medications were labetalol, amlodipine, insulin, propranolol, lactulose, and rifaximin. She was originally from China and moved to the United States 10 years earlier. Given concerns about her ability to consistently take medications, she had moved to a long-term facility. She did not use alcohol, tobacco, or illicit substances.

The normalization of the patient’s mental status after lactulose treatment, especially in the context of recurrent episodes, is characteristic of hepatic encephalopathy, in which ammonia and other substances bypass hepatic metabolism and impair cerebral function. Hepatic encephalopathy is the most common cause of lactulose-responsive encephalopathy, and may recur in the setting of infection or nonadherence with lactulose and rifaximin. Other causes of lactulose-responsive encephalopathy include hyperammonemia caused by urease-producing bacterial infection (eg, Proteus), valproic acid toxicity, and urea cycle abnormalities.

Other causes of confusion with a self-limited course should be considered for the current episode. A postictal state is possible, but convulsions were not reported. The patient is at risk of hypoglycemia from insulin use and impaired gluconeogenesis due to cirrhosis and ESRD, but low blood sugar would have likely been detected at the time of hospitalization. Finally, she might have experienced episodic encephalopathy from ingestion of unreported medications or toxins, whose effects may have resolved with abstinence during hospitalization.

The patient’s temperature was 37.8°C, pulse 73 beats/minute, blood pressure 133/69 mmHg, respiratory rate 12 breaths/minute, and oxygen saturation 98% on ambient air. Her body mass index (BMI) was 19 kg/m². She was somnolent but was moving all four extremities spontaneously. Her pupils were symmetric and reactive. There was no facial asymmetry. Biceps and patellar reflexes were 2+ bilaterally. Babinski sign was absent bilaterally. The patient could not cooperate with the assessment for asterixis. Her sclerae were anicteric. The jugular venous pressure was estimated at 13 cm of water. Her heart was regular with no murmurs. Her lungs were clear. She had a distended, nontender abdomen with caput medusae. She had symmetric pitting edema in her lower extremities up to the shins.

The elevated jugular venous pressure, lower extremity edema, and distended abdomen suggest volume overload. Jugular venous distention with clear lungs is characteristic of right ventricular failure from pulmonary hypertension, right ventricular myocardial infarction, tricuspid regurgitation, or constrictive pericarditis. However, chronic biventricular heart failure often presents in this manner and is more common than the aforementioned conditions. ESRD and cirrhosis may be contributing to the hypervolemia.

Although Asian patients may exhibit metabolic syndrome and NAFLD at a lower BMI than non-Asians, her BMI is uncharacteristically low for NAFLD, especially given the increased weight expected from volume overload. There are no signs of infection to account for worsening of hepatic encephalopathy.

Laboratory tests demonstrated a white blood cell count of 4400/µL with a normal differential, hemoglobin of 10.3 g/dL, and platelet count of 108,000 per cubic millimeter. Mean corpuscular volume was 103 fL. Basic metabolic panel was normal with the exception of blood urea nitrogen of 46 mg/dL and a creatinine of 6.4 mg/dL. Aspartate aminotransferase was 34 units/L, alanine aminotransferase 34 units/L, alkaline phosphatase 289 units/L (normal, 31-95), gamma-glutamyl transferase 104 units (GGT, normal, 12-43), total bilirubin 0.8 mg/dL, and albumin 2.5 g/dL (normal, 3.5-4.5). Pro-brain natriuretic peptide was 1429 pg/mL (normal, <100). The international normalized ratio (INR) was 1.0. Urinalysis showed trace proteinuria. The chest x-ray was normal. A noncontrast computed tomography (CT) of the head demonstrated no intracranial pathology. An abdominal ultrasound revealed a normal-sized nodular liver, a nonocclusive portal vein thrombus (PVT), splenomegaly (15 cm in length), and trace ascites. There was no biliary dilation, hepatic steatosis, or hepatic mass.

The evolving data set presents a mixed picture about the state of the liver. The distended abdominal wall veins, thrombocytopenia, and splenomegaly are commonly observed in advanced cirrhosis, but these findings reflect the associated portal hypertension and not the liver disease itself. The normal bilirubin and INR suggest preserved liver function and decrease the likelihood of cirrhosis being responsible for the portal hypertension. However, the elevated alkaline phosphatase and GGT levels suggest an infiltrative liver disease, such as lymphoma, sarcoidosis, or amyloidosis.

Furthermore, while a nodular liver on imaging is consistent with cirrhosis, no steatosis was noted to support the presumed diagnosis of NAFLD. One explanation for this discrepancy is that fatty infiltration may be absent when NAFLD-associated cirrhosis develops. In summary, there is evidence of liver disease, and there is evidence of portal hypertension, but there is no evidence of liver parenchymal failure. The key features of the latter – spider angiomata, palmar erythema, hyperbilirubinemia, and coagulopathy – are absent.

Noncirrhotic portal hypertension (NCPH) is an alternative explanation for the patient’s findings. NCPH is an elevation in the portal venous system pressure that arises from intrahepatic (but noncirrhotic) disease or from extrahepatic disease. Hepatic schistosomiasis is an example of intrahepatic but noncirrhotic portal hypertension. PVT that arises on account of a hypercoagulable condition (eg, abdominal malignancy, pancreatitis, or myeloproliferative disorders) is a prototype of extrahepatic NCPH. At this point, it is impossible to know if the PVT is a complication of NCPH or a cause of NCPH. PVT as a complication of cirrhosis is less likely.

An abdominal CT scan would better assess the hepatic parenchyma and exclude abdominal malignancies such as pancreatic adenocarcinoma. An echocardiogram is indicated to evaluate the cause of the elevated jugular venous pressure. A liver biopsy and measurement of portal venous pressure would help distinguish between cirrhotic and noncirrhotic portal hypertension.

Hepatitis A, B, and C serologies were negative as were antinuclear and antimitochondrial antibodies. Ferritin and ceruloplasmin levels were normal. A CT scan of the abdomen with contrast demonstrated a nodular liver contour, splenomegaly, and a nonocclusive PVT (Figure 1). A transthoracic echocardiogram showed normal biventricular systolic function and size, normal diastolic function, a pulmonary artery systolic pressure of 57 mmHg (normal, < 25), moderate tricuspid regurgitation, and no pericardial effusion or thickening. The patient’s confusion and somnolence resolved after two days of lactulose therapy. She denied the use of other medications, supplements, or herbs.

Schistosomiasis is the most common cause of NCPH worldwide. Parasite eggs trapped within the terminal portal venules cause inflammation, leading to fibrosis and intrahepatic portal hypertension. The liver becomes nodular on account of these changes, but the overall hepatic function is typically preserved. Portal hypertension, variceal bleeding, and pulmonary hypertension are common complications. The latter can arise from portosystemic shunting, which leads to embolization of schistosome eggs into the pulmonary circulation, where a granulomatous reaction ensues.

A percutaneous liver biopsy showed granulomatous inflammation and dilated portal venules consistent with increased resistance to venous inflow (Figure 2). There was no sinusoidal congestion to indicate impaired hepatic venous outflow. Mild sinusoidal and portal fibrosis and increased iron in Kupffer cells were noted. There was no evidence of cirrhosis or steatohepatitis. Stains for acid-fast bacilli and fungi were negative. 16S rDNA (a test assessing for bacterial DNA) and Mycobacterium tuberculosis polymerase chain reactions were negative. The biopsy confirmed the diagnosis of noncirrhotic portal hypertension.

Infections, such as brucellosis, Q fever, and tuberculosis, are common causes of granulomatous hepatitis in the developing world. Tuberculosis is prevalent in China, but the test results do not support tuberculosis as a unifying diagnosis.

Schistosomiasis accounts for the major clinical features (portal and pulmonary hypertension and preserved liver function) and hepatic pathology (ie, portal venous fibrosis with granulomatous inflammation) in this case and is prevalent in China, where the patient emigrated from. The biopsy specimen should be re-examined for schistosome eggs and serologic tests for schistosomiasis pursued.

Antibodies to human immunodeficiency virus, Brucella, Bartonella quintana, Bartonella henselae, Coxiella burnetii, Francisella tularensis, and Histoplasma were negative. Cryptococcal antigen and rapid plasma reagin were negative. IgG antibodies to Schistosoma were 0.21 units (normal, < 0.19 units). Based on the patient’s epidemiology, biopsy findings, and serology results, hepatic schistosomiasis was diagnosed. Praziquantel was prescribed. She continues to receive daily lactulose and rifaximin and has not had any episodes of encephalopathy in the year after discharge.

Portal hypertension arises when there is resistance to flow in the portal venous system. It is defined as a pressure gradient greater than 5 mmHg between the portal vein and the intra-abdominal portion of the inferior vena cava.¹ Clinicians are familiar with the manifestations of portal hypertension – portosystemic shunting leading to encephalopathy and variceal hemorrhage, ascites, and splenomegaly with thrombocytopenia – because of their close association with cirrhosis. In developed countries, cirrhosis accounts for over 90% of cases of portal hypertension.¹ In the remaining 10%, conditions such as portal vein thrombosis primarily affect the portal vasculature and increase resistance to portal blood flow while leaving hepatic synthetic function relatively spared (Figure 3). Therefore, cirrhosis cannot be inferred with certainty from signs of portal hypertension alone.

Liver biopsy is the gold standard for the diagnosis of cirrhosis, but this method is increasingly being replaced by noninvasive assessments of liver fibrosis, including imaging and scoring systems.² Clinicians often infer cirrhosis from the combination of a known cause of liver injury, abnormal liver biochemical tests, evidence of liver dysfunction, and signs of portal hypertension.³ However, when signs of portal hypertension are present, but liver dysfunction cannot be established on physical exam (eg, palmar erythema, spider nevi, gynecomastia, and testicular atrophy) or laboratory testing (eg, low albumin, elevated INR, and elevated bilirubin), noncirrhotic causes of portal hypertension should be considered. In this case, the biopsy showed vascular changes that suggested impaired venous inflow without bridging fibrosis, which pointed to NCPH.

NCPH is categorized based on the location of resistance to blood flow: prehepatic (eg, portal vein thrombosis), intrahepatic (eg, schistosomiasis), and posthepatic (eg, right-sided heart failure).¹ In our patient, the dilated portal venules (inflow) in the presence of normal hepatic vein outflow suggested an increased intrahepatic resistance to blood flow. This finding excluded a causal role of the portal vein thrombosis and prompted testing for schistosomiasis.

Schistosomiasis affects more than 200 million people worldwide and is prevalent in Sub-Saharan Africa, South America, Egypt, China, and Southeast Asia.^4,5 Transmission occurs in fresh water, where the infectious form of the parasite is released from snails.^4,6 Schistosome worms are not found in the United States, but as a result of immigration and travel, more than 400,000 people in the United States are estimated to be infected.⁵

Chronic schistosomiasis develops from the host’s granulomatous reaction to schistosome eggs whose location (depending on the species) leads to genitourinary, intestinal, hepatic, or rarely, neurologic disease.⁶ Hepatic schistosomiasis arises when eggs released in the portal venous system lodge in small portal venules and cause granulomatous inflammation, periportal fibrosis, and microvascular obstruction.⁶ The resultant portal hypertension develops insidiously, but the architecture and synthetic function of the liver is maintained until the very late stages of disease.^6,7 Pulmonary hypertension can arise from the embolization of eggs to the pulmonary arterioles via portosystemic collaterals.

The demonstration of eggs in stool is the gold standard for the diagnosis of hepatic schistosomiasis, which is most commonly caused by Schistosoma mansoni and S. japonicum.⁷ Serologic assays provide evidence of infection or exposure but may cross-react with other helminths. Liver biopsy may reveal characteristic histopathologic findings, including granulomatous inflammation, distorted vasculature, and the deposition of collagen deposits in the periportal space, leading to “pipestem fibrosis.”^8,9 If eggs cannot be detected on stool or histology, then serology, secondary histologic changes, and sometimes PCR are used to diagnose hepatic schistosomiasis. In our patient, the epidemiology, Schistosoma antibody titer, pulmonary hypertension, and liver biopsy with granulomatous inflammation, periportal fibrosis, and intrahepatic portal venule dilation were diagnostic of hepatic schistosomiasis.

The recurrent episodes of confusion which resolved with lactulose therapy were suggestive of hepatic encephalopathy, which results from shunting and accumulation of neurotoxic substances that would otherwise undergo hepatic metabolism.¹⁰ Clinicians are most familiar with hepatic encephalopathy in cirrhosis, where multiple liver functions – synthesis, excretion, metabolism, and circulation – simultaneously fail. NCPH represents a scenario where only the circulation is impaired, but this is sufficient to cause the portosystemic shunting that leads to encephalopathy. Our patient’s recurrent hepatic encephalopathy, despite adherence to lactulose and rifaximin and its resolution after praziquantel treatment, underscores the importance of addressing the underlying cause of portosystemic shunting.Associating portal hypertension with cirrhosis is efficient and accurate in many cases. However, when specific manifestations of cirrhosis are lacking, clinicians must decouple this association and pursue an alternative explanation for portal hypertension. The presence of some intrahepatic pathology (from schistosomiasis) but no cirrhosis made this case a particularly tough egg to crack.

Teaching Points

• In the developed world, 90% of portal hypertension is due to cirrhosis. Hepatic schistosomiasis is the most common cause of NCPH worldwide.
• Chronic schistosomiasis affects the gastrointestinal, hepatic, and genitourinary systems and causes significant global morbidity and mortality.
• Visualization of schistosome eggs is the diagnostic gold standard. Indirect testing such as schistosoma antibodies and secondary histologic changes may be required for the diagnosis in patients with a low burden of eggs.

Disclosures

Dr. Geha has no disclosures. Dr. Dhaliwal reports receiving honoraria from ISMIE Mutual Insurance Company and Physicians’ Reciprocal Insurers. Dr. Peters’ spouse is employed by Hoffman-La Roche. Dr. Manesh is supported by the Jeremiah A. Barondess Fellowship in the Clinical Transaction of the New York Academy of Medicine, in collaboration with the Accreditation Council for Graduate Medical Education (ACGME).

A 68-year-old woman presented to the emergency department with altered mental status. On the morning prior to admission, she was fully alert and oriented. Over the course of the day, she became more confused and somnolent, and by the evening, she was unarousable to voice. She had not fallen and had no head trauma.

Altered mental status may arise from metabolic (eg, hyponatremia), infectious (eg, urinary tract infection), structural (eg, subdural hematoma), or toxin-related (eg, adverse medication effect) processes. Any of these categories of encephalopathy can develop gradually over the course of a day.

One year prior, the patient was admitted for a similar episode of altered mental status. Asterixis and elevated transaminases prompted an abdominal ultrasound, which revealed a nodular liver and ascites. Paracentesis revealed a high serum-ascites albumin gradient. The diagnosis of cirrhosis was made based on these findings. Testing for viral hepatitis, autoimmune hepatitis, hemochromatosis, and Wilson’s disease were negative. Although steatosis was not detected on ultrasound, nonalcoholic fatty liver disease (NAFLD) was suspected based on the patient’s risk factors of hypertension and type 2 diabetes mellitus. She had four additional presentations of altered mental status with asterixis; each episode resolved with lactulose.

Other medical history included end-stage renal disease (ESRD) requiring hemodialysis. Her medications were labetalol, amlodipine, insulin, propranolol, lactulose, and rifaximin. She was originally from China and moved to the United States 10 years earlier. Given concerns about her ability to consistently take medications, she had moved to a long-term facility. She did not use alcohol, tobacco, or illicit substances.

The normalization of the patient’s mental status after lactulose treatment, especially in the context of recurrent episodes, is characteristic of hepatic encephalopathy, in which ammonia and other substances bypass hepatic metabolism and impair cerebral function. Hepatic encephalopathy is the most common cause of lactulose-responsive encephalopathy, and may recur in the setting of infection or nonadherence with lactulose and rifaximin. Other causes of lactulose-responsive encephalopathy include hyperammonemia caused by urease-producing bacterial infection (eg, Proteus), valproic acid toxicity, and urea cycle abnormalities.

Other causes of confusion with a self-limited course should be considered for the current episode. A postictal state is possible, but convulsions were not reported. The patient is at risk of hypoglycemia from insulin use and impaired gluconeogenesis due to cirrhosis and ESRD, but low blood sugar would have likely been detected at the time of hospitalization. Finally, she might have experienced episodic encephalopathy from ingestion of unreported medications or toxins, whose effects may have resolved with abstinence during hospitalization.

The patient’s temperature was 37.8°C, pulse 73 beats/minute, blood pressure 133/69 mmHg, respiratory rate 12 breaths/minute, and oxygen saturation 98% on ambient air. Her body mass index (BMI) was 19 kg/m². She was somnolent but was moving all four extremities spontaneously. Her pupils were symmetric and reactive. There was no facial asymmetry. Biceps and patellar reflexes were 2+ bilaterally. Babinski sign was absent bilaterally. The patient could not cooperate with the assessment for asterixis. Her sclerae were anicteric. The jugular venous pressure was estimated at 13 cm of water. Her heart was regular with no murmurs. Her lungs were clear. She had a distended, nontender abdomen with caput medusae. She had symmetric pitting edema in her lower extremities up to the shins.

The elevated jugular venous pressure, lower extremity edema, and distended abdomen suggest volume overload. Jugular venous distention with clear lungs is characteristic of right ventricular failure from pulmonary hypertension, right ventricular myocardial infarction, tricuspid regurgitation, or constrictive pericarditis. However, chronic biventricular heart failure often presents in this manner and is more common than the aforementioned conditions. ESRD and cirrhosis may be contributing to the hypervolemia.

Although Asian patients may exhibit metabolic syndrome and NAFLD at a lower BMI than non-Asians, her BMI is uncharacteristically low for NAFLD, especially given the increased weight expected from volume overload. There are no signs of infection to account for worsening of hepatic encephalopathy.

Laboratory tests demonstrated a white blood cell count of 4400/µL with a normal differential, hemoglobin of 10.3 g/dL, and platelet count of 108,000 per cubic millimeter. Mean corpuscular volume was 103 fL. Basic metabolic panel was normal with the exception of blood urea nitrogen of 46 mg/dL and a creatinine of 6.4 mg/dL. Aspartate aminotransferase was 34 units/L, alanine aminotransferase 34 units/L, alkaline phosphatase 289 units/L (normal, 31-95), gamma-glutamyl transferase 104 units (GGT, normal, 12-43), total bilirubin 0.8 mg/dL, and albumin 2.5 g/dL (normal, 3.5-4.5). Pro-brain natriuretic peptide was 1429 pg/mL (normal, <100). The international normalized ratio (INR) was 1.0. Urinalysis showed trace proteinuria. The chest x-ray was normal. A noncontrast computed tomography (CT) of the head demonstrated no intracranial pathology. An abdominal ultrasound revealed a normal-sized nodular liver, a nonocclusive portal vein thrombus (PVT), splenomegaly (15 cm in length), and trace ascites. There was no biliary dilation, hepatic steatosis, or hepatic mass.

The evolving data set presents a mixed picture about the state of the liver. The distended abdominal wall veins, thrombocytopenia, and splenomegaly are commonly observed in advanced cirrhosis, but these findings reflect the associated portal hypertension and not the liver disease itself. The normal bilirubin and INR suggest preserved liver function and decrease the likelihood of cirrhosis being responsible for the portal hypertension. However, the elevated alkaline phosphatase and GGT levels suggest an infiltrative liver disease, such as lymphoma, sarcoidosis, or amyloidosis.

Furthermore, while a nodular liver on imaging is consistent with cirrhosis, no steatosis was noted to support the presumed diagnosis of NAFLD. One explanation for this discrepancy is that fatty infiltration may be absent when NAFLD-associated cirrhosis develops. In summary, there is evidence of liver disease, and there is evidence of portal hypertension, but there is no evidence of liver parenchymal failure. The key features of the latter – spider angiomata, palmar erythema, hyperbilirubinemia, and coagulopathy – are absent.

Noncirrhotic portal hypertension (NCPH) is an alternative explanation for the patient’s findings. NCPH is an elevation in the portal venous system pressure that arises from intrahepatic (but noncirrhotic) disease or from extrahepatic disease. Hepatic schistosomiasis is an example of intrahepatic but noncirrhotic portal hypertension. PVT that arises on account of a hypercoagulable condition (eg, abdominal malignancy, pancreatitis, or myeloproliferative disorders) is a prototype of extrahepatic NCPH. At this point, it is impossible to know if the PVT is a complication of NCPH or a cause of NCPH. PVT as a complication of cirrhosis is less likely.

An abdominal CT scan would better assess the hepatic parenchyma and exclude abdominal malignancies such as pancreatic adenocarcinoma. An echocardiogram is indicated to evaluate the cause of the elevated jugular venous pressure. A liver biopsy and measurement of portal venous pressure would help distinguish between cirrhotic and noncirrhotic portal hypertension.

Hepatitis A, B, and C serologies were negative as were antinuclear and antimitochondrial antibodies. Ferritin and ceruloplasmin levels were normal. A CT scan of the abdomen with contrast demonstrated a nodular liver contour, splenomegaly, and a nonocclusive PVT (Figure 1). A transthoracic echocardiogram showed normal biventricular systolic function and size, normal diastolic function, a pulmonary artery systolic pressure of 57 mmHg (normal, < 25), moderate tricuspid regurgitation, and no pericardial effusion or thickening. The patient’s confusion and somnolence resolved after two days of lactulose therapy. She denied the use of other medications, supplements, or herbs.

Schistosomiasis is the most common cause of NCPH worldwide. Parasite eggs trapped within the terminal portal venules cause inflammation, leading to fibrosis and intrahepatic portal hypertension. The liver becomes nodular on account of these changes, but the overall hepatic function is typically preserved. Portal hypertension, variceal bleeding, and pulmonary hypertension are common complications. The latter can arise from portosystemic shunting, which leads to embolization of schistosome eggs into the pulmonary circulation, where a granulomatous reaction ensues.

A percutaneous liver biopsy showed granulomatous inflammation and dilated portal venules consistent with increased resistance to venous inflow (Figure 2). There was no sinusoidal congestion to indicate impaired hepatic venous outflow. Mild sinusoidal and portal fibrosis and increased iron in Kupffer cells were noted. There was no evidence of cirrhosis or steatohepatitis. Stains for acid-fast bacilli and fungi were negative. 16S rDNA (a test assessing for bacterial DNA) and Mycobacterium tuberculosis polymerase chain reactions were negative. The biopsy confirmed the diagnosis of noncirrhotic portal hypertension.

Infections, such as brucellosis, Q fever, and tuberculosis, are common causes of granulomatous hepatitis in the developing world. Tuberculosis is prevalent in China, but the test results do not support tuberculosis as a unifying diagnosis.

Schistosomiasis accounts for the major clinical features (portal and pulmonary hypertension and preserved liver function) and hepatic pathology (ie, portal venous fibrosis with granulomatous inflammation) in this case and is prevalent in China, where the patient emigrated from. The biopsy specimen should be re-examined for schistosome eggs and serologic tests for schistosomiasis pursued.

Antibodies to human immunodeficiency virus, Brucella, Bartonella quintana, Bartonella henselae, Coxiella burnetii, Francisella tularensis, and Histoplasma were negative. Cryptococcal antigen and rapid plasma reagin were negative. IgG antibodies to Schistosoma were 0.21 units (normal, < 0.19 units). Based on the patient’s epidemiology, biopsy findings, and serology results, hepatic schistosomiasis was diagnosed. Praziquantel was prescribed. She continues to receive daily lactulose and rifaximin and has not had any episodes of encephalopathy in the year after discharge.

Portal hypertension arises when there is resistance to flow in the portal venous system. It is defined as a pressure gradient greater than 5 mmHg between the portal vein and the intra-abdominal portion of the inferior vena cava.¹ Clinicians are familiar with the manifestations of portal hypertension – portosystemic shunting leading to encephalopathy and variceal hemorrhage, ascites, and splenomegaly with thrombocytopenia – because of their close association with cirrhosis. In developed countries, cirrhosis accounts for over 90% of cases of portal hypertension.¹ In the remaining 10%, conditions such as portal vein thrombosis primarily affect the portal vasculature and increase resistance to portal blood flow while leaving hepatic synthetic function relatively spared (Figure 3). Therefore, cirrhosis cannot be inferred with certainty from signs of portal hypertension alone.

Liver biopsy is the gold standard for the diagnosis of cirrhosis, but this method is increasingly being replaced by noninvasive assessments of liver fibrosis, including imaging and scoring systems.² Clinicians often infer cirrhosis from the combination of a known cause of liver injury, abnormal liver biochemical tests, evidence of liver dysfunction, and signs of portal hypertension.³ However, when signs of portal hypertension are present, but liver dysfunction cannot be established on physical exam (eg, palmar erythema, spider nevi, gynecomastia, and testicular atrophy) or laboratory testing (eg, low albumin, elevated INR, and elevated bilirubin), noncirrhotic causes of portal hypertension should be considered. In this case, the biopsy showed vascular changes that suggested impaired venous inflow without bridging fibrosis, which pointed to NCPH.

NCPH is categorized based on the location of resistance to blood flow: prehepatic (eg, portal vein thrombosis), intrahepatic (eg, schistosomiasis), and posthepatic (eg, right-sided heart failure).¹ In our patient, the dilated portal venules (inflow) in the presence of normal hepatic vein outflow suggested an increased intrahepatic resistance to blood flow. This finding excluded a causal role of the portal vein thrombosis and prompted testing for schistosomiasis.

Schistosomiasis affects more than 200 million people worldwide and is prevalent in Sub-Saharan Africa, South America, Egypt, China, and Southeast Asia.^4,5 Transmission occurs in fresh water, where the infectious form of the parasite is released from snails.^4,6 Schistosome worms are not found in the United States, but as a result of immigration and travel, more than 400,000 people in the United States are estimated to be infected.⁵

Chronic schistosomiasis develops from the host’s granulomatous reaction to schistosome eggs whose location (depending on the species) leads to genitourinary, intestinal, hepatic, or rarely, neurologic disease.⁶ Hepatic schistosomiasis arises when eggs released in the portal venous system lodge in small portal venules and cause granulomatous inflammation, periportal fibrosis, and microvascular obstruction.⁶ The resultant portal hypertension develops insidiously, but the architecture and synthetic function of the liver is maintained until the very late stages of disease.^6,7 Pulmonary hypertension can arise from the embolization of eggs to the pulmonary arterioles via portosystemic collaterals.

The demonstration of eggs in stool is the gold standard for the diagnosis of hepatic schistosomiasis, which is most commonly caused by Schistosoma mansoni and S. japonicum.⁷ Serologic assays provide evidence of infection or exposure but may cross-react with other helminths. Liver biopsy may reveal characteristic histopathologic findings, including granulomatous inflammation, distorted vasculature, and the deposition of collagen deposits in the periportal space, leading to “pipestem fibrosis.”^8,9 If eggs cannot be detected on stool or histology, then serology, secondary histologic changes, and sometimes PCR are used to diagnose hepatic schistosomiasis. In our patient, the epidemiology, Schistosoma antibody titer, pulmonary hypertension, and liver biopsy with granulomatous inflammation, periportal fibrosis, and intrahepatic portal venule dilation were diagnostic of hepatic schistosomiasis.

The recurrent episodes of confusion which resolved with lactulose therapy were suggestive of hepatic encephalopathy, which results from shunting and accumulation of neurotoxic substances that would otherwise undergo hepatic metabolism.¹⁰ Clinicians are most familiar with hepatic encephalopathy in cirrhosis, where multiple liver functions – synthesis, excretion, metabolism, and circulation – simultaneously fail. NCPH represents a scenario where only the circulation is impaired, but this is sufficient to cause the portosystemic shunting that leads to encephalopathy. Our patient’s recurrent hepatic encephalopathy, despite adherence to lactulose and rifaximin and its resolution after praziquantel treatment, underscores the importance of addressing the underlying cause of portosystemic shunting.Associating portal hypertension with cirrhosis is efficient and accurate in many cases. However, when specific manifestations of cirrhosis are lacking, clinicians must decouple this association and pursue an alternative explanation for portal hypertension. The presence of some intrahepatic pathology (from schistosomiasis) but no cirrhosis made this case a particularly tough egg to crack.

Teaching Points

• In the developed world, 90% of portal hypertension is due to cirrhosis. Hepatic schistosomiasis is the most common cause of NCPH worldwide.
• Chronic schistosomiasis affects the gastrointestinal, hepatic, and genitourinary systems and causes significant global morbidity and mortality.
• Visualization of schistosome eggs is the diagnostic gold standard. Indirect testing such as schistosoma antibodies and secondary histologic changes may be required for the diagnosis in patients with a low burden of eggs.

Disclosures

Dr. Geha has no disclosures. Dr. Dhaliwal reports receiving honoraria from ISMIE Mutual Insurance Company and Physicians’ Reciprocal Insurers. Dr. Peters’ spouse is employed by Hoffman-La Roche. Dr. Manesh is supported by the Jeremiah A. Barondess Fellowship in the Clinical Transaction of the New York Academy of Medicine, in collaboration with the Accreditation Council for Graduate Medical Education (ACGME).

A 68-year-old woman presented to the emergency department with altered mental status. On the morning prior to admission, she was fully alert and oriented. Over the course of the day, she became more confused and somnolent, and by the evening, she was unarousable to voice. She had not fallen and had no head trauma.

Altered mental status may arise from metabolic (eg, hyponatremia), infectious (eg, urinary tract infection), structural (eg, subdural hematoma), or toxin-related (eg, adverse medication effect) processes. Any of these categories of encephalopathy can develop gradually over the course of a day.

One year prior, the patient was admitted for a similar episode of altered mental status. Asterixis and elevated transaminases prompted an abdominal ultrasound, which revealed a nodular liver and ascites. Paracentesis revealed a high serum-ascites albumin gradient. The diagnosis of cirrhosis was made based on these findings. Testing for viral hepatitis, autoimmune hepatitis, hemochromatosis, and Wilson’s disease were negative. Although steatosis was not detected on ultrasound, nonalcoholic fatty liver disease (NAFLD) was suspected based on the patient’s risk factors of hypertension and type 2 diabetes mellitus. She had four additional presentations of altered mental status with asterixis; each episode resolved with lactulose.

Other medical history included end-stage renal disease (ESRD) requiring hemodialysis. Her medications were labetalol, amlodipine, insulin, propranolol, lactulose, and rifaximin. She was originally from China and moved to the United States 10 years earlier. Given concerns about her ability to consistently take medications, she had moved to a long-term facility. She did not use alcohol, tobacco, or illicit substances.

The normalization of the patient’s mental status after lactulose treatment, especially in the context of recurrent episodes, is characteristic of hepatic encephalopathy, in which ammonia and other substances bypass hepatic metabolism and impair cerebral function. Hepatic encephalopathy is the most common cause of lactulose-responsive encephalopathy, and may recur in the setting of infection or nonadherence with lactulose and rifaximin. Other causes of lactulose-responsive encephalopathy include hyperammonemia caused by urease-producing bacterial infection (eg, Proteus), valproic acid toxicity, and urea cycle abnormalities.

Other causes of confusion with a self-limited course should be considered for the current episode. A postictal state is possible, but convulsions were not reported. The patient is at risk of hypoglycemia from insulin use and impaired gluconeogenesis due to cirrhosis and ESRD, but low blood sugar would have likely been detected at the time of hospitalization. Finally, she might have experienced episodic encephalopathy from ingestion of unreported medications or toxins, whose effects may have resolved with abstinence during hospitalization.

The patient’s temperature was 37.8°C, pulse 73 beats/minute, blood pressure 133/69 mmHg, respiratory rate 12 breaths/minute, and oxygen saturation 98% on ambient air. Her body mass index (BMI) was 19 kg/m². She was somnolent but was moving all four extremities spontaneously. Her pupils were symmetric and reactive. There was no facial asymmetry. Biceps and patellar reflexes were 2+ bilaterally. Babinski sign was absent bilaterally. The patient could not cooperate with the assessment for asterixis. Her sclerae were anicteric. The jugular venous pressure was estimated at 13 cm of water. Her heart was regular with no murmurs. Her lungs were clear. She had a distended, nontender abdomen with caput medusae. She had symmetric pitting edema in her lower extremities up to the shins.

The elevated jugular venous pressure, lower extremity edema, and distended abdomen suggest volume overload. Jugular venous distention with clear lungs is characteristic of right ventricular failure from pulmonary hypertension, right ventricular myocardial infarction, tricuspid regurgitation, or constrictive pericarditis. However, chronic biventricular heart failure often presents in this manner and is more common than the aforementioned conditions. ESRD and cirrhosis may be contributing to the hypervolemia.

Although Asian patients may exhibit metabolic syndrome and NAFLD at a lower BMI than non-Asians, her BMI is uncharacteristically low for NAFLD, especially given the increased weight expected from volume overload. There are no signs of infection to account for worsening of hepatic encephalopathy.

Laboratory tests demonstrated a white blood cell count of 4400/µL with a normal differential, hemoglobin of 10.3 g/dL, and platelet count of 108,000 per cubic millimeter. Mean corpuscular volume was 103 fL. Basic metabolic panel was normal with the exception of blood urea nitrogen of 46 mg/dL and a creatinine of 6.4 mg/dL. Aspartate aminotransferase was 34 units/L, alanine aminotransferase 34 units/L, alkaline phosphatase 289 units/L (normal, 31-95), gamma-glutamyl transferase 104 units (GGT, normal, 12-43), total bilirubin 0.8 mg/dL, and albumin 2.5 g/dL (normal, 3.5-4.5). Pro-brain natriuretic peptide was 1429 pg/mL (normal, <100). The international normalized ratio (INR) was 1.0. Urinalysis showed trace proteinuria. The chest x-ray was normal. A noncontrast computed tomography (CT) of the head demonstrated no intracranial pathology. An abdominal ultrasound revealed a normal-sized nodular liver, a nonocclusive portal vein thrombus (PVT), splenomegaly (15 cm in length), and trace ascites. There was no biliary dilation, hepatic steatosis, or hepatic mass.

The evolving data set presents a mixed picture about the state of the liver. The distended abdominal wall veins, thrombocytopenia, and splenomegaly are commonly observed in advanced cirrhosis, but these findings reflect the associated portal hypertension and not the liver disease itself. The normal bilirubin and INR suggest preserved liver function and decrease the likelihood of cirrhosis being responsible for the portal hypertension. However, the elevated alkaline phosphatase and GGT levels suggest an infiltrative liver disease, such as lymphoma, sarcoidosis, or amyloidosis.

Furthermore, while a nodular liver on imaging is consistent with cirrhosis, no steatosis was noted to support the presumed diagnosis of NAFLD. One explanation for this discrepancy is that fatty infiltration may be absent when NAFLD-associated cirrhosis develops. In summary, there is evidence of liver disease, and there is evidence of portal hypertension, but there is no evidence of liver parenchymal failure. The key features of the latter – spider angiomata, palmar erythema, hyperbilirubinemia, and coagulopathy – are absent.

Noncirrhotic portal hypertension (NCPH) is an alternative explanation for the patient’s findings. NCPH is an elevation in the portal venous system pressure that arises from intrahepatic (but noncirrhotic) disease or from extrahepatic disease. Hepatic schistosomiasis is an example of intrahepatic but noncirrhotic portal hypertension. PVT that arises on account of a hypercoagulable condition (eg, abdominal malignancy, pancreatitis, or myeloproliferative disorders) is a prototype of extrahepatic NCPH. At this point, it is impossible to know if the PVT is a complication of NCPH or a cause of NCPH. PVT as a complication of cirrhosis is less likely.

An abdominal CT scan would better assess the hepatic parenchyma and exclude abdominal malignancies such as pancreatic adenocarcinoma. An echocardiogram is indicated to evaluate the cause of the elevated jugular venous pressure. A liver biopsy and measurement of portal venous pressure would help distinguish between cirrhotic and noncirrhotic portal hypertension.

Hepatitis A, B, and C serologies were negative as were antinuclear and antimitochondrial antibodies. Ferritin and ceruloplasmin levels were normal. A CT scan of the abdomen with contrast demonstrated a nodular liver contour, splenomegaly, and a nonocclusive PVT (Figure 1). A transthoracic echocardiogram showed normal biventricular systolic function and size, normal diastolic function, a pulmonary artery systolic pressure of 57 mmHg (normal, < 25), moderate tricuspid regurgitation, and no pericardial effusion or thickening. The patient’s confusion and somnolence resolved after two days of lactulose therapy. She denied the use of other medications, supplements, or herbs.

Schistosomiasis is the most common cause of NCPH worldwide. Parasite eggs trapped within the terminal portal venules cause inflammation, leading to fibrosis and intrahepatic portal hypertension. The liver becomes nodular on account of these changes, but the overall hepatic function is typically preserved. Portal hypertension, variceal bleeding, and pulmonary hypertension are common complications. The latter can arise from portosystemic shunting, which leads to embolization of schistosome eggs into the pulmonary circulation, where a granulomatous reaction ensues.

A percutaneous liver biopsy showed granulomatous inflammation and dilated portal venules consistent with increased resistance to venous inflow (Figure 2). There was no sinusoidal congestion to indicate impaired hepatic venous outflow. Mild sinusoidal and portal fibrosis and increased iron in Kupffer cells were noted. There was no evidence of cirrhosis or steatohepatitis. Stains for acid-fast bacilli and fungi were negative. 16S rDNA (a test assessing for bacterial DNA) and Mycobacterium tuberculosis polymerase chain reactions were negative. The biopsy confirmed the diagnosis of noncirrhotic portal hypertension.

Infections, such as brucellosis, Q fever, and tuberculosis, are common causes of granulomatous hepatitis in the developing world. Tuberculosis is prevalent in China, but the test results do not support tuberculosis as a unifying diagnosis.

Schistosomiasis accounts for the major clinical features (portal and pulmonary hypertension and preserved liver function) and hepatic pathology (ie, portal venous fibrosis with granulomatous inflammation) in this case and is prevalent in China, where the patient emigrated from. The biopsy specimen should be re-examined for schistosome eggs and serologic tests for schistosomiasis pursued.

Antibodies to human immunodeficiency virus, Brucella, Bartonella quintana, Bartonella henselae, Coxiella burnetii, Francisella tularensis, and Histoplasma were negative. Cryptococcal antigen and rapid plasma reagin were negative. IgG antibodies to Schistosoma were 0.21 units (normal, < 0.19 units). Based on the patient’s epidemiology, biopsy findings, and serology results, hepatic schistosomiasis was diagnosed. Praziquantel was prescribed. She continues to receive daily lactulose and rifaximin and has not had any episodes of encephalopathy in the year after discharge.

Portal hypertension arises when there is resistance to flow in the portal venous system. It is defined as a pressure gradient greater than 5 mmHg between the portal vein and the intra-abdominal portion of the inferior vena cava.¹ Clinicians are familiar with the manifestations of portal hypertension – portosystemic shunting leading to encephalopathy and variceal hemorrhage, ascites, and splenomegaly with thrombocytopenia – because of their close association with cirrhosis. In developed countries, cirrhosis accounts for over 90% of cases of portal hypertension.¹ In the remaining 10%, conditions such as portal vein thrombosis primarily affect the portal vasculature and increase resistance to portal blood flow while leaving hepatic synthetic function relatively spared (Figure 3). Therefore, cirrhosis cannot be inferred with certainty from signs of portal hypertension alone.

Liver biopsy is the gold standard for the diagnosis of cirrhosis, but this method is increasingly being replaced by noninvasive assessments of liver fibrosis, including imaging and scoring systems.² Clinicians often infer cirrhosis from the combination of a known cause of liver injury, abnormal liver biochemical tests, evidence of liver dysfunction, and signs of portal hypertension.³ However, when signs of portal hypertension are present, but liver dysfunction cannot be established on physical exam (eg, palmar erythema, spider nevi, gynecomastia, and testicular atrophy) or laboratory testing (eg, low albumin, elevated INR, and elevated bilirubin), noncirrhotic causes of portal hypertension should be considered. In this case, the biopsy showed vascular changes that suggested impaired venous inflow without bridging fibrosis, which pointed to NCPH.

NCPH is categorized based on the location of resistance to blood flow: prehepatic (eg, portal vein thrombosis), intrahepatic (eg, schistosomiasis), and posthepatic (eg, right-sided heart failure).¹ In our patient, the dilated portal venules (inflow) in the presence of normal hepatic vein outflow suggested an increased intrahepatic resistance to blood flow. This finding excluded a causal role of the portal vein thrombosis and prompted testing for schistosomiasis.

Schistosomiasis affects more than 200 million people worldwide and is prevalent in Sub-Saharan Africa, South America, Egypt, China, and Southeast Asia.^4,5 Transmission occurs in fresh water, where the infectious form of the parasite is released from snails.^4,6 Schistosome worms are not found in the United States, but as a result of immigration and travel, more than 400,000 people in the United States are estimated to be infected.⁵

Chronic schistosomiasis develops from the host’s granulomatous reaction to schistosome eggs whose location (depending on the species) leads to genitourinary, intestinal, hepatic, or rarely, neurologic disease.⁶ Hepatic schistosomiasis arises when eggs released in the portal venous system lodge in small portal venules and cause granulomatous inflammation, periportal fibrosis, and microvascular obstruction.⁶ The resultant portal hypertension develops insidiously, but the architecture and synthetic function of the liver is maintained until the very late stages of disease.^6,7 Pulmonary hypertension can arise from the embolization of eggs to the pulmonary arterioles via portosystemic collaterals.

The demonstration of eggs in stool is the gold standard for the diagnosis of hepatic schistosomiasis, which is most commonly caused by Schistosoma mansoni and S. japonicum.⁷ Serologic assays provide evidence of infection or exposure but may cross-react with other helminths. Liver biopsy may reveal characteristic histopathologic findings, including granulomatous inflammation, distorted vasculature, and the deposition of collagen deposits in the periportal space, leading to “pipestem fibrosis.”^8,9 If eggs cannot be detected on stool or histology, then serology, secondary histologic changes, and sometimes PCR are used to diagnose hepatic schistosomiasis. In our patient, the epidemiology, Schistosoma antibody titer, pulmonary hypertension, and liver biopsy with granulomatous inflammation, periportal fibrosis, and intrahepatic portal venule dilation were diagnostic of hepatic schistosomiasis.

The recurrent episodes of confusion which resolved with lactulose therapy were suggestive of hepatic encephalopathy, which results from shunting and accumulation of neurotoxic substances that would otherwise undergo hepatic metabolism.¹⁰ Clinicians are most familiar with hepatic encephalopathy in cirrhosis, where multiple liver functions – synthesis, excretion, metabolism, and circulation – simultaneously fail. NCPH represents a scenario where only the circulation is impaired, but this is sufficient to cause the portosystemic shunting that leads to encephalopathy. Our patient’s recurrent hepatic encephalopathy, despite adherence to lactulose and rifaximin and its resolution after praziquantel treatment, underscores the importance of addressing the underlying cause of portosystemic shunting.Associating portal hypertension with cirrhosis is efficient and accurate in many cases. However, when specific manifestations of cirrhosis are lacking, clinicians must decouple this association and pursue an alternative explanation for portal hypertension. The presence of some intrahepatic pathology (from schistosomiasis) but no cirrhosis made this case a particularly tough egg to crack.

Teaching Points

• In the developed world, 90% of portal hypertension is due to cirrhosis. Hepatic schistosomiasis is the most common cause of NCPH worldwide.
• Chronic schistosomiasis affects the gastrointestinal, hepatic, and genitourinary systems and causes significant global morbidity and mortality.
• Visualization of schistosome eggs is the diagnostic gold standard. Indirect testing such as schistosoma antibodies and secondary histologic changes may be required for the diagnosis in patients with a low burden of eggs.

Disclosures

Dr. Geha has no disclosures. Dr. Dhaliwal reports receiving honoraria from ISMIE Mutual Insurance Company and Physicians’ Reciprocal Insurers. Dr. Peters’ spouse is employed by Hoffman-La Roche. Dr. Manesh is supported by the Jeremiah A. Barondess Fellowship in the Clinical Transaction of the New York Academy of Medicine, in collaboration with the Accreditation Council for Graduate Medical Education (ACGME).

For the last 35 years, Medicare’s prospective payment system has transformed reimbursement for hospital-based care of patients. This “revolutionary” system shifted payment from being retrospective—the government paid hospitals for what they did—to prospective—the government paid hospitals against a predetermined fee schedule based on a patient’s condition and other factors.¹ When the system started in 1983, the then-new payment system classified patients into 467 Diagnosis-Related Groups (DRGs). In those early days, Medicare paid hospitals “an average price for an average patient within the DRG.”² Not surprisingly, early critics were concerned that this average payment would disadvantage hospitals that cared for more complex patients, such as teaching hospitals; studies then demonstrated that theoretical concern.³ The Severity of Illness (SOI) index, which was developed in the 1980s, attempted to correct this problem by using SOI-stratified DRGs as a payment mechanism. By adding SOI to DRGs, the homogeneity of resource consumption in each group increased, resulting in more accurate comparisons about complexity, outcomes, resource utilization, and ultimately payment. Eventually, along with the risk of mortality, the SOI made its way into the All Patients Refined (APR) DRG system, which is more representative of non-Medicare populations and thus could be applied to children.

The ongoing challenge with SOI classification is that its 4-level categories (1-mild, 2-moderate, 3-severe, 4-extreme) is not comparable across DRGs; that is, a “moderate” patient in one DRG may be sicker and use more resources than an “extreme” patient in another DRG. For this reason, more than a decade ago, Medicare replaced the DRG/SOI approach with the Medicare Severity (MS)-DRG for Medicare payments to hospitals. The distinguishing feature of MS-DRGs is that they represent a complete relative scale; the relative weights are not categorical but can be lined up and payments assigned relative to the average Medicare patient. For example, a look at the 2015 tables shows that heart transplant has the highest relative weight and is the most expensive one, whereas false labor has the lowest relative weight and is the least expensive.⁴ Due to its exclusive intent for use on Medicare patients, the system could not be used for pediatrics. Interestingly, New York State developed a Service Intensity Weight (SIW) in 2009 by using 3 years of Medicaid and commercial payer data to create a relative scale for payment within the state.⁵

Thanks to Richardson, et al, in this issue of Journal of Hospital Medicine, pediatrics has its first relative weight system for hospitalized children across the United States.⁶ Similar to the MS-DRG system, those with the interest or need can line up the APR-DRGs into a relative scale and see that a normal newborn has a relative weight on their H-RISK scale of 0.18, while a heart transplant patient has a weight of 91.66. This is a welcome and much-needed addition to the world of pediatric health services and health service research. Stakeholders can use this system for comparative analyses, risk adjustment, resource utilization comparison, and payment. For those inclined, one can explore the comparisons of relative weights on different scales; for example, the ratio between simple pneumonia and heart transplant is 21 on the MS-DRG, 60 on the NY State SIW scale,⁷ and 187 on H-RISK. A generation of health service researchers and economists may find great satisfaction in elucidating why this relativity in relative scales exists!

There are limitations to all weighting and relative weighting systems. The H-RISK is based on DRG and SOI, which rely on accurate coding. In addition, as the authors note, iatrogenic complications are not differentiated from naturally occurring ones. Thus, a hospital may obtain a higher relative weight applied to a patient who did not enter the hospital as sick as the final score suggests. Researchers noted this problem from the start of the DRG/SOI journey, and all systems that rely on post hoc scoring based on coded diagnoses and activities, without differentiation of presence on admission, have this limitation.⁸ Furthermore, children’s hospitals have far more variable use of observation status than in Medicare, and many DRG analyses exclude observation-status patients.

Despite these limitations, this is an important first step for children’s hospitals to be better able to do comparative analyses and benchmarking with a true relative weight scale that is appropriate for use among hospitalized children.

Disclosure 

The author declares no conflicts of interest.

For the last 35 years, Medicare’s prospective payment system has transformed reimbursement for hospital-based care of patients. This “revolutionary” system shifted payment from being retrospective—the government paid hospitals for what they did—to prospective—the government paid hospitals against a predetermined fee schedule based on a patient’s condition and other factors.¹ When the system started in 1983, the then-new payment system classified patients into 467 Diagnosis-Related Groups (DRGs). In those early days, Medicare paid hospitals “an average price for an average patient within the DRG.”² Not surprisingly, early critics were concerned that this average payment would disadvantage hospitals that cared for more complex patients, such as teaching hospitals; studies then demonstrated that theoretical concern.³ The Severity of Illness (SOI) index, which was developed in the 1980s, attempted to correct this problem by using SOI-stratified DRGs as a payment mechanism. By adding SOI to DRGs, the homogeneity of resource consumption in each group increased, resulting in more accurate comparisons about complexity, outcomes, resource utilization, and ultimately payment. Eventually, along with the risk of mortality, the SOI made its way into the All Patients Refined (APR) DRG system, which is more representative of non-Medicare populations and thus could be applied to children.

The ongoing challenge with SOI classification is that its 4-level categories (1-mild, 2-moderate, 3-severe, 4-extreme) is not comparable across DRGs; that is, a “moderate” patient in one DRG may be sicker and use more resources than an “extreme” patient in another DRG. For this reason, more than a decade ago, Medicare replaced the DRG/SOI approach with the Medicare Severity (MS)-DRG for Medicare payments to hospitals. The distinguishing feature of MS-DRGs is that they represent a complete relative scale; the relative weights are not categorical but can be lined up and payments assigned relative to the average Medicare patient. For example, a look at the 2015 tables shows that heart transplant has the highest relative weight and is the most expensive one, whereas false labor has the lowest relative weight and is the least expensive.⁴ Due to its exclusive intent for use on Medicare patients, the system could not be used for pediatrics. Interestingly, New York State developed a Service Intensity Weight (SIW) in 2009 by using 3 years of Medicaid and commercial payer data to create a relative scale for payment within the state.⁵

Thanks to Richardson, et al, in this issue of Journal of Hospital Medicine, pediatrics has its first relative weight system for hospitalized children across the United States.⁶ Similar to the MS-DRG system, those with the interest or need can line up the APR-DRGs into a relative scale and see that a normal newborn has a relative weight on their H-RISK scale of 0.18, while a heart transplant patient has a weight of 91.66. This is a welcome and much-needed addition to the world of pediatric health services and health service research. Stakeholders can use this system for comparative analyses, risk adjustment, resource utilization comparison, and payment. For those inclined, one can explore the comparisons of relative weights on different scales; for example, the ratio between simple pneumonia and heart transplant is 21 on the MS-DRG, 60 on the NY State SIW scale,⁷ and 187 on H-RISK. A generation of health service researchers and economists may find great satisfaction in elucidating why this relativity in relative scales exists!

There are limitations to all weighting and relative weighting systems. The H-RISK is based on DRG and SOI, which rely on accurate coding. In addition, as the authors note, iatrogenic complications are not differentiated from naturally occurring ones. Thus, a hospital may obtain a higher relative weight applied to a patient who did not enter the hospital as sick as the final score suggests. Researchers noted this problem from the start of the DRG/SOI journey, and all systems that rely on post hoc scoring based on coded diagnoses and activities, without differentiation of presence on admission, have this limitation.⁸ Furthermore, children’s hospitals have far more variable use of observation status than in Medicare, and many DRG analyses exclude observation-status patients.

Despite these limitations, this is an important first step for children’s hospitals to be better able to do comparative analyses and benchmarking with a true relative weight scale that is appropriate for use among hospitalized children.

Disclosure 

The author declares no conflicts of interest.

For the last 35 years, Medicare’s prospective payment system has transformed reimbursement for hospital-based care of patients. This “revolutionary” system shifted payment from being retrospective—the government paid hospitals for what they did—to prospective—the government paid hospitals against a predetermined fee schedule based on a patient’s condition and other factors.¹ When the system started in 1983, the then-new payment system classified patients into 467 Diagnosis-Related Groups (DRGs). In those early days, Medicare paid hospitals “an average price for an average patient within the DRG.”² Not surprisingly, early critics were concerned that this average payment would disadvantage hospitals that cared for more complex patients, such as teaching hospitals; studies then demonstrated that theoretical concern.³ The Severity of Illness (SOI) index, which was developed in the 1980s, attempted to correct this problem by using SOI-stratified DRGs as a payment mechanism. By adding SOI to DRGs, the homogeneity of resource consumption in each group increased, resulting in more accurate comparisons about complexity, outcomes, resource utilization, and ultimately payment. Eventually, along with the risk of mortality, the SOI made its way into the All Patients Refined (APR) DRG system, which is more representative of non-Medicare populations and thus could be applied to children.

The ongoing challenge with SOI classification is that its 4-level categories (1-mild, 2-moderate, 3-severe, 4-extreme) is not comparable across DRGs; that is, a “moderate” patient in one DRG may be sicker and use more resources than an “extreme” patient in another DRG. For this reason, more than a decade ago, Medicare replaced the DRG/SOI approach with the Medicare Severity (MS)-DRG for Medicare payments to hospitals. The distinguishing feature of MS-DRGs is that they represent a complete relative scale; the relative weights are not categorical but can be lined up and payments assigned relative to the average Medicare patient. For example, a look at the 2015 tables shows that heart transplant has the highest relative weight and is the most expensive one, whereas false labor has the lowest relative weight and is the least expensive.⁴ Due to its exclusive intent for use on Medicare patients, the system could not be used for pediatrics. Interestingly, New York State developed a Service Intensity Weight (SIW) in 2009 by using 3 years of Medicaid and commercial payer data to create a relative scale for payment within the state.⁵

Thanks to Richardson, et al, in this issue of Journal of Hospital Medicine, pediatrics has its first relative weight system for hospitalized children across the United States.⁶ Similar to the MS-DRG system, those with the interest or need can line up the APR-DRGs into a relative scale and see that a normal newborn has a relative weight on their H-RISK scale of 0.18, while a heart transplant patient has a weight of 91.66. This is a welcome and much-needed addition to the world of pediatric health services and health service research. Stakeholders can use this system for comparative analyses, risk adjustment, resource utilization comparison, and payment. For those inclined, one can explore the comparisons of relative weights on different scales; for example, the ratio between simple pneumonia and heart transplant is 21 on the MS-DRG, 60 on the NY State SIW scale,⁷ and 187 on H-RISK. A generation of health service researchers and economists may find great satisfaction in elucidating why this relativity in relative scales exists!

There are limitations to all weighting and relative weighting systems. The H-RISK is based on DRG and SOI, which rely on accurate coding. In addition, as the authors note, iatrogenic complications are not differentiated from naturally occurring ones. Thus, a hospital may obtain a higher relative weight applied to a patient who did not enter the hospital as sick as the final score suggests. Researchers noted this problem from the start of the DRG/SOI journey, and all systems that rely on post hoc scoring based on coded diagnoses and activities, without differentiation of presence on admission, have this limitation.⁸ Furthermore, children’s hospitals have far more variable use of observation status than in Medicare, and many DRG analyses exclude observation-status patients.

Despite these limitations, this is an important first step for children’s hospitals to be better able to do comparative analyses and benchmarking with a true relative weight scale that is appropriate for use among hospitalized children.

Disclosure 

The author declares no conflicts of interest.

Fifteen years ago, beepers with 5-digit call-back numbers were the norm. Pushing a call light button outside the patient’s room to flag the desk clerk that a new order had been hand-written was all part of the lived experience of residency. Using that as our baseline, we have clearly come a long way in the way that we communicate with other clinicians in hospitals. Communication among the patient care team in the digital age predominantly involves bidirectional messaging using mobile devices. The approach is both immediate and convenient. Mobile devices can improve work efficiency, patient safety, and quality of care, but their main advantage may be real-time bedside decision support.^1,2 However, the widespread use of mobile devices for communication in healthcare is not without its concerns. First and foremost, there has been abundant literature around short message service (SMS) use in the healthcare setting, and there are concerns surrounding both threats to privacy and the prevalence and impact of interruptions in clinical care.

The first SMS was sent in 1992.³ Text messaging since then has become ubiquitous, even in healthcare, raising concerns around the protection of patient health information under the Health Insurance Portability and Accountability Act (HIPAA). Interestingly, the United States Department of Health and Human Services Office for Civil Rights, enforcer of HIPAA, is tech neutral on the subject.³ Multiple studies have assessed physician stances on SMS communication in the healthcare setting using routine, non-HIPAA-compliant mobile phones. Overall, 60%-80% of respondents admitted to using SMS in patient care, while in another study, 72% and 80% of Internal Medicine residents surveyed found SMS to be the most efficient form of communication and overall preferred method of communication, respectively.^3,4 Interestingly, 82.5% of those same residents preferred the hospital-based alphanumeric paging system for security purposes, even though Freundlich et al. make a compelling argument that unidirectional alphanumeric paging systems are most certainly less HIPAA compliant, lacking encryption and password protection.⁵ Newer platforms that enable HIPAA-compliant messaging are promising, although they may not be fully adopted by clinical teams without full-scale implementation in hospitals.⁶In addition to privacy concerns with SMS applications on mobile phones, interruptions in healthcare – be it from phone calls, emails, text messages, or in-person conversations – are common. In fact, famed communication researcher Enrico Coeira has notoriously described healthcare communication as ”interrupt-driven.”⁷ Prior work has shown that frequent interruptions in the healthcare setting can lead to medication prescription errors, errors in computerized physician order entry, and even surgical procedural errors.^8-10

While studies have focused on interruptions in clinical care in the healthcare setting, little is known about how education may be compromised by interruptions due to mobile devices. Text messaging during dedicated conference time can lead to inadequate learning and a sense of frustration among residents. In this issue of the Journal of Hospital Medicine, Mendel et al. performed a quality improvement study involving eight academic inpatient clinical training units with the aim of reducing nonurgent text messages during education rounds.¹¹ Their unique interventions included learning sessions, posters, adding alerts to the digital communication platform, and alternative messaging options. Of four sequential interventions, a message alerting the sender that they will be interrupting educational rounds and suggesting a “delayed send” or “send as an FYI” showed the greatest impact, reducing the number of text interruptions per team per educational hour from 0.81 to 0.59 (95% CI 0.51-0.67). When comparing a four-week pre-intervention sample with a four-week end-intervention sample, the percentage of nonurgent messages decreased from 82% to 68% (P < .01).

While these results are promising, challenges to large-scale implementation of such a program exist. Buy-in from the ancillary healthcare team is critical for such interventions to succeed and be sustained. It also places a burden of “point triage” on the healthcare team members, who must assess the patient situation and determine the level of urgency and whether to immediately interrupt, delay interrupt or send an FYI message. For example, in the study by Mendel et al.,¹¹ it is noteworthy that urgent patient care issues were mislabeled as “FYI” in 2% of patients. While this is a seemingly low rate, even one of these mislabeled messages could result in significant adverse patient outcomes and should be considered a “never event.” Finally, the study used a messaging platform with programming flexibility and IT personnel to assist. This could be cost prohibitive for some programs, especially if rolled out to an entire institution.

Communication is critical for effective patient care and unfortunately, the timing of such communication is often not orderly but rather, chaotic. Text message communication can introduce interruptions into all aspects of patient care and education, not only dedicated learning conferences. If the goal is for all residents to attend all conferences, it seems impossible (and likely dangerous) to eliminate all messaging interruptions during conference hours. Nevertheless, it is worth noting that Mandel et al. have moved us creatively toward that goal with a multifaceted approach.¹¹ Future work should address more downstream outcomes, such as objective resident learning retention and adverse patient events relative to the number of interruptions per educational hour. If such studies showed improved learning outcomes and fewer adverse patient events, the next step would be to further strengthen and refine their protocol with real-time and scheduled feedback sessions between providers and other patient care team members in addition to the continued search for additional innovative approaches. In addition, combining artificial intelligence or predictive modeling may help us delineate when an interruption is warranted, for example, when a patient is at high clinical risk without intervention. Likewise, human factors research may help us understand the best way to time and execute an interruption to minimize the risk to clinical care or education. After all, the ideal system would not eliminate interruptions entirely but allow clinicians to know when someone should be interrupted and when they do not need to be interrupted.

Disclosures

The authors have no financial relationships relevant to this article to disclose.

Fifteen years ago, beepers with 5-digit call-back numbers were the norm. Pushing a call light button outside the patient’s room to flag the desk clerk that a new order had been hand-written was all part of the lived experience of residency. Using that as our baseline, we have clearly come a long way in the way that we communicate with other clinicians in hospitals. Communication among the patient care team in the digital age predominantly involves bidirectional messaging using mobile devices. The approach is both immediate and convenient. Mobile devices can improve work efficiency, patient safety, and quality of care, but their main advantage may be real-time bedside decision support.^1,2 However, the widespread use of mobile devices for communication in healthcare is not without its concerns. First and foremost, there has been abundant literature around short message service (SMS) use in the healthcare setting, and there are concerns surrounding both threats to privacy and the prevalence and impact of interruptions in clinical care.

The first SMS was sent in 1992.³ Text messaging since then has become ubiquitous, even in healthcare, raising concerns around the protection of patient health information under the Health Insurance Portability and Accountability Act (HIPAA). Interestingly, the United States Department of Health and Human Services Office for Civil Rights, enforcer of HIPAA, is tech neutral on the subject.³ Multiple studies have assessed physician stances on SMS communication in the healthcare setting using routine, non-HIPAA-compliant mobile phones. Overall, 60%-80% of respondents admitted to using SMS in patient care, while in another study, 72% and 80% of Internal Medicine residents surveyed found SMS to be the most efficient form of communication and overall preferred method of communication, respectively.^3,4 Interestingly, 82.5% of those same residents preferred the hospital-based alphanumeric paging system for security purposes, even though Freundlich et al. make a compelling argument that unidirectional alphanumeric paging systems are most certainly less HIPAA compliant, lacking encryption and password protection.⁵ Newer platforms that enable HIPAA-compliant messaging are promising, although they may not be fully adopted by clinical teams without full-scale implementation in hospitals.⁶In addition to privacy concerns with SMS applications on mobile phones, interruptions in healthcare – be it from phone calls, emails, text messages, or in-person conversations – are common. In fact, famed communication researcher Enrico Coeira has notoriously described healthcare communication as ”interrupt-driven.”⁷ Prior work has shown that frequent interruptions in the healthcare setting can lead to medication prescription errors, errors in computerized physician order entry, and even surgical procedural errors.^8-10

While studies have focused on interruptions in clinical care in the healthcare setting, little is known about how education may be compromised by interruptions due to mobile devices. Text messaging during dedicated conference time can lead to inadequate learning and a sense of frustration among residents. In this issue of the Journal of Hospital Medicine, Mendel et al. performed a quality improvement study involving eight academic inpatient clinical training units with the aim of reducing nonurgent text messages during education rounds.¹¹ Their unique interventions included learning sessions, posters, adding alerts to the digital communication platform, and alternative messaging options. Of four sequential interventions, a message alerting the sender that they will be interrupting educational rounds and suggesting a “delayed send” or “send as an FYI” showed the greatest impact, reducing the number of text interruptions per team per educational hour from 0.81 to 0.59 (95% CI 0.51-0.67). When comparing a four-week pre-intervention sample with a four-week end-intervention sample, the percentage of nonurgent messages decreased from 82% to 68% (P < .01).

While these results are promising, challenges to large-scale implementation of such a program exist. Buy-in from the ancillary healthcare team is critical for such interventions to succeed and be sustained. It also places a burden of “point triage” on the healthcare team members, who must assess the patient situation and determine the level of urgency and whether to immediately interrupt, delay interrupt or send an FYI message. For example, in the study by Mendel et al.,¹¹ it is noteworthy that urgent patient care issues were mislabeled as “FYI” in 2% of patients. While this is a seemingly low rate, even one of these mislabeled messages could result in significant adverse patient outcomes and should be considered a “never event.” Finally, the study used a messaging platform with programming flexibility and IT personnel to assist. This could be cost prohibitive for some programs, especially if rolled out to an entire institution.

Communication is critical for effective patient care and unfortunately, the timing of such communication is often not orderly but rather, chaotic. Text message communication can introduce interruptions into all aspects of patient care and education, not only dedicated learning conferences. If the goal is for all residents to attend all conferences, it seems impossible (and likely dangerous) to eliminate all messaging interruptions during conference hours. Nevertheless, it is worth noting that Mandel et al. have moved us creatively toward that goal with a multifaceted approach.¹¹ Future work should address more downstream outcomes, such as objective resident learning retention and adverse patient events relative to the number of interruptions per educational hour. If such studies showed improved learning outcomes and fewer adverse patient events, the next step would be to further strengthen and refine their protocol with real-time and scheduled feedback sessions between providers and other patient care team members in addition to the continued search for additional innovative approaches. In addition, combining artificial intelligence or predictive modeling may help us delineate when an interruption is warranted, for example, when a patient is at high clinical risk without intervention. Likewise, human factors research may help us understand the best way to time and execute an interruption to minimize the risk to clinical care or education. After all, the ideal system would not eliminate interruptions entirely but allow clinicians to know when someone should be interrupted and when they do not need to be interrupted.

Disclosures

The authors have no financial relationships relevant to this article to disclose.

Fifteen years ago, beepers with 5-digit call-back numbers were the norm. Pushing a call light button outside the patient’s room to flag the desk clerk that a new order had been hand-written was all part of the lived experience of residency. Using that as our baseline, we have clearly come a long way in the way that we communicate with other clinicians in hospitals. Communication among the patient care team in the digital age predominantly involves bidirectional messaging using mobile devices. The approach is both immediate and convenient. Mobile devices can improve work efficiency, patient safety, and quality of care, but their main advantage may be real-time bedside decision support.^1,2 However, the widespread use of mobile devices for communication in healthcare is not without its concerns. First and foremost, there has been abundant literature around short message service (SMS) use in the healthcare setting, and there are concerns surrounding both threats to privacy and the prevalence and impact of interruptions in clinical care.

The first SMS was sent in 1992.³ Text messaging since then has become ubiquitous, even in healthcare, raising concerns around the protection of patient health information under the Health Insurance Portability and Accountability Act (HIPAA). Interestingly, the United States Department of Health and Human Services Office for Civil Rights, enforcer of HIPAA, is tech neutral on the subject.³ Multiple studies have assessed physician stances on SMS communication in the healthcare setting using routine, non-HIPAA-compliant mobile phones. Overall, 60%-80% of respondents admitted to using SMS in patient care, while in another study, 72% and 80% of Internal Medicine residents surveyed found SMS to be the most efficient form of communication and overall preferred method of communication, respectively.^3,4 Interestingly, 82.5% of those same residents preferred the hospital-based alphanumeric paging system for security purposes, even though Freundlich et al. make a compelling argument that unidirectional alphanumeric paging systems are most certainly less HIPAA compliant, lacking encryption and password protection.⁵ Newer platforms that enable HIPAA-compliant messaging are promising, although they may not be fully adopted by clinical teams without full-scale implementation in hospitals.⁶In addition to privacy concerns with SMS applications on mobile phones, interruptions in healthcare – be it from phone calls, emails, text messages, or in-person conversations – are common. In fact, famed communication researcher Enrico Coeira has notoriously described healthcare communication as ”interrupt-driven.”⁷ Prior work has shown that frequent interruptions in the healthcare setting can lead to medication prescription errors, errors in computerized physician order entry, and even surgical procedural errors.^8-10

While studies have focused on interruptions in clinical care in the healthcare setting, little is known about how education may be compromised by interruptions due to mobile devices. Text messaging during dedicated conference time can lead to inadequate learning and a sense of frustration among residents. In this issue of the Journal of Hospital Medicine, Mendel et al. performed a quality improvement study involving eight academic inpatient clinical training units with the aim of reducing nonurgent text messages during education rounds.¹¹ Their unique interventions included learning sessions, posters, adding alerts to the digital communication platform, and alternative messaging options. Of four sequential interventions, a message alerting the sender that they will be interrupting educational rounds and suggesting a “delayed send” or “send as an FYI” showed the greatest impact, reducing the number of text interruptions per team per educational hour from 0.81 to 0.59 (95% CI 0.51-0.67). When comparing a four-week pre-intervention sample with a four-week end-intervention sample, the percentage of nonurgent messages decreased from 82% to 68% (P < .01).

While these results are promising, challenges to large-scale implementation of such a program exist. Buy-in from the ancillary healthcare team is critical for such interventions to succeed and be sustained. It also places a burden of “point triage” on the healthcare team members, who must assess the patient situation and determine the level of urgency and whether to immediately interrupt, delay interrupt or send an FYI message. For example, in the study by Mendel et al.,¹¹ it is noteworthy that urgent patient care issues were mislabeled as “FYI” in 2% of patients. While this is a seemingly low rate, even one of these mislabeled messages could result in significant adverse patient outcomes and should be considered a “never event.” Finally, the study used a messaging platform with programming flexibility and IT personnel to assist. This could be cost prohibitive for some programs, especially if rolled out to an entire institution.

Communication is critical for effective patient care and unfortunately, the timing of such communication is often not orderly but rather, chaotic. Text message communication can introduce interruptions into all aspects of patient care and education, not only dedicated learning conferences. If the goal is for all residents to attend all conferences, it seems impossible (and likely dangerous) to eliminate all messaging interruptions during conference hours. Nevertheless, it is worth noting that Mandel et al. have moved us creatively toward that goal with a multifaceted approach.¹¹ Future work should address more downstream outcomes, such as objective resident learning retention and adverse patient events relative to the number of interruptions per educational hour. If such studies showed improved learning outcomes and fewer adverse patient events, the next step would be to further strengthen and refine their protocol with real-time and scheduled feedback sessions between providers and other patient care team members in addition to the continued search for additional innovative approaches. In addition, combining artificial intelligence or predictive modeling may help us delineate when an interruption is warranted, for example, when a patient is at high clinical risk without intervention. Likewise, human factors research may help us understand the best way to time and execute an interruption to minimize the risk to clinical care or education. After all, the ideal system would not eliminate interruptions entirely but allow clinicians to know when someone should be interrupted and when they do not need to be interrupted.

Disclosures

The authors have no financial relationships relevant to this article to disclose.

This issue of the Journal of Hospital Medicine addresses an emerging trend in internal medicine graduate medical education: the hospitalist rotation.

In the article, Training Residents in Hospital Medicine: The Hospitalist Elective National Survey (HENS). by Ludwin et al., the authors present a descriptive overview of the composition of hospital medicine rotations, as described by program directors from some of the largest training programs. ¹ It can be said for sure that hospital medicine rotations exist: half of the 82 programs that replied to the survey noted that a hospital medicine rotation was already in place. That is where the certainty ends. Although there are common themes across these rotations, there is no one clear definition of such a rotation. Like all good contributions to the medical literature, this study inspires more questions than it answers.

The Mark Twain-inspired cynic would be quick to make an interpretation of the hospital medicine rotation: Is this not just a clever way to coax residents into using their elective time to cover the service needs left over from Accreditation Council for Graduate Medical Education (ACGME)-mandated shift limits and admission caps? Seventy-one percent of these rotations were involved in “admitting new patients.” And since forty-six percent were tasked with taking hold-over admissions, it is reasonable to surmise that these rotations are playing a role in covering patient care duties left over from traditional ward services.

But is there anything wrong with that? Within the confines of reasonable intensity, caring for more patients usually benefits a resident’s education. And if the resident is learning knowledge, skills and attitudes that are unique from those that are acquired on a traditional ward service, painting the fence for free might not be that bad. The question is: “Does the hospitalist rotation help in the acquisition of those unique knowledge, skills and attitudes?” Although this study alludes to such unique components via its qualitative analysis (ie, more autonomy, co-management of non-medicine services, etc.), it does not fully answer that question. It does, however, inspire the next study: How do residents perceive the unique and additional value (if any) of the hospital medicine rotation?

For the sake of argument, let’s say that residents’ perception of the hospital medicine rotation is one of meaning and value. Does that matter? It is great if they do, but equally important is the question of whether or not hospital medicine rotations are effective in preparing resident graduates for a career in hospital medicine. This study suggests that those who have designed these rotations have tried to anticipate and address this need. Components such as quality, patient safety, co-management, and billing and compliance are all clearly a part of a hospitalist’s practice, and all are elements that have not been traditionally emphasized in residency training. The question is: ”Are these elements the knowledge, skills and attitudes that are most lacking in the residency graduate as he/she enters the practice of hospital medicine?” The unfortunate answer is that we do not know for sure, and this uncertainty has been the Achilles heel of our current residency-training infrastructure. Not unique to hospital medicine, there is simply not a well-defined feedback loop between practice requirements and residency training requirements. A structured and regular gap analysis comparing the residents’ areas of competence at the end of training to what they need in practice, would go a long way in answering questions such as this one, and would most certainly inform the components of a hospital medicine elective going forward.

Even if the components of a hospital medicine rotation are valuable, and even if they do align with what the practice needs, there is still the question of whether a month-long hospital medicine rotation can even come close to closing the gap of what is needed versus what is delivered. One can surmise that the answer to that question is what has extended the “hospital medicine rotation” to the “hospital medicine track,” comprised of a multiple of such rotations. Like all discussions on time-constrained medical education curricula, what will be discarded to make room for these rotations? In thirty-six months of training, there is opportunity cost: every month spent on a hospital medicine elective is a month that could have been spent on something else (rheumatology, nephrology, etc.). Again, this is not unique to hospital medicine; the same could be said of the resident who does too many cardiology electives at the exclusion of learning about endocrinology. It would be overly dramatic to say that devoting a month to a hospital medicine rotation, or any elective for that matter, meaningfully compromises the resident’s overall competence as an internist. It is, instead, a question of degree: an excessive number of these electives would likely compromise the resident’s overall competence. The likelihood of this happening is proportional to the size of the gap between what is required to effectively enter hospital medicine practice and what can be delivered in a month-long hospital medicine rotation. We return, then, to the question: How much hospital medicine training in residency would be required to fully prepare a resident for the current practice of a hospitalist?

Whatever the answer might be, that question takes us to a difficult dilemma that has lurked in the background of residency training for some time now; one that is not at all unique to hospital medicine. Should residency training be “voc-tech” or “liberal arts”? A purist would argue that an understanding and appreciation of all things not hospital medicine is what truly makes for the great hospitalist. An understanding of primary care, for example, would seem to optimize a hospitalist’s performance with respect to transitions of care. Adding to the gravity of such an argument is that residency might be the last time to acquire such “non-hospital-medicine” experiences.

Noting that the practice of hospital medicine being so dynamic and heterogeneous, the realist might pile on by saying that it is simply impossible to fully prepare a resident for the actual practice of hospital medicine. Further, many of these skills might be impossible to fully master outside of being fully immersed in the practice of hospital medicine (i.e., billing and coding). The best that can be done is to set a solid foundation that would enable them to learn further as they practice; there will be opportunities to learn the specific components of the field later on.

On the other hand, it is hard to justify residency training if the graduate is unprepared to practice, and without the fundamental knowledge, skills and attitudes specific to their career as they practice. For example, it is reasonable to suspect that a new hospitalist who has had no prior training in quality improvement will, because of the inertia that comes with engaging in any new and foreign skill, find it much harder to engage in quality improvement as a part of her career. It is also worth considering the role that mastery, autonomy and purpose have upon the overall residency experience. Engaging in electives that have a palpable purpose for the resident’s eventual career, and engender an opportunity to begin developing a sense of mastery in that field, could be an effective antidote in mitigating the burn-out that is far too common in residency training today.

For residents engaged in a future practice of hospital medicine, the hospital medicine rotation seems like a promising way out of this dilemma. An effectively designed elective approach could enable maintaining a core foundational education, while getting an early start on the specific components necessary for a promising career in hospital medicine. The operative words, of course, are “effectively designed.” What exactly does that entail? That is why this study is so important; even if we do not fully know what it should look like, we now have our first glimpse of what it is.

Disclosures

The author has nothing to disclose.

This issue of the Journal of Hospital Medicine addresses an emerging trend in internal medicine graduate medical education: the hospitalist rotation.

In the article, Training Residents in Hospital Medicine: The Hospitalist Elective National Survey (HENS). by Ludwin et al., the authors present a descriptive overview of the composition of hospital medicine rotations, as described by program directors from some of the largest training programs. ¹ It can be said for sure that hospital medicine rotations exist: half of the 82 programs that replied to the survey noted that a hospital medicine rotation was already in place. That is where the certainty ends. Although there are common themes across these rotations, there is no one clear definition of such a rotation. Like all good contributions to the medical literature, this study inspires more questions than it answers.

The Mark Twain-inspired cynic would be quick to make an interpretation of the hospital medicine rotation: Is this not just a clever way to coax residents into using their elective time to cover the service needs left over from Accreditation Council for Graduate Medical Education (ACGME)-mandated shift limits and admission caps? Seventy-one percent of these rotations were involved in “admitting new patients.” And since forty-six percent were tasked with taking hold-over admissions, it is reasonable to surmise that these rotations are playing a role in covering patient care duties left over from traditional ward services.

But is there anything wrong with that? Within the confines of reasonable intensity, caring for more patients usually benefits a resident’s education. And if the resident is learning knowledge, skills and attitudes that are unique from those that are acquired on a traditional ward service, painting the fence for free might not be that bad. The question is: “Does the hospitalist rotation help in the acquisition of those unique knowledge, skills and attitudes?” Although this study alludes to such unique components via its qualitative analysis (ie, more autonomy, co-management of non-medicine services, etc.), it does not fully answer that question. It does, however, inspire the next study: How do residents perceive the unique and additional value (if any) of the hospital medicine rotation?

For the sake of argument, let’s say that residents’ perception of the hospital medicine rotation is one of meaning and value. Does that matter? It is great if they do, but equally important is the question of whether or not hospital medicine rotations are effective in preparing resident graduates for a career in hospital medicine. This study suggests that those who have designed these rotations have tried to anticipate and address this need. Components such as quality, patient safety, co-management, and billing and compliance are all clearly a part of a hospitalist’s practice, and all are elements that have not been traditionally emphasized in residency training. The question is: ”Are these elements the knowledge, skills and attitudes that are most lacking in the residency graduate as he/she enters the practice of hospital medicine?” The unfortunate answer is that we do not know for sure, and this uncertainty has been the Achilles heel of our current residency-training infrastructure. Not unique to hospital medicine, there is simply not a well-defined feedback loop between practice requirements and residency training requirements. A structured and regular gap analysis comparing the residents’ areas of competence at the end of training to what they need in practice, would go a long way in answering questions such as this one, and would most certainly inform the components of a hospital medicine elective going forward.

Even if the components of a hospital medicine rotation are valuable, and even if they do align with what the practice needs, there is still the question of whether a month-long hospital medicine rotation can even come close to closing the gap of what is needed versus what is delivered. One can surmise that the answer to that question is what has extended the “hospital medicine rotation” to the “hospital medicine track,” comprised of a multiple of such rotations. Like all discussions on time-constrained medical education curricula, what will be discarded to make room for these rotations? In thirty-six months of training, there is opportunity cost: every month spent on a hospital medicine elective is a month that could have been spent on something else (rheumatology, nephrology, etc.). Again, this is not unique to hospital medicine; the same could be said of the resident who does too many cardiology electives at the exclusion of learning about endocrinology. It would be overly dramatic to say that devoting a month to a hospital medicine rotation, or any elective for that matter, meaningfully compromises the resident’s overall competence as an internist. It is, instead, a question of degree: an excessive number of these electives would likely compromise the resident’s overall competence. The likelihood of this happening is proportional to the size of the gap between what is required to effectively enter hospital medicine practice and what can be delivered in a month-long hospital medicine rotation. We return, then, to the question: How much hospital medicine training in residency would be required to fully prepare a resident for the current practice of a hospitalist?

Whatever the answer might be, that question takes us to a difficult dilemma that has lurked in the background of residency training for some time now; one that is not at all unique to hospital medicine. Should residency training be “voc-tech” or “liberal arts”? A purist would argue that an understanding and appreciation of all things not hospital medicine is what truly makes for the great hospitalist. An understanding of primary care, for example, would seem to optimize a hospitalist’s performance with respect to transitions of care. Adding to the gravity of such an argument is that residency might be the last time to acquire such “non-hospital-medicine” experiences.

Noting that the practice of hospital medicine being so dynamic and heterogeneous, the realist might pile on by saying that it is simply impossible to fully prepare a resident for the actual practice of hospital medicine. Further, many of these skills might be impossible to fully master outside of being fully immersed in the practice of hospital medicine (i.e., billing and coding). The best that can be done is to set a solid foundation that would enable them to learn further as they practice; there will be opportunities to learn the specific components of the field later on.

On the other hand, it is hard to justify residency training if the graduate is unprepared to practice, and without the fundamental knowledge, skills and attitudes specific to their career as they practice. For example, it is reasonable to suspect that a new hospitalist who has had no prior training in quality improvement will, because of the inertia that comes with engaging in any new and foreign skill, find it much harder to engage in quality improvement as a part of her career. It is also worth considering the role that mastery, autonomy and purpose have upon the overall residency experience. Engaging in electives that have a palpable purpose for the resident’s eventual career, and engender an opportunity to begin developing a sense of mastery in that field, could be an effective antidote in mitigating the burn-out that is far too common in residency training today.

For residents engaged in a future practice of hospital medicine, the hospital medicine rotation seems like a promising way out of this dilemma. An effectively designed elective approach could enable maintaining a core foundational education, while getting an early start on the specific components necessary for a promising career in hospital medicine. The operative words, of course, are “effectively designed.” What exactly does that entail? That is why this study is so important; even if we do not fully know what it should look like, we now have our first glimpse of what it is.

Disclosures

The author has nothing to disclose.

This issue of the Journal of Hospital Medicine addresses an emerging trend in internal medicine graduate medical education: the hospitalist rotation.

In the article, Training Residents in Hospital Medicine: The Hospitalist Elective National Survey (HENS). by Ludwin et al., the authors present a descriptive overview of the composition of hospital medicine rotations, as described by program directors from some of the largest training programs. ¹ It can be said for sure that hospital medicine rotations exist: half of the 82 programs that replied to the survey noted that a hospital medicine rotation was already in place. That is where the certainty ends. Although there are common themes across these rotations, there is no one clear definition of such a rotation. Like all good contributions to the medical literature, this study inspires more questions than it answers.

The Mark Twain-inspired cynic would be quick to make an interpretation of the hospital medicine rotation: Is this not just a clever way to coax residents into using their elective time to cover the service needs left over from Accreditation Council for Graduate Medical Education (ACGME)-mandated shift limits and admission caps? Seventy-one percent of these rotations were involved in “admitting new patients.” And since forty-six percent were tasked with taking hold-over admissions, it is reasonable to surmise that these rotations are playing a role in covering patient care duties left over from traditional ward services.

But is there anything wrong with that? Within the confines of reasonable intensity, caring for more patients usually benefits a resident’s education. And if the resident is learning knowledge, skills and attitudes that are unique from those that are acquired on a traditional ward service, painting the fence for free might not be that bad. The question is: “Does the hospitalist rotation help in the acquisition of those unique knowledge, skills and attitudes?” Although this study alludes to such unique components via its qualitative analysis (ie, more autonomy, co-management of non-medicine services, etc.), it does not fully answer that question. It does, however, inspire the next study: How do residents perceive the unique and additional value (if any) of the hospital medicine rotation?

For the sake of argument, let’s say that residents’ perception of the hospital medicine rotation is one of meaning and value. Does that matter? It is great if they do, but equally important is the question of whether or not hospital medicine rotations are effective in preparing resident graduates for a career in hospital medicine. This study suggests that those who have designed these rotations have tried to anticipate and address this need. Components such as quality, patient safety, co-management, and billing and compliance are all clearly a part of a hospitalist’s practice, and all are elements that have not been traditionally emphasized in residency training. The question is: ”Are these elements the knowledge, skills and attitudes that are most lacking in the residency graduate as he/she enters the practice of hospital medicine?” The unfortunate answer is that we do not know for sure, and this uncertainty has been the Achilles heel of our current residency-training infrastructure. Not unique to hospital medicine, there is simply not a well-defined feedback loop between practice requirements and residency training requirements. A structured and regular gap analysis comparing the residents’ areas of competence at the end of training to what they need in practice, would go a long way in answering questions such as this one, and would most certainly inform the components of a hospital medicine elective going forward.

Even if the components of a hospital medicine rotation are valuable, and even if they do align with what the practice needs, there is still the question of whether a month-long hospital medicine rotation can even come close to closing the gap of what is needed versus what is delivered. One can surmise that the answer to that question is what has extended the “hospital medicine rotation” to the “hospital medicine track,” comprised of a multiple of such rotations. Like all discussions on time-constrained medical education curricula, what will be discarded to make room for these rotations? In thirty-six months of training, there is opportunity cost: every month spent on a hospital medicine elective is a month that could have been spent on something else (rheumatology, nephrology, etc.). Again, this is not unique to hospital medicine; the same could be said of the resident who does too many cardiology electives at the exclusion of learning about endocrinology. It would be overly dramatic to say that devoting a month to a hospital medicine rotation, or any elective for that matter, meaningfully compromises the resident’s overall competence as an internist. It is, instead, a question of degree: an excessive number of these electives would likely compromise the resident’s overall competence. The likelihood of this happening is proportional to the size of the gap between what is required to effectively enter hospital medicine practice and what can be delivered in a month-long hospital medicine rotation. We return, then, to the question: How much hospital medicine training in residency would be required to fully prepare a resident for the current practice of a hospitalist?

Whatever the answer might be, that question takes us to a difficult dilemma that has lurked in the background of residency training for some time now; one that is not at all unique to hospital medicine. Should residency training be “voc-tech” or “liberal arts”? A purist would argue that an understanding and appreciation of all things not hospital medicine is what truly makes for the great hospitalist. An understanding of primary care, for example, would seem to optimize a hospitalist’s performance with respect to transitions of care. Adding to the gravity of such an argument is that residency might be the last time to acquire such “non-hospital-medicine” experiences.

Noting that the practice of hospital medicine being so dynamic and heterogeneous, the realist might pile on by saying that it is simply impossible to fully prepare a resident for the actual practice of hospital medicine. Further, many of these skills might be impossible to fully master outside of being fully immersed in the practice of hospital medicine (i.e., billing and coding). The best that can be done is to set a solid foundation that would enable them to learn further as they practice; there will be opportunities to learn the specific components of the field later on.

On the other hand, it is hard to justify residency training if the graduate is unprepared to practice, and without the fundamental knowledge, skills and attitudes specific to their career as they practice. For example, it is reasonable to suspect that a new hospitalist who has had no prior training in quality improvement will, because of the inertia that comes with engaging in any new and foreign skill, find it much harder to engage in quality improvement as a part of her career. It is also worth considering the role that mastery, autonomy and purpose have upon the overall residency experience. Engaging in electives that have a palpable purpose for the resident’s eventual career, and engender an opportunity to begin developing a sense of mastery in that field, could be an effective antidote in mitigating the burn-out that is far too common in residency training today.

For residents engaged in a future practice of hospital medicine, the hospital medicine rotation seems like a promising way out of this dilemma. An effectively designed elective approach could enable maintaining a core foundational education, while getting an early start on the specific components necessary for a promising career in hospital medicine. The operative words, of course, are “effectively designed.” What exactly does that entail? That is why this study is so important; even if we do not fully know what it should look like, we now have our first glimpse of what it is.

Disclosures

The author has nothing to disclose.