Clinical question: Is earlier administration of epinephrine in patients with cardiac arrest due to nonshockable rhythms associated with increased return of spontaneous circulation, survival, and neurologically intact survival?

Background: About 200,000 hospitalized patients in the U.S. have a cardiac arrest, commonly due to nonshockable rhythms. Cardiopulmonary resuscitation has been the only efficacious intervention. There are no well-controlled trials of the use of epinephrine on survival and neurological outcomes.

Study design: Prospective cohort from a large multicenter registry of in-hospital cardiac arrests.

Setting: Data from 570 hospitals from 2000 to 2009.

Synopsis: Authors included 25,095 adults from 570 hospitals who had cardiac arrests in hospital with asystole or pulseless electrical activity as the initial rhythm. Time to first administration of epinephrine was recorded and then separated into quartiles, and odds ratios were evaluated using one to three minutes as the reference group. Outcomes of survival to hospital discharge (10%), return of spontaneous circulation (47%), and survival to hospital discharge with favorable neurologic status (7%) were assessed.

Survival to discharge decreased as the time to administration of the first dose of epinephrine increased. Of those patients receiving epinephrine in one minute, 12% survived. This dropped to 7% for those first receiving epinephrine after seven minutes. Return of spontaneous circulation and survival to discharge with favorable neurologic status showed a similar stepwise decrease with longer times to first administration of epinephrine.

Bottom line: Earlier administration of epinephrine to patients with cardiac arrest due to nonshockable rhythms is associated with improved survival to discharge, return of spontaneous circulation, and neurologically intact survival.

Citation: Donnino MW, Salciccioli JD, Howell MD, et al. Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: restrospective analysis of large in-hospital data registry. BMJ. 2014;348:g3028.

Clinical question: Is earlier administration of epinephrine in patients with cardiac arrest due to nonshockable rhythms associated with increased return of spontaneous circulation, survival, and neurologically intact survival?

Background: About 200,000 hospitalized patients in the U.S. have a cardiac arrest, commonly due to nonshockable rhythms. Cardiopulmonary resuscitation has been the only efficacious intervention. There are no well-controlled trials of the use of epinephrine on survival and neurological outcomes.

Study design: Prospective cohort from a large multicenter registry of in-hospital cardiac arrests.

Setting: Data from 570 hospitals from 2000 to 2009.

Synopsis: Authors included 25,095 adults from 570 hospitals who had cardiac arrests in hospital with asystole or pulseless electrical activity as the initial rhythm. Time to first administration of epinephrine was recorded and then separated into quartiles, and odds ratios were evaluated using one to three minutes as the reference group. Outcomes of survival to hospital discharge (10%), return of spontaneous circulation (47%), and survival to hospital discharge with favorable neurologic status (7%) were assessed.

Survival to discharge decreased as the time to administration of the first dose of epinephrine increased. Of those patients receiving epinephrine in one minute, 12% survived. This dropped to 7% for those first receiving epinephrine after seven minutes. Return of spontaneous circulation and survival to discharge with favorable neurologic status showed a similar stepwise decrease with longer times to first administration of epinephrine.

Bottom line: Earlier administration of epinephrine to patients with cardiac arrest due to nonshockable rhythms is associated with improved survival to discharge, return of spontaneous circulation, and neurologically intact survival.

Citation: Donnino MW, Salciccioli JD, Howell MD, et al. Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: restrospective analysis of large in-hospital data registry. BMJ. 2014;348:g3028.

Clinical question: Is earlier administration of epinephrine in patients with cardiac arrest due to nonshockable rhythms associated with increased return of spontaneous circulation, survival, and neurologically intact survival?

Background: About 200,000 hospitalized patients in the U.S. have a cardiac arrest, commonly due to nonshockable rhythms. Cardiopulmonary resuscitation has been the only efficacious intervention. There are no well-controlled trials of the use of epinephrine on survival and neurological outcomes.

Study design: Prospective cohort from a large multicenter registry of in-hospital cardiac arrests.

Setting: Data from 570 hospitals from 2000 to 2009.

Synopsis: Authors included 25,095 adults from 570 hospitals who had cardiac arrests in hospital with asystole or pulseless electrical activity as the initial rhythm. Time to first administration of epinephrine was recorded and then separated into quartiles, and odds ratios were evaluated using one to three minutes as the reference group. Outcomes of survival to hospital discharge (10%), return of spontaneous circulation (47%), and survival to hospital discharge with favorable neurologic status (7%) were assessed.

Survival to discharge decreased as the time to administration of the first dose of epinephrine increased. Of those patients receiving epinephrine in one minute, 12% survived. This dropped to 7% for those first receiving epinephrine after seven minutes. Return of spontaneous circulation and survival to discharge with favorable neurologic status showed a similar stepwise decrease with longer times to first administration of epinephrine.

Bottom line: Earlier administration of epinephrine to patients with cardiac arrest due to nonshockable rhythms is associated with improved survival to discharge, return of spontaneous circulation, and neurologically intact survival.

Citation: Donnino MW, Salciccioli JD, Howell MD, et al. Time to administration of epinephrine and outcome after in-hospital cardiac arrest with non-shockable rhythms: restrospective analysis of large in-hospital data registry. BMJ. 2014;348:g3028.

Clinical question: Is there a more accurate way to predict adverse post-operative outcomes in geriatric patients undergoing elective surgery?

Background: More than half of all operations in the U.S. involve geriatric patients. Most tools hospitalists use to predict post-operative outcomes are focused on cardiovascular events and do not account for frailty. Common in geriatric patients, frailty is thought to influence post-operative outcomes.

Study design: Prospective cohort study.

Setting: A 1,000-bed academic hospital in Seoul, South Korea.

Synopsis: A cohort of 275 elderly patients (>64 years old) who were scheduled for elective intermediate or high-risk surgery underwent a pre-operative comprehensive geriatric assessment (CGA) that included measures of frailty. This cohort was then followed for mortality, major post-operative complications (pneumonia, urinary infection, pulmonary embolism, and unplanned transfer to intensive care), length of stay, and transfer to a nursing home. Post-operative complications, transfer to a nursing facility, and one-year mortality were associated with a derived scoring tool that included the Charlson Comorbidity Index, activities of daily living (ADL), instrumental activities of daily living (IADL), dementia, risk for delirium, mid-arm circumference, and a mini-nutritional assessment.

This tool was more accurate at predicting one-year mortality than the American Society of Anesthesiologists (ASA) classification.

Bottom line: This study establishes that measures of frailty predict post-operative outcomes in geriatric patients undergoing elective surgery; however, the authors’ tool depends on CGA, which is time-consuming, cumbersome, and depends on indices not familiar to many hospitalists.

Citation: Kim SW, Han HS, Jung HW, et al. Multidimensional frailty scores for the prediction of postoperative mortality risk. JAMA Surg. 2014;149(7):633-640.

Clinical question: Is there a more accurate way to predict adverse post-operative outcomes in geriatric patients undergoing elective surgery?

Background: More than half of all operations in the U.S. involve geriatric patients. Most tools hospitalists use to predict post-operative outcomes are focused on cardiovascular events and do not account for frailty. Common in geriatric patients, frailty is thought to influence post-operative outcomes.

Study design: Prospective cohort study.

Setting: A 1,000-bed academic hospital in Seoul, South Korea.

Synopsis: A cohort of 275 elderly patients (>64 years old) who were scheduled for elective intermediate or high-risk surgery underwent a pre-operative comprehensive geriatric assessment (CGA) that included measures of frailty. This cohort was then followed for mortality, major post-operative complications (pneumonia, urinary infection, pulmonary embolism, and unplanned transfer to intensive care), length of stay, and transfer to a nursing home. Post-operative complications, transfer to a nursing facility, and one-year mortality were associated with a derived scoring tool that included the Charlson Comorbidity Index, activities of daily living (ADL), instrumental activities of daily living (IADL), dementia, risk for delirium, mid-arm circumference, and a mini-nutritional assessment.

This tool was more accurate at predicting one-year mortality than the American Society of Anesthesiologists (ASA) classification.

Bottom line: This study establishes that measures of frailty predict post-operative outcomes in geriatric patients undergoing elective surgery; however, the authors’ tool depends on CGA, which is time-consuming, cumbersome, and depends on indices not familiar to many hospitalists.

Citation: Kim SW, Han HS, Jung HW, et al. Multidimensional frailty scores for the prediction of postoperative mortality risk. JAMA Surg. 2014;149(7):633-640.

Clinical question: Is there a more accurate way to predict adverse post-operative outcomes in geriatric patients undergoing elective surgery?

Background: More than half of all operations in the U.S. involve geriatric patients. Most tools hospitalists use to predict post-operative outcomes are focused on cardiovascular events and do not account for frailty. Common in geriatric patients, frailty is thought to influence post-operative outcomes.

Study design: Prospective cohort study.

Setting: A 1,000-bed academic hospital in Seoul, South Korea.

Synopsis: A cohort of 275 elderly patients (>64 years old) who were scheduled for elective intermediate or high-risk surgery underwent a pre-operative comprehensive geriatric assessment (CGA) that included measures of frailty. This cohort was then followed for mortality, major post-operative complications (pneumonia, urinary infection, pulmonary embolism, and unplanned transfer to intensive care), length of stay, and transfer to a nursing home. Post-operative complications, transfer to a nursing facility, and one-year mortality were associated with a derived scoring tool that included the Charlson Comorbidity Index, activities of daily living (ADL), instrumental activities of daily living (IADL), dementia, risk for delirium, mid-arm circumference, and a mini-nutritional assessment.

This tool was more accurate at predicting one-year mortality than the American Society of Anesthesiologists (ASA) classification.

Bottom line: This study establishes that measures of frailty predict post-operative outcomes in geriatric patients undergoing elective surgery; however, the authors’ tool depends on CGA, which is time-consuming, cumbersome, and depends on indices not familiar to many hospitalists.

Citation: Kim SW, Han HS, Jung HW, et al. Multidimensional frailty scores for the prediction of postoperative mortality risk. JAMA Surg. 2014;149(7):633-640.

Clinical question: Should angiotension-converting enzyme inhibitors or angiotension receptor blockers (ACEI/ARB) be held the morning of elective joint replacement?

Background: In patients taking ACEI/ARB, the decision regarding whether or not to give these medications on the day of surgery is controversial. UptoDate recommends holding ACEI/ARB the day of surgery; American College of Physicians Guidelines and SHM Consult Medicine recommend giving these drugs on the day of surgery.

Study design: Retrospective cohort (case control) study.

Setting: A large academic hospital in Pennsylvania.

Synopsis: Researchers studied adults undergoing elective spinal fusion, total knee replacement, or total hip replacement, and compared outcomes in 323 patients who were taking an ACEI/ARB (study group) to outcomes in the 579 patients who were not taking an ACEI/ARB (control group) before surgery. It was assumed—but not studied—that the ACEI/ARB was continued the morning of surgery in all patients in the study group, because that was the standard practice at this hospital.

Compared to the control group, the study group had more post-induction hypotension (12.2% vs. 6.7%) and more post-operative acute kidney injury (5.76% vs. 3.28%). Patients who developed acute kidney injury had longer length of stay (5.76 vs. 3.28 days) but no difference in two-year mortality.

Patients in the study group had higher baseline creatinine, were older, were more likely to be taking a diuretic, and were more likely to have diabetes, heart failure, and coronary artery disease. The authors used multiple logistic regression to adjust for these differences. Anesthesia and intra-operative fluid management were not standardized or compared.

Bottom line: ACEI/ARB administration on the morning of elective major orthopedic surgery is likely associated with a higher risk of intra-operative hypotension and acute kidney injury.

Citation: Nielson E, Hennrikus E, Lehman E, Mets B. Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery. J Hosp Med. 2014;9(5):283-288.

Clinical question: Should angiotension-converting enzyme inhibitors or angiotension receptor blockers (ACEI/ARB) be held the morning of elective joint replacement?

Background: In patients taking ACEI/ARB, the decision regarding whether or not to give these medications on the day of surgery is controversial. UptoDate recommends holding ACEI/ARB the day of surgery; American College of Physicians Guidelines and SHM Consult Medicine recommend giving these drugs on the day of surgery.

Study design: Retrospective cohort (case control) study.

Setting: A large academic hospital in Pennsylvania.

Synopsis: Researchers studied adults undergoing elective spinal fusion, total knee replacement, or total hip replacement, and compared outcomes in 323 patients who were taking an ACEI/ARB (study group) to outcomes in the 579 patients who were not taking an ACEI/ARB (control group) before surgery. It was assumed—but not studied—that the ACEI/ARB was continued the morning of surgery in all patients in the study group, because that was the standard practice at this hospital.

Compared to the control group, the study group had more post-induction hypotension (12.2% vs. 6.7%) and more post-operative acute kidney injury (5.76% vs. 3.28%). Patients who developed acute kidney injury had longer length of stay (5.76 vs. 3.28 days) but no difference in two-year mortality.

Patients in the study group had higher baseline creatinine, were older, were more likely to be taking a diuretic, and were more likely to have diabetes, heart failure, and coronary artery disease. The authors used multiple logistic regression to adjust for these differences. Anesthesia and intra-operative fluid management were not standardized or compared.

Bottom line: ACEI/ARB administration on the morning of elective major orthopedic surgery is likely associated with a higher risk of intra-operative hypotension and acute kidney injury.

Citation: Nielson E, Hennrikus E, Lehman E, Mets B. Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery. J Hosp Med. 2014;9(5):283-288.

Clinical question: Should angiotension-converting enzyme inhibitors or angiotension receptor blockers (ACEI/ARB) be held the morning of elective joint replacement?

Background: In patients taking ACEI/ARB, the decision regarding whether or not to give these medications on the day of surgery is controversial. UptoDate recommends holding ACEI/ARB the day of surgery; American College of Physicians Guidelines and SHM Consult Medicine recommend giving these drugs on the day of surgery.

Study design: Retrospective cohort (case control) study.

Setting: A large academic hospital in Pennsylvania.

Synopsis: Researchers studied adults undergoing elective spinal fusion, total knee replacement, or total hip replacement, and compared outcomes in 323 patients who were taking an ACEI/ARB (study group) to outcomes in the 579 patients who were not taking an ACEI/ARB (control group) before surgery. It was assumed—but not studied—that the ACEI/ARB was continued the morning of surgery in all patients in the study group, because that was the standard practice at this hospital.

Compared to the control group, the study group had more post-induction hypotension (12.2% vs. 6.7%) and more post-operative acute kidney injury (5.76% vs. 3.28%). Patients who developed acute kidney injury had longer length of stay (5.76 vs. 3.28 days) but no difference in two-year mortality.

Patients in the study group had higher baseline creatinine, were older, were more likely to be taking a diuretic, and were more likely to have diabetes, heart failure, and coronary artery disease. The authors used multiple logistic regression to adjust for these differences. Anesthesia and intra-operative fluid management were not standardized or compared.

Bottom line: ACEI/ARB administration on the morning of elective major orthopedic surgery is likely associated with a higher risk of intra-operative hypotension and acute kidney injury.

Citation: Nielson E, Hennrikus E, Lehman E, Mets B. Angiotensin axis blockade, hypotension, and acute kidney injury in elective major orthopedic surgery. J Hosp Med. 2014;9(5):283-288.

Clinical question: Is the use of beta blockers within 24 hours of coronary artery bypass grafting (CABG) surgery without recent myocardial infarction (MI) associated with decreased peri-operative mortality?

Background: Several retrospective observational studies suggest a reduction in peri-operative mortality with CABG surgery if beta blockers are administered prior to surgery. Although the use of beta blockers pre-operatively for CABG is now a quality measure, the use of pre-operative beta blockers is still controversial due to the results of more recent studies, with the observed benefit thought to be driven mainly by patients with recent MI.

Study design: Retrospective cohort analysis.

Setting: More than 1,100 U.S. hospitals.

Synopsis: The Society of Thoracic Surgeons’ National Adult Cardiac Surgery database identified 506,110 adult patients (without MI within 21 days) nonemergently undergoing CABG surgery. Beta blocker use was defined as receiving a beta blocker within 24 hours before surgery. Although most patients (86%) received beta blockers prior to surgery, there was no significant difference in operative mortality, permanent stroke, prolonged ventilation, and renal failure between patients receiving beta blockers and those who did not, although atrial fibrillation (Afib) was more common with pre-operative beta blocker use.

Bottom line: For patients undergoing nonemergent CABG surgery without recent MI, pre-operative beta blocker use is not associated with improved outcomes and is associated with slightly higher rates of Afib.

Citation: Brinkman W, Herbert MA, O’Brien S, et al. Preoperative beta-blocker use in coronary artery bypass grafting surgery: national database analysis. JAMA Intern Med. 2014;174(8):1320-1327.

Clinical question: Is the use of beta blockers within 24 hours of coronary artery bypass grafting (CABG) surgery without recent myocardial infarction (MI) associated with decreased peri-operative mortality?

Background: Several retrospective observational studies suggest a reduction in peri-operative mortality with CABG surgery if beta blockers are administered prior to surgery. Although the use of beta blockers pre-operatively for CABG is now a quality measure, the use of pre-operative beta blockers is still controversial due to the results of more recent studies, with the observed benefit thought to be driven mainly by patients with recent MI.

Study design: Retrospective cohort analysis.

Setting: More than 1,100 U.S. hospitals.

Synopsis: The Society of Thoracic Surgeons’ National Adult Cardiac Surgery database identified 506,110 adult patients (without MI within 21 days) nonemergently undergoing CABG surgery. Beta blocker use was defined as receiving a beta blocker within 24 hours before surgery. Although most patients (86%) received beta blockers prior to surgery, there was no significant difference in operative mortality, permanent stroke, prolonged ventilation, and renal failure between patients receiving beta blockers and those who did not, although atrial fibrillation (Afib) was more common with pre-operative beta blocker use.

Bottom line: For patients undergoing nonemergent CABG surgery without recent MI, pre-operative beta blocker use is not associated with improved outcomes and is associated with slightly higher rates of Afib.

Citation: Brinkman W, Herbert MA, O’Brien S, et al. Preoperative beta-blocker use in coronary artery bypass grafting surgery: national database analysis. JAMA Intern Med. 2014;174(8):1320-1327.

Clinical question: Is the use of beta blockers within 24 hours of coronary artery bypass grafting (CABG) surgery without recent myocardial infarction (MI) associated with decreased peri-operative mortality?

Background: Several retrospective observational studies suggest a reduction in peri-operative mortality with CABG surgery if beta blockers are administered prior to surgery. Although the use of beta blockers pre-operatively for CABG is now a quality measure, the use of pre-operative beta blockers is still controversial due to the results of more recent studies, with the observed benefit thought to be driven mainly by patients with recent MI.

Study design: Retrospective cohort analysis.

Setting: More than 1,100 U.S. hospitals.

Synopsis: The Society of Thoracic Surgeons’ National Adult Cardiac Surgery database identified 506,110 adult patients (without MI within 21 days) nonemergently undergoing CABG surgery. Beta blocker use was defined as receiving a beta blocker within 24 hours before surgery. Although most patients (86%) received beta blockers prior to surgery, there was no significant difference in operative mortality, permanent stroke, prolonged ventilation, and renal failure between patients receiving beta blockers and those who did not, although atrial fibrillation (Afib) was more common with pre-operative beta blocker use.

Bottom line: For patients undergoing nonemergent CABG surgery without recent MI, pre-operative beta blocker use is not associated with improved outcomes and is associated with slightly higher rates of Afib.

Citation: Brinkman W, Herbert MA, O’Brien S, et al. Preoperative beta-blocker use in coronary artery bypass grafting surgery: national database analysis. JAMA Intern Med. 2014;174(8):1320-1327.

Clinical question: Does the CAM-S, a modified version of the Confusion Assessment Method (CAM), which measures delirium severity, correlate with clinical outcomes?

Background: In 1990, Dr. Sharon Inouye developed the CAM, which is a common, standard measure to identify the presence of delirium. Although other scoring systems exist to quantify delirium severity, Dr. Inouye proposes an extension of the CAM (CAM-S) to measure delirium severity.

Study design: Validation analysis.

Setting: Three academic medical centers in the U.S.

Synopsis: Two validation cohorts of patients 70 years or older without dementia and moderate-to-high-risk of developing delirium during hospitalization were studied. The first cohort comprised 300 patients scheduled for elective, noncardiac surgery; the second cohort was made up of 250 patients admitted to an inpatient medical service. The CAM-S uses the same items as the original CAM and rates each symptom 0 for absent, 1 for mild, or 2 for marked; acute onset of fluctuation receives 0 (absent) or 1 (present). Higher CAM-S scores appear to correlate with various outcome measures, including increased length of stay, new nursing home placement, and 90-day mortality.

Bottom line: Higher scores on the CAM-S, a scoring system based on the CAM and designed to measure delirium severity, are associated with worse in-hospital and post-discharge outcomes.

Citation: Inouye SK, Kosar CM, Tommet D, et al. The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Ann Intern Med. 2014;160(8):526-533.

Clinical question: Does the CAM-S, a modified version of the Confusion Assessment Method (CAM), which measures delirium severity, correlate with clinical outcomes?

Background: In 1990, Dr. Sharon Inouye developed the CAM, which is a common, standard measure to identify the presence of delirium. Although other scoring systems exist to quantify delirium severity, Dr. Inouye proposes an extension of the CAM (CAM-S) to measure delirium severity.

Study design: Validation analysis.

Setting: Three academic medical centers in the U.S.

Synopsis: Two validation cohorts of patients 70 years or older without dementia and moderate-to-high-risk of developing delirium during hospitalization were studied. The first cohort comprised 300 patients scheduled for elective, noncardiac surgery; the second cohort was made up of 250 patients admitted to an inpatient medical service. The CAM-S uses the same items as the original CAM and rates each symptom 0 for absent, 1 for mild, or 2 for marked; acute onset of fluctuation receives 0 (absent) or 1 (present). Higher CAM-S scores appear to correlate with various outcome measures, including increased length of stay, new nursing home placement, and 90-day mortality.

Bottom line: Higher scores on the CAM-S, a scoring system based on the CAM and designed to measure delirium severity, are associated with worse in-hospital and post-discharge outcomes.

Citation: Inouye SK, Kosar CM, Tommet D, et al. The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Ann Intern Med. 2014;160(8):526-533.

Clinical question: Does the CAM-S, a modified version of the Confusion Assessment Method (CAM), which measures delirium severity, correlate with clinical outcomes?

Background: In 1990, Dr. Sharon Inouye developed the CAM, which is a common, standard measure to identify the presence of delirium. Although other scoring systems exist to quantify delirium severity, Dr. Inouye proposes an extension of the CAM (CAM-S) to measure delirium severity.

Study design: Validation analysis.

Setting: Three academic medical centers in the U.S.

Synopsis: Two validation cohorts of patients 70 years or older without dementia and moderate-to-high-risk of developing delirium during hospitalization were studied. The first cohort comprised 300 patients scheduled for elective, noncardiac surgery; the second cohort was made up of 250 patients admitted to an inpatient medical service. The CAM-S uses the same items as the original CAM and rates each symptom 0 for absent, 1 for mild, or 2 for marked; acute onset of fluctuation receives 0 (absent) or 1 (present). Higher CAM-S scores appear to correlate with various outcome measures, including increased length of stay, new nursing home placement, and 90-day mortality.

Bottom line: Higher scores on the CAM-S, a scoring system based on the CAM and designed to measure delirium severity, are associated with worse in-hospital and post-discharge outcomes.

Citation: Inouye SK, Kosar CM, Tommet D, et al. The CAM-S: development and validation of a new scoring system for delirium severity in 2 cohorts. Ann Intern Med. 2014;160(8):526-533.

Clinical question: What are the mortality benefits and bleeding risks associated with thrombolytic therapy, compared with other anticoagulants, in pulmonary embolism (PE)?

Background: Thrombolytics are not routinely administered for PE but can be considered in patients with hemodynamic instability with massive PE and those not responding to anticoagulation.

Study design: Meta-analysis.

Setting: Sixteen randomized clinical trials (RCTs) occurring in a variety of settings.

Synopsis: Trials involving 2,115 patients (thrombolytic therapy cohort 1,061; anticoagulation cohort 1,054) with PE were studied, with special attention given to those patients with intermediate risk PEs defined by subclinical cardiovascular compromise. Thrombolytics were compared with low molecular weight heparin, unfractionated heparin, vitamin K antagonists, and fondaparinux. The primary outcomes were all-cause mortality and major bleeding. Secondary outcomes included risk of recurrence of the PE and intracranial hemorrhage.

Thrombolytic therapy was associated with lower all-cause mortality and with higher risk of bleeding. There was a 9.24% rate of major bleeding in the thrombolytic therapy cohort and a 3.42% rate in the anticoagulation cohort. Intracranial hemorrhage was greater in the thrombolytic therapy cohort (1.46% vs. 0.19%). Patients with intermediate risk PE had greater major bleeding rate (7.74% vs. 2.25%) and lower mortality (1.39% vs. 2.92%) with thrombolytics compared to anticoagulation. A net clinical benefit calculation (mortality benefit accounting for intracranial hemorrhage risk) was performed and demonstrated a net clinical benefit of 0.81% (95% CI, 0.65%-1.01%) for those patients who received thrombolytics versus other anticoagulation.

Bottom line: This study suggested a mortality benefit of thrombolytics overall, including those patients with intermediate risk PE.

Citation: Chatterjee S, Chakraborty A, Weinberg I, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA. 2014;311(23):2414-2421.

Clinical question: What are the mortality benefits and bleeding risks associated with thrombolytic therapy, compared with other anticoagulants, in pulmonary embolism (PE)?

Background: Thrombolytics are not routinely administered for PE but can be considered in patients with hemodynamic instability with massive PE and those not responding to anticoagulation.

Study design: Meta-analysis.

Setting: Sixteen randomized clinical trials (RCTs) occurring in a variety of settings.

Synopsis: Trials involving 2,115 patients (thrombolytic therapy cohort 1,061; anticoagulation cohort 1,054) with PE were studied, with special attention given to those patients with intermediate risk PEs defined by subclinical cardiovascular compromise. Thrombolytics were compared with low molecular weight heparin, unfractionated heparin, vitamin K antagonists, and fondaparinux. The primary outcomes were all-cause mortality and major bleeding. Secondary outcomes included risk of recurrence of the PE and intracranial hemorrhage.

Thrombolytic therapy was associated with lower all-cause mortality and with higher risk of bleeding. There was a 9.24% rate of major bleeding in the thrombolytic therapy cohort and a 3.42% rate in the anticoagulation cohort. Intracranial hemorrhage was greater in the thrombolytic therapy cohort (1.46% vs. 0.19%). Patients with intermediate risk PE had greater major bleeding rate (7.74% vs. 2.25%) and lower mortality (1.39% vs. 2.92%) with thrombolytics compared to anticoagulation. A net clinical benefit calculation (mortality benefit accounting for intracranial hemorrhage risk) was performed and demonstrated a net clinical benefit of 0.81% (95% CI, 0.65%-1.01%) for those patients who received thrombolytics versus other anticoagulation.

Bottom line: This study suggested a mortality benefit of thrombolytics overall, including those patients with intermediate risk PE.

Citation: Chatterjee S, Chakraborty A, Weinberg I, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA. 2014;311(23):2414-2421.

Clinical question: What are the mortality benefits and bleeding risks associated with thrombolytic therapy, compared with other anticoagulants, in pulmonary embolism (PE)?

Background: Thrombolytics are not routinely administered for PE but can be considered in patients with hemodynamic instability with massive PE and those not responding to anticoagulation.

Study design: Meta-analysis.

Setting: Sixteen randomized clinical trials (RCTs) occurring in a variety of settings.

Synopsis: Trials involving 2,115 patients (thrombolytic therapy cohort 1,061; anticoagulation cohort 1,054) with PE were studied, with special attention given to those patients with intermediate risk PEs defined by subclinical cardiovascular compromise. Thrombolytics were compared with low molecular weight heparin, unfractionated heparin, vitamin K antagonists, and fondaparinux. The primary outcomes were all-cause mortality and major bleeding. Secondary outcomes included risk of recurrence of the PE and intracranial hemorrhage.

Thrombolytic therapy was associated with lower all-cause mortality and with higher risk of bleeding. There was a 9.24% rate of major bleeding in the thrombolytic therapy cohort and a 3.42% rate in the anticoagulation cohort. Intracranial hemorrhage was greater in the thrombolytic therapy cohort (1.46% vs. 0.19%). Patients with intermediate risk PE had greater major bleeding rate (7.74% vs. 2.25%) and lower mortality (1.39% vs. 2.92%) with thrombolytics compared to anticoagulation. A net clinical benefit calculation (mortality benefit accounting for intracranial hemorrhage risk) was performed and demonstrated a net clinical benefit of 0.81% (95% CI, 0.65%-1.01%) for those patients who received thrombolytics versus other anticoagulation.

Bottom line: This study suggested a mortality benefit of thrombolytics overall, including those patients with intermediate risk PE.

Citation: Chatterjee S, Chakraborty A, Weinberg I, et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA. 2014;311(23):2414-2421.

Clinical question: Which interventions are most effective to prevent 30-day readmissions in medical or surgical patients?

Background: Preventing early readmissions has become a national priority. This study set out to determine which intervention had the largest impact on the prevention of early readmission.

Study design: Meta-analysis.

Setting: Forty-seven studies in multiple locations.

Synopsis: This study evaluated 47 randomized trials that assessed the effectiveness of peri-discharge interventions on the risk of all-cause or unplanned 30-day readmissions for medical and surgical patients. Outcomes included unplanned readmissions, all-cause readmissions, and a composite of unplanned and all-cause readmissions plus out-of-hospital deaths.

The included studies reported up to seven methods of preventing readmissions, including involvement of case management, home visits, education of patients, and self-care support. In 42 trials reporting readmission rates, the pooled relative risk of readmission was 0.82 (95 % CI, 0.73-0.91; P<0.001) within 30 days.

Multiple subgroup analyses noted that the most effective interventions on hospital readmission were those that were more complex and those that sought to augment patient capacity to access and enact dependable post-discharge care.

Limitations included single-center academic studies, lack of standard for dealing with missing data, existence of publication bias, and differing methods used to evaluate intervention effects.

Bottom line: This study was the largest of its kind, to date, and suggests that the interventions analyzed in this study, although complex (e.g. enhancing capacity for self-care at home), were efficacious in reducing 30-day readmissions.

Citation: Leppin AL, Gionfriddo MR, Kessler M, et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med. 2014;174(7):1095-1107.

Clinical question: Which interventions are most effective to prevent 30-day readmissions in medical or surgical patients?

Background: Preventing early readmissions has become a national priority. This study set out to determine which intervention had the largest impact on the prevention of early readmission.

Study design: Meta-analysis.

Setting: Forty-seven studies in multiple locations.

Synopsis: This study evaluated 47 randomized trials that assessed the effectiveness of peri-discharge interventions on the risk of all-cause or unplanned 30-day readmissions for medical and surgical patients. Outcomes included unplanned readmissions, all-cause readmissions, and a composite of unplanned and all-cause readmissions plus out-of-hospital deaths.

The included studies reported up to seven methods of preventing readmissions, including involvement of case management, home visits, education of patients, and self-care support. In 42 trials reporting readmission rates, the pooled relative risk of readmission was 0.82 (95 % CI, 0.73-0.91; P<0.001) within 30 days.

Multiple subgroup analyses noted that the most effective interventions on hospital readmission were those that were more complex and those that sought to augment patient capacity to access and enact dependable post-discharge care.

Limitations included single-center academic studies, lack of standard for dealing with missing data, existence of publication bias, and differing methods used to evaluate intervention effects.

Bottom line: This study was the largest of its kind, to date, and suggests that the interventions analyzed in this study, although complex (e.g. enhancing capacity for self-care at home), were efficacious in reducing 30-day readmissions.

Citation: Leppin AL, Gionfriddo MR, Kessler M, et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med. 2014;174(7):1095-1107.

Clinical question: Which interventions are most effective to prevent 30-day readmissions in medical or surgical patients?

Background: Preventing early readmissions has become a national priority. This study set out to determine which intervention had the largest impact on the prevention of early readmission.

Study design: Meta-analysis.

Setting: Forty-seven studies in multiple locations.

Synopsis: This study evaluated 47 randomized trials that assessed the effectiveness of peri-discharge interventions on the risk of all-cause or unplanned 30-day readmissions for medical and surgical patients. Outcomes included unplanned readmissions, all-cause readmissions, and a composite of unplanned and all-cause readmissions plus out-of-hospital deaths.

The included studies reported up to seven methods of preventing readmissions, including involvement of case management, home visits, education of patients, and self-care support. In 42 trials reporting readmission rates, the pooled relative risk of readmission was 0.82 (95 % CI, 0.73-0.91; P<0.001) within 30 days.

Multiple subgroup analyses noted that the most effective interventions on hospital readmission were those that were more complex and those that sought to augment patient capacity to access and enact dependable post-discharge care.

Limitations included single-center academic studies, lack of standard for dealing with missing data, existence of publication bias, and differing methods used to evaluate intervention effects.

Bottom line: This study was the largest of its kind, to date, and suggests that the interventions analyzed in this study, although complex (e.g. enhancing capacity for self-care at home), were efficacious in reducing 30-day readmissions.

Citation: Leppin AL, Gionfriddo MR, Kessler M, et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med. 2014;174(7):1095-1107.

For the last six months or so, not a week has gone by in which someone hasn’t asked me when the new SHM survey report will be released. The anticipation level is high, and rightly so. This will be the first new look at hospitalist practice characteristics in two years, and boy, have they been an eventful two years!

On behalf of SHM and the SHM Practice Analysis Committee (PAC), I’m thrilled to introduce SHM’s 2014 State of Hospital Medicine Report (SOHM) and the resumption of the monthly “Survey Insights” article written by PAC members. Here are a few key things you should know about the new SOHM report:

• The content is more wide-ranging than ever. SHM leaves the collection of hospitalist compensation and productivity data to the Medical Group Management Association—SHM licenses compensation and production data from MGMA and has incorporated it into the new SOHM report—but covers just about every other aspect of hospitalist group structure and operations imaginable. In addition to traditional questions regarding scope of services, staffing and scheduling models, and financial support, this year’s report includes new information about hospitalist back-up staffing plans, how academic hospitalist time is allocated, accountable care organization participation, electronic health record use, and the presence of other hospital-focused practice specialties.

Use the report to assess how your practice compares to your peers, but always keep in mind that surveys don’t tell you what should be—they only tell you what currently is..

—Leslie Flores, MHA

• The number of survey participants is larger than ever. This year SHM received eligible responses from 499 different hospitalist groups, an increase of about 7% over 2012. Respondents continue to represent all employer/ownership models and geographic regions, in roughly similar proportions to previous surveys. And we continue to get good participation by both academic and nonacademic hospital medicine groups. This means we have more—and more reliable—information than ever for different subgroups of hospitalists.
• The report is more accessible and easier to read than it has ever been. This year SHM has produced the SOHM report in full color, with professional layout and graphics; it’s a pleasure to read compared to previous versions. And, for the first time, SHM is making available a web-based version of the full report, so that you can refer to it anywhere and at any time.

As a consultant, I refer to my copy of the SOHM report almost every day and find it indispensable as a source of context when offering advice to my clients. And I’m always interested to see the diverse ways in which hospitalist groups across the country use survey information to make decisions about how to run their practices and to explain their environments to hospital leaders and other stakeholders.

I encourage you to obtain a copy of the SOHM report and review it carefully; you’ll almost certainly find more than one interesting and useful tidbit of information. Use the report to assess how your practice compares to your peers, but always keep in mind that surveys don’t tell you what should be—they only tell you what currently is. New best practices not reflected in survey data are emerging all the time, and the ways others do things won’t always be right for your group’s unique situation and needs. Whether you are partners or employees, you and your colleagues “own” the success of your practice and are the best judges of what is right for you.

Leslie Flores is a PAC member and partner of Nelson Flores Hospital Medicine Consultants.

For the last six months or so, not a week has gone by in which someone hasn’t asked me when the new SHM survey report will be released. The anticipation level is high, and rightly so. This will be the first new look at hospitalist practice characteristics in two years, and boy, have they been an eventful two years!

On behalf of SHM and the SHM Practice Analysis Committee (PAC), I’m thrilled to introduce SHM’s 2014 State of Hospital Medicine Report (SOHM) and the resumption of the monthly “Survey Insights” article written by PAC members. Here are a few key things you should know about the new SOHM report:

• The content is more wide-ranging than ever. SHM leaves the collection of hospitalist compensation and productivity data to the Medical Group Management Association—SHM licenses compensation and production data from MGMA and has incorporated it into the new SOHM report—but covers just about every other aspect of hospitalist group structure and operations imaginable. In addition to traditional questions regarding scope of services, staffing and scheduling models, and financial support, this year’s report includes new information about hospitalist back-up staffing plans, how academic hospitalist time is allocated, accountable care organization participation, electronic health record use, and the presence of other hospital-focused practice specialties.

Use the report to assess how your practice compares to your peers, but always keep in mind that surveys don’t tell you what should be—they only tell you what currently is..

—Leslie Flores, MHA

• The number of survey participants is larger than ever. This year SHM received eligible responses from 499 different hospitalist groups, an increase of about 7% over 2012. Respondents continue to represent all employer/ownership models and geographic regions, in roughly similar proportions to previous surveys. And we continue to get good participation by both academic and nonacademic hospital medicine groups. This means we have more—and more reliable—information than ever for different subgroups of hospitalists.
• The report is more accessible and easier to read than it has ever been. This year SHM has produced the SOHM report in full color, with professional layout and graphics; it’s a pleasure to read compared to previous versions. And, for the first time, SHM is making available a web-based version of the full report, so that you can refer to it anywhere and at any time.

As a consultant, I refer to my copy of the SOHM report almost every day and find it indispensable as a source of context when offering advice to my clients. And I’m always interested to see the diverse ways in which hospitalist groups across the country use survey information to make decisions about how to run their practices and to explain their environments to hospital leaders and other stakeholders.

I encourage you to obtain a copy of the SOHM report and review it carefully; you’ll almost certainly find more than one interesting and useful tidbit of information. Use the report to assess how your practice compares to your peers, but always keep in mind that surveys don’t tell you what should be—they only tell you what currently is. New best practices not reflected in survey data are emerging all the time, and the ways others do things won’t always be right for your group’s unique situation and needs. Whether you are partners or employees, you and your colleagues “own” the success of your practice and are the best judges of what is right for you.

Leslie Flores is a PAC member and partner of Nelson Flores Hospital Medicine Consultants.

For the last six months or so, not a week has gone by in which someone hasn’t asked me when the new SHM survey report will be released. The anticipation level is high, and rightly so. This will be the first new look at hospitalist practice characteristics in two years, and boy, have they been an eventful two years!

On behalf of SHM and the SHM Practice Analysis Committee (PAC), I’m thrilled to introduce SHM’s 2014 State of Hospital Medicine Report (SOHM) and the resumption of the monthly “Survey Insights” article written by PAC members. Here are a few key things you should know about the new SOHM report:

• The content is more wide-ranging than ever. SHM leaves the collection of hospitalist compensation and productivity data to the Medical Group Management Association—SHM licenses compensation and production data from MGMA and has incorporated it into the new SOHM report—but covers just about every other aspect of hospitalist group structure and operations imaginable. In addition to traditional questions regarding scope of services, staffing and scheduling models, and financial support, this year’s report includes new information about hospitalist back-up staffing plans, how academic hospitalist time is allocated, accountable care organization participation, electronic health record use, and the presence of other hospital-focused practice specialties.

Use the report to assess how your practice compares to your peers, but always keep in mind that surveys don’t tell you what should be—they only tell you what currently is..

—Leslie Flores, MHA

• The number of survey participants is larger than ever. This year SHM received eligible responses from 499 different hospitalist groups, an increase of about 7% over 2012. Respondents continue to represent all employer/ownership models and geographic regions, in roughly similar proportions to previous surveys. And we continue to get good participation by both academic and nonacademic hospital medicine groups. This means we have more—and more reliable—information than ever for different subgroups of hospitalists.
• The report is more accessible and easier to read than it has ever been. This year SHM has produced the SOHM report in full color, with professional layout and graphics; it’s a pleasure to read compared to previous versions. And, for the first time, SHM is making available a web-based version of the full report, so that you can refer to it anywhere and at any time.

As a consultant, I refer to my copy of the SOHM report almost every day and find it indispensable as a source of context when offering advice to my clients. And I’m always interested to see the diverse ways in which hospitalist groups across the country use survey information to make decisions about how to run their practices and to explain their environments to hospital leaders and other stakeholders.

I encourage you to obtain a copy of the SOHM report and review it carefully; you’ll almost certainly find more than one interesting and useful tidbit of information. Use the report to assess how your practice compares to your peers, but always keep in mind that surveys don’t tell you what should be—they only tell you what currently is. New best practices not reflected in survey data are emerging all the time, and the ways others do things won’t always be right for your group’s unique situation and needs. Whether you are partners or employees, you and your colleagues “own” the success of your practice and are the best judges of what is right for you.

Leslie Flores is a PAC member and partner of Nelson Flores Hospital Medicine Consultants.

Editor’s note: Second in a two-part series from SHM’s Information Technology committee offering practical recommendations for improving electronic health records (EHRs) to reduce readmissions. The first article appeared in the September issue of The Hospitalist.

Discharge Coach

Recommendation: Use EHR workflows to support discharge coaches.

David Ling, MD, is the chief medical information officer at Mary Washington Healthcare in Fredericksburg, Va. His team has applied Project Red functionality to use discharge coaches to improve transitions with EHR support. This intervention reduced readmissions to 7% from 11% from 2011 to 2012; there were no other initiatives during this time.

During this trial, a nurse functioned as discharge advocate, and clinical pharmacists called the patients within 72 hours of discharge. Nursing discharge advocates arranged follow-up appointments, reviewed medication reconciliation, and conducted patient education.

Patients were triaged to the service based on a diagnosis of heart failure, pneumonia, MI, or LACE (length of stay, acuity of admission, Charlson index [modified], number of ER visits in the last six months) risk stratification score greater than eight. The discharge advocate then reviewed prior encounters and determined educational needs.

Patient education was handled using care notes. The discharge advocate was the last person to review the discharge medication list. Pending labs were populated by the discharge advocate.

EHR support of this process required putting all of the discharge-related information in one spot in the EHR to make sure that all processes were completed by the multidisciplinary team prior to discharge.

I would encourage any member of SHM to go beyond learning from our experience to consider joining or even leading a SHM committee.

—Noah Finkel, MD, FHM, Lahey Hospital and Medical Center

Patient-Centric Discharge Instructions

Recommendation: Support EHR build, create patient-centric multidisciplinary discharge paperwork.

At Lahey Hospital and Medical Center in Burlington, Mass., Noah Finkel, MD, and his colleague, Daniela Urma, MD, knew they had a problem with discharge. Paperwork and medication lists were incomplete and illegible. They knew they could not wait until the transition to Epic EHR to solve their problems.

In-house technical expertise created a program called “discharge assistant.” Discharge instructions are added to a common form for all members of the multidisciplinary team. A discharge medication list is imported at discharge from the outpatient EHR. The program allows the provider to note whether a medication is new, changed, or the same, and to add comments and indications to each medication. All of the standard elements of discharge planning are included (i.e., diet, wound care, return to work, diagnosis list, and who to call for specific problems).

The form cannot be completed and printed without all of the required elements included. The primary benefits of this program are legibility, completeness, and multidisciplinary data entry.

Coordination of Post-Discharge Appointments and Tests Prior to Discharge

Recommendation: Support coordination of care with electronic means of scheduling post-discharge care prior to discharge.

Aroop Pal, MD, FACP, FHM, program director of the Transitions of Care Services at the University of Kansas Medical Center in Kansas City, knows that there are many barriers to coordination of care with outside providers prior to discharge. If patients are discharged during normal business hours, the discharging provider may have to schedule these appointments and tests. A patient discharged after hours may be sent back to his or her PCP with a note requesting specific follow-ups.

Kansas University initiatives to improve scheduling have allowed its team to keep readmission rates below 13%, despite being the primary teaching hospital for the state of Kansas.

The process involved submission of scheduling requests, via EHR, to dedicated schedulers who would make the appointments in real time. The schedulers would notify the primary team, who would communicate with the patient. This system reduced the time to make the appointment and improved scheduler and physician satisfaction.

Medication Compliance after Discharge

Recommendation: Reduce technical and financial barriers to communication of medication list and medication compliance at home.

Sriram Vissa, MD, FACP, FHM, is medical director for informatics and co-practice group leader of the hospitalists for DePaul Hospital, SSM Healthcare, in Bridgeton, Mo. His hospital has improved medication compliance through improved medication reconciliation, improved clarity of discharge instructions, and better pharmacy integration. These interventions and others have reduced readmission rates to 12.81% at 30 days.

Barriers to compliance include procurement, financial issues, health literacy, clarity of instructions, medication lists to primary physicians, and patient portals. The EHR allows insurance integration to make sure that the patient can afford the prescribed medication An electronic connection to an on-site pharmacy makes sure that medications are delivered to the patient’s room prior to discharge. Medication lists are routed to PCPs via continuity of care functionality, which complies with meaningful use stage 2.

Also, the patient portal allows inpatient providers to ask questions about medications or discharge instructions.

Dr. Finkel is a hospitalist at Lahey Hospital and Medical Center in Burlington, Mass., and a member of SHM’s Health IT Committee.

Editor’s note: Second in a two-part series from SHM’s Information Technology committee offering practical recommendations for improving electronic health records (EHRs) to reduce readmissions. The first article appeared in the September issue of The Hospitalist.

Discharge Coach

Recommendation: Use EHR workflows to support discharge coaches.

David Ling, MD, is the chief medical information officer at Mary Washington Healthcare in Fredericksburg, Va. His team has applied Project Red functionality to use discharge coaches to improve transitions with EHR support. This intervention reduced readmissions to 7% from 11% from 2011 to 2012; there were no other initiatives during this time.

During this trial, a nurse functioned as discharge advocate, and clinical pharmacists called the patients within 72 hours of discharge. Nursing discharge advocates arranged follow-up appointments, reviewed medication reconciliation, and conducted patient education.

Patients were triaged to the service based on a diagnosis of heart failure, pneumonia, MI, or LACE (length of stay, acuity of admission, Charlson index [modified], number of ER visits in the last six months) risk stratification score greater than eight. The discharge advocate then reviewed prior encounters and determined educational needs.

Patient education was handled using care notes. The discharge advocate was the last person to review the discharge medication list. Pending labs were populated by the discharge advocate.

EHR support of this process required putting all of the discharge-related information in one spot in the EHR to make sure that all processes were completed by the multidisciplinary team prior to discharge.

I would encourage any member of SHM to go beyond learning from our experience to consider joining or even leading a SHM committee.

—Noah Finkel, MD, FHM, Lahey Hospital and Medical Center

Patient-Centric Discharge Instructions

Recommendation: Support EHR build, create patient-centric multidisciplinary discharge paperwork.

At Lahey Hospital and Medical Center in Burlington, Mass., Noah Finkel, MD, and his colleague, Daniela Urma, MD, knew they had a problem with discharge. Paperwork and medication lists were incomplete and illegible. They knew they could not wait until the transition to Epic EHR to solve their problems.

In-house technical expertise created a program called “discharge assistant.” Discharge instructions are added to a common form for all members of the multidisciplinary team. A discharge medication list is imported at discharge from the outpatient EHR. The program allows the provider to note whether a medication is new, changed, or the same, and to add comments and indications to each medication. All of the standard elements of discharge planning are included (i.e., diet, wound care, return to work, diagnosis list, and who to call for specific problems).

The form cannot be completed and printed without all of the required elements included. The primary benefits of this program are legibility, completeness, and multidisciplinary data entry.

Coordination of Post-Discharge Appointments and Tests Prior to Discharge

Recommendation: Support coordination of care with electronic means of scheduling post-discharge care prior to discharge.

Aroop Pal, MD, FACP, FHM, program director of the Transitions of Care Services at the University of Kansas Medical Center in Kansas City, knows that there are many barriers to coordination of care with outside providers prior to discharge. If patients are discharged during normal business hours, the discharging provider may have to schedule these appointments and tests. A patient discharged after hours may be sent back to his or her PCP with a note requesting specific follow-ups.

Kansas University initiatives to improve scheduling have allowed its team to keep readmission rates below 13%, despite being the primary teaching hospital for the state of Kansas.

The process involved submission of scheduling requests, via EHR, to dedicated schedulers who would make the appointments in real time. The schedulers would notify the primary team, who would communicate with the patient. This system reduced the time to make the appointment and improved scheduler and physician satisfaction.

Medication Compliance after Discharge

Recommendation: Reduce technical and financial barriers to communication of medication list and medication compliance at home.

Sriram Vissa, MD, FACP, FHM, is medical director for informatics and co-practice group leader of the hospitalists for DePaul Hospital, SSM Healthcare, in Bridgeton, Mo. His hospital has improved medication compliance through improved medication reconciliation, improved clarity of discharge instructions, and better pharmacy integration. These interventions and others have reduced readmission rates to 12.81% at 30 days.

Barriers to compliance include procurement, financial issues, health literacy, clarity of instructions, medication lists to primary physicians, and patient portals. The EHR allows insurance integration to make sure that the patient can afford the prescribed medication An electronic connection to an on-site pharmacy makes sure that medications are delivered to the patient’s room prior to discharge. Medication lists are routed to PCPs via continuity of care functionality, which complies with meaningful use stage 2.

Also, the patient portal allows inpatient providers to ask questions about medications or discharge instructions.

Dr. Finkel is a hospitalist at Lahey Hospital and Medical Center in Burlington, Mass., and a member of SHM’s Health IT Committee.

Editor’s note: Second in a two-part series from SHM’s Information Technology committee offering practical recommendations for improving electronic health records (EHRs) to reduce readmissions. The first article appeared in the September issue of The Hospitalist.

Discharge Coach

Recommendation: Use EHR workflows to support discharge coaches.

David Ling, MD, is the chief medical information officer at Mary Washington Healthcare in Fredericksburg, Va. His team has applied Project Red functionality to use discharge coaches to improve transitions with EHR support. This intervention reduced readmissions to 7% from 11% from 2011 to 2012; there were no other initiatives during this time.

During this trial, a nurse functioned as discharge advocate, and clinical pharmacists called the patients within 72 hours of discharge. Nursing discharge advocates arranged follow-up appointments, reviewed medication reconciliation, and conducted patient education.

Patients were triaged to the service based on a diagnosis of heart failure, pneumonia, MI, or LACE (length of stay, acuity of admission, Charlson index [modified], number of ER visits in the last six months) risk stratification score greater than eight. The discharge advocate then reviewed prior encounters and determined educational needs.

Patient education was handled using care notes. The discharge advocate was the last person to review the discharge medication list. Pending labs were populated by the discharge advocate.

EHR support of this process required putting all of the discharge-related information in one spot in the EHR to make sure that all processes were completed by the multidisciplinary team prior to discharge.

I would encourage any member of SHM to go beyond learning from our experience to consider joining or even leading a SHM committee.

—Noah Finkel, MD, FHM, Lahey Hospital and Medical Center

Patient-Centric Discharge Instructions

Recommendation: Support EHR build, create patient-centric multidisciplinary discharge paperwork.

At Lahey Hospital and Medical Center in Burlington, Mass., Noah Finkel, MD, and his colleague, Daniela Urma, MD, knew they had a problem with discharge. Paperwork and medication lists were incomplete and illegible. They knew they could not wait until the transition to Epic EHR to solve their problems.

In-house technical expertise created a program called “discharge assistant.” Discharge instructions are added to a common form for all members of the multidisciplinary team. A discharge medication list is imported at discharge from the outpatient EHR. The program allows the provider to note whether a medication is new, changed, or the same, and to add comments and indications to each medication. All of the standard elements of discharge planning are included (i.e., diet, wound care, return to work, diagnosis list, and who to call for specific problems).

The form cannot be completed and printed without all of the required elements included. The primary benefits of this program are legibility, completeness, and multidisciplinary data entry.

Coordination of Post-Discharge Appointments and Tests Prior to Discharge

Recommendation: Support coordination of care with electronic means of scheduling post-discharge care prior to discharge.

Aroop Pal, MD, FACP, FHM, program director of the Transitions of Care Services at the University of Kansas Medical Center in Kansas City, knows that there are many barriers to coordination of care with outside providers prior to discharge. If patients are discharged during normal business hours, the discharging provider may have to schedule these appointments and tests. A patient discharged after hours may be sent back to his or her PCP with a note requesting specific follow-ups.

Kansas University initiatives to improve scheduling have allowed its team to keep readmission rates below 13%, despite being the primary teaching hospital for the state of Kansas.

The process involved submission of scheduling requests, via EHR, to dedicated schedulers who would make the appointments in real time. The schedulers would notify the primary team, who would communicate with the patient. This system reduced the time to make the appointment and improved scheduler and physician satisfaction.

Medication Compliance after Discharge

Recommendation: Reduce technical and financial barriers to communication of medication list and medication compliance at home.

Sriram Vissa, MD, FACP, FHM, is medical director for informatics and co-practice group leader of the hospitalists for DePaul Hospital, SSM Healthcare, in Bridgeton, Mo. His hospital has improved medication compliance through improved medication reconciliation, improved clarity of discharge instructions, and better pharmacy integration. These interventions and others have reduced readmission rates to 12.81% at 30 days.

Barriers to compliance include procurement, financial issues, health literacy, clarity of instructions, medication lists to primary physicians, and patient portals. The EHR allows insurance integration to make sure that the patient can afford the prescribed medication An electronic connection to an on-site pharmacy makes sure that medications are delivered to the patient’s room prior to discharge. Medication lists are routed to PCPs via continuity of care functionality, which complies with meaningful use stage 2.

Also, the patient portal allows inpatient providers to ask questions about medications or discharge instructions.

Dr. Finkel is a hospitalist at Lahey Hospital and Medical Center in Burlington, Mass., and a member of SHM’s Health IT Committee.

Nov. 3-6

Leadership Academy

Demand continues for SHM’s Leadership Academy in Honolulu. The first course, “Leadership Foundations,” is sold out, but (as of press time) registration is still open for the Advanced Leadership courses: “Influential Management” and “Mastering Teamwork.”

SHM also is accepting registrations to be placed on a waiting list for “Leadership Foundations.”

For more information, visit www.hospitalmedicine.org/leadership.

Dec. 17

Master in Hospital Medicine

The Master in Hospital Medicine (MHM) designation is the “Hall of Fame” for the specialty. Do you know a hospitalist who deserves the designation? Make sure your nomination is in by December 17.

To submit a nomination, visit www.hospitalmedicine.org/fellows.

Jan. 9, 2015

Deadline for FHM, SFHM Application

It’s not too early to start working on your FHM or SFHM applications. Applications require letters of recommendation and self-assessments, so procrastinators might find themselves missing the deadline.

Feb. 2, 2015

Early Registration Deadline for HM15

Start planning today for Hospital Medicine 2015 in National Harbor, Md., just minutes from Washington, D.C. HM15 will set the stage for all of hospital medicine next year and will include new educational sessions specifically geared toward medical students, residents, and hospitalists just starting their careers.

During the annual meeting, SHM will be organizing its next “Hospitalists on the Hill” event, in which a delegation of hospitalists will talk with lawmakers in Congress about the policies that affect care for hospitalized patients. To register: www.hospitalmedicine2015.org.

Nov. 3-6

Leadership Academy

Demand continues for SHM’s Leadership Academy in Honolulu. The first course, “Leadership Foundations,” is sold out, but (as of press time) registration is still open for the Advanced Leadership courses: “Influential Management” and “Mastering Teamwork.”

SHM also is accepting registrations to be placed on a waiting list for “Leadership Foundations.”

For more information, visit www.hospitalmedicine.org/leadership.

Dec. 17

Master in Hospital Medicine

The Master in Hospital Medicine (MHM) designation is the “Hall of Fame” for the specialty. Do you know a hospitalist who deserves the designation? Make sure your nomination is in by December 17.

To submit a nomination, visit www.hospitalmedicine.org/fellows.

Jan. 9, 2015

Deadline for FHM, SFHM Application

It’s not too early to start working on your FHM or SFHM applications. Applications require letters of recommendation and self-assessments, so procrastinators might find themselves missing the deadline.

Feb. 2, 2015

Early Registration Deadline for HM15

Start planning today for Hospital Medicine 2015 in National Harbor, Md., just minutes from Washington, D.C. HM15 will set the stage for all of hospital medicine next year and will include new educational sessions specifically geared toward medical students, residents, and hospitalists just starting their careers.

During the annual meeting, SHM will be organizing its next “Hospitalists on the Hill” event, in which a delegation of hospitalists will talk with lawmakers in Congress about the policies that affect care for hospitalized patients. To register: www.hospitalmedicine2015.org.

Nov. 3-6

Leadership Academy

Demand continues for SHM’s Leadership Academy in Honolulu. The first course, “Leadership Foundations,” is sold out, but (as of press time) registration is still open for the Advanced Leadership courses: “Influential Management” and “Mastering Teamwork.”

SHM also is accepting registrations to be placed on a waiting list for “Leadership Foundations.”

For more information, visit www.hospitalmedicine.org/leadership.

Dec. 17

Master in Hospital Medicine

The Master in Hospital Medicine (MHM) designation is the “Hall of Fame” for the specialty. Do you know a hospitalist who deserves the designation? Make sure your nomination is in by December 17.

To submit a nomination, visit www.hospitalmedicine.org/fellows.

Jan. 9, 2015

Deadline for FHM, SFHM Application

It’s not too early to start working on your FHM or SFHM applications. Applications require letters of recommendation and self-assessments, so procrastinators might find themselves missing the deadline.

Feb. 2, 2015

Early Registration Deadline for HM15

Start planning today for Hospital Medicine 2015 in National Harbor, Md., just minutes from Washington, D.C. HM15 will set the stage for all of hospital medicine next year and will include new educational sessions specifically geared toward medical students, residents, and hospitalists just starting their careers.

During the annual meeting, SHM will be organizing its next “Hospitalists on the Hill” event, in which a delegation of hospitalists will talk with lawmakers in Congress about the policies that affect care for hospitalized patients. To register: www.hospitalmedicine2015.org.