Beth Papetti

Having nocturnist coverage in your practice is a coveted position to be in for many hospital medicine providers. Rick Washington, MD, medical director for WellStar Kennestone Hospital in Marietta, Ga., says that “not only does it make it easier to recruit and retain daytime physicians when you have nocturnists as a part of your program, but they also serve a very valuable role in the continuity of the program throughout the nighttime hours, providing a stable admitting presence in the emergency department at all times.”

According to the 2012 State of Hospital Medicine Report, nearly half of all hospital medicine groups (HMGs) serving adults only incorporate nocturnists into their programs. Nocturnists are most common in HMGs employed by universities or medical schools (67%) and hospitals/integrated delivery systems (50%). The prevalence among management company-employed groups is much lower (25%), and no data was available for multispecialty groups or private hospitalist-only groups (see Figure 1).

As could be expected, the prevalence of nocturnists increases dramatically as the number of total FTEs of the practice increases. As the number of patients on a service, and thus the number of FTEs, grows, so does the expectation to provide on-site night coverage.

The percentage of compensation paid as base salary also has an impact; in general, the higher the percentage of compensation in base salary, the more likely that practice is to have nocturnists. Typically, night shifts tend to be less productive from a billable encounter perspective, so having a base rate of pay tends to be an essential factor in successfully maintaining nocturnists.

click for large version

However, surprisingly, in the 63% of groups that reported paying a nocturnist differential, the clinicians earned only a median of 15% more in total compensation than their non-nocturnist counterparts. Perhaps this has to do with other factors that programs are utilizing in order to entice and retain nocturnists, which includes the possibility of doing fewer shifts or shorter shifts than their colleagues. In fact, 49% of respondent groups reported implementing a nocturnist schedule differential, most commonly in the range of one to 20% fewer shifts than non-nocturnist hospitalists in the same practice.

Other practices implement a schedule differential by shortening the length of nocturnist shifts, instead of reducing the number of shifts worked.

“For me, the key to doing this long term has been the ability to have an eight-hour shift rather than 12 hours,” says Dr. Nancy Maignan, who soon will celebrate five years as a nocturnist at WellStar Kennestone Hospital. “Another factor is flexibility with our schedule. We do not work 7-on/7-off. My schedule is dependent on my family’s schedule…this allows me to attend field trips and be off for most of their [her kids] school break.”

Although she points out that a supportive family is crucial, a supportive HMG is key. I would encourage groups thinking of implementing a nocturnist role to think carefully about how to make the job one that hospitalists can successfully do for a long time, rather than just trying to attract people to the role by making it financially lucrative.

Beth Papetti is assistant vice president of WellStar Medical Group in Marrietta, Ga. She is a member of SHM’s Practice Analysis Committee.

Beth Papetti

Having nocturnist coverage in your practice is a coveted position to be in for many hospital medicine providers. Rick Washington, MD, medical director for WellStar Kennestone Hospital in Marietta, Ga., says that “not only does it make it easier to recruit and retain daytime physicians when you have nocturnists as a part of your program, but they also serve a very valuable role in the continuity of the program throughout the nighttime hours, providing a stable admitting presence in the emergency department at all times.”

According to the 2012 State of Hospital Medicine Report, nearly half of all hospital medicine groups (HMGs) serving adults only incorporate nocturnists into their programs. Nocturnists are most common in HMGs employed by universities or medical schools (67%) and hospitals/integrated delivery systems (50%). The prevalence among management company-employed groups is much lower (25%), and no data was available for multispecialty groups or private hospitalist-only groups (see Figure 1).

As could be expected, the prevalence of nocturnists increases dramatically as the number of total FTEs of the practice increases. As the number of patients on a service, and thus the number of FTEs, grows, so does the expectation to provide on-site night coverage.

The percentage of compensation paid as base salary also has an impact; in general, the higher the percentage of compensation in base salary, the more likely that practice is to have nocturnists. Typically, night shifts tend to be less productive from a billable encounter perspective, so having a base rate of pay tends to be an essential factor in successfully maintaining nocturnists.

click for large version

However, surprisingly, in the 63% of groups that reported paying a nocturnist differential, the clinicians earned only a median of 15% more in total compensation than their non-nocturnist counterparts. Perhaps this has to do with other factors that programs are utilizing in order to entice and retain nocturnists, which includes the possibility of doing fewer shifts or shorter shifts than their colleagues. In fact, 49% of respondent groups reported implementing a nocturnist schedule differential, most commonly in the range of one to 20% fewer shifts than non-nocturnist hospitalists in the same practice.

Other practices implement a schedule differential by shortening the length of nocturnist shifts, instead of reducing the number of shifts worked.

“For me, the key to doing this long term has been the ability to have an eight-hour shift rather than 12 hours,” says Dr. Nancy Maignan, who soon will celebrate five years as a nocturnist at WellStar Kennestone Hospital. “Another factor is flexibility with our schedule. We do not work 7-on/7-off. My schedule is dependent on my family’s schedule…this allows me to attend field trips and be off for most of their [her kids] school break.”

Although she points out that a supportive family is crucial, a supportive HMG is key. I would encourage groups thinking of implementing a nocturnist role to think carefully about how to make the job one that hospitalists can successfully do for a long time, rather than just trying to attract people to the role by making it financially lucrative.

Beth Papetti is assistant vice president of WellStar Medical Group in Marrietta, Ga. She is a member of SHM’s Practice Analysis Committee.

Beth Papetti

Having nocturnist coverage in your practice is a coveted position to be in for many hospital medicine providers. Rick Washington, MD, medical director for WellStar Kennestone Hospital in Marietta, Ga., says that “not only does it make it easier to recruit and retain daytime physicians when you have nocturnists as a part of your program, but they also serve a very valuable role in the continuity of the program throughout the nighttime hours, providing a stable admitting presence in the emergency department at all times.”

According to the 2012 State of Hospital Medicine Report, nearly half of all hospital medicine groups (HMGs) serving adults only incorporate nocturnists into their programs. Nocturnists are most common in HMGs employed by universities or medical schools (67%) and hospitals/integrated delivery systems (50%). The prevalence among management company-employed groups is much lower (25%), and no data was available for multispecialty groups or private hospitalist-only groups (see Figure 1).

As could be expected, the prevalence of nocturnists increases dramatically as the number of total FTEs of the practice increases. As the number of patients on a service, and thus the number of FTEs, grows, so does the expectation to provide on-site night coverage.

The percentage of compensation paid as base salary also has an impact; in general, the higher the percentage of compensation in base salary, the more likely that practice is to have nocturnists. Typically, night shifts tend to be less productive from a billable encounter perspective, so having a base rate of pay tends to be an essential factor in successfully maintaining nocturnists.

click for large version

However, surprisingly, in the 63% of groups that reported paying a nocturnist differential, the clinicians earned only a median of 15% more in total compensation than their non-nocturnist counterparts. Perhaps this has to do with other factors that programs are utilizing in order to entice and retain nocturnists, which includes the possibility of doing fewer shifts or shorter shifts than their colleagues. In fact, 49% of respondent groups reported implementing a nocturnist schedule differential, most commonly in the range of one to 20% fewer shifts than non-nocturnist hospitalists in the same practice.

Other practices implement a schedule differential by shortening the length of nocturnist shifts, instead of reducing the number of shifts worked.

“For me, the key to doing this long term has been the ability to have an eight-hour shift rather than 12 hours,” says Dr. Nancy Maignan, who soon will celebrate five years as a nocturnist at WellStar Kennestone Hospital. “Another factor is flexibility with our schedule. We do not work 7-on/7-off. My schedule is dependent on my family’s schedule…this allows me to attend field trips and be off for most of their [her kids] school break.”

Although she points out that a supportive family is crucial, a supportive HMG is key. I would encourage groups thinking of implementing a nocturnist role to think carefully about how to make the job one that hospitalists can successfully do for a long time, rather than just trying to attract people to the role by making it financially lucrative.

Beth Papetti is assistant vice president of WellStar Medical Group in Marrietta, Ga. She is a member of SHM’s Practice Analysis Committee.

HMX in 3 Minutes or Less

More than 2,500 hospitalists have logged into HMX to share their experiences and ask questions on a wide variety of topics, from HM group practice management to clinical details about glycemic control.

New communities are being added regularly, so be sure to set up your account, sign up for customizable e-mail notifications, and check back regularly to follow your favorite discussions.

Have a question or idea for other hospitalists? Share it today.

Here’s how to get started. All you need are your SHM login credentials.

1. Go to www.hmxchange.org.
2. In the top right-hand corner, click the link that reads, “Login to see members only content.”
3. Enter your SHM login credentials and click login.
4. Now you’re logged in. On the right-hand side, you will find a box with a list of the various communities. Click on the community you would like to view and/or post in.
5. Click the “Discussions” tab and, on the right, click the square button that says “+ Post New Message.”
6. Compose your message with subject and body (and you can include an attachment if you want).
7. Click “Send.”

Hospitalists can now follow their favorite discussions on the go with the Member Centric app for HMX.

1. Go to your preferred app store and download “MemberCentric.”
2. Search for “Society of Hospital Medicine” in the list of organizations.
3. Log in with your SHM/HMX username and password.
4. Get access to your discussions, contacts, private message inbox, and events calendar.

HMX in 3 Minutes or Less

More than 2,500 hospitalists have logged into HMX to share their experiences and ask questions on a wide variety of topics, from HM group practice management to clinical details about glycemic control.

New communities are being added regularly, so be sure to set up your account, sign up for customizable e-mail notifications, and check back regularly to follow your favorite discussions.

Have a question or idea for other hospitalists? Share it today.

Here’s how to get started. All you need are your SHM login credentials.

1. Go to www.hmxchange.org.
2. In the top right-hand corner, click the link that reads, “Login to see members only content.”
3. Enter your SHM login credentials and click login.
4. Now you’re logged in. On the right-hand side, you will find a box with a list of the various communities. Click on the community you would like to view and/or post in.
5. Click the “Discussions” tab and, on the right, click the square button that says “+ Post New Message.”
6. Compose your message with subject and body (and you can include an attachment if you want).
7. Click “Send.”

Hospitalists can now follow their favorite discussions on the go with the Member Centric app for HMX.

1. Go to your preferred app store and download “MemberCentric.”
2. Search for “Society of Hospital Medicine” in the list of organizations.
3. Log in with your SHM/HMX username and password.
4. Get access to your discussions, contacts, private message inbox, and events calendar.

HMX in 3 Minutes or Less

More than 2,500 hospitalists have logged into HMX to share their experiences and ask questions on a wide variety of topics, from HM group practice management to clinical details about glycemic control.

New communities are being added regularly, so be sure to set up your account, sign up for customizable e-mail notifications, and check back regularly to follow your favorite discussions.

Have a question or idea for other hospitalists? Share it today.

Here’s how to get started. All you need are your SHM login credentials.

1. Go to www.hmxchange.org.
2. In the top right-hand corner, click the link that reads, “Login to see members only content.”
3. Enter your SHM login credentials and click login.
4. Now you’re logged in. On the right-hand side, you will find a box with a list of the various communities. Click on the community you would like to view and/or post in.
5. Click the “Discussions” tab and, on the right, click the square button that says “+ Post New Message.”
6. Compose your message with subject and body (and you can include an attachment if you want).
7. Click “Send.”

Hospitalists can now follow their favorite discussions on the go with the Member Centric app for HMX.

1. Go to your preferred app store and download “MemberCentric.”
2. Search for “Society of Hospital Medicine” in the list of organizations.
3. Log in with your SHM/HMX username and password.
4. Get access to your discussions, contacts, private message inbox, and events calendar.

Randy J. Ferrance, DC, MD, FHM

Dr. Ferrance is medical director of the hospitalist service, hospice, and hospital-based quality at Riverside Tappahannock Hospital in Virginia. He began his medical career as a chiropractor before deciding to take a different path, entering medical school, and finding that he loved inpatient care. He is triple board-certified in internal medicine, pediatrics, and palliative care; this last specialty is the area he is most passionate about.

Undergraduate education: Indiana University of Pennsylvania for two years before gaining early admission into Life University College of Chiropractic in Marietta, Ga. After several years in private practice, Dr. Ferrance entered medical school. Thus, he holds two doctorates and no bachelor’s degree.

Medical school: The Medical College of Virginia in Richmond.

Notable: Riverside Tappahannock Hospital is a closed, rural hospital, so Dr. Ferrance and his team of four hospitalists and one nurse practitioner handle all medical admissions, as well as most of the surgical admissions. They manage the ICU and do most of their own procedures.

FYI: He has authored two fiction articles published in the Journal of Hospital Medicine, titled “Death is a crafty adversary” and “Death is a crafty old friend.”^1,2 He also makes custom pens as a hobby, using exotic woods and acrylics.

Quotable: “To me, being a SHM fellow is recognition of the time and energy I’ve given to hospital medicine. I have worked hard to bring good quality care to my small hospital through the use of standardized order sets, real-time chart review, and mentoring.”

Caitlin Cromley

References

1. Ferrance RJ. Death is a crafty adversary. J Hosp Med. 2006;1(2):133-135.
2. Ferrance RJ. Death is a crafty old friend. J Hosp Med. 2008;3(6):495-497.

Randy J. Ferrance, DC, MD, FHM

Dr. Ferrance is medical director of the hospitalist service, hospice, and hospital-based quality at Riverside Tappahannock Hospital in Virginia. He began his medical career as a chiropractor before deciding to take a different path, entering medical school, and finding that he loved inpatient care. He is triple board-certified in internal medicine, pediatrics, and palliative care; this last specialty is the area he is most passionate about.

Undergraduate education: Indiana University of Pennsylvania for two years before gaining early admission into Life University College of Chiropractic in Marietta, Ga. After several years in private practice, Dr. Ferrance entered medical school. Thus, he holds two doctorates and no bachelor’s degree.

Medical school: The Medical College of Virginia in Richmond.

Notable: Riverside Tappahannock Hospital is a closed, rural hospital, so Dr. Ferrance and his team of four hospitalists and one nurse practitioner handle all medical admissions, as well as most of the surgical admissions. They manage the ICU and do most of their own procedures.

FYI: He has authored two fiction articles published in the Journal of Hospital Medicine, titled “Death is a crafty adversary” and “Death is a crafty old friend.”^1,2 He also makes custom pens as a hobby, using exotic woods and acrylics.

Quotable: “To me, being a SHM fellow is recognition of the time and energy I’ve given to hospital medicine. I have worked hard to bring good quality care to my small hospital through the use of standardized order sets, real-time chart review, and mentoring.”

Caitlin Cromley

References

1. Ferrance RJ. Death is a crafty adversary. J Hosp Med. 2006;1(2):133-135.
2. Ferrance RJ. Death is a crafty old friend. J Hosp Med. 2008;3(6):495-497.

Randy J. Ferrance, DC, MD, FHM

Dr. Ferrance is medical director of the hospitalist service, hospice, and hospital-based quality at Riverside Tappahannock Hospital in Virginia. He began his medical career as a chiropractor before deciding to take a different path, entering medical school, and finding that he loved inpatient care. He is triple board-certified in internal medicine, pediatrics, and palliative care; this last specialty is the area he is most passionate about.

Undergraduate education: Indiana University of Pennsylvania for two years before gaining early admission into Life University College of Chiropractic in Marietta, Ga. After several years in private practice, Dr. Ferrance entered medical school. Thus, he holds two doctorates and no bachelor’s degree.

Medical school: The Medical College of Virginia in Richmond.

Notable: Riverside Tappahannock Hospital is a closed, rural hospital, so Dr. Ferrance and his team of four hospitalists and one nurse practitioner handle all medical admissions, as well as most of the surgical admissions. They manage the ICU and do most of their own procedures.

FYI: He has authored two fiction articles published in the Journal of Hospital Medicine, titled “Death is a crafty adversary” and “Death is a crafty old friend.”^1,2 He also makes custom pens as a hobby, using exotic woods and acrylics.

Quotable: “To me, being a SHM fellow is recognition of the time and energy I’ve given to hospital medicine. I have worked hard to bring good quality care to my small hospital through the use of standardized order sets, real-time chart review, and mentoring.”

Caitlin Cromley

References

1. Ferrance RJ. Death is a crafty adversary. J Hosp Med. 2006;1(2):133-135.
2. Ferrance RJ. Death is a crafty old friend. J Hosp Med. 2008;3(6):495-497.

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SHM asked leaders of the Hospital-Based Quality Improvement in Stroke Prevention for Patients with Atrial Fibrillation (AF) Project, Hiren Shah, MD, MBA, SFHM, and Andrew Masica, MD, SFHM, to provide an overview of the program.

“AF is a disease state that is highly prevalent, and the numbers are rising yearly. We also know that it is one of the most common inpatient diagnoses,” Dr. Shah says. “However, when you look at the quality of care provided to our AF patients, it is quite variable and has implications for other hospital performance metrics such as 30-day readmission rates. This makes AF a high-impact target for inpatient quality improvement initiatives.”

Dr. Shah is assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director at Northwestern Memorial Hospital in Chicago. Dr. Masica is vice president of clinical effectiveness at Baylor Health Care System in Dallas.

The implementation guide for SHM’s AF project will be available later in December at www.hospitalmedicine.org/afib.

Question: What is the scope of your project?

Dr. Masica

Dr. Masica: That is a question we wrestled with. Numerous care processes related to AF are amenable to inpatient quality improvement. We chose to focus our efforts on stroke prevention in AF and the development of a toolkit to help hospital-based practitioners to assess stroke and bleeding risk consistently and, if indicated, to initiate antithrombotic therapy.

Dr. Shah: Along those lines, we know that at least 25% of AF-related strokes are potentially preventable with adherence to evidence-based care; however, current data indicate that only 50% to 60% of patients with AF who are eligible to receive antithrombotic therapy are on active stroke prophylaxis.

Q: Why do you think there are such large gaps in stroke prophylaxis for AF patients?

Dr. Masica: The prophylaxis decision requires the clinician to do an anticoagulation net-benefit and risk assessment, and although there are validated tools to do this type of assessment, use of these tools hasn’t yet become hardwired into daily hospital practice. Empiric clinical assessments often overestimate the bleed risk and underestimate stroke risk, so the ultimate result can be underuse of antithrombotic therapy.

“Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.”

–Dr. Shah

Dr. Shah: Another barrier is that in many hospitals, there are not reminders in place in our workflow for this assessment to happen at all. Hospitalists may think that the anticoagulation decision is an outpatient issue, better addressed by their primary care doctor, so it is sometimes even intentionally bypassed. Another barrier is that it takes time to discuss a patient’s values and preferences in the anticoagulation decision.

Q: But isn’t stroke prevention in AF more of an outpatient issue?

Dr. Shah: We think the hospital is a great place to start this evaluation and to make the anticoagulation decision. Of course, we should discuss these issues with the primary care doctor. Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.

Q: What specific tools for stroke and bleed risk are you referring to?

Dr. Shah: The CHADS2 scoring system is a well-validated tool for estimating the risk of stroke in AF patients, one that most clinicians may be aware of. The CHA2DS2-VASc is a slightly more refined scoring system. When it comes to bleeding, however, fewer clinicians are aware of the HAS-BLED bleeding risk assessment method.

Dr. Masica: The scoring systems represent a consistent, reproducible approach by which to evaluate inpatients with AF. Of course, there is some discretion for other patient-specific factors (e.g. fall risk) that are not captured in the scoring systems, but they are good starting points in the decision-making process. Finally and most importantly, although it is often overlooked, shared decision-making should take place with the patients, because their values in facing the risk of stroke versus bleeding often tip the balance one way or the other.

Q: How will the project help hospitals in this process?

Dr. Shah: We have written a QI Implementation Guide for hospitals with tools intended to improve the care of patients with AF in the hospital setting. This book will be similar to SHM’s VTE Prevention Implementation Guide, published a few years ago. We also will have an upcoming AF QI resource room within the SHM website. Additionally, similar to VTE, there are likely to be future mentored implementation projects where we will be working directly with hospitals and coaching them in this initiative.

Dr. Masica: We also have given a recent SHM-sponsored webinar that outlines some content of the guide. It can be accessed on the SHM website. This webinar reviews how to start a QI project in AF, assess your current state of care, build an interdisciplinary team, use validated tools, and deploy interventions to help make the stroke risk assessment and prophylaxis decision. I would note that the intended audience for these tools is broad and includes frontline hospitalists, QI directors, CMOs, and COOs, as well as nursing leadership, NPs, PAs, pharmacists, and other care providers.

Q: Does healthcare reform impact your efforts in this area?

Dr. Shah: Value-based purchasing, preventing readmissions, accountable care organizations, and bundled payments are all aspects of reform that will involve this therapeutic area, as their scope will impact the quality of care we deliver, how our cost structures are, and how we improve fragmentation of care across care transitions.

Dr. Masica: In addition, market forces, healthcare legislation, conceptual shifts regarding the need for systematic approaches to healthcare improvement, and new rules that may impact hospital reimbursement will continue to make AF an important healthcare quality issue. Thus, we think the discussion around delivering patient-centered care in AF is really just beginning.

Brendon Shank is SHM’s associate vice president of communications.

SHM asked leaders of the Hospital-Based Quality Improvement in Stroke Prevention for Patients with Atrial Fibrillation (AF) Project, Hiren Shah, MD, MBA, SFHM, and Andrew Masica, MD, SFHM, to provide an overview of the program.

“AF is a disease state that is highly prevalent, and the numbers are rising yearly. We also know that it is one of the most common inpatient diagnoses,” Dr. Shah says. “However, when you look at the quality of care provided to our AF patients, it is quite variable and has implications for other hospital performance metrics such as 30-day readmission rates. This makes AF a high-impact target for inpatient quality improvement initiatives.”

Dr. Shah is assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director at Northwestern Memorial Hospital in Chicago. Dr. Masica is vice president of clinical effectiveness at Baylor Health Care System in Dallas.

The implementation guide for SHM’s AF project will be available later in December at www.hospitalmedicine.org/afib.

Question: What is the scope of your project?

Dr. Masica

Dr. Masica: That is a question we wrestled with. Numerous care processes related to AF are amenable to inpatient quality improvement. We chose to focus our efforts on stroke prevention in AF and the development of a toolkit to help hospital-based practitioners to assess stroke and bleeding risk consistently and, if indicated, to initiate antithrombotic therapy.

Dr. Shah: Along those lines, we know that at least 25% of AF-related strokes are potentially preventable with adherence to evidence-based care; however, current data indicate that only 50% to 60% of patients with AF who are eligible to receive antithrombotic therapy are on active stroke prophylaxis.

Q: Why do you think there are such large gaps in stroke prophylaxis for AF patients?

Dr. Masica: The prophylaxis decision requires the clinician to do an anticoagulation net-benefit and risk assessment, and although there are validated tools to do this type of assessment, use of these tools hasn’t yet become hardwired into daily hospital practice. Empiric clinical assessments often overestimate the bleed risk and underestimate stroke risk, so the ultimate result can be underuse of antithrombotic therapy.

“Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.”

–Dr. Shah

Dr. Shah: Another barrier is that in many hospitals, there are not reminders in place in our workflow for this assessment to happen at all. Hospitalists may think that the anticoagulation decision is an outpatient issue, better addressed by their primary care doctor, so it is sometimes even intentionally bypassed. Another barrier is that it takes time to discuss a patient’s values and preferences in the anticoagulation decision.

Q: But isn’t stroke prevention in AF more of an outpatient issue?

Dr. Shah: We think the hospital is a great place to start this evaluation and to make the anticoagulation decision. Of course, we should discuss these issues with the primary care doctor. Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.

Q: What specific tools for stroke and bleed risk are you referring to?

Dr. Shah: The CHADS2 scoring system is a well-validated tool for estimating the risk of stroke in AF patients, one that most clinicians may be aware of. The CHA2DS2-VASc is a slightly more refined scoring system. When it comes to bleeding, however, fewer clinicians are aware of the HAS-BLED bleeding risk assessment method.

Dr. Masica: The scoring systems represent a consistent, reproducible approach by which to evaluate inpatients with AF. Of course, there is some discretion for other patient-specific factors (e.g. fall risk) that are not captured in the scoring systems, but they are good starting points in the decision-making process. Finally and most importantly, although it is often overlooked, shared decision-making should take place with the patients, because their values in facing the risk of stroke versus bleeding often tip the balance one way or the other.

Q: How will the project help hospitals in this process?

Dr. Shah: We have written a QI Implementation Guide for hospitals with tools intended to improve the care of patients with AF in the hospital setting. This book will be similar to SHM’s VTE Prevention Implementation Guide, published a few years ago. We also will have an upcoming AF QI resource room within the SHM website. Additionally, similar to VTE, there are likely to be future mentored implementation projects where we will be working directly with hospitals and coaching them in this initiative.

Dr. Masica: We also have given a recent SHM-sponsored webinar that outlines some content of the guide. It can be accessed on the SHM website. This webinar reviews how to start a QI project in AF, assess your current state of care, build an interdisciplinary team, use validated tools, and deploy interventions to help make the stroke risk assessment and prophylaxis decision. I would note that the intended audience for these tools is broad and includes frontline hospitalists, QI directors, CMOs, and COOs, as well as nursing leadership, NPs, PAs, pharmacists, and other care providers.

Q: Does healthcare reform impact your efforts in this area?

Dr. Shah: Value-based purchasing, preventing readmissions, accountable care organizations, and bundled payments are all aspects of reform that will involve this therapeutic area, as their scope will impact the quality of care we deliver, how our cost structures are, and how we improve fragmentation of care across care transitions.

Dr. Masica: In addition, market forces, healthcare legislation, conceptual shifts regarding the need for systematic approaches to healthcare improvement, and new rules that may impact hospital reimbursement will continue to make AF an important healthcare quality issue. Thus, we think the discussion around delivering patient-centered care in AF is really just beginning.

Brendon Shank is SHM’s associate vice president of communications.

SHM asked leaders of the Hospital-Based Quality Improvement in Stroke Prevention for Patients with Atrial Fibrillation (AF) Project, Hiren Shah, MD, MBA, SFHM, and Andrew Masica, MD, SFHM, to provide an overview of the program.

“AF is a disease state that is highly prevalent, and the numbers are rising yearly. We also know that it is one of the most common inpatient diagnoses,” Dr. Shah says. “However, when you look at the quality of care provided to our AF patients, it is quite variable and has implications for other hospital performance metrics such as 30-day readmission rates. This makes AF a high-impact target for inpatient quality improvement initiatives.”

Dr. Shah is assistant professor of medicine at Northwestern University’s Feinberg School of Medicine and medical director at Northwestern Memorial Hospital in Chicago. Dr. Masica is vice president of clinical effectiveness at Baylor Health Care System in Dallas.

The implementation guide for SHM’s AF project will be available later in December at www.hospitalmedicine.org/afib.

Question: What is the scope of your project?

Dr. Masica

Dr. Masica: That is a question we wrestled with. Numerous care processes related to AF are amenable to inpatient quality improvement. We chose to focus our efforts on stroke prevention in AF and the development of a toolkit to help hospital-based practitioners to assess stroke and bleeding risk consistently and, if indicated, to initiate antithrombotic therapy.

Dr. Shah: Along those lines, we know that at least 25% of AF-related strokes are potentially preventable with adherence to evidence-based care; however, current data indicate that only 50% to 60% of patients with AF who are eligible to receive antithrombotic therapy are on active stroke prophylaxis.

Q: Why do you think there are such large gaps in stroke prophylaxis for AF patients?

Dr. Masica: The prophylaxis decision requires the clinician to do an anticoagulation net-benefit and risk assessment, and although there are validated tools to do this type of assessment, use of these tools hasn’t yet become hardwired into daily hospital practice. Empiric clinical assessments often overestimate the bleed risk and underestimate stroke risk, so the ultimate result can be underuse of antithrombotic therapy.

“Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.”

–Dr. Shah

Dr. Shah: Another barrier is that in many hospitals, there are not reminders in place in our workflow for this assessment to happen at all. Hospitalists may think that the anticoagulation decision is an outpatient issue, better addressed by their primary care doctor, so it is sometimes even intentionally bypassed. Another barrier is that it takes time to discuss a patient’s values and preferences in the anticoagulation decision.

Q: But isn’t stroke prevention in AF more of an outpatient issue?

Dr. Shah: We think the hospital is a great place to start this evaluation and to make the anticoagulation decision. Of course, we should discuss these issues with the primary care doctor. Ideally, we would like to start anticoagulation during the hospital stay or on discharge, if indicated, but even if we clearly communicate a patient’s stroke and bleed risk to the PCP on discharge, we can help ensure that this issue will be addressed on outpatient follow-up.

Q: What specific tools for stroke and bleed risk are you referring to?

Dr. Shah: The CHADS2 scoring system is a well-validated tool for estimating the risk of stroke in AF patients, one that most clinicians may be aware of. The CHA2DS2-VASc is a slightly more refined scoring system. When it comes to bleeding, however, fewer clinicians are aware of the HAS-BLED bleeding risk assessment method.

Dr. Masica: The scoring systems represent a consistent, reproducible approach by which to evaluate inpatients with AF. Of course, there is some discretion for other patient-specific factors (e.g. fall risk) that are not captured in the scoring systems, but they are good starting points in the decision-making process. Finally and most importantly, although it is often overlooked, shared decision-making should take place with the patients, because their values in facing the risk of stroke versus bleeding often tip the balance one way or the other.

Q: How will the project help hospitals in this process?

Dr. Shah: We have written a QI Implementation Guide for hospitals with tools intended to improve the care of patients with AF in the hospital setting. This book will be similar to SHM’s VTE Prevention Implementation Guide, published a few years ago. We also will have an upcoming AF QI resource room within the SHM website. Additionally, similar to VTE, there are likely to be future mentored implementation projects where we will be working directly with hospitals and coaching them in this initiative.

Dr. Masica: We also have given a recent SHM-sponsored webinar that outlines some content of the guide. It can be accessed on the SHM website. This webinar reviews how to start a QI project in AF, assess your current state of care, build an interdisciplinary team, use validated tools, and deploy interventions to help make the stroke risk assessment and prophylaxis decision. I would note that the intended audience for these tools is broad and includes frontline hospitalists, QI directors, CMOs, and COOs, as well as nursing leadership, NPs, PAs, pharmacists, and other care providers.

Q: Does healthcare reform impact your efforts in this area?

Dr. Shah: Value-based purchasing, preventing readmissions, accountable care organizations, and bundled payments are all aspects of reform that will involve this therapeutic area, as their scope will impact the quality of care we deliver, how our cost structures are, and how we improve fragmentation of care across care transitions.

Dr. Masica: In addition, market forces, healthcare legislation, conceptual shifts regarding the need for systematic approaches to healthcare improvement, and new rules that may impact hospital reimbursement will continue to make AF an important healthcare quality issue. Thus, we think the discussion around delivering patient-centered care in AF is really just beginning.

Brendon Shank is SHM’s associate vice president of communications.

President Obama has nominated 37-year-old Boston hospitalist Vivek Murthy, MD, MBA, as surgeon general of the United States. Dr. Murthy has worked since 2006 as a hospitalist and assistant professor of medicine at Harvard Medical School and Brigham and Women’s Hospital in Boston. He is co-founder and president of Doctors for America, a Washington, D.C.-based group of 16,000 physicians and medical students that advocates for access to affordable, high quality health care and has been a strong supporter of the Affordable Care Act.

If confirmed by the U.S. Senate, Dr. Murthy would replace acting surgeon general Boris Lushniak. The surgeon general serves a four-year term. “We share a belief that access to quality health care is a basic human right,” Brigham president Dr. Betsy Nabel said in a statement about Dr. Murthy. “I am confident that he will be a passionate advocate and that he will have an extraordinary impact as our nation’s surgeon general.”

Dr. Murthy studied at Harvard, received his medical degree at Yale School of Medicine, and earned an MBA from Yale School of Management. In 2011, he was appointed to serve as a member of the Advisory Group on Prevention, Health Promotion, and Integrative and Public Health. He was co-founder and is chairman of the board of TrialNetworks, formerly known as Epernicus, since 2007. He co-founded VISIONS Worldwide in 1995, a non-profit organization focused on HIV/AIDS education in India and the United States, where he served as president from 1995 to 2000 and chairman of the board from 2000 to 2003.

Daniel Virnich, MD, MBA, has been named TeamHealth Hospital Medicine’s new chief medical officer. Dr. Virnich previously served as the company’s western region medical director. He currently serves on SHM’s Practice Management Committee and SHM’s Patient Experience Task Force. TeamHealth, based in Knoxville, Tenn., provides private hospitalist services in 47 states.

Dean Dalili, MD, FHM, is the new vice president of medical affairs at Hollywood, Fla.-based Hospital Physician Partners (HPP), a private hospitalist management company with services in more than 20 states. Dr. Dalili previously served as HPP medical director and regional medical director. He was recognized in 2012 and this year as one of HPP’s outstanding medical directors in the hospital medicine division for his operational and leadership excellence.

David Roe is the new executive director of IPC The Hospitalist Company’s Northeast Tenn./Southwest Virginia region, where he will oversee operations at both acute and post-acute care facilities throughout the region. Roe previously served as executive director of THS Physician Partners, a multi-specialty physician group based in Charleston, W.Va.

Robert Mickelsen, MD, has been appointed system medical director for Lovelace Hospitalist Services in Albuquerque, N.M. The programs at Lovelace’s three hospital facilities are all managed by Hospital Physician Partners (HPP), and Dr. Mickelsen will be charged with overseeing operations at all three hospitals. Dr. Mickelsen comes to his new role from Gerald Champion Regional Medical Center in Alamogordo, N.M., where he served as hospitalist medical director.

Francisco Loya, MD, MSc, has been named chief medical officer for EmCare Hospital Medicine. Dr. Loya earned his medical degree at the University of Texas Southwestern Medical School in Dallas and completed his internal medicine residency at Brigham and Women’s Hospital in Boston. He earned his master of science degree in healthcare management from Harvard School of Public Health in Boston. After earning his master’s degree, Dr. Loya created a software tool (CMORx) that uses deductive algorithms to fill the gaps in medical records, which he will bring with him to EmCare. Based in Dallas, EmCare provides hospitalist and other services to more than 500 hospitals nationwide.

Business Moves

ECI Healthcare Partners, based in Traverse City, Mich., will now provide hospitalist services to O’Bleness Memorial Hospital in Athens, Ohio. O’Bleness Memorial has been serving the neighborhoods in and around Athens since 1921. ECI Healthcare Partners provides hospitalist and emergency medicine services to hospitals in more than 30 states.

Michael O’Neal is a freelance writer in New York City.

President Obama has nominated 37-year-old Boston hospitalist Vivek Murthy, MD, MBA, as surgeon general of the United States. Dr. Murthy has worked since 2006 as a hospitalist and assistant professor of medicine at Harvard Medical School and Brigham and Women’s Hospital in Boston. He is co-founder and president of Doctors for America, a Washington, D.C.-based group of 16,000 physicians and medical students that advocates for access to affordable, high quality health care and has been a strong supporter of the Affordable Care Act.

If confirmed by the U.S. Senate, Dr. Murthy would replace acting surgeon general Boris Lushniak. The surgeon general serves a four-year term. “We share a belief that access to quality health care is a basic human right,” Brigham president Dr. Betsy Nabel said in a statement about Dr. Murthy. “I am confident that he will be a passionate advocate and that he will have an extraordinary impact as our nation’s surgeon general.”

Dr. Murthy studied at Harvard, received his medical degree at Yale School of Medicine, and earned an MBA from Yale School of Management. In 2011, he was appointed to serve as a member of the Advisory Group on Prevention, Health Promotion, and Integrative and Public Health. He was co-founder and is chairman of the board of TrialNetworks, formerly known as Epernicus, since 2007. He co-founded VISIONS Worldwide in 1995, a non-profit organization focused on HIV/AIDS education in India and the United States, where he served as president from 1995 to 2000 and chairman of the board from 2000 to 2003.

Daniel Virnich, MD, MBA, has been named TeamHealth Hospital Medicine’s new chief medical officer. Dr. Virnich previously served as the company’s western region medical director. He currently serves on SHM’s Practice Management Committee and SHM’s Patient Experience Task Force. TeamHealth, based in Knoxville, Tenn., provides private hospitalist services in 47 states.

Dean Dalili, MD, FHM, is the new vice president of medical affairs at Hollywood, Fla.-based Hospital Physician Partners (HPP), a private hospitalist management company with services in more than 20 states. Dr. Dalili previously served as HPP medical director and regional medical director. He was recognized in 2012 and this year as one of HPP’s outstanding medical directors in the hospital medicine division for his operational and leadership excellence.

David Roe is the new executive director of IPC The Hospitalist Company’s Northeast Tenn./Southwest Virginia region, where he will oversee operations at both acute and post-acute care facilities throughout the region. Roe previously served as executive director of THS Physician Partners, a multi-specialty physician group based in Charleston, W.Va.

Robert Mickelsen, MD, has been appointed system medical director for Lovelace Hospitalist Services in Albuquerque, N.M. The programs at Lovelace’s three hospital facilities are all managed by Hospital Physician Partners (HPP), and Dr. Mickelsen will be charged with overseeing operations at all three hospitals. Dr. Mickelsen comes to his new role from Gerald Champion Regional Medical Center in Alamogordo, N.M., where he served as hospitalist medical director.

Francisco Loya, MD, MSc, has been named chief medical officer for EmCare Hospital Medicine. Dr. Loya earned his medical degree at the University of Texas Southwestern Medical School in Dallas and completed his internal medicine residency at Brigham and Women’s Hospital in Boston. He earned his master of science degree in healthcare management from Harvard School of Public Health in Boston. After earning his master’s degree, Dr. Loya created a software tool (CMORx) that uses deductive algorithms to fill the gaps in medical records, which he will bring with him to EmCare. Based in Dallas, EmCare provides hospitalist and other services to more than 500 hospitals nationwide.

Business Moves

ECI Healthcare Partners, based in Traverse City, Mich., will now provide hospitalist services to O’Bleness Memorial Hospital in Athens, Ohio. O’Bleness Memorial has been serving the neighborhoods in and around Athens since 1921. ECI Healthcare Partners provides hospitalist and emergency medicine services to hospitals in more than 30 states.

Michael O’Neal is a freelance writer in New York City.

President Obama has nominated 37-year-old Boston hospitalist Vivek Murthy, MD, MBA, as surgeon general of the United States. Dr. Murthy has worked since 2006 as a hospitalist and assistant professor of medicine at Harvard Medical School and Brigham and Women’s Hospital in Boston. He is co-founder and president of Doctors for America, a Washington, D.C.-based group of 16,000 physicians and medical students that advocates for access to affordable, high quality health care and has been a strong supporter of the Affordable Care Act.

If confirmed by the U.S. Senate, Dr. Murthy would replace acting surgeon general Boris Lushniak. The surgeon general serves a four-year term. “We share a belief that access to quality health care is a basic human right,” Brigham president Dr. Betsy Nabel said in a statement about Dr. Murthy. “I am confident that he will be a passionate advocate and that he will have an extraordinary impact as our nation’s surgeon general.”

Dr. Murthy studied at Harvard, received his medical degree at Yale School of Medicine, and earned an MBA from Yale School of Management. In 2011, he was appointed to serve as a member of the Advisory Group on Prevention, Health Promotion, and Integrative and Public Health. He was co-founder and is chairman of the board of TrialNetworks, formerly known as Epernicus, since 2007. He co-founded VISIONS Worldwide in 1995, a non-profit organization focused on HIV/AIDS education in India and the United States, where he served as president from 1995 to 2000 and chairman of the board from 2000 to 2003.

Daniel Virnich, MD, MBA, has been named TeamHealth Hospital Medicine’s new chief medical officer. Dr. Virnich previously served as the company’s western region medical director. He currently serves on SHM’s Practice Management Committee and SHM’s Patient Experience Task Force. TeamHealth, based in Knoxville, Tenn., provides private hospitalist services in 47 states.

Dean Dalili, MD, FHM, is the new vice president of medical affairs at Hollywood, Fla.-based Hospital Physician Partners (HPP), a private hospitalist management company with services in more than 20 states. Dr. Dalili previously served as HPP medical director and regional medical director. He was recognized in 2012 and this year as one of HPP’s outstanding medical directors in the hospital medicine division for his operational and leadership excellence.

David Roe is the new executive director of IPC The Hospitalist Company’s Northeast Tenn./Southwest Virginia region, where he will oversee operations at both acute and post-acute care facilities throughout the region. Roe previously served as executive director of THS Physician Partners, a multi-specialty physician group based in Charleston, W.Va.

Robert Mickelsen, MD, has been appointed system medical director for Lovelace Hospitalist Services in Albuquerque, N.M. The programs at Lovelace’s three hospital facilities are all managed by Hospital Physician Partners (HPP), and Dr. Mickelsen will be charged with overseeing operations at all three hospitals. Dr. Mickelsen comes to his new role from Gerald Champion Regional Medical Center in Alamogordo, N.M., where he served as hospitalist medical director.

Francisco Loya, MD, MSc, has been named chief medical officer for EmCare Hospital Medicine. Dr. Loya earned his medical degree at the University of Texas Southwestern Medical School in Dallas and completed his internal medicine residency at Brigham and Women’s Hospital in Boston. He earned his master of science degree in healthcare management from Harvard School of Public Health in Boston. After earning his master’s degree, Dr. Loya created a software tool (CMORx) that uses deductive algorithms to fill the gaps in medical records, which he will bring with him to EmCare. Based in Dallas, EmCare provides hospitalist and other services to more than 500 hospitals nationwide.

Business Moves

ECI Healthcare Partners, based in Traverse City, Mich., will now provide hospitalist services to O’Bleness Memorial Hospital in Athens, Ohio. O’Bleness Memorial has been serving the neighborhoods in and around Athens since 1921. ECI Healthcare Partners provides hospitalist and emergency medicine services to hospitals in more than 30 states.

Michael O’Neal is a freelance writer in New York City.

One of hospital medicine’s premiere experts on urinary catheter use says that even though UTIs might be the main catheter issue with which hospitalists concern themselves, it’s just one of the issues to be thinking about when caring for patients with the devices.

“Non-infectious complications—trauma during time of insertion, pain, discomfort, hematuria after catheter removal—are also very important issues that a hospitalist needs to be aware of, even though we tend not to track those issues as closely as infections related to the catheter,” says Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor.

Often, there’s no easy way to know whether a patient might have sustained some injury at the time of insertion, because it’s not noted anywhere how many attempts at insertion there were. So it takes extra care to take that into account.

Simply having a catheter can lead to some problems that hospitalists usually try to prevent, he said.

“The catheter tethers the patient to the bed and acts as a one-point restraint,” says Dr. Saint, who many years ago co-wrote an article on the topic.4 “So it prevents them from getting up and out of bed, increasing the risk for venous thromboembolism [and] pressure sores, and the de-conditioning may lead to falls.”

A urinary catheter alone is not a recipe for bed rest.

“The patient could still get up and out of bed, but there needs to be close attention paid to the drainage bag and making sure that the drainage bag is kept below the bladder to prevent the reflux of urine into the bladder,” he says.

It’s similar to the recognition that ICU and hip-replacement patients benefit from early mobilization.

“We just have to be mindful of making sure that we do good catheter and drainage bag maintenance so that it minimizes the risk of infection,” Dr. Saint says.

Tom Collins is a freelance writer in South Florida.

One of hospital medicine’s premiere experts on urinary catheter use says that even though UTIs might be the main catheter issue with which hospitalists concern themselves, it’s just one of the issues to be thinking about when caring for patients with the devices.

“Non-infectious complications—trauma during time of insertion, pain, discomfort, hematuria after catheter removal—are also very important issues that a hospitalist needs to be aware of, even though we tend not to track those issues as closely as infections related to the catheter,” says Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor.

Often, there’s no easy way to know whether a patient might have sustained some injury at the time of insertion, because it’s not noted anywhere how many attempts at insertion there were. So it takes extra care to take that into account.

Simply having a catheter can lead to some problems that hospitalists usually try to prevent, he said.

“The catheter tethers the patient to the bed and acts as a one-point restraint,” says Dr. Saint, who many years ago co-wrote an article on the topic.4 “So it prevents them from getting up and out of bed, increasing the risk for venous thromboembolism [and] pressure sores, and the de-conditioning may lead to falls.”

A urinary catheter alone is not a recipe for bed rest.

“The patient could still get up and out of bed, but there needs to be close attention paid to the drainage bag and making sure that the drainage bag is kept below the bladder to prevent the reflux of urine into the bladder,” he says.

It’s similar to the recognition that ICU and hip-replacement patients benefit from early mobilization.

“We just have to be mindful of making sure that we do good catheter and drainage bag maintenance so that it minimizes the risk of infection,” Dr. Saint says.

Tom Collins is a freelance writer in South Florida.

One of hospital medicine’s premiere experts on urinary catheter use says that even though UTIs might be the main catheter issue with which hospitalists concern themselves, it’s just one of the issues to be thinking about when caring for patients with the devices.

“Non-infectious complications—trauma during time of insertion, pain, discomfort, hematuria after catheter removal—are also very important issues that a hospitalist needs to be aware of, even though we tend not to track those issues as closely as infections related to the catheter,” says Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor.

Often, there’s no easy way to know whether a patient might have sustained some injury at the time of insertion, because it’s not noted anywhere how many attempts at insertion there were. So it takes extra care to take that into account.

Simply having a catheter can lead to some problems that hospitalists usually try to prevent, he said.

“The catheter tethers the patient to the bed and acts as a one-point restraint,” says Dr. Saint, who many years ago co-wrote an article on the topic.4 “So it prevents them from getting up and out of bed, increasing the risk for venous thromboembolism [and] pressure sores, and the de-conditioning may lead to falls.”

A urinary catheter alone is not a recipe for bed rest.

“The patient could still get up and out of bed, but there needs to be close attention paid to the drainage bag and making sure that the drainage bag is kept below the bladder to prevent the reflux of urine into the bladder,” he says.

It’s similar to the recognition that ICU and hip-replacement patients benefit from early mobilization.

“We just have to be mindful of making sure that we do good catheter and drainage bag maintenance so that it minimizes the risk of infection,” Dr. Saint says.

Tom Collins is a freelance writer in South Florida.

Dr. Danella

10 Things: At A Glance

1. Take out urinary catheters as soon as possible.
2. But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.
3. Beware certain types of medications in vulnerable patients.
4. Don’t discharge patients who are having difficulty voiding.
5. Broach sensitive topics, but do so gently.
6. Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.
7. Diabetic patients require extra attention.
8. Practice good antibiotic stewardship.
9. Determine whether the patient can be seen as an outpatient.
10. Embrace your role as eyes and ears.

1: Intravenous Haloperidol Does Not Prevent ICU Delirium

Urology is an area in which hospitalists might not have much formal training, but because many of these patients undergo highly complicated surgical procedures with great potential for complications, hospitalists can be vital for good outcomes, urologists say.

The use of urinary catheters is a prime area of concern when it comes to quality and safety, making hospitalists’ role in the care of urological patients even more crucial.

The Hospitalist spoke with a half dozen urologists and well-versed HM clinicians about caring for patients with urological disorders. Here are the best nuggets of guidance for hospitalists.

Take out urinary catheters as soon as possible.

John Bulger, DO, FACOI, FACP, SFHM, a hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, says that, all too often, urinary catheters are left in too long. “There’s pretty good data to suggest that there’s a very direct relationship with the length of time the catheter’s in and the chance of it getting infected,” he says. “Upwards to half of the urinary catheters that are in in hospitals right now wouldn’t meet the guidelines of having a urinary catheter in.”

Dr. Bulger is chair of SHM’s Choosing Wisely subcommittee. One of SHM’s Choosing Wisely recommendations warns physicians not to place, or leave in place, catheters for incontinence, convenience, or monitoring of non-critically ill patients.¹

2: But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.

William Steers, MD, chair of urology at the University of Virginia and editor of the Journal of Urology, says there are risks associated with taking catheters out when it’s not appropriate, especially in patients who’ve undergone surgery.

“We’ve seen situations where we’re called into the operating room by another team,” Dr. Steers says. “Let’s say there was a bladder injury of another service. We’ve repaired the bladder with a catheter in for seven to 10 days. It’s taken out day one; the bladder fills and has the potential of causing harm.”

Early removal before the bladder wall heals can cause bladder rupture, requiring emergency surgery.

“So the devil’s in the details,” he says.

Mark Austenfeld, MD, FACS, president of the American Association of Clinical Urologists, which is dedicated to political action, advocacy, and best practice parameters, says catheters should remain in place for patients with mental status changes, or those who are debilitated in some way and can’t get out of bed or don’t have the wherewithal to ask for help from a nurse.

He says he realizes hospitalists are following pay-for-performance protocols, but he adds a caveat.

“Many times these protocols cannot take into account all of these specialized situations,” says Dr. Austenfeld, a urologist with Kansas City Urology Care. He stresses, though, that the hospitalists he’s worked with do high-quality work.

Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor, says that even with these issues, early removal should remain a priority when appropriate.

“There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while,” Dr. Saint explains. “But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.”²

Dr. Steers says most agree that urinary catheters are often “overutilized.”

“You do want to get them out as soon as possible,” he says. “But if it’s ever in doubt, there should be communication with the urology team.”

3: Beware certain types of medications in vulnerable patients.

Hospitalists should tread carefully with medications that might be difficult to handle for patients with kidney issues, like stones or obstructive disease, Dr. Bulger says.

“If they only have one kidney that works well, you have to pay particular attention to drugs that are toxic to the kidneys,” he says. He notes that the nature of the patient’s health “will change the doses of some drugs, as well, depending on what the function of their kidney is.”

Dr. Austenfeld says that drugs with anticholinergic side effects, including some cold remedies such as Benadryl, should possibly be avoided in patients who are having trouble emptying their bladders, because they might make it more difficult for a patient to urinate. Some sedatives, such as amitriptyline, have similar effects and should be used cautiously in these patients, Dr. Austenfeld points out.

“That class of drugs—sometimes I see patients on them for a long time, or placed on them, and they do have a little trouble emptying their bladders,” he says.

4: Don’t discharge patients who are having difficulty voiding.

“If patients are in the hospital and they’ve been taking narcotics post-surgically, or they’re a diabetic patient and they’ve had urinary catheter infections, we should be very careful that these patients are emptying their bladders,” says Dennis Pessis, professor of urology at Rush University Medical Center in Chicago and immediate past president of the American Urological Association. “You can do a very simple ultrasound of the bladder to be sure that they’re emptying. Because if they’re not emptying well, and if they’re going to go home, they may not empty their bladders well and may colonize bacteria.”

Dr. Pessis says it’s not common, but it does happen.

“It’s something that’s of concern,” he says. “It happens often enough that we should be very alert to watching for those problems.”

5: Broach sensitive topics, but do so gently.

“Sexual dysfunction is a significant issue,” Dr. Bulger says. “I think that it’s in the best interest of the patient to address that up front. Generally, urologists are pretty good at that as well. Because you’re co-managing with them, they’re going to help out with that. But it’s important to always remember what’s going to concern the patient.”

Incontinence can be similarly sensitive but important to discuss.

“I think it helps sometimes if the physician brings it up in an appropriate way and kind of opens the door to be able to have the discussion,” Dr. Bulger said.

[Diabetic patients] may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders. They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.

—Dennis Pessis, professor of urology, Rush University Medical Center, Chicago, immediate past president, American Urological Association

6: Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.

One rule of thumb is, if you try twice to put in a urinary catheter without success, call in someone else to do it.

“You don’t want what we call ‘false passages,’” Dr. Pessis says. “If you are having difficulty inserting the catheter, if it’s not moving down the channel well, then you should back off and either consult someone that has more experience in catheterizing or contact the urologist.”

Two reasons the placement might be difficult: strictures like old scar formations, within the urethra, or an enlarged prostate.

Dr. Danella

John Danella, MD, FACS, head of urology for the Geisinger Health System, says a coudé catheter, with a curved tip to help it navigate around the prostate, should be tried on male patients over 50.

“If that’s not successful, then I think you need to call the urologist,” he says. “It’s better to call them before there’s been trauma to the urethra than afterwards.”

Dr. Danella says he understands that attempts by hospitalists in the face of difficulty are made with “best intentions” to save the urologist the time. But when injuries happen, “often times you’re forced to take that patient to the operating room for cystoscopy.”

7: Diabetic patients require extra attention.

“They may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders,” Dr. Pessis explains. “They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.”

8: Practice good antibiotic stewardship.

After 72 hours, almost all urine cultures from a catheterized patient are positive. That doesn’t mean they all need antibiotics, Dr. Steers says.

“Unless the patient’s symptomatic, we don’t treat until a catheter comes out,” he says. “The constant use of antibiotics in somebody with an in-dwelling catheter is creating tremendous problems with resistance and biofilms, etc.”

Dr. Steers says hospitalists can be an educational resource for care teams, using the latest infectious disease literature to say, “Hey, this antibiotic should be stopped. You don’t need to continue this many days.”

“One of the problems we’re having with guidelines is every specialty has their own antibiotic prophylaxis guidelines,” he adds. “So it can be very confusing for the hospitalist.”

9: Determine whether the patient can be seen as an outpatient.

Dr. Danella says that determination often is not made carefully enough. After initial treatment, follow-up with the urologist often can be done on an outpatient basis.

“Sometimes, they’re waiting around all day before we’re free and we can come see them. So I think in many cases, at least in our system, it would be helpful if folks could just place a phone call or just send a message and say, ‘Do you need to see this patient or can we send them home?’” Dr. Danella says. “I think it’s better for everybody if we can do that.”

One common example is an elderly patient who comes to the hospital, is put into a bed, and can’t void. Often, the patient would respond to a catheter and an alpha-blocker (if no contraindication), he says. But, that day, there’s nothing the urologist will be able to do to help make them void immediately, he says.

Another example is a patient with a small kidney stone, less than 5 mm, who probably would respond to medical therapy and won’t need an intervention, Dr. Danella says.

There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while. But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.

—Sanjay Saint, MD, MPH, FHM, hospitalist, professor of internal medicine, University of Michigan, Ann Arbor

10: Embrace your role as eyes and ears.

If a surgical patient’s note isn’t changed in three or four days, the hospitalist needs to ask the surgical team about what has changed in the case, Dr. Steers says.

“At the end of the day, it’s communication with urologists and surgeons,” he says. “And most would appreciate that. I think the [attitude from the] old days of ‘untold command of my patient, I want no other input,’ is really short-sighted.”

Hospitalist vigilance is especially important for complicated patients, such as those who’ve undergone radical cystectomy for bladder cancer. That’s the procedure with the highest mortality rate in urology, as patients are generally older, smoke, and often are obese. And they have high readmission rates—nearly 30 percent.³

Dr. Steers says hospitalists are needed to look for early warning signs in these patients.

“We look for that sort of input, especially when it comes to being the early eyes and ears of potential problems or somebody helping in discharge planning,” he says. “It might be a little too early to go home, and being readmitted is not very good for the hospital as a whole, but, more importantly, the patient.”

Tom Collins is a freelance writer in South Florida.

References

1. Society of Hospital Medicine. Five things physicians and patients should question. SHM website. Available at: http://www.hospitalmedicine.org/AM/pdf/SHM-Adult_5things_List_Web.pdf. Accessed October 24, 2013.
2. Loeb M, Hunt D, O’Halloran K, Carusone SC, Dafoe N, Walter SD. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. J Gen Intern Med. 2008;23(6):816-820.
3. Stimson CJ, Chang SS, Barocas DA, et al. Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series. J Urol. 2010;184(4):1296-1300.
4. Saint S, Lipsky BA, Goold SD. Indwelling urinary catheters: a one-point restraint? Ann Intern Med. 2002;137(2):125-127.

Dr. Danella

10 Things: At A Glance

1. Take out urinary catheters as soon as possible.
2. But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.
3. Beware certain types of medications in vulnerable patients.
4. Don’t discharge patients who are having difficulty voiding.
5. Broach sensitive topics, but do so gently.
6. Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.
7. Diabetic patients require extra attention.
8. Practice good antibiotic stewardship.
9. Determine whether the patient can be seen as an outpatient.
10. Embrace your role as eyes and ears.

1: Intravenous Haloperidol Does Not Prevent ICU Delirium

Urology is an area in which hospitalists might not have much formal training, but because many of these patients undergo highly complicated surgical procedures with great potential for complications, hospitalists can be vital for good outcomes, urologists say.

The use of urinary catheters is a prime area of concern when it comes to quality and safety, making hospitalists’ role in the care of urological patients even more crucial.

The Hospitalist spoke with a half dozen urologists and well-versed HM clinicians about caring for patients with urological disorders. Here are the best nuggets of guidance for hospitalists.

Take out urinary catheters as soon as possible.

John Bulger, DO, FACOI, FACP, SFHM, a hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, says that, all too often, urinary catheters are left in too long. “There’s pretty good data to suggest that there’s a very direct relationship with the length of time the catheter’s in and the chance of it getting infected,” he says. “Upwards to half of the urinary catheters that are in in hospitals right now wouldn’t meet the guidelines of having a urinary catheter in.”

Dr. Bulger is chair of SHM’s Choosing Wisely subcommittee. One of SHM’s Choosing Wisely recommendations warns physicians not to place, or leave in place, catheters for incontinence, convenience, or monitoring of non-critically ill patients.¹

2: But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.

William Steers, MD, chair of urology at the University of Virginia and editor of the Journal of Urology, says there are risks associated with taking catheters out when it’s not appropriate, especially in patients who’ve undergone surgery.

“We’ve seen situations where we’re called into the operating room by another team,” Dr. Steers says. “Let’s say there was a bladder injury of another service. We’ve repaired the bladder with a catheter in for seven to 10 days. It’s taken out day one; the bladder fills and has the potential of causing harm.”

Early removal before the bladder wall heals can cause bladder rupture, requiring emergency surgery.

“So the devil’s in the details,” he says.

Mark Austenfeld, MD, FACS, president of the American Association of Clinical Urologists, which is dedicated to political action, advocacy, and best practice parameters, says catheters should remain in place for patients with mental status changes, or those who are debilitated in some way and can’t get out of bed or don’t have the wherewithal to ask for help from a nurse.

He says he realizes hospitalists are following pay-for-performance protocols, but he adds a caveat.

“Many times these protocols cannot take into account all of these specialized situations,” says Dr. Austenfeld, a urologist with Kansas City Urology Care. He stresses, though, that the hospitalists he’s worked with do high-quality work.

Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor, says that even with these issues, early removal should remain a priority when appropriate.

“There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while,” Dr. Saint explains. “But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.”²

Dr. Steers says most agree that urinary catheters are often “overutilized.”

“You do want to get them out as soon as possible,” he says. “But if it’s ever in doubt, there should be communication with the urology team.”

3: Beware certain types of medications in vulnerable patients.

Hospitalists should tread carefully with medications that might be difficult to handle for patients with kidney issues, like stones or obstructive disease, Dr. Bulger says.

“If they only have one kidney that works well, you have to pay particular attention to drugs that are toxic to the kidneys,” he says. He notes that the nature of the patient’s health “will change the doses of some drugs, as well, depending on what the function of their kidney is.”

Dr. Austenfeld says that drugs with anticholinergic side effects, including some cold remedies such as Benadryl, should possibly be avoided in patients who are having trouble emptying their bladders, because they might make it more difficult for a patient to urinate. Some sedatives, such as amitriptyline, have similar effects and should be used cautiously in these patients, Dr. Austenfeld points out.

“That class of drugs—sometimes I see patients on them for a long time, or placed on them, and they do have a little trouble emptying their bladders,” he says.

4: Don’t discharge patients who are having difficulty voiding.

“If patients are in the hospital and they’ve been taking narcotics post-surgically, or they’re a diabetic patient and they’ve had urinary catheter infections, we should be very careful that these patients are emptying their bladders,” says Dennis Pessis, professor of urology at Rush University Medical Center in Chicago and immediate past president of the American Urological Association. “You can do a very simple ultrasound of the bladder to be sure that they’re emptying. Because if they’re not emptying well, and if they’re going to go home, they may not empty their bladders well and may colonize bacteria.”

Dr. Pessis says it’s not common, but it does happen.

“It’s something that’s of concern,” he says. “It happens often enough that we should be very alert to watching for those problems.”

5: Broach sensitive topics, but do so gently.

“Sexual dysfunction is a significant issue,” Dr. Bulger says. “I think that it’s in the best interest of the patient to address that up front. Generally, urologists are pretty good at that as well. Because you’re co-managing with them, they’re going to help out with that. But it’s important to always remember what’s going to concern the patient.”

Incontinence can be similarly sensitive but important to discuss.

“I think it helps sometimes if the physician brings it up in an appropriate way and kind of opens the door to be able to have the discussion,” Dr. Bulger said.

[Diabetic patients] may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders. They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.

—Dennis Pessis, professor of urology, Rush University Medical Center, Chicago, immediate past president, American Urological Association

6: Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.

One rule of thumb is, if you try twice to put in a urinary catheter without success, call in someone else to do it.

“You don’t want what we call ‘false passages,’” Dr. Pessis says. “If you are having difficulty inserting the catheter, if it’s not moving down the channel well, then you should back off and either consult someone that has more experience in catheterizing or contact the urologist.”

Two reasons the placement might be difficult: strictures like old scar formations, within the urethra, or an enlarged prostate.

Dr. Danella

John Danella, MD, FACS, head of urology for the Geisinger Health System, says a coudé catheter, with a curved tip to help it navigate around the prostate, should be tried on male patients over 50.

“If that’s not successful, then I think you need to call the urologist,” he says. “It’s better to call them before there’s been trauma to the urethra than afterwards.”

Dr. Danella says he understands that attempts by hospitalists in the face of difficulty are made with “best intentions” to save the urologist the time. But when injuries happen, “often times you’re forced to take that patient to the operating room for cystoscopy.”

7: Diabetic patients require extra attention.

“They may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders,” Dr. Pessis explains. “They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.”

8: Practice good antibiotic stewardship.

After 72 hours, almost all urine cultures from a catheterized patient are positive. That doesn’t mean they all need antibiotics, Dr. Steers says.

“Unless the patient’s symptomatic, we don’t treat until a catheter comes out,” he says. “The constant use of antibiotics in somebody with an in-dwelling catheter is creating tremendous problems with resistance and biofilms, etc.”

Dr. Steers says hospitalists can be an educational resource for care teams, using the latest infectious disease literature to say, “Hey, this antibiotic should be stopped. You don’t need to continue this many days.”

“One of the problems we’re having with guidelines is every specialty has their own antibiotic prophylaxis guidelines,” he adds. “So it can be very confusing for the hospitalist.”

9: Determine whether the patient can be seen as an outpatient.

Dr. Danella says that determination often is not made carefully enough. After initial treatment, follow-up with the urologist often can be done on an outpatient basis.

“Sometimes, they’re waiting around all day before we’re free and we can come see them. So I think in many cases, at least in our system, it would be helpful if folks could just place a phone call or just send a message and say, ‘Do you need to see this patient or can we send them home?’” Dr. Danella says. “I think it’s better for everybody if we can do that.”

One common example is an elderly patient who comes to the hospital, is put into a bed, and can’t void. Often, the patient would respond to a catheter and an alpha-blocker (if no contraindication), he says. But, that day, there’s nothing the urologist will be able to do to help make them void immediately, he says.

Another example is a patient with a small kidney stone, less than 5 mm, who probably would respond to medical therapy and won’t need an intervention, Dr. Danella says.

There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while. But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.

—Sanjay Saint, MD, MPH, FHM, hospitalist, professor of internal medicine, University of Michigan, Ann Arbor

10: Embrace your role as eyes and ears.

If a surgical patient’s note isn’t changed in three or four days, the hospitalist needs to ask the surgical team about what has changed in the case, Dr. Steers says.

“At the end of the day, it’s communication with urologists and surgeons,” he says. “And most would appreciate that. I think the [attitude from the] old days of ‘untold command of my patient, I want no other input,’ is really short-sighted.”

Hospitalist vigilance is especially important for complicated patients, such as those who’ve undergone radical cystectomy for bladder cancer. That’s the procedure with the highest mortality rate in urology, as patients are generally older, smoke, and often are obese. And they have high readmission rates—nearly 30 percent.³

Dr. Steers says hospitalists are needed to look for early warning signs in these patients.

“We look for that sort of input, especially when it comes to being the early eyes and ears of potential problems or somebody helping in discharge planning,” he says. “It might be a little too early to go home, and being readmitted is not very good for the hospital as a whole, but, more importantly, the patient.”

Tom Collins is a freelance writer in South Florida.

References

1. Society of Hospital Medicine. Five things physicians and patients should question. SHM website. Available at: http://www.hospitalmedicine.org/AM/pdf/SHM-Adult_5things_List_Web.pdf. Accessed October 24, 2013.
2. Loeb M, Hunt D, O’Halloran K, Carusone SC, Dafoe N, Walter SD. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. J Gen Intern Med. 2008;23(6):816-820.
3. Stimson CJ, Chang SS, Barocas DA, et al. Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series. J Urol. 2010;184(4):1296-1300.
4. Saint S, Lipsky BA, Goold SD. Indwelling urinary catheters: a one-point restraint? Ann Intern Med. 2002;137(2):125-127.

Dr. Danella

10 Things: At A Glance

1. Take out urinary catheters as soon as possible.
2. But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.
3. Beware certain types of medications in vulnerable patients.
4. Don’t discharge patients who are having difficulty voiding.
5. Broach sensitive topics, but do so gently.
6. Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.
7. Diabetic patients require extra attention.
8. Practice good antibiotic stewardship.
9. Determine whether the patient can be seen as an outpatient.
10. Embrace your role as eyes and ears.

1: Intravenous Haloperidol Does Not Prevent ICU Delirium

Urology is an area in which hospitalists might not have much formal training, but because many of these patients undergo highly complicated surgical procedures with great potential for complications, hospitalists can be vital for good outcomes, urologists say.

The use of urinary catheters is a prime area of concern when it comes to quality and safety, making hospitalists’ role in the care of urological patients even more crucial.

The Hospitalist spoke with a half dozen urologists and well-versed HM clinicians about caring for patients with urological disorders. Here are the best nuggets of guidance for hospitalists.

Take out urinary catheters as soon as possible.

John Bulger, DO, FACOI, FACP, SFHM, a hospitalist and chief quality officer at Geisinger Health System in Pennsylvania, says that, all too often, urinary catheters are left in too long. “There’s pretty good data to suggest that there’s a very direct relationship with the length of time the catheter’s in and the chance of it getting infected,” he says. “Upwards to half of the urinary catheters that are in in hospitals right now wouldn’t meet the guidelines of having a urinary catheter in.”

Dr. Bulger is chair of SHM’s Choosing Wisely subcommittee. One of SHM’s Choosing Wisely recommendations warns physicians not to place, or leave in place, catheters for incontinence, convenience, or monitoring of non-critically ill patients.¹

2: But don’t carry the Choosing Wisely directive on urinary catheters—and in-house protocols—too far.

William Steers, MD, chair of urology at the University of Virginia and editor of the Journal of Urology, says there are risks associated with taking catheters out when it’s not appropriate, especially in patients who’ve undergone surgery.

“We’ve seen situations where we’re called into the operating room by another team,” Dr. Steers says. “Let’s say there was a bladder injury of another service. We’ve repaired the bladder with a catheter in for seven to 10 days. It’s taken out day one; the bladder fills and has the potential of causing harm.”

Early removal before the bladder wall heals can cause bladder rupture, requiring emergency surgery.

“So the devil’s in the details,” he says.

Mark Austenfeld, MD, FACS, president of the American Association of Clinical Urologists, which is dedicated to political action, advocacy, and best practice parameters, says catheters should remain in place for patients with mental status changes, or those who are debilitated in some way and can’t get out of bed or don’t have the wherewithal to ask for help from a nurse.

He says he realizes hospitalists are following pay-for-performance protocols, but he adds a caveat.

“Many times these protocols cannot take into account all of these specialized situations,” says Dr. Austenfeld, a urologist with Kansas City Urology Care. He stresses, though, that the hospitalists he’s worked with do high-quality work.

Sanjay Saint, MD, MPH, FHM, hospitalist and professor of internal medicine at the University of Michigan in Ann Arbor, says that even with these issues, early removal should remain a priority when appropriate.

“There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while,” Dr. Saint explains. “But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.”²

Dr. Steers says most agree that urinary catheters are often “overutilized.”

“You do want to get them out as soon as possible,” he says. “But if it’s ever in doubt, there should be communication with the urology team.”

3: Beware certain types of medications in vulnerable patients.

Hospitalists should tread carefully with medications that might be difficult to handle for patients with kidney issues, like stones or obstructive disease, Dr. Bulger says.

“If they only have one kidney that works well, you have to pay particular attention to drugs that are toxic to the kidneys,” he says. He notes that the nature of the patient’s health “will change the doses of some drugs, as well, depending on what the function of their kidney is.”

Dr. Austenfeld says that drugs with anticholinergic side effects, including some cold remedies such as Benadryl, should possibly be avoided in patients who are having trouble emptying their bladders, because they might make it more difficult for a patient to urinate. Some sedatives, such as amitriptyline, have similar effects and should be used cautiously in these patients, Dr. Austenfeld points out.

“That class of drugs—sometimes I see patients on them for a long time, or placed on them, and they do have a little trouble emptying their bladders,” he says.

4: Don’t discharge patients who are having difficulty voiding.

“If patients are in the hospital and they’ve been taking narcotics post-surgically, or they’re a diabetic patient and they’ve had urinary catheter infections, we should be very careful that these patients are emptying their bladders,” says Dennis Pessis, professor of urology at Rush University Medical Center in Chicago and immediate past president of the American Urological Association. “You can do a very simple ultrasound of the bladder to be sure that they’re emptying. Because if they’re not emptying well, and if they’re going to go home, they may not empty their bladders well and may colonize bacteria.”

Dr. Pessis says it’s not common, but it does happen.

“It’s something that’s of concern,” he says. “It happens often enough that we should be very alert to watching for those problems.”

5: Broach sensitive topics, but do so gently.

“Sexual dysfunction is a significant issue,” Dr. Bulger says. “I think that it’s in the best interest of the patient to address that up front. Generally, urologists are pretty good at that as well. Because you’re co-managing with them, they’re going to help out with that. But it’s important to always remember what’s going to concern the patient.”

Incontinence can be similarly sensitive but important to discuss.

“I think it helps sometimes if the physician brings it up in an appropriate way and kind of opens the door to be able to have the discussion,” Dr. Bulger said.

[Diabetic patients] may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders. They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.

—Dennis Pessis, professor of urology, Rush University Medical Center, Chicago, immediate past president, American Urological Association

6: Call in a urologist, or someone with more experience, when you have difficulty placing a catheter.

One rule of thumb is, if you try twice to put in a urinary catheter without success, call in someone else to do it.

“You don’t want what we call ‘false passages,’” Dr. Pessis says. “If you are having difficulty inserting the catheter, if it’s not moving down the channel well, then you should back off and either consult someone that has more experience in catheterizing or contact the urologist.”

Two reasons the placement might be difficult: strictures like old scar formations, within the urethra, or an enlarged prostate.

Dr. Danella

John Danella, MD, FACS, head of urology for the Geisinger Health System, says a coudé catheter, with a curved tip to help it navigate around the prostate, should be tried on male patients over 50.

“If that’s not successful, then I think you need to call the urologist,” he says. “It’s better to call them before there’s been trauma to the urethra than afterwards.”

Dr. Danella says he understands that attempts by hospitalists in the face of difficulty are made with “best intentions” to save the urologist the time. But when injuries happen, “often times you’re forced to take that patient to the operating room for cystoscopy.”

7: Diabetic patients require extra attention.

“They may have what we call a diabetic type of neuropathy for the bladder, which means that they don’t have the sensation and they may not empty their bladders,” Dr. Pessis explains. “They’re also susceptible to a higher incidence of bladder infection. So if you do have a diabetic patient, be sure they’re not infected before they leave. And be sure they’re emptying their bladders well.”

8: Practice good antibiotic stewardship.

After 72 hours, almost all urine cultures from a catheterized patient are positive. That doesn’t mean they all need antibiotics, Dr. Steers says.

“Unless the patient’s symptomatic, we don’t treat until a catheter comes out,” he says. “The constant use of antibiotics in somebody with an in-dwelling catheter is creating tremendous problems with resistance and biofilms, etc.”

Dr. Steers says hospitalists can be an educational resource for care teams, using the latest infectious disease literature to say, “Hey, this antibiotic should be stopped. You don’t need to continue this many days.”

“One of the problems we’re having with guidelines is every specialty has their own antibiotic prophylaxis guidelines,” he adds. “So it can be very confusing for the hospitalist.”

9: Determine whether the patient can be seen as an outpatient.

Dr. Danella says that determination often is not made carefully enough. After initial treatment, follow-up with the urologist often can be done on an outpatient basis.

“Sometimes, they’re waiting around all day before we’re free and we can come see them. So I think in many cases, at least in our system, it would be helpful if folks could just place a phone call or just send a message and say, ‘Do you need to see this patient or can we send them home?’” Dr. Danella says. “I think it’s better for everybody if we can do that.”

One common example is an elderly patient who comes to the hospital, is put into a bed, and can’t void. Often, the patient would respond to a catheter and an alpha-blocker (if no contraindication), he says. But, that day, there’s nothing the urologist will be able to do to help make them void immediately, he says.

Another example is a patient with a small kidney stone, less than 5 mm, who probably would respond to medical therapy and won’t need an intervention, Dr. Danella says.

There’s going to be anecdotal evidence that in some particular patients, when the catheter is removed, it needs to be reinserted when they haven’t urinated for a while. But I think, in general, the studies that have looked at reinsertion have not found a statistically significant increase in reinsertion of the catheter after some type of a stop-order or nurse initiative, protocol, or urinary catheter reminder system has been put in place.

—Sanjay Saint, MD, MPH, FHM, hospitalist, professor of internal medicine, University of Michigan, Ann Arbor

10: Embrace your role as eyes and ears.

If a surgical patient’s note isn’t changed in three or four days, the hospitalist needs to ask the surgical team about what has changed in the case, Dr. Steers says.

“At the end of the day, it’s communication with urologists and surgeons,” he says. “And most would appreciate that. I think the [attitude from the] old days of ‘untold command of my patient, I want no other input,’ is really short-sighted.”

Hospitalist vigilance is especially important for complicated patients, such as those who’ve undergone radical cystectomy for bladder cancer. That’s the procedure with the highest mortality rate in urology, as patients are generally older, smoke, and often are obese. And they have high readmission rates—nearly 30 percent.³

Dr. Steers says hospitalists are needed to look for early warning signs in these patients.

“We look for that sort of input, especially when it comes to being the early eyes and ears of potential problems or somebody helping in discharge planning,” he says. “It might be a little too early to go home, and being readmitted is not very good for the hospital as a whole, but, more importantly, the patient.”

Tom Collins is a freelance writer in South Florida.

References

1. Society of Hospital Medicine. Five things physicians and patients should question. SHM website. Available at: http://www.hospitalmedicine.org/AM/pdf/SHM-Adult_5things_List_Web.pdf. Accessed October 24, 2013.
2. Loeb M, Hunt D, O’Halloran K, Carusone SC, Dafoe N, Walter SD. Stop orders to reduce inappropriate urinary catheterization in hospitalized patients: a randomized controlled trial. J Gen Intern Med. 2008;23(6):816-820.
3. Stimson CJ, Chang SS, Barocas DA, et al. Early and late perioperative outcomes following radical cystectomy: 90-day readmissions, morbidity and mortality in a contemporary series. J Urol. 2010;184(4):1296-1300.
4. Saint S, Lipsky BA, Goold SD. Indwelling urinary catheters: a one-point restraint? Ann Intern Med. 2002;137(2):125-127.

Palliative care increasingly is the subject of clinical and administrative research in medical literature, with investigators examining its impact on costs and utilization of hospital care and other health services, as well as on such outcomes as pain and symptom management and patient and family satisfaction with health services.

An influential study of cost savings associated with hospital palliative care consultation services, conducted by R. Sean Morrison, MD, and colleagues at the National Palliative Care Research Center at Mount Sinai School of Medicine in New York City, matched 2,630 palliative care patients to 18,472 “usual care patients” and concluded that the cost savings averaged $4,988 per patient in direct costs per day for those dying in the hospital.³ A follow-up study in 2010 confirmed these results, and Dr. Morrison and colleagues have documented improved quality from palliative care based on a survey of bereaved family members of patients who received palliative care.^4,5

A 2010 study by a group at Massachusetts General Hospital, led by Jennifer Temel, MD, reached the surprising conclusion that early palliative care for patients with metastatic non-small-cell lung cancer led not only to significant improvements in quality of life and mood and less provision of aggressive care at the end of life—but also to longer survival.⁶ The researchers have studied possible mechanisms for this result, as well as the integration of palliative care with oncology and the importance of palliative care support provided outside of the hospital, in community-based and outpatient settings. ^7,8,9

Community-based palliative care is a significant new direction for palliative care in America, and the availability of palliative care outside of the hospital’s four walls is viewed as important to improving care transitions and preventing readmissions in the seriously ill patients typically targeted for palliative care. The effects of palliative care on 30-day readmissions rates was studied by Susan Enguidanos, PhD, MPH, and colleagues at the University of Southern California School of Gerontology; they found that receipt of palliative care following hospital discharge were a significant factor in reducing 30-day rehospitalizations.¹⁰

A study from Albert Einstein College of Medicine in New York explored outcomes from a dedicated acute palliative care unit in an academic medical center, while others have looked at the diverse landscape of palliative care in outpatient clinics and its potential for rapid growth.^11,12

—Larry Beresford

References

1. Lupu D. American Academy of Hospice and Palliative Medicine Workforce Task Force. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage. 2010;40(6):899-911.
2. Quill TE, Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med. 2013;368(13):1173-1175.
3. Morrison RS, Penrod JD, Cassel JB, et al. Palliative Care Leadership Centers' Outcomes Group. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.
4. Penrod JD, Deb P, Dellenbaugh C, et al. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973-979.
5. Gelfman LP, Meier DE, Morrison RS. Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage. 2008;36(1):22-28.
6. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
7. Irwin KE, Greer JA, Khatib J, Temel JS, Pirl WF. Early palliative care and metastatic non-small cell lung cancer: potential mechanisms of prolonged survival. Chron Respir Dis. 2013;10(1):35-47.
8. Von Roenn JN, Temel J. The integration of palliative care and oncology: the evidence. Oncology. 2011;25(13):1258-1260,1262,1264-1265.
9. Yoong J, Park ER, Greer JA, etc. Early palliative care in advanced lung cancer: a qualitative study. JAMA Intern Med. 2013;173(4):283-290.
10. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
11. Eti S, O’Mahony S, McHugh M, Guilbe R, Blank A, Selwyn P. Outcomes of the acute palliative care unit in an academic medical center [published online ahead of print May 10, 2013]. Am J Hosp Palliat Care. PMID: 23666616.
12. Smith AK, Thai JN, Bakitas MA, et al. The diverse landscape of palliative care clinics. J Palliat Med. 2013;16(6):661-668.

Palliative care increasingly is the subject of clinical and administrative research in medical literature, with investigators examining its impact on costs and utilization of hospital care and other health services, as well as on such outcomes as pain and symptom management and patient and family satisfaction with health services.

An influential study of cost savings associated with hospital palliative care consultation services, conducted by R. Sean Morrison, MD, and colleagues at the National Palliative Care Research Center at Mount Sinai School of Medicine in New York City, matched 2,630 palliative care patients to 18,472 “usual care patients” and concluded that the cost savings averaged $4,988 per patient in direct costs per day for those dying in the hospital.³ A follow-up study in 2010 confirmed these results, and Dr. Morrison and colleagues have documented improved quality from palliative care based on a survey of bereaved family members of patients who received palliative care.^4,5

A 2010 study by a group at Massachusetts General Hospital, led by Jennifer Temel, MD, reached the surprising conclusion that early palliative care for patients with metastatic non-small-cell lung cancer led not only to significant improvements in quality of life and mood and less provision of aggressive care at the end of life—but also to longer survival.⁶ The researchers have studied possible mechanisms for this result, as well as the integration of palliative care with oncology and the importance of palliative care support provided outside of the hospital, in community-based and outpatient settings. ^7,8,9

Community-based palliative care is a significant new direction for palliative care in America, and the availability of palliative care outside of the hospital’s four walls is viewed as important to improving care transitions and preventing readmissions in the seriously ill patients typically targeted for palliative care. The effects of palliative care on 30-day readmissions rates was studied by Susan Enguidanos, PhD, MPH, and colleagues at the University of Southern California School of Gerontology; they found that receipt of palliative care following hospital discharge were a significant factor in reducing 30-day rehospitalizations.¹⁰

A study from Albert Einstein College of Medicine in New York explored outcomes from a dedicated acute palliative care unit in an academic medical center, while others have looked at the diverse landscape of palliative care in outpatient clinics and its potential for rapid growth.^11,12

—Larry Beresford

References

1. Lupu D. American Academy of Hospice and Palliative Medicine Workforce Task Force. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage. 2010;40(6):899-911.
2. Quill TE, Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med. 2013;368(13):1173-1175.
3. Morrison RS, Penrod JD, Cassel JB, et al. Palliative Care Leadership Centers' Outcomes Group. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.
4. Penrod JD, Deb P, Dellenbaugh C, et al. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973-979.
5. Gelfman LP, Meier DE, Morrison RS. Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage. 2008;36(1):22-28.
6. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
7. Irwin KE, Greer JA, Khatib J, Temel JS, Pirl WF. Early palliative care and metastatic non-small cell lung cancer: potential mechanisms of prolonged survival. Chron Respir Dis. 2013;10(1):35-47.
8. Von Roenn JN, Temel J. The integration of palliative care and oncology: the evidence. Oncology. 2011;25(13):1258-1260,1262,1264-1265.
9. Yoong J, Park ER, Greer JA, etc. Early palliative care in advanced lung cancer: a qualitative study. JAMA Intern Med. 2013;173(4):283-290.
10. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
11. Eti S, O’Mahony S, McHugh M, Guilbe R, Blank A, Selwyn P. Outcomes of the acute palliative care unit in an academic medical center [published online ahead of print May 10, 2013]. Am J Hosp Palliat Care. PMID: 23666616.
12. Smith AK, Thai JN, Bakitas MA, et al. The diverse landscape of palliative care clinics. J Palliat Med. 2013;16(6):661-668.

Palliative care increasingly is the subject of clinical and administrative research in medical literature, with investigators examining its impact on costs and utilization of hospital care and other health services, as well as on such outcomes as pain and symptom management and patient and family satisfaction with health services.

An influential study of cost savings associated with hospital palliative care consultation services, conducted by R. Sean Morrison, MD, and colleagues at the National Palliative Care Research Center at Mount Sinai School of Medicine in New York City, matched 2,630 palliative care patients to 18,472 “usual care patients” and concluded that the cost savings averaged $4,988 per patient in direct costs per day for those dying in the hospital.³ A follow-up study in 2010 confirmed these results, and Dr. Morrison and colleagues have documented improved quality from palliative care based on a survey of bereaved family members of patients who received palliative care.^4,5

A 2010 study by a group at Massachusetts General Hospital, led by Jennifer Temel, MD, reached the surprising conclusion that early palliative care for patients with metastatic non-small-cell lung cancer led not only to significant improvements in quality of life and mood and less provision of aggressive care at the end of life—but also to longer survival.⁶ The researchers have studied possible mechanisms for this result, as well as the integration of palliative care with oncology and the importance of palliative care support provided outside of the hospital, in community-based and outpatient settings. ^7,8,9

Community-based palliative care is a significant new direction for palliative care in America, and the availability of palliative care outside of the hospital’s four walls is viewed as important to improving care transitions and preventing readmissions in the seriously ill patients typically targeted for palliative care. The effects of palliative care on 30-day readmissions rates was studied by Susan Enguidanos, PhD, MPH, and colleagues at the University of Southern California School of Gerontology; they found that receipt of palliative care following hospital discharge were a significant factor in reducing 30-day rehospitalizations.¹⁰

A study from Albert Einstein College of Medicine in New York explored outcomes from a dedicated acute palliative care unit in an academic medical center, while others have looked at the diverse landscape of palliative care in outpatient clinics and its potential for rapid growth.^11,12

—Larry Beresford

References

1. Lupu D. American Academy of Hospice and Palliative Medicine Workforce Task Force. Estimate of current hospice and palliative medicine physician workforce shortage. J Pain Symptom Manage. 2010;40(6):899-911.
2. Quill TE, Abernethy AP. Generalist plus specialist palliative care—creating a more sustainable model. N Engl J Med. 2013;368(13):1173-1175.
3. Morrison RS, Penrod JD, Cassel JB, et al. Palliative Care Leadership Centers' Outcomes Group. Cost savings associated with US hospital palliative care consultation programs. Arch Intern Med. 2008;168(16):1783-1790.
4. Penrod JD, Deb P, Dellenbaugh C, et al. Hospital-based palliative care consultation: effects on hospital cost. J Palliat Med. 2010;13(8):973-979.
5. Gelfman LP, Meier DE, Morrison RS. Does palliative care improve quality? A survey of bereaved family members. J Pain Symptom Manage. 2008;36(1):22-28.
6. Temel JS, Greer JA, Muzikansky A, et al. Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010;363(8):733-742.
7. Irwin KE, Greer JA, Khatib J, Temel JS, Pirl WF. Early palliative care and metastatic non-small cell lung cancer: potential mechanisms of prolonged survival. Chron Respir Dis. 2013;10(1):35-47.
8. Von Roenn JN, Temel J. The integration of palliative care and oncology: the evidence. Oncology. 2011;25(13):1258-1260,1262,1264-1265.
9. Yoong J, Park ER, Greer JA, etc. Early palliative care in advanced lung cancer: a qualitative study. JAMA Intern Med. 2013;173(4):283-290.
10. Enguidanos S, Vesper E, Lorenz K. 30-day readmissions among seriously ill older adults. J Palliat Med. 2012;15(12):1356-1361.
11. Eti S, O’Mahony S, McHugh M, Guilbe R, Blank A, Selwyn P. Outcomes of the acute palliative care unit in an academic medical center [published online ahead of print May 10, 2013]. Am J Hosp Palliat Care. PMID: 23666616.
12. Smith AK, Thai JN, Bakitas MA, et al. The diverse landscape of palliative care clinics. J Palliat Med. 2013;16(6):661-668.

Valerie Phillips was diagnosed with stage IV breast cancer in 2010 and is a shining example of the difference a palliative care consultation can make. After she was diagnosed, the Austin, Texas, native continued to work and enjoy a relatively normal life. But when the disease metastasized to her hip, she began to take opioid analgesics for the pain.

Phillips says she felt foolish when she ended up in the ED, profoundly uncomfortable from a four-day impaction due to the analgesic and oral cancer drugs. “But nobody told me about all that,” she says.

She thinks her oncologist was giving good care, “but her area was treating the disease.”

Upon admission, a hospitalist referred Phillips for an inpatient palliative care consultation with Stephen Bekanich, MD, a former hospitalist who now co-directs Seton Palliative Care for the Seton Health System in Austin.

“I learned there’s a big difference between fighting the disease and treating the needs of the patient as a person,” Phillips explains. “A palliative care doctor like Stephen changes everything. He found a way for me to better navigate the healthcare system, carrying all of that information in his head. He said to me, ‘OK, we’re going to make sure this doesn’t happen again.’

I trusted him—and it worked.” Phillips says she understands that her long-term prospects aren’t great, and she expects to enroll in hospice soon. She hasn’t been back to the hospital, but has continued to see Dr. Bekanich as an outpatient.

“For me, there was an informational and educational gap, and I have a master’s degree and a career in management,” she says. “Stephen was able to tie everything together for me.”

Phillips says hospitalists should focus on the connection between disease treatment and the quality of life palliative care affords. “They should go hand in hand. Patients should be able to count on somebody who can take us by the hand and make the whole process as painless—and worry-free—as possible.”

—Larry Beresford

Valerie Phillips was diagnosed with stage IV breast cancer in 2010 and is a shining example of the difference a palliative care consultation can make. After she was diagnosed, the Austin, Texas, native continued to work and enjoy a relatively normal life. But when the disease metastasized to her hip, she began to take opioid analgesics for the pain.

Phillips says she felt foolish when she ended up in the ED, profoundly uncomfortable from a four-day impaction due to the analgesic and oral cancer drugs. “But nobody told me about all that,” she says.

She thinks her oncologist was giving good care, “but her area was treating the disease.”

Upon admission, a hospitalist referred Phillips for an inpatient palliative care consultation with Stephen Bekanich, MD, a former hospitalist who now co-directs Seton Palliative Care for the Seton Health System in Austin.

“I learned there’s a big difference between fighting the disease and treating the needs of the patient as a person,” Phillips explains. “A palliative care doctor like Stephen changes everything. He found a way for me to better navigate the healthcare system, carrying all of that information in his head. He said to me, ‘OK, we’re going to make sure this doesn’t happen again.’

I trusted him—and it worked.” Phillips says she understands that her long-term prospects aren’t great, and she expects to enroll in hospice soon. She hasn’t been back to the hospital, but has continued to see Dr. Bekanich as an outpatient.

“For me, there was an informational and educational gap, and I have a master’s degree and a career in management,” she says. “Stephen was able to tie everything together for me.”

Phillips says hospitalists should focus on the connection between disease treatment and the quality of life palliative care affords. “They should go hand in hand. Patients should be able to count on somebody who can take us by the hand and make the whole process as painless—and worry-free—as possible.”

—Larry Beresford

Valerie Phillips was diagnosed with stage IV breast cancer in 2010 and is a shining example of the difference a palliative care consultation can make. After she was diagnosed, the Austin, Texas, native continued to work and enjoy a relatively normal life. But when the disease metastasized to her hip, she began to take opioid analgesics for the pain.

Phillips says she felt foolish when she ended up in the ED, profoundly uncomfortable from a four-day impaction due to the analgesic and oral cancer drugs. “But nobody told me about all that,” she says.

She thinks her oncologist was giving good care, “but her area was treating the disease.”

Upon admission, a hospitalist referred Phillips for an inpatient palliative care consultation with Stephen Bekanich, MD, a former hospitalist who now co-directs Seton Palliative Care for the Seton Health System in Austin.

“I learned there’s a big difference between fighting the disease and treating the needs of the patient as a person,” Phillips explains. “A palliative care doctor like Stephen changes everything. He found a way for me to better navigate the healthcare system, carrying all of that information in his head. He said to me, ‘OK, we’re going to make sure this doesn’t happen again.’

I trusted him—and it worked.” Phillips says she understands that her long-term prospects aren’t great, and she expects to enroll in hospice soon. She hasn’t been back to the hospital, but has continued to see Dr. Bekanich as an outpatient.

“For me, there was an informational and educational gap, and I have a master’s degree and a career in management,” she says. “Stephen was able to tie everything together for me.”

Phillips says hospitalists should focus on the connection between disease treatment and the quality of life palliative care affords. “They should go hand in hand. Patients should be able to count on somebody who can take us by the hand and make the whole process as painless—and worry-free—as possible.”

—Larry Beresford