Increasingly, there is a focus on prevention of hospital‐acquired conditions including venous thromboembolism (VTE). Many studies have evaluated pulmonary embolism (PE) and lower extremity deep vein thrombosis (LEDVT), but despite increasing recognition of upper extremity deep vein thrombosis (UEDVT),[1, 2, 3, 4] less is known about this condition in hospitalized patients.

UEDVTs may be classified as primary, including disorders such as Paget‐Schroetter syndrome or other structural abnormality, or may be idiopathic; the majority are secondary clots.[5] Conventional risk factors for LEDVT including older age and obesity have been found to be less commonly associated,[1, 2, 5, 6, 7] and patients with UEDVT are generally younger, leaner, and a higher proportion are men. They are more likely to have malignancy or history of VTE and have undergone recent surgery or intensive care unit stay.[1, 2, 6] Central venous catheters (CVCs), often used in hospitalized patients, remain among the biggest known risks for UEDVT[1, 2, 3, 7, 8, 9, 10]; concomitant malignancy, VTE history, severe infection, surgery lasting >1 hour, and length of stay (LOS) >10 days confer additional risks with CVCs.[6, 7, 8, 11]

UEDVTs, once thought to be relatively benign, are now recognized to result in complications including PE, progression, recurrence, and post‐thrombotic syndrome.[2, 4, 12, 13] Despite extensive efforts to increase appropriate VTE prophylaxis in inpatients,[14] the role of chemoprophylaxis to prevent UEDVT remains undefined. Current guidelines recommend anticoagulation for treatment and complication prevention,[13, 15] but to date the evidence derives largely from observational studies or is extrapolated from the LEDVT literature.[2, 13]

To improve understanding of UEDVT at our institution, we set out to (1) determine UEDVT incidence in hospitalized patients, (2) describe associated risks and outcomes, and (3) assess management during hospitalization and at discharge.

METHODS

We identified all consecutive adult patients diagnosed with Doppler ultrasound‐confirmed UEDVT during hospitalization at Harborview Medical Center between September 2011 and November 2012. For patients who were readmitted during the study period, the first of their hospitalizations was used to describe associated factors, management, and outcomes. We present characteristics of all other hospitalizations during this time period for comparison. Harborview is a 413‐bed academic tertiary referral center and the only level 1 trauma center in a 5‐state area. Patients with UEDVT were identified using an information technology (IT) tool (the Harborview VTE tool) (Figure 1), which captures VTE events from vascular laboratory and radiology studies using natural language processing. Doppler ultrasound to assess for deep vein thrombosis (DVT) and computed tomographic scans to diagnose PE were ordered by inpatient physicians for symptomatic patients. The reason for obtaining the study is included in the ultrasound reports. We do not routinely screen for UEDVT at our institution. UEDVT included clots in the deep veins of the upper extremities including internal jugular, subclavian, axillary, and brachial veins. Superficial thrombosis and thrombophlebitis were excluded. We previously compared VTE events captured by this tool with administrative billing data and found that all VTE events that were coded were captured with the tool.

Figure 1

The VTE tool (Figure 1) displays imaging results together with demographic, clinical, and medication data and links this information with admission, discharge, and death summaries as well as CVC insertion procedure notes from the electronic health record (EHR). Additional data, including comorbid conditions, primary reason for hospitalization, past medical history such as prior VTE events, and cause of death (if not available in the admission note or discharge/death summaries), were obtained from EHR abstraction by 1 of the investigators. A 10% random sample of charts was rereviewed by another investigator with complete concordance. Supplementary data about date of CVC insertion if placed at an outside facility, date of CVC removal if applicable, clinical assessments regarding whether a clot was CVC‐associated, and contraindications to therapeutic anticoagulation were also abstracted directly from the EHR. Administrative data were used to identify the case mix index, an indicator of severity of illness.

Pharmacologic VTE prophylaxis included all chemical prophylaxis specified on our institutional guideline, most commonly subcutaneous unfractionated heparin 5000 units every 8 hours or low molecular weight heparin (LMWH), either enoxaparin 40 mg every 12 or 24 hours or dalteparin 5000 units every 24 hours. Mechanical prophylaxis was defined as use of sequential compression devices (SCDs) when pharmacologic prophylaxis was contraindicated. Prophylaxis was considered to be appropriate if it was applied according to our guideline for >90% of hospital days prior to UEDVT diagnosis. Therapeutic anticoagulation included heparin bridging (most commonly continuous heparin infusion, LMWH 1 mg/kg or dalteparin) as well as oral vitamin K antagonists. The VTE tool (Figure 1) allows identification of pharmacologic prophylaxis and therapy that is actually administered (not just ordered) directly from our pharmacy IT system. SCD application (not just ordered SCDs) is electronically integrated into the tool from nursing documentation.

CVCs included internal jugular or subclavian triple lumen catheters, tunneled dialysis catheters, or peripherally inserted central catheters (PICCs), single or double lumen. Criteria used to identify that a UEDVT was CVC‐associated included temporal relationship (CVC was placed prior to clot diagnosis), plausibility (ipsilateral clot), evidence of clot surrounding CVC on ultrasound, and physician designation of association (as documented in progress notes or discharge summary).

Simple percentages of patient characteristics, associated factors, management, and outcomes were calculated using counts as the numerator and number of patients as the denominator. For information about UEDVTs, we used total number of UEDVTs as the denominator. Line days were day counts from insertion until removal if applicable. The CVC placement date was available in our mandated central line placement procedure notes (directly accessed from the VTE tool) for all lines placed at our institution; date of removal (if applicable) was determined from chart abstraction. For the vast majority of patients whose CVCs were placed at outside facilities, date of placement was available in the EHR (often in the admission note or in the ultrasound report/reason for study). If date of line placement at an outside facility was not known, date of admission was used. The University of Washington Human Subjects Board approved this review.

RESULTS

DISCUSSION

UEDVT is increasingly recognized in hospitalized patients.[3, 9] At our medical center, 0.2% of symptomatic inpatients were diagnosed with UEDVT over 14 months. These patients were predominantly men with high rates of CVCs, malignancy, VTE history, severe infection, and renal disease. Interestingly, although the literature suggests that some proportion of patients with UEDVT have anatomic abnormalities, such as Paget‐Schroetter syndrome,[15] none of the patients in our study were found to have these anomalies. In our review, hospitalized patients with UEDVT were critically ill, with a long LOS and high morbidity and mortality, suggesting that in addition to just being a complication of hospitalization,[1, 6] UEDVT may be a marker of severe illness.

In our institution, clinical presentation was consistent with what has been described with the majority of patients presenting with upper extremity swelling.[1, 3] The internal jugular veins were the most common anatomic UEDVT site, followed by brachial then axillary veins. In other series including both in‐ and outpatients, subclavian clots were most commonly diagnosed, reflecting in part higher rates of CVC association and CVC location in those studies.[3, 9] Concurrent DVT and PE rates were similar to those reported.[1, 3, 10]

Although many studies have focused on prevention of LEDVT and PE, few trials have specifically targeted UEDVT. Among our patients with UEDVTs that were not present on admission, VTE prophylaxis rates were considerably higher than what has been reported,[1, 6] suggesting that in these critically ill patients' prophylaxis may not prevent symptomatic UEDVT. It is unknown how many UEDVTs were prevented with prophylaxis, as only patients with symptomatic UEDVT were included. Adequacy of prophylaxis at outside hospitals for patients transferred in could not be assessed. Nonetheless, low numbers of UEDVT at a trauma referral center with many high‐risk patients raise the question of whether prophylaxis makes a difference. Additional study is needed to further define the role of chemoprophylaxis to prevent UEDVT in hospitalized patients.

In our inpatient group, 84% required CVCs; 44% of patients were thought to have CVC‐associated UEDVTs. Careful patient selection and attention to potentially modifiable risks, such as insertion site, catheter type, and tip position, may need further examination in this population.[3, 11, 16] Catheter duration was long; focus on removing CVCs when no longer necessary is important. Interestingly, almost 10% in our study underwent diagnostic ultrasound because a new CVC could not be successfully placed suggesting that UEDVT may develop in critically ill patients regardless of CVCs.

In our study, there were high rates of guideline‐recommended pharmacologic treatment; surprisingly the majority of CVCs with associated clot were removed. Guidelines currently support 3 months of anticoagulation for treatment of UEDVT[2, 13, 17]; evidence derives from observational trials or is largely extrapolated from LEDVT literature.[2, 13] Routine CVC removal is not specifically recommended for CVC‐associated UEDVT, particularly if lines remain functional and medically necessary; systemic anticoagulation should be provided.[13]

In our review, no hospitalized patients with UEDVT developed complications or were readmitted to our medical center within 30 days for clot progression, new PE, or post‐thrombotic syndrome, which is lower than rates reported over longer time periods.[2, 6, 10, 12] Ten percent died during hospitalization, all from their primary disease rather than from complications of VTE or VTE treatment, and no additional patients died at our institution within 30 days. Although these rates are lower than have been otherwise reported,[2, 10] the inpatient mortality rate is similar to a recent study that included inpatients; however, all patients who died in that study had cancer and CVCs.[3] In the latter study, 6.4% died within 30 days of discharge.

CONCLUSIONS

Among hospitalized patients, UEDVT is increasingly recognized. In our medical center, hospitalized patients diagnosed with UEDVT were more likely to have CVCs, malignancy, renal disease, and severe infection. Many of these patients were transferred critically ill, had prolonged LOS, and had high in‐hospital mortality. Most developed UEDVT despite prophylaxis, and the majority of UEDVTs were treated even in the absence of concurrent LEDVT or PE. As we move toward an era of increasing accountability, with a focus on preventing hospital‐acquired conditions including VTE, additional research is needed to identify modifiable risks, explore opportunities for effective prevention, and optimize outcomes such as prevention of complications or readmissions, particularly in critically ill patients with UEDVT.

Increasingly, there is a focus on prevention of hospital‐acquired conditions including venous thromboembolism (VTE). Many studies have evaluated pulmonary embolism (PE) and lower extremity deep vein thrombosis (LEDVT), but despite increasing recognition of upper extremity deep vein thrombosis (UEDVT),[1, 2, 3, 4] less is known about this condition in hospitalized patients.

UEDVTs may be classified as primary, including disorders such as Paget‐Schroetter syndrome or other structural abnormality, or may be idiopathic; the majority are secondary clots.[5] Conventional risk factors for LEDVT including older age and obesity have been found to be less commonly associated,[1, 2, 5, 6, 7] and patients with UEDVT are generally younger, leaner, and a higher proportion are men. They are more likely to have malignancy or history of VTE and have undergone recent surgery or intensive care unit stay.[1, 2, 6] Central venous catheters (CVCs), often used in hospitalized patients, remain among the biggest known risks for UEDVT[1, 2, 3, 7, 8, 9, 10]; concomitant malignancy, VTE history, severe infection, surgery lasting >1 hour, and length of stay (LOS) >10 days confer additional risks with CVCs.[6, 7, 8, 11]

UEDVTs, once thought to be relatively benign, are now recognized to result in complications including PE, progression, recurrence, and post‐thrombotic syndrome.[2, 4, 12, 13] Despite extensive efforts to increase appropriate VTE prophylaxis in inpatients,[14] the role of chemoprophylaxis to prevent UEDVT remains undefined. Current guidelines recommend anticoagulation for treatment and complication prevention,[13, 15] but to date the evidence derives largely from observational studies or is extrapolated from the LEDVT literature.[2, 13]

To improve understanding of UEDVT at our institution, we set out to (1) determine UEDVT incidence in hospitalized patients, (2) describe associated risks and outcomes, and (3) assess management during hospitalization and at discharge.

METHODS

We identified all consecutive adult patients diagnosed with Doppler ultrasound‐confirmed UEDVT during hospitalization at Harborview Medical Center between September 2011 and November 2012. For patients who were readmitted during the study period, the first of their hospitalizations was used to describe associated factors, management, and outcomes. We present characteristics of all other hospitalizations during this time period for comparison. Harborview is a 413‐bed academic tertiary referral center and the only level 1 trauma center in a 5‐state area. Patients with UEDVT were identified using an information technology (IT) tool (the Harborview VTE tool) (Figure 1), which captures VTE events from vascular laboratory and radiology studies using natural language processing. Doppler ultrasound to assess for deep vein thrombosis (DVT) and computed tomographic scans to diagnose PE were ordered by inpatient physicians for symptomatic patients. The reason for obtaining the study is included in the ultrasound reports. We do not routinely screen for UEDVT at our institution. UEDVT included clots in the deep veins of the upper extremities including internal jugular, subclavian, axillary, and brachial veins. Superficial thrombosis and thrombophlebitis were excluded. We previously compared VTE events captured by this tool with administrative billing data and found that all VTE events that were coded were captured with the tool.

Figure 1

The VTE tool (Figure 1) displays imaging results together with demographic, clinical, and medication data and links this information with admission, discharge, and death summaries as well as CVC insertion procedure notes from the electronic health record (EHR). Additional data, including comorbid conditions, primary reason for hospitalization, past medical history such as prior VTE events, and cause of death (if not available in the admission note or discharge/death summaries), were obtained from EHR abstraction by 1 of the investigators. A 10% random sample of charts was rereviewed by another investigator with complete concordance. Supplementary data about date of CVC insertion if placed at an outside facility, date of CVC removal if applicable, clinical assessments regarding whether a clot was CVC‐associated, and contraindications to therapeutic anticoagulation were also abstracted directly from the EHR. Administrative data were used to identify the case mix index, an indicator of severity of illness.

Pharmacologic VTE prophylaxis included all chemical prophylaxis specified on our institutional guideline, most commonly subcutaneous unfractionated heparin 5000 units every 8 hours or low molecular weight heparin (LMWH), either enoxaparin 40 mg every 12 or 24 hours or dalteparin 5000 units every 24 hours. Mechanical prophylaxis was defined as use of sequential compression devices (SCDs) when pharmacologic prophylaxis was contraindicated. Prophylaxis was considered to be appropriate if it was applied according to our guideline for >90% of hospital days prior to UEDVT diagnosis. Therapeutic anticoagulation included heparin bridging (most commonly continuous heparin infusion, LMWH 1 mg/kg or dalteparin) as well as oral vitamin K antagonists. The VTE tool (Figure 1) allows identification of pharmacologic prophylaxis and therapy that is actually administered (not just ordered) directly from our pharmacy IT system. SCD application (not just ordered SCDs) is electronically integrated into the tool from nursing documentation.

CVCs included internal jugular or subclavian triple lumen catheters, tunneled dialysis catheters, or peripherally inserted central catheters (PICCs), single or double lumen. Criteria used to identify that a UEDVT was CVC‐associated included temporal relationship (CVC was placed prior to clot diagnosis), plausibility (ipsilateral clot), evidence of clot surrounding CVC on ultrasound, and physician designation of association (as documented in progress notes or discharge summary).

Simple percentages of patient characteristics, associated factors, management, and outcomes were calculated using counts as the numerator and number of patients as the denominator. For information about UEDVTs, we used total number of UEDVTs as the denominator. Line days were day counts from insertion until removal if applicable. The CVC placement date was available in our mandated central line placement procedure notes (directly accessed from the VTE tool) for all lines placed at our institution; date of removal (if applicable) was determined from chart abstraction. For the vast majority of patients whose CVCs were placed at outside facilities, date of placement was available in the EHR (often in the admission note or in the ultrasound report/reason for study). If date of line placement at an outside facility was not known, date of admission was used. The University of Washington Human Subjects Board approved this review.

RESULTS

DISCUSSION

UEDVT is increasingly recognized in hospitalized patients.[3, 9] At our medical center, 0.2% of symptomatic inpatients were diagnosed with UEDVT over 14 months. These patients were predominantly men with high rates of CVCs, malignancy, VTE history, severe infection, and renal disease. Interestingly, although the literature suggests that some proportion of patients with UEDVT have anatomic abnormalities, such as Paget‐Schroetter syndrome,[15] none of the patients in our study were found to have these anomalies. In our review, hospitalized patients with UEDVT were critically ill, with a long LOS and high morbidity and mortality, suggesting that in addition to just being a complication of hospitalization,[1, 6] UEDVT may be a marker of severe illness.

In our institution, clinical presentation was consistent with what has been described with the majority of patients presenting with upper extremity swelling.[1, 3] The internal jugular veins were the most common anatomic UEDVT site, followed by brachial then axillary veins. In other series including both in‐ and outpatients, subclavian clots were most commonly diagnosed, reflecting in part higher rates of CVC association and CVC location in those studies.[3, 9] Concurrent DVT and PE rates were similar to those reported.[1, 3, 10]

Although many studies have focused on prevention of LEDVT and PE, few trials have specifically targeted UEDVT. Among our patients with UEDVTs that were not present on admission, VTE prophylaxis rates were considerably higher than what has been reported,[1, 6] suggesting that in these critically ill patients' prophylaxis may not prevent symptomatic UEDVT. It is unknown how many UEDVTs were prevented with prophylaxis, as only patients with symptomatic UEDVT were included. Adequacy of prophylaxis at outside hospitals for patients transferred in could not be assessed. Nonetheless, low numbers of UEDVT at a trauma referral center with many high‐risk patients raise the question of whether prophylaxis makes a difference. Additional study is needed to further define the role of chemoprophylaxis to prevent UEDVT in hospitalized patients.

In our inpatient group, 84% required CVCs; 44% of patients were thought to have CVC‐associated UEDVTs. Careful patient selection and attention to potentially modifiable risks, such as insertion site, catheter type, and tip position, may need further examination in this population.[3, 11, 16] Catheter duration was long; focus on removing CVCs when no longer necessary is important. Interestingly, almost 10% in our study underwent diagnostic ultrasound because a new CVC could not be successfully placed suggesting that UEDVT may develop in critically ill patients regardless of CVCs.

In our study, there were high rates of guideline‐recommended pharmacologic treatment; surprisingly the majority of CVCs with associated clot were removed. Guidelines currently support 3 months of anticoagulation for treatment of UEDVT[2, 13, 17]; evidence derives from observational trials or is largely extrapolated from LEDVT literature.[2, 13] Routine CVC removal is not specifically recommended for CVC‐associated UEDVT, particularly if lines remain functional and medically necessary; systemic anticoagulation should be provided.[13]

In our review, no hospitalized patients with UEDVT developed complications or were readmitted to our medical center within 30 days for clot progression, new PE, or post‐thrombotic syndrome, which is lower than rates reported over longer time periods.[2, 6, 10, 12] Ten percent died during hospitalization, all from their primary disease rather than from complications of VTE or VTE treatment, and no additional patients died at our institution within 30 days. Although these rates are lower than have been otherwise reported,[2, 10] the inpatient mortality rate is similar to a recent study that included inpatients; however, all patients who died in that study had cancer and CVCs.[3] In the latter study, 6.4% died within 30 days of discharge.

CONCLUSIONS

Among hospitalized patients, UEDVT is increasingly recognized. In our medical center, hospitalized patients diagnosed with UEDVT were more likely to have CVCs, malignancy, renal disease, and severe infection. Many of these patients were transferred critically ill, had prolonged LOS, and had high in‐hospital mortality. Most developed UEDVT despite prophylaxis, and the majority of UEDVTs were treated even in the absence of concurrent LEDVT or PE. As we move toward an era of increasing accountability, with a focus on preventing hospital‐acquired conditions including VTE, additional research is needed to identify modifiable risks, explore opportunities for effective prevention, and optimize outcomes such as prevention of complications or readmissions, particularly in critically ill patients with UEDVT.

Increasingly, there is a focus on prevention of hospital‐acquired conditions including venous thromboembolism (VTE). Many studies have evaluated pulmonary embolism (PE) and lower extremity deep vein thrombosis (LEDVT), but despite increasing recognition of upper extremity deep vein thrombosis (UEDVT),[1, 2, 3, 4] less is known about this condition in hospitalized patients.

UEDVTs may be classified as primary, including disorders such as Paget‐Schroetter syndrome or other structural abnormality, or may be idiopathic; the majority are secondary clots.[5] Conventional risk factors for LEDVT including older age and obesity have been found to be less commonly associated,[1, 2, 5, 6, 7] and patients with UEDVT are generally younger, leaner, and a higher proportion are men. They are more likely to have malignancy or history of VTE and have undergone recent surgery or intensive care unit stay.[1, 2, 6] Central venous catheters (CVCs), often used in hospitalized patients, remain among the biggest known risks for UEDVT[1, 2, 3, 7, 8, 9, 10]; concomitant malignancy, VTE history, severe infection, surgery lasting >1 hour, and length of stay (LOS) >10 days confer additional risks with CVCs.[6, 7, 8, 11]

UEDVTs, once thought to be relatively benign, are now recognized to result in complications including PE, progression, recurrence, and post‐thrombotic syndrome.[2, 4, 12, 13] Despite extensive efforts to increase appropriate VTE prophylaxis in inpatients,[14] the role of chemoprophylaxis to prevent UEDVT remains undefined. Current guidelines recommend anticoagulation for treatment and complication prevention,[13, 15] but to date the evidence derives largely from observational studies or is extrapolated from the LEDVT literature.[2, 13]

To improve understanding of UEDVT at our institution, we set out to (1) determine UEDVT incidence in hospitalized patients, (2) describe associated risks and outcomes, and (3) assess management during hospitalization and at discharge.

METHODS

We identified all consecutive adult patients diagnosed with Doppler ultrasound‐confirmed UEDVT during hospitalization at Harborview Medical Center between September 2011 and November 2012. For patients who were readmitted during the study period, the first of their hospitalizations was used to describe associated factors, management, and outcomes. We present characteristics of all other hospitalizations during this time period for comparison. Harborview is a 413‐bed academic tertiary referral center and the only level 1 trauma center in a 5‐state area. Patients with UEDVT were identified using an information technology (IT) tool (the Harborview VTE tool) (Figure 1), which captures VTE events from vascular laboratory and radiology studies using natural language processing. Doppler ultrasound to assess for deep vein thrombosis (DVT) and computed tomographic scans to diagnose PE were ordered by inpatient physicians for symptomatic patients. The reason for obtaining the study is included in the ultrasound reports. We do not routinely screen for UEDVT at our institution. UEDVT included clots in the deep veins of the upper extremities including internal jugular, subclavian, axillary, and brachial veins. Superficial thrombosis and thrombophlebitis were excluded. We previously compared VTE events captured by this tool with administrative billing data and found that all VTE events that were coded were captured with the tool.

Figure 1

The VTE tool (Figure 1) displays imaging results together with demographic, clinical, and medication data and links this information with admission, discharge, and death summaries as well as CVC insertion procedure notes from the electronic health record (EHR). Additional data, including comorbid conditions, primary reason for hospitalization, past medical history such as prior VTE events, and cause of death (if not available in the admission note or discharge/death summaries), were obtained from EHR abstraction by 1 of the investigators. A 10% random sample of charts was rereviewed by another investigator with complete concordance. Supplementary data about date of CVC insertion if placed at an outside facility, date of CVC removal if applicable, clinical assessments regarding whether a clot was CVC‐associated, and contraindications to therapeutic anticoagulation were also abstracted directly from the EHR. Administrative data were used to identify the case mix index, an indicator of severity of illness.

Pharmacologic VTE prophylaxis included all chemical prophylaxis specified on our institutional guideline, most commonly subcutaneous unfractionated heparin 5000 units every 8 hours or low molecular weight heparin (LMWH), either enoxaparin 40 mg every 12 or 24 hours or dalteparin 5000 units every 24 hours. Mechanical prophylaxis was defined as use of sequential compression devices (SCDs) when pharmacologic prophylaxis was contraindicated. Prophylaxis was considered to be appropriate if it was applied according to our guideline for >90% of hospital days prior to UEDVT diagnosis. Therapeutic anticoagulation included heparin bridging (most commonly continuous heparin infusion, LMWH 1 mg/kg or dalteparin) as well as oral vitamin K antagonists. The VTE tool (Figure 1) allows identification of pharmacologic prophylaxis and therapy that is actually administered (not just ordered) directly from our pharmacy IT system. SCD application (not just ordered SCDs) is electronically integrated into the tool from nursing documentation.

CVCs included internal jugular or subclavian triple lumen catheters, tunneled dialysis catheters, or peripherally inserted central catheters (PICCs), single or double lumen. Criteria used to identify that a UEDVT was CVC‐associated included temporal relationship (CVC was placed prior to clot diagnosis), plausibility (ipsilateral clot), evidence of clot surrounding CVC on ultrasound, and physician designation of association (as documented in progress notes or discharge summary).

Simple percentages of patient characteristics, associated factors, management, and outcomes were calculated using counts as the numerator and number of patients as the denominator. For information about UEDVTs, we used total number of UEDVTs as the denominator. Line days were day counts from insertion until removal if applicable. The CVC placement date was available in our mandated central line placement procedure notes (directly accessed from the VTE tool) for all lines placed at our institution; date of removal (if applicable) was determined from chart abstraction. For the vast majority of patients whose CVCs were placed at outside facilities, date of placement was available in the EHR (often in the admission note or in the ultrasound report/reason for study). If date of line placement at an outside facility was not known, date of admission was used. The University of Washington Human Subjects Board approved this review.

RESULTS

DISCUSSION

UEDVT is increasingly recognized in hospitalized patients.[3, 9] At our medical center, 0.2% of symptomatic inpatients were diagnosed with UEDVT over 14 months. These patients were predominantly men with high rates of CVCs, malignancy, VTE history, severe infection, and renal disease. Interestingly, although the literature suggests that some proportion of patients with UEDVT have anatomic abnormalities, such as Paget‐Schroetter syndrome,[15] none of the patients in our study were found to have these anomalies. In our review, hospitalized patients with UEDVT were critically ill, with a long LOS and high morbidity and mortality, suggesting that in addition to just being a complication of hospitalization,[1, 6] UEDVT may be a marker of severe illness.

In our institution, clinical presentation was consistent with what has been described with the majority of patients presenting with upper extremity swelling.[1, 3] The internal jugular veins were the most common anatomic UEDVT site, followed by brachial then axillary veins. In other series including both in‐ and outpatients, subclavian clots were most commonly diagnosed, reflecting in part higher rates of CVC association and CVC location in those studies.[3, 9] Concurrent DVT and PE rates were similar to those reported.[1, 3, 10]

Although many studies have focused on prevention of LEDVT and PE, few trials have specifically targeted UEDVT. Among our patients with UEDVTs that were not present on admission, VTE prophylaxis rates were considerably higher than what has been reported,[1, 6] suggesting that in these critically ill patients' prophylaxis may not prevent symptomatic UEDVT. It is unknown how many UEDVTs were prevented with prophylaxis, as only patients with symptomatic UEDVT were included. Adequacy of prophylaxis at outside hospitals for patients transferred in could not be assessed. Nonetheless, low numbers of UEDVT at a trauma referral center with many high‐risk patients raise the question of whether prophylaxis makes a difference. Additional study is needed to further define the role of chemoprophylaxis to prevent UEDVT in hospitalized patients.

In our inpatient group, 84% required CVCs; 44% of patients were thought to have CVC‐associated UEDVTs. Careful patient selection and attention to potentially modifiable risks, such as insertion site, catheter type, and tip position, may need further examination in this population.[3, 11, 16] Catheter duration was long; focus on removing CVCs when no longer necessary is important. Interestingly, almost 10% in our study underwent diagnostic ultrasound because a new CVC could not be successfully placed suggesting that UEDVT may develop in critically ill patients regardless of CVCs.

In our study, there were high rates of guideline‐recommended pharmacologic treatment; surprisingly the majority of CVCs with associated clot were removed. Guidelines currently support 3 months of anticoagulation for treatment of UEDVT[2, 13, 17]; evidence derives from observational trials or is largely extrapolated from LEDVT literature.[2, 13] Routine CVC removal is not specifically recommended for CVC‐associated UEDVT, particularly if lines remain functional and medically necessary; systemic anticoagulation should be provided.[13]

In our review, no hospitalized patients with UEDVT developed complications or were readmitted to our medical center within 30 days for clot progression, new PE, or post‐thrombotic syndrome, which is lower than rates reported over longer time periods.[2, 6, 10, 12] Ten percent died during hospitalization, all from their primary disease rather than from complications of VTE or VTE treatment, and no additional patients died at our institution within 30 days. Although these rates are lower than have been otherwise reported,[2, 10] the inpatient mortality rate is similar to a recent study that included inpatients; however, all patients who died in that study had cancer and CVCs.[3] In the latter study, 6.4% died within 30 days of discharge.

CONCLUSIONS

Among hospitalized patients, UEDVT is increasingly recognized. In our medical center, hospitalized patients diagnosed with UEDVT were more likely to have CVCs, malignancy, renal disease, and severe infection. Many of these patients were transferred critically ill, had prolonged LOS, and had high in‐hospital mortality. Most developed UEDVT despite prophylaxis, and the majority of UEDVTs were treated even in the absence of concurrent LEDVT or PE. As we move toward an era of increasing accountability, with a focus on preventing hospital‐acquired conditions including VTE, additional research is needed to identify modifiable risks, explore opportunities for effective prevention, and optimize outcomes such as prevention of complications or readmissions, particularly in critically ill patients with UEDVT.

Since Wachter and Goldman coined the term hospitalist in 1996,[1] the number of hospitalists in the United States has grown rapidly, to more than 30,000 in recent estimates, with at least 80% of hospitals with 200 beds or more having hospital medicine programs.[2] A number of factors have led to the growth of such programs. First, hospital‐level incentives to use hospitalists exist to improve patient flow and maximize bed use, thereby reducing length of stay (LOS) and improving efficiency. Hospitals also employ hospitalists to address limitations on the number of hours that medical residents can work. Second, the use of hospitalists allows primary care physicians (PCPs) to focus their practices on outpatient care, thus avoiding the complexity of hospital‐based medicine, which requires both hospital‐focused clinical skills as well as institutional knowledge. Supporters of the hospitalist movement claim that hospitalists can improve efficiency and quality of care because hospitalists (1) have more experience managing inpatient care, (2) are more available to patients, and (3) have greater commitment to hospital quality improvements than (nonemployed) community PCPs.[3, 4, 5] On the other hand, criticisms of hospitalists include concerns related to (1) discontinuity in care and patient handoffs, (2) patient dissatisfaction at being treated by someone other than their PCP, (3) loss of acute care skills by PCPs, and (4) hospitalist burnout due to large workloads and poor institutional support.[3, 4, 5]

Hospitalists have been shown to have an effect on lowering total patient costs through better resource utilization and reduced LOS.[6, 7, 8, 9] There is no clear agreement, however, that hospitalists more often implement guideline‐recommended care.[10, 11, 12] In fact, most evaluations have found no significant differences between mortality and readmission rates among hospitalist and nonhospitalist groups.[12, 13, 14, 15, 16] The majority of these studies, however, were conducted in individual institutions or with small sample sizes, thus limiting their generalizability.

As 1 of the fastest‐growing medical specialties, hospitalists have assumed a significant role in inpatient care. The Centers for Medicare and Medicaid Services (CMS) have identified heart failure (HF), acute myocardial infarction (AMI), and pneumonia (PN) as important inpatient conditions associated with substantial morbidity and mortality among the Medicare population. Further, Jencks et al.[17] found that nearly one‐fifth of Medicare beneficiaries discharged from a hospital were readmitted within 30 days, which incurred an estimated cost to Medicare of $17.4 billion in 2004. Hospital readmission is of particular importance under healthcare reform because CMS introduced financial penalties in 2013 for hospitals with excessive readmission rates. The reimbursement penalty related to readmissions is included in the Patient Protection and Affordable Care Act and will be gradually expanded across many other outcomes.[18]

METHODS

RESULTS

DISCUSSION

Most previous studies have used patient‐level data from single institutions, and have shown inconsistent association between hospitalist care and clinical outcomes. Only a few studies have been conducted at the national level, and we know of only 1 that uses the same types of clinical outcomes as in our approach. In particular, Goodrich et al. conducted an in‐depth survey of hospitalist programs, and found that hospitalist presence had a significant association with HF readmissions.[29] Our results, similar to those of Goodrich et al., showed that the presence of hospitalists was not associated with risk‐standardized, 30‐day, all‐cause predicted excess mortality rates for Medicare patients hospitalized for any of these 3 conditions. The presence of hospitalists was, however, associated with lower‐risk standardized, 30‐day, all‐cause predicted excess readmission rates in our study. Our analyses resulted in somewhat different coefficients than Goodrich et al., but that is most likely due to: (1) different sample sizes, (2) use of similar yet not identical control variables, and (3) reporting error, as we used different sets of self‐reported data to indicate hospitalist services. The presence of a hospital‐level association with inconclusive patient‐level evidence suggests that there may be a more nuanced relationship between hospitalists and quality of care than has been previously explored.

This result may be explained by a number of reasons, the first of which is that hospitalists generally have more experience in the increasingly specialized practice of hospital‐based medicine than PCPs or nonhospitalists. For example, Meltzer et al.[30] found that hospitalists have more experience than nonhospitalists in treating acute manifestations of cardiovascular and respiratory diseases. Even though we might expect that greater experience with hospital‐based medicine would be associated with lower mortality rates, this outcome may not be captured because mortality is a rare event in the reported 30‐day postdischarge period and may be less preventable than readmission. There are a number of other factors possibly affecting hospital readmission, such as inadequate information transfer by discharge planners, poor patient compliance, inadequate follow‐up, insufficient use of family caregivers, deterioration of a patient's clinical condition, and medical errors.[31]

Studies have found that hospitalists have had positive effects related to managing case complexity and navigating the discharge process, perhaps due to their increased availability to patients and commitment to hospital quality improvements.[16, 32] Some determinants of patient outcomes may be difficult for hospitalists to influence, however, such as poor patient compliance or lack of support by family caregivers. Hospitalists who have extensive discharge experience may understand key challenges and adopt strategies to ameliorate these negative effects, for instance by using appropriate motivational strategies to encourage compliance and capitalizing on family caregivers.[33] Being located in the hospital, hospitalists are more available to deal with emergencies that occur during the hospitalization, and may be more available and active in discharge planning. Benbassat and Taragin[34] found that between 9% and 48% of all readmissions were preventable because they were associated with indicators of substandard care during the index hospitalization. They further estimated between 12% and 75% more readmissions could have been prevented by implementing patient education, predischarge assessment, and at‐home aftercare programs. Hospitalists are in a unique position to use their specialized training to improve transitions from hospital to home, communicate needs with the family and caregivers during the index hospitalization, and ensure that adequate postdischarge care is received. Although the use of hospitalists creates another handoff in the transition between inpatient and outpatient settings, hospitalist care may have a positive effect on many of the determinants of readmission sufficient to overcome that discontinuity.

Quality of care may also be affected by tertiary factors such as hospital administration or organizational culture. Lower AMI mortality has been associated with factors beyond cardiologist care, including organizational behavior and the appointment of physician and nurse champions.[35] Although the exact mechanism is unclear, better patient outcomes may be a result of this combination of direct clinical care, care transition management, and administrative or organizational factors. The models showed several hospital and community characteristics having coefficients larger in magnitude than the hospitalist variable, including classification as a teaching hospital, region, and hospital county median income. Teaching hospitals have been shown to have varying effects on quality of care depending on the type of care being provided, and teaching status may also be a proxy for factors related to organizational culture or mission.[36] Community‐level contextual factors including poverty and income have been shown previously to be related to readmission rates, possibly due to lack of social support and financial resources in the community to help discharged patients manage their healthcare needs in community settings.

CONCLUSION

Reducing medical errors and improving patient outcomes are becoming more important in light of increased reporting of hospital performance and outcome measures. Post‐discharge 30‐day mortality and hospital readmission represent 2 major undesirable patient outcomes, and Medicare's new pay‐for‐performance initiatives only provide further incentives for hospitals to take action in reducing these rates. Because the likelihood of receiving inpatient care provided by a hospitalist has significantly increased among Medicare patients since the 1990s,[39] hospitalists have become important players in potentially reducing mortality and readmission for patients discharged from inpatient settings. This study has shown that use of hospitalists may be associated with lower hospital readmissions, a clear quality measure, but are not associated with any changes in 30‐day mortality.

Further studies are needed, however, to better characterize and validate the observed associations, as well as to determine how hospitalist programs can be enhanced to improve inpatient care quality. Case studies could be carried out within hospitals with high‐ and low‐performing hospitalist services to help identify key aspects of hospitalist care most closely associated with desirable outcomes. Discharge and transitional care processes could also be standardized according to best practices, with their implementation tailored to individual hospital settings. Finally, as patient‐level data become increasingly available, researchers should merge these data with hospital‐level data to assess more robustly the multilevel effect of hospitalists on inpatient quality of care and individual patient outcomes. Such information will be valuable to policymakers and health administrators alike in the ongoing and volatile economic and political environment surrounding healthcare.

Since Wachter and Goldman coined the term hospitalist in 1996,[1] the number of hospitalists in the United States has grown rapidly, to more than 30,000 in recent estimates, with at least 80% of hospitals with 200 beds or more having hospital medicine programs.[2] A number of factors have led to the growth of such programs. First, hospital‐level incentives to use hospitalists exist to improve patient flow and maximize bed use, thereby reducing length of stay (LOS) and improving efficiency. Hospitals also employ hospitalists to address limitations on the number of hours that medical residents can work. Second, the use of hospitalists allows primary care physicians (PCPs) to focus their practices on outpatient care, thus avoiding the complexity of hospital‐based medicine, which requires both hospital‐focused clinical skills as well as institutional knowledge. Supporters of the hospitalist movement claim that hospitalists can improve efficiency and quality of care because hospitalists (1) have more experience managing inpatient care, (2) are more available to patients, and (3) have greater commitment to hospital quality improvements than (nonemployed) community PCPs.[3, 4, 5] On the other hand, criticisms of hospitalists include concerns related to (1) discontinuity in care and patient handoffs, (2) patient dissatisfaction at being treated by someone other than their PCP, (3) loss of acute care skills by PCPs, and (4) hospitalist burnout due to large workloads and poor institutional support.[3, 4, 5]

Hospitalists have been shown to have an effect on lowering total patient costs through better resource utilization and reduced LOS.[6, 7, 8, 9] There is no clear agreement, however, that hospitalists more often implement guideline‐recommended care.[10, 11, 12] In fact, most evaluations have found no significant differences between mortality and readmission rates among hospitalist and nonhospitalist groups.[12, 13, 14, 15, 16] The majority of these studies, however, were conducted in individual institutions or with small sample sizes, thus limiting their generalizability.

As 1 of the fastest‐growing medical specialties, hospitalists have assumed a significant role in inpatient care. The Centers for Medicare and Medicaid Services (CMS) have identified heart failure (HF), acute myocardial infarction (AMI), and pneumonia (PN) as important inpatient conditions associated with substantial morbidity and mortality among the Medicare population. Further, Jencks et al.[17] found that nearly one‐fifth of Medicare beneficiaries discharged from a hospital were readmitted within 30 days, which incurred an estimated cost to Medicare of $17.4 billion in 2004. Hospital readmission is of particular importance under healthcare reform because CMS introduced financial penalties in 2013 for hospitals with excessive readmission rates. The reimbursement penalty related to readmissions is included in the Patient Protection and Affordable Care Act and will be gradually expanded across many other outcomes.[18]

METHODS

RESULTS

DISCUSSION

Most previous studies have used patient‐level data from single institutions, and have shown inconsistent association between hospitalist care and clinical outcomes. Only a few studies have been conducted at the national level, and we know of only 1 that uses the same types of clinical outcomes as in our approach. In particular, Goodrich et al. conducted an in‐depth survey of hospitalist programs, and found that hospitalist presence had a significant association with HF readmissions.[29] Our results, similar to those of Goodrich et al., showed that the presence of hospitalists was not associated with risk‐standardized, 30‐day, all‐cause predicted excess mortality rates for Medicare patients hospitalized for any of these 3 conditions. The presence of hospitalists was, however, associated with lower‐risk standardized, 30‐day, all‐cause predicted excess readmission rates in our study. Our analyses resulted in somewhat different coefficients than Goodrich et al., but that is most likely due to: (1) different sample sizes, (2) use of similar yet not identical control variables, and (3) reporting error, as we used different sets of self‐reported data to indicate hospitalist services. The presence of a hospital‐level association with inconclusive patient‐level evidence suggests that there may be a more nuanced relationship between hospitalists and quality of care than has been previously explored.

This result may be explained by a number of reasons, the first of which is that hospitalists generally have more experience in the increasingly specialized practice of hospital‐based medicine than PCPs or nonhospitalists. For example, Meltzer et al.[30] found that hospitalists have more experience than nonhospitalists in treating acute manifestations of cardiovascular and respiratory diseases. Even though we might expect that greater experience with hospital‐based medicine would be associated with lower mortality rates, this outcome may not be captured because mortality is a rare event in the reported 30‐day postdischarge period and may be less preventable than readmission. There are a number of other factors possibly affecting hospital readmission, such as inadequate information transfer by discharge planners, poor patient compliance, inadequate follow‐up, insufficient use of family caregivers, deterioration of a patient's clinical condition, and medical errors.[31]

Studies have found that hospitalists have had positive effects related to managing case complexity and navigating the discharge process, perhaps due to their increased availability to patients and commitment to hospital quality improvements.[16, 32] Some determinants of patient outcomes may be difficult for hospitalists to influence, however, such as poor patient compliance or lack of support by family caregivers. Hospitalists who have extensive discharge experience may understand key challenges and adopt strategies to ameliorate these negative effects, for instance by using appropriate motivational strategies to encourage compliance and capitalizing on family caregivers.[33] Being located in the hospital, hospitalists are more available to deal with emergencies that occur during the hospitalization, and may be more available and active in discharge planning. Benbassat and Taragin[34] found that between 9% and 48% of all readmissions were preventable because they were associated with indicators of substandard care during the index hospitalization. They further estimated between 12% and 75% more readmissions could have been prevented by implementing patient education, predischarge assessment, and at‐home aftercare programs. Hospitalists are in a unique position to use their specialized training to improve transitions from hospital to home, communicate needs with the family and caregivers during the index hospitalization, and ensure that adequate postdischarge care is received. Although the use of hospitalists creates another handoff in the transition between inpatient and outpatient settings, hospitalist care may have a positive effect on many of the determinants of readmission sufficient to overcome that discontinuity.

Quality of care may also be affected by tertiary factors such as hospital administration or organizational culture. Lower AMI mortality has been associated with factors beyond cardiologist care, including organizational behavior and the appointment of physician and nurse champions.[35] Although the exact mechanism is unclear, better patient outcomes may be a result of this combination of direct clinical care, care transition management, and administrative or organizational factors. The models showed several hospital and community characteristics having coefficients larger in magnitude than the hospitalist variable, including classification as a teaching hospital, region, and hospital county median income. Teaching hospitals have been shown to have varying effects on quality of care depending on the type of care being provided, and teaching status may also be a proxy for factors related to organizational culture or mission.[36] Community‐level contextual factors including poverty and income have been shown previously to be related to readmission rates, possibly due to lack of social support and financial resources in the community to help discharged patients manage their healthcare needs in community settings.

CONCLUSION

Reducing medical errors and improving patient outcomes are becoming more important in light of increased reporting of hospital performance and outcome measures. Post‐discharge 30‐day mortality and hospital readmission represent 2 major undesirable patient outcomes, and Medicare's new pay‐for‐performance initiatives only provide further incentives for hospitals to take action in reducing these rates. Because the likelihood of receiving inpatient care provided by a hospitalist has significantly increased among Medicare patients since the 1990s,[39] hospitalists have become important players in potentially reducing mortality and readmission for patients discharged from inpatient settings. This study has shown that use of hospitalists may be associated with lower hospital readmissions, a clear quality measure, but are not associated with any changes in 30‐day mortality.

Further studies are needed, however, to better characterize and validate the observed associations, as well as to determine how hospitalist programs can be enhanced to improve inpatient care quality. Case studies could be carried out within hospitals with high‐ and low‐performing hospitalist services to help identify key aspects of hospitalist care most closely associated with desirable outcomes. Discharge and transitional care processes could also be standardized according to best practices, with their implementation tailored to individual hospital settings. Finally, as patient‐level data become increasingly available, researchers should merge these data with hospital‐level data to assess more robustly the multilevel effect of hospitalists on inpatient quality of care and individual patient outcomes. Such information will be valuable to policymakers and health administrators alike in the ongoing and volatile economic and political environment surrounding healthcare.

Since Wachter and Goldman coined the term hospitalist in 1996,[1] the number of hospitalists in the United States has grown rapidly, to more than 30,000 in recent estimates, with at least 80% of hospitals with 200 beds or more having hospital medicine programs.[2] A number of factors have led to the growth of such programs. First, hospital‐level incentives to use hospitalists exist to improve patient flow and maximize bed use, thereby reducing length of stay (LOS) and improving efficiency. Hospitals also employ hospitalists to address limitations on the number of hours that medical residents can work. Second, the use of hospitalists allows primary care physicians (PCPs) to focus their practices on outpatient care, thus avoiding the complexity of hospital‐based medicine, which requires both hospital‐focused clinical skills as well as institutional knowledge. Supporters of the hospitalist movement claim that hospitalists can improve efficiency and quality of care because hospitalists (1) have more experience managing inpatient care, (2) are more available to patients, and (3) have greater commitment to hospital quality improvements than (nonemployed) community PCPs.[3, 4, 5] On the other hand, criticisms of hospitalists include concerns related to (1) discontinuity in care and patient handoffs, (2) patient dissatisfaction at being treated by someone other than their PCP, (3) loss of acute care skills by PCPs, and (4) hospitalist burnout due to large workloads and poor institutional support.[3, 4, 5]

Hospitalists have been shown to have an effect on lowering total patient costs through better resource utilization and reduced LOS.[6, 7, 8, 9] There is no clear agreement, however, that hospitalists more often implement guideline‐recommended care.[10, 11, 12] In fact, most evaluations have found no significant differences between mortality and readmission rates among hospitalist and nonhospitalist groups.[12, 13, 14, 15, 16] The majority of these studies, however, were conducted in individual institutions or with small sample sizes, thus limiting their generalizability.

As 1 of the fastest‐growing medical specialties, hospitalists have assumed a significant role in inpatient care. The Centers for Medicare and Medicaid Services (CMS) have identified heart failure (HF), acute myocardial infarction (AMI), and pneumonia (PN) as important inpatient conditions associated with substantial morbidity and mortality among the Medicare population. Further, Jencks et al.[17] found that nearly one‐fifth of Medicare beneficiaries discharged from a hospital were readmitted within 30 days, which incurred an estimated cost to Medicare of $17.4 billion in 2004. Hospital readmission is of particular importance under healthcare reform because CMS introduced financial penalties in 2013 for hospitals with excessive readmission rates. The reimbursement penalty related to readmissions is included in the Patient Protection and Affordable Care Act and will be gradually expanded across many other outcomes.[18]

METHODS

RESULTS

DISCUSSION

Most previous studies have used patient‐level data from single institutions, and have shown inconsistent association between hospitalist care and clinical outcomes. Only a few studies have been conducted at the national level, and we know of only 1 that uses the same types of clinical outcomes as in our approach. In particular, Goodrich et al. conducted an in‐depth survey of hospitalist programs, and found that hospitalist presence had a significant association with HF readmissions.[29] Our results, similar to those of Goodrich et al., showed that the presence of hospitalists was not associated with risk‐standardized, 30‐day, all‐cause predicted excess mortality rates for Medicare patients hospitalized for any of these 3 conditions. The presence of hospitalists was, however, associated with lower‐risk standardized, 30‐day, all‐cause predicted excess readmission rates in our study. Our analyses resulted in somewhat different coefficients than Goodrich et al., but that is most likely due to: (1) different sample sizes, (2) use of similar yet not identical control variables, and (3) reporting error, as we used different sets of self‐reported data to indicate hospitalist services. The presence of a hospital‐level association with inconclusive patient‐level evidence suggests that there may be a more nuanced relationship between hospitalists and quality of care than has been previously explored.

This result may be explained by a number of reasons, the first of which is that hospitalists generally have more experience in the increasingly specialized practice of hospital‐based medicine than PCPs or nonhospitalists. For example, Meltzer et al.[30] found that hospitalists have more experience than nonhospitalists in treating acute manifestations of cardiovascular and respiratory diseases. Even though we might expect that greater experience with hospital‐based medicine would be associated with lower mortality rates, this outcome may not be captured because mortality is a rare event in the reported 30‐day postdischarge period and may be less preventable than readmission. There are a number of other factors possibly affecting hospital readmission, such as inadequate information transfer by discharge planners, poor patient compliance, inadequate follow‐up, insufficient use of family caregivers, deterioration of a patient's clinical condition, and medical errors.[31]

Studies have found that hospitalists have had positive effects related to managing case complexity and navigating the discharge process, perhaps due to their increased availability to patients and commitment to hospital quality improvements.[16, 32] Some determinants of patient outcomes may be difficult for hospitalists to influence, however, such as poor patient compliance or lack of support by family caregivers. Hospitalists who have extensive discharge experience may understand key challenges and adopt strategies to ameliorate these negative effects, for instance by using appropriate motivational strategies to encourage compliance and capitalizing on family caregivers.[33] Being located in the hospital, hospitalists are more available to deal with emergencies that occur during the hospitalization, and may be more available and active in discharge planning. Benbassat and Taragin[34] found that between 9% and 48% of all readmissions were preventable because they were associated with indicators of substandard care during the index hospitalization. They further estimated between 12% and 75% more readmissions could have been prevented by implementing patient education, predischarge assessment, and at‐home aftercare programs. Hospitalists are in a unique position to use their specialized training to improve transitions from hospital to home, communicate needs with the family and caregivers during the index hospitalization, and ensure that adequate postdischarge care is received. Although the use of hospitalists creates another handoff in the transition between inpatient and outpatient settings, hospitalist care may have a positive effect on many of the determinants of readmission sufficient to overcome that discontinuity.

Quality of care may also be affected by tertiary factors such as hospital administration or organizational culture. Lower AMI mortality has been associated with factors beyond cardiologist care, including organizational behavior and the appointment of physician and nurse champions.[35] Although the exact mechanism is unclear, better patient outcomes may be a result of this combination of direct clinical care, care transition management, and administrative or organizational factors. The models showed several hospital and community characteristics having coefficients larger in magnitude than the hospitalist variable, including classification as a teaching hospital, region, and hospital county median income. Teaching hospitals have been shown to have varying effects on quality of care depending on the type of care being provided, and teaching status may also be a proxy for factors related to organizational culture or mission.[36] Community‐level contextual factors including poverty and income have been shown previously to be related to readmission rates, possibly due to lack of social support and financial resources in the community to help discharged patients manage their healthcare needs in community settings.

CONCLUSION

Reducing medical errors and improving patient outcomes are becoming more important in light of increased reporting of hospital performance and outcome measures. Post‐discharge 30‐day mortality and hospital readmission represent 2 major undesirable patient outcomes, and Medicare's new pay‐for‐performance initiatives only provide further incentives for hospitals to take action in reducing these rates. Because the likelihood of receiving inpatient care provided by a hospitalist has significantly increased among Medicare patients since the 1990s,[39] hospitalists have become important players in potentially reducing mortality and readmission for patients discharged from inpatient settings. This study has shown that use of hospitalists may be associated with lower hospital readmissions, a clear quality measure, but are not associated with any changes in 30‐day mortality.

Further studies are needed, however, to better characterize and validate the observed associations, as well as to determine how hospitalist programs can be enhanced to improve inpatient care quality. Case studies could be carried out within hospitals with high‐ and low‐performing hospitalist services to help identify key aspects of hospitalist care most closely associated with desirable outcomes. Discharge and transitional care processes could also be standardized according to best practices, with their implementation tailored to individual hospital settings. Finally, as patient‐level data become increasingly available, researchers should merge these data with hospital‐level data to assess more robustly the multilevel effect of hospitalists on inpatient quality of care and individual patient outcomes. Such information will be valuable to policymakers and health administrators alike in the ongoing and volatile economic and political environment surrounding healthcare.

The transfusion of blood is the most frequently performed procedure in US hospitals.[1] Every year, approximately 14 million units of packed red blood cells are used,[2] and 1 in 10 hospitalized patients is transfused.[3] In a recent large retrospective analysis, the prevalence of anemia at hospital discharge was 12.8%.[4] In some patients hospitalized with heart failure or pneumonia, the prevalence of anemia may exceed 50%.[5, 6] Randomized controlled trials in multiple patient populations show that a restrictive transfusion strategy (using lower hemoglobin thresholds for transfusion) is safe and may be associated with less morbidity and mortality compared to a liberal transfusion strategy.[7, 8, 9] In a recent randomized clinical trial of patients with acute upper gastrointestinal bleeding, Villanueva and colleagues found a 4% increased risk of mortality when a liberal rather than a restrictive transfusion strategy was used.[10]

Transfusions are considered to be a high risk procedure, with morbidity and mortality increasing with each unit of blood received.[11] The costs associated with transfusion are substantial, with a median cost of $761 per unit (in 2010 dollars), which translates into >$11 billion annually for red cells alone.[12] Despite this, health outcomes research shows that more than half of red cell transfusions may be inappropriate.[13] Furthermore, there is wide variation in practice that is unexplained by patient characteristics.[14, 15] Given the financial and human costs, the status quo of overuse and practice variation is no longer acceptable.

The traditional focus of transfusion medicine, blood banks, and blood utilization committees has been on ensuring that we have an adequate supply of product (ie, blood components) and safe and reliable methods of administering the product. The work that has been done to secure the supply of blood components and the safety of transfusion is both necessary and laudable. More recently, attention has focused on the promise of a restrictive approach to transfusion.[7, 8, 9] This approach, in addition to easing the supply side, has the potential to improve patient care by avoiding transfusions in situations where the probability of harm may exceed the probability of benefit. The American Medical Association and the Joint Commission have recently identified blood transfusions as 1 of 5 overused medical procedures that pose a quality and safety concern.[16] The Society for Hospital Medicine recognizes blood overutilization as a high priority issue by urging avoidance of red blood cell transfusions for arbitrary hemoglobin levels in their Choosing Wisely campaign.[17]

A transformational next step is to move beyond the decision of whether and when to transfuse blood components and to focus on patient blood management.

WHAT IS PATIENT BLOOD MANAGEMENT?

Patient‐centered blood management (PBM) aspires to improve patient outcomes by actively managing the patient's own blood and hematopoietic system recognizing that the transfusion of blood components is but 1 of many therapeutic options. PBM is a multimodal, multidisciplinary effort and is defined as the timely application of evidence‐based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss in an effort to improve patient outcomes.[18] These principles are shown in Figure 1. PBM strategies should be implemented in surgical and nonsurgical settings in virtually all stages of patient care.[18, 19] These strategies fall into 4 general categories: anemia management, coagulation optimization, blood conservation, and patient‐centered decision making (Table 1).

Figure 1

The appropriate use of these tools as part of an evidence‐based, multidisciplinary, patient‐focused program has the potential to reduce transfusions and improve patient outcomes.[18, 19, 20] The value of PBM programs as tools for improved outcomes has been endorsed by many regulatory and professional organizations including the American Association of Blood Banks,[21] the Joint Commission,[22] and the US Department of Health and Human Services.[23] There are currently 92 self‐identified PBM Programs in the United States.[18] Internationally, initiatives are underway to bring about change and implement PBM. In 2008, the Western Australia Department of Health implemented a comprehensive health‐systemwide PBM program. As a result of this program, despite increasing activity, red blood cell utilization to the entire state progressively decreased from 70,103 units in 2008 to 65,742 units in 2011.[24]

Although transfusion rates are an easy end point to measure, PBM's ultimate aim is to improve patient outcomes, not simply lower transfusion rates. To date, randomized clinical trials have not been performed comparing patient populations managed with PBM principles to a control arm. However, in large joint arthroplasty, a PBM approach was associated with decreased length of stay, decreased readmission, in addition to a decreased transfusion rate compared to historical controls.[25] Similar findings have been described in other patient populations when comparing Jehovah's Witnesses patients to non‐Jehovah's Witnesses patients.[26]

ANEMIA MANAGEMENT

Anemia has been identified as an independent predictor of morbidity, including increased postoperative infection, length of stay, and mortality.[27] The presence of anemia is also a risk factor for blood transfusion.[22] However, transfusion has not been proven to decrease the morbidity and mortality associated with anemia. Anemia is a highly prevalent finding in both medical and surgical patients.[3] Its prevalence increases after the age 50 years, to over 20% in the elderly (85 years).[28] Patients should be screened and evaluated for anemia throughout their course of care.[20] An audit of more than 9000 patients undergoing elective orthopedic surgery found that more than one‐third of patients were considered to be anemic (hemoglobin <13 g/dL) during preadmission testing.[29] Despite the association with negative outcomes, preexisting anemia is often ignored and remains untreated.[30]

PBM includes the identification of patients at risk of anemia and development of a treatment plan. The detection, evaluation, and correction of preoperative anemia should be undertaken 3 to 4 weeks before elective surgery, so treatment can be initiated prior to surgery with appropriate therapy.[31] Management of anemia consists of treating the underlying cause and use of hematinic agents to rapidly restore hemoglobin levels to normal.[20] Anemia therapy, which often includes iron supplementation and erythropoietic‐stimulating drugs, increases red blood cell mass, thus reducing or eliminating the need for allogenic blood.[32] An overview of the management of preoperative anemia can be found in Figure 2.

Figure 2

Available evidence suggests that in many clinical situations, transfusion of red blood cells for modest anemia does not improve outcomes and may cause harm.[7, 8, 9, 10] Although using transfusion trigger hemoglobin levels of 7 to 8 g/dL appears to be preferable to using triggers of 9 to 10 g/dL, we have no high‐quality evidence to suggest what, if any, the optimal trigger should be. Furthermore, although the traditional rationale for red cell transfusion is to improve tissue oxygen delivery, some evidence suggests that tissue oxygen delivery is maintained even at hemoglobin levels as low as 5 g/dL.[33] Available evidence suggests that for nonhemorrhaging patients, routinely transfusing at a hemoglobin level of greater than 7 to 8 g/dL should be avoided. Whether a hemoglobin of 8, 7, 6, or 5 g/dL should serve as a trigger for transfusion is unclear. Our recommendation is to focus less on the number and more on the patient with regard to assessing symptoms and treatment preferences.

OPTIMIZING COAGULATION

Prior to surgery, patients should be screened for bleeding disorders by taking a structured bleeding history and performing coagulation testing if areas of concern arise. The first‐line coagulation tests commonly used are activated partial thromboplastin time and prothrombin time.[34] Testing may also be considered in patients with conditions potentially associated with hemorrhage such as liver disease, sepsis, diffuse intravascular coagulation, preeclampsia, cholestasis, and poor nutritional states.[35]

Point‐of‐care (POC) testing for rapid testing of hemostatic function can provide fast and accurate identification of coagulation abnormalities. Platelet function has been assessed using impedance or turbidimetric aggregometry testing of whole‐blood samples. Viscoelastic tests using thromboelastometry and thromboelastography measure time and dynamics of clot formation and stability of clots over time.[36] POC coagulation testing has shown positive outcomes in surgery, critical care, organ transplantation, and trauma patients.[36] In surgical and organ transplant patients, POC testing has been shown to lower perioperative blood losses and decrease the use of allogenic transfusions.

Protocols are needed for discontinuing drugs that may affect coagulation or increase bleeding such as warfarin, aspirin, clopidogrel, herbal supplements,[32] low molecular weight heparins, selective factor Xa inhibitors, and direct thrombin inhibitors.[36] Interruption of oral anticoagulant therapy provides gradual reduction of the coagulation effects of warfarin but provides more rapid reduction from agents such as dabigatran.[37] Warfarin‐treated patients in emergency situations, such as excessive bleeding, emergent surgery, or international normalized ratio (INR) >10 require rapid anticoagulation reversal that cannot be achieved by drug discontinuation alone. Vitamin K (phytonadione) therapy can be used in these situations and may be given intravenously or orally; however, the intramuscular and subcutaneous routes are not recommended.[37]

Fresh frozen plasma (FFP) provides fast, partial reversal of coagulopathy by replacement of factors II, VII, IX, and X; however, volume overload may make it difficult to administer an adequate FFP dose. In patients with very high INRs, replacement of hemostatic levels of these factors cannot be achieved with tolerable doses of FFP.[37] Prothrombin complex concentrates (PCC) are an alternative to FFP for reversal of warfarin and other oral anticoagulants.[37] Both 3‐factor PCC and 4‐factor PCC products are available, all containing factors II, IX, and X with variable amounts of FVII.[37] The 4 factor products provide larger amounts of factor VII compared to the 3 factor products.[37] In studies comparing PCCs to FFP, PCCs showed superior efficacy in decreasing time to INR correction, with a lower risk of thrombotic adverse events.[37]

Although some aspects of optimizing coagulation are well within the domain of hospital medicine, others require collaboration with hematology. As with all aspects of patient blood management, the optimal approach is often multidisciplinary and multimodal.

INTERDISCIPLINARY BLOOD CONSERVATION MODALITIES

The minimization of intraoperative bleeding is one of the cornerstones of effective PBM. Perioperative blood loss is an important factor in increasing postoperative morbidity and mortality.[19] Blood loss during surgery increases patient exposure to blood transfusions and their associated risks.[27] In postoperative patients, blood transfusion has been shown to be an independent risk factor for respiratory complications, infection, and intensive care unit (ICU) admissions. Patients receiving more than 2 U of blood had twice the risk of complications and ICU admissions.[39]

The management of surgical bleeding requires multiple techniques, including excellent surgical technique, the use of minimally invasive surgery, reinfusion of shed blood, and the use of topical hemostatic agents. Meticulous surgical technique is the cornerstone of intraoperative blood conservation.[32] During surgery, various techniques can be used to help decrease allogeneic blood exposure. These include techniques such as intraoperative blood recovery and acute normovolemic hemodilution.[40] Energy‐based technologies, such as electrosurgery, harmonic scalpels, argon beam coagulation, and radiofrequency technology have also been used to aid in hemostasis.[41] Interventions such as pharmacologic agents and topical hemostatic/sealant agents can also be utilized to minimize intraoperative blood loss. Not surprisingly, operative blood loss has been associated with an increased risk of death.[42] Blood loss and allogeneic blood transfusion can be greatly reduced with the utilization of an appropriate combination of therapies.

Hospital‐acquired anemia is a common complication affecting almost two‐thirds of patients admitted to the hospital. Although anemia of chronic disease is the leading cause of hospital‐acquired anemia, phlebotomy‐induced blood loss is an important contributing factor.[43] In critical care patients, phlebotomy volume is an independent predictor of transfusion requirements. On average, these patients undergo 4 to 5 blood draws per day.[44] Healthcare professionals can help decrease the development of hospital‐acquired anemia by employing strategies aimed at decreasing phlebotomy blood loss.[32] Losses in the range of 41 to 65 mL of blood per day have been reported in the medical literature and are associated with development of anemia.[45] Phlebotomy blood loss can be reduced by strategies that include eliminating arterial line blood discard, using small volume (ie, pediatric size) blood collection tubes, and ordering laboratory tests only when clinically justified.[45]

PATIENT‐CENTERED DECISION MAKING

Patient‐centered medicine is the practice of taking into account patients' individual preferences, objectives, and values.[46] Physicians are responsible for providing patients with complete and understandable information regarding treatment, and potential benefits and risks of available treatment options. Patients, in turn, must communicate their preferences and feelings with regard to their treatment.[47] A recent observational study by Weiner confirmed that employing theses practices is associated with improved health outcomes.[48]

An individualized approach to PBM helps ensure the right fit for each individual patient by informing them of risks, benefits, and alternatives of treatment choices and listening to their needs, desires, and concerns. Patients may have specific religious or cultural factors that may need to be considered. Some patients, such as Jehovah's Witnesses, decline blood products and may refuse agents derived from human or animal plasma. Some patients from other cultural or religious backgrounds may refuse agents that have factors derived from a specific animal.

Informed consent for transfusions is often obtained via a printed form offered without discussion with the patient by clerical or nursing staff. Obtaining a patient's signature to comply with Joint Commission and CMS mandates is too often the goal of this process. True informed consent requires that patients understand treatments and are informed of both the possible benefits and risks of the proposed treatment. Patients should also be informed of available treatment alternatives.[27] The benefit of transfusions are sometimes overstated, whereas the risks, such as transfusion‐related acute lung injury and transfusion‐associated circulatory overload, are often overlooked.[49] A comprehensive informed consent process, including a frank and open discussion between physician and patient, is a vital component of patient‐centered decision making.

THE HOSPITALIST'S ROLE IN PBM

Hospitalists often have the responsibility for prescribing and obtaining consent for the administration of blood components. Therefore, understanding the complexities that surround PBM and the transfusion process, including the potential for harm vs the potential for benefit, as well as the economic impact of transfusions, are essential for providing effective patient care.

Although hospitalists are not primarily based in the operating room, they are uniquely positioned to champion the value of PBM throughout their institution. Many hospitalists play a vital role in preoperative anemia detection and management via clinical and administrative roles in preadmission testing. In addition, hospitalists can serve as the connectors that bring anesthesiologists, surgeons, and others to the table to explore ways to decrease the widespread incidence of hospital‐acquired anemia. Improving perioperative blood conservation, optimizing coagulation, and managing anemia all require a multidisciplinary approach.

Hospitalists can play a major role in affecting gradual changes in organizational culture. Whether it is helping a subspecialist become comfortable with not reflexively transfusing at a threshold hemoglobin, or working with pharmacists and nurses to increase their comfort level with intravenous iron and vitamin K, a sustained effort with ongoing communication and education is required to change practice. Recognizing and engaging existing institutional stakeholders and existent efforts related to blood management (eg, transfusion committees, blood banks, blood utilization committees) is also essential to successful implementation of patient blood‐management principles. Hospitalists are often the ones who combine the credibility and the connections to the disparate stakeholders to drive the necessary culture change forward.

It is the dual role as both front‐line care provider and champion for quality improvement that uniquely positions hospitalists to lead implementation of PBM strategies. Improving quality and safety while decreasing costs, and centering decision making on the patient, are goals of effective PBM that are intimately aligned with the goals of hospital medicine. By developing, implementing, and practicing PBM, hospitalists have the opportunity to yet again lead the way in improving patient care within their organizations.

The transfusion of blood is the most frequently performed procedure in US hospitals.[1] Every year, approximately 14 million units of packed red blood cells are used,[2] and 1 in 10 hospitalized patients is transfused.[3] In a recent large retrospective analysis, the prevalence of anemia at hospital discharge was 12.8%.[4] In some patients hospitalized with heart failure or pneumonia, the prevalence of anemia may exceed 50%.[5, 6] Randomized controlled trials in multiple patient populations show that a restrictive transfusion strategy (using lower hemoglobin thresholds for transfusion) is safe and may be associated with less morbidity and mortality compared to a liberal transfusion strategy.[7, 8, 9] In a recent randomized clinical trial of patients with acute upper gastrointestinal bleeding, Villanueva and colleagues found a 4% increased risk of mortality when a liberal rather than a restrictive transfusion strategy was used.[10]

Transfusions are considered to be a high risk procedure, with morbidity and mortality increasing with each unit of blood received.[11] The costs associated with transfusion are substantial, with a median cost of $761 per unit (in 2010 dollars), which translates into >$11 billion annually for red cells alone.[12] Despite this, health outcomes research shows that more than half of red cell transfusions may be inappropriate.[13] Furthermore, there is wide variation in practice that is unexplained by patient characteristics.[14, 15] Given the financial and human costs, the status quo of overuse and practice variation is no longer acceptable.

The traditional focus of transfusion medicine, blood banks, and blood utilization committees has been on ensuring that we have an adequate supply of product (ie, blood components) and safe and reliable methods of administering the product. The work that has been done to secure the supply of blood components and the safety of transfusion is both necessary and laudable. More recently, attention has focused on the promise of a restrictive approach to transfusion.[7, 8, 9] This approach, in addition to easing the supply side, has the potential to improve patient care by avoiding transfusions in situations where the probability of harm may exceed the probability of benefit. The American Medical Association and the Joint Commission have recently identified blood transfusions as 1 of 5 overused medical procedures that pose a quality and safety concern.[16] The Society for Hospital Medicine recognizes blood overutilization as a high priority issue by urging avoidance of red blood cell transfusions for arbitrary hemoglobin levels in their Choosing Wisely campaign.[17]

A transformational next step is to move beyond the decision of whether and when to transfuse blood components and to focus on patient blood management.

WHAT IS PATIENT BLOOD MANAGEMENT?

Patient‐centered blood management (PBM) aspires to improve patient outcomes by actively managing the patient's own blood and hematopoietic system recognizing that the transfusion of blood components is but 1 of many therapeutic options. PBM is a multimodal, multidisciplinary effort and is defined as the timely application of evidence‐based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss in an effort to improve patient outcomes.[18] These principles are shown in Figure 1. PBM strategies should be implemented in surgical and nonsurgical settings in virtually all stages of patient care.[18, 19] These strategies fall into 4 general categories: anemia management, coagulation optimization, blood conservation, and patient‐centered decision making (Table 1).

Figure 1

The appropriate use of these tools as part of an evidence‐based, multidisciplinary, patient‐focused program has the potential to reduce transfusions and improve patient outcomes.[18, 19, 20] The value of PBM programs as tools for improved outcomes has been endorsed by many regulatory and professional organizations including the American Association of Blood Banks,[21] the Joint Commission,[22] and the US Department of Health and Human Services.[23] There are currently 92 self‐identified PBM Programs in the United States.[18] Internationally, initiatives are underway to bring about change and implement PBM. In 2008, the Western Australia Department of Health implemented a comprehensive health‐systemwide PBM program. As a result of this program, despite increasing activity, red blood cell utilization to the entire state progressively decreased from 70,103 units in 2008 to 65,742 units in 2011.[24]

Although transfusion rates are an easy end point to measure, PBM's ultimate aim is to improve patient outcomes, not simply lower transfusion rates. To date, randomized clinical trials have not been performed comparing patient populations managed with PBM principles to a control arm. However, in large joint arthroplasty, a PBM approach was associated with decreased length of stay, decreased readmission, in addition to a decreased transfusion rate compared to historical controls.[25] Similar findings have been described in other patient populations when comparing Jehovah's Witnesses patients to non‐Jehovah's Witnesses patients.[26]

ANEMIA MANAGEMENT

Anemia has been identified as an independent predictor of morbidity, including increased postoperative infection, length of stay, and mortality.[27] The presence of anemia is also a risk factor for blood transfusion.[22] However, transfusion has not been proven to decrease the morbidity and mortality associated with anemia. Anemia is a highly prevalent finding in both medical and surgical patients.[3] Its prevalence increases after the age 50 years, to over 20% in the elderly (85 years).[28] Patients should be screened and evaluated for anemia throughout their course of care.[20] An audit of more than 9000 patients undergoing elective orthopedic surgery found that more than one‐third of patients were considered to be anemic (hemoglobin <13 g/dL) during preadmission testing.[29] Despite the association with negative outcomes, preexisting anemia is often ignored and remains untreated.[30]

PBM includes the identification of patients at risk of anemia and development of a treatment plan. The detection, evaluation, and correction of preoperative anemia should be undertaken 3 to 4 weeks before elective surgery, so treatment can be initiated prior to surgery with appropriate therapy.[31] Management of anemia consists of treating the underlying cause and use of hematinic agents to rapidly restore hemoglobin levels to normal.[20] Anemia therapy, which often includes iron supplementation and erythropoietic‐stimulating drugs, increases red blood cell mass, thus reducing or eliminating the need for allogenic blood.[32] An overview of the management of preoperative anemia can be found in Figure 2.

Figure 2

Available evidence suggests that in many clinical situations, transfusion of red blood cells for modest anemia does not improve outcomes and may cause harm.[7, 8, 9, 10] Although using transfusion trigger hemoglobin levels of 7 to 8 g/dL appears to be preferable to using triggers of 9 to 10 g/dL, we have no high‐quality evidence to suggest what, if any, the optimal trigger should be. Furthermore, although the traditional rationale for red cell transfusion is to improve tissue oxygen delivery, some evidence suggests that tissue oxygen delivery is maintained even at hemoglobin levels as low as 5 g/dL.[33] Available evidence suggests that for nonhemorrhaging patients, routinely transfusing at a hemoglobin level of greater than 7 to 8 g/dL should be avoided. Whether a hemoglobin of 8, 7, 6, or 5 g/dL should serve as a trigger for transfusion is unclear. Our recommendation is to focus less on the number and more on the patient with regard to assessing symptoms and treatment preferences.

OPTIMIZING COAGULATION

Prior to surgery, patients should be screened for bleeding disorders by taking a structured bleeding history and performing coagulation testing if areas of concern arise. The first‐line coagulation tests commonly used are activated partial thromboplastin time and prothrombin time.[34] Testing may also be considered in patients with conditions potentially associated with hemorrhage such as liver disease, sepsis, diffuse intravascular coagulation, preeclampsia, cholestasis, and poor nutritional states.[35]

Point‐of‐care (POC) testing for rapid testing of hemostatic function can provide fast and accurate identification of coagulation abnormalities. Platelet function has been assessed using impedance or turbidimetric aggregometry testing of whole‐blood samples. Viscoelastic tests using thromboelastometry and thromboelastography measure time and dynamics of clot formation and stability of clots over time.[36] POC coagulation testing has shown positive outcomes in surgery, critical care, organ transplantation, and trauma patients.[36] In surgical and organ transplant patients, POC testing has been shown to lower perioperative blood losses and decrease the use of allogenic transfusions.

Protocols are needed for discontinuing drugs that may affect coagulation or increase bleeding such as warfarin, aspirin, clopidogrel, herbal supplements,[32] low molecular weight heparins, selective factor Xa inhibitors, and direct thrombin inhibitors.[36] Interruption of oral anticoagulant therapy provides gradual reduction of the coagulation effects of warfarin but provides more rapid reduction from agents such as dabigatran.[37] Warfarin‐treated patients in emergency situations, such as excessive bleeding, emergent surgery, or international normalized ratio (INR) >10 require rapid anticoagulation reversal that cannot be achieved by drug discontinuation alone. Vitamin K (phytonadione) therapy can be used in these situations and may be given intravenously or orally; however, the intramuscular and subcutaneous routes are not recommended.[37]

Fresh frozen plasma (FFP) provides fast, partial reversal of coagulopathy by replacement of factors II, VII, IX, and X; however, volume overload may make it difficult to administer an adequate FFP dose. In patients with very high INRs, replacement of hemostatic levels of these factors cannot be achieved with tolerable doses of FFP.[37] Prothrombin complex concentrates (PCC) are an alternative to FFP for reversal of warfarin and other oral anticoagulants.[37] Both 3‐factor PCC and 4‐factor PCC products are available, all containing factors II, IX, and X with variable amounts of FVII.[37] The 4 factor products provide larger amounts of factor VII compared to the 3 factor products.[37] In studies comparing PCCs to FFP, PCCs showed superior efficacy in decreasing time to INR correction, with a lower risk of thrombotic adverse events.[37]

Although some aspects of optimizing coagulation are well within the domain of hospital medicine, others require collaboration with hematology. As with all aspects of patient blood management, the optimal approach is often multidisciplinary and multimodal.

INTERDISCIPLINARY BLOOD CONSERVATION MODALITIES

The minimization of intraoperative bleeding is one of the cornerstones of effective PBM. Perioperative blood loss is an important factor in increasing postoperative morbidity and mortality.[19] Blood loss during surgery increases patient exposure to blood transfusions and their associated risks.[27] In postoperative patients, blood transfusion has been shown to be an independent risk factor for respiratory complications, infection, and intensive care unit (ICU) admissions. Patients receiving more than 2 U of blood had twice the risk of complications and ICU admissions.[39]

The management of surgical bleeding requires multiple techniques, including excellent surgical technique, the use of minimally invasive surgery, reinfusion of shed blood, and the use of topical hemostatic agents. Meticulous surgical technique is the cornerstone of intraoperative blood conservation.[32] During surgery, various techniques can be used to help decrease allogeneic blood exposure. These include techniques such as intraoperative blood recovery and acute normovolemic hemodilution.[40] Energy‐based technologies, such as electrosurgery, harmonic scalpels, argon beam coagulation, and radiofrequency technology have also been used to aid in hemostasis.[41] Interventions such as pharmacologic agents and topical hemostatic/sealant agents can also be utilized to minimize intraoperative blood loss. Not surprisingly, operative blood loss has been associated with an increased risk of death.[42] Blood loss and allogeneic blood transfusion can be greatly reduced with the utilization of an appropriate combination of therapies.

Hospital‐acquired anemia is a common complication affecting almost two‐thirds of patients admitted to the hospital. Although anemia of chronic disease is the leading cause of hospital‐acquired anemia, phlebotomy‐induced blood loss is an important contributing factor.[43] In critical care patients, phlebotomy volume is an independent predictor of transfusion requirements. On average, these patients undergo 4 to 5 blood draws per day.[44] Healthcare professionals can help decrease the development of hospital‐acquired anemia by employing strategies aimed at decreasing phlebotomy blood loss.[32] Losses in the range of 41 to 65 mL of blood per day have been reported in the medical literature and are associated with development of anemia.[45] Phlebotomy blood loss can be reduced by strategies that include eliminating arterial line blood discard, using small volume (ie, pediatric size) blood collection tubes, and ordering laboratory tests only when clinically justified.[45]

PATIENT‐CENTERED DECISION MAKING

Patient‐centered medicine is the practice of taking into account patients' individual preferences, objectives, and values.[46] Physicians are responsible for providing patients with complete and understandable information regarding treatment, and potential benefits and risks of available treatment options. Patients, in turn, must communicate their preferences and feelings with regard to their treatment.[47] A recent observational study by Weiner confirmed that employing theses practices is associated with improved health outcomes.[48]

An individualized approach to PBM helps ensure the right fit for each individual patient by informing them of risks, benefits, and alternatives of treatment choices and listening to their needs, desires, and concerns. Patients may have specific religious or cultural factors that may need to be considered. Some patients, such as Jehovah's Witnesses, decline blood products and may refuse agents derived from human or animal plasma. Some patients from other cultural or religious backgrounds may refuse agents that have factors derived from a specific animal.

Informed consent for transfusions is often obtained via a printed form offered without discussion with the patient by clerical or nursing staff. Obtaining a patient's signature to comply with Joint Commission and CMS mandates is too often the goal of this process. True informed consent requires that patients understand treatments and are informed of both the possible benefits and risks of the proposed treatment. Patients should also be informed of available treatment alternatives.[27] The benefit of transfusions are sometimes overstated, whereas the risks, such as transfusion‐related acute lung injury and transfusion‐associated circulatory overload, are often overlooked.[49] A comprehensive informed consent process, including a frank and open discussion between physician and patient, is a vital component of patient‐centered decision making.

THE HOSPITALIST'S ROLE IN PBM

Hospitalists often have the responsibility for prescribing and obtaining consent for the administration of blood components. Therefore, understanding the complexities that surround PBM and the transfusion process, including the potential for harm vs the potential for benefit, as well as the economic impact of transfusions, are essential for providing effective patient care.

Although hospitalists are not primarily based in the operating room, they are uniquely positioned to champion the value of PBM throughout their institution. Many hospitalists play a vital role in preoperative anemia detection and management via clinical and administrative roles in preadmission testing. In addition, hospitalists can serve as the connectors that bring anesthesiologists, surgeons, and others to the table to explore ways to decrease the widespread incidence of hospital‐acquired anemia. Improving perioperative blood conservation, optimizing coagulation, and managing anemia all require a multidisciplinary approach.

Hospitalists can play a major role in affecting gradual changes in organizational culture. Whether it is helping a subspecialist become comfortable with not reflexively transfusing at a threshold hemoglobin, or working with pharmacists and nurses to increase their comfort level with intravenous iron and vitamin K, a sustained effort with ongoing communication and education is required to change practice. Recognizing and engaging existing institutional stakeholders and existent efforts related to blood management (eg, transfusion committees, blood banks, blood utilization committees) is also essential to successful implementation of patient blood‐management principles. Hospitalists are often the ones who combine the credibility and the connections to the disparate stakeholders to drive the necessary culture change forward.

It is the dual role as both front‐line care provider and champion for quality improvement that uniquely positions hospitalists to lead implementation of PBM strategies. Improving quality and safety while decreasing costs, and centering decision making on the patient, are goals of effective PBM that are intimately aligned with the goals of hospital medicine. By developing, implementing, and practicing PBM, hospitalists have the opportunity to yet again lead the way in improving patient care within their organizations.

The transfusion of blood is the most frequently performed procedure in US hospitals.[1] Every year, approximately 14 million units of packed red blood cells are used,[2] and 1 in 10 hospitalized patients is transfused.[3] In a recent large retrospective analysis, the prevalence of anemia at hospital discharge was 12.8%.[4] In some patients hospitalized with heart failure or pneumonia, the prevalence of anemia may exceed 50%.[5, 6] Randomized controlled trials in multiple patient populations show that a restrictive transfusion strategy (using lower hemoglobin thresholds for transfusion) is safe and may be associated with less morbidity and mortality compared to a liberal transfusion strategy.[7, 8, 9] In a recent randomized clinical trial of patients with acute upper gastrointestinal bleeding, Villanueva and colleagues found a 4% increased risk of mortality when a liberal rather than a restrictive transfusion strategy was used.[10]

Transfusions are considered to be a high risk procedure, with morbidity and mortality increasing with each unit of blood received.[11] The costs associated with transfusion are substantial, with a median cost of $761 per unit (in 2010 dollars), which translates into >$11 billion annually for red cells alone.[12] Despite this, health outcomes research shows that more than half of red cell transfusions may be inappropriate.[13] Furthermore, there is wide variation in practice that is unexplained by patient characteristics.[14, 15] Given the financial and human costs, the status quo of overuse and practice variation is no longer acceptable.

The traditional focus of transfusion medicine, blood banks, and blood utilization committees has been on ensuring that we have an adequate supply of product (ie, blood components) and safe and reliable methods of administering the product. The work that has been done to secure the supply of blood components and the safety of transfusion is both necessary and laudable. More recently, attention has focused on the promise of a restrictive approach to transfusion.[7, 8, 9] This approach, in addition to easing the supply side, has the potential to improve patient care by avoiding transfusions in situations where the probability of harm may exceed the probability of benefit. The American Medical Association and the Joint Commission have recently identified blood transfusions as 1 of 5 overused medical procedures that pose a quality and safety concern.[16] The Society for Hospital Medicine recognizes blood overutilization as a high priority issue by urging avoidance of red blood cell transfusions for arbitrary hemoglobin levels in their Choosing Wisely campaign.[17]

A transformational next step is to move beyond the decision of whether and when to transfuse blood components and to focus on patient blood management.

WHAT IS PATIENT BLOOD MANAGEMENT?

Patient‐centered blood management (PBM) aspires to improve patient outcomes by actively managing the patient's own blood and hematopoietic system recognizing that the transfusion of blood components is but 1 of many therapeutic options. PBM is a multimodal, multidisciplinary effort and is defined as the timely application of evidence‐based medical and surgical concepts designed to maintain hemoglobin concentration, optimize hemostasis, and minimize blood loss in an effort to improve patient outcomes.[18] These principles are shown in Figure 1. PBM strategies should be implemented in surgical and nonsurgical settings in virtually all stages of patient care.[18, 19] These strategies fall into 4 general categories: anemia management, coagulation optimization, blood conservation, and patient‐centered decision making (Table 1).

Figure 1

The appropriate use of these tools as part of an evidence‐based, multidisciplinary, patient‐focused program has the potential to reduce transfusions and improve patient outcomes.[18, 19, 20] The value of PBM programs as tools for improved outcomes has been endorsed by many regulatory and professional organizations including the American Association of Blood Banks,[21] the Joint Commission,[22] and the US Department of Health and Human Services.[23] There are currently 92 self‐identified PBM Programs in the United States.[18] Internationally, initiatives are underway to bring about change and implement PBM. In 2008, the Western Australia Department of Health implemented a comprehensive health‐systemwide PBM program. As a result of this program, despite increasing activity, red blood cell utilization to the entire state progressively decreased from 70,103 units in 2008 to 65,742 units in 2011.[24]

Although transfusion rates are an easy end point to measure, PBM's ultimate aim is to improve patient outcomes, not simply lower transfusion rates. To date, randomized clinical trials have not been performed comparing patient populations managed with PBM principles to a control arm. However, in large joint arthroplasty, a PBM approach was associated with decreased length of stay, decreased readmission, in addition to a decreased transfusion rate compared to historical controls.[25] Similar findings have been described in other patient populations when comparing Jehovah's Witnesses patients to non‐Jehovah's Witnesses patients.[26]

ANEMIA MANAGEMENT

Anemia has been identified as an independent predictor of morbidity, including increased postoperative infection, length of stay, and mortality.[27] The presence of anemia is also a risk factor for blood transfusion.[22] However, transfusion has not been proven to decrease the morbidity and mortality associated with anemia. Anemia is a highly prevalent finding in both medical and surgical patients.[3] Its prevalence increases after the age 50 years, to over 20% in the elderly (85 years).[28] Patients should be screened and evaluated for anemia throughout their course of care.[20] An audit of more than 9000 patients undergoing elective orthopedic surgery found that more than one‐third of patients were considered to be anemic (hemoglobin <13 g/dL) during preadmission testing.[29] Despite the association with negative outcomes, preexisting anemia is often ignored and remains untreated.[30]

PBM includes the identification of patients at risk of anemia and development of a treatment plan. The detection, evaluation, and correction of preoperative anemia should be undertaken 3 to 4 weeks before elective surgery, so treatment can be initiated prior to surgery with appropriate therapy.[31] Management of anemia consists of treating the underlying cause and use of hematinic agents to rapidly restore hemoglobin levels to normal.[20] Anemia therapy, which often includes iron supplementation and erythropoietic‐stimulating drugs, increases red blood cell mass, thus reducing or eliminating the need for allogenic blood.[32] An overview of the management of preoperative anemia can be found in Figure 2.

Figure 2

Available evidence suggests that in many clinical situations, transfusion of red blood cells for modest anemia does not improve outcomes and may cause harm.[7, 8, 9, 10] Although using transfusion trigger hemoglobin levels of 7 to 8 g/dL appears to be preferable to using triggers of 9 to 10 g/dL, we have no high‐quality evidence to suggest what, if any, the optimal trigger should be. Furthermore, although the traditional rationale for red cell transfusion is to improve tissue oxygen delivery, some evidence suggests that tissue oxygen delivery is maintained even at hemoglobin levels as low as 5 g/dL.[33] Available evidence suggests that for nonhemorrhaging patients, routinely transfusing at a hemoglobin level of greater than 7 to 8 g/dL should be avoided. Whether a hemoglobin of 8, 7, 6, or 5 g/dL should serve as a trigger for transfusion is unclear. Our recommendation is to focus less on the number and more on the patient with regard to assessing symptoms and treatment preferences.

OPTIMIZING COAGULATION

Prior to surgery, patients should be screened for bleeding disorders by taking a structured bleeding history and performing coagulation testing if areas of concern arise. The first‐line coagulation tests commonly used are activated partial thromboplastin time and prothrombin time.[34] Testing may also be considered in patients with conditions potentially associated with hemorrhage such as liver disease, sepsis, diffuse intravascular coagulation, preeclampsia, cholestasis, and poor nutritional states.[35]

Point‐of‐care (POC) testing for rapid testing of hemostatic function can provide fast and accurate identification of coagulation abnormalities. Platelet function has been assessed using impedance or turbidimetric aggregometry testing of whole‐blood samples. Viscoelastic tests using thromboelastometry and thromboelastography measure time and dynamics of clot formation and stability of clots over time.[36] POC coagulation testing has shown positive outcomes in surgery, critical care, organ transplantation, and trauma patients.[36] In surgical and organ transplant patients, POC testing has been shown to lower perioperative blood losses and decrease the use of allogenic transfusions.

Protocols are needed for discontinuing drugs that may affect coagulation or increase bleeding such as warfarin, aspirin, clopidogrel, herbal supplements,[32] low molecular weight heparins, selective factor Xa inhibitors, and direct thrombin inhibitors.[36] Interruption of oral anticoagulant therapy provides gradual reduction of the coagulation effects of warfarin but provides more rapid reduction from agents such as dabigatran.[37] Warfarin‐treated patients in emergency situations, such as excessive bleeding, emergent surgery, or international normalized ratio (INR) >10 require rapid anticoagulation reversal that cannot be achieved by drug discontinuation alone. Vitamin K (phytonadione) therapy can be used in these situations and may be given intravenously or orally; however, the intramuscular and subcutaneous routes are not recommended.[37]

Fresh frozen plasma (FFP) provides fast, partial reversal of coagulopathy by replacement of factors II, VII, IX, and X; however, volume overload may make it difficult to administer an adequate FFP dose. In patients with very high INRs, replacement of hemostatic levels of these factors cannot be achieved with tolerable doses of FFP.[37] Prothrombin complex concentrates (PCC) are an alternative to FFP for reversal of warfarin and other oral anticoagulants.[37] Both 3‐factor PCC and 4‐factor PCC products are available, all containing factors II, IX, and X with variable amounts of FVII.[37] The 4 factor products provide larger amounts of factor VII compared to the 3 factor products.[37] In studies comparing PCCs to FFP, PCCs showed superior efficacy in decreasing time to INR correction, with a lower risk of thrombotic adverse events.[37]

Although some aspects of optimizing coagulation are well within the domain of hospital medicine, others require collaboration with hematology. As with all aspects of patient blood management, the optimal approach is often multidisciplinary and multimodal.

INTERDISCIPLINARY BLOOD CONSERVATION MODALITIES

The minimization of intraoperative bleeding is one of the cornerstones of effective PBM. Perioperative blood loss is an important factor in increasing postoperative morbidity and mortality.[19] Blood loss during surgery increases patient exposure to blood transfusions and their associated risks.[27] In postoperative patients, blood transfusion has been shown to be an independent risk factor for respiratory complications, infection, and intensive care unit (ICU) admissions. Patients receiving more than 2 U of blood had twice the risk of complications and ICU admissions.[39]

The management of surgical bleeding requires multiple techniques, including excellent surgical technique, the use of minimally invasive surgery, reinfusion of shed blood, and the use of topical hemostatic agents. Meticulous surgical technique is the cornerstone of intraoperative blood conservation.[32] During surgery, various techniques can be used to help decrease allogeneic blood exposure. These include techniques such as intraoperative blood recovery and acute normovolemic hemodilution.[40] Energy‐based technologies, such as electrosurgery, harmonic scalpels, argon beam coagulation, and radiofrequency technology have also been used to aid in hemostasis.[41] Interventions such as pharmacologic agents and topical hemostatic/sealant agents can also be utilized to minimize intraoperative blood loss. Not surprisingly, operative blood loss has been associated with an increased risk of death.[42] Blood loss and allogeneic blood transfusion can be greatly reduced with the utilization of an appropriate combination of therapies.

Hospital‐acquired anemia is a common complication affecting almost two‐thirds of patients admitted to the hospital. Although anemia of chronic disease is the leading cause of hospital‐acquired anemia, phlebotomy‐induced blood loss is an important contributing factor.[43] In critical care patients, phlebotomy volume is an independent predictor of transfusion requirements. On average, these patients undergo 4 to 5 blood draws per day.[44] Healthcare professionals can help decrease the development of hospital‐acquired anemia by employing strategies aimed at decreasing phlebotomy blood loss.[32] Losses in the range of 41 to 65 mL of blood per day have been reported in the medical literature and are associated with development of anemia.[45] Phlebotomy blood loss can be reduced by strategies that include eliminating arterial line blood discard, using small volume (ie, pediatric size) blood collection tubes, and ordering laboratory tests only when clinically justified.[45]

PATIENT‐CENTERED DECISION MAKING

Patient‐centered medicine is the practice of taking into account patients' individual preferences, objectives, and values.[46] Physicians are responsible for providing patients with complete and understandable information regarding treatment, and potential benefits and risks of available treatment options. Patients, in turn, must communicate their preferences and feelings with regard to their treatment.[47] A recent observational study by Weiner confirmed that employing theses practices is associated with improved health outcomes.[48]

An individualized approach to PBM helps ensure the right fit for each individual patient by informing them of risks, benefits, and alternatives of treatment choices and listening to their needs, desires, and concerns. Patients may have specific religious or cultural factors that may need to be considered. Some patients, such as Jehovah's Witnesses, decline blood products and may refuse agents derived from human or animal plasma. Some patients from other cultural or religious backgrounds may refuse agents that have factors derived from a specific animal.

Informed consent for transfusions is often obtained via a printed form offered without discussion with the patient by clerical or nursing staff. Obtaining a patient's signature to comply with Joint Commission and CMS mandates is too often the goal of this process. True informed consent requires that patients understand treatments and are informed of both the possible benefits and risks of the proposed treatment. Patients should also be informed of available treatment alternatives.[27] The benefit of transfusions are sometimes overstated, whereas the risks, such as transfusion‐related acute lung injury and transfusion‐associated circulatory overload, are often overlooked.[49] A comprehensive informed consent process, including a frank and open discussion between physician and patient, is a vital component of patient‐centered decision making.

THE HOSPITALIST'S ROLE IN PBM

Hospitalists often have the responsibility for prescribing and obtaining consent for the administration of blood components. Therefore, understanding the complexities that surround PBM and the transfusion process, including the potential for harm vs the potential for benefit, as well as the economic impact of transfusions, are essential for providing effective patient care.

Although hospitalists are not primarily based in the operating room, they are uniquely positioned to champion the value of PBM throughout their institution. Many hospitalists play a vital role in preoperative anemia detection and management via clinical and administrative roles in preadmission testing. In addition, hospitalists can serve as the connectors that bring anesthesiologists, surgeons, and others to the table to explore ways to decrease the widespread incidence of hospital‐acquired anemia. Improving perioperative blood conservation, optimizing coagulation, and managing anemia all require a multidisciplinary approach.

Hospitalists can play a major role in affecting gradual changes in organizational culture. Whether it is helping a subspecialist become comfortable with not reflexively transfusing at a threshold hemoglobin, or working with pharmacists and nurses to increase their comfort level with intravenous iron and vitamin K, a sustained effort with ongoing communication and education is required to change practice. Recognizing and engaging existing institutional stakeholders and existent efforts related to blood management (eg, transfusion committees, blood banks, blood utilization committees) is also essential to successful implementation of patient blood‐management principles. Hospitalists are often the ones who combine the credibility and the connections to the disparate stakeholders to drive the necessary culture change forward.

It is the dual role as both front‐line care provider and champion for quality improvement that uniquely positions hospitalists to lead implementation of PBM strategies. Improving quality and safety while decreasing costs, and centering decision making on the patient, are goals of effective PBM that are intimately aligned with the goals of hospital medicine. By developing, implementing, and practicing PBM, hospitalists have the opportunity to yet again lead the way in improving patient care within their organizations.