Hospital medicine is a main component of healthcare in the United States and is growing.[1] In 1995, 9% of inpatient care performed by general internists to Medicare patients was provided by hospitalists; by 2006, this had increased to 37%.[2] The estimated 30,000 practicing hospitalists account for 19% of all practicing general internists[2, 3, 4] and have had a major impact on the treatment of inpatients at US hospitals.[5] Other specialties are adopting the hospital‐based physician model.[6, 7] The hospitalist model does have unique challenges. One notable aspect of hospitalist care, which is frequently shift based, is the transfer of care among providers at shift change.

The Society of Hospital Medicine recognizes patient handoffs/sign‐outs as a core competency for hospitalists,[8] but there is little literature evaluating hospitalist sign‐out quality.[9] A systematic review in 2009 found no studies of hospitalist handoffs.[8] Furthermore, early work suggests that hospitalist handoffs are not consistently effective.[10] In a recent survey, 13% of hospitalists reported they had received an incomplete handoff, and 16% of hospitalists reported at least 1 near‐miss attributed to incomplete communication.[11] Last, hospitalists perform no better than housestaff on evaluations of sign‐out quality.[12]

Cross‐coverage situations, in which sign‐out is key, have been shown to place patients at risk.[13, 14] One study showed 7.1 problems related to sign‐out per 100 patient‐days.[15] Failure during sign‐out can ultimately threaten patient safety.[16] Therefore, evaluating the quality of hospitalist sign‐outs by assessing how well the sign‐out prepares the night team for overnight events is necessary to improve hospitalist sign‐outs and ultimately increase patient safety.

METHODS

Data Collection

Hospitalists who consented were provided a single pocket card during their shift. For every inquiry that involved a patient that the hospitalist was covering, the hospitalist recorded who originated the inquiry, the clinical significance, the sufficiency of written sign‐out, which information was used other than the written sign‐out, and information regarding the anticipation of the event by the daytime team (Figure 1).

Figure 1

Data were collected on 6 days and distributed from April 30, 2012 through June 12, 2012. Dates were chosen based on staffing to maximize the number of eligible physicians each night and included both weekdays and weekend days. The written sign‐out for the entire service was printed for each night data collection took place.

RESULTS

Hospitalists recorded 124 inquiries about 96 patients. Altogether, 15 of 19 (79%) eligible hospitalists returned surveys. Of the 96 patients, we obtained the written sign‐out for 68 (71%). The remainder were new patients for whom the sign‐out had not yet been prepared, or patients who had not yet been assigned to the hospitalist service at the time the sign‐out report was printed.

Hospitalists referenced the sign‐out for 89 (74%) inquiries, and the sign‐out was considered sufficient to respond to 27 (30%) of these inquiries (ie, the sign‐out was adequate to answer the inquiry without any supplemental information). Hospitalists physically saw the patient for 14 (12%) inquiries. Nurses were the originator for most inquiries (102 [82%]). The most common inquiry topics were medications (55 [45%]), plan of care (26 [21%]) and clinical changes (26 [21%]). Ninety‐five (77%) inquiries were considered to be somewhat or very clinically important by the hospitalist (Table 1).

No written sign‐outs had a composite score of 0 or 1; 3 (4%) had a composite score of 2; 31 (46%) had a composite score of 3; and 34 (50%) had a composite score of 4. Seventy‐two percent of written sign‐outs included neither anticipatory guidance nor tasks, 21% had 1 anticipatory guidance item or task, and 6% had 2 or more anticipatory guidance items and/or tasks.

The primary team caring for a patient did not predict 102 (86%) inquiries, and hospitalists rated 47 (46%) of those unpredicted events as possible for the primary team to predict. Five responses to this question were incomplete and excluded. Of the 64 events predicted by the primary team or rated as predictable by the night hospitalists, 17 (27%) were predicted by the primary team (Table 1).

Sign‐out was considered sufficient in isolation to answer the majority of order reconciliation inquiries (5 [71%]), but was less effective at helping to answer inquiries about clinical change (7 [29%]), medications (10 [28%]), and plan of care (5 [24%]) (P=0.001). (Table 2) Ninety‐five events were rated as either very or somewhat clinically important, but this did not affect the likelihood of sign‐out being sufficient in isolation relative to the not at all clinically important group. Specifically, 33% of sign‐outs were rated sufficient in the very important group, 19% in the somewhat important group, and 50% in the not at all group (P=0.059).

Sign‐out was considered sufficient in isolation more frequently for inquiries about patients admitted <2 days prior to data collection than for inquiries about patients admitted more than 2 days prior to data collection (21 [40%] vs 6 [16%], respectively) (P=0.015) (Table 2).

Sign‐outs with 2 or more anticipatory guidance items were considered sufficient in isolation more often than sign‐outs with 1 or fewer anticipatory guidance item (60% for 2 or more, 14% for 1, 34% for 0; P=0.006) (Table 2). The composite score was grouped into 2 categoriesscore <4 and score=4with no statistical difference in sign‐out sufficiency between the 2 groups (P=0.22) (Table 2).

In multivariable analysis, no predictor variable was significantly associated with sufficient sign‐out (Table 3).

DISCUSSION

In this study of written sign‐out among hospitalists and physician‐extenders on a hospitalist service, we found that the sign‐out was used to answer three‐quarters of overnight inquiries, despite the advanced level of training (completion of all postgraduate medical education) of the covering clinicians and the presence of a robust EHR. The effectiveness of the written sign‐out, however, was not as consistently high as its use. Overall, the sign‐out was sufficient to answer less than a third of inquiries in which it was referenced. Thus, although most studies of sign‐out quality have focused on trainees, our results make it clear that hospitalists also rely on sign‐out, and its effectiveness can be improved.

There are few studies of attending‐level sign‐outs. Hinami et al. found that nearly 1 in 5 hospitalists was uncertain of the care plan after assuming care of a new set of patients, despite having received a handoff from the departing hospitalist.[11] Handoffs between emergency physicians and hospitalists have repeatedly been noted to have content omissions and to contribute to adverse events.[7, 12, 21, 22] Ilan et al. videotaped attending handoffs in the intensive care unit and found that they did not follow any of 3 commonly recommended structures; however, this study did not assess the effectiveness of the handoffs.[23] Williams et al. found that the transfer of patient information among surgical team members, including attending surgeons, was suboptimal, and these problems were commonly related to decreased surgeon familiarity with a particular patient, a theme common to hospital medicine, and a contributor to adverse events and decreased efficiency.[24]

This study extends the literature in several ways. By studying overnight events, we generate a comprehensive view of the information sources hospitalists use to care for patients overnight. Interestingly, our results were similar to the overnight information‐gathering habits of trainees in a study of pediatric trainees.[25] Furthermore, by linking each inquiry to the accompanying written sign‐out, we are able to analyze which characteristics of a written sign‐out are associated with sign‐out effectiveness, and we are able to describe the utility of written sign‐out to answer different types of clinical scenarios.

Our data show that hospitalists rely heavily on written sign‐out to care for patients overnight, with the physician note being the most‐utilized secondary reference used by covering physicians. The written sign‐out was most useful for order clarification compared to other topics, and the patient was only seen for 12% of inquiries. Most notable, however, was the suggestion that sign‐outs with more anticipatory guidance were more likely to be effective for overnight care, as were sign‐outs created earlier in the hospital course. Future efforts to improve the utility of the written sign‐out might focus on these items, whether through training or audit/feedback.

The use of electronic handoff tools has been shown to increase the ease of use, efficiency, and perceptions of patient safety and quality in several studies.[3, 26, 27] This study relied on an electronic tool as the only means of information transfer during sign‐out. Without the confounding effect of verbal information transfer, we are better able to understand the efficacy of the written component alone. Nonetheless, most expert opinion statements as well as The Joint Commission include a recommendation for verbal and written components to handoff communication.[8, 20, 28, 29, 30] It is possible that sign‐outs would more often have been rated sufficient if the handoff process had reliably included verbal handoff. Future studies are warranted to compare written‐only to written‐plus‐verbal sign‐out, to determine the added benefit of verbal communication. With a robust EHR, it is also an open question whether sign‐out needs to be sufficient to answer overnight inquiries or whether it would be acceptable or even preferable to have overnight staff consistently review the EHR directly, especially as the physician notes are the most common nonsign‐out reference used. Nonetheless, the fact that hospitalists rely heavily on written sign‐out despite the availability of other information sources suggests that hospitalists find specific benefit in written sign‐out.

Limitations of this study include the relatively small sample size, the limited collection time period, and the single‐site nature. The YNHH Hospitalist Service uses only written documents to sign out, so the external validity to programs that use verbal sign‐out is limited. The written‐only nature, however, removes the variable of the discussion at time of sign‐out, improving the purity of the written sign‐out assessment. We did not assess workload, which might have affected sign‐out quality. The interpretation of the composite score is limited, due to little variation in scoring in our sample, as well as lack of validation in other studies. An additional limitation is that sign‐outs are not entirely drafted by the hospitalist attendings. Hospitalists draft the initial sign‐out document, but it is updated on subsequent days by the mid‐level provider under the direction of the hospitalist attending. It is therefore possible that sign‐outs maintained directly by hospitalists would have been of different quality. In this regard it is interesting to note that in a different study of verbal sign‐out we were not able to detect a difference in quality among hospitalists, trainees, and midlevels.[12] Last, hindsight bias may be present, as the covering physician's perspective of the event includes more information than available to the provider creating the sign‐out document.

Overall, we found that attending hospitalists rely heavily on written sign‐out documents to address overnight inquiries, but those sign‐outs are not reliably effective. Future work to better understand the roles of written and verbal components in sign‐out is needed to help improve the safety of overnight care.

Hospital medicine is a main component of healthcare in the United States and is growing.[1] In 1995, 9% of inpatient care performed by general internists to Medicare patients was provided by hospitalists; by 2006, this had increased to 37%.[2] The estimated 30,000 practicing hospitalists account for 19% of all practicing general internists[2, 3, 4] and have had a major impact on the treatment of inpatients at US hospitals.[5] Other specialties are adopting the hospital‐based physician model.[6, 7] The hospitalist model does have unique challenges. One notable aspect of hospitalist care, which is frequently shift based, is the transfer of care among providers at shift change.

The Society of Hospital Medicine recognizes patient handoffs/sign‐outs as a core competency for hospitalists,[8] but there is little literature evaluating hospitalist sign‐out quality.[9] A systematic review in 2009 found no studies of hospitalist handoffs.[8] Furthermore, early work suggests that hospitalist handoffs are not consistently effective.[10] In a recent survey, 13% of hospitalists reported they had received an incomplete handoff, and 16% of hospitalists reported at least 1 near‐miss attributed to incomplete communication.[11] Last, hospitalists perform no better than housestaff on evaluations of sign‐out quality.[12]

Cross‐coverage situations, in which sign‐out is key, have been shown to place patients at risk.[13, 14] One study showed 7.1 problems related to sign‐out per 100 patient‐days.[15] Failure during sign‐out can ultimately threaten patient safety.[16] Therefore, evaluating the quality of hospitalist sign‐outs by assessing how well the sign‐out prepares the night team for overnight events is necessary to improve hospitalist sign‐outs and ultimately increase patient safety.

METHODS

Data Collection

Hospitalists who consented were provided a single pocket card during their shift. For every inquiry that involved a patient that the hospitalist was covering, the hospitalist recorded who originated the inquiry, the clinical significance, the sufficiency of written sign‐out, which information was used other than the written sign‐out, and information regarding the anticipation of the event by the daytime team (Figure 1).

Figure 1

Data were collected on 6 days and distributed from April 30, 2012 through June 12, 2012. Dates were chosen based on staffing to maximize the number of eligible physicians each night and included both weekdays and weekend days. The written sign‐out for the entire service was printed for each night data collection took place.

RESULTS

Hospitalists recorded 124 inquiries about 96 patients. Altogether, 15 of 19 (79%) eligible hospitalists returned surveys. Of the 96 patients, we obtained the written sign‐out for 68 (71%). The remainder were new patients for whom the sign‐out had not yet been prepared, or patients who had not yet been assigned to the hospitalist service at the time the sign‐out report was printed.

Hospitalists referenced the sign‐out for 89 (74%) inquiries, and the sign‐out was considered sufficient to respond to 27 (30%) of these inquiries (ie, the sign‐out was adequate to answer the inquiry without any supplemental information). Hospitalists physically saw the patient for 14 (12%) inquiries. Nurses were the originator for most inquiries (102 [82%]). The most common inquiry topics were medications (55 [45%]), plan of care (26 [21%]) and clinical changes (26 [21%]). Ninety‐five (77%) inquiries were considered to be somewhat or very clinically important by the hospitalist (Table 1).

No written sign‐outs had a composite score of 0 or 1; 3 (4%) had a composite score of 2; 31 (46%) had a composite score of 3; and 34 (50%) had a composite score of 4. Seventy‐two percent of written sign‐outs included neither anticipatory guidance nor tasks, 21% had 1 anticipatory guidance item or task, and 6% had 2 or more anticipatory guidance items and/or tasks.

The primary team caring for a patient did not predict 102 (86%) inquiries, and hospitalists rated 47 (46%) of those unpredicted events as possible for the primary team to predict. Five responses to this question were incomplete and excluded. Of the 64 events predicted by the primary team or rated as predictable by the night hospitalists, 17 (27%) were predicted by the primary team (Table 1).

Sign‐out was considered sufficient in isolation to answer the majority of order reconciliation inquiries (5 [71%]), but was less effective at helping to answer inquiries about clinical change (7 [29%]), medications (10 [28%]), and plan of care (5 [24%]) (P=0.001). (Table 2) Ninety‐five events were rated as either very or somewhat clinically important, but this did not affect the likelihood of sign‐out being sufficient in isolation relative to the not at all clinically important group. Specifically, 33% of sign‐outs were rated sufficient in the very important group, 19% in the somewhat important group, and 50% in the not at all group (P=0.059).

Sign‐out was considered sufficient in isolation more frequently for inquiries about patients admitted <2 days prior to data collection than for inquiries about patients admitted more than 2 days prior to data collection (21 [40%] vs 6 [16%], respectively) (P=0.015) (Table 2).

Sign‐outs with 2 or more anticipatory guidance items were considered sufficient in isolation more often than sign‐outs with 1 or fewer anticipatory guidance item (60% for 2 or more, 14% for 1, 34% for 0; P=0.006) (Table 2). The composite score was grouped into 2 categoriesscore <4 and score=4with no statistical difference in sign‐out sufficiency between the 2 groups (P=0.22) (Table 2).

In multivariable analysis, no predictor variable was significantly associated with sufficient sign‐out (Table 3).

DISCUSSION

In this study of written sign‐out among hospitalists and physician‐extenders on a hospitalist service, we found that the sign‐out was used to answer three‐quarters of overnight inquiries, despite the advanced level of training (completion of all postgraduate medical education) of the covering clinicians and the presence of a robust EHR. The effectiveness of the written sign‐out, however, was not as consistently high as its use. Overall, the sign‐out was sufficient to answer less than a third of inquiries in which it was referenced. Thus, although most studies of sign‐out quality have focused on trainees, our results make it clear that hospitalists also rely on sign‐out, and its effectiveness can be improved.

There are few studies of attending‐level sign‐outs. Hinami et al. found that nearly 1 in 5 hospitalists was uncertain of the care plan after assuming care of a new set of patients, despite having received a handoff from the departing hospitalist.[11] Handoffs between emergency physicians and hospitalists have repeatedly been noted to have content omissions and to contribute to adverse events.[7, 12, 21, 22] Ilan et al. videotaped attending handoffs in the intensive care unit and found that they did not follow any of 3 commonly recommended structures; however, this study did not assess the effectiveness of the handoffs.[23] Williams et al. found that the transfer of patient information among surgical team members, including attending surgeons, was suboptimal, and these problems were commonly related to decreased surgeon familiarity with a particular patient, a theme common to hospital medicine, and a contributor to adverse events and decreased efficiency.[24]

This study extends the literature in several ways. By studying overnight events, we generate a comprehensive view of the information sources hospitalists use to care for patients overnight. Interestingly, our results were similar to the overnight information‐gathering habits of trainees in a study of pediatric trainees.[25] Furthermore, by linking each inquiry to the accompanying written sign‐out, we are able to analyze which characteristics of a written sign‐out are associated with sign‐out effectiveness, and we are able to describe the utility of written sign‐out to answer different types of clinical scenarios.

Our data show that hospitalists rely heavily on written sign‐out to care for patients overnight, with the physician note being the most‐utilized secondary reference used by covering physicians. The written sign‐out was most useful for order clarification compared to other topics, and the patient was only seen for 12% of inquiries. Most notable, however, was the suggestion that sign‐outs with more anticipatory guidance were more likely to be effective for overnight care, as were sign‐outs created earlier in the hospital course. Future efforts to improve the utility of the written sign‐out might focus on these items, whether through training or audit/feedback.

The use of electronic handoff tools has been shown to increase the ease of use, efficiency, and perceptions of patient safety and quality in several studies.[3, 26, 27] This study relied on an electronic tool as the only means of information transfer during sign‐out. Without the confounding effect of verbal information transfer, we are better able to understand the efficacy of the written component alone. Nonetheless, most expert opinion statements as well as The Joint Commission include a recommendation for verbal and written components to handoff communication.[8, 20, 28, 29, 30] It is possible that sign‐outs would more often have been rated sufficient if the handoff process had reliably included verbal handoff. Future studies are warranted to compare written‐only to written‐plus‐verbal sign‐out, to determine the added benefit of verbal communication. With a robust EHR, it is also an open question whether sign‐out needs to be sufficient to answer overnight inquiries or whether it would be acceptable or even preferable to have overnight staff consistently review the EHR directly, especially as the physician notes are the most common nonsign‐out reference used. Nonetheless, the fact that hospitalists rely heavily on written sign‐out despite the availability of other information sources suggests that hospitalists find specific benefit in written sign‐out.

Limitations of this study include the relatively small sample size, the limited collection time period, and the single‐site nature. The YNHH Hospitalist Service uses only written documents to sign out, so the external validity to programs that use verbal sign‐out is limited. The written‐only nature, however, removes the variable of the discussion at time of sign‐out, improving the purity of the written sign‐out assessment. We did not assess workload, which might have affected sign‐out quality. The interpretation of the composite score is limited, due to little variation in scoring in our sample, as well as lack of validation in other studies. An additional limitation is that sign‐outs are not entirely drafted by the hospitalist attendings. Hospitalists draft the initial sign‐out document, but it is updated on subsequent days by the mid‐level provider under the direction of the hospitalist attending. It is therefore possible that sign‐outs maintained directly by hospitalists would have been of different quality. In this regard it is interesting to note that in a different study of verbal sign‐out we were not able to detect a difference in quality among hospitalists, trainees, and midlevels.[12] Last, hindsight bias may be present, as the covering physician's perspective of the event includes more information than available to the provider creating the sign‐out document.

Overall, we found that attending hospitalists rely heavily on written sign‐out documents to address overnight inquiries, but those sign‐outs are not reliably effective. Future work to better understand the roles of written and verbal components in sign‐out is needed to help improve the safety of overnight care.

Hospital medicine is a main component of healthcare in the United States and is growing.[1] In 1995, 9% of inpatient care performed by general internists to Medicare patients was provided by hospitalists; by 2006, this had increased to 37%.[2] The estimated 30,000 practicing hospitalists account for 19% of all practicing general internists[2, 3, 4] and have had a major impact on the treatment of inpatients at US hospitals.[5] Other specialties are adopting the hospital‐based physician model.[6, 7] The hospitalist model does have unique challenges. One notable aspect of hospitalist care, which is frequently shift based, is the transfer of care among providers at shift change.

The Society of Hospital Medicine recognizes patient handoffs/sign‐outs as a core competency for hospitalists,[8] but there is little literature evaluating hospitalist sign‐out quality.[9] A systematic review in 2009 found no studies of hospitalist handoffs.[8] Furthermore, early work suggests that hospitalist handoffs are not consistently effective.[10] In a recent survey, 13% of hospitalists reported they had received an incomplete handoff, and 16% of hospitalists reported at least 1 near‐miss attributed to incomplete communication.[11] Last, hospitalists perform no better than housestaff on evaluations of sign‐out quality.[12]

Cross‐coverage situations, in which sign‐out is key, have been shown to place patients at risk.[13, 14] One study showed 7.1 problems related to sign‐out per 100 patient‐days.[15] Failure during sign‐out can ultimately threaten patient safety.[16] Therefore, evaluating the quality of hospitalist sign‐outs by assessing how well the sign‐out prepares the night team for overnight events is necessary to improve hospitalist sign‐outs and ultimately increase patient safety.

METHODS

Data Collection

Hospitalists who consented were provided a single pocket card during their shift. For every inquiry that involved a patient that the hospitalist was covering, the hospitalist recorded who originated the inquiry, the clinical significance, the sufficiency of written sign‐out, which information was used other than the written sign‐out, and information regarding the anticipation of the event by the daytime team (Figure 1).

Figure 1

Data were collected on 6 days and distributed from April 30, 2012 through June 12, 2012. Dates were chosen based on staffing to maximize the number of eligible physicians each night and included both weekdays and weekend days. The written sign‐out for the entire service was printed for each night data collection took place.

RESULTS

Hospitalists recorded 124 inquiries about 96 patients. Altogether, 15 of 19 (79%) eligible hospitalists returned surveys. Of the 96 patients, we obtained the written sign‐out for 68 (71%). The remainder were new patients for whom the sign‐out had not yet been prepared, or patients who had not yet been assigned to the hospitalist service at the time the sign‐out report was printed.

Hospitalists referenced the sign‐out for 89 (74%) inquiries, and the sign‐out was considered sufficient to respond to 27 (30%) of these inquiries (ie, the sign‐out was adequate to answer the inquiry without any supplemental information). Hospitalists physically saw the patient for 14 (12%) inquiries. Nurses were the originator for most inquiries (102 [82%]). The most common inquiry topics were medications (55 [45%]), plan of care (26 [21%]) and clinical changes (26 [21%]). Ninety‐five (77%) inquiries were considered to be somewhat or very clinically important by the hospitalist (Table 1).

No written sign‐outs had a composite score of 0 or 1; 3 (4%) had a composite score of 2; 31 (46%) had a composite score of 3; and 34 (50%) had a composite score of 4. Seventy‐two percent of written sign‐outs included neither anticipatory guidance nor tasks, 21% had 1 anticipatory guidance item or task, and 6% had 2 or more anticipatory guidance items and/or tasks.

The primary team caring for a patient did not predict 102 (86%) inquiries, and hospitalists rated 47 (46%) of those unpredicted events as possible for the primary team to predict. Five responses to this question were incomplete and excluded. Of the 64 events predicted by the primary team or rated as predictable by the night hospitalists, 17 (27%) were predicted by the primary team (Table 1).

Sign‐out was considered sufficient in isolation to answer the majority of order reconciliation inquiries (5 [71%]), but was less effective at helping to answer inquiries about clinical change (7 [29%]), medications (10 [28%]), and plan of care (5 [24%]) (P=0.001). (Table 2) Ninety‐five events were rated as either very or somewhat clinically important, but this did not affect the likelihood of sign‐out being sufficient in isolation relative to the not at all clinically important group. Specifically, 33% of sign‐outs were rated sufficient in the very important group, 19% in the somewhat important group, and 50% in the not at all group (P=0.059).

Sign‐out was considered sufficient in isolation more frequently for inquiries about patients admitted <2 days prior to data collection than for inquiries about patients admitted more than 2 days prior to data collection (21 [40%] vs 6 [16%], respectively) (P=0.015) (Table 2).

Sign‐outs with 2 or more anticipatory guidance items were considered sufficient in isolation more often than sign‐outs with 1 or fewer anticipatory guidance item (60% for 2 or more, 14% for 1, 34% for 0; P=0.006) (Table 2). The composite score was grouped into 2 categoriesscore <4 and score=4with no statistical difference in sign‐out sufficiency between the 2 groups (P=0.22) (Table 2).

In multivariable analysis, no predictor variable was significantly associated with sufficient sign‐out (Table 3).

DISCUSSION

In this study of written sign‐out among hospitalists and physician‐extenders on a hospitalist service, we found that the sign‐out was used to answer three‐quarters of overnight inquiries, despite the advanced level of training (completion of all postgraduate medical education) of the covering clinicians and the presence of a robust EHR. The effectiveness of the written sign‐out, however, was not as consistently high as its use. Overall, the sign‐out was sufficient to answer less than a third of inquiries in which it was referenced. Thus, although most studies of sign‐out quality have focused on trainees, our results make it clear that hospitalists also rely on sign‐out, and its effectiveness can be improved.

There are few studies of attending‐level sign‐outs. Hinami et al. found that nearly 1 in 5 hospitalists was uncertain of the care plan after assuming care of a new set of patients, despite having received a handoff from the departing hospitalist.[11] Handoffs between emergency physicians and hospitalists have repeatedly been noted to have content omissions and to contribute to adverse events.[7, 12, 21, 22] Ilan et al. videotaped attending handoffs in the intensive care unit and found that they did not follow any of 3 commonly recommended structures; however, this study did not assess the effectiveness of the handoffs.[23] Williams et al. found that the transfer of patient information among surgical team members, including attending surgeons, was suboptimal, and these problems were commonly related to decreased surgeon familiarity with a particular patient, a theme common to hospital medicine, and a contributor to adverse events and decreased efficiency.[24]

This study extends the literature in several ways. By studying overnight events, we generate a comprehensive view of the information sources hospitalists use to care for patients overnight. Interestingly, our results were similar to the overnight information‐gathering habits of trainees in a study of pediatric trainees.[25] Furthermore, by linking each inquiry to the accompanying written sign‐out, we are able to analyze which characteristics of a written sign‐out are associated with sign‐out effectiveness, and we are able to describe the utility of written sign‐out to answer different types of clinical scenarios.

Our data show that hospitalists rely heavily on written sign‐out to care for patients overnight, with the physician note being the most‐utilized secondary reference used by covering physicians. The written sign‐out was most useful for order clarification compared to other topics, and the patient was only seen for 12% of inquiries. Most notable, however, was the suggestion that sign‐outs with more anticipatory guidance were more likely to be effective for overnight care, as were sign‐outs created earlier in the hospital course. Future efforts to improve the utility of the written sign‐out might focus on these items, whether through training or audit/feedback.

The use of electronic handoff tools has been shown to increase the ease of use, efficiency, and perceptions of patient safety and quality in several studies.[3, 26, 27] This study relied on an electronic tool as the only means of information transfer during sign‐out. Without the confounding effect of verbal information transfer, we are better able to understand the efficacy of the written component alone. Nonetheless, most expert opinion statements as well as The Joint Commission include a recommendation for verbal and written components to handoff communication.[8, 20, 28, 29, 30] It is possible that sign‐outs would more often have been rated sufficient if the handoff process had reliably included verbal handoff. Future studies are warranted to compare written‐only to written‐plus‐verbal sign‐out, to determine the added benefit of verbal communication. With a robust EHR, it is also an open question whether sign‐out needs to be sufficient to answer overnight inquiries or whether it would be acceptable or even preferable to have overnight staff consistently review the EHR directly, especially as the physician notes are the most common nonsign‐out reference used. Nonetheless, the fact that hospitalists rely heavily on written sign‐out despite the availability of other information sources suggests that hospitalists find specific benefit in written sign‐out.

Limitations of this study include the relatively small sample size, the limited collection time period, and the single‐site nature. The YNHH Hospitalist Service uses only written documents to sign out, so the external validity to programs that use verbal sign‐out is limited. The written‐only nature, however, removes the variable of the discussion at time of sign‐out, improving the purity of the written sign‐out assessment. We did not assess workload, which might have affected sign‐out quality. The interpretation of the composite score is limited, due to little variation in scoring in our sample, as well as lack of validation in other studies. An additional limitation is that sign‐outs are not entirely drafted by the hospitalist attendings. Hospitalists draft the initial sign‐out document, but it is updated on subsequent days by the mid‐level provider under the direction of the hospitalist attending. It is therefore possible that sign‐outs maintained directly by hospitalists would have been of different quality. In this regard it is interesting to note that in a different study of verbal sign‐out we were not able to detect a difference in quality among hospitalists, trainees, and midlevels.[12] Last, hindsight bias may be present, as the covering physician's perspective of the event includes more information than available to the provider creating the sign‐out document.

Overall, we found that attending hospitalists rely heavily on written sign‐out documents to address overnight inquiries, but those sign‐outs are not reliably effective. Future work to better understand the roles of written and verbal components in sign‐out is needed to help improve the safety of overnight care.

Patient‐centered communication may impact several aspects of the patientdoctor relationship including patient disclosure of illness‐related information, patient satisfaction, anxiety, and compliance with medical recommendations.[1, 2, 3, 4] Etiquette‐based medicine, a term coined by Kahn, involves simple patient‐centered communication strategies that convey professionalism and respect to patients.[5] Studies have confirmed that patients prefer physicians who practice etiquette‐based medicine behaviors, including sitting down and introducing one's self.[6, 7, 8, 9] Performance of etiquette‐based medicine is associated with higher Press Ganey patient satisfaction scores. However, these easy‐to‐practice behaviors may not be modeled commonly in the inpatient setting.[10] We sought to understand whether etiquette‐based communication behaviors are practiced by trainees on inpatient medicine rotations.

METHODS

RESULTS

A total of 732 inpatient encounters were observed during 118 intern shifts. Interns were observed for a mean of 25 patient encounters each (range, 361; standard deviation [SD] 17). Overall, interns introduced themselves 40% of the time and stated their role 37% of the time (Table 2). Interns touched patients on 65% of visits, sat down with patients during 9% of visits, and asked open‐ended questions on 75% of visits. Interns performed all 5 of the behaviors during 4% of the total encounters. The percentage of the 5 behaviors performed by each intern during all observed visits ranged from 24% to 100%, with a mean of 51% (SD 17%) per intern.

During night shifts as compared to day shifts, interns were more likely to introduce themselves (48% vs 37%, P=0.01) and their role (45% vs 34%, P0.01). During shifts in which they admitted patients as compared to coverage shifts, interns were more likely to introduce themselves (46% vs 34%, P0.01) and their role (42% vs 30%, P0.01). Interns at UMMC as compared to JHH interns were more likely to introduce themselves (45% vs 35%, P0.01) and describe their role to patients (44% vs 29%, P0.01). Interns at UMMC were also more likely to ask open‐ended questions (81% vs 70%, P0.01) and to touch patients (69% vs 62%, P=0.04). Performance of these behaviors did not vary significantly by gender, time of day, or shift. After adjustment for clustering at the observer and intern levels, differences by institution persisted in the rate of introducing oneself and one's role.

We performed a sensitivity analysis examining the first patient encounters of the day, and found that interns were somewhat more likely to introduce themselves (50% vs 40%, P=0.03) but were not significantly more likely to introduce their role, sit down, ask open‐ended questions, or touch the patient.

Nine of the 10 interns at JHH who participated in the study completed the survey (response rate=90%). Interns estimated introducing themselves and their role and sitting with patients significantly more frequently than was observed (80% vs 40%, P0.01; 80% vs 37%, P0.01; and 58% vs 9%, P0.01, respectively) (Figure 1).

Figure 1

DISCUSSION

The interns we observed in 2 urban academic internal medicine residency programs did not routinely practice etiquette‐based communication. Interns surveyed tended to overestimate their performance of these behaviors. These behaviors are simple to perform and are each associated with improved patient experiences of hospital care. Tackett et al. recently demonstrated that interns are not alone. Hospitalist physicians do not universally practice etiquette‐based medicine, even though these behaviors correlate with patient satisfaction scores.[10]

Introducing oneself to patients may improve patient satisfaction and acceptance of trainee involvement in care.[6] However, only 10% of hospitalized patients in 1 study correctly identified a physician on their inpatient team, demonstrating the need for introductions during each and every inpatient encounter.[11] The interns we observed introduced themselves to patients in only 40% of encounters. During admitting shifts, when the first encounter with a patient likely took place, interns introduced themselves during 46% of encounters.

A comforting touch has been shown to reduce anxiety levels among patients and improve compliance with treatment regimens, but the interns did not touch patients in one‐third of visits, including during admitting shifts. Sixty‐six percent of patients consider a physician's touch comforting, and 58% believe it to be healing.[8]

A randomized trial found that most patients preferred a sitting physician, and believed that practitioners who sat were more compassionate and spent more time with them.[9] Unfortunately, interns sat down with patients in fewer than 10% of encounters.

We do not know why interns do not engage in these simple behaviors, but it is not surprising given that their role models, including hospitalist physicians, do not practice them universally.[10] Personality differences, medical school experiences, and hospital factors such as patient volume and complexity may explain variability in performance.

Importantly, we know that habits learned in residency tend to be retained when physicians enter independent practice.[12] If we want attending physicians to practice etiquette‐based communication, then it must be role modeled, taught, and evaluated during residency by clinical educators and hospitalist physicians. The gap between intern perceptions and actual practice of these behaviors provides a window of opportunity for education and feedback in bedside communication. Attending physicians rate communication skills as 1 of the top values they seek to pass on to house officers.[13] Curricula on communication skills improve physician attitudes and beliefs about the importance of good communication as well as long‐term performance of communication skills.[14]

Our study had several limitations. First, all 732 patient encounters were assessed, regardless of whether the intern had seen the patient previously. This differed slightly from Kahn's assertion that these behaviors be performed at least on the first encounter with the patient. We believe that the need for common courtesy does not diminish after the first visit, and although certain behaviors may not be indicated on 100% of visits, our sensitivity analysis indicated performance of these behaviors was not likely even on the first visit of the day.

Second, our observations were limited to medicine interns at 2 programs in Baltimore during a single month, limiting generalizability. A convenience sample of interns was chosen for recruitment based on rotation on a general medicine rotation during the study month. We observed interns over the course of several shifts and throughout various positions in the call cycle.

Third, in any observational study, the Hawthorne effect is a potential limitation. We attempted to limit this bias by collecting information anonymously and not indicating to the interns which aspects of the patient encounter were being recorded.

Fourth, we defined the behaviors broadly in an attempt to measure the outcomes conservatively and maximize inter‐rater reliability. For instance, we did not differentiate in data collection between comforting touch and physical examination. Because chairs may not be readily available in all patient rooms, we included sitting on the patient's bed or crouching next to the bed as sitting with the patient. Use of open‐ended questions was observed as a more general form of Kahn's recommendation to ask how the patient is feeling.

Fifth, our poststudy survey was conducted 6 months after the observations were performed, used an ordinal rather than continuous response scale, and was limited to only 1 of the 2 programs and 9 of the 29 participants. Given this small sample size, generalizability of the results is limited. Additionally, intern practice of etiquette‐based communication may have improved between the observations and survey that took place 6 months later.

As hospital admissions are a time of vulnerability for patients, physicians can take a basic etiquette‐based communication approach to comfort patients and help them feel more secure. We found that even though interns believed they were practicing Kahn's recommended etiquette‐based communication, only a minority actually were. Curricula on communication styles or environmental changes, such as providing chairs in patient rooms or photographs identifying members of the medical team, may encourage performance of these behaviors.[15]

Patient‐centered communication may impact several aspects of the patientdoctor relationship including patient disclosure of illness‐related information, patient satisfaction, anxiety, and compliance with medical recommendations.[1, 2, 3, 4] Etiquette‐based medicine, a term coined by Kahn, involves simple patient‐centered communication strategies that convey professionalism and respect to patients.[5] Studies have confirmed that patients prefer physicians who practice etiquette‐based medicine behaviors, including sitting down and introducing one's self.[6, 7, 8, 9] Performance of etiquette‐based medicine is associated with higher Press Ganey patient satisfaction scores. However, these easy‐to‐practice behaviors may not be modeled commonly in the inpatient setting.[10] We sought to understand whether etiquette‐based communication behaviors are practiced by trainees on inpatient medicine rotations.

METHODS

RESULTS

A total of 732 inpatient encounters were observed during 118 intern shifts. Interns were observed for a mean of 25 patient encounters each (range, 361; standard deviation [SD] 17). Overall, interns introduced themselves 40% of the time and stated their role 37% of the time (Table 2). Interns touched patients on 65% of visits, sat down with patients during 9% of visits, and asked open‐ended questions on 75% of visits. Interns performed all 5 of the behaviors during 4% of the total encounters. The percentage of the 5 behaviors performed by each intern during all observed visits ranged from 24% to 100%, with a mean of 51% (SD 17%) per intern.

During night shifts as compared to day shifts, interns were more likely to introduce themselves (48% vs 37%, P=0.01) and their role (45% vs 34%, P0.01). During shifts in which they admitted patients as compared to coverage shifts, interns were more likely to introduce themselves (46% vs 34%, P0.01) and their role (42% vs 30%, P0.01). Interns at UMMC as compared to JHH interns were more likely to introduce themselves (45% vs 35%, P0.01) and describe their role to patients (44% vs 29%, P0.01). Interns at UMMC were also more likely to ask open‐ended questions (81% vs 70%, P0.01) and to touch patients (69% vs 62%, P=0.04). Performance of these behaviors did not vary significantly by gender, time of day, or shift. After adjustment for clustering at the observer and intern levels, differences by institution persisted in the rate of introducing oneself and one's role.

We performed a sensitivity analysis examining the first patient encounters of the day, and found that interns were somewhat more likely to introduce themselves (50% vs 40%, P=0.03) but were not significantly more likely to introduce their role, sit down, ask open‐ended questions, or touch the patient.

Nine of the 10 interns at JHH who participated in the study completed the survey (response rate=90%). Interns estimated introducing themselves and their role and sitting with patients significantly more frequently than was observed (80% vs 40%, P0.01; 80% vs 37%, P0.01; and 58% vs 9%, P0.01, respectively) (Figure 1).

Figure 1

DISCUSSION

The interns we observed in 2 urban academic internal medicine residency programs did not routinely practice etiquette‐based communication. Interns surveyed tended to overestimate their performance of these behaviors. These behaviors are simple to perform and are each associated with improved patient experiences of hospital care. Tackett et al. recently demonstrated that interns are not alone. Hospitalist physicians do not universally practice etiquette‐based medicine, even though these behaviors correlate with patient satisfaction scores.[10]

Introducing oneself to patients may improve patient satisfaction and acceptance of trainee involvement in care.[6] However, only 10% of hospitalized patients in 1 study correctly identified a physician on their inpatient team, demonstrating the need for introductions during each and every inpatient encounter.[11] The interns we observed introduced themselves to patients in only 40% of encounters. During admitting shifts, when the first encounter with a patient likely took place, interns introduced themselves during 46% of encounters.

A comforting touch has been shown to reduce anxiety levels among patients and improve compliance with treatment regimens, but the interns did not touch patients in one‐third of visits, including during admitting shifts. Sixty‐six percent of patients consider a physician's touch comforting, and 58% believe it to be healing.[8]

A randomized trial found that most patients preferred a sitting physician, and believed that practitioners who sat were more compassionate and spent more time with them.[9] Unfortunately, interns sat down with patients in fewer than 10% of encounters.

We do not know why interns do not engage in these simple behaviors, but it is not surprising given that their role models, including hospitalist physicians, do not practice them universally.[10] Personality differences, medical school experiences, and hospital factors such as patient volume and complexity may explain variability in performance.

Importantly, we know that habits learned in residency tend to be retained when physicians enter independent practice.[12] If we want attending physicians to practice etiquette‐based communication, then it must be role modeled, taught, and evaluated during residency by clinical educators and hospitalist physicians. The gap between intern perceptions and actual practice of these behaviors provides a window of opportunity for education and feedback in bedside communication. Attending physicians rate communication skills as 1 of the top values they seek to pass on to house officers.[13] Curricula on communication skills improve physician attitudes and beliefs about the importance of good communication as well as long‐term performance of communication skills.[14]

Our study had several limitations. First, all 732 patient encounters were assessed, regardless of whether the intern had seen the patient previously. This differed slightly from Kahn's assertion that these behaviors be performed at least on the first encounter with the patient. We believe that the need for common courtesy does not diminish after the first visit, and although certain behaviors may not be indicated on 100% of visits, our sensitivity analysis indicated performance of these behaviors was not likely even on the first visit of the day.

Second, our observations were limited to medicine interns at 2 programs in Baltimore during a single month, limiting generalizability. A convenience sample of interns was chosen for recruitment based on rotation on a general medicine rotation during the study month. We observed interns over the course of several shifts and throughout various positions in the call cycle.

Third, in any observational study, the Hawthorne effect is a potential limitation. We attempted to limit this bias by collecting information anonymously and not indicating to the interns which aspects of the patient encounter were being recorded.

Fourth, we defined the behaviors broadly in an attempt to measure the outcomes conservatively and maximize inter‐rater reliability. For instance, we did not differentiate in data collection between comforting touch and physical examination. Because chairs may not be readily available in all patient rooms, we included sitting on the patient's bed or crouching next to the bed as sitting with the patient. Use of open‐ended questions was observed as a more general form of Kahn's recommendation to ask how the patient is feeling.

Fifth, our poststudy survey was conducted 6 months after the observations were performed, used an ordinal rather than continuous response scale, and was limited to only 1 of the 2 programs and 9 of the 29 participants. Given this small sample size, generalizability of the results is limited. Additionally, intern practice of etiquette‐based communication may have improved between the observations and survey that took place 6 months later.

As hospital admissions are a time of vulnerability for patients, physicians can take a basic etiquette‐based communication approach to comfort patients and help them feel more secure. We found that even though interns believed they were practicing Kahn's recommended etiquette‐based communication, only a minority actually were. Curricula on communication styles or environmental changes, such as providing chairs in patient rooms or photographs identifying members of the medical team, may encourage performance of these behaviors.[15]

Patient‐centered communication may impact several aspects of the patientdoctor relationship including patient disclosure of illness‐related information, patient satisfaction, anxiety, and compliance with medical recommendations.[1, 2, 3, 4] Etiquette‐based medicine, a term coined by Kahn, involves simple patient‐centered communication strategies that convey professionalism and respect to patients.[5] Studies have confirmed that patients prefer physicians who practice etiquette‐based medicine behaviors, including sitting down and introducing one's self.[6, 7, 8, 9] Performance of etiquette‐based medicine is associated with higher Press Ganey patient satisfaction scores. However, these easy‐to‐practice behaviors may not be modeled commonly in the inpatient setting.[10] We sought to understand whether etiquette‐based communication behaviors are practiced by trainees on inpatient medicine rotations.

METHODS

RESULTS

A total of 732 inpatient encounters were observed during 118 intern shifts. Interns were observed for a mean of 25 patient encounters each (range, 361; standard deviation [SD] 17). Overall, interns introduced themselves 40% of the time and stated their role 37% of the time (Table 2). Interns touched patients on 65% of visits, sat down with patients during 9% of visits, and asked open‐ended questions on 75% of visits. Interns performed all 5 of the behaviors during 4% of the total encounters. The percentage of the 5 behaviors performed by each intern during all observed visits ranged from 24% to 100%, with a mean of 51% (SD 17%) per intern.

During night shifts as compared to day shifts, interns were more likely to introduce themselves (48% vs 37%, P=0.01) and their role (45% vs 34%, P0.01). During shifts in which they admitted patients as compared to coverage shifts, interns were more likely to introduce themselves (46% vs 34%, P0.01) and their role (42% vs 30%, P0.01). Interns at UMMC as compared to JHH interns were more likely to introduce themselves (45% vs 35%, P0.01) and describe their role to patients (44% vs 29%, P0.01). Interns at UMMC were also more likely to ask open‐ended questions (81% vs 70%, P0.01) and to touch patients (69% vs 62%, P=0.04). Performance of these behaviors did not vary significantly by gender, time of day, or shift. After adjustment for clustering at the observer and intern levels, differences by institution persisted in the rate of introducing oneself and one's role.

We performed a sensitivity analysis examining the first patient encounters of the day, and found that interns were somewhat more likely to introduce themselves (50% vs 40%, P=0.03) but were not significantly more likely to introduce their role, sit down, ask open‐ended questions, or touch the patient.

Nine of the 10 interns at JHH who participated in the study completed the survey (response rate=90%). Interns estimated introducing themselves and their role and sitting with patients significantly more frequently than was observed (80% vs 40%, P0.01; 80% vs 37%, P0.01; and 58% vs 9%, P0.01, respectively) (Figure 1).

Figure 1

DISCUSSION

The interns we observed in 2 urban academic internal medicine residency programs did not routinely practice etiquette‐based communication. Interns surveyed tended to overestimate their performance of these behaviors. These behaviors are simple to perform and are each associated with improved patient experiences of hospital care. Tackett et al. recently demonstrated that interns are not alone. Hospitalist physicians do not universally practice etiquette‐based medicine, even though these behaviors correlate with patient satisfaction scores.[10]

Introducing oneself to patients may improve patient satisfaction and acceptance of trainee involvement in care.[6] However, only 10% of hospitalized patients in 1 study correctly identified a physician on their inpatient team, demonstrating the need for introductions during each and every inpatient encounter.[11] The interns we observed introduced themselves to patients in only 40% of encounters. During admitting shifts, when the first encounter with a patient likely took place, interns introduced themselves during 46% of encounters.

A comforting touch has been shown to reduce anxiety levels among patients and improve compliance with treatment regimens, but the interns did not touch patients in one‐third of visits, including during admitting shifts. Sixty‐six percent of patients consider a physician's touch comforting, and 58% believe it to be healing.[8]

A randomized trial found that most patients preferred a sitting physician, and believed that practitioners who sat were more compassionate and spent more time with them.[9] Unfortunately, interns sat down with patients in fewer than 10% of encounters.

We do not know why interns do not engage in these simple behaviors, but it is not surprising given that their role models, including hospitalist physicians, do not practice them universally.[10] Personality differences, medical school experiences, and hospital factors such as patient volume and complexity may explain variability in performance.

Importantly, we know that habits learned in residency tend to be retained when physicians enter independent practice.[12] If we want attending physicians to practice etiquette‐based communication, then it must be role modeled, taught, and evaluated during residency by clinical educators and hospitalist physicians. The gap between intern perceptions and actual practice of these behaviors provides a window of opportunity for education and feedback in bedside communication. Attending physicians rate communication skills as 1 of the top values they seek to pass on to house officers.[13] Curricula on communication skills improve physician attitudes and beliefs about the importance of good communication as well as long‐term performance of communication skills.[14]

Our study had several limitations. First, all 732 patient encounters were assessed, regardless of whether the intern had seen the patient previously. This differed slightly from Kahn's assertion that these behaviors be performed at least on the first encounter with the patient. We believe that the need for common courtesy does not diminish after the first visit, and although certain behaviors may not be indicated on 100% of visits, our sensitivity analysis indicated performance of these behaviors was not likely even on the first visit of the day.

Second, our observations were limited to medicine interns at 2 programs in Baltimore during a single month, limiting generalizability. A convenience sample of interns was chosen for recruitment based on rotation on a general medicine rotation during the study month. We observed interns over the course of several shifts and throughout various positions in the call cycle.

Third, in any observational study, the Hawthorne effect is a potential limitation. We attempted to limit this bias by collecting information anonymously and not indicating to the interns which aspects of the patient encounter were being recorded.

Fourth, we defined the behaviors broadly in an attempt to measure the outcomes conservatively and maximize inter‐rater reliability. For instance, we did not differentiate in data collection between comforting touch and physical examination. Because chairs may not be readily available in all patient rooms, we included sitting on the patient's bed or crouching next to the bed as sitting with the patient. Use of open‐ended questions was observed as a more general form of Kahn's recommendation to ask how the patient is feeling.

Fifth, our poststudy survey was conducted 6 months after the observations were performed, used an ordinal rather than continuous response scale, and was limited to only 1 of the 2 programs and 9 of the 29 participants. Given this small sample size, generalizability of the results is limited. Additionally, intern practice of etiquette‐based communication may have improved between the observations and survey that took place 6 months later.

As hospital admissions are a time of vulnerability for patients, physicians can take a basic etiquette‐based communication approach to comfort patients and help them feel more secure. We found that even though interns believed they were practicing Kahn's recommended etiquette‐based communication, only a minority actually were. Curricula on communication styles or environmental changes, such as providing chairs in patient rooms or photographs identifying members of the medical team, may encourage performance of these behaviors.[15]

Over the last 40 years, innovations in medical care have dramatically improved the survival rates of children born with chronic illness or disabling health conditions; more than 90% are now expected to live beyond age 20 years, with approximately 500,000 reaching age 18 years every year.[1] The subset of these children with complex chronic disease use significant inpatient resources, accounting for 19.2% of pediatric inpatients, 48.9% of total pediatric hospital days, and 53.2% of pediatric hospital charges.[2, 3] This trend for high inpatient utilization and cost continues as the population ages, posing a potentially significant burden on pediatric hospitals.[4, 5] To reserve their specialized services for children, many pediatric hospitals impose age cutoffs for inpatient care; a national survey showed that 67% to 75% of patients over age 18 years with 4 specific chronic conditions (congenital heart disease [CHD], cystic fibrosis [CF], sickle cell disease [SCD], and spina bifida) were admitted to adult‐centered hospitals, as opposed to those providing exclusively pediatric or mixed services.[6] Admission rates for some conditions are growing faster in adults than in children, possibly due to increasing comorbidities with age.[7]

Although outpatient general internists indicated agreement that young adults with chronic diseases of childhood onset (CDoCO) should receive adult‐centered care, a majority did not feel comfortable providing it, or indicated a subspecialist should serve as the primary care provider.[8] Internal medicine residents also cite discomfort both with inpatient and outpatient management of patients with childhood onset illnesses and developmental disabilities.[9]

Due to their practice focus and the high inpatient utilization of this transitioning population, hospitalists will increasingly care for these adults. Academic hospitalists play an important role in medical education on the wards and can facilitate internal medicine residents learning about these patients. To date, no needs assessment has been completed regarding adult‐centered hospitalist perspectives regarding this population. This exploratory survey was designed to investigate adult hospitalist comfort level and concerns in caring for adults with CDoCO to guide potential educational interventions and improve care for this vulnerable population.

METHODS

RESULTS

Of the email requests delivered, 2713 were opened during the initial wave and 2535 during the second wave. A total of 179 respondents completed the survey.

DISCUSSION

In keeping with the increasing survival of children with chronic disease, a majority of hospitalists participating in adult‐centered settings were caring for adults with CDoCO. Despite their responsibility for these patients, a large proportion of both IM‐trained and community‐based providers in all specialties did not feel comfortable caring for them. These results correlate with an outpatient survey that showed less than a third of IM providers felt comfortable caring for specific CDoCO (CHD, SCD, CF).[8] The increased comfort of FM and MP hospitalists is consistent with their additional training in pediatric disease and development; however, a majority of hospitalists continue to be IM trained, highlighting the need for intervention for these providers. Increased comfort among providers closer to residency may reflect increased exposure to this growing population during training or fledgling educational initiatives.

Among IM providers, medical competence in adolescent development, behavior, and disease‐specific issues emerged as major concerns, likely compounded by insufficient subspecialty access. Outpatient internists similarly report insufficient training as a top barrier, although clinic‐based issues, such as lack of appointment time and reimbursement, were also highly rated.[10, 11] This survey indicates that educational initiatives should include hospitalists and highlights access to a medical knowledge base and disease‐specific support. Although specific training in all conditions would be out of the scope for most busy practitioners, targeting common conditions and issues, such as developmental disability and supportive devices, would be high yield. Extending educational interventions into trainee education has been postulated and well received by IM residents, who favor a multidimensional curricula in which hospitalists can play an important part.[12]

IM providers cited identifying partnering providers, both subspecialists and outpatient providers, to support ongoing care as a secondary theme. An outpatient survey of pediatric and IM providers showed at least half felt identifying an adult‐centered primary care provider would be difficult and care coordination inadequate; poor outpatient subspecialty access for common conditions was less prevalent.[11] The discomfort of outpatient IM providers may be limiting; however, early identification of need, improved coordination throughout inpatient stay, and discharge planning could ease this transition for all providers. Care coordination support staff would benefit from familiarizing themselves with this population's needs, which are different from typical adult inpatients. Even though meeting psychosocial needs was a highly rated barrier, clarifying questions about those needs did not show a pattern in this or prior outpatient surveys, limiting targeted interventions.

Engaging the community of adult‐centered providers is key to providing appropriate health care services that continue uninterrupted as the individual moves from adolescence to adulthood as charged by a joint consensus statement on transition of patients with CDoCO.[13] Overall comfort level is likely affected by the interaction between insufficient knowledge base on CDoCO and perception of insufficient subspecialty support or unclear outpatient follow‐up. Future directions should center on curricular development surrounding high‐yield CDoCO topics and improved inpatient care coordination.

CONCLUSIONS

The steadily growing population of adults with CDoCO and their high inpatient utilization have lead to increased care by adult‐centered hospitalists, many of whom do not feel comfortable caring for them. Educational initiatives aimed at increasing the medical knowledge base for common issues, training in adolescent development, increased care coordination, and access to address psychosocial issues would improve hospitalist comfort and patient care for this vulnerable population.

Over the last 40 years, innovations in medical care have dramatically improved the survival rates of children born with chronic illness or disabling health conditions; more than 90% are now expected to live beyond age 20 years, with approximately 500,000 reaching age 18 years every year.[1] The subset of these children with complex chronic disease use significant inpatient resources, accounting for 19.2% of pediatric inpatients, 48.9% of total pediatric hospital days, and 53.2% of pediatric hospital charges.[2, 3] This trend for high inpatient utilization and cost continues as the population ages, posing a potentially significant burden on pediatric hospitals.[4, 5] To reserve their specialized services for children, many pediatric hospitals impose age cutoffs for inpatient care; a national survey showed that 67% to 75% of patients over age 18 years with 4 specific chronic conditions (congenital heart disease [CHD], cystic fibrosis [CF], sickle cell disease [SCD], and spina bifida) were admitted to adult‐centered hospitals, as opposed to those providing exclusively pediatric or mixed services.[6] Admission rates for some conditions are growing faster in adults than in children, possibly due to increasing comorbidities with age.[7]

Although outpatient general internists indicated agreement that young adults with chronic diseases of childhood onset (CDoCO) should receive adult‐centered care, a majority did not feel comfortable providing it, or indicated a subspecialist should serve as the primary care provider.[8] Internal medicine residents also cite discomfort both with inpatient and outpatient management of patients with childhood onset illnesses and developmental disabilities.[9]

Due to their practice focus and the high inpatient utilization of this transitioning population, hospitalists will increasingly care for these adults. Academic hospitalists play an important role in medical education on the wards and can facilitate internal medicine residents learning about these patients. To date, no needs assessment has been completed regarding adult‐centered hospitalist perspectives regarding this population. This exploratory survey was designed to investigate adult hospitalist comfort level and concerns in caring for adults with CDoCO to guide potential educational interventions and improve care for this vulnerable population.

METHODS

RESULTS

Of the email requests delivered, 2713 were opened during the initial wave and 2535 during the second wave. A total of 179 respondents completed the survey.

DISCUSSION

In keeping with the increasing survival of children with chronic disease, a majority of hospitalists participating in adult‐centered settings were caring for adults with CDoCO. Despite their responsibility for these patients, a large proportion of both IM‐trained and community‐based providers in all specialties did not feel comfortable caring for them. These results correlate with an outpatient survey that showed less than a third of IM providers felt comfortable caring for specific CDoCO (CHD, SCD, CF).[8] The increased comfort of FM and MP hospitalists is consistent with their additional training in pediatric disease and development; however, a majority of hospitalists continue to be IM trained, highlighting the need for intervention for these providers. Increased comfort among providers closer to residency may reflect increased exposure to this growing population during training or fledgling educational initiatives.

Among IM providers, medical competence in adolescent development, behavior, and disease‐specific issues emerged as major concerns, likely compounded by insufficient subspecialty access. Outpatient internists similarly report insufficient training as a top barrier, although clinic‐based issues, such as lack of appointment time and reimbursement, were also highly rated.[10, 11] This survey indicates that educational initiatives should include hospitalists and highlights access to a medical knowledge base and disease‐specific support. Although specific training in all conditions would be out of the scope for most busy practitioners, targeting common conditions and issues, such as developmental disability and supportive devices, would be high yield. Extending educational interventions into trainee education has been postulated and well received by IM residents, who favor a multidimensional curricula in which hospitalists can play an important part.[12]

IM providers cited identifying partnering providers, both subspecialists and outpatient providers, to support ongoing care as a secondary theme. An outpatient survey of pediatric and IM providers showed at least half felt identifying an adult‐centered primary care provider would be difficult and care coordination inadequate; poor outpatient subspecialty access for common conditions was less prevalent.[11] The discomfort of outpatient IM providers may be limiting; however, early identification of need, improved coordination throughout inpatient stay, and discharge planning could ease this transition for all providers. Care coordination support staff would benefit from familiarizing themselves with this population's needs, which are different from typical adult inpatients. Even though meeting psychosocial needs was a highly rated barrier, clarifying questions about those needs did not show a pattern in this or prior outpatient surveys, limiting targeted interventions.

Engaging the community of adult‐centered providers is key to providing appropriate health care services that continue uninterrupted as the individual moves from adolescence to adulthood as charged by a joint consensus statement on transition of patients with CDoCO.[13] Overall comfort level is likely affected by the interaction between insufficient knowledge base on CDoCO and perception of insufficient subspecialty support or unclear outpatient follow‐up. Future directions should center on curricular development surrounding high‐yield CDoCO topics and improved inpatient care coordination.

CONCLUSIONS

The steadily growing population of adults with CDoCO and their high inpatient utilization have lead to increased care by adult‐centered hospitalists, many of whom do not feel comfortable caring for them. Educational initiatives aimed at increasing the medical knowledge base for common issues, training in adolescent development, increased care coordination, and access to address psychosocial issues would improve hospitalist comfort and patient care for this vulnerable population.

Over the last 40 years, innovations in medical care have dramatically improved the survival rates of children born with chronic illness or disabling health conditions; more than 90% are now expected to live beyond age 20 years, with approximately 500,000 reaching age 18 years every year.[1] The subset of these children with complex chronic disease use significant inpatient resources, accounting for 19.2% of pediatric inpatients, 48.9% of total pediatric hospital days, and 53.2% of pediatric hospital charges.[2, 3] This trend for high inpatient utilization and cost continues as the population ages, posing a potentially significant burden on pediatric hospitals.[4, 5] To reserve their specialized services for children, many pediatric hospitals impose age cutoffs for inpatient care; a national survey showed that 67% to 75% of patients over age 18 years with 4 specific chronic conditions (congenital heart disease [CHD], cystic fibrosis [CF], sickle cell disease [SCD], and spina bifida) were admitted to adult‐centered hospitals, as opposed to those providing exclusively pediatric or mixed services.[6] Admission rates for some conditions are growing faster in adults than in children, possibly due to increasing comorbidities with age.[7]

Although outpatient general internists indicated agreement that young adults with chronic diseases of childhood onset (CDoCO) should receive adult‐centered care, a majority did not feel comfortable providing it, or indicated a subspecialist should serve as the primary care provider.[8] Internal medicine residents also cite discomfort both with inpatient and outpatient management of patients with childhood onset illnesses and developmental disabilities.[9]

Due to their practice focus and the high inpatient utilization of this transitioning population, hospitalists will increasingly care for these adults. Academic hospitalists play an important role in medical education on the wards and can facilitate internal medicine residents learning about these patients. To date, no needs assessment has been completed regarding adult‐centered hospitalist perspectives regarding this population. This exploratory survey was designed to investigate adult hospitalist comfort level and concerns in caring for adults with CDoCO to guide potential educational interventions and improve care for this vulnerable population.

METHODS

RESULTS

Of the email requests delivered, 2713 were opened during the initial wave and 2535 during the second wave. A total of 179 respondents completed the survey.

DISCUSSION

In keeping with the increasing survival of children with chronic disease, a majority of hospitalists participating in adult‐centered settings were caring for adults with CDoCO. Despite their responsibility for these patients, a large proportion of both IM‐trained and community‐based providers in all specialties did not feel comfortable caring for them. These results correlate with an outpatient survey that showed less than a third of IM providers felt comfortable caring for specific CDoCO (CHD, SCD, CF).[8] The increased comfort of FM and MP hospitalists is consistent with their additional training in pediatric disease and development; however, a majority of hospitalists continue to be IM trained, highlighting the need for intervention for these providers. Increased comfort among providers closer to residency may reflect increased exposure to this growing population during training or fledgling educational initiatives.

Among IM providers, medical competence in adolescent development, behavior, and disease‐specific issues emerged as major concerns, likely compounded by insufficient subspecialty access. Outpatient internists similarly report insufficient training as a top barrier, although clinic‐based issues, such as lack of appointment time and reimbursement, were also highly rated.[10, 11] This survey indicates that educational initiatives should include hospitalists and highlights access to a medical knowledge base and disease‐specific support. Although specific training in all conditions would be out of the scope for most busy practitioners, targeting common conditions and issues, such as developmental disability and supportive devices, would be high yield. Extending educational interventions into trainee education has been postulated and well received by IM residents, who favor a multidimensional curricula in which hospitalists can play an important part.[12]

IM providers cited identifying partnering providers, both subspecialists and outpatient providers, to support ongoing care as a secondary theme. An outpatient survey of pediatric and IM providers showed at least half felt identifying an adult‐centered primary care provider would be difficult and care coordination inadequate; poor outpatient subspecialty access for common conditions was less prevalent.[11] The discomfort of outpatient IM providers may be limiting; however, early identification of need, improved coordination throughout inpatient stay, and discharge planning could ease this transition for all providers. Care coordination support staff would benefit from familiarizing themselves with this population's needs, which are different from typical adult inpatients. Even though meeting psychosocial needs was a highly rated barrier, clarifying questions about those needs did not show a pattern in this or prior outpatient surveys, limiting targeted interventions.

Engaging the community of adult‐centered providers is key to providing appropriate health care services that continue uninterrupted as the individual moves from adolescence to adulthood as charged by a joint consensus statement on transition of patients with CDoCO.[13] Overall comfort level is likely affected by the interaction between insufficient knowledge base on CDoCO and perception of insufficient subspecialty support or unclear outpatient follow‐up. Future directions should center on curricular development surrounding high‐yield CDoCO topics and improved inpatient care coordination.

CONCLUSIONS

The steadily growing population of adults with CDoCO and their high inpatient utilization have lead to increased care by adult‐centered hospitalists, many of whom do not feel comfortable caring for them. Educational initiatives aimed at increasing the medical knowledge base for common issues, training in adolescent development, increased care coordination, and access to address psychosocial issues would improve hospitalist comfort and patient care for this vulnerable population.

The focus on care transitions and readmissions is expanding beyond the development of risk scores based on objective clinical data to quality improvement interventions involving the key stakeholders in the process, namely the patients and their multidisciplinary providers.[1, 2] The Institute for Healthcare Improvement's State Action on Avoidable Rehospitalizations initiative promotes formulating a specific transition plan and developing multidisciplinary management strategies for all patients.[3] The Transition of Care Consensus Policy Statement developed by a coalition including the American College of Physicians and Society of Hospital Medicine emphasizes accountability, communication, and involvement of the patient and family members in plans of care.[4] Yet, interventions to reduce readmissions and improve the quality and safety of care transitions remain only modestly and inconsistently effective.

Successful interventions are those that are combined and coordinated, and shared across the hospital and community settings.[5] In this study, we sought to understand the issues leading to readmissions and barriers as perceived by patients, family members, physicians, nurses, and social workers. We compared and contrasted the perspectives by discipline and used this information to design a descriptive framework of a multidisciplinary, collaborative, and coordinated support network integral to effective care transitions, which we term a Patient Care Circle (PCC) (Figure 1).

Figure 1

METHODS

RESULTS

We recruited 43 interview and 28 focus group participants (Table 1). From our transcript analysis, we generated 22 codes and categorized them into 5 themes embodying the issues pertinent to readmissions from the perspective of the stakeholders: (1) teamwork, (2) health systems navigation and management, (3) illness severity and health needs, (4) psychosocial stability; and (5) medications (Table 2).

We applied these codes and themes to build a descriptive framework depicting what we believed is the essential foundation for successful care transitions, a collaborative unified patient‐centered network to address complex healthcare‐related issues across disciplines and across settings (Figure 1). Our model illustrates the interplay between the various physician and care‐provider roles as well as the relationship of the structure of the care circle to each theme.

DISCUSSION

We categorized our findings into5 principle themes that influence care transitions: teamwork, systems navigation and management, illness severity, and health needs, psychosocial stability, and medications. Many of these themes have been targeted in the literature for interventions to reduce readmissions and improve care transitions. An overarching theme of our study was the importance of the Patient Care Circle, a support system required to implement and execute comprehensive patient‐centered plans for safe and effective transitions across all settings.

Collectively, our themes emphasized that communication and comprehensive planning between all members of the PCC were instrumental to the circle's ability to address issues pertaining to the patient‐centered themes: systems navigation and management, illness severity and health needs, psychosocial stability, and medications. The strength of the bonds and collaboration within the PCC were directly dependent on the success of teamwork.

The interplay between the 4 patient‐centered themes and the degree to which they affect readmissions were variable and patient dependent. Complexities of the healthcare system and issues surrounding medications became more apparent with worsening disease severity and psychosocial instability. Complicated patients requiring more multidisciplinary interaction highlighted limitations of dispersed teams and staffing ratios. Patients faced with insurance restrictions, difficulties attending appointments, and obtaining medications required pooling the efforts of multiple PCC members to help them. Thus, these themes emphasized not only the importance of teamwork required for care coordination, but also guided the membership of the PCC to meet the patient's specific needs across the inpatient and outpatient settings.

When participants were asked to identify modifiable reasons for readmissions, the overwhelming collective response was inadequate communication and collaboration among PCC members. Clear role assignments and delegation of responsibility were also necessary to avoid gaps in care. Significant barriers to improvement included limited resources and inability to maintain the integrity of the support network needed for safe transitions.

Finally, we compared and contrasted the perceptions of the different disciplines on the factors contributing to each patient's readmission. Over all, there was substantial overlap. However, each perspective added additional layers of information allowing for a more comprehensive understanding of the problem. This demonstrated the utility of multidisciplinary patient‐centered interviews to examine readmissions and elucidate areas for intervention.

Several disciplines were not included in interviews or focus groups but were identified by our study participants as integral to a comprehensive Patient Care Circle. These include emergency medicine physicians, inpatient and outpatient pharmacists, and outpatient social workers. Some disciplines were not included due to challenges identifying discrete providers and with arranging interviews or focus groups. As their roles were mentioned several times in multiple forums, we have included them in our descriptive framework.

We designed this study with the hope of completing a full complement of patient‐specific interviews that included all stakeholders for 4 male and 4 female patients. For several reasons, we were unable to do so including challenges contacting providers and family members, and coordinating the timing of interviews with patient visits. Further, our focus on English‐speaking patients admitted to general medicine teams may limit generalizability to other vulnerable patient groups. Nevertheless, we believe we succeeded in interviewing a representative sample and obtained thematic saturation with the information obtained from our interviews and focus groups.

Last, the focus of this project was to obtain the perspectives of a full spectrum of stakeholders in the care transitions process to gain a better understanding of the reasons for readmissions. Although we did ask study participants to identify areas that may have been modifiable, we did not expand the discussion to include potential interventions, which will be the next step in our study.

CONCLUSION

Our article describes 5 main themes derived from the perspectives of multiple stakeholders involved in the care transitions process. An overarching theme was the importance of a multidisciplinary, coordinated collaborative care circle to ensure safe patient‐centered care in all settings.

The results of this study can be used by researchers and applied by care providers to improve the care transitions process. Researchers can build on our model by studying methods and interventions to improve the function of the care circle and design guidelines to create a more effective and integrated network. Institutions can adapt our methodology and tools to identify the needs of their own patient population and optimize membership in the PCC accordingly.

We feel that improving the structure and function of the care circle is necessary prior to designing interventions targeting the patient‐centered themes. Strengthening the teamwork of the PCC is fundamental to improving the quality of care transitions and reducing preventable readmissions.