Emergency department (ED) crowding leads to ambulance diversion,1 which can delay care and worsen outcomes, including mortality.2 A national survey showed that 90% of EDs were overcrowded, and 70% reported time on diversion.3 One of the causes of ED crowding is boarding of admitted patients.4 Boarding admitted patients decreases quality of care and satisfaction.57

Improved ED triage, bedside registration, physical expansion of hospitals, and regional ambulance programs have been implemented to decrease ED diversion.812 Despite these attempts, ED diversion continues to be prevalent.

Interventions involving hospitalists have been tested to improve throughput and quality of care for admitted medicine patients boarded in the ED. Howell and colleagues decreased ED diversion through active bed management by hospitalists.13 Briones and colleagues dedicated a hospitalist team to patients boarded in the ED and improved their quality of care.14

Denver Health Medical Center (DHMC) is an urban, academic safety net hospital. In 2009, the ED saw an average of 133 patients daily and an average of 25 were admitted to the medical service. DHMC's ED diversion rate was a mean of 12.4% in 2009. Boarded medicine patients occupied 16% of ED medicine bed capacity. Teaching and nonteaching medical floor teams cared for patients in the ED awaiting inpatient beds, who were the last to be seen. Nursing supervisors transferred boarded patients from the ED to hospital units. Patients with the greatest duration of time in the ED had priority for open beds.

ED diversion is costly.15, 16 DHMC implemented codified diversion criteria, calling the administrator on‐call prior to diversion, and increasing frequency of rounding in the ED, with no sustained effect seen in the rate of ED diversion.

In 2009, the DHMC Hospital Medicine Service addressed the issue of ED crowding, ED diversion, and care of boarded ED patients by creating a hospital medicine ED (HMED) team with 2 functions: (1) to provide ongoing care for medicine patients in the ED awaiting inpatient beds; and (2) to work with nursing supervisors to improve patient flow by adding physician clinical expertise to bed management.

METHODS

Intervention

In 2009, DHMC, which uses Toyota Lean for quality improvement, performed a Rapid Improvement Event (RIE) to address ED diversion and care of admitted patients boarded in the ED. The RIE team consisted of hospital medicine physicians, ED physicians, social workers, and nurses. Over a 4‐day period, the team examined the present state, created an ideal future state, devised a solution, and tested this solution.

Based upon the results of the RIE, DHMC implemented an HMED team to care for admitted patients boarded in the ED and assist in active bed management. The HMED team is a 24/7 service. During the day shift, the HMED team is composed of 1 dedicated attending and 1 allied health provider (AHP). Since the medicine services were already staffing existing patients in the ED, the 2.0 full‐time equivalent (FTE) needed to staff the HMED team attending and the AHP was reallocated from existing FTE within the hospitalist division. During the evening and night shifts, the HMED team's responsibilities were rolled into existing hospitalist duties.

The HMED team provides clinical care for 2 groups of patients in the ED. The first group represents admitted patients who are still awaiting a medicine ward bed as of 7:00 AM. The HMED team provides ongoing care until discharge from the ED or transfer to a medicine floor. The second group of patients includes new admissions that need to stay in the ED due to a lack of available medicine floor beds. For these patients, the HMED team initiates and continues care until discharge from the ED or transfer to a medical floor (Figure 1).

Figure 1

The physician on the HMED team assists nursing supervisors with bed management by providing detailed clinical knowledge, including proximity to discharge as well as updated information on telemetry and intensive care unit (ICU) appropriateness. The HMED team's physician maintains constant knowledge of hospital census via an electronic bed board, and communicates regularly with medical floors about anticipated discharges and transfers to understand the hospital's patient flow status (Figure 2).

Figure 2

The RIE that resulted in the HMED team was part of the Inpatient Medicine Value Stream, which had the overall goal of saving DHMC $300,000 for 2009. Ten RIEs were planned for this value stream in 2009, with an average of $30,000 of savings expected from each RIE.

RESULTS

The ED saw 48,595 patients during the intervention period (August 1, 2009June 30,2010) which did not differ statistically from the 50,469 patients seen in the control period (August 1, 2008June 30, 2009). The number of admissions to the medicine service during the control period (9727) and intervention period (10,013), and the number of total medical/surgical admissions during the control (20,716) and intervention (20,574) periods did not statistically differ. ED staffing during the intervention did not change. The overall number of licensed beds did not increase during the study period. During the control period, staffed medical/surgical beds increased from 395 to 400 beds, while the number of staffed medical/surgical beds decreased from 400 to 397 beds during the intervention period. Patient characteristics were similar during the 2 time periods, with the exception of race (Table 1).

DISCUSSION

This study suggests that an HMED team can decrease ED diversion, due to hospital bed capacity, by improving patient flow and timeliness of care for boarded medicine patients in the ED.

After participating in bed management, ED diversion due to a lack of medicine beds decreased. This is consistent with findings by Howell and colleagues who were able to improve throughput and decrease ED diversion with active bed management.13 Howell and colleagues decreased diversion hours due to temporary ED overload, and diversion hours due to a lack of telemetry or critical care beds. At DHMC, diversion is attributed to either a lack of ED capacity or lack of hospital beds. The primary outcome was the diversion rate due to lack of hospital beds, but it is possible that increased discharges directly from the ED contributed to the decrease in diversion due to ED capacity, underestimating the effect our intervention had on total ED diversion. There were no other initiatives to decrease diversion due to ED capacity during the study periods, and ED capacity and volume did not change during the intervention period.

While there were no statistically significant changes in staffed medical/surgical beds or medicine admissions, staffed medical/surgical beds during the intervention period decreased while there were more admissions to medicine. Both of these variables would increase diversion, resulting in an underestimation of the effect of the intervention.

Howell and colleagues improved throughput in the ED by implementing a service which provided active bed management without clinical responsibilities,13 while Briones and colleagues improved clinical care of patients boarded in the ED without affecting throughput.14 The HMED team improved throughput and decreased ED diversion while improving timeliness of care and perception of care quality for patients boarding in the ED.

By decreasing unnecessary transfers to medicine units and increasing discharges from the ED, patient flow was improved. While there was no difference in ED LOS, there was a trend towards decreased total LOS. A larger sample size or a longer period of observation would be necessary to determine if the trend toward decreased total LOS is statistically significant. ED LOS may not have been decreased because patients who would have been sent to the floor only to be discharged within 8 hours were kept in the ED to expedite testing and discharge, while sicker patients were sent to the medical floor. This decreased the turnover time of inpatient beds and allowed more boarded patients to be moved to floor units.

There was concern that an HMED team would fragment care, which would lead to an increased LOS for those patients who were transferred to a medical floor and cared for by an additional medicine team before discharge.17 As noted, there was a trend towards a decreased LOS for patients initially cared for by the HMED team.

In this intervention, hospital medicine physicians provided information regarding ongoing care of patients boarded in the ED to nursing supervisors. Prior to the intervention, nursing supervisors relied upon information from the ED staff and the boarded patient's time in the ED to assign a medical floor. However, ED staff was not providing care to boarded patients and did not know the most up‐to‐date status of the patient. This queuing process and lack of communication resulted in patients ready for discharge being transferred to floor beds and discharged within a few hours of transfer. The HMED team allowed nursing supervisors to have direct knowledge regarding clinical status, including telemetry and ICU criteria (similar to Howell and colleagues13), and readiness for discharge from the physician taking care of the patient.

By managing boarded patients, an HMED team can improve timeliness and coordination of care. Prior to the intervention, boarded ED patients were the last to be seen on rounds. The HMED team rounds only in the ED, expediting care and discharges. The increased proportion of boarded patients discharged from the ED by the HMED team is consistent with Briones and colleagues' clinically oriented team managing boarding patients in the ED.14

Potential adverse effects of our intervention included increased returns to the ED, increased ICU transfer rate, and decreased housestaff satisfaction. There was no increase in the 48‐hour return rate and no increase in the ICU transfer rate for patients cared for by the HMED team. Housestaff at DHMC are satisfied with the HMED team, since the presence of the HMED team allows them to concentrate on patients on the medical floors.

This intervention provides DHMC with an additional $525,600 in revenue annually. Since existing FTE were reallocated to create the HMED team, no additional FTE were required. In our facility, AHPs take on duties of housestaff. However, only 1 physician may be needed to staff an HMED team. This physician's clinical productivity is about 75% of other physicians; therefore, 25% of time is spent in bed management. At DHMC, other medicine teams picked up for the decreased clinical productivity of the HMED team, so the budget was neutral. However, using 2 FTE to staff 1 physician daily for 365 days a year, one would need to allocate 0.5 physician FTE (0.25 decrease in clinical productivity 2 FTE) for an HMED team.

Our study has several limitations. As a single center study, our findings may not extrapolate to other settings. The study used historical controls, therefore, undetected confounders may exist. We could not control for simultaneous changes in the hospital, however, we did not know of any other concurrent interventions aimed at decreasing ED diversion. Also, the decision to admit or not is partially based on individual ED attendings, which causes variability in practice. Finally, while we were able to measure rounding times as a process measure to reflect timeliness of care and staff perceptions of quality of care, due to our data infrastructure and the way our housestaff and attendings rotate, we were not able to assess more downstream measures of quality of care.

CONCLUSION

ED crowding decreases throughput and worsens clinical care; there are few proven solutions. This study demonstrates an intervention that reduced the percentage of patients transferred to a medicine floor and discharged within 8 hours, increased the number of discharges from the ED of admitted medicine patients, and decreased ED diversion while improving the timeliness of clinical care for patients boarded in the ED.

Emergency department (ED) crowding leads to ambulance diversion,1 which can delay care and worsen outcomes, including mortality.2 A national survey showed that 90% of EDs were overcrowded, and 70% reported time on diversion.3 One of the causes of ED crowding is boarding of admitted patients.4 Boarding admitted patients decreases quality of care and satisfaction.57

Improved ED triage, bedside registration, physical expansion of hospitals, and regional ambulance programs have been implemented to decrease ED diversion.812 Despite these attempts, ED diversion continues to be prevalent.

Interventions involving hospitalists have been tested to improve throughput and quality of care for admitted medicine patients boarded in the ED. Howell and colleagues decreased ED diversion through active bed management by hospitalists.13 Briones and colleagues dedicated a hospitalist team to patients boarded in the ED and improved their quality of care.14

Denver Health Medical Center (DHMC) is an urban, academic safety net hospital. In 2009, the ED saw an average of 133 patients daily and an average of 25 were admitted to the medical service. DHMC's ED diversion rate was a mean of 12.4% in 2009. Boarded medicine patients occupied 16% of ED medicine bed capacity. Teaching and nonteaching medical floor teams cared for patients in the ED awaiting inpatient beds, who were the last to be seen. Nursing supervisors transferred boarded patients from the ED to hospital units. Patients with the greatest duration of time in the ED had priority for open beds.

ED diversion is costly.15, 16 DHMC implemented codified diversion criteria, calling the administrator on‐call prior to diversion, and increasing frequency of rounding in the ED, with no sustained effect seen in the rate of ED diversion.

In 2009, the DHMC Hospital Medicine Service addressed the issue of ED crowding, ED diversion, and care of boarded ED patients by creating a hospital medicine ED (HMED) team with 2 functions: (1) to provide ongoing care for medicine patients in the ED awaiting inpatient beds; and (2) to work with nursing supervisors to improve patient flow by adding physician clinical expertise to bed management.

METHODS

Intervention

In 2009, DHMC, which uses Toyota Lean for quality improvement, performed a Rapid Improvement Event (RIE) to address ED diversion and care of admitted patients boarded in the ED. The RIE team consisted of hospital medicine physicians, ED physicians, social workers, and nurses. Over a 4‐day period, the team examined the present state, created an ideal future state, devised a solution, and tested this solution.

Based upon the results of the RIE, DHMC implemented an HMED team to care for admitted patients boarded in the ED and assist in active bed management. The HMED team is a 24/7 service. During the day shift, the HMED team is composed of 1 dedicated attending and 1 allied health provider (AHP). Since the medicine services were already staffing existing patients in the ED, the 2.0 full‐time equivalent (FTE) needed to staff the HMED team attending and the AHP was reallocated from existing FTE within the hospitalist division. During the evening and night shifts, the HMED team's responsibilities were rolled into existing hospitalist duties.

The HMED team provides clinical care for 2 groups of patients in the ED. The first group represents admitted patients who are still awaiting a medicine ward bed as of 7:00 AM. The HMED team provides ongoing care until discharge from the ED or transfer to a medicine floor. The second group of patients includes new admissions that need to stay in the ED due to a lack of available medicine floor beds. For these patients, the HMED team initiates and continues care until discharge from the ED or transfer to a medical floor (Figure 1).

Figure 1

The physician on the HMED team assists nursing supervisors with bed management by providing detailed clinical knowledge, including proximity to discharge as well as updated information on telemetry and intensive care unit (ICU) appropriateness. The HMED team's physician maintains constant knowledge of hospital census via an electronic bed board, and communicates regularly with medical floors about anticipated discharges and transfers to understand the hospital's patient flow status (Figure 2).

Figure 2

The RIE that resulted in the HMED team was part of the Inpatient Medicine Value Stream, which had the overall goal of saving DHMC $300,000 for 2009. Ten RIEs were planned for this value stream in 2009, with an average of $30,000 of savings expected from each RIE.

RESULTS

The ED saw 48,595 patients during the intervention period (August 1, 2009June 30,2010) which did not differ statistically from the 50,469 patients seen in the control period (August 1, 2008June 30, 2009). The number of admissions to the medicine service during the control period (9727) and intervention period (10,013), and the number of total medical/surgical admissions during the control (20,716) and intervention (20,574) periods did not statistically differ. ED staffing during the intervention did not change. The overall number of licensed beds did not increase during the study period. During the control period, staffed medical/surgical beds increased from 395 to 400 beds, while the number of staffed medical/surgical beds decreased from 400 to 397 beds during the intervention period. Patient characteristics were similar during the 2 time periods, with the exception of race (Table 1).

DISCUSSION

This study suggests that an HMED team can decrease ED diversion, due to hospital bed capacity, by improving patient flow and timeliness of care for boarded medicine patients in the ED.

After participating in bed management, ED diversion due to a lack of medicine beds decreased. This is consistent with findings by Howell and colleagues who were able to improve throughput and decrease ED diversion with active bed management.13 Howell and colleagues decreased diversion hours due to temporary ED overload, and diversion hours due to a lack of telemetry or critical care beds. At DHMC, diversion is attributed to either a lack of ED capacity or lack of hospital beds. The primary outcome was the diversion rate due to lack of hospital beds, but it is possible that increased discharges directly from the ED contributed to the decrease in diversion due to ED capacity, underestimating the effect our intervention had on total ED diversion. There were no other initiatives to decrease diversion due to ED capacity during the study periods, and ED capacity and volume did not change during the intervention period.

While there were no statistically significant changes in staffed medical/surgical beds or medicine admissions, staffed medical/surgical beds during the intervention period decreased while there were more admissions to medicine. Both of these variables would increase diversion, resulting in an underestimation of the effect of the intervention.

Howell and colleagues improved throughput in the ED by implementing a service which provided active bed management without clinical responsibilities,13 while Briones and colleagues improved clinical care of patients boarded in the ED without affecting throughput.14 The HMED team improved throughput and decreased ED diversion while improving timeliness of care and perception of care quality for patients boarding in the ED.

By decreasing unnecessary transfers to medicine units and increasing discharges from the ED, patient flow was improved. While there was no difference in ED LOS, there was a trend towards decreased total LOS. A larger sample size or a longer period of observation would be necessary to determine if the trend toward decreased total LOS is statistically significant. ED LOS may not have been decreased because patients who would have been sent to the floor only to be discharged within 8 hours were kept in the ED to expedite testing and discharge, while sicker patients were sent to the medical floor. This decreased the turnover time of inpatient beds and allowed more boarded patients to be moved to floor units.

There was concern that an HMED team would fragment care, which would lead to an increased LOS for those patients who were transferred to a medical floor and cared for by an additional medicine team before discharge.17 As noted, there was a trend towards a decreased LOS for patients initially cared for by the HMED team.

In this intervention, hospital medicine physicians provided information regarding ongoing care of patients boarded in the ED to nursing supervisors. Prior to the intervention, nursing supervisors relied upon information from the ED staff and the boarded patient's time in the ED to assign a medical floor. However, ED staff was not providing care to boarded patients and did not know the most up‐to‐date status of the patient. This queuing process and lack of communication resulted in patients ready for discharge being transferred to floor beds and discharged within a few hours of transfer. The HMED team allowed nursing supervisors to have direct knowledge regarding clinical status, including telemetry and ICU criteria (similar to Howell and colleagues13), and readiness for discharge from the physician taking care of the patient.

By managing boarded patients, an HMED team can improve timeliness and coordination of care. Prior to the intervention, boarded ED patients were the last to be seen on rounds. The HMED team rounds only in the ED, expediting care and discharges. The increased proportion of boarded patients discharged from the ED by the HMED team is consistent with Briones and colleagues' clinically oriented team managing boarding patients in the ED.14

Potential adverse effects of our intervention included increased returns to the ED, increased ICU transfer rate, and decreased housestaff satisfaction. There was no increase in the 48‐hour return rate and no increase in the ICU transfer rate for patients cared for by the HMED team. Housestaff at DHMC are satisfied with the HMED team, since the presence of the HMED team allows them to concentrate on patients on the medical floors.

This intervention provides DHMC with an additional $525,600 in revenue annually. Since existing FTE were reallocated to create the HMED team, no additional FTE were required. In our facility, AHPs take on duties of housestaff. However, only 1 physician may be needed to staff an HMED team. This physician's clinical productivity is about 75% of other physicians; therefore, 25% of time is spent in bed management. At DHMC, other medicine teams picked up for the decreased clinical productivity of the HMED team, so the budget was neutral. However, using 2 FTE to staff 1 physician daily for 365 days a year, one would need to allocate 0.5 physician FTE (0.25 decrease in clinical productivity 2 FTE) for an HMED team.

Our study has several limitations. As a single center study, our findings may not extrapolate to other settings. The study used historical controls, therefore, undetected confounders may exist. We could not control for simultaneous changes in the hospital, however, we did not know of any other concurrent interventions aimed at decreasing ED diversion. Also, the decision to admit or not is partially based on individual ED attendings, which causes variability in practice. Finally, while we were able to measure rounding times as a process measure to reflect timeliness of care and staff perceptions of quality of care, due to our data infrastructure and the way our housestaff and attendings rotate, we were not able to assess more downstream measures of quality of care.

CONCLUSION

ED crowding decreases throughput and worsens clinical care; there are few proven solutions. This study demonstrates an intervention that reduced the percentage of patients transferred to a medicine floor and discharged within 8 hours, increased the number of discharges from the ED of admitted medicine patients, and decreased ED diversion while improving the timeliness of clinical care for patients boarded in the ED.

Emergency department (ED) crowding leads to ambulance diversion,1 which can delay care and worsen outcomes, including mortality.2 A national survey showed that 90% of EDs were overcrowded, and 70% reported time on diversion.3 One of the causes of ED crowding is boarding of admitted patients.4 Boarding admitted patients decreases quality of care and satisfaction.57

Improved ED triage, bedside registration, physical expansion of hospitals, and regional ambulance programs have been implemented to decrease ED diversion.812 Despite these attempts, ED diversion continues to be prevalent.

Interventions involving hospitalists have been tested to improve throughput and quality of care for admitted medicine patients boarded in the ED. Howell and colleagues decreased ED diversion through active bed management by hospitalists.13 Briones and colleagues dedicated a hospitalist team to patients boarded in the ED and improved their quality of care.14

Denver Health Medical Center (DHMC) is an urban, academic safety net hospital. In 2009, the ED saw an average of 133 patients daily and an average of 25 were admitted to the medical service. DHMC's ED diversion rate was a mean of 12.4% in 2009. Boarded medicine patients occupied 16% of ED medicine bed capacity. Teaching and nonteaching medical floor teams cared for patients in the ED awaiting inpatient beds, who were the last to be seen. Nursing supervisors transferred boarded patients from the ED to hospital units. Patients with the greatest duration of time in the ED had priority for open beds.

ED diversion is costly.15, 16 DHMC implemented codified diversion criteria, calling the administrator on‐call prior to diversion, and increasing frequency of rounding in the ED, with no sustained effect seen in the rate of ED diversion.

In 2009, the DHMC Hospital Medicine Service addressed the issue of ED crowding, ED diversion, and care of boarded ED patients by creating a hospital medicine ED (HMED) team with 2 functions: (1) to provide ongoing care for medicine patients in the ED awaiting inpatient beds; and (2) to work with nursing supervisors to improve patient flow by adding physician clinical expertise to bed management.

METHODS

Intervention

In 2009, DHMC, which uses Toyota Lean for quality improvement, performed a Rapid Improvement Event (RIE) to address ED diversion and care of admitted patients boarded in the ED. The RIE team consisted of hospital medicine physicians, ED physicians, social workers, and nurses. Over a 4‐day period, the team examined the present state, created an ideal future state, devised a solution, and tested this solution.

Based upon the results of the RIE, DHMC implemented an HMED team to care for admitted patients boarded in the ED and assist in active bed management. The HMED team is a 24/7 service. During the day shift, the HMED team is composed of 1 dedicated attending and 1 allied health provider (AHP). Since the medicine services were already staffing existing patients in the ED, the 2.0 full‐time equivalent (FTE) needed to staff the HMED team attending and the AHP was reallocated from existing FTE within the hospitalist division. During the evening and night shifts, the HMED team's responsibilities were rolled into existing hospitalist duties.

The HMED team provides clinical care for 2 groups of patients in the ED. The first group represents admitted patients who are still awaiting a medicine ward bed as of 7:00 AM. The HMED team provides ongoing care until discharge from the ED or transfer to a medicine floor. The second group of patients includes new admissions that need to stay in the ED due to a lack of available medicine floor beds. For these patients, the HMED team initiates and continues care until discharge from the ED or transfer to a medical floor (Figure 1).

Figure 1

The physician on the HMED team assists nursing supervisors with bed management by providing detailed clinical knowledge, including proximity to discharge as well as updated information on telemetry and intensive care unit (ICU) appropriateness. The HMED team's physician maintains constant knowledge of hospital census via an electronic bed board, and communicates regularly with medical floors about anticipated discharges and transfers to understand the hospital's patient flow status (Figure 2).

Figure 2

The RIE that resulted in the HMED team was part of the Inpatient Medicine Value Stream, which had the overall goal of saving DHMC $300,000 for 2009. Ten RIEs were planned for this value stream in 2009, with an average of $30,000 of savings expected from each RIE.

RESULTS

The ED saw 48,595 patients during the intervention period (August 1, 2009June 30,2010) which did not differ statistically from the 50,469 patients seen in the control period (August 1, 2008June 30, 2009). The number of admissions to the medicine service during the control period (9727) and intervention period (10,013), and the number of total medical/surgical admissions during the control (20,716) and intervention (20,574) periods did not statistically differ. ED staffing during the intervention did not change. The overall number of licensed beds did not increase during the study period. During the control period, staffed medical/surgical beds increased from 395 to 400 beds, while the number of staffed medical/surgical beds decreased from 400 to 397 beds during the intervention period. Patient characteristics were similar during the 2 time periods, with the exception of race (Table 1).

DISCUSSION

This study suggests that an HMED team can decrease ED diversion, due to hospital bed capacity, by improving patient flow and timeliness of care for boarded medicine patients in the ED.

After participating in bed management, ED diversion due to a lack of medicine beds decreased. This is consistent with findings by Howell and colleagues who were able to improve throughput and decrease ED diversion with active bed management.13 Howell and colleagues decreased diversion hours due to temporary ED overload, and diversion hours due to a lack of telemetry or critical care beds. At DHMC, diversion is attributed to either a lack of ED capacity or lack of hospital beds. The primary outcome was the diversion rate due to lack of hospital beds, but it is possible that increased discharges directly from the ED contributed to the decrease in diversion due to ED capacity, underestimating the effect our intervention had on total ED diversion. There were no other initiatives to decrease diversion due to ED capacity during the study periods, and ED capacity and volume did not change during the intervention period.

While there were no statistically significant changes in staffed medical/surgical beds or medicine admissions, staffed medical/surgical beds during the intervention period decreased while there were more admissions to medicine. Both of these variables would increase diversion, resulting in an underestimation of the effect of the intervention.

Howell and colleagues improved throughput in the ED by implementing a service which provided active bed management without clinical responsibilities,13 while Briones and colleagues improved clinical care of patients boarded in the ED without affecting throughput.14 The HMED team improved throughput and decreased ED diversion while improving timeliness of care and perception of care quality for patients boarding in the ED.

By decreasing unnecessary transfers to medicine units and increasing discharges from the ED, patient flow was improved. While there was no difference in ED LOS, there was a trend towards decreased total LOS. A larger sample size or a longer period of observation would be necessary to determine if the trend toward decreased total LOS is statistically significant. ED LOS may not have been decreased because patients who would have been sent to the floor only to be discharged within 8 hours were kept in the ED to expedite testing and discharge, while sicker patients were sent to the medical floor. This decreased the turnover time of inpatient beds and allowed more boarded patients to be moved to floor units.

There was concern that an HMED team would fragment care, which would lead to an increased LOS for those patients who were transferred to a medical floor and cared for by an additional medicine team before discharge.17 As noted, there was a trend towards a decreased LOS for patients initially cared for by the HMED team.

In this intervention, hospital medicine physicians provided information regarding ongoing care of patients boarded in the ED to nursing supervisors. Prior to the intervention, nursing supervisors relied upon information from the ED staff and the boarded patient's time in the ED to assign a medical floor. However, ED staff was not providing care to boarded patients and did not know the most up‐to‐date status of the patient. This queuing process and lack of communication resulted in patients ready for discharge being transferred to floor beds and discharged within a few hours of transfer. The HMED team allowed nursing supervisors to have direct knowledge regarding clinical status, including telemetry and ICU criteria (similar to Howell and colleagues13), and readiness for discharge from the physician taking care of the patient.

By managing boarded patients, an HMED team can improve timeliness and coordination of care. Prior to the intervention, boarded ED patients were the last to be seen on rounds. The HMED team rounds only in the ED, expediting care and discharges. The increased proportion of boarded patients discharged from the ED by the HMED team is consistent with Briones and colleagues' clinically oriented team managing boarding patients in the ED.14

Potential adverse effects of our intervention included increased returns to the ED, increased ICU transfer rate, and decreased housestaff satisfaction. There was no increase in the 48‐hour return rate and no increase in the ICU transfer rate for patients cared for by the HMED team. Housestaff at DHMC are satisfied with the HMED team, since the presence of the HMED team allows them to concentrate on patients on the medical floors.

This intervention provides DHMC with an additional $525,600 in revenue annually. Since existing FTE were reallocated to create the HMED team, no additional FTE were required. In our facility, AHPs take on duties of housestaff. However, only 1 physician may be needed to staff an HMED team. This physician's clinical productivity is about 75% of other physicians; therefore, 25% of time is spent in bed management. At DHMC, other medicine teams picked up for the decreased clinical productivity of the HMED team, so the budget was neutral. However, using 2 FTE to staff 1 physician daily for 365 days a year, one would need to allocate 0.5 physician FTE (0.25 decrease in clinical productivity 2 FTE) for an HMED team.

Our study has several limitations. As a single center study, our findings may not extrapolate to other settings. The study used historical controls, therefore, undetected confounders may exist. We could not control for simultaneous changes in the hospital, however, we did not know of any other concurrent interventions aimed at decreasing ED diversion. Also, the decision to admit or not is partially based on individual ED attendings, which causes variability in practice. Finally, while we were able to measure rounding times as a process measure to reflect timeliness of care and staff perceptions of quality of care, due to our data infrastructure and the way our housestaff and attendings rotate, we were not able to assess more downstream measures of quality of care.

CONCLUSION

ED crowding decreases throughput and worsens clinical care; there are few proven solutions. This study demonstrates an intervention that reduced the percentage of patients transferred to a medicine floor and discharged within 8 hours, increased the number of discharges from the ED of admitted medicine patients, and decreased ED diversion while improving the timeliness of clinical care for patients boarded in the ED.

Hospital medicine is growing rapidly across the nation with more than 30,000 active hospitalists in more than 90% of all hospitals across the country.1 Although initially focused in the community sector, hospitalists have had an increasing presence within academic centers. The University Healthsystem Consortium 2006 survey found that hospitalists were practicing in 86% of university hospitals, and the average age of the hospital medicine programs was only 4.6 years.2 This changing inpatient work force has had consequences on medical education with an increased hospitalist presence in both resident and student training. The full effects of this have not yet been completely elucidated.

Initially met by educators with apprehension, there is a growing body of literature to suggest that hospitalists are perceived by students to be more effective clinical teachers than non‐hospitalists.3, 4 Multiple studies have demonstrated improved trainee satisfaction, attending teaching efficacy, trainee's perception of attending knowledge, and attending involvement in patient care decisions when working with hospitalists.58 Early concerns regarding diminished trainee autonomy are not supported by the available data.4

However, the extent to which hospitalists are involved in teaching Internal Medicine (IM) to medical students is not known. A study reported in 2000 suggests that hospitalists are prevalent within education.9 Over the past decade though, the hospitalist movement has grown exponentially; the role of hospitalists within teaching activities have likely changed significantly over this same time period. Hospital medicine is the fastest growing medical specialty in this country. In order to determine the role of hospitalists in medical student education within the United States and Canada, we queried clerkship directors in Internal Medicine as part of the 2010 annual Clerkship Directors in Internal Medicine (CDIM) survey.

METHODS

In June 2010, CDIM surveyed its North American institutional members, which represents 107 of 143 Departments of Medicine in the US and Canada. CDIM membership consists of university affiliated academic programs with a medical school. In 2009, 52% were public/state‐funded institutions, 40% were private medical schools, and 3% were military. All CDIM institutional members were sent an electronic mail cover message that explained the purpose of the survey and contained a link to the confidential electronic survey. Nonrespondents were contacted up to 3 additional times by e‐mail and once by telephone. Participants were blinded to any specific hypothesis of the study. The institutional review board (IRB) at Case Western Reserve University reviewed the protocol and determined that the CDIM Survey research protocol did not fit the definition of human subjects' research per 45 CFR 46.102, and declared the study exempt from further IRB review.

RESULTS

Eighty‐two (77%) of 107 departments of medicine responded to the survey. At these academic institutions, the majority of departments indicated that hospitalists serve as teaching attendings at their teaching hospital (91%).

We summarize clerkship directors' responses regarding the percentage of students that rotate with academic hospitalists in Table 1. At 20 medical schools (24%), up to one‐quarter of students rotate with hospitalists. At 23 medical schools (28%), one‐quarter to one‐half of students rotate with hospitalists. Ten departments (12%) indicated that 50% to 75% of students rotate with hospitalists, and 22 departments (27%) reported that 75% to 100% of their students are taught by hospitalists in the clinical setting.

Most students work with hospitalists on resident teaching services. However, 7 departments (9%) indicated that medical students doing their core clerkship rotate with hospitalists on non‐resident covered services. Few formal educational sessions are conducted by hospitalists (Table 2). In 19 of the IM clerkships (23%), hospitalists conduct no formalized educational sessions. Forty‐two departments (51%) report that up to a quarter of these sessions are conducted by hospitalists. Eight (10%) report more than half of the formal educational sessions are conducted by academic hospitalists.

Clerkship directors reported that hospitalists play a role during student call experiences. The majority of respondents reported that students are directly supervised by a combination of residents and/or in‐house hospitalists (Table 3). Thirty‐three departments (42%) answered that in‐house hospitalists are involved in supervising core IM clerkship students during their nighttime call requirements. Students are supervised directly by residents at 59 (72%). Eight departments (10%) reported that students do not interact with hospitalists during call requirements. Three reported that in‐house hospitalists supervise students without residents (4%). Seven departments (9%) reported no call requirement, and 4 (5%) were unable to answer the question.

When asked to identify positions hospitalists hold in educational administration, 16 departments (20%) reported that academic hospitalists hold no educational administrative positions at their institution (Figure 1). Fourteen (17%) responded that academic hospitalists only have roles in patient safety. Eight (10%) reported other unspecified as the only administrative position at their institution. The remaining 44 departments of medicine (53%) responding reported that academic hospitalists hold clerkship and/or residency program leadership roles. In 7 departments (9%), the clerkship director is a hospitalist. At all programs in which this is the case, academic hospitalists hold additional educational administrative roles. The associate clerkship director was reported to be a hospitalist in 18 departments (22%). Site clerkship directors are hospitalists in 8 (10%). In residency education, hospitalists are slightly less prevalent. One participant responded that the residency program director was a hospitalist, while in 18 departments (22%), the hospitalists have roles as associate residency program directors.

Figure 1

Respondents were asked to comment on other clinical responsibilities for teaching attendings while on‐service. Thirteen (16%) indicated that teaching hospitalists had other clinical responsibilities, whereas 43 (52%) non‐hospitalist teaching attendings were reported to have other clinical responsibilities while on teaching service ( = 33.09, P < 0.0001). The additional responsibilities for teaching hospitalists included general medicine consults (3 programs), quality initiatives (2 programs), clinics (2 programs), additional nonteaching service patients (2 programs), and educational commitments (4 programs). Responsibilities identified for non‐hospitalist teaching attendings were primarily outpatient clinics (29 programs) or were unspecified (14 programs).

DISCUSSION

Over the past decade, hospital medicine has grown exponentially. This clinical growth has been mirrored in medical education. Our study finds that hospitalists teach in core Internal Medicine clerkships in the large majority of Departments of Internal Medicine throughout the US and Canada. Compared to 2000, in which approximately 50% of IM departments employed hospitalists and 80% of these worked with medical students (roughly 40% of all departments),9 we find that 91% of academic IM programs utilize hospitalists for core clerkship education. However, the majority of respondents (72%) reported that less than 25% of formal educational sessions were conducted by academic hospitalists during their core Internal Medicine clerkship. Thus, although hospitalists appear to be involved heavily in supervising medical students during the IM clerkship, the primary teaching modalities utilized appear to be informal. This may be due to the relative youth of the hospitalist movement, with newer faculty being less frequently recruited to conduct didactics. Alternatively, this may result from an historical reliance on subspecialists for Internal Medicine lectures (ie, renal failure lectures are given by a nephrologist, chest pain lectures are given by a cardiologist).

Our study shows that a significant number of hospitalists are involved in student overnight calls. Notably, almost half of the students doing overnight calls were supervised by in‐house hospitalists. This is an expected trend, particularly in the current environment in which intern night hours have been limited and extended shifts are less common.10 Residency programs have frequently shifted to night float systems, the value of which is unknown with regards to education and patient safety.11 Experienced attendings in the hospital afford a unique educational opportunity for third year medical students, and it appears they are being utilized as such.

Although the majority of core IM clerkship students rotate with resident teaching services, we found a small but measureable number of students who are on resident uncovered services. The educational efficacy of this model is not fully defined. In the subinternship setting, resident uncovered teaching hospitalist services were rated equivalently as compared to resident covered teaching services on measures of supervision, faculty assessment, the frequency and value of teaching sessions, and educational value of patient problems. However, students on uncovered services scored these lower on knowledge learned, intellectual discussions, and patient variety.12 Based on this feedback, caution should be taken in assigning more junior students to uncovered hospitalist services. This is especially true in the post‐duty hour setting which has already prompted concern related to student exposure to basic medical conditions.13

Despite the level of hospitalist involvement in core clerkship education, few clerkship directors are hospitalists. However, more than half of the Departments of Internal Medicine report hospitalists in some clerkship or residency educational position. Our survey did not address more senior College of Medicine leadership roles, and may, in fact, underrepresent educational leadership positions. Additionally, a large number of hospitalist have additional roles in patient safety, underscoring hospital medicine's leadership in this important niche post in the Institute of Medicine (IOM) report To Err is Human.14

Our findings indicate that hospitalists are significantly less likely to have additional clinical commitments while on‐service as compared to non‐hospitalist teaching attending. Non‐hospitalist teaching attendings were reported to frequently have outpatient clinic duties while teaching on the inpatient service. Conventional wisdom suggests that educators who are able to focus on teaching activities primarily will likely be better teachers. To date, literature has shown notable learner satisfaction with hospitalist educators.3, 4 However, there are no data on teaching efficacy and learning outcomes. Further studies need to explore the relationship between hospitalist attending status and improved trainee education.

Our study has several limitations. Our report is a survey of institutional members of CDIM. Since not all Departments of Medicine within Schools of Medicine have membership in CDIM, our results may have sampling bias. Additionally, our survey only asked clerkship directors in one discipline to report educational practices. There may be variability at different educational sites that are not captured by the responses. The Society of Hospital Medicine defines a hospitalist as a physician who specializes in the practice of hospital medicine, however, there remains some ambiguity with regards to how much inpatient focus is necessary to employ the term, and this may lead to errors in reporting. Nonetheless, our response rate of 82% is quite high, and suggests that this survey is reflective of national trends.

In summary, hospitalists are involved in medical student education in the majority of Departments of Internal Medicine throughout the US and Canada. They frequently supervise students in‐house at night, and some students rotate on non‐resident covered services. Hospitalists have a notable presence in academic education leadership positions and have significantly less outside clinical responsibilities, allowing them greater focus on teaching. Further studies should to be conducted to determine the effects of hospitalists on learning outcomes. Additional data is needed to determine the influence of hospitalists on students' attitudes and career choices with regards to Internal Medicine.

Hospital medicine is growing rapidly across the nation with more than 30,000 active hospitalists in more than 90% of all hospitals across the country.1 Although initially focused in the community sector, hospitalists have had an increasing presence within academic centers. The University Healthsystem Consortium 2006 survey found that hospitalists were practicing in 86% of university hospitals, and the average age of the hospital medicine programs was only 4.6 years.2 This changing inpatient work force has had consequences on medical education with an increased hospitalist presence in both resident and student training. The full effects of this have not yet been completely elucidated.

Initially met by educators with apprehension, there is a growing body of literature to suggest that hospitalists are perceived by students to be more effective clinical teachers than non‐hospitalists.3, 4 Multiple studies have demonstrated improved trainee satisfaction, attending teaching efficacy, trainee's perception of attending knowledge, and attending involvement in patient care decisions when working with hospitalists.58 Early concerns regarding diminished trainee autonomy are not supported by the available data.4

However, the extent to which hospitalists are involved in teaching Internal Medicine (IM) to medical students is not known. A study reported in 2000 suggests that hospitalists are prevalent within education.9 Over the past decade though, the hospitalist movement has grown exponentially; the role of hospitalists within teaching activities have likely changed significantly over this same time period. Hospital medicine is the fastest growing medical specialty in this country. In order to determine the role of hospitalists in medical student education within the United States and Canada, we queried clerkship directors in Internal Medicine as part of the 2010 annual Clerkship Directors in Internal Medicine (CDIM) survey.

METHODS

In June 2010, CDIM surveyed its North American institutional members, which represents 107 of 143 Departments of Medicine in the US and Canada. CDIM membership consists of university affiliated academic programs with a medical school. In 2009, 52% were public/state‐funded institutions, 40% were private medical schools, and 3% were military. All CDIM institutional members were sent an electronic mail cover message that explained the purpose of the survey and contained a link to the confidential electronic survey. Nonrespondents were contacted up to 3 additional times by e‐mail and once by telephone. Participants were blinded to any specific hypothesis of the study. The institutional review board (IRB) at Case Western Reserve University reviewed the protocol and determined that the CDIM Survey research protocol did not fit the definition of human subjects' research per 45 CFR 46.102, and declared the study exempt from further IRB review.

RESULTS

Eighty‐two (77%) of 107 departments of medicine responded to the survey. At these academic institutions, the majority of departments indicated that hospitalists serve as teaching attendings at their teaching hospital (91%).

We summarize clerkship directors' responses regarding the percentage of students that rotate with academic hospitalists in Table 1. At 20 medical schools (24%), up to one‐quarter of students rotate with hospitalists. At 23 medical schools (28%), one‐quarter to one‐half of students rotate with hospitalists. Ten departments (12%) indicated that 50% to 75% of students rotate with hospitalists, and 22 departments (27%) reported that 75% to 100% of their students are taught by hospitalists in the clinical setting.

Most students work with hospitalists on resident teaching services. However, 7 departments (9%) indicated that medical students doing their core clerkship rotate with hospitalists on non‐resident covered services. Few formal educational sessions are conducted by hospitalists (Table 2). In 19 of the IM clerkships (23%), hospitalists conduct no formalized educational sessions. Forty‐two departments (51%) report that up to a quarter of these sessions are conducted by hospitalists. Eight (10%) report more than half of the formal educational sessions are conducted by academic hospitalists.

Clerkship directors reported that hospitalists play a role during student call experiences. The majority of respondents reported that students are directly supervised by a combination of residents and/or in‐house hospitalists (Table 3). Thirty‐three departments (42%) answered that in‐house hospitalists are involved in supervising core IM clerkship students during their nighttime call requirements. Students are supervised directly by residents at 59 (72%). Eight departments (10%) reported that students do not interact with hospitalists during call requirements. Three reported that in‐house hospitalists supervise students without residents (4%). Seven departments (9%) reported no call requirement, and 4 (5%) were unable to answer the question.

When asked to identify positions hospitalists hold in educational administration, 16 departments (20%) reported that academic hospitalists hold no educational administrative positions at their institution (Figure 1). Fourteen (17%) responded that academic hospitalists only have roles in patient safety. Eight (10%) reported other unspecified as the only administrative position at their institution. The remaining 44 departments of medicine (53%) responding reported that academic hospitalists hold clerkship and/or residency program leadership roles. In 7 departments (9%), the clerkship director is a hospitalist. At all programs in which this is the case, academic hospitalists hold additional educational administrative roles. The associate clerkship director was reported to be a hospitalist in 18 departments (22%). Site clerkship directors are hospitalists in 8 (10%). In residency education, hospitalists are slightly less prevalent. One participant responded that the residency program director was a hospitalist, while in 18 departments (22%), the hospitalists have roles as associate residency program directors.

Figure 1

Respondents were asked to comment on other clinical responsibilities for teaching attendings while on‐service. Thirteen (16%) indicated that teaching hospitalists had other clinical responsibilities, whereas 43 (52%) non‐hospitalist teaching attendings were reported to have other clinical responsibilities while on teaching service ( = 33.09, P < 0.0001). The additional responsibilities for teaching hospitalists included general medicine consults (3 programs), quality initiatives (2 programs), clinics (2 programs), additional nonteaching service patients (2 programs), and educational commitments (4 programs). Responsibilities identified for non‐hospitalist teaching attendings were primarily outpatient clinics (29 programs) or were unspecified (14 programs).

DISCUSSION

Over the past decade, hospital medicine has grown exponentially. This clinical growth has been mirrored in medical education. Our study finds that hospitalists teach in core Internal Medicine clerkships in the large majority of Departments of Internal Medicine throughout the US and Canada. Compared to 2000, in which approximately 50% of IM departments employed hospitalists and 80% of these worked with medical students (roughly 40% of all departments),9 we find that 91% of academic IM programs utilize hospitalists for core clerkship education. However, the majority of respondents (72%) reported that less than 25% of formal educational sessions were conducted by academic hospitalists during their core Internal Medicine clerkship. Thus, although hospitalists appear to be involved heavily in supervising medical students during the IM clerkship, the primary teaching modalities utilized appear to be informal. This may be due to the relative youth of the hospitalist movement, with newer faculty being less frequently recruited to conduct didactics. Alternatively, this may result from an historical reliance on subspecialists for Internal Medicine lectures (ie, renal failure lectures are given by a nephrologist, chest pain lectures are given by a cardiologist).

Our study shows that a significant number of hospitalists are involved in student overnight calls. Notably, almost half of the students doing overnight calls were supervised by in‐house hospitalists. This is an expected trend, particularly in the current environment in which intern night hours have been limited and extended shifts are less common.10 Residency programs have frequently shifted to night float systems, the value of which is unknown with regards to education and patient safety.11 Experienced attendings in the hospital afford a unique educational opportunity for third year medical students, and it appears they are being utilized as such.

Although the majority of core IM clerkship students rotate with resident teaching services, we found a small but measureable number of students who are on resident uncovered services. The educational efficacy of this model is not fully defined. In the subinternship setting, resident uncovered teaching hospitalist services were rated equivalently as compared to resident covered teaching services on measures of supervision, faculty assessment, the frequency and value of teaching sessions, and educational value of patient problems. However, students on uncovered services scored these lower on knowledge learned, intellectual discussions, and patient variety.12 Based on this feedback, caution should be taken in assigning more junior students to uncovered hospitalist services. This is especially true in the post‐duty hour setting which has already prompted concern related to student exposure to basic medical conditions.13

Despite the level of hospitalist involvement in core clerkship education, few clerkship directors are hospitalists. However, more than half of the Departments of Internal Medicine report hospitalists in some clerkship or residency educational position. Our survey did not address more senior College of Medicine leadership roles, and may, in fact, underrepresent educational leadership positions. Additionally, a large number of hospitalist have additional roles in patient safety, underscoring hospital medicine's leadership in this important niche post in the Institute of Medicine (IOM) report To Err is Human.14

Our findings indicate that hospitalists are significantly less likely to have additional clinical commitments while on‐service as compared to non‐hospitalist teaching attending. Non‐hospitalist teaching attendings were reported to frequently have outpatient clinic duties while teaching on the inpatient service. Conventional wisdom suggests that educators who are able to focus on teaching activities primarily will likely be better teachers. To date, literature has shown notable learner satisfaction with hospitalist educators.3, 4 However, there are no data on teaching efficacy and learning outcomes. Further studies need to explore the relationship between hospitalist attending status and improved trainee education.

Our study has several limitations. Our report is a survey of institutional members of CDIM. Since not all Departments of Medicine within Schools of Medicine have membership in CDIM, our results may have sampling bias. Additionally, our survey only asked clerkship directors in one discipline to report educational practices. There may be variability at different educational sites that are not captured by the responses. The Society of Hospital Medicine defines a hospitalist as a physician who specializes in the practice of hospital medicine, however, there remains some ambiguity with regards to how much inpatient focus is necessary to employ the term, and this may lead to errors in reporting. Nonetheless, our response rate of 82% is quite high, and suggests that this survey is reflective of national trends.

In summary, hospitalists are involved in medical student education in the majority of Departments of Internal Medicine throughout the US and Canada. They frequently supervise students in‐house at night, and some students rotate on non‐resident covered services. Hospitalists have a notable presence in academic education leadership positions and have significantly less outside clinical responsibilities, allowing them greater focus on teaching. Further studies should to be conducted to determine the effects of hospitalists on learning outcomes. Additional data is needed to determine the influence of hospitalists on students' attitudes and career choices with regards to Internal Medicine.

Hospital medicine is growing rapidly across the nation with more than 30,000 active hospitalists in more than 90% of all hospitals across the country.1 Although initially focused in the community sector, hospitalists have had an increasing presence within academic centers. The University Healthsystem Consortium 2006 survey found that hospitalists were practicing in 86% of university hospitals, and the average age of the hospital medicine programs was only 4.6 years.2 This changing inpatient work force has had consequences on medical education with an increased hospitalist presence in both resident and student training. The full effects of this have not yet been completely elucidated.

Initially met by educators with apprehension, there is a growing body of literature to suggest that hospitalists are perceived by students to be more effective clinical teachers than non‐hospitalists.3, 4 Multiple studies have demonstrated improved trainee satisfaction, attending teaching efficacy, trainee's perception of attending knowledge, and attending involvement in patient care decisions when working with hospitalists.58 Early concerns regarding diminished trainee autonomy are not supported by the available data.4

However, the extent to which hospitalists are involved in teaching Internal Medicine (IM) to medical students is not known. A study reported in 2000 suggests that hospitalists are prevalent within education.9 Over the past decade though, the hospitalist movement has grown exponentially; the role of hospitalists within teaching activities have likely changed significantly over this same time period. Hospital medicine is the fastest growing medical specialty in this country. In order to determine the role of hospitalists in medical student education within the United States and Canada, we queried clerkship directors in Internal Medicine as part of the 2010 annual Clerkship Directors in Internal Medicine (CDIM) survey.

METHODS

In June 2010, CDIM surveyed its North American institutional members, which represents 107 of 143 Departments of Medicine in the US and Canada. CDIM membership consists of university affiliated academic programs with a medical school. In 2009, 52% were public/state‐funded institutions, 40% were private medical schools, and 3% were military. All CDIM institutional members were sent an electronic mail cover message that explained the purpose of the survey and contained a link to the confidential electronic survey. Nonrespondents were contacted up to 3 additional times by e‐mail and once by telephone. Participants were blinded to any specific hypothesis of the study. The institutional review board (IRB) at Case Western Reserve University reviewed the protocol and determined that the CDIM Survey research protocol did not fit the definition of human subjects' research per 45 CFR 46.102, and declared the study exempt from further IRB review.

RESULTS

Eighty‐two (77%) of 107 departments of medicine responded to the survey. At these academic institutions, the majority of departments indicated that hospitalists serve as teaching attendings at their teaching hospital (91%).

We summarize clerkship directors' responses regarding the percentage of students that rotate with academic hospitalists in Table 1. At 20 medical schools (24%), up to one‐quarter of students rotate with hospitalists. At 23 medical schools (28%), one‐quarter to one‐half of students rotate with hospitalists. Ten departments (12%) indicated that 50% to 75% of students rotate with hospitalists, and 22 departments (27%) reported that 75% to 100% of their students are taught by hospitalists in the clinical setting.

Most students work with hospitalists on resident teaching services. However, 7 departments (9%) indicated that medical students doing their core clerkship rotate with hospitalists on non‐resident covered services. Few formal educational sessions are conducted by hospitalists (Table 2). In 19 of the IM clerkships (23%), hospitalists conduct no formalized educational sessions. Forty‐two departments (51%) report that up to a quarter of these sessions are conducted by hospitalists. Eight (10%) report more than half of the formal educational sessions are conducted by academic hospitalists.

Clerkship directors reported that hospitalists play a role during student call experiences. The majority of respondents reported that students are directly supervised by a combination of residents and/or in‐house hospitalists (Table 3). Thirty‐three departments (42%) answered that in‐house hospitalists are involved in supervising core IM clerkship students during their nighttime call requirements. Students are supervised directly by residents at 59 (72%). Eight departments (10%) reported that students do not interact with hospitalists during call requirements. Three reported that in‐house hospitalists supervise students without residents (4%). Seven departments (9%) reported no call requirement, and 4 (5%) were unable to answer the question.

When asked to identify positions hospitalists hold in educational administration, 16 departments (20%) reported that academic hospitalists hold no educational administrative positions at their institution (Figure 1). Fourteen (17%) responded that academic hospitalists only have roles in patient safety. Eight (10%) reported other unspecified as the only administrative position at their institution. The remaining 44 departments of medicine (53%) responding reported that academic hospitalists hold clerkship and/or residency program leadership roles. In 7 departments (9%), the clerkship director is a hospitalist. At all programs in which this is the case, academic hospitalists hold additional educational administrative roles. The associate clerkship director was reported to be a hospitalist in 18 departments (22%). Site clerkship directors are hospitalists in 8 (10%). In residency education, hospitalists are slightly less prevalent. One participant responded that the residency program director was a hospitalist, while in 18 departments (22%), the hospitalists have roles as associate residency program directors.

Figure 1

Respondents were asked to comment on other clinical responsibilities for teaching attendings while on‐service. Thirteen (16%) indicated that teaching hospitalists had other clinical responsibilities, whereas 43 (52%) non‐hospitalist teaching attendings were reported to have other clinical responsibilities while on teaching service ( = 33.09, P < 0.0001). The additional responsibilities for teaching hospitalists included general medicine consults (3 programs), quality initiatives (2 programs), clinics (2 programs), additional nonteaching service patients (2 programs), and educational commitments (4 programs). Responsibilities identified for non‐hospitalist teaching attendings were primarily outpatient clinics (29 programs) or were unspecified (14 programs).

DISCUSSION

Over the past decade, hospital medicine has grown exponentially. This clinical growth has been mirrored in medical education. Our study finds that hospitalists teach in core Internal Medicine clerkships in the large majority of Departments of Internal Medicine throughout the US and Canada. Compared to 2000, in which approximately 50% of IM departments employed hospitalists and 80% of these worked with medical students (roughly 40% of all departments),9 we find that 91% of academic IM programs utilize hospitalists for core clerkship education. However, the majority of respondents (72%) reported that less than 25% of formal educational sessions were conducted by academic hospitalists during their core Internal Medicine clerkship. Thus, although hospitalists appear to be involved heavily in supervising medical students during the IM clerkship, the primary teaching modalities utilized appear to be informal. This may be due to the relative youth of the hospitalist movement, with newer faculty being less frequently recruited to conduct didactics. Alternatively, this may result from an historical reliance on subspecialists for Internal Medicine lectures (ie, renal failure lectures are given by a nephrologist, chest pain lectures are given by a cardiologist).

Our study shows that a significant number of hospitalists are involved in student overnight calls. Notably, almost half of the students doing overnight calls were supervised by in‐house hospitalists. This is an expected trend, particularly in the current environment in which intern night hours have been limited and extended shifts are less common.10 Residency programs have frequently shifted to night float systems, the value of which is unknown with regards to education and patient safety.11 Experienced attendings in the hospital afford a unique educational opportunity for third year medical students, and it appears they are being utilized as such.

Although the majority of core IM clerkship students rotate with resident teaching services, we found a small but measureable number of students who are on resident uncovered services. The educational efficacy of this model is not fully defined. In the subinternship setting, resident uncovered teaching hospitalist services were rated equivalently as compared to resident covered teaching services on measures of supervision, faculty assessment, the frequency and value of teaching sessions, and educational value of patient problems. However, students on uncovered services scored these lower on knowledge learned, intellectual discussions, and patient variety.12 Based on this feedback, caution should be taken in assigning more junior students to uncovered hospitalist services. This is especially true in the post‐duty hour setting which has already prompted concern related to student exposure to basic medical conditions.13

Despite the level of hospitalist involvement in core clerkship education, few clerkship directors are hospitalists. However, more than half of the Departments of Internal Medicine report hospitalists in some clerkship or residency educational position. Our survey did not address more senior College of Medicine leadership roles, and may, in fact, underrepresent educational leadership positions. Additionally, a large number of hospitalist have additional roles in patient safety, underscoring hospital medicine's leadership in this important niche post in the Institute of Medicine (IOM) report To Err is Human.14

Our findings indicate that hospitalists are significantly less likely to have additional clinical commitments while on‐service as compared to non‐hospitalist teaching attending. Non‐hospitalist teaching attendings were reported to frequently have outpatient clinic duties while teaching on the inpatient service. Conventional wisdom suggests that educators who are able to focus on teaching activities primarily will likely be better teachers. To date, literature has shown notable learner satisfaction with hospitalist educators.3, 4 However, there are no data on teaching efficacy and learning outcomes. Further studies need to explore the relationship between hospitalist attending status and improved trainee education.

Our study has several limitations. Our report is a survey of institutional members of CDIM. Since not all Departments of Medicine within Schools of Medicine have membership in CDIM, our results may have sampling bias. Additionally, our survey only asked clerkship directors in one discipline to report educational practices. There may be variability at different educational sites that are not captured by the responses. The Society of Hospital Medicine defines a hospitalist as a physician who specializes in the practice of hospital medicine, however, there remains some ambiguity with regards to how much inpatient focus is necessary to employ the term, and this may lead to errors in reporting. Nonetheless, our response rate of 82% is quite high, and suggests that this survey is reflective of national trends.

In summary, hospitalists are involved in medical student education in the majority of Departments of Internal Medicine throughout the US and Canada. They frequently supervise students in‐house at night, and some students rotate on non‐resident covered services. Hospitalists have a notable presence in academic education leadership positions and have significantly less outside clinical responsibilities, allowing them greater focus on teaching. Further studies should to be conducted to determine the effects of hospitalists on learning outcomes. Additional data is needed to determine the influence of hospitalists on students' attitudes and career choices with regards to Internal Medicine.

Postgraduate medical education has traditionally relied on a training model of progressive independence, where housestaff learn patient care through increasing autonomy and decreasing levels of supervision.1 While this framework has little empirical backing, it is grounded in sound educational theory from similar disciplines and endorsed by medical associations.1, 2 The Accreditation Council for Graduate Medical Education (ACGME) recently implemented regulations requiring that first‐year residents have a qualified supervisor physically present or immediately available at all times.3 Previously, oversight by an offsite supervisor (for example, an attending physician at home) was considered adequate. These new regulations, although motivated by patient safety imperatives,4 have elicited concerns that increased supervision may lead to decreased housestaff autonomy and an increased reliance on supervisors for clinical guidance.5 Such changes could ultimately produce less qualified practitioners by the completion of training.

Critics of the current training model point to a patient safety mechanism where housestaff must take responsibility for requesting attending‐level help when situations arise that surpass their skill level.5 For resident physicians, however, the decision to request support is often complex and dependent not only on the clinical question, but also on unique and variable trainee and supervisor factors.6 Survey data from 1999, prior to the current training regulations, showed that increased faculty presence improved resident reports of educational value, quality of patient care, and autonomy.7 A recent survey, performed after the initiation of overnight attending supervision at an academic medical center, demonstrated perceived improvements in educational value and patient‐level outcomes by both faculty and housestaff.8 Whether increased supervision and resident autonomy can coexist remains undetermined.

Overnight rotations for residents (commonly referred to as night float) are often times of little direct or indirect supervision. A recent systematic review of clinical supervision practices for housestaff in all fields found scarce literature on overnight supervision practices.9 There remains limited and conflicting data regarding the quality of patient care provided by the resident night float,10 as well as evidence revealing a low perceived educational value of night rotations when compared with non‐night float rotations.11 Yet in 2006, more than three‐quarters of all internal medicine programs employed night float rotations.12 In response to ACGME guidelines mandating decreased shift lengths with continued restrictions on overall duty hours, it appears likely even more training programs will implement night float systems.

The presence of overnight hospitalists (also known as nocturnists) is growing within the academic setting, yet their role in relation to trainees is either poorly defined13 or independent of housestaff.14 To better understand the impact of increasing levels of supervision on residency training, we investigated housestaff perceptions of education, autonomy, and clinical decision‐making before and after implementation of an in‐hospital, overnight attending physician (nocturnist).

METHODS

The study was conducted at a 570‐bed academic, tertiary care medical center affiliated with an internal medicine residency program of 170 housestaff. At our institution, all first year residents perform a week of intern night float consisting of overnight cross‐coverage of general medicine patients on the floor, step‐down, and intensive care units (ICUs). Second and third year residents each complete 4 to 6 days of resident night float each year at this hospital. They are responsible for assisting the intern night float with cross‐coverage, in addition to admitting general medicine patients to the floor, step‐down unit, and intensive care units. Every night at our medical center, 1 intern night float and 1 resident night float are on duty in the hospital; this is in addition to a resident from the on‐call medicine team and a resident working in the ICU. Prior to July 2010, no internal medicine attending physicians were physically present in the hospital at night. Oversight for the intern and resident night float was provided by the attending physician for the on‐call resident ward team, who was at home and available by pager. The night float housestaff were instructed to contact the responsible attending physician only when a major change in clinical status occurred for hospitalized or newly admitted patients, though this expectation was neither standardized nor monitored.

We established a nocturnist program at the start of the 2010 academic year. The position was staffed by hospitalists from within the Division of Hospital Medicine without the use of moonlighters. Two‐thirds of shifts were filled by 3 dedicated nocturnists with remaining staffing provided by junior hospitalist faculty. The dedicated nocturnists had recently completed their internal medicine residency at our institution. Shift length was 12 hours and dedicated nocturnists worked, on average, 10 shifts per month. The nocturnist filled a critical overnight safety role through mandatory bedside staffing of newly admitted ICU patients within 2 hours of admission, discussion in person or via telephone of newly admitted step‐down unit patients within 6 hours of admission, and direct or indirect supervision of the care of any patients undergoing a major change in clinical status. The overnight hospitalist was also available for clinical questions and to assist housestaff with triaging of overnight admissions. After nocturnist implementation, overnight housestaff received direct supervision or had immediate access to direct supervision, while prior to the nocturnist, residents had access only to indirect supervision.

In addition, the nocturnist admitted medicine patients after 1 _AM in a 1:1 ratio with the admitting night float resident, performed medical consults, and provided coverage of non‐teaching medicine services. While actual volume numbers were not obtained, the estimated average of resident admissions per night was 2 to 3, and the number of nocturnist admissions was 1 to 2. The nocturnist also met nightly with night float housestaff for half‐hour didactics focusing on the management of common overnight clinical scenarios. The role of the new nocturnist was described to all housestaff in orientation materials given prior to their night float rotation and their general medicine ward rotation.

We administered pre‐rolling surveys and post‐rolling surveys of internal medicine intern and resident physicians who underwent the night float rotation at our hospital during the 2010 to 2011 academic year. Surveys examined housestaff perceptions of the night float rotation with regard to supervisory roles, educational and clinical value, and clinical decision‐making prior to and after implementation of the nocturnist. Surveys were designed by the study investigators based on prior literature,1, 510 personal experience, and housestaff suggestion, and were refined during works‐in‐progress meetings. Surveys were composed of Likert‐style questions asking housestaff to rate their level of agreement (15, strongly disagree to strongly agree) with statements regarding the supervisory and educational experience of the night float rotation, and to judge their frequency of contact (15, never to always/nightly) with an attending physician for specific clinical scenarios. The clinical scenarios described situations dealing with attendingresident communication around transfers of care, diagnostic evaluation, therapeutic interventions, and adverse events. Scenarios were taken from previous literature describing supervision preferences of faculty and residents during times of critical clinical decision‐making.15

One week prior to the beginning their night float rotation for the 20102011 academic year, housestaff were sent an e‐mail request to complete an online survey asking about their night float rotation during the prior academic year, when no nocturnist was present. One week after completion of their night float rotation for the 20102011 academic year, housestaff received an e‐mail with a link to a post‐survey asking about their recently completed, nocturnist‐supervised, night float rotation. First year residents received only a post‐survey at the completion of their night float rotation, as they would be unable to reflect on prior experience.

Informed consent was imbedded within the e‐mail survey request. Survey requests were sent by a fellow within the Division of Hospital Medicine with a brief message cosigned by an associate program director of the residency program. We did not collect unique identifiers from respondents in order to offer additional assurances to the participants that the survey was anonymous. There was no incentive offered for completion of the survey. Survey data were anonymous and downloaded to a database by a third party. Data were analyzed using Microsoft Excel, and pre‐responses and post‐responses compared using a Student t test. The study was approved by the medical center's Institutional Review Board.

RESULTS

Rates of response for pre‐surveys and post‐surveys were 57% (43 respondents) and 51% (53 respondents), respectively. Due to response rates and in order to convey accurately the perceptions of the training program as a whole, we collapsed responses of the pre‐surveys and post‐surveys based on level of training. After implementation of the overnight attending, we observed a significant increase in the perceived clinical value of the night float rotation (3.95 vs 4.27, P = 0.01) as well as in the adequacy of overnight supervision (3.65 vs 4.30, P < 0.0001; Table 1). There was no reported change in housestaff decision‐making autonomy (4.35 vs 4.45, P = 0.44). In addition, we noted a nonsignificant trend towards an increased perception of the night float rotation as a valuable educational experience (3.83 vs 4.04, P = 0.24). After implementation of the nocturnist, more resident physicians agreed that overnight supervision by an attending positively impacted patient outcomes (3.79 vs 4.30, P = 0.002).

After implementation of the nocturnist, night float providers demonstrated increased rates of contacting an attending physician overnight (Table 2). There were significantly greater rates of attending contact for transfers from outside facilities (2.00 vs 3.20, P = 0.006) and during times of adverse events (2.51 vs 3.25, P = 0.04). We observed a reported increase in attending contact prior to ordering invasive diagnostic procedures (1.75 vs 2.76, P = 0.004) and noninvasive diagnostic procedures (1.09 vs 1.31, P = 0.03), as well as prior to initiation of intravenous antibiotics (1.11 vs 1.47, P = 0.007) and vasopressors (1.52 vs 2.40, P = 0.004).

After initiating the program, the nocturnist became the most commonly contacted overnight provider by the night float housestaff (Table 3). We observed a decrease in peer to peer contact between the night float housestaff and the on‐call overnight resident after implementation of the nocturnist (2.67 vs 2.04, P = 0.006).

Attending presence led to increased agreement that there was a defined overnight attending to contact (2.97 vs 1.96, P < 0.0001) and a decreased fear of waking an attending overnight for assistance (3.26 vs 2.72, P = 0.03). Increased attending availability, however, did not change resident physician's fear of revealing knowledge gaps, their desire to make decisions independently, or their belief that contacting an attending would not change a patient's outcome (Table 4).

DISCUSSION

The ACGME's new duty hour regulations require that supervision for first‐year residents be provided by a qualified physician (advanced resident, fellow, or attending physician) who is physically present at the hospital. Our study demonstrates that increased direct overnight supervision provided by an in‐house nocturnist enhanced the clinical value of the night float rotation and the perceived quality of patient care. In our study, increased attending supervision did not reduce perceived decision‐making autonomy, and in fact led to increased rates of attending contact during times of critical clinical decision‐making. Such results may help assuage fears that recent regulations mandating enhanced attending supervision will produce less capable practitioners, and offers reassurance that such changes are positively impacting patient care.

Many academic institutions are implementing nocturnists, although their precise roles and responsibilities are still being defined. Our nocturnist program was explicitly designed with housestaff supervision as a core responsibility, with the goal of improving patient safety and housestaff education overnight. We found that availability barriers to attending contact were logically decreased with in‐house faculty presence. Potentially harmful attitudes, however, around requesting support (such as fear of revealing knowledge gaps or the desire to make decisions independently) remained. Furthermore, despite statistically significant increases in contact between faculty and residents at times of critical decision‐making, overall rates of attending contact for diagnostic and therapeutic interventions remained low. It is unknown from our study or previous research, however, what level of contact is appropriate or ideal for many clinical scenarios.

Additionally, we described a novel role of an academic nocturnist at a tertiary care teaching hospital and offered a potential template for the development of academic nocturnists at similar institutions seeking to increase direct overnight supervision. Such roles have not been previously well defined in the literature. Based on our experience, the nocturnist's role was manageable and well utilized by housestaff, particularly for assistance with critically ill patients and overnight triaging. We believe there are a number of factors associated with the success of this role. First, clear guidelines were presented to housestaff and nocturnists regarding expectations for supervision (for example, staffing ICU admissions within 2 hours). These guidelines likely contributed to the increased attending contact observed during critical clinical decision‐making, as well as the perceived improved patient outcomes by our housestaff. Second, the nocturnists were expected to be an integral part of the overnight care team. In many systems, the nocturnists act completely independently of the housestaff teams, creating an additional barrier to contact and communication. In our system, because of clear guidelines and their integral role in staffing overnight admissions, the nocturnists were an essential partner in care for the housestaff. Third, most of the nocturnists had recently completed their residency training at this institution. Although our survey does not directly address this, we believe their knowledge of the hospital, appreciation of the role of the intern and the resident within our system, and understanding of the need to preserve housestaff autonomy were essential to building a successful nocturnist role. Lastly, the nocturnists were not only expected to supervise and staff new admissions, but were also given a teaching expectation. We believe they were viewed by housestaff as qualified teaching attendings, similar to the daytime hospitalist. These findings may provide guidelines for other institutions seeking to balance overnight hospitalist supervision with preserving resident's ability to make autonomous decisions.

There are several limitations to our study. The findings represent the experience of internal medicine housestaff at a single academic, tertiary care medical center and may not be reflective of other institutions or specialties. We asked housestaff to recall night float experiences from the prior year, which may have introduced recall bias, though responses were obtained before participants underwent the new curriculum. Maturation of housestaff over time could have led to changes in perceived autonomy, value of the night float rotation, and rates of attending contact independent of nocturnist implementation. In addition, there may have been unaccounted changes to other elements of the residency program, hospital, or patient volume between rotations. The implementation of the nocturnist, however, was the only major change to our training program that academic year, and there were no significant changes in patient volume, structure of the teaching or non‐resident services, or other policies around resident supervision.

It is possible that the nocturnist may have contributed to reports of increased clinical value and perceived quality of patient care simply by decreasing overnight workload for housestaff, and enhanced supervision and teaching may have played a lesser role. Even if this were true, optimizing resident workload is in itself an important goal for teaching hospitals and residency programs alike in order to maximize patient safety. Inclusion of intern post‐rotation surveys may have influenced data; though, we had no reason to suspect the surveyed interns would respond in a different manner than prior resident groups. The responses of both junior and senior housestaff were pooled; while this potentially weighted the results in favor of higher responding groups, we felt that it conveyed the residents' accurate sentiments on the program. Finally, while we compared two models of overnight supervision, we reported only housestaff perceptions of education, autonomy, patient outcomes, and supervisory contact, and not direct measures of knowledge or patient care. Further research will be required to define the relationship between supervision practices and patient‐level clinical outcomes.

The new ACGME regulations around resident supervision, as well as the broader movement to improve the safety and quality of care, require residency programs to negotiate a delicate balance between providing high‐quality patient care while preserving graduated independence in clinical training. Our study demonstrates that increased overnight supervision by nocturnists with well‐defined supervisory and teaching roles can preserve housestaff autonomy, improve the clinical experience for trainees, increase access to support during times of critical decision‐making, and potentially lead to improved patient outcomes.

Postgraduate medical education has traditionally relied on a training model of progressive independence, where housestaff learn patient care through increasing autonomy and decreasing levels of supervision.1 While this framework has little empirical backing, it is grounded in sound educational theory from similar disciplines and endorsed by medical associations.1, 2 The Accreditation Council for Graduate Medical Education (ACGME) recently implemented regulations requiring that first‐year residents have a qualified supervisor physically present or immediately available at all times.3 Previously, oversight by an offsite supervisor (for example, an attending physician at home) was considered adequate. These new regulations, although motivated by patient safety imperatives,4 have elicited concerns that increased supervision may lead to decreased housestaff autonomy and an increased reliance on supervisors for clinical guidance.5 Such changes could ultimately produce less qualified practitioners by the completion of training.

Critics of the current training model point to a patient safety mechanism where housestaff must take responsibility for requesting attending‐level help when situations arise that surpass their skill level.5 For resident physicians, however, the decision to request support is often complex and dependent not only on the clinical question, but also on unique and variable trainee and supervisor factors.6 Survey data from 1999, prior to the current training regulations, showed that increased faculty presence improved resident reports of educational value, quality of patient care, and autonomy.7 A recent survey, performed after the initiation of overnight attending supervision at an academic medical center, demonstrated perceived improvements in educational value and patient‐level outcomes by both faculty and housestaff.8 Whether increased supervision and resident autonomy can coexist remains undetermined.

Overnight rotations for residents (commonly referred to as night float) are often times of little direct or indirect supervision. A recent systematic review of clinical supervision practices for housestaff in all fields found scarce literature on overnight supervision practices.9 There remains limited and conflicting data regarding the quality of patient care provided by the resident night float,10 as well as evidence revealing a low perceived educational value of night rotations when compared with non‐night float rotations.11 Yet in 2006, more than three‐quarters of all internal medicine programs employed night float rotations.12 In response to ACGME guidelines mandating decreased shift lengths with continued restrictions on overall duty hours, it appears likely even more training programs will implement night float systems.

The presence of overnight hospitalists (also known as nocturnists) is growing within the academic setting, yet their role in relation to trainees is either poorly defined13 or independent of housestaff.14 To better understand the impact of increasing levels of supervision on residency training, we investigated housestaff perceptions of education, autonomy, and clinical decision‐making before and after implementation of an in‐hospital, overnight attending physician (nocturnist).

METHODS

The study was conducted at a 570‐bed academic, tertiary care medical center affiliated with an internal medicine residency program of 170 housestaff. At our institution, all first year residents perform a week of intern night float consisting of overnight cross‐coverage of general medicine patients on the floor, step‐down, and intensive care units (ICUs). Second and third year residents each complete 4 to 6 days of resident night float each year at this hospital. They are responsible for assisting the intern night float with cross‐coverage, in addition to admitting general medicine patients to the floor, step‐down unit, and intensive care units. Every night at our medical center, 1 intern night float and 1 resident night float are on duty in the hospital; this is in addition to a resident from the on‐call medicine team and a resident working in the ICU. Prior to July 2010, no internal medicine attending physicians were physically present in the hospital at night. Oversight for the intern and resident night float was provided by the attending physician for the on‐call resident ward team, who was at home and available by pager. The night float housestaff were instructed to contact the responsible attending physician only when a major change in clinical status occurred for hospitalized or newly admitted patients, though this expectation was neither standardized nor monitored.

We established a nocturnist program at the start of the 2010 academic year. The position was staffed by hospitalists from within the Division of Hospital Medicine without the use of moonlighters. Two‐thirds of shifts were filled by 3 dedicated nocturnists with remaining staffing provided by junior hospitalist faculty. The dedicated nocturnists had recently completed their internal medicine residency at our institution. Shift length was 12 hours and dedicated nocturnists worked, on average, 10 shifts per month. The nocturnist filled a critical overnight safety role through mandatory bedside staffing of newly admitted ICU patients within 2 hours of admission, discussion in person or via telephone of newly admitted step‐down unit patients within 6 hours of admission, and direct or indirect supervision of the care of any patients undergoing a major change in clinical status. The overnight hospitalist was also available for clinical questions and to assist housestaff with triaging of overnight admissions. After nocturnist implementation, overnight housestaff received direct supervision or had immediate access to direct supervision, while prior to the nocturnist, residents had access only to indirect supervision.

In addition, the nocturnist admitted medicine patients after 1 _AM in a 1:1 ratio with the admitting night float resident, performed medical consults, and provided coverage of non‐teaching medicine services. While actual volume numbers were not obtained, the estimated average of resident admissions per night was 2 to 3, and the number of nocturnist admissions was 1 to 2. The nocturnist also met nightly with night float housestaff for half‐hour didactics focusing on the management of common overnight clinical scenarios. The role of the new nocturnist was described to all housestaff in orientation materials given prior to their night float rotation and their general medicine ward rotation.

We administered pre‐rolling surveys and post‐rolling surveys of internal medicine intern and resident physicians who underwent the night float rotation at our hospital during the 2010 to 2011 academic year. Surveys examined housestaff perceptions of the night float rotation with regard to supervisory roles, educational and clinical value, and clinical decision‐making prior to and after implementation of the nocturnist. Surveys were designed by the study investigators based on prior literature,1, 510 personal experience, and housestaff suggestion, and were refined during works‐in‐progress meetings. Surveys were composed of Likert‐style questions asking housestaff to rate their level of agreement (15, strongly disagree to strongly agree) with statements regarding the supervisory and educational experience of the night float rotation, and to judge their frequency of contact (15, never to always/nightly) with an attending physician for specific clinical scenarios. The clinical scenarios described situations dealing with attendingresident communication around transfers of care, diagnostic evaluation, therapeutic interventions, and adverse events. Scenarios were taken from previous literature describing supervision preferences of faculty and residents during times of critical clinical decision‐making.15

One week prior to the beginning their night float rotation for the 20102011 academic year, housestaff were sent an e‐mail request to complete an online survey asking about their night float rotation during the prior academic year, when no nocturnist was present. One week after completion of their night float rotation for the 20102011 academic year, housestaff received an e‐mail with a link to a post‐survey asking about their recently completed, nocturnist‐supervised, night float rotation. First year residents received only a post‐survey at the completion of their night float rotation, as they would be unable to reflect on prior experience.

Informed consent was imbedded within the e‐mail survey request. Survey requests were sent by a fellow within the Division of Hospital Medicine with a brief message cosigned by an associate program director of the residency program. We did not collect unique identifiers from respondents in order to offer additional assurances to the participants that the survey was anonymous. There was no incentive offered for completion of the survey. Survey data were anonymous and downloaded to a database by a third party. Data were analyzed using Microsoft Excel, and pre‐responses and post‐responses compared using a Student t test. The study was approved by the medical center's Institutional Review Board.

RESULTS

Rates of response for pre‐surveys and post‐surveys were 57% (43 respondents) and 51% (53 respondents), respectively. Due to response rates and in order to convey accurately the perceptions of the training program as a whole, we collapsed responses of the pre‐surveys and post‐surveys based on level of training. After implementation of the overnight attending, we observed a significant increase in the perceived clinical value of the night float rotation (3.95 vs 4.27, P = 0.01) as well as in the adequacy of overnight supervision (3.65 vs 4.30, P < 0.0001; Table 1). There was no reported change in housestaff decision‐making autonomy (4.35 vs 4.45, P = 0.44). In addition, we noted a nonsignificant trend towards an increased perception of the night float rotation as a valuable educational experience (3.83 vs 4.04, P = 0.24). After implementation of the nocturnist, more resident physicians agreed that overnight supervision by an attending positively impacted patient outcomes (3.79 vs 4.30, P = 0.002).

After implementation of the nocturnist, night float providers demonstrated increased rates of contacting an attending physician overnight (Table 2). There were significantly greater rates of attending contact for transfers from outside facilities (2.00 vs 3.20, P = 0.006) and during times of adverse events (2.51 vs 3.25, P = 0.04). We observed a reported increase in attending contact prior to ordering invasive diagnostic procedures (1.75 vs 2.76, P = 0.004) and noninvasive diagnostic procedures (1.09 vs 1.31, P = 0.03), as well as prior to initiation of intravenous antibiotics (1.11 vs 1.47, P = 0.007) and vasopressors (1.52 vs 2.40, P = 0.004).

After initiating the program, the nocturnist became the most commonly contacted overnight provider by the night float housestaff (Table 3). We observed a decrease in peer to peer contact between the night float housestaff and the on‐call overnight resident after implementation of the nocturnist (2.67 vs 2.04, P = 0.006).

Attending presence led to increased agreement that there was a defined overnight attending to contact (2.97 vs 1.96, P < 0.0001) and a decreased fear of waking an attending overnight for assistance (3.26 vs 2.72, P = 0.03). Increased attending availability, however, did not change resident physician's fear of revealing knowledge gaps, their desire to make decisions independently, or their belief that contacting an attending would not change a patient's outcome (Table 4).

DISCUSSION

The ACGME's new duty hour regulations require that supervision for first‐year residents be provided by a qualified physician (advanced resident, fellow, or attending physician) who is physically present at the hospital. Our study demonstrates that increased direct overnight supervision provided by an in‐house nocturnist enhanced the clinical value of the night float rotation and the perceived quality of patient care. In our study, increased attending supervision did not reduce perceived decision‐making autonomy, and in fact led to increased rates of attending contact during times of critical clinical decision‐making. Such results may help assuage fears that recent regulations mandating enhanced attending supervision will produce less capable practitioners, and offers reassurance that such changes are positively impacting patient care.

Many academic institutions are implementing nocturnists, although their precise roles and responsibilities are still being defined. Our nocturnist program was explicitly designed with housestaff supervision as a core responsibility, with the goal of improving patient safety and housestaff education overnight. We found that availability barriers to attending contact were logically decreased with in‐house faculty presence. Potentially harmful attitudes, however, around requesting support (such as fear of revealing knowledge gaps or the desire to make decisions independently) remained. Furthermore, despite statistically significant increases in contact between faculty and residents at times of critical decision‐making, overall rates of attending contact for diagnostic and therapeutic interventions remained low. It is unknown from our study or previous research, however, what level of contact is appropriate or ideal for many clinical scenarios.

Additionally, we described a novel role of an academic nocturnist at a tertiary care teaching hospital and offered a potential template for the development of academic nocturnists at similar institutions seeking to increase direct overnight supervision. Such roles have not been previously well defined in the literature. Based on our experience, the nocturnist's role was manageable and well utilized by housestaff, particularly for assistance with critically ill patients and overnight triaging. We believe there are a number of factors associated with the success of this role. First, clear guidelines were presented to housestaff and nocturnists regarding expectations for supervision (for example, staffing ICU admissions within 2 hours). These guidelines likely contributed to the increased attending contact observed during critical clinical decision‐making, as well as the perceived improved patient outcomes by our housestaff. Second, the nocturnists were expected to be an integral part of the overnight care team. In many systems, the nocturnists act completely independently of the housestaff teams, creating an additional barrier to contact and communication. In our system, because of clear guidelines and their integral role in staffing overnight admissions, the nocturnists were an essential partner in care for the housestaff. Third, most of the nocturnists had recently completed their residency training at this institution. Although our survey does not directly address this, we believe their knowledge of the hospital, appreciation of the role of the intern and the resident within our system, and understanding of the need to preserve housestaff autonomy were essential to building a successful nocturnist role. Lastly, the nocturnists were not only expected to supervise and staff new admissions, but were also given a teaching expectation. We believe they were viewed by housestaff as qualified teaching attendings, similar to the daytime hospitalist. These findings may provide guidelines for other institutions seeking to balance overnight hospitalist supervision with preserving resident's ability to make autonomous decisions.

There are several limitations to our study. The findings represent the experience of internal medicine housestaff at a single academic, tertiary care medical center and may not be reflective of other institutions or specialties. We asked housestaff to recall night float experiences from the prior year, which may have introduced recall bias, though responses were obtained before participants underwent the new curriculum. Maturation of housestaff over time could have led to changes in perceived autonomy, value of the night float rotation, and rates of attending contact independent of nocturnist implementation. In addition, there may have been unaccounted changes to other elements of the residency program, hospital, or patient volume between rotations. The implementation of the nocturnist, however, was the only major change to our training program that academic year, and there were no significant changes in patient volume, structure of the teaching or non‐resident services, or other policies around resident supervision.

It is possible that the nocturnist may have contributed to reports of increased clinical value and perceived quality of patient care simply by decreasing overnight workload for housestaff, and enhanced supervision and teaching may have played a lesser role. Even if this were true, optimizing resident workload is in itself an important goal for teaching hospitals and residency programs alike in order to maximize patient safety. Inclusion of intern post‐rotation surveys may have influenced data; though, we had no reason to suspect the surveyed interns would respond in a different manner than prior resident groups. The responses of both junior and senior housestaff were pooled; while this potentially weighted the results in favor of higher responding groups, we felt that it conveyed the residents' accurate sentiments on the program. Finally, while we compared two models of overnight supervision, we reported only housestaff perceptions of education, autonomy, patient outcomes, and supervisory contact, and not direct measures of knowledge or patient care. Further research will be required to define the relationship between supervision practices and patient‐level clinical outcomes.

The new ACGME regulations around resident supervision, as well as the broader movement to improve the safety and quality of care, require residency programs to negotiate a delicate balance between providing high‐quality patient care while preserving graduated independence in clinical training. Our study demonstrates that increased overnight supervision by nocturnists with well‐defined supervisory and teaching roles can preserve housestaff autonomy, improve the clinical experience for trainees, increase access to support during times of critical decision‐making, and potentially lead to improved patient outcomes.

Postgraduate medical education has traditionally relied on a training model of progressive independence, where housestaff learn patient care through increasing autonomy and decreasing levels of supervision.1 While this framework has little empirical backing, it is grounded in sound educational theory from similar disciplines and endorsed by medical associations.1, 2 The Accreditation Council for Graduate Medical Education (ACGME) recently implemented regulations requiring that first‐year residents have a qualified supervisor physically present or immediately available at all times.3 Previously, oversight by an offsite supervisor (for example, an attending physician at home) was considered adequate. These new regulations, although motivated by patient safety imperatives,4 have elicited concerns that increased supervision may lead to decreased housestaff autonomy and an increased reliance on supervisors for clinical guidance.5 Such changes could ultimately produce less qualified practitioners by the completion of training.

Critics of the current training model point to a patient safety mechanism where housestaff must take responsibility for requesting attending‐level help when situations arise that surpass their skill level.5 For resident physicians, however, the decision to request support is often complex and dependent not only on the clinical question, but also on unique and variable trainee and supervisor factors.6 Survey data from 1999, prior to the current training regulations, showed that increased faculty presence improved resident reports of educational value, quality of patient care, and autonomy.7 A recent survey, performed after the initiation of overnight attending supervision at an academic medical center, demonstrated perceived improvements in educational value and patient‐level outcomes by both faculty and housestaff.8 Whether increased supervision and resident autonomy can coexist remains undetermined.

Overnight rotations for residents (commonly referred to as night float) are often times of little direct or indirect supervision. A recent systematic review of clinical supervision practices for housestaff in all fields found scarce literature on overnight supervision practices.9 There remains limited and conflicting data regarding the quality of patient care provided by the resident night float,10 as well as evidence revealing a low perceived educational value of night rotations when compared with non‐night float rotations.11 Yet in 2006, more than three‐quarters of all internal medicine programs employed night float rotations.12 In response to ACGME guidelines mandating decreased shift lengths with continued restrictions on overall duty hours, it appears likely even more training programs will implement night float systems.

The presence of overnight hospitalists (also known as nocturnists) is growing within the academic setting, yet their role in relation to trainees is either poorly defined13 or independent of housestaff.14 To better understand the impact of increasing levels of supervision on residency training, we investigated housestaff perceptions of education, autonomy, and clinical decision‐making before and after implementation of an in‐hospital, overnight attending physician (nocturnist).

METHODS

The study was conducted at a 570‐bed academic, tertiary care medical center affiliated with an internal medicine residency program of 170 housestaff. At our institution, all first year residents perform a week of intern night float consisting of overnight cross‐coverage of general medicine patients on the floor, step‐down, and intensive care units (ICUs). Second and third year residents each complete 4 to 6 days of resident night float each year at this hospital. They are responsible for assisting the intern night float with cross‐coverage, in addition to admitting general medicine patients to the floor, step‐down unit, and intensive care units. Every night at our medical center, 1 intern night float and 1 resident night float are on duty in the hospital; this is in addition to a resident from the on‐call medicine team and a resident working in the ICU. Prior to July 2010, no internal medicine attending physicians were physically present in the hospital at night. Oversight for the intern and resident night float was provided by the attending physician for the on‐call resident ward team, who was at home and available by pager. The night float housestaff were instructed to contact the responsible attending physician only when a major change in clinical status occurred for hospitalized or newly admitted patients, though this expectation was neither standardized nor monitored.

We established a nocturnist program at the start of the 2010 academic year. The position was staffed by hospitalists from within the Division of Hospital Medicine without the use of moonlighters. Two‐thirds of shifts were filled by 3 dedicated nocturnists with remaining staffing provided by junior hospitalist faculty. The dedicated nocturnists had recently completed their internal medicine residency at our institution. Shift length was 12 hours and dedicated nocturnists worked, on average, 10 shifts per month. The nocturnist filled a critical overnight safety role through mandatory bedside staffing of newly admitted ICU patients within 2 hours of admission, discussion in person or via telephone of newly admitted step‐down unit patients within 6 hours of admission, and direct or indirect supervision of the care of any patients undergoing a major change in clinical status. The overnight hospitalist was also available for clinical questions and to assist housestaff with triaging of overnight admissions. After nocturnist implementation, overnight housestaff received direct supervision or had immediate access to direct supervision, while prior to the nocturnist, residents had access only to indirect supervision.

In addition, the nocturnist admitted medicine patients after 1 _AM in a 1:1 ratio with the admitting night float resident, performed medical consults, and provided coverage of non‐teaching medicine services. While actual volume numbers were not obtained, the estimated average of resident admissions per night was 2 to 3, and the number of nocturnist admissions was 1 to 2. The nocturnist also met nightly with night float housestaff for half‐hour didactics focusing on the management of common overnight clinical scenarios. The role of the new nocturnist was described to all housestaff in orientation materials given prior to their night float rotation and their general medicine ward rotation.

We administered pre‐rolling surveys and post‐rolling surveys of internal medicine intern and resident physicians who underwent the night float rotation at our hospital during the 2010 to 2011 academic year. Surveys examined housestaff perceptions of the night float rotation with regard to supervisory roles, educational and clinical value, and clinical decision‐making prior to and after implementation of the nocturnist. Surveys were designed by the study investigators based on prior literature,1, 510 personal experience, and housestaff suggestion, and were refined during works‐in‐progress meetings. Surveys were composed of Likert‐style questions asking housestaff to rate their level of agreement (15, strongly disagree to strongly agree) with statements regarding the supervisory and educational experience of the night float rotation, and to judge their frequency of contact (15, never to always/nightly) with an attending physician for specific clinical scenarios. The clinical scenarios described situations dealing with attendingresident communication around transfers of care, diagnostic evaluation, therapeutic interventions, and adverse events. Scenarios were taken from previous literature describing supervision preferences of faculty and residents during times of critical clinical decision‐making.15

One week prior to the beginning their night float rotation for the 20102011 academic year, housestaff were sent an e‐mail request to complete an online survey asking about their night float rotation during the prior academic year, when no nocturnist was present. One week after completion of their night float rotation for the 20102011 academic year, housestaff received an e‐mail with a link to a post‐survey asking about their recently completed, nocturnist‐supervised, night float rotation. First year residents received only a post‐survey at the completion of their night float rotation, as they would be unable to reflect on prior experience.

Informed consent was imbedded within the e‐mail survey request. Survey requests were sent by a fellow within the Division of Hospital Medicine with a brief message cosigned by an associate program director of the residency program. We did not collect unique identifiers from respondents in order to offer additional assurances to the participants that the survey was anonymous. There was no incentive offered for completion of the survey. Survey data were anonymous and downloaded to a database by a third party. Data were analyzed using Microsoft Excel, and pre‐responses and post‐responses compared using a Student t test. The study was approved by the medical center's Institutional Review Board.

RESULTS

Rates of response for pre‐surveys and post‐surveys were 57% (43 respondents) and 51% (53 respondents), respectively. Due to response rates and in order to convey accurately the perceptions of the training program as a whole, we collapsed responses of the pre‐surveys and post‐surveys based on level of training. After implementation of the overnight attending, we observed a significant increase in the perceived clinical value of the night float rotation (3.95 vs 4.27, P = 0.01) as well as in the adequacy of overnight supervision (3.65 vs 4.30, P < 0.0001; Table 1). There was no reported change in housestaff decision‐making autonomy (4.35 vs 4.45, P = 0.44). In addition, we noted a nonsignificant trend towards an increased perception of the night float rotation as a valuable educational experience (3.83 vs 4.04, P = 0.24). After implementation of the nocturnist, more resident physicians agreed that overnight supervision by an attending positively impacted patient outcomes (3.79 vs 4.30, P = 0.002).

After implementation of the nocturnist, night float providers demonstrated increased rates of contacting an attending physician overnight (Table 2). There were significantly greater rates of attending contact for transfers from outside facilities (2.00 vs 3.20, P = 0.006) and during times of adverse events (2.51 vs 3.25, P = 0.04). We observed a reported increase in attending contact prior to ordering invasive diagnostic procedures (1.75 vs 2.76, P = 0.004) and noninvasive diagnostic procedures (1.09 vs 1.31, P = 0.03), as well as prior to initiation of intravenous antibiotics (1.11 vs 1.47, P = 0.007) and vasopressors (1.52 vs 2.40, P = 0.004).

After initiating the program, the nocturnist became the most commonly contacted overnight provider by the night float housestaff (Table 3). We observed a decrease in peer to peer contact between the night float housestaff and the on‐call overnight resident after implementation of the nocturnist (2.67 vs 2.04, P = 0.006).

Attending presence led to increased agreement that there was a defined overnight attending to contact (2.97 vs 1.96, P < 0.0001) and a decreased fear of waking an attending overnight for assistance (3.26 vs 2.72, P = 0.03). Increased attending availability, however, did not change resident physician's fear of revealing knowledge gaps, their desire to make decisions independently, or their belief that contacting an attending would not change a patient's outcome (Table 4).

DISCUSSION

The ACGME's new duty hour regulations require that supervision for first‐year residents be provided by a qualified physician (advanced resident, fellow, or attending physician) who is physically present at the hospital. Our study demonstrates that increased direct overnight supervision provided by an in‐house nocturnist enhanced the clinical value of the night float rotation and the perceived quality of patient care. In our study, increased attending supervision did not reduce perceived decision‐making autonomy, and in fact led to increased rates of attending contact during times of critical clinical decision‐making. Such results may help assuage fears that recent regulations mandating enhanced attending supervision will produce less capable practitioners, and offers reassurance that such changes are positively impacting patient care.

Many academic institutions are implementing nocturnists, although their precise roles and responsibilities are still being defined. Our nocturnist program was explicitly designed with housestaff supervision as a core responsibility, with the goal of improving patient safety and housestaff education overnight. We found that availability barriers to attending contact were logically decreased with in‐house faculty presence. Potentially harmful attitudes, however, around requesting support (such as fear of revealing knowledge gaps or the desire to make decisions independently) remained. Furthermore, despite statistically significant increases in contact between faculty and residents at times of critical decision‐making, overall rates of attending contact for diagnostic and therapeutic interventions remained low. It is unknown from our study or previous research, however, what level of contact is appropriate or ideal for many clinical scenarios.

Additionally, we described a novel role of an academic nocturnist at a tertiary care teaching hospital and offered a potential template for the development of academic nocturnists at similar institutions seeking to increase direct overnight supervision. Such roles have not been previously well defined in the literature. Based on our experience, the nocturnist's role was manageable and well utilized by housestaff, particularly for assistance with critically ill patients and overnight triaging. We believe there are a number of factors associated with the success of this role. First, clear guidelines were presented to housestaff and nocturnists regarding expectations for supervision (for example, staffing ICU admissions within 2 hours). These guidelines likely contributed to the increased attending contact observed during critical clinical decision‐making, as well as the perceived improved patient outcomes by our housestaff. Second, the nocturnists were expected to be an integral part of the overnight care team. In many systems, the nocturnists act completely independently of the housestaff teams, creating an additional barrier to contact and communication. In our system, because of clear guidelines and their integral role in staffing overnight admissions, the nocturnists were an essential partner in care for the housestaff. Third, most of the nocturnists had recently completed their residency training at this institution. Although our survey does not directly address this, we believe their knowledge of the hospital, appreciation of the role of the intern and the resident within our system, and understanding of the need to preserve housestaff autonomy were essential to building a successful nocturnist role. Lastly, the nocturnists were not only expected to supervise and staff new admissions, but were also given a teaching expectation. We believe they were viewed by housestaff as qualified teaching attendings, similar to the daytime hospitalist. These findings may provide guidelines for other institutions seeking to balance overnight hospitalist supervision with preserving resident's ability to make autonomous decisions.

There are several limitations to our study. The findings represent the experience of internal medicine housestaff at a single academic, tertiary care medical center and may not be reflective of other institutions or specialties. We asked housestaff to recall night float experiences from the prior year, which may have introduced recall bias, though responses were obtained before participants underwent the new curriculum. Maturation of housestaff over time could have led to changes in perceived autonomy, value of the night float rotation, and rates of attending contact independent of nocturnist implementation. In addition, there may have been unaccounted changes to other elements of the residency program, hospital, or patient volume between rotations. The implementation of the nocturnist, however, was the only major change to our training program that academic year, and there were no significant changes in patient volume, structure of the teaching or non‐resident services, or other policies around resident supervision.

It is possible that the nocturnist may have contributed to reports of increased clinical value and perceived quality of patient care simply by decreasing overnight workload for housestaff, and enhanced supervision and teaching may have played a lesser role. Even if this were true, optimizing resident workload is in itself an important goal for teaching hospitals and residency programs alike in order to maximize patient safety. Inclusion of intern post‐rotation surveys may have influenced data; though, we had no reason to suspect the surveyed interns would respond in a different manner than prior resident groups. The responses of both junior and senior housestaff were pooled; while this potentially weighted the results in favor of higher responding groups, we felt that it conveyed the residents' accurate sentiments on the program. Finally, while we compared two models of overnight supervision, we reported only housestaff perceptions of education, autonomy, patient outcomes, and supervisory contact, and not direct measures of knowledge or patient care. Further research will be required to define the relationship between supervision practices and patient‐level clinical outcomes.

The new ACGME regulations around resident supervision, as well as the broader movement to improve the safety and quality of care, require residency programs to negotiate a delicate balance between providing high‐quality patient care while preserving graduated independence in clinical training. Our study demonstrates that increased overnight supervision by nocturnists with well‐defined supervisory and teaching roles can preserve housestaff autonomy, improve the clinical experience for trainees, increase access to support during times of critical decision‐making, and potentially lead to improved patient outcomes.

Treatment of hospitalized patients is becoming more and more complex as a result of rising patient age, multiple comorbidities, and more complex procedures, yet most are hospitalized in a non‐intensive care unit (non‐ICU) setting. With this rising complexity, a large proportion of hospital patients experience serious adverse events during their hospital stay, including cardiac arrest, respiratory failure, and shock, leading to unplanned admissions to the ICU, and death.1 For patients with unexpected clinical deterioration, delayed or suboptimal intervention is associated with increased morbidity and mortality.2, 3 This has prompted many hospitals to implement some form of a rapid response system (RRS) for early detection of clinical deterioration, and adequate response through rapid response teams (RRT).2, 4, 5 Still, evidence suggests that many of these systems are deficient in the detection and/or the response phase, and do not lead to the expected outcomes in terms of preventing critical events.6, 7

Researchers have established that patients frequently demonstrate clinical signs of deterioration hours before cardiac arrests or urgent transfers to ICUs.8, 9 The importance of timely interventions in many acute clinical conditions like sepsis, acute myocardial infarction, and stroke is also well established.1012 Taking these facts together with the observed shortcomings of most current rapid response systems has led experts to call for a shift of focus from the efferent limb of the RRS (the response team) to the afferent limb (the means of detecting patients at risk and obtaining help).13 A consensus conference held in 2008 emphasized the importance of accurate monitoring of vital signs for all hospitalized patients, and at the same time recommended, if practical and affordable, that all patients be monitored continuously by monitoring technology, which improves patient comfort, is easy to use, and reduces the number of false alerts.13

Technology applications that allow for continuous vital sign monitoring designed for non‐ICU settings may help hospitals achieve meaningful results by providing earlier detection of clinical deterioration, either when implemented as part of an RRS or as a stand‐alone system. To fit this description, monitors would have to be easy to use by the staff, impose little limitation on the patient, and be capable of trend analyses so that they minimize the incidence of false alerts and alert fatigue. We set out to investigate the capability of such a system to predict patient deterioration in a medical floor setting.

METHODS

RESULTS

Of 149 patients monitored by the Earlysense system for this study, 113 had at least 30 hours of monitoring. The characteristics of these patients are presented in Table 1. Of these 113 patients, 9 had a major clinical event (8.0%), including 2 patients who were transferred to an ICU, 1 patient who was intubated and ventilated in the study unit and later had a cardiac arrest and died, and 6 more patients who developed cardiac arrest and died in the study units (overall, 10 major clinical events). Comparing patients with a major clinical event to patients without, we found no significant difference in age, gender, body mass index, or comorbidity (Charlson score), however, patients who had a clinical event stayed significantly longer than those without a clinical event (Table 1). On average, time from admission to the major clinical event was 11.6 days (range 228).

Overall, this study included a total of 8628 recording hours for the 113 patients we analyzed. Using the vital signs thresholds found to provide the highest sensitivity and specificity, we recorded 898 RR alerts (average frequency of 2.4 alerts per patient‐day) and 107 HR alerts (average frequency of 0.3 alerts per patient‐day). For the entire study, we have found 63 trend alerts (46 RR and 17 HR) when using thresholds for maximal sensitivity and specificity, at a frequency of 0.2 alerts per patient‐day.

In Table 2, we summarize the sensitivity, specificity, positive predictive value, and negative predictive value of alerts in predicting a major clinical deterioration per patient for both the threshold alerts and the trend alerts. The cutoff values are those of optimal performance (maximal sensitivity plus specificity) along the ROC curves presented in Figure 1. The optimal cutoffs for the threshold alerts were HRs below 40 or above 115 beats/min, and RRs below 8 or above 40 breaths/min. For the trend alerts, when comparing between time periods, we found that a cutoff of a rise of 20 or more beats/min and 5 or more breaths/min corresponded with a maximal sensitivity and specificity, and we used these as the thresholds for the trending alerts.

Figure 1

For the determined alerts, out of the 10 clinical events, in 7 cases the alerts would have indicated the deterioration within more than 1 hour from the actual event and within 24 hours prior to the clinical event. In one case, the alert would have indicated the risk within less than 1 hour; in another case, within the 2448 hours window; and in the last case, the alerts would have done so more than 48 hours prior to the event (these last 2 cases were considered false‐negative for our post hoc analysis).

The ROC analysis for both the threshold alerts and the trend alerts for both HR and RR correlated well with the clinical events (P < 0.05 for all models) (Figure 1). When comparing the threshold alerts with the trend alerts, trend alerts had a higher AUC, suggesting that these would be more accurate in alerting for major clinical events. Specifically, the model for HR 6‐hour trend alerts demonstrated a larger AUC (0.9 and 0.85, respectively), while the combination of HR and RR had the largest AUC (0.93).

DISCUSSION

The development of monitoring systems designed for hospitalized patients on non‐ICU floors derives from the need to minimize preventable in‐hospital mortality. This study has explored one such possible solution. Through retrospective definition of optimal alert settings and internal validation within a derivation cohort, we have found the Earlysense monitor to be accurate in predicting major clinical deterioration by using both simple thresholds and a vital signs trend algorithm. We found that the post hoc determined alerts were relatively infrequent. We also found that trend alerts showed greater ability to accurately capture these deteriorations compared with simple alert thresholds, and that using a combination alert based on both HR and RR trends provided the highest accuracy and confidence for predicting clinical deterioration. These results suggest the advantages that smart alerts can bringincreasing sensitivity while lowering the alert burden and reducing the number of false alerts.

An effective and efficient patient monitoring system must be able to quickly detect acute life‐threatening events or subacute patient deterioration that will lead to a life‐threatening event; in addition, this system should have a low false‐positive rate (few false alerts). While a high sensitivity is desirable,16 this usually comes at the cost of lower specificity and higher false‐positive rates. Studies have found alerts from monitoring systems in an ICU and emergency department environment to be tremendously frequent and with an extremely high false‐positive rate.1721 Unsurprisingly, it has been reported that only about 10% of alerts are responded to by the clinical staff.22 In an attempt to improve alert relevancy and accuracy, newly designed integrated monitoring systems for ICUs use alert algorithms and trend analysis performed on data received from multiple vital signs monitors.2327 With the evident need to continuously monitor patients on hospital floors,13, 28 there is a clear gap to‐date in such experience and a need to study the implications for patients and staff as we try to optimize the monitoring tools for this environment.

As more emphasis is placed on the afferent limb of rapid response systems, we can expect to see a greater need for systems able to detect changes in clinical status that might lead to patient deterioration. The intermittent vital sign measurement performed by nurses and support staff on the floors is now regarded as inadequate by itself, because it may not be performed predictably, accurately, or completely.28 Continuous monitoring systems should complement manual intermittent vital signs monitoring and play an important role in bringing the nurse to the patient's side at the right time so that a complete assessment can be done.29, 30 There remains no substitution for a nurse evaluating the patient and making critical decisions based on his or her knowledge of the patient's condition.

While today, both electrocardiographic monitoring (telemetry) and continuous pulse oximetry provide some solution for the need for continuous monitoring on the floors, these carry disadvantages that prevent them from becoming the optimal solution. While telemetry is invaluable for higher risk cardiac patients, significant overuse of this application does occur,31 and most monitored patients gain little cardiac arrest survival benefits.32 Pulse oximetry, although regarded as one of the most important technological advancements in monitoring patients, carries important limitations that might prevent early detection of respiratory failure.33, 34 Furthermore, these 2 modalities require continuous contact of leads/sensors to the patient, a disadvantage when regarding monitoring for low/average risk patients on non‐ICU hospital floors. Related to these disadvantages, the results presented here might position the implementation of the Earlysense monitor as a preferred alternative.

This study has several important limitations. This was a retrospective noninterventional study limited to internal medicine patients. Our patients served as a derivation cohort, alert thresholds were set post hoc, and sensitivity and specificity were internally validated. It remains to be shown that the results shown here can be reproduced in a real‐time interventional study. We only included patients who were considered above average risk within medical wards, as we were hoping to capture more clinical deteriorations with a relatively small cohort. We cannot rule out that our results might be biased and may not similarly apply to all non‐ICU medical patients. Finally, the retrospective nature of this study did not allow us to assess other outcomes of appropriateness, such as staff objective assessment of alert appropriateness or change in clinical management as a result of an alert. When using these devices in the alert mode, alert thresholds may be changed by the clinical staff based on clinical judgment to further lower false alerts and alert frequency. We also did not collect information that could have allowed us to assess clinical usefulness of the alerts compared to routine clinical assessment. Documenting whether the clinical events were suspected beforehand by the clinical teams could have allowed us to assess clinical usefulness. Future interventional studies are needed to validate the Earlysense system prospectively in both medical and surgical floor settings, first using a common alert threshold alerting system and secondly using the smart trend alerts described here.

In conclusion, we found that the Earlysense monitor is able to continuously measure RR and HR, providing low alert frequency. The current study demonstrates the potential of this system to provide timely prediction of patient deterioration. Utilizing a smart trend algorithm has been shown to improve the device's accuracy and reduce associated alert burden and false‐positive alerts.

Treatment of hospitalized patients is becoming more and more complex as a result of rising patient age, multiple comorbidities, and more complex procedures, yet most are hospitalized in a non‐intensive care unit (non‐ICU) setting. With this rising complexity, a large proportion of hospital patients experience serious adverse events during their hospital stay, including cardiac arrest, respiratory failure, and shock, leading to unplanned admissions to the ICU, and death.1 For patients with unexpected clinical deterioration, delayed or suboptimal intervention is associated with increased morbidity and mortality.2, 3 This has prompted many hospitals to implement some form of a rapid response system (RRS) for early detection of clinical deterioration, and adequate response through rapid response teams (RRT).2, 4, 5 Still, evidence suggests that many of these systems are deficient in the detection and/or the response phase, and do not lead to the expected outcomes in terms of preventing critical events.6, 7

Researchers have established that patients frequently demonstrate clinical signs of deterioration hours before cardiac arrests or urgent transfers to ICUs.8, 9 The importance of timely interventions in many acute clinical conditions like sepsis, acute myocardial infarction, and stroke is also well established.1012 Taking these facts together with the observed shortcomings of most current rapid response systems has led experts to call for a shift of focus from the efferent limb of the RRS (the response team) to the afferent limb (the means of detecting patients at risk and obtaining help).13 A consensus conference held in 2008 emphasized the importance of accurate monitoring of vital signs for all hospitalized patients, and at the same time recommended, if practical and affordable, that all patients be monitored continuously by monitoring technology, which improves patient comfort, is easy to use, and reduces the number of false alerts.13

Technology applications that allow for continuous vital sign monitoring designed for non‐ICU settings may help hospitals achieve meaningful results by providing earlier detection of clinical deterioration, either when implemented as part of an RRS or as a stand‐alone system. To fit this description, monitors would have to be easy to use by the staff, impose little limitation on the patient, and be capable of trend analyses so that they minimize the incidence of false alerts and alert fatigue. We set out to investigate the capability of such a system to predict patient deterioration in a medical floor setting.

METHODS

RESULTS

Of 149 patients monitored by the Earlysense system for this study, 113 had at least 30 hours of monitoring. The characteristics of these patients are presented in Table 1. Of these 113 patients, 9 had a major clinical event (8.0%), including 2 patients who were transferred to an ICU, 1 patient who was intubated and ventilated in the study unit and later had a cardiac arrest and died, and 6 more patients who developed cardiac arrest and died in the study units (overall, 10 major clinical events). Comparing patients with a major clinical event to patients without, we found no significant difference in age, gender, body mass index, or comorbidity (Charlson score), however, patients who had a clinical event stayed significantly longer than those without a clinical event (Table 1). On average, time from admission to the major clinical event was 11.6 days (range 228).

Overall, this study included a total of 8628 recording hours for the 113 patients we analyzed. Using the vital signs thresholds found to provide the highest sensitivity and specificity, we recorded 898 RR alerts (average frequency of 2.4 alerts per patient‐day) and 107 HR alerts (average frequency of 0.3 alerts per patient‐day). For the entire study, we have found 63 trend alerts (46 RR and 17 HR) when using thresholds for maximal sensitivity and specificity, at a frequency of 0.2 alerts per patient‐day.

In Table 2, we summarize the sensitivity, specificity, positive predictive value, and negative predictive value of alerts in predicting a major clinical deterioration per patient for both the threshold alerts and the trend alerts. The cutoff values are those of optimal performance (maximal sensitivity plus specificity) along the ROC curves presented in Figure 1. The optimal cutoffs for the threshold alerts were HRs below 40 or above 115 beats/min, and RRs below 8 or above 40 breaths/min. For the trend alerts, when comparing between time periods, we found that a cutoff of a rise of 20 or more beats/min and 5 or more breaths/min corresponded with a maximal sensitivity and specificity, and we used these as the thresholds for the trending alerts.

Figure 1

For the determined alerts, out of the 10 clinical events, in 7 cases the alerts would have indicated the deterioration within more than 1 hour from the actual event and within 24 hours prior to the clinical event. In one case, the alert would have indicated the risk within less than 1 hour; in another case, within the 2448 hours window; and in the last case, the alerts would have done so more than 48 hours prior to the event (these last 2 cases were considered false‐negative for our post hoc analysis).

The ROC analysis for both the threshold alerts and the trend alerts for both HR and RR correlated well with the clinical events (P < 0.05 for all models) (Figure 1). When comparing the threshold alerts with the trend alerts, trend alerts had a higher AUC, suggesting that these would be more accurate in alerting for major clinical events. Specifically, the model for HR 6‐hour trend alerts demonstrated a larger AUC (0.9 and 0.85, respectively), while the combination of HR and RR had the largest AUC (0.93).

DISCUSSION

The development of monitoring systems designed for hospitalized patients on non‐ICU floors derives from the need to minimize preventable in‐hospital mortality. This study has explored one such possible solution. Through retrospective definition of optimal alert settings and internal validation within a derivation cohort, we have found the Earlysense monitor to be accurate in predicting major clinical deterioration by using both simple thresholds and a vital signs trend algorithm. We found that the post hoc determined alerts were relatively infrequent. We also found that trend alerts showed greater ability to accurately capture these deteriorations compared with simple alert thresholds, and that using a combination alert based on both HR and RR trends provided the highest accuracy and confidence for predicting clinical deterioration. These results suggest the advantages that smart alerts can bringincreasing sensitivity while lowering the alert burden and reducing the number of false alerts.

An effective and efficient patient monitoring system must be able to quickly detect acute life‐threatening events or subacute patient deterioration that will lead to a life‐threatening event; in addition, this system should have a low false‐positive rate (few false alerts). While a high sensitivity is desirable,16 this usually comes at the cost of lower specificity and higher false‐positive rates. Studies have found alerts from monitoring systems in an ICU and emergency department environment to be tremendously frequent and with an extremely high false‐positive rate.1721 Unsurprisingly, it has been reported that only about 10% of alerts are responded to by the clinical staff.22 In an attempt to improve alert relevancy and accuracy, newly designed integrated monitoring systems for ICUs use alert algorithms and trend analysis performed on data received from multiple vital signs monitors.2327 With the evident need to continuously monitor patients on hospital floors,13, 28 there is a clear gap to‐date in such experience and a need to study the implications for patients and staff as we try to optimize the monitoring tools for this environment.

As more emphasis is placed on the afferent limb of rapid response systems, we can expect to see a greater need for systems able to detect changes in clinical status that might lead to patient deterioration. The intermittent vital sign measurement performed by nurses and support staff on the floors is now regarded as inadequate by itself, because it may not be performed predictably, accurately, or completely.28 Continuous monitoring systems should complement manual intermittent vital signs monitoring and play an important role in bringing the nurse to the patient's side at the right time so that a complete assessment can be done.29, 30 There remains no substitution for a nurse evaluating the patient and making critical decisions based on his or her knowledge of the patient's condition.

While today, both electrocardiographic monitoring (telemetry) and continuous pulse oximetry provide some solution for the need for continuous monitoring on the floors, these carry disadvantages that prevent them from becoming the optimal solution. While telemetry is invaluable for higher risk cardiac patients, significant overuse of this application does occur,31 and most monitored patients gain little cardiac arrest survival benefits.32 Pulse oximetry, although regarded as one of the most important technological advancements in monitoring patients, carries important limitations that might prevent early detection of respiratory failure.33, 34 Furthermore, these 2 modalities require continuous contact of leads/sensors to the patient, a disadvantage when regarding monitoring for low/average risk patients on non‐ICU hospital floors. Related to these disadvantages, the results presented here might position the implementation of the Earlysense monitor as a preferred alternative.

This study has several important limitations. This was a retrospective noninterventional study limited to internal medicine patients. Our patients served as a derivation cohort, alert thresholds were set post hoc, and sensitivity and specificity were internally validated. It remains to be shown that the results shown here can be reproduced in a real‐time interventional study. We only included patients who were considered above average risk within medical wards, as we were hoping to capture more clinical deteriorations with a relatively small cohort. We cannot rule out that our results might be biased and may not similarly apply to all non‐ICU medical patients. Finally, the retrospective nature of this study did not allow us to assess other outcomes of appropriateness, such as staff objective assessment of alert appropriateness or change in clinical management as a result of an alert. When using these devices in the alert mode, alert thresholds may be changed by the clinical staff based on clinical judgment to further lower false alerts and alert frequency. We also did not collect information that could have allowed us to assess clinical usefulness of the alerts compared to routine clinical assessment. Documenting whether the clinical events were suspected beforehand by the clinical teams could have allowed us to assess clinical usefulness. Future interventional studies are needed to validate the Earlysense system prospectively in both medical and surgical floor settings, first using a common alert threshold alerting system and secondly using the smart trend alerts described here.

In conclusion, we found that the Earlysense monitor is able to continuously measure RR and HR, providing low alert frequency. The current study demonstrates the potential of this system to provide timely prediction of patient deterioration. Utilizing a smart trend algorithm has been shown to improve the device's accuracy and reduce associated alert burden and false‐positive alerts.

Treatment of hospitalized patients is becoming more and more complex as a result of rising patient age, multiple comorbidities, and more complex procedures, yet most are hospitalized in a non‐intensive care unit (non‐ICU) setting. With this rising complexity, a large proportion of hospital patients experience serious adverse events during their hospital stay, including cardiac arrest, respiratory failure, and shock, leading to unplanned admissions to the ICU, and death.1 For patients with unexpected clinical deterioration, delayed or suboptimal intervention is associated with increased morbidity and mortality.2, 3 This has prompted many hospitals to implement some form of a rapid response system (RRS) for early detection of clinical deterioration, and adequate response through rapid response teams (RRT).2, 4, 5 Still, evidence suggests that many of these systems are deficient in the detection and/or the response phase, and do not lead to the expected outcomes in terms of preventing critical events.6, 7

Researchers have established that patients frequently demonstrate clinical signs of deterioration hours before cardiac arrests or urgent transfers to ICUs.8, 9 The importance of timely interventions in many acute clinical conditions like sepsis, acute myocardial infarction, and stroke is also well established.1012 Taking these facts together with the observed shortcomings of most current rapid response systems has led experts to call for a shift of focus from the efferent limb of the RRS (the response team) to the afferent limb (the means of detecting patients at risk and obtaining help).13 A consensus conference held in 2008 emphasized the importance of accurate monitoring of vital signs for all hospitalized patients, and at the same time recommended, if practical and affordable, that all patients be monitored continuously by monitoring technology, which improves patient comfort, is easy to use, and reduces the number of false alerts.13

Technology applications that allow for continuous vital sign monitoring designed for non‐ICU settings may help hospitals achieve meaningful results by providing earlier detection of clinical deterioration, either when implemented as part of an RRS or as a stand‐alone system. To fit this description, monitors would have to be easy to use by the staff, impose little limitation on the patient, and be capable of trend analyses so that they minimize the incidence of false alerts and alert fatigue. We set out to investigate the capability of such a system to predict patient deterioration in a medical floor setting.

METHODS

RESULTS

Of 149 patients monitored by the Earlysense system for this study, 113 had at least 30 hours of monitoring. The characteristics of these patients are presented in Table 1. Of these 113 patients, 9 had a major clinical event (8.0%), including 2 patients who were transferred to an ICU, 1 patient who was intubated and ventilated in the study unit and later had a cardiac arrest and died, and 6 more patients who developed cardiac arrest and died in the study units (overall, 10 major clinical events). Comparing patients with a major clinical event to patients without, we found no significant difference in age, gender, body mass index, or comorbidity (Charlson score), however, patients who had a clinical event stayed significantly longer than those without a clinical event (Table 1). On average, time from admission to the major clinical event was 11.6 days (range 228).

Overall, this study included a total of 8628 recording hours for the 113 patients we analyzed. Using the vital signs thresholds found to provide the highest sensitivity and specificity, we recorded 898 RR alerts (average frequency of 2.4 alerts per patient‐day) and 107 HR alerts (average frequency of 0.3 alerts per patient‐day). For the entire study, we have found 63 trend alerts (46 RR and 17 HR) when using thresholds for maximal sensitivity and specificity, at a frequency of 0.2 alerts per patient‐day.

In Table 2, we summarize the sensitivity, specificity, positive predictive value, and negative predictive value of alerts in predicting a major clinical deterioration per patient for both the threshold alerts and the trend alerts. The cutoff values are those of optimal performance (maximal sensitivity plus specificity) along the ROC curves presented in Figure 1. The optimal cutoffs for the threshold alerts were HRs below 40 or above 115 beats/min, and RRs below 8 or above 40 breaths/min. For the trend alerts, when comparing between time periods, we found that a cutoff of a rise of 20 or more beats/min and 5 or more breaths/min corresponded with a maximal sensitivity and specificity, and we used these as the thresholds for the trending alerts.

Figure 1

For the determined alerts, out of the 10 clinical events, in 7 cases the alerts would have indicated the deterioration within more than 1 hour from the actual event and within 24 hours prior to the clinical event. In one case, the alert would have indicated the risk within less than 1 hour; in another case, within the 2448 hours window; and in the last case, the alerts would have done so more than 48 hours prior to the event (these last 2 cases were considered false‐negative for our post hoc analysis).

The ROC analysis for both the threshold alerts and the trend alerts for both HR and RR correlated well with the clinical events (P < 0.05 for all models) (Figure 1). When comparing the threshold alerts with the trend alerts, trend alerts had a higher AUC, suggesting that these would be more accurate in alerting for major clinical events. Specifically, the model for HR 6‐hour trend alerts demonstrated a larger AUC (0.9 and 0.85, respectively), while the combination of HR and RR had the largest AUC (0.93).

DISCUSSION

The development of monitoring systems designed for hospitalized patients on non‐ICU floors derives from the need to minimize preventable in‐hospital mortality. This study has explored one such possible solution. Through retrospective definition of optimal alert settings and internal validation within a derivation cohort, we have found the Earlysense monitor to be accurate in predicting major clinical deterioration by using both simple thresholds and a vital signs trend algorithm. We found that the post hoc determined alerts were relatively infrequent. We also found that trend alerts showed greater ability to accurately capture these deteriorations compared with simple alert thresholds, and that using a combination alert based on both HR and RR trends provided the highest accuracy and confidence for predicting clinical deterioration. These results suggest the advantages that smart alerts can bringincreasing sensitivity while lowering the alert burden and reducing the number of false alerts.

An effective and efficient patient monitoring system must be able to quickly detect acute life‐threatening events or subacute patient deterioration that will lead to a life‐threatening event; in addition, this system should have a low false‐positive rate (few false alerts). While a high sensitivity is desirable,16 this usually comes at the cost of lower specificity and higher false‐positive rates. Studies have found alerts from monitoring systems in an ICU and emergency department environment to be tremendously frequent and with an extremely high false‐positive rate.1721 Unsurprisingly, it has been reported that only about 10% of alerts are responded to by the clinical staff.22 In an attempt to improve alert relevancy and accuracy, newly designed integrated monitoring systems for ICUs use alert algorithms and trend analysis performed on data received from multiple vital signs monitors.2327 With the evident need to continuously monitor patients on hospital floors,13, 28 there is a clear gap to‐date in such experience and a need to study the implications for patients and staff as we try to optimize the monitoring tools for this environment.

As more emphasis is placed on the afferent limb of rapid response systems, we can expect to see a greater need for systems able to detect changes in clinical status that might lead to patient deterioration. The intermittent vital sign measurement performed by nurses and support staff on the floors is now regarded as inadequate by itself, because it may not be performed predictably, accurately, or completely.28 Continuous monitoring systems should complement manual intermittent vital signs monitoring and play an important role in bringing the nurse to the patient's side at the right time so that a complete assessment can be done.29, 30 There remains no substitution for a nurse evaluating the patient and making critical decisions based on his or her knowledge of the patient's condition.

While today, both electrocardiographic monitoring (telemetry) and continuous pulse oximetry provide some solution for the need for continuous monitoring on the floors, these carry disadvantages that prevent them from becoming the optimal solution. While telemetry is invaluable for higher risk cardiac patients, significant overuse of this application does occur,31 and most monitored patients gain little cardiac arrest survival benefits.32 Pulse oximetry, although regarded as one of the most important technological advancements in monitoring patients, carries important limitations that might prevent early detection of respiratory failure.33, 34 Furthermore, these 2 modalities require continuous contact of leads/sensors to the patient, a disadvantage when regarding monitoring for low/average risk patients on non‐ICU hospital floors. Related to these disadvantages, the results presented here might position the implementation of the Earlysense monitor as a preferred alternative.

This study has several important limitations. This was a retrospective noninterventional study limited to internal medicine patients. Our patients served as a derivation cohort, alert thresholds were set post hoc, and sensitivity and specificity were internally validated. It remains to be shown that the results shown here can be reproduced in a real‐time interventional study. We only included patients who were considered above average risk within medical wards, as we were hoping to capture more clinical deteriorations with a relatively small cohort. We cannot rule out that our results might be biased and may not similarly apply to all non‐ICU medical patients. Finally, the retrospective nature of this study did not allow us to assess other outcomes of appropriateness, such as staff objective assessment of alert appropriateness or change in clinical management as a result of an alert. When using these devices in the alert mode, alert thresholds may be changed by the clinical staff based on clinical judgment to further lower false alerts and alert frequency. We also did not collect information that could have allowed us to assess clinical usefulness of the alerts compared to routine clinical assessment. Documenting whether the clinical events were suspected beforehand by the clinical teams could have allowed us to assess clinical usefulness. Future interventional studies are needed to validate the Earlysense system prospectively in both medical and surgical floor settings, first using a common alert threshold alerting system and secondly using the smart trend alerts described here.

In conclusion, we found that the Earlysense monitor is able to continuously measure RR and HR, providing low alert frequency. The current study demonstrates the potential of this system to provide timely prediction of patient deterioration. Utilizing a smart trend algorithm has been shown to improve the device's accuracy and reduce associated alert burden and false‐positive alerts.

Sepsis is a major cause of death in hospitalized patients.13 It is recommended that patients with sepsis be treated with early appropriate antibiotics, as well as early goal‐directed therapy including fluid and vasopressor support according to evidence‐based guidelines.46 Following such evidence‐based protocols and process‐of‐care interventions has been shown to be associated with better patient outcomes, including decreased mortality.7, 8

Most patients with severe sepsis are cared for in intensive care units (ICUs). At times, there are no beds available in the primary ICU and patients presenting to the hospital with sepsis are cared for in other units. Patients admitted to a non‐preferred clinical inpatient setting are sometimes referred to as overflow.9 ICUs can differ significantly in staffing patterns, equipment, and training.10 It is not known if overflow sepsis patients receive similar care when admitted to non‐primary ICUs.

At our hospital, we have an active bed management system led by the hospitalist division.11 This system includes protocols to place sepsis patients in the overflow ICU if the primary ICU is full. We hypothesized that process‐of‐care interventions would be more strictly adhered to when sepsis patients were in the primary ICU rather than in the overflow unit at our institution.

METHODS

RESULTS

There were 100 patients admitted to the MICU and 41 patients admitted to the CICU during the study period (Table 1). The majority of the patients were admitted to the ICUs directly from the emergency department (ED) (n = 129), with a small number of patients who were transferred from the Medicine floors (n = 12).

There were no significant differences between the 2 study groups in terms of age, sex, primary site of infection, mean APACHE II score, SOFA scores on day 1, chronic organ insufficiency, immune suppression, or need for mechanical ventilation (Table 1). The most common site of infection was lung. There were significantly more patients with severe sepsis in the MICU (88% vs 51%, P <0.001).

DISCUSSION

Since sepsis is more commonly treated in the medical ICU and some data suggests that specialty ICUs may be better at providing desired care,18, 19 we believed that patients treated in the MICU would be more likely to receive guideline‐concordant care. The study refutes our a priori hypothesis and reveals that evidence‐based processes‐of‐care associated with improved outcomes for sepsis are similarly implemented at our institution in the primary and overflow ICU. These findings are important, as ICU bed availability is a frequent problem and many hospitals overflow patients to non‐primary ICUs.9, 20

The observed equivalence in the care delivered may be a function of the relatively high number of patients with sepsis treated in the overflow unit, thereby giving the delivery teams enough experience to provide the desired care. An alternative explanation could be that the residents in CICU brought with them the experience from having previously trained in the MICU. Although, some of the care processes for sepsis patients are influenced by the CPOE (with embedded order sets and protocols), it is unlikely that CPOE can fully account for similarity in care because many processes and therapies (like use of steroids, amount of fluid delivered in first 24 hours, packed red blood cells [PRBC] transfusion, and spontaneous breathing trials) are not embedded within order sets.

The significant difference noted in the areas of deep vein thrombosis (DVT) and gastrointestinal (GI) prophylaxis within 24 hours of ICU admission was unexpected. These preventive therapies are included in initial order sets in the CPOE, which prompt physicians to order them as standard‐of‐care. With respect to DVT prophylaxis, we suspect that some of the difference might be attributable to specific contraindications to its use, which could have been more common in one of the units. There were more patients in MICU on mechanical ventilation (although not statistically significant) and with severe sepsis (statistically significant) at time of admission, which might have contributed to the difference noted in use of GI prophylaxis. It is also plausible that these differences might have disappeared if they were reassessed beyond 24 hours into the ICU admission. We cannot rule out the presence of unit‐ and physician‐level differences that contributed to this. Likewise, there was an unexpected trend towards significance, wherein more patients in CICU had spontaneous breathing trials within 24 hours of admission. This might also be explained by the higher number of patients with severe sepsis in the MICU (preempting any weaning attempts). These caveats aside, it is reassuring that, at our institution, admitting septic patients to the first available ICU bed does not adversely affect important processes‐of‐care.

One might ask whether this study's data should reassure other sites who are boarding septic patients in non‐primary ICUs. Irrespective of the number of patients studied or the degree of statistical significance of the associations, an observational study design cannot prove that boarding septic patients in non‐primary ICUs is either safe or unsafe. However, we hope that readers reflect on, and take inventory of, systems issues that may be different between unitswith an eye towards eliminating variation such that all units managing septic patients are primed to deliver guideline‐concordant care. Other hospitals that use CPOE with sepsis order sets, have protocols for sepsis care, and who train nursing and respiratory therapists to meet high standards might be pleased to see that the patients in our study received comparable, high‐quality care across the 2 units. While our data suggests that boarding patients in overflow units may be safe, these findings would need to be replicated at other sites using prospective designs to prove safety.

Length of emergency room stay prior to admission is associated with higher mortality rates.2123 At many hospitals, critical care beds are a scarce resource such that most hospitals have a policy for the triage of patients to critical care beds.24, 25 Lundberg and colleagues' study demonstrated that patients who developed septic shock on the medical wards experienced delays in receipt of intravenous fluids, inotropic agents and transfer to a critical care setting.26 Thus, rather than waiting in the ED or on the medical service for an MICU bed to become available, it may be most wise to admit a critically sick septic patient to the first available ICU bed, even to an overflow ICU. In a recent study by Sidlow and Aggarwal, 1104 patients discharged from the coronary care unit (CCU) with a non‐cardiac primary diagnosis were compared to patients admitted to the MICU in the same hospital.27 The study found no differences in patient mortality, 30‐day readmission rate, hospital LOS, ICU LOS, and safety outcomes of ventilator‐associated pneumonia and catheter‐associated bloodstream infections between ICUs. However, their study did not examine processes‐of‐care delivered between the primary ICU and the overflow unit, and did not validate the primary diagnoses of patients admitted to the ICU.

Several limitations of this study should be considered. First, this study was conducted at a single center. Second, we used a retrospective study design; however, a prospective study randomizing patients to 1 of the 2 units would likely never be possible. Third, the relatively small number of patients limited the power of the study to detect mortality differences between the units. However, this was a pilot study focused on processes of care as opposed to clinical outcomes. Fourth, it is possible that we did not capture every single patient with sepsis with our keyword search. Our use of a previously validated screening process should have limited the number of missed cases.15, 16 Fifth, although the 2 ICUs have exclusive nursing staff and attending physicians, the housestaff and respiratory therapists do rotate between the 2 ICUs and place orders in the common CPOE. The rotating housestaff may certainly represent a source for confounding, but the large numbers (>30) of evenly spread housestaff over the study period minimizes the potential for any trainee to be responsible for a large proportion of observed practice. Sixth, ICU attendings are the physicians of record and could influence the results. Because no attending physician was on service for more than 4 weeks during the study period, and patients were equally spread over this same time, concerns about clustering and biases this may have created should be minimal but cannot be ruled out. Seventh, some interventions and processes, such as antibiotic administration and measurement of lactate, may have been initiated in the ED, thereby decreasing the potential for differences between the groups. Additionally, we cannot rule out the possibility that factors other than bed availability drove the admission process (we found that the relative proportion of patients admitted to overflow ICU during hours of ambulance diversion was similar to the overflow ICU admissions during non‐ambulance diversion hours). It is possible that some selection bias by the hospitalist assigning patients to specific ICUs influenced their triage decisionsalthough all triaging doctors go through the same process of training in active bed management.11 While more patients admitted to the MICU had severe sepsis, there were no differences between groups in APACHE II or SOFA scores. However, we cannot rule out that there were other residual confounders. Finally, in a small number of cases (4/41, 10%), the CICU team consulted the MICU attending for assistance. This input had the potential to reduce disparities in care between the units.

Overflowing patients to non‐primary ICUs occurs in many hospitals. Our study demonstrates that sepsis treatment for overflow patients may be similar to that received in the primary ICU. While a large multicentered and randomized trial could determine whether significant management and outcome differences exist between primary and overflow ICUs, feasibility concerns make it unlikely that such a study will ever be conducted.

Sepsis is a major cause of death in hospitalized patients.13 It is recommended that patients with sepsis be treated with early appropriate antibiotics, as well as early goal‐directed therapy including fluid and vasopressor support according to evidence‐based guidelines.46 Following such evidence‐based protocols and process‐of‐care interventions has been shown to be associated with better patient outcomes, including decreased mortality.7, 8

Most patients with severe sepsis are cared for in intensive care units (ICUs). At times, there are no beds available in the primary ICU and patients presenting to the hospital with sepsis are cared for in other units. Patients admitted to a non‐preferred clinical inpatient setting are sometimes referred to as overflow.9 ICUs can differ significantly in staffing patterns, equipment, and training.10 It is not known if overflow sepsis patients receive similar care when admitted to non‐primary ICUs.

At our hospital, we have an active bed management system led by the hospitalist division.11 This system includes protocols to place sepsis patients in the overflow ICU if the primary ICU is full. We hypothesized that process‐of‐care interventions would be more strictly adhered to when sepsis patients were in the primary ICU rather than in the overflow unit at our institution.

METHODS

RESULTS

There were 100 patients admitted to the MICU and 41 patients admitted to the CICU during the study period (Table 1). The majority of the patients were admitted to the ICUs directly from the emergency department (ED) (n = 129), with a small number of patients who were transferred from the Medicine floors (n = 12).

There were no significant differences between the 2 study groups in terms of age, sex, primary site of infection, mean APACHE II score, SOFA scores on day 1, chronic organ insufficiency, immune suppression, or need for mechanical ventilation (Table 1). The most common site of infection was lung. There were significantly more patients with severe sepsis in the MICU (88% vs 51%, P <0.001).

DISCUSSION

Since sepsis is more commonly treated in the medical ICU and some data suggests that specialty ICUs may be better at providing desired care,18, 19 we believed that patients treated in the MICU would be more likely to receive guideline‐concordant care. The study refutes our a priori hypothesis and reveals that evidence‐based processes‐of‐care associated with improved outcomes for sepsis are similarly implemented at our institution in the primary and overflow ICU. These findings are important, as ICU bed availability is a frequent problem and many hospitals overflow patients to non‐primary ICUs.9, 20

The observed equivalence in the care delivered may be a function of the relatively high number of patients with sepsis treated in the overflow unit, thereby giving the delivery teams enough experience to provide the desired care. An alternative explanation could be that the residents in CICU brought with them the experience from having previously trained in the MICU. Although, some of the care processes for sepsis patients are influenced by the CPOE (with embedded order sets and protocols), it is unlikely that CPOE can fully account for similarity in care because many processes and therapies (like use of steroids, amount of fluid delivered in first 24 hours, packed red blood cells [PRBC] transfusion, and spontaneous breathing trials) are not embedded within order sets.

The significant difference noted in the areas of deep vein thrombosis (DVT) and gastrointestinal (GI) prophylaxis within 24 hours of ICU admission was unexpected. These preventive therapies are included in initial order sets in the CPOE, which prompt physicians to order them as standard‐of‐care. With respect to DVT prophylaxis, we suspect that some of the difference might be attributable to specific contraindications to its use, which could have been more common in one of the units. There were more patients in MICU on mechanical ventilation (although not statistically significant) and with severe sepsis (statistically significant) at time of admission, which might have contributed to the difference noted in use of GI prophylaxis. It is also plausible that these differences might have disappeared if they were reassessed beyond 24 hours into the ICU admission. We cannot rule out the presence of unit‐ and physician‐level differences that contributed to this. Likewise, there was an unexpected trend towards significance, wherein more patients in CICU had spontaneous breathing trials within 24 hours of admission. This might also be explained by the higher number of patients with severe sepsis in the MICU (preempting any weaning attempts). These caveats aside, it is reassuring that, at our institution, admitting septic patients to the first available ICU bed does not adversely affect important processes‐of‐care.

One might ask whether this study's data should reassure other sites who are boarding septic patients in non‐primary ICUs. Irrespective of the number of patients studied or the degree of statistical significance of the associations, an observational study design cannot prove that boarding septic patients in non‐primary ICUs is either safe or unsafe. However, we hope that readers reflect on, and take inventory of, systems issues that may be different between unitswith an eye towards eliminating variation such that all units managing septic patients are primed to deliver guideline‐concordant care. Other hospitals that use CPOE with sepsis order sets, have protocols for sepsis care, and who train nursing and respiratory therapists to meet high standards might be pleased to see that the patients in our study received comparable, high‐quality care across the 2 units. While our data suggests that boarding patients in overflow units may be safe, these findings would need to be replicated at other sites using prospective designs to prove safety.

Length of emergency room stay prior to admission is associated with higher mortality rates.2123 At many hospitals, critical care beds are a scarce resource such that most hospitals have a policy for the triage of patients to critical care beds.24, 25 Lundberg and colleagues' study demonstrated that patients who developed septic shock on the medical wards experienced delays in receipt of intravenous fluids, inotropic agents and transfer to a critical care setting.26 Thus, rather than waiting in the ED or on the medical service for an MICU bed to become available, it may be most wise to admit a critically sick septic patient to the first available ICU bed, even to an overflow ICU. In a recent study by Sidlow and Aggarwal, 1104 patients discharged from the coronary care unit (CCU) with a non‐cardiac primary diagnosis were compared to patients admitted to the MICU in the same hospital.27 The study found no differences in patient mortality, 30‐day readmission rate, hospital LOS, ICU LOS, and safety outcomes of ventilator‐associated pneumonia and catheter‐associated bloodstream infections between ICUs. However, their study did not examine processes‐of‐care delivered between the primary ICU and the overflow unit, and did not validate the primary diagnoses of patients admitted to the ICU.

Several limitations of this study should be considered. First, this study was conducted at a single center. Second, we used a retrospective study design; however, a prospective study randomizing patients to 1 of the 2 units would likely never be possible. Third, the relatively small number of patients limited the power of the study to detect mortality differences between the units. However, this was a pilot study focused on processes of care as opposed to clinical outcomes. Fourth, it is possible that we did not capture every single patient with sepsis with our keyword search. Our use of a previously validated screening process should have limited the number of missed cases.15, 16 Fifth, although the 2 ICUs have exclusive nursing staff and attending physicians, the housestaff and respiratory therapists do rotate between the 2 ICUs and place orders in the common CPOE. The rotating housestaff may certainly represent a source for confounding, but the large numbers (>30) of evenly spread housestaff over the study period minimizes the potential for any trainee to be responsible for a large proportion of observed practice. Sixth, ICU attendings are the physicians of record and could influence the results. Because no attending physician was on service for more than 4 weeks during the study period, and patients were equally spread over this same time, concerns about clustering and biases this may have created should be minimal but cannot be ruled out. Seventh, some interventions and processes, such as antibiotic administration and measurement of lactate, may have been initiated in the ED, thereby decreasing the potential for differences between the groups. Additionally, we cannot rule out the possibility that factors other than bed availability drove the admission process (we found that the relative proportion of patients admitted to overflow ICU during hours of ambulance diversion was similar to the overflow ICU admissions during non‐ambulance diversion hours). It is possible that some selection bias by the hospitalist assigning patients to specific ICUs influenced their triage decisionsalthough all triaging doctors go through the same process of training in active bed management.11 While more patients admitted to the MICU had severe sepsis, there were no differences between groups in APACHE II or SOFA scores. However, we cannot rule out that there were other residual confounders. Finally, in a small number of cases (4/41, 10%), the CICU team consulted the MICU attending for assistance. This input had the potential to reduce disparities in care between the units.

Overflowing patients to non‐primary ICUs occurs in many hospitals. Our study demonstrates that sepsis treatment for overflow patients may be similar to that received in the primary ICU. While a large multicentered and randomized trial could determine whether significant management and outcome differences exist between primary and overflow ICUs, feasibility concerns make it unlikely that such a study will ever be conducted.

Sepsis is a major cause of death in hospitalized patients.13 It is recommended that patients with sepsis be treated with early appropriate antibiotics, as well as early goal‐directed therapy including fluid and vasopressor support according to evidence‐based guidelines.46 Following such evidence‐based protocols and process‐of‐care interventions has been shown to be associated with better patient outcomes, including decreased mortality.7, 8

Most patients with severe sepsis are cared for in intensive care units (ICUs). At times, there are no beds available in the primary ICU and patients presenting to the hospital with sepsis are cared for in other units. Patients admitted to a non‐preferred clinical inpatient setting are sometimes referred to as overflow.9 ICUs can differ significantly in staffing patterns, equipment, and training.10 It is not known if overflow sepsis patients receive similar care when admitted to non‐primary ICUs.

At our hospital, we have an active bed management system led by the hospitalist division.11 This system includes protocols to place sepsis patients in the overflow ICU if the primary ICU is full. We hypothesized that process‐of‐care interventions would be more strictly adhered to when sepsis patients were in the primary ICU rather than in the overflow unit at our institution.

METHODS