Hospitalized patients are becoming increasingly complex. The care of such patients may be impacted by the limited resources of the general ward and might benefit from more intensive monitoring in an intensive care unit (ICU)‐like setting. In light of this problem, the intermediate care units (ImCU) may provide a cost‐effective alternative by providing higher levels of staffing tailored to patient needs, without incurring the cost of an ICU admission. The ImCU can reduce costs and improves ICU utilization for sicker patients, decrease ICU readmissions, promote greater flexibility in patient triage, and decrease mortality rates in hospital wards.18

The characteristics of ImCUs depend on resource availability, institutional infrastructure, and the organization and funding of the parent healthcare system. The ImCU may function as a step‐up or step‐down unit, or may provide specialty care for cardiac, neurologic, respiratory, or surgical conditions.811 These units can expand opportunities for co‐management and, at the same time, offer the occasion for training residents to follow up patients through different levels of care (from the general ward to ImCU). In the same way, the multidisciplinary approach of the ImCU can improve the center's teaching potential.

Characterizing the ImCU population requires the assessment of their severity of illness, which is crucial for the evaluation of risk‐adjusted outcomes. The present study evaluated the impact of a hospitalist‐led ImCU on observed‐to‐expected mortality ratios, as well as its role in co‐management and teaching.

PATIENTS AND METHODS

We performed a retrospective observational study, with data collected from April 2006 to April 2010 in a single academic medical center in Pamplona, Spain. The ImCU is a 9‐bed unit adjacent to, but independent from, the mixed ICU. Each bed is equipped with continuous telemetry, pulse oximetry, noninvasive arterial blood pressure, central venous pressure monitoring, and noninvasive pressure support ventilation. The signals are relayed to a central monitoring station and the nurse‐to‐patient ratio is 1:3.

The ImCU rounding team is multidisciplinary, and involves the hospital pharmacist, a nurse, the ImCU resident, the specialist or surgeon, and the attending hospitalist. After the triage process, ImCU patients were admitted to the attending hospitalist, who was responsible for admission and discharge of all ImCU patients. The hospitalist ordered diagnostic or therapeutic interventions as needed, with the exception of orders for procedures or consultations related with specialist/surgeon's specific needs.

Admission and discharge criteria for the ImCU were set according to guidelines defined by The American College of Critical Care Medicine,10 and also served as inclusion criteria for the present study. Exclusion criteria included: age less than 18 years old, severe respiratory failure, status epilepticus, and catastrophic brain illness. Patients admitted for drug administration and desensitization, and also ImCU readmissions, were excluded from data analysis. Patients came from medical and surgical wards, ICU, the operating room, and the emergency room.

A total of 756 patients were admitted to our ImCU during the study period. Patient demographics, past medical history, physiologic parameters at the time of admission, and survival to hospital discharge were recorded for all patients. Patient demographics include: age, gender, location before ImCU admission, length of stay before ImCU admission, reason for ImCU admission, anatomic site of surgery (if applicable), planned or unplanned admission, and infection status (nosocomial). Past medical history includes: the presence of arterial hypertension, diabetes, cirrhosis, chronic renal failure, chronic heart failure, cancer, hematological malignancy, chronic obstructive pulmonary disease (COPD), human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), immunosuppression, radiotherapy, chemotherapy, steroid treatment, and alcoholism. Physiologic parameters abstracted are described in Table 1. We used the Simplified Acute Physiology Score II (SAPS II),12 as a prognostic and severity score. SAPS II is the only previously validated score in intermediate care.13 In‐hospital mortality was the clinical outcome measured.

Data were entered into a computer database by the authors. Statistical analysis was not blinded, and was performed using SPSS for Windows, version 15.0 (SPSS Inc, Chicago, IL). Continuous variables were reported as mean standard deviation or median (25%‐75% interquartile range). For nonparametric measure of statistical dependence of quantitative variables, we used Spearman's correlation coefficient. Discrimination was evaluated by calculating the area under receiver operating characteristic curve (AUROC).

The study protocol was approved by the institutional review board at the Clnica Universidad de Navarra in Pamplona, Spain.

RESULTS

Four hundred fifty‐six patients were included in data analysis. Three hundred patients were excluded: 61 low‐risk patients (drug administration and desensitization), 147 readmissions, and 92 patients for missing variables. Patient characteristics, including probability of death following ImCU admission and discharge location, are summarized in Table 2. The mean age was 65.6 years, and about 35% of patients had a SAPS II‐based risk of death higher than 25% at the time of ImCU admission. The median length of stay was 4 (3‐7) days.

Outcomes

The mean SAPS II of the cohort was 37 12 points, and the expected mortality derived from this score was 23.2%. The observed in‐hospital mortality was 20.6% (94/456) resulting in an observed‐to‐expected mortality ratio of 0.89 (Table 2). Reasons for ImCU admission, as well as mortality ratios, are described in Table 3. The correlation between SAPS II predicted and observed death rates was accurate and statistically significant (Rho = 1.0, P < 0.001) (Figure 1). The AUROC for SAPS II predicting in‐hospital mortality was 0.75 (P < 0.001).

Figure 1

Table 3.Reasons for ImCU Admission and Severity Score Index

Condition	Patients	SAPS II	Expected Mortality	Observed Mortality	O/E Ratio
Abbreviations: GI, gastrointestinal complications; ImCU, intermediate care unit; O/E ratio, observed‐to‐expected mortality ratios; SAPS II, Simplified Acute Physiology Score II.
Respiratory failure	153 (33.6%)	36.1 9.7	21.5 15.3%	25.5% (39)	1.19
Sepsis	88 (19.3%)	45.7 15.1	37.5 25.1%	22.7% (20)	0.61
Cardiovascular	72 (15.8%)	35.7 11.0	21.3 16.6%	23.6% (17)	1.11
Perioperative	59 (12.9%)	28.9 9.9	12.9 11.7%	5.1% (3)	0.40
Complex monitoring	34 (7.5%)	33.2 12.1	19.1 16.3%	14.7% (5)	0.77
GI complications	33 (7.2%)	32.1 8.3	15.6 10.7%	12.1% (4)	0.78
Neurologic	10 (2.2%)	40.9 10.6	29.7 20.0%	30.0% (3)	1.01
Liver failure	7 (1.5%)	42.1 17.2	30.9 29.4%	42.9% (3)	1.39

DISCUSSION

To the best of our knowledge, this is the first description of hospitalists in intermediate care. In Spain, where hospital medicine is early in development but expanding, critical and intermediate care units are usually staffed by intensivists or anesthesiologists. Staffing an ImCU with hospitalists, using a multidisciplinary co‐management model, is a novel staffing solution for acutely ill patients.

Approximately 35% of ICU patients are low risk, admitted mainly for monitoring purposes.9, 14 In contrast, some patients are treated on general wards when they should receive more intensive care and monitoring.15 Intermediate care units could improve cost containment and triage flexibility, while tailoring treatments according to patient needs. In general, ImCUs require lower nurse‐to‐patient ratios, and less expensive equipment and supplies than ICUs, while retaining the capability of responding appropriately to acute events.16 Moreover, patient and family satisfaction may be increased as a result of more liberal visitation policies and a less noisy environment.17

This study was not designed to measure the cost‐effectiveness of the ImCU. Surprisingly, there are few reports in the last 2 decades demonstrating the efficacy and cost containment of intermediate care. The majority of the studies were retrospective or uncontrolled observations.27 To our knowledge, only 1 randomized controlled trial1 and 1 multicenter prospective cost study exist.8 Further research is needed in this area, with larger, prospective randomized controlled trials, before the benefits and limitations of intermediate care can be fully determined.

Description of the ImCU patients depends on accurate severity scoring. The efficacy and reliability of these scores has been described only for ICU patients and their role for predicting mortality in the ImCU is uncertain. There is only 1 report using SAPS II in intermediate care, showing good discriminant power and calibration in a cohort of 433 patients.13 Auriant et al described, in that cohort, an observed mortality rate of 8.1% with an expected mortality rate of 8.7%.13 In contrast, our expected mortality rate was considerably higher (23.2%). Although ImCUs are generally created for low‐risk patients and monitoring purposes, our population was more similar to an ICU population, with very high risk for major complications and mortality.1823 The contribution of oncologic patients (22% of the total series; most of them with advanced disease, elevated SAPS II [42.2 13.6] and do‐not‐resuscitate orders), probably contributed to the higher acuity of our ImCU population. The correlation of our present data supports the value of SAPS II as a prognostic score in intermediate care, even for patients sicker than those reported by Auriant et al.13 Intermediate care is also a valuable setting to expand a co‐management model with different medical and surgical specialties.

Similarly, since the creation of the ImCU at our institution in 2006, there is a substantial increase in the number of residents rotating through our ImCU. Previous studies showed positive results of hospitalists as clinical educators in various settings.24, 25

In conclusion, intermediate care serves as an expansion of role for hospitalists at our institution; and clinicians, trainees, and patients may benefit from co‐management and teaching opportunities at this unique level of care. An ImCU led by hospitalists showed encouraging results in terms of observed‐to‐expected mortality ratios for acutely ill patients. SAPS II is a useful tool for prognostic evaluation of ImCU patients. However, results of this study should be confirmed with larger, prospective trials at multiple centers.

Hospitalized patients are becoming increasingly complex. The care of such patients may be impacted by the limited resources of the general ward and might benefit from more intensive monitoring in an intensive care unit (ICU)‐like setting. In light of this problem, the intermediate care units (ImCU) may provide a cost‐effective alternative by providing higher levels of staffing tailored to patient needs, without incurring the cost of an ICU admission. The ImCU can reduce costs and improves ICU utilization for sicker patients, decrease ICU readmissions, promote greater flexibility in patient triage, and decrease mortality rates in hospital wards.18

The characteristics of ImCUs depend on resource availability, institutional infrastructure, and the organization and funding of the parent healthcare system. The ImCU may function as a step‐up or step‐down unit, or may provide specialty care for cardiac, neurologic, respiratory, or surgical conditions.811 These units can expand opportunities for co‐management and, at the same time, offer the occasion for training residents to follow up patients through different levels of care (from the general ward to ImCU). In the same way, the multidisciplinary approach of the ImCU can improve the center's teaching potential.

Characterizing the ImCU population requires the assessment of their severity of illness, which is crucial for the evaluation of risk‐adjusted outcomes. The present study evaluated the impact of a hospitalist‐led ImCU on observed‐to‐expected mortality ratios, as well as its role in co‐management and teaching.

PATIENTS AND METHODS

We performed a retrospective observational study, with data collected from April 2006 to April 2010 in a single academic medical center in Pamplona, Spain. The ImCU is a 9‐bed unit adjacent to, but independent from, the mixed ICU. Each bed is equipped with continuous telemetry, pulse oximetry, noninvasive arterial blood pressure, central venous pressure monitoring, and noninvasive pressure support ventilation. The signals are relayed to a central monitoring station and the nurse‐to‐patient ratio is 1:3.

The ImCU rounding team is multidisciplinary, and involves the hospital pharmacist, a nurse, the ImCU resident, the specialist or surgeon, and the attending hospitalist. After the triage process, ImCU patients were admitted to the attending hospitalist, who was responsible for admission and discharge of all ImCU patients. The hospitalist ordered diagnostic or therapeutic interventions as needed, with the exception of orders for procedures or consultations related with specialist/surgeon's specific needs.

Admission and discharge criteria for the ImCU were set according to guidelines defined by The American College of Critical Care Medicine,10 and also served as inclusion criteria for the present study. Exclusion criteria included: age less than 18 years old, severe respiratory failure, status epilepticus, and catastrophic brain illness. Patients admitted for drug administration and desensitization, and also ImCU readmissions, were excluded from data analysis. Patients came from medical and surgical wards, ICU, the operating room, and the emergency room.

A total of 756 patients were admitted to our ImCU during the study period. Patient demographics, past medical history, physiologic parameters at the time of admission, and survival to hospital discharge were recorded for all patients. Patient demographics include: age, gender, location before ImCU admission, length of stay before ImCU admission, reason for ImCU admission, anatomic site of surgery (if applicable), planned or unplanned admission, and infection status (nosocomial). Past medical history includes: the presence of arterial hypertension, diabetes, cirrhosis, chronic renal failure, chronic heart failure, cancer, hematological malignancy, chronic obstructive pulmonary disease (COPD), human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), immunosuppression, radiotherapy, chemotherapy, steroid treatment, and alcoholism. Physiologic parameters abstracted are described in Table 1. We used the Simplified Acute Physiology Score II (SAPS II),12 as a prognostic and severity score. SAPS II is the only previously validated score in intermediate care.13 In‐hospital mortality was the clinical outcome measured.

Data were entered into a computer database by the authors. Statistical analysis was not blinded, and was performed using SPSS for Windows, version 15.0 (SPSS Inc, Chicago, IL). Continuous variables were reported as mean standard deviation or median (25%‐75% interquartile range). For nonparametric measure of statistical dependence of quantitative variables, we used Spearman's correlation coefficient. Discrimination was evaluated by calculating the area under receiver operating characteristic curve (AUROC).

The study protocol was approved by the institutional review board at the Clnica Universidad de Navarra in Pamplona, Spain.

RESULTS

Four hundred fifty‐six patients were included in data analysis. Three hundred patients were excluded: 61 low‐risk patients (drug administration and desensitization), 147 readmissions, and 92 patients for missing variables. Patient characteristics, including probability of death following ImCU admission and discharge location, are summarized in Table 2. The mean age was 65.6 years, and about 35% of patients had a SAPS II‐based risk of death higher than 25% at the time of ImCU admission. The median length of stay was 4 (3‐7) days.

Outcomes

The mean SAPS II of the cohort was 37 12 points, and the expected mortality derived from this score was 23.2%. The observed in‐hospital mortality was 20.6% (94/456) resulting in an observed‐to‐expected mortality ratio of 0.89 (Table 2). Reasons for ImCU admission, as well as mortality ratios, are described in Table 3. The correlation between SAPS II predicted and observed death rates was accurate and statistically significant (Rho = 1.0, P < 0.001) (Figure 1). The AUROC for SAPS II predicting in‐hospital mortality was 0.75 (P < 0.001).

Figure 1

Table 3.Reasons for ImCU Admission and Severity Score Index

Condition	Patients	SAPS II	Expected Mortality	Observed Mortality	O/E Ratio
Abbreviations: GI, gastrointestinal complications; ImCU, intermediate care unit; O/E ratio, observed‐to‐expected mortality ratios; SAPS II, Simplified Acute Physiology Score II.
Respiratory failure	153 (33.6%)	36.1 9.7	21.5 15.3%	25.5% (39)	1.19
Sepsis	88 (19.3%)	45.7 15.1	37.5 25.1%	22.7% (20)	0.61
Cardiovascular	72 (15.8%)	35.7 11.0	21.3 16.6%	23.6% (17)	1.11
Perioperative	59 (12.9%)	28.9 9.9	12.9 11.7%	5.1% (3)	0.40
Complex monitoring	34 (7.5%)	33.2 12.1	19.1 16.3%	14.7% (5)	0.77
GI complications	33 (7.2%)	32.1 8.3	15.6 10.7%	12.1% (4)	0.78
Neurologic	10 (2.2%)	40.9 10.6	29.7 20.0%	30.0% (3)	1.01
Liver failure	7 (1.5%)	42.1 17.2	30.9 29.4%	42.9% (3)	1.39

DISCUSSION

To the best of our knowledge, this is the first description of hospitalists in intermediate care. In Spain, where hospital medicine is early in development but expanding, critical and intermediate care units are usually staffed by intensivists or anesthesiologists. Staffing an ImCU with hospitalists, using a multidisciplinary co‐management model, is a novel staffing solution for acutely ill patients.

Approximately 35% of ICU patients are low risk, admitted mainly for monitoring purposes.9, 14 In contrast, some patients are treated on general wards when they should receive more intensive care and monitoring.15 Intermediate care units could improve cost containment and triage flexibility, while tailoring treatments according to patient needs. In general, ImCUs require lower nurse‐to‐patient ratios, and less expensive equipment and supplies than ICUs, while retaining the capability of responding appropriately to acute events.16 Moreover, patient and family satisfaction may be increased as a result of more liberal visitation policies and a less noisy environment.17

This study was not designed to measure the cost‐effectiveness of the ImCU. Surprisingly, there are few reports in the last 2 decades demonstrating the efficacy and cost containment of intermediate care. The majority of the studies were retrospective or uncontrolled observations.27 To our knowledge, only 1 randomized controlled trial1 and 1 multicenter prospective cost study exist.8 Further research is needed in this area, with larger, prospective randomized controlled trials, before the benefits and limitations of intermediate care can be fully determined.

Description of the ImCU patients depends on accurate severity scoring. The efficacy and reliability of these scores has been described only for ICU patients and their role for predicting mortality in the ImCU is uncertain. There is only 1 report using SAPS II in intermediate care, showing good discriminant power and calibration in a cohort of 433 patients.13 Auriant et al described, in that cohort, an observed mortality rate of 8.1% with an expected mortality rate of 8.7%.13 In contrast, our expected mortality rate was considerably higher (23.2%). Although ImCUs are generally created for low‐risk patients and monitoring purposes, our population was more similar to an ICU population, with very high risk for major complications and mortality.1823 The contribution of oncologic patients (22% of the total series; most of them with advanced disease, elevated SAPS II [42.2 13.6] and do‐not‐resuscitate orders), probably contributed to the higher acuity of our ImCU population. The correlation of our present data supports the value of SAPS II as a prognostic score in intermediate care, even for patients sicker than those reported by Auriant et al.13 Intermediate care is also a valuable setting to expand a co‐management model with different medical and surgical specialties.

Similarly, since the creation of the ImCU at our institution in 2006, there is a substantial increase in the number of residents rotating through our ImCU. Previous studies showed positive results of hospitalists as clinical educators in various settings.24, 25

In conclusion, intermediate care serves as an expansion of role for hospitalists at our institution; and clinicians, trainees, and patients may benefit from co‐management and teaching opportunities at this unique level of care. An ImCU led by hospitalists showed encouraging results in terms of observed‐to‐expected mortality ratios for acutely ill patients. SAPS II is a useful tool for prognostic evaluation of ImCU patients. However, results of this study should be confirmed with larger, prospective trials at multiple centers.

Hospitalized patients are becoming increasingly complex. The care of such patients may be impacted by the limited resources of the general ward and might benefit from more intensive monitoring in an intensive care unit (ICU)‐like setting. In light of this problem, the intermediate care units (ImCU) may provide a cost‐effective alternative by providing higher levels of staffing tailored to patient needs, without incurring the cost of an ICU admission. The ImCU can reduce costs and improves ICU utilization for sicker patients, decrease ICU readmissions, promote greater flexibility in patient triage, and decrease mortality rates in hospital wards.18

The characteristics of ImCUs depend on resource availability, institutional infrastructure, and the organization and funding of the parent healthcare system. The ImCU may function as a step‐up or step‐down unit, or may provide specialty care for cardiac, neurologic, respiratory, or surgical conditions.811 These units can expand opportunities for co‐management and, at the same time, offer the occasion for training residents to follow up patients through different levels of care (from the general ward to ImCU). In the same way, the multidisciplinary approach of the ImCU can improve the center's teaching potential.

Characterizing the ImCU population requires the assessment of their severity of illness, which is crucial for the evaluation of risk‐adjusted outcomes. The present study evaluated the impact of a hospitalist‐led ImCU on observed‐to‐expected mortality ratios, as well as its role in co‐management and teaching.

PATIENTS AND METHODS

We performed a retrospective observational study, with data collected from April 2006 to April 2010 in a single academic medical center in Pamplona, Spain. The ImCU is a 9‐bed unit adjacent to, but independent from, the mixed ICU. Each bed is equipped with continuous telemetry, pulse oximetry, noninvasive arterial blood pressure, central venous pressure monitoring, and noninvasive pressure support ventilation. The signals are relayed to a central monitoring station and the nurse‐to‐patient ratio is 1:3.

The ImCU rounding team is multidisciplinary, and involves the hospital pharmacist, a nurse, the ImCU resident, the specialist or surgeon, and the attending hospitalist. After the triage process, ImCU patients were admitted to the attending hospitalist, who was responsible for admission and discharge of all ImCU patients. The hospitalist ordered diagnostic or therapeutic interventions as needed, with the exception of orders for procedures or consultations related with specialist/surgeon's specific needs.

Admission and discharge criteria for the ImCU were set according to guidelines defined by The American College of Critical Care Medicine,10 and also served as inclusion criteria for the present study. Exclusion criteria included: age less than 18 years old, severe respiratory failure, status epilepticus, and catastrophic brain illness. Patients admitted for drug administration and desensitization, and also ImCU readmissions, were excluded from data analysis. Patients came from medical and surgical wards, ICU, the operating room, and the emergency room.

A total of 756 patients were admitted to our ImCU during the study period. Patient demographics, past medical history, physiologic parameters at the time of admission, and survival to hospital discharge were recorded for all patients. Patient demographics include: age, gender, location before ImCU admission, length of stay before ImCU admission, reason for ImCU admission, anatomic site of surgery (if applicable), planned or unplanned admission, and infection status (nosocomial). Past medical history includes: the presence of arterial hypertension, diabetes, cirrhosis, chronic renal failure, chronic heart failure, cancer, hematological malignancy, chronic obstructive pulmonary disease (COPD), human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), immunosuppression, radiotherapy, chemotherapy, steroid treatment, and alcoholism. Physiologic parameters abstracted are described in Table 1. We used the Simplified Acute Physiology Score II (SAPS II),12 as a prognostic and severity score. SAPS II is the only previously validated score in intermediate care.13 In‐hospital mortality was the clinical outcome measured.

Data were entered into a computer database by the authors. Statistical analysis was not blinded, and was performed using SPSS for Windows, version 15.0 (SPSS Inc, Chicago, IL). Continuous variables were reported as mean standard deviation or median (25%‐75% interquartile range). For nonparametric measure of statistical dependence of quantitative variables, we used Spearman's correlation coefficient. Discrimination was evaluated by calculating the area under receiver operating characteristic curve (AUROC).

The study protocol was approved by the institutional review board at the Clnica Universidad de Navarra in Pamplona, Spain.

RESULTS

Four hundred fifty‐six patients were included in data analysis. Three hundred patients were excluded: 61 low‐risk patients (drug administration and desensitization), 147 readmissions, and 92 patients for missing variables. Patient characteristics, including probability of death following ImCU admission and discharge location, are summarized in Table 2. The mean age was 65.6 years, and about 35% of patients had a SAPS II‐based risk of death higher than 25% at the time of ImCU admission. The median length of stay was 4 (3‐7) days.

Outcomes

The mean SAPS II of the cohort was 37 12 points, and the expected mortality derived from this score was 23.2%. The observed in‐hospital mortality was 20.6% (94/456) resulting in an observed‐to‐expected mortality ratio of 0.89 (Table 2). Reasons for ImCU admission, as well as mortality ratios, are described in Table 3. The correlation between SAPS II predicted and observed death rates was accurate and statistically significant (Rho = 1.0, P < 0.001) (Figure 1). The AUROC for SAPS II predicting in‐hospital mortality was 0.75 (P < 0.001).

Figure 1

Table 3.Reasons for ImCU Admission and Severity Score Index

Condition	Patients	SAPS II	Expected Mortality	Observed Mortality	O/E Ratio
Abbreviations: GI, gastrointestinal complications; ImCU, intermediate care unit; O/E ratio, observed‐to‐expected mortality ratios; SAPS II, Simplified Acute Physiology Score II.
Respiratory failure	153 (33.6%)	36.1 9.7	21.5 15.3%	25.5% (39)	1.19
Sepsis	88 (19.3%)	45.7 15.1	37.5 25.1%	22.7% (20)	0.61
Cardiovascular	72 (15.8%)	35.7 11.0	21.3 16.6%	23.6% (17)	1.11
Perioperative	59 (12.9%)	28.9 9.9	12.9 11.7%	5.1% (3)	0.40
Complex monitoring	34 (7.5%)	33.2 12.1	19.1 16.3%	14.7% (5)	0.77
GI complications	33 (7.2%)	32.1 8.3	15.6 10.7%	12.1% (4)	0.78
Neurologic	10 (2.2%)	40.9 10.6	29.7 20.0%	30.0% (3)	1.01
Liver failure	7 (1.5%)	42.1 17.2	30.9 29.4%	42.9% (3)	1.39

DISCUSSION

To the best of our knowledge, this is the first description of hospitalists in intermediate care. In Spain, where hospital medicine is early in development but expanding, critical and intermediate care units are usually staffed by intensivists or anesthesiologists. Staffing an ImCU with hospitalists, using a multidisciplinary co‐management model, is a novel staffing solution for acutely ill patients.

Approximately 35% of ICU patients are low risk, admitted mainly for monitoring purposes.9, 14 In contrast, some patients are treated on general wards when they should receive more intensive care and monitoring.15 Intermediate care units could improve cost containment and triage flexibility, while tailoring treatments according to patient needs. In general, ImCUs require lower nurse‐to‐patient ratios, and less expensive equipment and supplies than ICUs, while retaining the capability of responding appropriately to acute events.16 Moreover, patient and family satisfaction may be increased as a result of more liberal visitation policies and a less noisy environment.17

This study was not designed to measure the cost‐effectiveness of the ImCU. Surprisingly, there are few reports in the last 2 decades demonstrating the efficacy and cost containment of intermediate care. The majority of the studies were retrospective or uncontrolled observations.27 To our knowledge, only 1 randomized controlled trial1 and 1 multicenter prospective cost study exist.8 Further research is needed in this area, with larger, prospective randomized controlled trials, before the benefits and limitations of intermediate care can be fully determined.

Description of the ImCU patients depends on accurate severity scoring. The efficacy and reliability of these scores has been described only for ICU patients and their role for predicting mortality in the ImCU is uncertain. There is only 1 report using SAPS II in intermediate care, showing good discriminant power and calibration in a cohort of 433 patients.13 Auriant et al described, in that cohort, an observed mortality rate of 8.1% with an expected mortality rate of 8.7%.13 In contrast, our expected mortality rate was considerably higher (23.2%). Although ImCUs are generally created for low‐risk patients and monitoring purposes, our population was more similar to an ICU population, with very high risk for major complications and mortality.1823 The contribution of oncologic patients (22% of the total series; most of them with advanced disease, elevated SAPS II [42.2 13.6] and do‐not‐resuscitate orders), probably contributed to the higher acuity of our ImCU population. The correlation of our present data supports the value of SAPS II as a prognostic score in intermediate care, even for patients sicker than those reported by Auriant et al.13 Intermediate care is also a valuable setting to expand a co‐management model with different medical and surgical specialties.

Similarly, since the creation of the ImCU at our institution in 2006, there is a substantial increase in the number of residents rotating through our ImCU. Previous studies showed positive results of hospitalists as clinical educators in various settings.24, 25

In conclusion, intermediate care serves as an expansion of role for hospitalists at our institution; and clinicians, trainees, and patients may benefit from co‐management and teaching opportunities at this unique level of care. An ImCU led by hospitalists showed encouraging results in terms of observed‐to‐expected mortality ratios for acutely ill patients. SAPS II is a useful tool for prognostic evaluation of ImCU patients. However, results of this study should be confirmed with larger, prospective trials at multiple centers.

Over the past 15 years, there has been dramatic growth in the number of hospitalist physicians in the United States and in the number of hospitals served by them.13 Hospitals are motivated to hire experienced hospitalists to staff their inpatient services,4 with goals that include obtaining cost‐savings and higher quality.59 The rapid growth of Hospital Medicine saw multiple types of hospital practice models emerge with differing job characteristics, clinical duties, workload, and compensation schemes.10 The extent of the variability of hospitalist jobs across practice models is not known.

Intensifying recruitment efforts and the concomitant increase in compensation for hospitalists over the last decade suggest that demand for hospitalists is strong and sustained.11 As a result, today's cohort of hospitalists has a wide range of choices of types of jobs, practice models, and locations. The diversity of available hospitalist jobs is characterized, for example, by setting (community hospital vs academic hospital), employer (hospital vs private practice), job duties (the amount and type of clinical work, and other administrative, teaching, or research duties), and intensity (work hours and duties to maximize income or lifestyle). How these choices relate to job satisfaction and burnout are also unknown.

The Society of Hospital Medicine (SHM) has administered surveys to hospitalist group leaders biennially since 2003.1215 These surveys, however, do not address issues related to individual hospitalist worklife, recruitment, and retention. In 2005, SHM convened a Career Satisfaction Task Force that designed and executed a national survey of hospitalists in 2009‐2010. The objective of this study is to evaluate how job characteristics vary by practice model, and the association of these characteristics and practice models with job satisfaction and burnout.

METHODS

RESULTS

Response Rate

Of the 5389 originally sampled addresses, 1868 were undeliverable. Addresses were further excluded if they appeared in duplicate or were outdated. This yielded a total of 3105 eligible surveyees in the sample. As illustrated in Figure 1, 841 responded to the mailed survey and 5 responded to the Web‐based survey. After rejecting 67 non‐hospitalist respondents and 3 duplicate surveys, a total of 776 surveys were included in the final analysis. The adjusted response rate was 25.6% (776/3035). Members of SHM were more likely to return the survey than nonmembers. The adjusted response rate from hospitalists affiliated with the 3 sponsoring institutions was 6% (40/662). Because these respondents were more likely to be non‐members of SHM, we opted to analyze the responses from the sponsor hospitalists together with the sampled hospitalists. The demographics of the resulting pool of 816 respondents affiliated with over 650 unique hospitalist groups were representative of the original survey frame. We analyzed data from 794 of these who responded to the item indicating their hospitalist practice model. Demographic characteristics of responders and nonresponders to the practice model survey item were similar.

Figure 1

Components of Job Satisfaction

Hospitalists' rankings of the most important factors for job satisfaction revealed differences across models (Figure 2). Overall, hospitalists were most likely to consider optimal workload and compensation as important factors for job satisfaction from a list of 13 considerations. Local groups and academics were least likely to rank optimal workload as a top factor, and local group hospitalists were more likely to rank optimal autonomy than those of other models. Academic hospitalists had less concern for substantial pay, and more concern for the variety of tasks they perform and recognition by leaders, than other hospitalists.

Figure 2

Job Satisfaction and Burnout Risk

Differences in the ratings of 4 of the 11 satisfaction and job characteristic domains were found across the practice models (Figure 3). Multispecialty group hospitalists were less satisfied with autonomy and their relationship with patients than other practice models, and along with multistate groups, reported the highest perceived workload. Organizational fairness was rated much higher by local group hospitalists than other practice models. Despite these differences in work patterns and satisfaction, there were no differences found in level of global job satisfaction, specialty satisfaction, or burnout across the practice models. Overall, 62% of respondents reported high job satisfaction (4 on a 1 to 5 scale), and 30% indicated burnout symptoms.

Figure 3

DISCUSSION

In our sample of US hospitalists, we found major differences in work patterns and compensation across hospitalist practice models, but no differences in job satisfaction, specialty satisfaction, and burnout. In particular, differences across these models included variations in hospitalist workload, hours, pay, and distribution of work activities. We found that hospitalists perform a variety of clinical and nonclinical tasks, for many of which there are not standard reimbursement mechanisms. We also found that features of a job that individual hospitalists considered most important vary by practice model.

Previous analysis of this data explored the overall state of hospitalist satisfaction.16 The present analysis offers a glimpse into hospitalists' systems‐orientation through a deeper look at their work patterns. The growth in the number of hospitalists who participate in intensive care medicine, specialty comanagement, and other work that involves close working relationships with specialist physicians confirms collaborative care as one of the dominant drivers of the hospitalist movement. At the level of indirect patient care, nearly all hospitalists contributed to work that facilitates coordination, quality, patient safety, or information technology. Understanding the integrative value of hospitalists outside of their clinical productivity may be of interest to hospital administrators.

Global satisfaction measures were similar across practice models. This finding is particularly interesting given the major differences in job characteristics seen among the practice models. This similarity in global satisfaction despite real differences in the nature of the job suggests that individuals find settings that allow them to address their individual professional goals. Our study demonstrates that, in 2010, Hospital Medicine has evolved enough to accommodate a wide variety of goals and needs.

While global satisfaction did not differ among practice types, hospitalists from various models did report differences in factors considered important to global satisfaction. While workload and pay were rated as influential across most models, the degree of importance was significantly different. In academic settings, substantial pay was not a top consideration for overall job satisfaction, whereas in local and multistate hospitalist groups, pay was a very close second in importance to optimal workload. These results may prove helpful for individual hospitalists trying to find their optimal job. For example, someone who is less concerned about workload, but wants to be paid well and have a high degree of autonomy, may find satisfaction in local hospitalist groups. However, for someone who is willing to sacrifice a higher salary for variety of activities, academic Hospital Medicine may be a better fit.

There is a concerning aspect of hospitalist job satisfaction that different practice models do not seem to solve. Control over personal time is a top consideration for many hospitalists across practice models, yet their satisfaction with personal time is low. As control over personal time is seen as a draw to the Hospital Medicine specialty, group leaders may need to evaluate their programs to ensure that schedules and workload support efforts for hospitalists to balance work and homelife commitments.

There are additional findings that are important for Hospital Medicine group leaders. Regardless of practice model, compensation and workload are often used as tools to recruit and retain hospitalists. While these tools may be effective, leaders may find more nuanced approaches to improving their hospitalists' overall satisfaction. Leaders of local hospitalist groups may find their hospitalists tolerant of heavier workloads as long as they are adequately rewarded and are given real autonomy over their work. However, leaders of academic programs may be missing the primary factor that can improve their hospitalists' satisfaction. Rather than asking for higher salaries to remain competitive, it may be more effective to advocate for time and training for their hospitalists to pursue important other activities beyond direct clinical care. Given that resources will always be limited, group leaders need to understand all of the elements that can contribute to hospitalist job satisfaction.

We point out several limitations to this study. First, our adjusted response rate of 25.6% is low for survey research, in general. As mentioned above, hospitalists are not easily identified in any available national physician database. Therefore, we deliberately designed our sampling strategy to error on the side of including ineligible surveyees to reduce systematic exclusion of practicing hospitalists. Using simple post hoc methods, we identified many nonhospitalists and bad addresses from our sample, but because these methods were exclusionary as opposed to confirmatory, we believe that a significant proportion of remaining nonrespondents may also have been ineligible for the survey. Although this does not fully address concerns about potential response bias, we believe that our sample representing a large number of hospitalist groups is adequate to make estimations about a nationally representative sample of practicing hospitalists. Second, in spite of our inclusive approach, we may still have excluded categories of practicing hospitalists. We were careful not to allow SHM members to represent all US hospitalists and included non‐members in the sampling frame, but the possibility of systematic exclusion that may alter our results remains a concern. Additionally, one of our goals was to characterize pediatric hospitalists independently from their adult‐patient counterparts. Despite oversampling of pediatricians, their sample was too small for a more detailed comparison across practice models. Also, self‐reported data about workload and compensation are subject to inaccuracies related to recall and cognitive biases. Last, this is a cross‐sectional study of hospitalist satisfaction at one point in time. Consequently, our sample may not be representative of very dissatisfied hospitalists who have already left their jobs.

The diversity found across existing practice models and the characteristics of the practices provide physicians with the opportunity to bring their unique skills and motivations to the hospitalist movement. As hospitals and other organizations seek to create, maintain, or grow hospitalist programs, the data provided here may prove useful to understand the relationship between practice characteristics and individual job satisfaction. Additionally, hospitalists looking for a job can consider these results as additional information to guide their choice of practice model and work patterns.

Over the past 15 years, there has been dramatic growth in the number of hospitalist physicians in the United States and in the number of hospitals served by them.13 Hospitals are motivated to hire experienced hospitalists to staff their inpatient services,4 with goals that include obtaining cost‐savings and higher quality.59 The rapid growth of Hospital Medicine saw multiple types of hospital practice models emerge with differing job characteristics, clinical duties, workload, and compensation schemes.10 The extent of the variability of hospitalist jobs across practice models is not known.

Intensifying recruitment efforts and the concomitant increase in compensation for hospitalists over the last decade suggest that demand for hospitalists is strong and sustained.11 As a result, today's cohort of hospitalists has a wide range of choices of types of jobs, practice models, and locations. The diversity of available hospitalist jobs is characterized, for example, by setting (community hospital vs academic hospital), employer (hospital vs private practice), job duties (the amount and type of clinical work, and other administrative, teaching, or research duties), and intensity (work hours and duties to maximize income or lifestyle). How these choices relate to job satisfaction and burnout are also unknown.

The Society of Hospital Medicine (SHM) has administered surveys to hospitalist group leaders biennially since 2003.1215 These surveys, however, do not address issues related to individual hospitalist worklife, recruitment, and retention. In 2005, SHM convened a Career Satisfaction Task Force that designed and executed a national survey of hospitalists in 2009‐2010. The objective of this study is to evaluate how job characteristics vary by practice model, and the association of these characteristics and practice models with job satisfaction and burnout.

METHODS

RESULTS

Response Rate

Of the 5389 originally sampled addresses, 1868 were undeliverable. Addresses were further excluded if they appeared in duplicate or were outdated. This yielded a total of 3105 eligible surveyees in the sample. As illustrated in Figure 1, 841 responded to the mailed survey and 5 responded to the Web‐based survey. After rejecting 67 non‐hospitalist respondents and 3 duplicate surveys, a total of 776 surveys were included in the final analysis. The adjusted response rate was 25.6% (776/3035). Members of SHM were more likely to return the survey than nonmembers. The adjusted response rate from hospitalists affiliated with the 3 sponsoring institutions was 6% (40/662). Because these respondents were more likely to be non‐members of SHM, we opted to analyze the responses from the sponsor hospitalists together with the sampled hospitalists. The demographics of the resulting pool of 816 respondents affiliated with over 650 unique hospitalist groups were representative of the original survey frame. We analyzed data from 794 of these who responded to the item indicating their hospitalist practice model. Demographic characteristics of responders and nonresponders to the practice model survey item were similar.

Figure 1

Components of Job Satisfaction

Hospitalists' rankings of the most important factors for job satisfaction revealed differences across models (Figure 2). Overall, hospitalists were most likely to consider optimal workload and compensation as important factors for job satisfaction from a list of 13 considerations. Local groups and academics were least likely to rank optimal workload as a top factor, and local group hospitalists were more likely to rank optimal autonomy than those of other models. Academic hospitalists had less concern for substantial pay, and more concern for the variety of tasks they perform and recognition by leaders, than other hospitalists.

Figure 2

Job Satisfaction and Burnout Risk

Differences in the ratings of 4 of the 11 satisfaction and job characteristic domains were found across the practice models (Figure 3). Multispecialty group hospitalists were less satisfied with autonomy and their relationship with patients than other practice models, and along with multistate groups, reported the highest perceived workload. Organizational fairness was rated much higher by local group hospitalists than other practice models. Despite these differences in work patterns and satisfaction, there were no differences found in level of global job satisfaction, specialty satisfaction, or burnout across the practice models. Overall, 62% of respondents reported high job satisfaction (4 on a 1 to 5 scale), and 30% indicated burnout symptoms.

Figure 3

DISCUSSION

In our sample of US hospitalists, we found major differences in work patterns and compensation across hospitalist practice models, but no differences in job satisfaction, specialty satisfaction, and burnout. In particular, differences across these models included variations in hospitalist workload, hours, pay, and distribution of work activities. We found that hospitalists perform a variety of clinical and nonclinical tasks, for many of which there are not standard reimbursement mechanisms. We also found that features of a job that individual hospitalists considered most important vary by practice model.

Previous analysis of this data explored the overall state of hospitalist satisfaction.16 The present analysis offers a glimpse into hospitalists' systems‐orientation through a deeper look at their work patterns. The growth in the number of hospitalists who participate in intensive care medicine, specialty comanagement, and other work that involves close working relationships with specialist physicians confirms collaborative care as one of the dominant drivers of the hospitalist movement. At the level of indirect patient care, nearly all hospitalists contributed to work that facilitates coordination, quality, patient safety, or information technology. Understanding the integrative value of hospitalists outside of their clinical productivity may be of interest to hospital administrators.

Global satisfaction measures were similar across practice models. This finding is particularly interesting given the major differences in job characteristics seen among the practice models. This similarity in global satisfaction despite real differences in the nature of the job suggests that individuals find settings that allow them to address their individual professional goals. Our study demonstrates that, in 2010, Hospital Medicine has evolved enough to accommodate a wide variety of goals and needs.

While global satisfaction did not differ among practice types, hospitalists from various models did report differences in factors considered important to global satisfaction. While workload and pay were rated as influential across most models, the degree of importance was significantly different. In academic settings, substantial pay was not a top consideration for overall job satisfaction, whereas in local and multistate hospitalist groups, pay was a very close second in importance to optimal workload. These results may prove helpful for individual hospitalists trying to find their optimal job. For example, someone who is less concerned about workload, but wants to be paid well and have a high degree of autonomy, may find satisfaction in local hospitalist groups. However, for someone who is willing to sacrifice a higher salary for variety of activities, academic Hospital Medicine may be a better fit.

There is a concerning aspect of hospitalist job satisfaction that different practice models do not seem to solve. Control over personal time is a top consideration for many hospitalists across practice models, yet their satisfaction with personal time is low. As control over personal time is seen as a draw to the Hospital Medicine specialty, group leaders may need to evaluate their programs to ensure that schedules and workload support efforts for hospitalists to balance work and homelife commitments.

There are additional findings that are important for Hospital Medicine group leaders. Regardless of practice model, compensation and workload are often used as tools to recruit and retain hospitalists. While these tools may be effective, leaders may find more nuanced approaches to improving their hospitalists' overall satisfaction. Leaders of local hospitalist groups may find their hospitalists tolerant of heavier workloads as long as they are adequately rewarded and are given real autonomy over their work. However, leaders of academic programs may be missing the primary factor that can improve their hospitalists' satisfaction. Rather than asking for higher salaries to remain competitive, it may be more effective to advocate for time and training for their hospitalists to pursue important other activities beyond direct clinical care. Given that resources will always be limited, group leaders need to understand all of the elements that can contribute to hospitalist job satisfaction.

We point out several limitations to this study. First, our adjusted response rate of 25.6% is low for survey research, in general. As mentioned above, hospitalists are not easily identified in any available national physician database. Therefore, we deliberately designed our sampling strategy to error on the side of including ineligible surveyees to reduce systematic exclusion of practicing hospitalists. Using simple post hoc methods, we identified many nonhospitalists and bad addresses from our sample, but because these methods were exclusionary as opposed to confirmatory, we believe that a significant proportion of remaining nonrespondents may also have been ineligible for the survey. Although this does not fully address concerns about potential response bias, we believe that our sample representing a large number of hospitalist groups is adequate to make estimations about a nationally representative sample of practicing hospitalists. Second, in spite of our inclusive approach, we may still have excluded categories of practicing hospitalists. We were careful not to allow SHM members to represent all US hospitalists and included non‐members in the sampling frame, but the possibility of systematic exclusion that may alter our results remains a concern. Additionally, one of our goals was to characterize pediatric hospitalists independently from their adult‐patient counterparts. Despite oversampling of pediatricians, their sample was too small for a more detailed comparison across practice models. Also, self‐reported data about workload and compensation are subject to inaccuracies related to recall and cognitive biases. Last, this is a cross‐sectional study of hospitalist satisfaction at one point in time. Consequently, our sample may not be representative of very dissatisfied hospitalists who have already left their jobs.

The diversity found across existing practice models and the characteristics of the practices provide physicians with the opportunity to bring their unique skills and motivations to the hospitalist movement. As hospitals and other organizations seek to create, maintain, or grow hospitalist programs, the data provided here may prove useful to understand the relationship between practice characteristics and individual job satisfaction. Additionally, hospitalists looking for a job can consider these results as additional information to guide their choice of practice model and work patterns.

Over the past 15 years, there has been dramatic growth in the number of hospitalist physicians in the United States and in the number of hospitals served by them.13 Hospitals are motivated to hire experienced hospitalists to staff their inpatient services,4 with goals that include obtaining cost‐savings and higher quality.59 The rapid growth of Hospital Medicine saw multiple types of hospital practice models emerge with differing job characteristics, clinical duties, workload, and compensation schemes.10 The extent of the variability of hospitalist jobs across practice models is not known.

Intensifying recruitment efforts and the concomitant increase in compensation for hospitalists over the last decade suggest that demand for hospitalists is strong and sustained.11 As a result, today's cohort of hospitalists has a wide range of choices of types of jobs, practice models, and locations. The diversity of available hospitalist jobs is characterized, for example, by setting (community hospital vs academic hospital), employer (hospital vs private practice), job duties (the amount and type of clinical work, and other administrative, teaching, or research duties), and intensity (work hours and duties to maximize income or lifestyle). How these choices relate to job satisfaction and burnout are also unknown.

The Society of Hospital Medicine (SHM) has administered surveys to hospitalist group leaders biennially since 2003.1215 These surveys, however, do not address issues related to individual hospitalist worklife, recruitment, and retention. In 2005, SHM convened a Career Satisfaction Task Force that designed and executed a national survey of hospitalists in 2009‐2010. The objective of this study is to evaluate how job characteristics vary by practice model, and the association of these characteristics and practice models with job satisfaction and burnout.

METHODS

RESULTS

Response Rate

Of the 5389 originally sampled addresses, 1868 were undeliverable. Addresses were further excluded if they appeared in duplicate or were outdated. This yielded a total of 3105 eligible surveyees in the sample. As illustrated in Figure 1, 841 responded to the mailed survey and 5 responded to the Web‐based survey. After rejecting 67 non‐hospitalist respondents and 3 duplicate surveys, a total of 776 surveys were included in the final analysis. The adjusted response rate was 25.6% (776/3035). Members of SHM were more likely to return the survey than nonmembers. The adjusted response rate from hospitalists affiliated with the 3 sponsoring institutions was 6% (40/662). Because these respondents were more likely to be non‐members of SHM, we opted to analyze the responses from the sponsor hospitalists together with the sampled hospitalists. The demographics of the resulting pool of 816 respondents affiliated with over 650 unique hospitalist groups were representative of the original survey frame. We analyzed data from 794 of these who responded to the item indicating their hospitalist practice model. Demographic characteristics of responders and nonresponders to the practice model survey item were similar.

Figure 1

Components of Job Satisfaction

Hospitalists' rankings of the most important factors for job satisfaction revealed differences across models (Figure 2). Overall, hospitalists were most likely to consider optimal workload and compensation as important factors for job satisfaction from a list of 13 considerations. Local groups and academics were least likely to rank optimal workload as a top factor, and local group hospitalists were more likely to rank optimal autonomy than those of other models. Academic hospitalists had less concern for substantial pay, and more concern for the variety of tasks they perform and recognition by leaders, than other hospitalists.

Figure 2

Job Satisfaction and Burnout Risk

Differences in the ratings of 4 of the 11 satisfaction and job characteristic domains were found across the practice models (Figure 3). Multispecialty group hospitalists were less satisfied with autonomy and their relationship with patients than other practice models, and along with multistate groups, reported the highest perceived workload. Organizational fairness was rated much higher by local group hospitalists than other practice models. Despite these differences in work patterns and satisfaction, there were no differences found in level of global job satisfaction, specialty satisfaction, or burnout across the practice models. Overall, 62% of respondents reported high job satisfaction (4 on a 1 to 5 scale), and 30% indicated burnout symptoms.

Figure 3

DISCUSSION

In our sample of US hospitalists, we found major differences in work patterns and compensation across hospitalist practice models, but no differences in job satisfaction, specialty satisfaction, and burnout. In particular, differences across these models included variations in hospitalist workload, hours, pay, and distribution of work activities. We found that hospitalists perform a variety of clinical and nonclinical tasks, for many of which there are not standard reimbursement mechanisms. We also found that features of a job that individual hospitalists considered most important vary by practice model.

Previous analysis of this data explored the overall state of hospitalist satisfaction.16 The present analysis offers a glimpse into hospitalists' systems‐orientation through a deeper look at their work patterns. The growth in the number of hospitalists who participate in intensive care medicine, specialty comanagement, and other work that involves close working relationships with specialist physicians confirms collaborative care as one of the dominant drivers of the hospitalist movement. At the level of indirect patient care, nearly all hospitalists contributed to work that facilitates coordination, quality, patient safety, or information technology. Understanding the integrative value of hospitalists outside of their clinical productivity may be of interest to hospital administrators.

Global satisfaction measures were similar across practice models. This finding is particularly interesting given the major differences in job characteristics seen among the practice models. This similarity in global satisfaction despite real differences in the nature of the job suggests that individuals find settings that allow them to address their individual professional goals. Our study demonstrates that, in 2010, Hospital Medicine has evolved enough to accommodate a wide variety of goals and needs.

While global satisfaction did not differ among practice types, hospitalists from various models did report differences in factors considered important to global satisfaction. While workload and pay were rated as influential across most models, the degree of importance was significantly different. In academic settings, substantial pay was not a top consideration for overall job satisfaction, whereas in local and multistate hospitalist groups, pay was a very close second in importance to optimal workload. These results may prove helpful for individual hospitalists trying to find their optimal job. For example, someone who is less concerned about workload, but wants to be paid well and have a high degree of autonomy, may find satisfaction in local hospitalist groups. However, for someone who is willing to sacrifice a higher salary for variety of activities, academic Hospital Medicine may be a better fit.

There is a concerning aspect of hospitalist job satisfaction that different practice models do not seem to solve. Control over personal time is a top consideration for many hospitalists across practice models, yet their satisfaction with personal time is low. As control over personal time is seen as a draw to the Hospital Medicine specialty, group leaders may need to evaluate their programs to ensure that schedules and workload support efforts for hospitalists to balance work and homelife commitments.

There are additional findings that are important for Hospital Medicine group leaders. Regardless of practice model, compensation and workload are often used as tools to recruit and retain hospitalists. While these tools may be effective, leaders may find more nuanced approaches to improving their hospitalists' overall satisfaction. Leaders of local hospitalist groups may find their hospitalists tolerant of heavier workloads as long as they are adequately rewarded and are given real autonomy over their work. However, leaders of academic programs may be missing the primary factor that can improve their hospitalists' satisfaction. Rather than asking for higher salaries to remain competitive, it may be more effective to advocate for time and training for their hospitalists to pursue important other activities beyond direct clinical care. Given that resources will always be limited, group leaders need to understand all of the elements that can contribute to hospitalist job satisfaction.

We point out several limitations to this study. First, our adjusted response rate of 25.6% is low for survey research, in general. As mentioned above, hospitalists are not easily identified in any available national physician database. Therefore, we deliberately designed our sampling strategy to error on the side of including ineligible surveyees to reduce systematic exclusion of practicing hospitalists. Using simple post hoc methods, we identified many nonhospitalists and bad addresses from our sample, but because these methods were exclusionary as opposed to confirmatory, we believe that a significant proportion of remaining nonrespondents may also have been ineligible for the survey. Although this does not fully address concerns about potential response bias, we believe that our sample representing a large number of hospitalist groups is adequate to make estimations about a nationally representative sample of practicing hospitalists. Second, in spite of our inclusive approach, we may still have excluded categories of practicing hospitalists. We were careful not to allow SHM members to represent all US hospitalists and included non‐members in the sampling frame, but the possibility of systematic exclusion that may alter our results remains a concern. Additionally, one of our goals was to characterize pediatric hospitalists independently from their adult‐patient counterparts. Despite oversampling of pediatricians, their sample was too small for a more detailed comparison across practice models. Also, self‐reported data about workload and compensation are subject to inaccuracies related to recall and cognitive biases. Last, this is a cross‐sectional study of hospitalist satisfaction at one point in time. Consequently, our sample may not be representative of very dissatisfied hospitalists who have already left their jobs.

The diversity found across existing practice models and the characteristics of the practices provide physicians with the opportunity to bring their unique skills and motivations to the hospitalist movement. As hospitals and other organizations seek to create, maintain, or grow hospitalist programs, the data provided here may prove useful to understand the relationship between practice characteristics and individual job satisfaction. Additionally, hospitalists looking for a job can consider these results as additional information to guide their choice of practice model and work patterns.

Anorexia nervosa occurs in 0.9% of women and 0.3% of men in the United States1 and is associated with a prolonged course,2 extensive medical complications that can affect almost every organ system,3, 4 and a 5% mean crude mortality rate9.6 times expected for age‐matched women in the United States.2, 5 Those with anorexia nervosa die as a complication of their illness more frequently than any other mental illness.3 Anorexia nervosa is commonly diagnosed during the adolescent years,2 with almost 25% going on to develop chronic anorexia nervosa.2, 6 Consequently, many patients with severe anorexia nervosa will receive treatment by adult medicine practitioners.

Patients with anorexia nervosa frequently require hospitalization. Published guidelines suggest that those who are 70% or less than ideal body weight, bradycardic, hypotensive, or those with severe electrolyte disturbances warrant admission for medical stabilization.79 Once admitted, however, there are no published guidelines for best practices to medically stabilize patients.7, 10 Although most experts advocate a multidisciplinary approach with weight restoration and medical stability as the goals of hospital admission,8, 9 controversy exists in the literature about how best to achieve these goals.7, 10

It is known, however, that for patients with complicated medical illnesses, such as human immunodeficiency virus (HIV) and sepsis, higher volumes of patient caseloads treated by physicians with disease‐specific expertise has been found to lead to improved outcomes in patients.11, 12 The adult patient with severe anorexia nervosa who requires inpatient medical stabilization may also benefit from a multidisciplinary trained staff familiar with the medical management of anorexia nervosa. Accordingly, we have developed the Acute Comprehensive Urgent Treatment for Eating Disorders (ACUTE) Center.

PROGRAM DESCRIPTION

The ACUTE Center at Denver Health is a 5‐bed unit dedicated to the medical stabilization of patients with severe malnutrition due to anorexia nervosa or severe electrolyte disorders due to bulimia nervosa. ACUTE accepts patients 17 years and older with medical complications related to chronic malnutrition and refeeding.

ACUTE uses a multidisciplinary approach to patient care. The physician team is composed of a hospital medicine attending physician, consultative expertise by an internal medicine specialist in the management of the medical complications of eating disorders, and a psychiatrist specializing in eating disorders. There is a dedicated team of nurses, two dieticians, physical therapists, certified nursing assistants, speech therapists, a psychotherapist, and a chaplain.

ACUTE patients are on continuous telemetry monitoring for the duration of their hospitalization to monitor for arrhythmias as well as signs of covert exercise. As part of the initial intake, a full set of vital signs is obtained, including height and weight. Patients are weighed daily with their back to the scale. There is no discussion of weight fluctuations. Patients may walk at a slow pace around the unit. No exercise is allowed.

Each patient at the ACUTE Center has an individualized meal plan and are started on an oral caloric intake 200 kcal below their basal energy expenditure (BEE). Indirect calorimetry is performed on the first hospital day. Each patient meets on a daily basis with the registered dietician to choose meals that meet their caloric goals.

All patients have a sitter continuously for their first week, and thereafter sitter time may be reduced to supervision surrounding each meal. Patients who fail to finish their prescribed meal are required to drink a liquid supplement to meet caloric goals. Calories are increased weekly until the patient's weight shows a clear pattern of weight increase. 0

Figure 1

Patients are discharged from the ACUTE Center when they have achieved several basic goals: They are consuming greater than 2000 kcal per day, they are consistently gaining 23 pounds per week, their laboratory values have stabilized without electrolyte supplementation, and they are strong enough for an inpatient eating disorder program.

METHODS

Patients admitted to the ACUTE Center between October 2008 and December 2010 for medical stabilization and monitored refeeding were included. Patients with a diagnosis of bulimia nervosa were excluded. Demographic data and laboratory results were obtained electronically from our data repository, whereas weight, height, and other clinical characteristics were obtained by manual chart abstraction. The statistical analysis was conducted in SAS Enterprise Guide v4.1 (SAS Institute, Cary, NC).

RESULTS

In its first 27 months, the ACUTE Center had 76 total admissions, comprising 59 patients. Of the 76 admissions, the 62 admissions for medical stabilization and monitored refeeding of 54 patients with anorexia nervosa were included. Forty‐eight of the 54 (89%) included patients were female. Six patients were hospitalized twice, and 1 patient 3 times. There were 3 transfers to the intensive care unit, and no inpatient mortality. Of the 62 admissions, 11 (18%) discharges were to home, and 51 (82%) were to inpatient psychiatric eating disorder units.

The mean age at admission was 27 years (range 1765 years). The mean percent of ideal body weight (IBW) on admission was 62.2% 10.2%. The mean body mass index (BMI) was 12.9 2.0 kg/m² on admission, and 13.1 1.9 kg/m² upon discharge. The median length of stay was 16 days (interquartile range [IQR] 929 days). Median calculated BEE (1119 [10671184 IQR]) was higher than measured BEE by indirect calorimetry (792 [6341094]), (Table 1).

The majority of admission laboratory values, including serum albumin, blood urea nitrogen (BUN), creatinine, potassium, magnesium, and phosphate levels, were within normal limits. Fifty‐six percent were hyponatremic at admission, with a mean serum sodium level of 133 6 mmol/L (Table 2).

DISCUSSION

Hospital Medicine is currently the fastest growing area of specialization in medicine.13 Palliative care, inpatient geriatrics, short stay units, and bedside procedures have evolved into hospitalist‐led services.1418 The management of the medical complications of severe eating disorders is another potential niche for hospitalists.

The ACUTE Center at Denver Health represents a center in which highly specialized, multidisciplinary care is provided for a rare and extremely ill population of patients. Prior to entering the ACUTE Center, the patients described in our program had each experienced prolonged and unsuccessful stays for medical stabilization in acute care hospitals across the country, after being denied treatment in eating disorder programs due to medical instability.

Patients transferred to ACUTE often received medical care reflecting a lack of specific expertise, training, and exposure. The most common management discrepancy we noted was over‐aggressive provision of intravenous fluids. Consequently, we often diurese 1020 pounds of edema weight, gained during a prior medical hospitalization, before beginning the process of weight restoration. This edema weight artificially increases admission weight and results in less than expected weight gain from admission to discharge.

Even without substantial weight gain, medical stabilization is evidenced by consistent caloric oral intake, and fluid and electrolyte stabilization after initial refeeding. Accordingly, patients who have been treated at the ACUTE Center often become eligible for admission to eating disorder programs at body weights below the typical 70% of ideal body weight that most programs use as a threshold for admission.

From a clinical research perspective, centers such as ACUTE allow for opportunities to better understand and investigate the nuances of patient care in the setting of severe malnutrition. From our cohort of patients to date, we have noted unique issues in albumin levels,19 coagulopathy,20 and liver function,21 among others. As an example, the cohort of patients with anorexia nervosa described here had profoundly low body weight, but relatively normal admission labs. Even the serum albumin, a parameter often used to reflect nutrition in an adult internal medicine setting, is usually normal, reflecting, in an otherwise generally healthy young population, the absence of a malignant, inflammatory, or infectious etiology of weight loss.19

Hospitalists also advocate for their patients by helping to maximize the benefits of their health care coverage. Many health care plans place limits on inpatient psychiatric care benefits. Patients who are severely malnourished from their eating disorder may waste valuable psychiatric care benefits undergoing medical stabilization in psychiatric units while physically unable to undergo psychotherapy. This has become increasingly important as health insurance plans continue to decrease coverage for residential care of patients with anorexia.22

In contrast, the medical benefits of most health plans are more robust. Accordingly, from the patient perspective, medical stabilization in an acute medical unit before admission to a psychiatry unit maximizes their ability to participate in the intensive psychiatric therapy which is still needed after medical stabilization. A recent study from a residential eating disorder program confirmed that a higher discharge BMI was the single best predictor of full recovery from anorexia nervosa.23

In the future, we believe that a continuing concentration of care and experience may also lend itself to the development of protocols and management guidelines which may benefit patients beyond our own unit. Severely malnourished patients with anorexia nervosa, or bulimic patients with complicated electrolyte disorders, are likely to benefit both medically and financially from centers of excellence. Inpatient or residential psychiatric eating disorder programs may act in synergy with medical eating disorders units, like ACUTE, to most efficiently care for the severely malnourished patient. Hospitalists, with the proper training and experience, are uniquely positioned to develop such centers of excellence.

Anorexia nervosa occurs in 0.9% of women and 0.3% of men in the United States1 and is associated with a prolonged course,2 extensive medical complications that can affect almost every organ system,3, 4 and a 5% mean crude mortality rate9.6 times expected for age‐matched women in the United States.2, 5 Those with anorexia nervosa die as a complication of their illness more frequently than any other mental illness.3 Anorexia nervosa is commonly diagnosed during the adolescent years,2 with almost 25% going on to develop chronic anorexia nervosa.2, 6 Consequently, many patients with severe anorexia nervosa will receive treatment by adult medicine practitioners.

Patients with anorexia nervosa frequently require hospitalization. Published guidelines suggest that those who are 70% or less than ideal body weight, bradycardic, hypotensive, or those with severe electrolyte disturbances warrant admission for medical stabilization.79 Once admitted, however, there are no published guidelines for best practices to medically stabilize patients.7, 10 Although most experts advocate a multidisciplinary approach with weight restoration and medical stability as the goals of hospital admission,8, 9 controversy exists in the literature about how best to achieve these goals.7, 10

It is known, however, that for patients with complicated medical illnesses, such as human immunodeficiency virus (HIV) and sepsis, higher volumes of patient caseloads treated by physicians with disease‐specific expertise has been found to lead to improved outcomes in patients.11, 12 The adult patient with severe anorexia nervosa who requires inpatient medical stabilization may also benefit from a multidisciplinary trained staff familiar with the medical management of anorexia nervosa. Accordingly, we have developed the Acute Comprehensive Urgent Treatment for Eating Disorders (ACUTE) Center.

PROGRAM DESCRIPTION

The ACUTE Center at Denver Health is a 5‐bed unit dedicated to the medical stabilization of patients with severe malnutrition due to anorexia nervosa or severe electrolyte disorders due to bulimia nervosa. ACUTE accepts patients 17 years and older with medical complications related to chronic malnutrition and refeeding.

ACUTE uses a multidisciplinary approach to patient care. The physician team is composed of a hospital medicine attending physician, consultative expertise by an internal medicine specialist in the management of the medical complications of eating disorders, and a psychiatrist specializing in eating disorders. There is a dedicated team of nurses, two dieticians, physical therapists, certified nursing assistants, speech therapists, a psychotherapist, and a chaplain.

ACUTE patients are on continuous telemetry monitoring for the duration of their hospitalization to monitor for arrhythmias as well as signs of covert exercise. As part of the initial intake, a full set of vital signs is obtained, including height and weight. Patients are weighed daily with their back to the scale. There is no discussion of weight fluctuations. Patients may walk at a slow pace around the unit. No exercise is allowed.

Each patient at the ACUTE Center has an individualized meal plan and are started on an oral caloric intake 200 kcal below their basal energy expenditure (BEE). Indirect calorimetry is performed on the first hospital day. Each patient meets on a daily basis with the registered dietician to choose meals that meet their caloric goals.

All patients have a sitter continuously for their first week, and thereafter sitter time may be reduced to supervision surrounding each meal. Patients who fail to finish their prescribed meal are required to drink a liquid supplement to meet caloric goals. Calories are increased weekly until the patient's weight shows a clear pattern of weight increase. 0

Figure 1

Patients are discharged from the ACUTE Center when they have achieved several basic goals: They are consuming greater than 2000 kcal per day, they are consistently gaining 23 pounds per week, their laboratory values have stabilized without electrolyte supplementation, and they are strong enough for an inpatient eating disorder program.

METHODS

Patients admitted to the ACUTE Center between October 2008 and December 2010 for medical stabilization and monitored refeeding were included. Patients with a diagnosis of bulimia nervosa were excluded. Demographic data and laboratory results were obtained electronically from our data repository, whereas weight, height, and other clinical characteristics were obtained by manual chart abstraction. The statistical analysis was conducted in SAS Enterprise Guide v4.1 (SAS Institute, Cary, NC).

RESULTS

In its first 27 months, the ACUTE Center had 76 total admissions, comprising 59 patients. Of the 76 admissions, the 62 admissions for medical stabilization and monitored refeeding of 54 patients with anorexia nervosa were included. Forty‐eight of the 54 (89%) included patients were female. Six patients were hospitalized twice, and 1 patient 3 times. There were 3 transfers to the intensive care unit, and no inpatient mortality. Of the 62 admissions, 11 (18%) discharges were to home, and 51 (82%) were to inpatient psychiatric eating disorder units.

The mean age at admission was 27 years (range 1765 years). The mean percent of ideal body weight (IBW) on admission was 62.2% 10.2%. The mean body mass index (BMI) was 12.9 2.0 kg/m² on admission, and 13.1 1.9 kg/m² upon discharge. The median length of stay was 16 days (interquartile range [IQR] 929 days). Median calculated BEE (1119 [10671184 IQR]) was higher than measured BEE by indirect calorimetry (792 [6341094]), (Table 1).

The majority of admission laboratory values, including serum albumin, blood urea nitrogen (BUN), creatinine, potassium, magnesium, and phosphate levels, were within normal limits. Fifty‐six percent were hyponatremic at admission, with a mean serum sodium level of 133 6 mmol/L (Table 2).

DISCUSSION

Hospital Medicine is currently the fastest growing area of specialization in medicine.13 Palliative care, inpatient geriatrics, short stay units, and bedside procedures have evolved into hospitalist‐led services.1418 The management of the medical complications of severe eating disorders is another potential niche for hospitalists.

The ACUTE Center at Denver Health represents a center in which highly specialized, multidisciplinary care is provided for a rare and extremely ill population of patients. Prior to entering the ACUTE Center, the patients described in our program had each experienced prolonged and unsuccessful stays for medical stabilization in acute care hospitals across the country, after being denied treatment in eating disorder programs due to medical instability.

Patients transferred to ACUTE often received medical care reflecting a lack of specific expertise, training, and exposure. The most common management discrepancy we noted was over‐aggressive provision of intravenous fluids. Consequently, we often diurese 1020 pounds of edema weight, gained during a prior medical hospitalization, before beginning the process of weight restoration. This edema weight artificially increases admission weight and results in less than expected weight gain from admission to discharge.

Even without substantial weight gain, medical stabilization is evidenced by consistent caloric oral intake, and fluid and electrolyte stabilization after initial refeeding. Accordingly, patients who have been treated at the ACUTE Center often become eligible for admission to eating disorder programs at body weights below the typical 70% of ideal body weight that most programs use as a threshold for admission.

From a clinical research perspective, centers such as ACUTE allow for opportunities to better understand and investigate the nuances of patient care in the setting of severe malnutrition. From our cohort of patients to date, we have noted unique issues in albumin levels,19 coagulopathy,20 and liver function,21 among others. As an example, the cohort of patients with anorexia nervosa described here had profoundly low body weight, but relatively normal admission labs. Even the serum albumin, a parameter often used to reflect nutrition in an adult internal medicine setting, is usually normal, reflecting, in an otherwise generally healthy young population, the absence of a malignant, inflammatory, or infectious etiology of weight loss.19

Hospitalists also advocate for their patients by helping to maximize the benefits of their health care coverage. Many health care plans place limits on inpatient psychiatric care benefits. Patients who are severely malnourished from their eating disorder may waste valuable psychiatric care benefits undergoing medical stabilization in psychiatric units while physically unable to undergo psychotherapy. This has become increasingly important as health insurance plans continue to decrease coverage for residential care of patients with anorexia.22

In contrast, the medical benefits of most health plans are more robust. Accordingly, from the patient perspective, medical stabilization in an acute medical unit before admission to a psychiatry unit maximizes their ability to participate in the intensive psychiatric therapy which is still needed after medical stabilization. A recent study from a residential eating disorder program confirmed that a higher discharge BMI was the single best predictor of full recovery from anorexia nervosa.23

In the future, we believe that a continuing concentration of care and experience may also lend itself to the development of protocols and management guidelines which may benefit patients beyond our own unit. Severely malnourished patients with anorexia nervosa, or bulimic patients with complicated electrolyte disorders, are likely to benefit both medically and financially from centers of excellence. Inpatient or residential psychiatric eating disorder programs may act in synergy with medical eating disorders units, like ACUTE, to most efficiently care for the severely malnourished patient. Hospitalists, with the proper training and experience, are uniquely positioned to develop such centers of excellence.

Anorexia nervosa occurs in 0.9% of women and 0.3% of men in the United States1 and is associated with a prolonged course,2 extensive medical complications that can affect almost every organ system,3, 4 and a 5% mean crude mortality rate9.6 times expected for age‐matched women in the United States.2, 5 Those with anorexia nervosa die as a complication of their illness more frequently than any other mental illness.3 Anorexia nervosa is commonly diagnosed during the adolescent years,2 with almost 25% going on to develop chronic anorexia nervosa.2, 6 Consequently, many patients with severe anorexia nervosa will receive treatment by adult medicine practitioners.

Patients with anorexia nervosa frequently require hospitalization. Published guidelines suggest that those who are 70% or less than ideal body weight, bradycardic, hypotensive, or those with severe electrolyte disturbances warrant admission for medical stabilization.79 Once admitted, however, there are no published guidelines for best practices to medically stabilize patients.7, 10 Although most experts advocate a multidisciplinary approach with weight restoration and medical stability as the goals of hospital admission,8, 9 controversy exists in the literature about how best to achieve these goals.7, 10

It is known, however, that for patients with complicated medical illnesses, such as human immunodeficiency virus (HIV) and sepsis, higher volumes of patient caseloads treated by physicians with disease‐specific expertise has been found to lead to improved outcomes in patients.11, 12 The adult patient with severe anorexia nervosa who requires inpatient medical stabilization may also benefit from a multidisciplinary trained staff familiar with the medical management of anorexia nervosa. Accordingly, we have developed the Acute Comprehensive Urgent Treatment for Eating Disorders (ACUTE) Center.

PROGRAM DESCRIPTION

The ACUTE Center at Denver Health is a 5‐bed unit dedicated to the medical stabilization of patients with severe malnutrition due to anorexia nervosa or severe electrolyte disorders due to bulimia nervosa. ACUTE accepts patients 17 years and older with medical complications related to chronic malnutrition and refeeding.

ACUTE uses a multidisciplinary approach to patient care. The physician team is composed of a hospital medicine attending physician, consultative expertise by an internal medicine specialist in the management of the medical complications of eating disorders, and a psychiatrist specializing in eating disorders. There is a dedicated team of nurses, two dieticians, physical therapists, certified nursing assistants, speech therapists, a psychotherapist, and a chaplain.

ACUTE patients are on continuous telemetry monitoring for the duration of their hospitalization to monitor for arrhythmias as well as signs of covert exercise. As part of the initial intake, a full set of vital signs is obtained, including height and weight. Patients are weighed daily with their back to the scale. There is no discussion of weight fluctuations. Patients may walk at a slow pace around the unit. No exercise is allowed.

Each patient at the ACUTE Center has an individualized meal plan and are started on an oral caloric intake 200 kcal below their basal energy expenditure (BEE). Indirect calorimetry is performed on the first hospital day. Each patient meets on a daily basis with the registered dietician to choose meals that meet their caloric goals.

All patients have a sitter continuously for their first week, and thereafter sitter time may be reduced to supervision surrounding each meal. Patients who fail to finish their prescribed meal are required to drink a liquid supplement to meet caloric goals. Calories are increased weekly until the patient's weight shows a clear pattern of weight increase. 0

Figure 1

Patients are discharged from the ACUTE Center when they have achieved several basic goals: They are consuming greater than 2000 kcal per day, they are consistently gaining 23 pounds per week, their laboratory values have stabilized without electrolyte supplementation, and they are strong enough for an inpatient eating disorder program.

METHODS

Patients admitted to the ACUTE Center between October 2008 and December 2010 for medical stabilization and monitored refeeding were included. Patients with a diagnosis of bulimia nervosa were excluded. Demographic data and laboratory results were obtained electronically from our data repository, whereas weight, height, and other clinical characteristics were obtained by manual chart abstraction. The statistical analysis was conducted in SAS Enterprise Guide v4.1 (SAS Institute, Cary, NC).

RESULTS

In its first 27 months, the ACUTE Center had 76 total admissions, comprising 59 patients. Of the 76 admissions, the 62 admissions for medical stabilization and monitored refeeding of 54 patients with anorexia nervosa were included. Forty‐eight of the 54 (89%) included patients were female. Six patients were hospitalized twice, and 1 patient 3 times. There were 3 transfers to the intensive care unit, and no inpatient mortality. Of the 62 admissions, 11 (18%) discharges were to home, and 51 (82%) were to inpatient psychiatric eating disorder units.

The mean age at admission was 27 years (range 1765 years). The mean percent of ideal body weight (IBW) on admission was 62.2% 10.2%. The mean body mass index (BMI) was 12.9 2.0 kg/m² on admission, and 13.1 1.9 kg/m² upon discharge. The median length of stay was 16 days (interquartile range [IQR] 929 days). Median calculated BEE (1119 [10671184 IQR]) was higher than measured BEE by indirect calorimetry (792 [6341094]), (Table 1).

The majority of admission laboratory values, including serum albumin, blood urea nitrogen (BUN), creatinine, potassium, magnesium, and phosphate levels, were within normal limits. Fifty‐six percent were hyponatremic at admission, with a mean serum sodium level of 133 6 mmol/L (Table 2).

DISCUSSION

Hospital Medicine is currently the fastest growing area of specialization in medicine.13 Palliative care, inpatient geriatrics, short stay units, and bedside procedures have evolved into hospitalist‐led services.1418 The management of the medical complications of severe eating disorders is another potential niche for hospitalists.

The ACUTE Center at Denver Health represents a center in which highly specialized, multidisciplinary care is provided for a rare and extremely ill population of patients. Prior to entering the ACUTE Center, the patients described in our program had each experienced prolonged and unsuccessful stays for medical stabilization in acute care hospitals across the country, after being denied treatment in eating disorder programs due to medical instability.

Patients transferred to ACUTE often received medical care reflecting a lack of specific expertise, training, and exposure. The most common management discrepancy we noted was over‐aggressive provision of intravenous fluids. Consequently, we often diurese 1020 pounds of edema weight, gained during a prior medical hospitalization, before beginning the process of weight restoration. This edema weight artificially increases admission weight and results in less than expected weight gain from admission to discharge.

Even without substantial weight gain, medical stabilization is evidenced by consistent caloric oral intake, and fluid and electrolyte stabilization after initial refeeding. Accordingly, patients who have been treated at the ACUTE Center often become eligible for admission to eating disorder programs at body weights below the typical 70% of ideal body weight that most programs use as a threshold for admission.

From a clinical research perspective, centers such as ACUTE allow for opportunities to better understand and investigate the nuances of patient care in the setting of severe malnutrition. From our cohort of patients to date, we have noted unique issues in albumin levels,19 coagulopathy,20 and liver function,21 among others. As an example, the cohort of patients with anorexia nervosa described here had profoundly low body weight, but relatively normal admission labs. Even the serum albumin, a parameter often used to reflect nutrition in an adult internal medicine setting, is usually normal, reflecting, in an otherwise generally healthy young population, the absence of a malignant, inflammatory, or infectious etiology of weight loss.19

Hospitalists also advocate for their patients by helping to maximize the benefits of their health care coverage. Many health care plans place limits on inpatient psychiatric care benefits. Patients who are severely malnourished from their eating disorder may waste valuable psychiatric care benefits undergoing medical stabilization in psychiatric units while physically unable to undergo psychotherapy. This has become increasingly important as health insurance plans continue to decrease coverage for residential care of patients with anorexia.22

In contrast, the medical benefits of most health plans are more robust. Accordingly, from the patient perspective, medical stabilization in an acute medical unit before admission to a psychiatry unit maximizes their ability to participate in the intensive psychiatric therapy which is still needed after medical stabilization. A recent study from a residential eating disorder program confirmed that a higher discharge BMI was the single best predictor of full recovery from anorexia nervosa.23

In the future, we believe that a continuing concentration of care and experience may also lend itself to the development of protocols and management guidelines which may benefit patients beyond our own unit. Severely malnourished patients with anorexia nervosa, or bulimic patients with complicated electrolyte disorders, are likely to benefit both medically and financially from centers of excellence. Inpatient or residential psychiatric eating disorder programs may act in synergy with medical eating disorders units, like ACUTE, to most efficiently care for the severely malnourished patient. Hospitalists, with the proper training and experience, are uniquely positioned to develop such centers of excellence.

Mycoplasma pneumoniae is a common cause of community‐acquired pneumonia (CAP), among school‐age children and adolescents.14 Though pneumonia caused by M. pneumoniae is typically self‐limited, severe illness may occur.5 M. pneumoniae has also been implicated in airway inflammation, which may lead to the onset and development of chronic pulmonary disease.610 Few studies have directly addressed appropriate treatment strategies for M. pneumoniae pneumonia,11 and, despite its high prevalence and potential for causing severe complications, treatment recommendations remain inconsistent.

The efficacy of macrolide therapy in particular for M. pneumoniae remains unclear. In vitro susceptibility studies have shown bacteriostatic activity of erythromycin, clarithromycin, and azithromycin against M. pneumoniae.1218 Additionally, several small retrospective studies have shown that among children with atypical CAP (including M. pneumoniae pneumonia), those treated with macrolides were less likely to have persistence or progression of signs and symptoms after 3 days of therapy.19, 20 Lu et al21 found a shorter duration of fever among macrolide recipients compared with non‐recipients. In adults, Shames et al22 found a shorter duration of fever and hospitalization among erythromycin recipients compared with controls. Other randomized controlled trials have also addressed the use of macrolides in treatment of M. pneumoniae, but the ability to draw meaningful conclusions is limited by small samples sizes and by lack of details about the number of patients with M. pneumoniae.11

In addition to their antimicrobial effect, macrolides also have anti‐inflammatory properties.2327 The importance of these anti‐inflammatory properties is supported by studies showing clinical cure in patients treated with macrolides despite persistence of M. pneumoniae organisms,2831 clinical improvement despite the administration of doses that provide tissue levels below the minimum inhibitory concentration of the organism,3234 and clinical cure in patients with macrolide‐resistant M. pneumoniae.18, 35

The objectives of the current study were to examine the impact of macrolide therapy on the length of stay (LOS) and short‐ and longer‐term readmissions, including longer‐term asthma‐related readmissions, in children hospitalized with M. pneumoniae pneumonia.

METHODS

RESULTS