While researchers and policymakers are making progress in finding ways to prevent and diagnose diabetes, physicians can take small steps every day in their offices to help their patients. A diabetes-themed event, held by journal Health Affairs, focused on some of the recent findings, and we spoke with a few of the leaders in the field, including the U.S. Surgeon General, Dr. Regina Benjamin.

While researchers and policymakers are making progress in finding ways to prevent and diagnose diabetes, physicians can take small steps every day in their offices to help their patients. A diabetes-themed event, held by journal Health Affairs, focused on some of the recent findings, and we spoke with a few of the leaders in the field, including the U.S. Surgeon General, Dr. Regina Benjamin.

While researchers and policymakers are making progress in finding ways to prevent and diagnose diabetes, physicians can take small steps every day in their offices to help their patients. A diabetes-themed event, held by journal Health Affairs, focused on some of the recent findings, and we spoke with a few of the leaders in the field, including the U.S. Surgeon General, Dr. Regina Benjamin.

SAN DIEGO – Novel genetic alterations have been identified in a new subtype of high-risk B-cell acute lymphoblastic leukemia that could be effectively targeted with existing therapies.

The subtype, termed Ph-like ALL, was first identified by the Children’s Oncology Group in 2009 (N. Engl. J. Med. 2009;360:470-80), and accounts for up to 15% of pediatric acute lymphoblastic leukemia (ALL) cases.

"Until this study, the genetic basis of Ph-like ALL was unknown," said Kathryn G. Roberts, Ph.D., lead author of the cooperative research study.

Ph-like ALL is associated with alteration of lymphoid transcription factors, most commonly IKZF1, and has a gene expression profile similar to that of Philadelphia chromosome–positive (Ph+) ALL. Ph+ ALL accounts for just 5% of pediatric ALL cases, but because it is driven by the oncogenic tyrosine kinase, BCR-ABL1, it can be effectively treated with available tyrosine kinase inhibitors such as imatinib (Gleevec).

Ph-like ALL, however, is BCR-ABL negative, so patients with this poor-outcome subtype are currently treated with conventional chemotherapy. Higher doses and intensified regimens are limited by toxicity.

Screening ALL patients at the time of diagnosis could identify those with Ph-like ALL, and determine who may benefit from more-aggressive treatment with targeted therapies, said Dr. Roberts, a postdoctoral pathology fellow at St. Jude Children’s Research Hospital in Memphis, Tenn.

In an effort to better understand the genetic basis of Ph-like ALL, the investigators used next-generation genome sequencing and other techniques to analyze the transcriptome or RNA sequence of 12 patients with Ph-like ALL. Strikingly, 11 of the 12 cases harbored alterations disrupting kinase and cytokine receptor signaling, which provides a treatable target with current drugs, she said. The alterations included novel rearrangements, structural variations, and sequence mutations.

Specifically, the spectrum of alterations included NUP214-ABL1 or RANBP2-ABL1 rearrangements, immunoglobulin heavy chain rearrangements involving the cytokine receptor genes CRLF2 and EPOR, and in-frame fusions of EBF1-PDGFRB (platelet-derived growth factor receptor beta), BCR-JAK2 or STRN3-JAK2. In addition, activating mutations within IL7R, and loss of function SH2B3 deletions were also identified.

Importantly, laboratory studies showed that patient samples harboring the ABL1 rearrangement were sensitive to the tyrosine kinase inhibitors imatinib, dasatinib (Sprycel), and XL228, whereas the JAK2-rearranged samples were sensitive to the JAK2 inhibitors XL019 and ruxolitinib (Jakafi), which was recently approved for the treatment of myelofibrosis. Furthermore, mouse cells harboring the EBF1-PDGFRB fusion responded to imatinib, dasatinib, and dovitinib, a specific PDGFRB/FGFR (fibroblast growth factor receptor) inhibitor, Dr. Roberts reported.

The group also screened 231 additional high-risk ALL patients (aged 1 year 2 months to 17 years 6 months) and found that the genetic alterations were present in 40 cases (17%), suggesting that these genetic lesions are "hallmarks of this subtype of ALL," she said.

Dr. Martin Tallman, chief of the leukemia service at Memorial Sloan-Kettering Cancer Center in New York, told reporters at a press briefing that the study could potentially change the standard of care, and "provides further evidence that we’re able to target specific leukemias with specific, directed therapy rather than continuing to give relatively indiscriminate chemotherapy."

The diversity of lesions in Ph-like ALL suggests that screening methods to identify patients at diagnosis may be more attractive than transcriptome sequencing, Dr. Roberts noted. Phosphoflow cytometric signaling analysis can be used to detect activation of pathways common to the novel genetic lesions and to identify patients who will most likely respond to targeted therapy. Gene expression profiling is also being investigated as a complimentary approach to identify Ph-like ALL patients.

St. Jude is currently not screening its ALL patients for Ph-like ALL, but the researchers hope to be able to start treating children who have ALL based on their genetic alterations in the next 12 months, she said in an interview.

The researchers are also currently establishing Ph-like ALL animal models and plan to broaden the scope of their testing to include young adolescents and adults. The current study earned the outstanding abstract achievement award for a postdoctoral fellow at the meeting.

Dr. Roberts reported no conflicts of interest. A coauthor, Dr. Steve Hunger, reported that his children own stock in Bristol-Myers Squibb and that he is a member of an entity’s board of directors or advisory committee.

SAN DIEGO – Novel genetic alterations have been identified in a new subtype of high-risk B-cell acute lymphoblastic leukemia that could be effectively targeted with existing therapies.

The subtype, termed Ph-like ALL, was first identified by the Children’s Oncology Group in 2009 (N. Engl. J. Med. 2009;360:470-80), and accounts for up to 15% of pediatric acute lymphoblastic leukemia (ALL) cases.

"Until this study, the genetic basis of Ph-like ALL was unknown," said Kathryn G. Roberts, Ph.D., lead author of the cooperative research study.

Ph-like ALL is associated with alteration of lymphoid transcription factors, most commonly IKZF1, and has a gene expression profile similar to that of Philadelphia chromosome–positive (Ph+) ALL. Ph+ ALL accounts for just 5% of pediatric ALL cases, but because it is driven by the oncogenic tyrosine kinase, BCR-ABL1, it can be effectively treated with available tyrosine kinase inhibitors such as imatinib (Gleevec).

Ph-like ALL, however, is BCR-ABL negative, so patients with this poor-outcome subtype are currently treated with conventional chemotherapy. Higher doses and intensified regimens are limited by toxicity.

Screening ALL patients at the time of diagnosis could identify those with Ph-like ALL, and determine who may benefit from more-aggressive treatment with targeted therapies, said Dr. Roberts, a postdoctoral pathology fellow at St. Jude Children’s Research Hospital in Memphis, Tenn.

In an effort to better understand the genetic basis of Ph-like ALL, the investigators used next-generation genome sequencing and other techniques to analyze the transcriptome or RNA sequence of 12 patients with Ph-like ALL. Strikingly, 11 of the 12 cases harbored alterations disrupting kinase and cytokine receptor signaling, which provides a treatable target with current drugs, she said. The alterations included novel rearrangements, structural variations, and sequence mutations.

Specifically, the spectrum of alterations included NUP214-ABL1 or RANBP2-ABL1 rearrangements, immunoglobulin heavy chain rearrangements involving the cytokine receptor genes CRLF2 and EPOR, and in-frame fusions of EBF1-PDGFRB (platelet-derived growth factor receptor beta), BCR-JAK2 or STRN3-JAK2. In addition, activating mutations within IL7R, and loss of function SH2B3 deletions were also identified.

Importantly, laboratory studies showed that patient samples harboring the ABL1 rearrangement were sensitive to the tyrosine kinase inhibitors imatinib, dasatinib (Sprycel), and XL228, whereas the JAK2-rearranged samples were sensitive to the JAK2 inhibitors XL019 and ruxolitinib (Jakafi), which was recently approved for the treatment of myelofibrosis. Furthermore, mouse cells harboring the EBF1-PDGFRB fusion responded to imatinib, dasatinib, and dovitinib, a specific PDGFRB/FGFR (fibroblast growth factor receptor) inhibitor, Dr. Roberts reported.

The group also screened 231 additional high-risk ALL patients (aged 1 year 2 months to 17 years 6 months) and found that the genetic alterations were present in 40 cases (17%), suggesting that these genetic lesions are "hallmarks of this subtype of ALL," she said.

Dr. Martin Tallman, chief of the leukemia service at Memorial Sloan-Kettering Cancer Center in New York, told reporters at a press briefing that the study could potentially change the standard of care, and "provides further evidence that we’re able to target specific leukemias with specific, directed therapy rather than continuing to give relatively indiscriminate chemotherapy."

The diversity of lesions in Ph-like ALL suggests that screening methods to identify patients at diagnosis may be more attractive than transcriptome sequencing, Dr. Roberts noted. Phosphoflow cytometric signaling analysis can be used to detect activation of pathways common to the novel genetic lesions and to identify patients who will most likely respond to targeted therapy. Gene expression profiling is also being investigated as a complimentary approach to identify Ph-like ALL patients.

St. Jude is currently not screening its ALL patients for Ph-like ALL, but the researchers hope to be able to start treating children who have ALL based on their genetic alterations in the next 12 months, she said in an interview.

The researchers are also currently establishing Ph-like ALL animal models and plan to broaden the scope of their testing to include young adolescents and adults. The current study earned the outstanding abstract achievement award for a postdoctoral fellow at the meeting.

Dr. Roberts reported no conflicts of interest. A coauthor, Dr. Steve Hunger, reported that his children own stock in Bristol-Myers Squibb and that he is a member of an entity’s board of directors or advisory committee.

SAN DIEGO – Novel genetic alterations have been identified in a new subtype of high-risk B-cell acute lymphoblastic leukemia that could be effectively targeted with existing therapies.

The subtype, termed Ph-like ALL, was first identified by the Children’s Oncology Group in 2009 (N. Engl. J. Med. 2009;360:470-80), and accounts for up to 15% of pediatric acute lymphoblastic leukemia (ALL) cases.

"Until this study, the genetic basis of Ph-like ALL was unknown," said Kathryn G. Roberts, Ph.D., lead author of the cooperative research study.

Ph-like ALL is associated with alteration of lymphoid transcription factors, most commonly IKZF1, and has a gene expression profile similar to that of Philadelphia chromosome–positive (Ph+) ALL. Ph+ ALL accounts for just 5% of pediatric ALL cases, but because it is driven by the oncogenic tyrosine kinase, BCR-ABL1, it can be effectively treated with available tyrosine kinase inhibitors such as imatinib (Gleevec).

Ph-like ALL, however, is BCR-ABL negative, so patients with this poor-outcome subtype are currently treated with conventional chemotherapy. Higher doses and intensified regimens are limited by toxicity.

Screening ALL patients at the time of diagnosis could identify those with Ph-like ALL, and determine who may benefit from more-aggressive treatment with targeted therapies, said Dr. Roberts, a postdoctoral pathology fellow at St. Jude Children’s Research Hospital in Memphis, Tenn.

In an effort to better understand the genetic basis of Ph-like ALL, the investigators used next-generation genome sequencing and other techniques to analyze the transcriptome or RNA sequence of 12 patients with Ph-like ALL. Strikingly, 11 of the 12 cases harbored alterations disrupting kinase and cytokine receptor signaling, which provides a treatable target with current drugs, she said. The alterations included novel rearrangements, structural variations, and sequence mutations.

Specifically, the spectrum of alterations included NUP214-ABL1 or RANBP2-ABL1 rearrangements, immunoglobulin heavy chain rearrangements involving the cytokine receptor genes CRLF2 and EPOR, and in-frame fusions of EBF1-PDGFRB (platelet-derived growth factor receptor beta), BCR-JAK2 or STRN3-JAK2. In addition, activating mutations within IL7R, and loss of function SH2B3 deletions were also identified.

Importantly, laboratory studies showed that patient samples harboring the ABL1 rearrangement were sensitive to the tyrosine kinase inhibitors imatinib, dasatinib (Sprycel), and XL228, whereas the JAK2-rearranged samples were sensitive to the JAK2 inhibitors XL019 and ruxolitinib (Jakafi), which was recently approved for the treatment of myelofibrosis. Furthermore, mouse cells harboring the EBF1-PDGFRB fusion responded to imatinib, dasatinib, and dovitinib, a specific PDGFRB/FGFR (fibroblast growth factor receptor) inhibitor, Dr. Roberts reported.

The group also screened 231 additional high-risk ALL patients (aged 1 year 2 months to 17 years 6 months) and found that the genetic alterations were present in 40 cases (17%), suggesting that these genetic lesions are "hallmarks of this subtype of ALL," she said.

Dr. Martin Tallman, chief of the leukemia service at Memorial Sloan-Kettering Cancer Center in New York, told reporters at a press briefing that the study could potentially change the standard of care, and "provides further evidence that we’re able to target specific leukemias with specific, directed therapy rather than continuing to give relatively indiscriminate chemotherapy."

The diversity of lesions in Ph-like ALL suggests that screening methods to identify patients at diagnosis may be more attractive than transcriptome sequencing, Dr. Roberts noted. Phosphoflow cytometric signaling analysis can be used to detect activation of pathways common to the novel genetic lesions and to identify patients who will most likely respond to targeted therapy. Gene expression profiling is also being investigated as a complimentary approach to identify Ph-like ALL patients.

St. Jude is currently not screening its ALL patients for Ph-like ALL, but the researchers hope to be able to start treating children who have ALL based on their genetic alterations in the next 12 months, she said in an interview.

The researchers are also currently establishing Ph-like ALL animal models and plan to broaden the scope of their testing to include young adolescents and adults. The current study earned the outstanding abstract achievement award for a postdoctoral fellow at the meeting.

Dr. Roberts reported no conflicts of interest. A coauthor, Dr. Steve Hunger, reported that his children own stock in Bristol-Myers Squibb and that he is a member of an entity’s board of directors or advisory committee.

Hospitalists should consider the arena of antimicrobial stewardship one of the newest frontiers of clinical efficiency and cost savings, according to the author of a study in a supplement to this month's Journal of Hospital Medicine.

David Rosenberg, MD, MPH, FACP, SFHM, of the Department of Medicine, Section of Hospital Medicine at North Shore University Hospital in Manhasset, N.Y., says that changing the mindset on antibiotic resistance might seem like a daunting task, but it dovetails neatly with HM's current focus on quality and safety, particularly when it can help reduce length of stay (LOS).

"Think different about antibiotics and build that into your practice," he says.

The supplement highlights four related papers tackling the issues of appropriate initiation and selection of antibiotics, antimicrobial de-escalation strategies, duration and cessation of treatment, and Dr. Rosenberg's paper, "The Emerging Role of Hospitalists." The research includes an online CME component.

Dr. Rosenberg writes that hospitalists "are positioned as excellent champions of the principles and practices of antimicrobial stewardship." That means revamping the use of antibiotics both for individual patients and on an institutional level. That leadership means accepting that "culture change is slow" and physicians often feel "trapped" in letting an antibiotic treatment run its course rather than reassessing midstream.

Still, Dr. Rosenberg says, national guidelines on antibiotic overuse are likely to be developed in the coming years, and hospitalists would do well to get ahead of that curve.

"We're talking about the optimal treatment of patients we are already taking care of," he says. "Stewardship is a natural step forward."

Hospitalists should consider the arena of antimicrobial stewardship one of the newest frontiers of clinical efficiency and cost savings, according to the author of a study in a supplement to this month's Journal of Hospital Medicine.

David Rosenberg, MD, MPH, FACP, SFHM, of the Department of Medicine, Section of Hospital Medicine at North Shore University Hospital in Manhasset, N.Y., says that changing the mindset on antibiotic resistance might seem like a daunting task, but it dovetails neatly with HM's current focus on quality and safety, particularly when it can help reduce length of stay (LOS).

"Think different about antibiotics and build that into your practice," he says.

The supplement highlights four related papers tackling the issues of appropriate initiation and selection of antibiotics, antimicrobial de-escalation strategies, duration and cessation of treatment, and Dr. Rosenberg's paper, "The Emerging Role of Hospitalists." The research includes an online CME component.

Dr. Rosenberg writes that hospitalists "are positioned as excellent champions of the principles and practices of antimicrobial stewardship." That means revamping the use of antibiotics both for individual patients and on an institutional level. That leadership means accepting that "culture change is slow" and physicians often feel "trapped" in letting an antibiotic treatment run its course rather than reassessing midstream.

Still, Dr. Rosenberg says, national guidelines on antibiotic overuse are likely to be developed in the coming years, and hospitalists would do well to get ahead of that curve.

"We're talking about the optimal treatment of patients we are already taking care of," he says. "Stewardship is a natural step forward."

Hospitalists should consider the arena of antimicrobial stewardship one of the newest frontiers of clinical efficiency and cost savings, according to the author of a study in a supplement to this month's Journal of Hospital Medicine.

David Rosenberg, MD, MPH, FACP, SFHM, of the Department of Medicine, Section of Hospital Medicine at North Shore University Hospital in Manhasset, N.Y., says that changing the mindset on antibiotic resistance might seem like a daunting task, but it dovetails neatly with HM's current focus on quality and safety, particularly when it can help reduce length of stay (LOS).

"Think different about antibiotics and build that into your practice," he says.

The supplement highlights four related papers tackling the issues of appropriate initiation and selection of antibiotics, antimicrobial de-escalation strategies, duration and cessation of treatment, and Dr. Rosenberg's paper, "The Emerging Role of Hospitalists." The research includes an online CME component.

Dr. Rosenberg writes that hospitalists "are positioned as excellent champions of the principles and practices of antimicrobial stewardship." That means revamping the use of antibiotics both for individual patients and on an institutional level. That leadership means accepting that "culture change is slow" and physicians often feel "trapped" in letting an antibiotic treatment run its course rather than reassessing midstream.

Still, Dr. Rosenberg says, national guidelines on antibiotic overuse are likely to be developed in the coming years, and hospitalists would do well to get ahead of that curve.

"We're talking about the optimal treatment of patients we are already taking care of," he says. "Stewardship is a natural step forward."

Clinical question: What is the association between time to clinical stability (TCS) and post-discharge death or readmission in patients hospitalized with community-acquired pneumonia (CAP)?

Background: In patients with CAP, inflammatory response during hospitalization might be associated with adverse outcomes after discharge. Studies have not evaluated if time to clinical stability, a reflection of inflammatory response, can be used to identify patients at high risk of adverse outcomes after discharge.

Study design: Retrospective cohort study.

Setting: Veterans Hospital, Louisville, Ky.

Synopsis: Of 464 hospitalized patients with CAP, those with TCS >3 days had a higher rate of readmission or death within 30 days after discharge compared with those who had a TCS =3 days (26% versus 15%; OR 1.98; 95% CI, 1.19-3.3; P=0.008). Longer TCS during hospitalization was associated with a significantly increased risk of adverse outcomes (adjusted OR 1.06, 1.54, 2.40, 10.53 if TCS was reached at days 2, 3, 4, 5 versus Day 1, respectively). The authors proposed that patients with delays in reaching clinical stability should receive a special discharge management approach to decrease the risk of morbidity and mortality after discharge; this may include close observation, home visits, and a follow-up clinic appointment within 10 days.

As a retrospective cohort study, unaccounted-for confounders might exist between TCS and adverse outcomes. The small sample size precluded development of a fully predictive model. Additionally, the population studied was elderly men in a single hospital, which might limit generalizability.

Bottom line: Hospitalized patients with community-acquired pneumonia whose time to clinical stability was greater than three days had a higher risk of readmission or death within 30 days after discharge.

Citation: Aliberti S, Peyrani P, Filardo G, et al. Association between time to clinical stability and outcomes after discharge in hospitalized patients with community-acquired pneumonia. Chest. 2011;140:482-488.

For more physician reviews of HM-relevant research, visit our website.

Clinical question: What is the association between time to clinical stability (TCS) and post-discharge death or readmission in patients hospitalized with community-acquired pneumonia (CAP)?

Background: In patients with CAP, inflammatory response during hospitalization might be associated with adverse outcomes after discharge. Studies have not evaluated if time to clinical stability, a reflection of inflammatory response, can be used to identify patients at high risk of adverse outcomes after discharge.

Study design: Retrospective cohort study.

Setting: Veterans Hospital, Louisville, Ky.

Synopsis: Of 464 hospitalized patients with CAP, those with TCS >3 days had a higher rate of readmission or death within 30 days after discharge compared with those who had a TCS =3 days (26% versus 15%; OR 1.98; 95% CI, 1.19-3.3; P=0.008). Longer TCS during hospitalization was associated with a significantly increased risk of adverse outcomes (adjusted OR 1.06, 1.54, 2.40, 10.53 if TCS was reached at days 2, 3, 4, 5 versus Day 1, respectively). The authors proposed that patients with delays in reaching clinical stability should receive a special discharge management approach to decrease the risk of morbidity and mortality after discharge; this may include close observation, home visits, and a follow-up clinic appointment within 10 days.

As a retrospective cohort study, unaccounted-for confounders might exist between TCS and adverse outcomes. The small sample size precluded development of a fully predictive model. Additionally, the population studied was elderly men in a single hospital, which might limit generalizability.

Bottom line: Hospitalized patients with community-acquired pneumonia whose time to clinical stability was greater than three days had a higher risk of readmission or death within 30 days after discharge.

Citation: Aliberti S, Peyrani P, Filardo G, et al. Association between time to clinical stability and outcomes after discharge in hospitalized patients with community-acquired pneumonia. Chest. 2011;140:482-488.

For more physician reviews of HM-relevant research, visit our website.

Clinical question: What is the association between time to clinical stability (TCS) and post-discharge death or readmission in patients hospitalized with community-acquired pneumonia (CAP)?

Background: In patients with CAP, inflammatory response during hospitalization might be associated with adverse outcomes after discharge. Studies have not evaluated if time to clinical stability, a reflection of inflammatory response, can be used to identify patients at high risk of adverse outcomes after discharge.

Study design: Retrospective cohort study.

Setting: Veterans Hospital, Louisville, Ky.

Synopsis: Of 464 hospitalized patients with CAP, those with TCS >3 days had a higher rate of readmission or death within 30 days after discharge compared with those who had a TCS =3 days (26% versus 15%; OR 1.98; 95% CI, 1.19-3.3; P=0.008). Longer TCS during hospitalization was associated with a significantly increased risk of adverse outcomes (adjusted OR 1.06, 1.54, 2.40, 10.53 if TCS was reached at days 2, 3, 4, 5 versus Day 1, respectively). The authors proposed that patients with delays in reaching clinical stability should receive a special discharge management approach to decrease the risk of morbidity and mortality after discharge; this may include close observation, home visits, and a follow-up clinic appointment within 10 days.

As a retrospective cohort study, unaccounted-for confounders might exist between TCS and adverse outcomes. The small sample size precluded development of a fully predictive model. Additionally, the population studied was elderly men in a single hospital, which might limit generalizability.

Bottom line: Hospitalized patients with community-acquired pneumonia whose time to clinical stability was greater than three days had a higher risk of readmission or death within 30 days after discharge.

Citation: Aliberti S, Peyrani P, Filardo G, et al. Association between time to clinical stability and outcomes after discharge in hospitalized patients with community-acquired pneumonia. Chest. 2011;140:482-488.

For more physician reviews of HM-relevant research, visit our website.

A new study evaluating outcomes for hospitals participating in the American Heart Association’s Get with the Guidelines program found no correlation between high performance on adhering to measures and care standards for acute myocardial infarction and for heart failure despite overlap between the sets of care processes (J Am Coll Cardio. 2011;58:637-644).

A total of 400,000 heart patients were studied, and 283 participating hospitals were stratified into thirds based on their adherence to core quality measures for each disease, with the upper third labeled superior in performance. Lead author Tracy Wang, MD, MHS, MSc, of the Duke Clinical Research Institute in Durham, N.C., and colleagues found that superior performance for only one of the two diseases led to such end-result outcomes as in-hospital mortality that were no better than for hospitals that were not high performers for either condition. But hospitals with superior performance for both conditions had lower in-hospital mortality rates.

“Perhaps quality is more than just following checklists,” Dr. Wang says. “There’s something special about these high-performing hospitals across the board, with better QI, perhaps a little more investment in infrastructure for quality.”

This result, Dr. Wang says, should give ammunition for hospitalists and other physicians to go to their hospital administrators to request more investment in quality improvement overall, not just for specific conditions.

A new study evaluating outcomes for hospitals participating in the American Heart Association’s Get with the Guidelines program found no correlation between high performance on adhering to measures and care standards for acute myocardial infarction and for heart failure despite overlap between the sets of care processes (J Am Coll Cardio. 2011;58:637-644).

A total of 400,000 heart patients were studied, and 283 participating hospitals were stratified into thirds based on their adherence to core quality measures for each disease, with the upper third labeled superior in performance. Lead author Tracy Wang, MD, MHS, MSc, of the Duke Clinical Research Institute in Durham, N.C., and colleagues found that superior performance for only one of the two diseases led to such end-result outcomes as in-hospital mortality that were no better than for hospitals that were not high performers for either condition. But hospitals with superior performance for both conditions had lower in-hospital mortality rates.

“Perhaps quality is more than just following checklists,” Dr. Wang says. “There’s something special about these high-performing hospitals across the board, with better QI, perhaps a little more investment in infrastructure for quality.”

This result, Dr. Wang says, should give ammunition for hospitalists and other physicians to go to their hospital administrators to request more investment in quality improvement overall, not just for specific conditions.

A new study evaluating outcomes for hospitals participating in the American Heart Association’s Get with the Guidelines program found no correlation between high performance on adhering to measures and care standards for acute myocardial infarction and for heart failure despite overlap between the sets of care processes (J Am Coll Cardio. 2011;58:637-644).

A total of 400,000 heart patients were studied, and 283 participating hospitals were stratified into thirds based on their adherence to core quality measures for each disease, with the upper third labeled superior in performance. Lead author Tracy Wang, MD, MHS, MSc, of the Duke Clinical Research Institute in Durham, N.C., and colleagues found that superior performance for only one of the two diseases led to such end-result outcomes as in-hospital mortality that were no better than for hospitals that were not high performers for either condition. But hospitals with superior performance for both conditions had lower in-hospital mortality rates.

“Perhaps quality is more than just following checklists,” Dr. Wang says. “There’s something special about these high-performing hospitals across the board, with better QI, perhaps a little more investment in infrastructure for quality.”

This result, Dr. Wang says, should give ammunition for hospitalists and other physicians to go to their hospital administrators to request more investment in quality improvement overall, not just for specific conditions.

When James Davis, BSN, RN, CCRN, CIC, first began his nursing career, central venous catheters were widely considered a welcome convenience. “And then we found out that if patients don’t need that line to save their lives, it could kill them, and we need to get them out,” says Davis, now a senior infection prevention analyst with the Pennsylvania Patient Safety Authority in Harrisburg.

Many facilities have dramatically lowered their rates of central-line-associated bloodstream infections (CLABSIs) through a bundled approach focused on proper insertion protocols. But as Davis and other researchers have found, that’s not nearly enough. “If you listen to the infection prevention specialists out there, they’re saying, ‘Well, we’ve done all this, we’ve gotten good results, but there has to be something else because we’re seeing reductions but we still have these infections,’” he says.

That something else, as he discovered in a recent study, may very well be the breakdown of central-line maintenance that causes a late-onset CLABSI, especially after five days post-insertion. From analyzing reports submitted to the National Healthcare Safety Network by 104 acute-care facilities in Pennsylvania, Davis found that nearly 72% of the reported CLABSIs in 2010 were late in onset, occurring after the fifth day.¹

CLABSI expert Marcia Ryder, PhD, MS, RN, research scientist at Ryder Science in San Marcos, Calif., says the study is the first to obtain a clear picture of the average time to event from a large hospital-based data set. Dr. Ryder says the results also strongly suggest that most CLABSIs are caused by maintenance failures and bacterial biofilm formation in the catheter’s internal lumen rather than insertion problems and the presence of an extraluminal biofilm.

The study may help reinforce a message that many CLABSI experts are already sharing with their colleagues. “I like to say that the most important risk factor for a CLABSI is the presence of a central line,” says Sheri Chernetsky Tejedor, MD, SFHM, assistant professor in the division of hospital medicine at Emory University School of Medicine in Atlanta. “If a CVC is not needed, it needs to be removed. The longer they stay in, the higher the cumulative risk of CLABSI.

Current Practices Not Enough

Dr. Ryder says the new research highlights the absurdity of efforts that focus primarily on ICUs. “We’ve always been doing surveillance and monitoring in critical-care units, which is not where the major problem is,” she says. In the U.S., the average length of stay in a critical-care unit is roughly four days. “If most infections are happening after that, they’re never even being picked up, and they’re saying, ‘Well, we have zero infections,’ when indeed they don’t,” she says.

Davis says infection-prevention specialists—hospitalists included—should be regularly reviewing their facility’s central-line-maintenance practices. Perhaps the most important first step is to begin recording both the catheter insertion date and the infection date—line items that are still voluntary in many states like Pennsylvania. With that critical data, studies by Davis and other researchers can provide a better sense of CLABSI origins. “Can we put a fulcrum between insertion and maintenance and show facilities how to look to see which way their scale is tipping?” he asks. If so, those facilities will know how to reallocate their resources accordingly.

Bryn Nelson, PhD, is a freelance writer based in Seattle.

Reference

1. Davis J. Central-line associated bloodstream infection: comprehensive, data-driven prevention. Pa Patient Saf Advis. 2011;8:100-105.

When James Davis, BSN, RN, CCRN, CIC, first began his nursing career, central venous catheters were widely considered a welcome convenience. “And then we found out that if patients don’t need that line to save their lives, it could kill them, and we need to get them out,” says Davis, now a senior infection prevention analyst with the Pennsylvania Patient Safety Authority in Harrisburg.

Many facilities have dramatically lowered their rates of central-line-associated bloodstream infections (CLABSIs) through a bundled approach focused on proper insertion protocols. But as Davis and other researchers have found, that’s not nearly enough. “If you listen to the infection prevention specialists out there, they’re saying, ‘Well, we’ve done all this, we’ve gotten good results, but there has to be something else because we’re seeing reductions but we still have these infections,’” he says.

That something else, as he discovered in a recent study, may very well be the breakdown of central-line maintenance that causes a late-onset CLABSI, especially after five days post-insertion. From analyzing reports submitted to the National Healthcare Safety Network by 104 acute-care facilities in Pennsylvania, Davis found that nearly 72% of the reported CLABSIs in 2010 were late in onset, occurring after the fifth day.¹

CLABSI expert Marcia Ryder, PhD, MS, RN, research scientist at Ryder Science in San Marcos, Calif., says the study is the first to obtain a clear picture of the average time to event from a large hospital-based data set. Dr. Ryder says the results also strongly suggest that most CLABSIs are caused by maintenance failures and bacterial biofilm formation in the catheter’s internal lumen rather than insertion problems and the presence of an extraluminal biofilm.

The study may help reinforce a message that many CLABSI experts are already sharing with their colleagues. “I like to say that the most important risk factor for a CLABSI is the presence of a central line,” says Sheri Chernetsky Tejedor, MD, SFHM, assistant professor in the division of hospital medicine at Emory University School of Medicine in Atlanta. “If a CVC is not needed, it needs to be removed. The longer they stay in, the higher the cumulative risk of CLABSI.

Current Practices Not Enough

Dr. Ryder says the new research highlights the absurdity of efforts that focus primarily on ICUs. “We’ve always been doing surveillance and monitoring in critical-care units, which is not where the major problem is,” she says. In the U.S., the average length of stay in a critical-care unit is roughly four days. “If most infections are happening after that, they’re never even being picked up, and they’re saying, ‘Well, we have zero infections,’ when indeed they don’t,” she says.

Davis says infection-prevention specialists—hospitalists included—should be regularly reviewing their facility’s central-line-maintenance practices. Perhaps the most important first step is to begin recording both the catheter insertion date and the infection date—line items that are still voluntary in many states like Pennsylvania. With that critical data, studies by Davis and other researchers can provide a better sense of CLABSI origins. “Can we put a fulcrum between insertion and maintenance and show facilities how to look to see which way their scale is tipping?” he asks. If so, those facilities will know how to reallocate their resources accordingly.

Bryn Nelson, PhD, is a freelance writer based in Seattle.

Reference

1. Davis J. Central-line associated bloodstream infection: comprehensive, data-driven prevention. Pa Patient Saf Advis. 2011;8:100-105.

When James Davis, BSN, RN, CCRN, CIC, first began his nursing career, central venous catheters were widely considered a welcome convenience. “And then we found out that if patients don’t need that line to save their lives, it could kill them, and we need to get them out,” says Davis, now a senior infection prevention analyst with the Pennsylvania Patient Safety Authority in Harrisburg.

Many facilities have dramatically lowered their rates of central-line-associated bloodstream infections (CLABSIs) through a bundled approach focused on proper insertion protocols. But as Davis and other researchers have found, that’s not nearly enough. “If you listen to the infection prevention specialists out there, they’re saying, ‘Well, we’ve done all this, we’ve gotten good results, but there has to be something else because we’re seeing reductions but we still have these infections,’” he says.

That something else, as he discovered in a recent study, may very well be the breakdown of central-line maintenance that causes a late-onset CLABSI, especially after five days post-insertion. From analyzing reports submitted to the National Healthcare Safety Network by 104 acute-care facilities in Pennsylvania, Davis found that nearly 72% of the reported CLABSIs in 2010 were late in onset, occurring after the fifth day.¹

CLABSI expert Marcia Ryder, PhD, MS, RN, research scientist at Ryder Science in San Marcos, Calif., says the study is the first to obtain a clear picture of the average time to event from a large hospital-based data set. Dr. Ryder says the results also strongly suggest that most CLABSIs are caused by maintenance failures and bacterial biofilm formation in the catheter’s internal lumen rather than insertion problems and the presence of an extraluminal biofilm.

The study may help reinforce a message that many CLABSI experts are already sharing with their colleagues. “I like to say that the most important risk factor for a CLABSI is the presence of a central line,” says Sheri Chernetsky Tejedor, MD, SFHM, assistant professor in the division of hospital medicine at Emory University School of Medicine in Atlanta. “If a CVC is not needed, it needs to be removed. The longer they stay in, the higher the cumulative risk of CLABSI.

Current Practices Not Enough

Dr. Ryder says the new research highlights the absurdity of efforts that focus primarily on ICUs. “We’ve always been doing surveillance and monitoring in critical-care units, which is not where the major problem is,” she says. In the U.S., the average length of stay in a critical-care unit is roughly four days. “If most infections are happening after that, they’re never even being picked up, and they’re saying, ‘Well, we have zero infections,’ when indeed they don’t,” she says.

Davis says infection-prevention specialists—hospitalists included—should be regularly reviewing their facility’s central-line-maintenance practices. Perhaps the most important first step is to begin recording both the catheter insertion date and the infection date—line items that are still voluntary in many states like Pennsylvania. With that critical data, studies by Davis and other researchers can provide a better sense of CLABSI origins. “Can we put a fulcrum between insertion and maintenance and show facilities how to look to see which way their scale is tipping?” he asks. If so, those facilities will know how to reallocate their resources accordingly.

Bryn Nelson, PhD, is a freelance writer based in Seattle.

Reference

1. Davis J. Central-line associated bloodstream infection: comprehensive, data-driven prevention. Pa Patient Saf Advis. 2011;8:100-105.

Research that shows 1 in 3 adult patients does not see a physician within 30 days of discharge is the latest sign that more communication is needed between hospital physicians their community colleagues, a researcher says.

A report from the National Institute for Health Care Reform (NIHCR) found that after 90 days, 17.6% of adults still have not seen a physician, nurse practitioner, or physician assistant, says Anna Sommers, PhD, senior health researcher at the Center for Studying Health System Change, which conducts research for NIHCR. She adds that better communication between hospitalists and PCPs or specialists can be encouraged by important health information technology (HIT), but the process isn't a simple fix.

"That's not just about getting a shared medical record in place," she adds. "A medical record, even for just one inpatient stay, can be large. How does the doctor sift through all that? ... [Technology] can be part of the solution, but I think everyone is still learning how to use the technology and developing interfaces that are useful to the users. It's an evolving process.”

Hospitalists have helped address transitional-care issues with initiatives including post-discharge clinics, but more work needs to be done, Dr. Sommers says. She adds that the depth of the readmission issue is particularly striking as the research found that non-elderly adults with public coverage, a population that historically has higher rates of chronic conditions, were no more likely to see a doctor with 30 days of discharge than a person with private insurance.

"This problem is occurring all over the place," Dr. Sommers says. "It's a systematic problem, not a problem of one population in the health system."

Research that shows 1 in 3 adult patients does not see a physician within 30 days of discharge is the latest sign that more communication is needed between hospital physicians their community colleagues, a researcher says.

A report from the National Institute for Health Care Reform (NIHCR) found that after 90 days, 17.6% of adults still have not seen a physician, nurse practitioner, or physician assistant, says Anna Sommers, PhD, senior health researcher at the Center for Studying Health System Change, which conducts research for NIHCR. She adds that better communication between hospitalists and PCPs or specialists can be encouraged by important health information technology (HIT), but the process isn't a simple fix.

"That's not just about getting a shared medical record in place," she adds. "A medical record, even for just one inpatient stay, can be large. How does the doctor sift through all that? ... [Technology] can be part of the solution, but I think everyone is still learning how to use the technology and developing interfaces that are useful to the users. It's an evolving process.”

Hospitalists have helped address transitional-care issues with initiatives including post-discharge clinics, but more work needs to be done, Dr. Sommers says. She adds that the depth of the readmission issue is particularly striking as the research found that non-elderly adults with public coverage, a population that historically has higher rates of chronic conditions, were no more likely to see a doctor with 30 days of discharge than a person with private insurance.

"This problem is occurring all over the place," Dr. Sommers says. "It's a systematic problem, not a problem of one population in the health system."

Research that shows 1 in 3 adult patients does not see a physician within 30 days of discharge is the latest sign that more communication is needed between hospital physicians their community colleagues, a researcher says.

A report from the National Institute for Health Care Reform (NIHCR) found that after 90 days, 17.6% of adults still have not seen a physician, nurse practitioner, or physician assistant, says Anna Sommers, PhD, senior health researcher at the Center for Studying Health System Change, which conducts research for NIHCR. She adds that better communication between hospitalists and PCPs or specialists can be encouraged by important health information technology (HIT), but the process isn't a simple fix.

"That's not just about getting a shared medical record in place," she adds. "A medical record, even for just one inpatient stay, can be large. How does the doctor sift through all that? ... [Technology] can be part of the solution, but I think everyone is still learning how to use the technology and developing interfaces that are useful to the users. It's an evolving process.”

Hospitalists have helped address transitional-care issues with initiatives including post-discharge clinics, but more work needs to be done, Dr. Sommers says. She adds that the depth of the readmission issue is particularly striking as the research found that non-elderly adults with public coverage, a population that historically has higher rates of chronic conditions, were no more likely to see a doctor with 30 days of discharge than a person with private insurance.

"This problem is occurring all over the place," Dr. Sommers says. "It's a systematic problem, not a problem of one population in the health system."

Improving discharge processes calls for hospitalists to be the voice of change within their facilities, Michelle Mourad, MD, hospitalist and director of quality at the University of California at San Francisco Medical Center, said at UCSF's 19th annual Management of the Hospitalized Patient conference in San Francisco.

"Be the role model. Be the one who always does discharges right," she said in a breakout session focused on discharge improvement.

Dr. Mourad and co-presenter Ryan Greyson, MD, MHS, MA, both sit on UCSF's multidisciplinary Discharge Improvement Team, an approach they recommend to other hospitals. They also say fixing hospital discharges won't be easy, and it requires an individualized approach tailored to each facility and its unique culture.

"Think about the little things you can do. Figure out which steps are needed for safe discharges," she added.

UCSF has implemented a post-discharge hotline for patients to call with follow-up medical problems, and also makes outgoing follow-up calls. A discharge pharmacist performs medication reconciliation for patients with high-risk medications or multiple prescriptions.

A folder called "Your Discharge Information," which encapsulates the patient's medications, discharge plans, follow-up appointments, and the like, goes home with each patient. Unless the patient is known to be reliable, hospital staff also schedule the initial post-discharge medical appointment.

UCSF has developed relationships with local home health agencies, encouraging them to qualify patients with complex needs, including multiple prescriptions, for home health coverage. The home-care nurse then revisits medication reconciliation once the patient is settled back into the home setting. The medical center is developing an agreement with the pharmacy across the street to share the costs of uncovered prescriptions for patients who can't afford to buy them, and often sends patients home with prescription supplies ranging from seven to 30 days, depending on diagnosis.

UCSF's discharge improvements have made an impact on internal-medicine readmission rates. The rate of readmission for patients under age 65 was 16.5% in calendar year 2008, 15.5% in 2009, and 13.2% in 2010.

"Discharge has to be an institutional priority," Dr. Mourad concluded. It requires support from the top down and from the bottom up. It will be hard to succeed, "unless the whole institution believes that it is important."

Improving discharge processes calls for hospitalists to be the voice of change within their facilities, Michelle Mourad, MD, hospitalist and director of quality at the University of California at San Francisco Medical Center, said at UCSF's 19th annual Management of the Hospitalized Patient conference in San Francisco.

"Be the role model. Be the one who always does discharges right," she said in a breakout session focused on discharge improvement.

Dr. Mourad and co-presenter Ryan Greyson, MD, MHS, MA, both sit on UCSF's multidisciplinary Discharge Improvement Team, an approach they recommend to other hospitals. They also say fixing hospital discharges won't be easy, and it requires an individualized approach tailored to each facility and its unique culture.

"Think about the little things you can do. Figure out which steps are needed for safe discharges," she added.

UCSF has implemented a post-discharge hotline for patients to call with follow-up medical problems, and also makes outgoing follow-up calls. A discharge pharmacist performs medication reconciliation for patients with high-risk medications or multiple prescriptions.

A folder called "Your Discharge Information," which encapsulates the patient's medications, discharge plans, follow-up appointments, and the like, goes home with each patient. Unless the patient is known to be reliable, hospital staff also schedule the initial post-discharge medical appointment.

UCSF has developed relationships with local home health agencies, encouraging them to qualify patients with complex needs, including multiple prescriptions, for home health coverage. The home-care nurse then revisits medication reconciliation once the patient is settled back into the home setting. The medical center is developing an agreement with the pharmacy across the street to share the costs of uncovered prescriptions for patients who can't afford to buy them, and often sends patients home with prescription supplies ranging from seven to 30 days, depending on diagnosis.

UCSF's discharge improvements have made an impact on internal-medicine readmission rates. The rate of readmission for patients under age 65 was 16.5% in calendar year 2008, 15.5% in 2009, and 13.2% in 2010.

"Discharge has to be an institutional priority," Dr. Mourad concluded. It requires support from the top down and from the bottom up. It will be hard to succeed, "unless the whole institution believes that it is important."

Improving discharge processes calls for hospitalists to be the voice of change within their facilities, Michelle Mourad, MD, hospitalist and director of quality at the University of California at San Francisco Medical Center, said at UCSF's 19th annual Management of the Hospitalized Patient conference in San Francisco.

"Be the role model. Be the one who always does discharges right," she said in a breakout session focused on discharge improvement.

Dr. Mourad and co-presenter Ryan Greyson, MD, MHS, MA, both sit on UCSF's multidisciplinary Discharge Improvement Team, an approach they recommend to other hospitals. They also say fixing hospital discharges won't be easy, and it requires an individualized approach tailored to each facility and its unique culture.

"Think about the little things you can do. Figure out which steps are needed for safe discharges," she added.

UCSF has implemented a post-discharge hotline for patients to call with follow-up medical problems, and also makes outgoing follow-up calls. A discharge pharmacist performs medication reconciliation for patients with high-risk medications or multiple prescriptions.

A folder called "Your Discharge Information," which encapsulates the patient's medications, discharge plans, follow-up appointments, and the like, goes home with each patient. Unless the patient is known to be reliable, hospital staff also schedule the initial post-discharge medical appointment.

UCSF has developed relationships with local home health agencies, encouraging them to qualify patients with complex needs, including multiple prescriptions, for home health coverage. The home-care nurse then revisits medication reconciliation once the patient is settled back into the home setting. The medical center is developing an agreement with the pharmacy across the street to share the costs of uncovered prescriptions for patients who can't afford to buy them, and often sends patients home with prescription supplies ranging from seven to 30 days, depending on diagnosis.

UCSF's discharge improvements have made an impact on internal-medicine readmission rates. The rate of readmission for patients under age 65 was 16.5% in calendar year 2008, 15.5% in 2009, and 13.2% in 2010.

"Discharge has to be an institutional priority," Dr. Mourad concluded. It requires support from the top down and from the bottom up. It will be hard to succeed, "unless the whole institution believes that it is important."

The recent surge in attention to catheter-associated urinary tract infections (CAUTIs) has increased the focus on both preventing and removing inappropriate catheterizations. Ironically, one outcome rate currently reported by hospitals—the number of infections per 1,000 catheter days—could unfairly punish those facilities that are doing the most to address the problem.

You may end up having a paradoxical increased rate of CAUTI after your successful initiative has reduced catheter use.

—Sanjay Saint, MD, MPH, FHM, professor of internal medicine, University of Michigan, Ann Arbor VA Medical Center

“If your focus is on not putting in the catheter or removing a catheter as soon as possible, you now reduce that denominator of catheter days,” explains Sanjay Saint, MD, MPH, FHM, professor of internal medicine at the University of Michigan and the Ann Arbor VA Medical Center. “The only people who now get a catheter in your hospital are those who are pretty sick; therefore, they need a catheter. These people, because of their underlying sickness, are more likely to have an infection, so you may end up having a paradoxical increased rate of CAUTI after your successful initiative has reduced catheter use.”

Using the wrong denominator, in other words, could defeat the whole point: reducing infections by reducing catheter use.

“If we’re going to publicly report data, we have to make sure that the data we’re reporting and the metrics that we’re using are actually the best metrics for the intended purpose,” Dr. Saint says.

For quality-improvement (QI) efforts, his recommendation is to use 10,000 patient days as a more appropriate denominator.

The recent surge in attention to catheter-associated urinary tract infections (CAUTIs) has increased the focus on both preventing and removing inappropriate catheterizations. Ironically, one outcome rate currently reported by hospitals—the number of infections per 1,000 catheter days—could unfairly punish those facilities that are doing the most to address the problem.

You may end up having a paradoxical increased rate of CAUTI after your successful initiative has reduced catheter use.

—Sanjay Saint, MD, MPH, FHM, professor of internal medicine, University of Michigan, Ann Arbor VA Medical Center

“If your focus is on not putting in the catheter or removing a catheter as soon as possible, you now reduce that denominator of catheter days,” explains Sanjay Saint, MD, MPH, FHM, professor of internal medicine at the University of Michigan and the Ann Arbor VA Medical Center. “The only people who now get a catheter in your hospital are those who are pretty sick; therefore, they need a catheter. These people, because of their underlying sickness, are more likely to have an infection, so you may end up having a paradoxical increased rate of CAUTI after your successful initiative has reduced catheter use.”

Using the wrong denominator, in other words, could defeat the whole point: reducing infections by reducing catheter use.

“If we’re going to publicly report data, we have to make sure that the data we’re reporting and the metrics that we’re using are actually the best metrics for the intended purpose,” Dr. Saint says.

For quality-improvement (QI) efforts, his recommendation is to use 10,000 patient days as a more appropriate denominator.

The recent surge in attention to catheter-associated urinary tract infections (CAUTIs) has increased the focus on both preventing and removing inappropriate catheterizations. Ironically, one outcome rate currently reported by hospitals—the number of infections per 1,000 catheter days—could unfairly punish those facilities that are doing the most to address the problem.

You may end up having a paradoxical increased rate of CAUTI after your successful initiative has reduced catheter use.

—Sanjay Saint, MD, MPH, FHM, professor of internal medicine, University of Michigan, Ann Arbor VA Medical Center

“If your focus is on not putting in the catheter or removing a catheter as soon as possible, you now reduce that denominator of catheter days,” explains Sanjay Saint, MD, MPH, FHM, professor of internal medicine at the University of Michigan and the Ann Arbor VA Medical Center. “The only people who now get a catheter in your hospital are those who are pretty sick; therefore, they need a catheter. These people, because of their underlying sickness, are more likely to have an infection, so you may end up having a paradoxical increased rate of CAUTI after your successful initiative has reduced catheter use.”

Using the wrong denominator, in other words, could defeat the whole point: reducing infections by reducing catheter use.

“If we’re going to publicly report data, we have to make sure that the data we’re reporting and the metrics that we’re using are actually the best metrics for the intended purpose,” Dr. Saint says.

For quality-improvement (QI) efforts, his recommendation is to use 10,000 patient days as a more appropriate denominator.

Because “med rec” is a responsibility shared by providers, patients, and families, it’s important to engage everyone in the process.

Although the patient is—and should be, if capable—the ultimate owner of the correct healthcare record, “We have a responsibility as healthcare providers to help them be successful,” says Blake Lesselroth, MD, assistant professor of medicine at Oregon Health Sciences University and director of the Portland Patient Safety Center of Inquiry at the Portland VA Medical Center. “We haven’t done that.”

Hospitals and healthcare systems use varied strategies for including and empowering patients in the med-rec process:

• The Joint Commission launched its “Speak Up” program (PDF), which gives patients tools to help avoid mistakes with their medications.
• Last year, Southern California Kaiser Permanente rolled out its “medicine in a bag” initiative, according to hospitalist David Wong, MD. Patients are instructed to bring all of their medications (in their respective containers) to the hospital when they are admitted. Then, as the med-rec process is completed, medications are placed in green (take these meds), red (stop these meds), and yellow bags (which may include herbal supplements or other questionable items). In addition, orders are written and explained in simple language: i.e., “twice per day” instead of b.i.d. When patients visit their PCP after discharge, they are instructed to bring the color-coded bags so that the PCPs can verify the coherence of the orders. Clarity reports are filed for each physician, allowing a feedback mechanism to make sure that med rec is taking place.
• Open charting at Griffin Hospital in Derby, Conn., in affiliation with the principles of the nonprofit, patient-centered Planetree organization, supplies another means of double-checking the veracity of patients’ medication lists. It also allows for meaningful patient education and dialogue about treatment and discharge plans, says Dorothea Wild, MD, Griffin Hospital’s chief hospitalist.

Gretchen Henkel is a freelance writer based in California.

Because “med rec” is a responsibility shared by providers, patients, and families, it’s important to engage everyone in the process.

Although the patient is—and should be, if capable—the ultimate owner of the correct healthcare record, “We have a responsibility as healthcare providers to help them be successful,” says Blake Lesselroth, MD, assistant professor of medicine at Oregon Health Sciences University and director of the Portland Patient Safety Center of Inquiry at the Portland VA Medical Center. “We haven’t done that.”

Hospitals and healthcare systems use varied strategies for including and empowering patients in the med-rec process:

• The Joint Commission launched its “Speak Up” program (PDF), which gives patients tools to help avoid mistakes with their medications.
• Last year, Southern California Kaiser Permanente rolled out its “medicine in a bag” initiative, according to hospitalist David Wong, MD. Patients are instructed to bring all of their medications (in their respective containers) to the hospital when they are admitted. Then, as the med-rec process is completed, medications are placed in green (take these meds), red (stop these meds), and yellow bags (which may include herbal supplements or other questionable items). In addition, orders are written and explained in simple language: i.e., “twice per day” instead of b.i.d. When patients visit their PCP after discharge, they are instructed to bring the color-coded bags so that the PCPs can verify the coherence of the orders. Clarity reports are filed for each physician, allowing a feedback mechanism to make sure that med rec is taking place.
• Open charting at Griffin Hospital in Derby, Conn., in affiliation with the principles of the nonprofit, patient-centered Planetree organization, supplies another means of double-checking the veracity of patients’ medication lists. It also allows for meaningful patient education and dialogue about treatment and discharge plans, says Dorothea Wild, MD, Griffin Hospital’s chief hospitalist.

Gretchen Henkel is a freelance writer based in California.

Because “med rec” is a responsibility shared by providers, patients, and families, it’s important to engage everyone in the process.

Although the patient is—and should be, if capable—the ultimate owner of the correct healthcare record, “We have a responsibility as healthcare providers to help them be successful,” says Blake Lesselroth, MD, assistant professor of medicine at Oregon Health Sciences University and director of the Portland Patient Safety Center of Inquiry at the Portland VA Medical Center. “We haven’t done that.”

Hospitals and healthcare systems use varied strategies for including and empowering patients in the med-rec process:

• The Joint Commission launched its “Speak Up” program (PDF), which gives patients tools to help avoid mistakes with their medications.
• Last year, Southern California Kaiser Permanente rolled out its “medicine in a bag” initiative, according to hospitalist David Wong, MD. Patients are instructed to bring all of their medications (in their respective containers) to the hospital when they are admitted. Then, as the med-rec process is completed, medications are placed in green (take these meds), red (stop these meds), and yellow bags (which may include herbal supplements or other questionable items). In addition, orders are written and explained in simple language: i.e., “twice per day” instead of b.i.d. When patients visit their PCP after discharge, they are instructed to bring the color-coded bags so that the PCPs can verify the coherence of the orders. Clarity reports are filed for each physician, allowing a feedback mechanism to make sure that med rec is taking place.
• Open charting at Griffin Hospital in Derby, Conn., in affiliation with the principles of the nonprofit, patient-centered Planetree organization, supplies another means of double-checking the veracity of patients’ medication lists. It also allows for meaningful patient education and dialogue about treatment and discharge plans, says Dorothea Wild, MD, Griffin Hospital’s chief hospitalist.

Gretchen Henkel is a freelance writer based in California.