With the aging of the US population, complex medication regimens to treat multiple comorbidities are increasingly common.1 Nevertheless, patients often do not fully understand the instructions for safe and effective medication use. Aspects of medication understanding include knowledge of the drug indication, dose, frequency, and for certain medications, special instructions.2 Medication understanding is associated with better medication adherence, fewer drug‐related problems, and fewer emergency department visits.3 Among patients with chronic conditions, such as cardiovascular disease (CVD), understanding and adherence to the medication regimen are critical for successful disease control and clinical outcomes.4

Patients' understanding of their medication regimen is also vitally important upon admission to the hospital. Patients often are the main source of information for the admission medication history and subsequent medication reconciliation.5 Poor patient understanding of the preadmission medication regimen can contribute to errors in inpatient and postdischarge medication orders, and adversely affect patient safety.6 However, little research has examined patients' understanding of the preadmission medication regimen and factors that affect it.

In the outpatient setting, previous investigations have suggested that low health literacy, advanced age, and impaired cognitive function adversely affect patients' understanding of medication instructions.2, 7, 8 These studies were limited by a small sample size, single site, or focus on a specific population, such as inner‐city patients. Additionally, the measures used to assess medication understanding were time‐consuming and required patients' medications to be present for testing, thus limiting their utility.2

To address these gaps in the literature, we developed and implemented the Medication Understanding Questionnaire (MUQ), an original and relatively rapid measure that does not require patients' medications be present for testing. In a study of adults at 2 large teaching hospitals, we examined the association of health literacy, age, cognitive function, number of preadmission medications, and other factors on patients' understanding of their preadmission medication regimen. We hypothesized that lower health literacy would be independently associated with lower medication understanding as assessed using the MUQ.

METHODS

The present study was a cross‐sectional assessment conducted using baseline interview data from the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL‐CVD) Study (ClinicalTrials.gov Registration #NCT00632021; available at: http://clinicaltrials.gov/show/NCT00632021). The PILL‐CVD Study is a randomized controlled trial of a pharmacist‐based intervention, consisting of pharmacist‐assisted medication reconciliation, inpatient counseling, low‐literacy adherence aids, and postdischarge telephone follow‐up. It was conducted at 2 academic medical centersVanderbilt University Hospital (VUH) in Nashville, Tennessee, and Brigham and Women's Hospital (BWH) in Boston, Massachusetts.9 This study was approved by the Institutional Review Board at each site, and all participants provided written informed consent.

RESULTS

Predictors of Medication Understanding

Unadjusted relationships of health literacy, cognition, and number of medications with medication understanding are shown in Figure 1 (panels A, B, and C, respectively). The figure demonstrates a linear relationship with both health literacy (Figure 1A) and cognition (Figure 1B), and a nonlinear relationship between number of preadmission medications and MUQ score (Figure 1C).

Figure 1

Adjusted relationships using imputed data for missing covariates are shown in Figure 2. Lower health literacy, cognitive impairment, male gender, and black race were independently associated with lower understanding of preadmission medications. Each 1 point increase in s‐TOFHLA or Mini‐Cog score led to an increase in medication understanding (OR = 1.04; 95% CI, 1.02 to 1.06; P = 0.0001; and OR = 1.24; 95% CI, 1.1 to 1.4; P = 0.001; respectively). Patients with marginal or inadequate health literacy had lower odds of understanding their regimen (OR = 0.53; 95% CI, 0.34 to 0.84; and OR = 0.49; 95% CI, 0.31 to 0.78, respectively) compared to those with adequate health literacy. Impaired cognitive function (Mini‐Cog score <3, indicating dementia) was also associated with lower odds of medication understanding (OR = 0.57; 95% CI, 0.38 to 0.86) compared to those with no cognitive impairment. An increase in the number of preadmission medications (up to 10) was also strongly associated with lower MUQ scores. For each increase by 1 medication, there was a significant decrease in medication understanding, up to 10 medications, beyond which understanding did not significantly decrease further. Patients on 6 medications were about half as likely to understand their medication regimen as patients on only 1 medication (OR = 0.52; 95% CI, 0.36 to 0.75). For patients on 11 medications, the odds of medication understanding were 24% lower than for patients on 6 medications (OR = 0.76; 95% CI, 0.65 to 0.89). Patients' age, years of schooling, and household income were not independently associated with medication understanding. Results were similar using data without multiple imputation.

Figure 2

DISCUSSION

We used a novel four‐component medication understanding questionnaire, developed for this study, to assess patients' understanding of up to 5 drugs selected randomly from the participant's preadmission medication list. The MUQ proved to be easy to administer by nonmedical staff within a short period of time (approximately 5 minutes per patient). It was well understood by patients. By limiting the assessment to 5 or fewer medications, the MUQ has a distinct advantage over existing measures of medication understanding that require testing the entire regimen. We did not find any limitations related to cutting off the assessment at 5 medications. In addition, this tool affords assessment of medication understanding without requiring medication bottles be present, enhancing its utility in the inpatient setting.

MUQ scores were associated with health literacy and other patient characteristics in an expected manner. We demonstrated that inadequate or marginal health literacy, as well as impaired cognitive function, were associated with low medication understanding. We also were able to demonstrate a relationship between increasing number of medications and lower medication understanding. Interestingly, in our patient population, understanding continued to decrease until reaching 10 medications, beyond which further increases in the number of medications had no additional detrimental effect on medication understanding. This nonlinear relationship between number of medications and medication understanding has potential implications for prescribing practice.

Our findings which utilize the MUQ among inpatients are consistent with prior literature in other settings.2, 7, 8 In a previous outpatient study, we identified that health literacy plays an important role in a patient's ability to successfully report and manage their daily medications.2 Other studies have also shown that patients with low health literacy have more difficulty understanding prescription drug information, and that they often experience medication‐related problems after hospital discharge.15, 16 The number and often the types of medications an individual takes have also been shown to increase the risk for adverse events and nonadherence to the treatment plan.1720 We postulate that this risk of adverse drug events is related at least in part to a patient's understanding of their medication regimen.

There are several limitations to this study. First, the MUQ did not assess certain aspects of medication understanding, such as knowledge of pill appearance or side effects, nor did it assess components of patients' actual drug‐taking behavior, such as organization of medications or behavioral cues. Thus, adaptive behaviors that patients may perform to improve their medication management, such as writing on labels or memory cues, are not captured by this test. Second, in administering and scoring the MUQ, we used the patient's preadmission medication list documented in the EHR as the reference standard. This was the best available reference list, and was generally accurate, as both hospitals had medication reconciliation systems in use at the time of the study21; nevertheless, it may contain inaccuracies. Documentation for certain medications, such as warfarin, in which dose can change frequently, often did not reflect the latest prescribed dose. In such cases, we scored the patient's answer as correct if the dose appeared reasonable and appropriate to the clinical pharmacist. As a result, a patient's MUQ score may have been overestimated in these cases.

Additional research will be needed to further validate the MUQ in other settings. In particular, studies should establish the relationship between the MUQ, serious medication errors after discharge, and potential to benefit from educational interventions. Also, as noted above, the nonlinear relationship between number of medications and medication understanding should be confirmed in other studies.

In conclusion, we demonstrated that patients with low health literacy, impaired cognition, or a higher number of medications had significantly poorer understanding of their preadmission medication regimen. These findings have important clinical implications. It would be appropriate to exercise greater caution when taking a medication history from patients who cannot readily provide the purpose, strength, units, and frequency of their medications. Attempts to validate the information obtained from patients with other sources of data, such as family members, inpatient or outpatient health records, and community pharmacy records should be considered. Patients at high risk for poor medication understanding, either measured directly using the MUQ or identified via risk factors such as polypharmacy, low cognition, or low health literacy, may warrant more intensive medication reconciliation interventions and/or educational counseling and follow‐up to prevent postdischarge adverse drug events. Further research is needed to determine if targeting these populations for interventions improves medication safety during transitions in care.

With the aging of the US population, complex medication regimens to treat multiple comorbidities are increasingly common.1 Nevertheless, patients often do not fully understand the instructions for safe and effective medication use. Aspects of medication understanding include knowledge of the drug indication, dose, frequency, and for certain medications, special instructions.2 Medication understanding is associated with better medication adherence, fewer drug‐related problems, and fewer emergency department visits.3 Among patients with chronic conditions, such as cardiovascular disease (CVD), understanding and adherence to the medication regimen are critical for successful disease control and clinical outcomes.4

Patients' understanding of their medication regimen is also vitally important upon admission to the hospital. Patients often are the main source of information for the admission medication history and subsequent medication reconciliation.5 Poor patient understanding of the preadmission medication regimen can contribute to errors in inpatient and postdischarge medication orders, and adversely affect patient safety.6 However, little research has examined patients' understanding of the preadmission medication regimen and factors that affect it.

In the outpatient setting, previous investigations have suggested that low health literacy, advanced age, and impaired cognitive function adversely affect patients' understanding of medication instructions.2, 7, 8 These studies were limited by a small sample size, single site, or focus on a specific population, such as inner‐city patients. Additionally, the measures used to assess medication understanding were time‐consuming and required patients' medications to be present for testing, thus limiting their utility.2

To address these gaps in the literature, we developed and implemented the Medication Understanding Questionnaire (MUQ), an original and relatively rapid measure that does not require patients' medications be present for testing. In a study of adults at 2 large teaching hospitals, we examined the association of health literacy, age, cognitive function, number of preadmission medications, and other factors on patients' understanding of their preadmission medication regimen. We hypothesized that lower health literacy would be independently associated with lower medication understanding as assessed using the MUQ.

METHODS

The present study was a cross‐sectional assessment conducted using baseline interview data from the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL‐CVD) Study (ClinicalTrials.gov Registration #NCT00632021; available at: http://clinicaltrials.gov/show/NCT00632021). The PILL‐CVD Study is a randomized controlled trial of a pharmacist‐based intervention, consisting of pharmacist‐assisted medication reconciliation, inpatient counseling, low‐literacy adherence aids, and postdischarge telephone follow‐up. It was conducted at 2 academic medical centersVanderbilt University Hospital (VUH) in Nashville, Tennessee, and Brigham and Women's Hospital (BWH) in Boston, Massachusetts.9 This study was approved by the Institutional Review Board at each site, and all participants provided written informed consent.

RESULTS

Predictors of Medication Understanding

Unadjusted relationships of health literacy, cognition, and number of medications with medication understanding are shown in Figure 1 (panels A, B, and C, respectively). The figure demonstrates a linear relationship with both health literacy (Figure 1A) and cognition (Figure 1B), and a nonlinear relationship between number of preadmission medications and MUQ score (Figure 1C).

Figure 1

Adjusted relationships using imputed data for missing covariates are shown in Figure 2. Lower health literacy, cognitive impairment, male gender, and black race were independently associated with lower understanding of preadmission medications. Each 1 point increase in s‐TOFHLA or Mini‐Cog score led to an increase in medication understanding (OR = 1.04; 95% CI, 1.02 to 1.06; P = 0.0001; and OR = 1.24; 95% CI, 1.1 to 1.4; P = 0.001; respectively). Patients with marginal or inadequate health literacy had lower odds of understanding their regimen (OR = 0.53; 95% CI, 0.34 to 0.84; and OR = 0.49; 95% CI, 0.31 to 0.78, respectively) compared to those with adequate health literacy. Impaired cognitive function (Mini‐Cog score <3, indicating dementia) was also associated with lower odds of medication understanding (OR = 0.57; 95% CI, 0.38 to 0.86) compared to those with no cognitive impairment. An increase in the number of preadmission medications (up to 10) was also strongly associated with lower MUQ scores. For each increase by 1 medication, there was a significant decrease in medication understanding, up to 10 medications, beyond which understanding did not significantly decrease further. Patients on 6 medications were about half as likely to understand their medication regimen as patients on only 1 medication (OR = 0.52; 95% CI, 0.36 to 0.75). For patients on 11 medications, the odds of medication understanding were 24% lower than for patients on 6 medications (OR = 0.76; 95% CI, 0.65 to 0.89). Patients' age, years of schooling, and household income were not independently associated with medication understanding. Results were similar using data without multiple imputation.

Figure 2

DISCUSSION

We used a novel four‐component medication understanding questionnaire, developed for this study, to assess patients' understanding of up to 5 drugs selected randomly from the participant's preadmission medication list. The MUQ proved to be easy to administer by nonmedical staff within a short period of time (approximately 5 minutes per patient). It was well understood by patients. By limiting the assessment to 5 or fewer medications, the MUQ has a distinct advantage over existing measures of medication understanding that require testing the entire regimen. We did not find any limitations related to cutting off the assessment at 5 medications. In addition, this tool affords assessment of medication understanding without requiring medication bottles be present, enhancing its utility in the inpatient setting.

MUQ scores were associated with health literacy and other patient characteristics in an expected manner. We demonstrated that inadequate or marginal health literacy, as well as impaired cognitive function, were associated with low medication understanding. We also were able to demonstrate a relationship between increasing number of medications and lower medication understanding. Interestingly, in our patient population, understanding continued to decrease until reaching 10 medications, beyond which further increases in the number of medications had no additional detrimental effect on medication understanding. This nonlinear relationship between number of medications and medication understanding has potential implications for prescribing practice.

Our findings which utilize the MUQ among inpatients are consistent with prior literature in other settings.2, 7, 8 In a previous outpatient study, we identified that health literacy plays an important role in a patient's ability to successfully report and manage their daily medications.2 Other studies have also shown that patients with low health literacy have more difficulty understanding prescription drug information, and that they often experience medication‐related problems after hospital discharge.15, 16 The number and often the types of medications an individual takes have also been shown to increase the risk for adverse events and nonadherence to the treatment plan.1720 We postulate that this risk of adverse drug events is related at least in part to a patient's understanding of their medication regimen.

There are several limitations to this study. First, the MUQ did not assess certain aspects of medication understanding, such as knowledge of pill appearance or side effects, nor did it assess components of patients' actual drug‐taking behavior, such as organization of medications or behavioral cues. Thus, adaptive behaviors that patients may perform to improve their medication management, such as writing on labels or memory cues, are not captured by this test. Second, in administering and scoring the MUQ, we used the patient's preadmission medication list documented in the EHR as the reference standard. This was the best available reference list, and was generally accurate, as both hospitals had medication reconciliation systems in use at the time of the study21; nevertheless, it may contain inaccuracies. Documentation for certain medications, such as warfarin, in which dose can change frequently, often did not reflect the latest prescribed dose. In such cases, we scored the patient's answer as correct if the dose appeared reasonable and appropriate to the clinical pharmacist. As a result, a patient's MUQ score may have been overestimated in these cases.

Additional research will be needed to further validate the MUQ in other settings. In particular, studies should establish the relationship between the MUQ, serious medication errors after discharge, and potential to benefit from educational interventions. Also, as noted above, the nonlinear relationship between number of medications and medication understanding should be confirmed in other studies.

In conclusion, we demonstrated that patients with low health literacy, impaired cognition, or a higher number of medications had significantly poorer understanding of their preadmission medication regimen. These findings have important clinical implications. It would be appropriate to exercise greater caution when taking a medication history from patients who cannot readily provide the purpose, strength, units, and frequency of their medications. Attempts to validate the information obtained from patients with other sources of data, such as family members, inpatient or outpatient health records, and community pharmacy records should be considered. Patients at high risk for poor medication understanding, either measured directly using the MUQ or identified via risk factors such as polypharmacy, low cognition, or low health literacy, may warrant more intensive medication reconciliation interventions and/or educational counseling and follow‐up to prevent postdischarge adverse drug events. Further research is needed to determine if targeting these populations for interventions improves medication safety during transitions in care.

With the aging of the US population, complex medication regimens to treat multiple comorbidities are increasingly common.1 Nevertheless, patients often do not fully understand the instructions for safe and effective medication use. Aspects of medication understanding include knowledge of the drug indication, dose, frequency, and for certain medications, special instructions.2 Medication understanding is associated with better medication adherence, fewer drug‐related problems, and fewer emergency department visits.3 Among patients with chronic conditions, such as cardiovascular disease (CVD), understanding and adherence to the medication regimen are critical for successful disease control and clinical outcomes.4

Patients' understanding of their medication regimen is also vitally important upon admission to the hospital. Patients often are the main source of information for the admission medication history and subsequent medication reconciliation.5 Poor patient understanding of the preadmission medication regimen can contribute to errors in inpatient and postdischarge medication orders, and adversely affect patient safety.6 However, little research has examined patients' understanding of the preadmission medication regimen and factors that affect it.

In the outpatient setting, previous investigations have suggested that low health literacy, advanced age, and impaired cognitive function adversely affect patients' understanding of medication instructions.2, 7, 8 These studies were limited by a small sample size, single site, or focus on a specific population, such as inner‐city patients. Additionally, the measures used to assess medication understanding were time‐consuming and required patients' medications to be present for testing, thus limiting their utility.2

To address these gaps in the literature, we developed and implemented the Medication Understanding Questionnaire (MUQ), an original and relatively rapid measure that does not require patients' medications be present for testing. In a study of adults at 2 large teaching hospitals, we examined the association of health literacy, age, cognitive function, number of preadmission medications, and other factors on patients' understanding of their preadmission medication regimen. We hypothesized that lower health literacy would be independently associated with lower medication understanding as assessed using the MUQ.

METHODS

The present study was a cross‐sectional assessment conducted using baseline interview data from the Pharmacist Intervention for Low Literacy in Cardiovascular Disease (PILL‐CVD) Study (ClinicalTrials.gov Registration #NCT00632021; available at: http://clinicaltrials.gov/show/NCT00632021). The PILL‐CVD Study is a randomized controlled trial of a pharmacist‐based intervention, consisting of pharmacist‐assisted medication reconciliation, inpatient counseling, low‐literacy adherence aids, and postdischarge telephone follow‐up. It was conducted at 2 academic medical centersVanderbilt University Hospital (VUH) in Nashville, Tennessee, and Brigham and Women's Hospital (BWH) in Boston, Massachusetts.9 This study was approved by the Institutional Review Board at each site, and all participants provided written informed consent.

RESULTS

Predictors of Medication Understanding

Unadjusted relationships of health literacy, cognition, and number of medications with medication understanding are shown in Figure 1 (panels A, B, and C, respectively). The figure demonstrates a linear relationship with both health literacy (Figure 1A) and cognition (Figure 1B), and a nonlinear relationship between number of preadmission medications and MUQ score (Figure 1C).

Figure 1

Adjusted relationships using imputed data for missing covariates are shown in Figure 2. Lower health literacy, cognitive impairment, male gender, and black race were independently associated with lower understanding of preadmission medications. Each 1 point increase in s‐TOFHLA or Mini‐Cog score led to an increase in medication understanding (OR = 1.04; 95% CI, 1.02 to 1.06; P = 0.0001; and OR = 1.24; 95% CI, 1.1 to 1.4; P = 0.001; respectively). Patients with marginal or inadequate health literacy had lower odds of understanding their regimen (OR = 0.53; 95% CI, 0.34 to 0.84; and OR = 0.49; 95% CI, 0.31 to 0.78, respectively) compared to those with adequate health literacy. Impaired cognitive function (Mini‐Cog score <3, indicating dementia) was also associated with lower odds of medication understanding (OR = 0.57; 95% CI, 0.38 to 0.86) compared to those with no cognitive impairment. An increase in the number of preadmission medications (up to 10) was also strongly associated with lower MUQ scores. For each increase by 1 medication, there was a significant decrease in medication understanding, up to 10 medications, beyond which understanding did not significantly decrease further. Patients on 6 medications were about half as likely to understand their medication regimen as patients on only 1 medication (OR = 0.52; 95% CI, 0.36 to 0.75). For patients on 11 medications, the odds of medication understanding were 24% lower than for patients on 6 medications (OR = 0.76; 95% CI, 0.65 to 0.89). Patients' age, years of schooling, and household income were not independently associated with medication understanding. Results were similar using data without multiple imputation.

Figure 2

DISCUSSION

We used a novel four‐component medication understanding questionnaire, developed for this study, to assess patients' understanding of up to 5 drugs selected randomly from the participant's preadmission medication list. The MUQ proved to be easy to administer by nonmedical staff within a short period of time (approximately 5 minutes per patient). It was well understood by patients. By limiting the assessment to 5 or fewer medications, the MUQ has a distinct advantage over existing measures of medication understanding that require testing the entire regimen. We did not find any limitations related to cutting off the assessment at 5 medications. In addition, this tool affords assessment of medication understanding without requiring medication bottles be present, enhancing its utility in the inpatient setting.

MUQ scores were associated with health literacy and other patient characteristics in an expected manner. We demonstrated that inadequate or marginal health literacy, as well as impaired cognitive function, were associated with low medication understanding. We also were able to demonstrate a relationship between increasing number of medications and lower medication understanding. Interestingly, in our patient population, understanding continued to decrease until reaching 10 medications, beyond which further increases in the number of medications had no additional detrimental effect on medication understanding. This nonlinear relationship between number of medications and medication understanding has potential implications for prescribing practice.

Our findings which utilize the MUQ among inpatients are consistent with prior literature in other settings.2, 7, 8 In a previous outpatient study, we identified that health literacy plays an important role in a patient's ability to successfully report and manage their daily medications.2 Other studies have also shown that patients with low health literacy have more difficulty understanding prescription drug information, and that they often experience medication‐related problems after hospital discharge.15, 16 The number and often the types of medications an individual takes have also been shown to increase the risk for adverse events and nonadherence to the treatment plan.1720 We postulate that this risk of adverse drug events is related at least in part to a patient's understanding of their medication regimen.

There are several limitations to this study. First, the MUQ did not assess certain aspects of medication understanding, such as knowledge of pill appearance or side effects, nor did it assess components of patients' actual drug‐taking behavior, such as organization of medications or behavioral cues. Thus, adaptive behaviors that patients may perform to improve their medication management, such as writing on labels or memory cues, are not captured by this test. Second, in administering and scoring the MUQ, we used the patient's preadmission medication list documented in the EHR as the reference standard. This was the best available reference list, and was generally accurate, as both hospitals had medication reconciliation systems in use at the time of the study21; nevertheless, it may contain inaccuracies. Documentation for certain medications, such as warfarin, in which dose can change frequently, often did not reflect the latest prescribed dose. In such cases, we scored the patient's answer as correct if the dose appeared reasonable and appropriate to the clinical pharmacist. As a result, a patient's MUQ score may have been overestimated in these cases.

Additional research will be needed to further validate the MUQ in other settings. In particular, studies should establish the relationship between the MUQ, serious medication errors after discharge, and potential to benefit from educational interventions. Also, as noted above, the nonlinear relationship between number of medications and medication understanding should be confirmed in other studies.

In conclusion, we demonstrated that patients with low health literacy, impaired cognition, or a higher number of medications had significantly poorer understanding of their preadmission medication regimen. These findings have important clinical implications. It would be appropriate to exercise greater caution when taking a medication history from patients who cannot readily provide the purpose, strength, units, and frequency of their medications. Attempts to validate the information obtained from patients with other sources of data, such as family members, inpatient or outpatient health records, and community pharmacy records should be considered. Patients at high risk for poor medication understanding, either measured directly using the MUQ or identified via risk factors such as polypharmacy, low cognition, or low health literacy, may warrant more intensive medication reconciliation interventions and/or educational counseling and follow‐up to prevent postdischarge adverse drug events. Further research is needed to determine if targeting these populations for interventions improves medication safety during transitions in care.

Recent studies have shown that a patient's discharge from the hospital is a vulnerable period for patient safety.14 With the reduction in length of stay (LOS) and the increase in patient acuity over the past decade, patients are discharged from acute care settings quicker and sicker, resulting in management of ongoing illness in a less‐monitored environment.5, 6 In addition, in teaching hospitals, residents are supervised by hospital‐based physicians who are rarely the primary care physician (PCP) for the residents' patients, which creates discontinuity of care.

One in 5 medical discharges is complicated by an adverse event believed, in part, to be due to poor communication between caregivers during this transition time.2 Discharge summaries, a key form of that communication, are not always done in a timely fashion and may lack key pieces of information.7, 8 For approximately 68% of patient discharges, the PCP will not have a discharge summary available for the patient's first follow‐up visit.911 In a survey of PCPs whose patients were in the hospital, only 23% reported direct communication with the hospital care team.12 This leaves PCPs unaware of pending test results or recommended follow‐up evaluations.10, 11, 13, 14 All of these factors are believed to contribute to adverse events, emergency department (ED) visits, and readmissions.

A recently published consensus statement on transitions of care by 6 major medical societies emphasizes the need for timely communication and transfer of information.15 These important processes are especially challenging to meet at academic medical centers, where discharge summaries and transition communication are done by residents in a hectic and challenging work environment, with multiple simultaneous and competing demands including outpatient clinic and required conferences.12 Residents have little formal training in how to write an effective discharge summary or how to systematically approach discharge planning. One study found higher error rates in discharge summaries written by residents compared with attending physicians.16 While the Accreditation Council for Graduate Medical Education (ACGME) limits the number of admissions per intern for both patient safety and educational reasons, the number of discharges per day is not limited despite the considerable amount of time required for appropriate discharge planning and communication.

Many interventions have been tried to improve the discharge process and reduce patient adverse events.17 Arranging early follow‐up appointments to reduce emergency department visits and readmissions has shown mixed results.13, 1820 Interventions that focus on specific populations, such as the elderly or patients with congestive heart failure, have been more successful.2123 Some interventions employed additional resources, such as a discharge form, transition coach, or discharge advocate, again with varying impact on results.18, 2427 A recent study by Jack et al. used nurse discharge advocates (DAs) to help with discharge planning and communication at an academic medical center.25 These DAs were independent of the care team, and focused on patient education and follow‐up plans, and reduced hospital reutilization in a selected population.

No studies have assessed the potential benefit of helping residents with the physician components of the discharge process. Prior studies have mainly focused on patient communication and follow‐up appointments, yet safe transitions also involve timely discharge summaries, physician‐to‐physician communication, physician‐to‐nurse communication, and medication reconciliation. Without support and time, these tasks can be very challenging for resident physicians with work‐hour limitations. We undertook a randomized, controlled trial to evaluate the impact on the discharge process of embedding a discharge facilitator in a resident medical team to help with the physician discharge process. We studied the effect for all the patients discharged from the resident team, rather than focusing on a select group or patients with a single diagnosis.

METHODS

RESULTS

Study Sample

During the 5‐month intervention (November 12, 2008 to April 14, 2009), a combined total of 999 patients were admitted to the intervention and control general medical teams. We excluded 96 patients who were not discharged but transferred to another service or intensive care units, and 24 patients who died. We also excluded 7 patients who were discharged from both teams the first day of the study, because the DF was not involved with the patients' discharge planning. That left 872 patients discharged to either home, a facility, or having left against medical advice (AMA) included in the study: 440 patients on the intervention team and 432 patients on the control team (Figure 1). Baseline patient demographic and clinical characteristics were similar across both teams with only gender being significantly different (Table 1). The mean age was 63 years (range, 1896) and the mean comorbidity score was 2.3 (range, 012). Of note, about a quarter of patients were discharged to facilities, about half were Medicare recipients, and approximately 80% had a PCP. The DF participated in the discharge process for nearly all of the intervention patients; she reported contributing approximately 50% of the content to the discharge summaries.

Figure 1

Table 1.Baseline Participant Characteristics

Characteristics	Intervention Team	Control Team
	n = 440	n = 432
Abbreviations: AMA, against medical advice; COPD, chronic obstructive pulmonary disease; PCP, primary care physician; SD, standard deviation. * P < 0.05; no other comparisons were statistically significant. Deyo Modification of the Charlson Comorbidity Index.
Mean age (SD), year	63 (18)	63 (18)
Women, n (%)*	181 (41)	207 (48)
Race, n (%)
White non‐Hispanic	267 (61)	243 (56)
Black non‐Hispanic	24 (5)	33 (8)
Hispanic	21 (5)	17 (4)
Unknown/other	128 (29)	139 (32)
Health insurance, n (%)
Medicare	213 (48)	226 (52)
Medicaid	85 (19)	81 (19)
Private	110 (25)	91 (21)
Other	32 (7)	34 (8)
PCP on admission, n (%)	370 (84)	356 (82)
Discharge disposition, n (%)
AMA	12 (3)	14 (3)
Home	305 (69)	315 (73)
Facility	123 (28)	103 (24)
Mean comorbidity index score (SD)	2.3 (2.4)	2.3 (2.4)
Diagnoses
Congestive heart failure	30 (6%)	27 (5%)
COPD/asthma	34 (7%)	47 (9%)
Cardiovascular disease	54 (11%)	50 (8%)
Alcohol/substance abuse	29 (6%)	34 (7%)
Gastrointestinal bleeds/ulcers	38 (8%)	41 (8%)
Hepatobiliary disease	30 (6%)	36 (7%)
Renal failure/kidney disease	33 (7%)	37 (7%)
Pneumonia	36 (7%)	22 (4%)
Musculoskeletal disease	26 (5%)	23 (5%)
Neurologic disease	22 (4%)	25 (5%)
Other	163 (33%)	172 (35%)

DISCUSSION

Our study embedded a nurse practitioner on a busy resident general medical team to help with all aspects of the discharge process for which physicians are responsible. Previous studies have been limited to patients with specific diagnoses, age, or disposition plans.1825 In this study, we included all general medical patients. Our intervention improved several important quality of care elements: the timeliness of completion of discharge summaries; and increased number of early follow‐up appointments, with more patients seen within 2 and 4 weeks after discharge. Patients reported better understanding of their follow‐up plans and more satisfaction with the discharge process. While not statistically significant, there was a trend towards better communication with nurses. For residents with work‐hour limitations, there was time savings with a trend towards finishing attending rounds on time and statistically significant earlier sign‐out rounds (46 minutes earlier). This intervention had no effect on patient length of stay, readmissions, or emergency department visits in the 30 days after discharge.

Despite improving many aspects of the discharge process and communication that have previously been raised as areas of concern for patient safety, there was no improvement in readmissions rates and ED utilization which are often used as the quality indicators for effective discharge planning. Similar types of interventions on general medical patients have generally also failed to show improvement in readmission rates.1820, 25 Weinberger et al. arranged follow‐up appointments within 1 week for patients discharged from a Veterans Administrative hospital; while patients were seen more often, the intervention actually increased readmission rates.20 Fitzgerald et al. had a case manager contact patients at home and encourage follow‐up, which increased follow‐up visits, but again had no effect on readmission.19 Einstadter et al. had a nurse case manager coordinate outpatient follow‐up on a resident team and also did not effect readmission rates or ED visits.18 Jack et al. in project reengineered discharge (RED) did show a significant reduction in combined hospital utilization measures. However, their study focused on a more limited patient population, and employed both a discharge advocate to arrange follow‐up and improve patient education, and a pharmacist to make postdischarge phone calls.25

So why did readmissions rates and ED visits not change in our study? It would be reasonable to think that having earlier follow‐up appointments, better and timely physician‐to‐physician communication, and a facilitator for patient questions should improve the quality of the discharge process. In a recent study, Jha et al. found there was no association between chart‐based measures of discharge quality and readmissions rates, and only a modest association for patient‐reported measures of discharge quality and readmission rates.28 The authors suggest readmission rates are driven by many factors beyond just improved discharge safety. Perhaps readmission rates are too complex a measure to use to assess discharge process improvement. For fiscal reasons, it is understandable that hospitals, insurance companies, and the Centers for Medicare and Medicaid want to reduce readmission rates and ED utilization. Jencks et al. noted the cost of readmissions in 2004 was 17.4 billion dollars.29 However, sweeping efforts to improve the discharge process for all general medical patients may not yield significant reductions in readmissions, as this study suggests. We may need to focus aggressive intervention on smaller target populations, as prior studies on focused groups suggest.2123

There are no evidence‐based studies to suggest when optimal follow‐up should occur after discharge.26 Several medical society guidelines recommend 2 weeks. More patients on the intervention team were seen within 2 weeks, but readmission rates were not affected. The University Health System Consortium recently reported that the majority of readmissions occurred within 6 days, with the average being about 2 to 3 days.30 In this study, the median days to readmit were 12 for the intervention team and 10 for the control. It is possible that even with our improved 2‐week follow‐up, this was not early enough to reduce readmissions. Follow‐up may need to be within 13 days of discharge for highly vulnerable patients, to significantly change readmission rates. Further studies focusing on this question would be helpful.

Finally, with ACGME limitation of work hours, many residency programs are looking for ways to reduce residents' workload and increase time for education. With a significant trend towards finishing attending rounds on time, it is likely that more residents on the intervention team were able to attend the noon‐time educational conferences. We speculate that this was due to fewer interruptions during rounds because the DF was available for nurses' questions. Sign‐out rounds occurred significantly earlier, possibly because of improved resident efficiency due to the DF's help with the discharge process. While residents may lose some educational experience from not performing all discharge tasks, they gain experience working in interdisciplinary teams, have increased time for education, and reduced work hours. Since the ACGME limits the number of residents per program and increasing the residency size is not an option, a DF should be considered as a possible solution to ACGME work‐hour restrictions.

This study had several limitations. First, the intervention team had 1 specific person embedded, and therefore the results of this study may have limited generalizability. Second, the limited number of residents working with the DF could have biased the intervention, as not all residents worked equally well with the DF. However, this may represent the real‐world experience on any teaching service, given variation in working styles and learning curves of residents over their training. Third, this study was done at 1 university‐affiliated urban Academic Medical Center, making it potentially less generalizable to resident teams in community hospitals. Fourth, we were not able to capture readmissions and ED visits at institutions outside the MGHPartners Healthcare System. However, given that patients were assigned at random to either team, this factor should have impacted both teams equally. Fifth, the study occurred during Massachusetts healthcare reform which requires everyone to have health insurance. This may have affected the rates of ED visits and readmission rates, especially with a shortage of primary care physicians and office visits. Finally, this intervention was not cost‐neutral. Paying for a nurse practitioner to help residents with the work of discharge and providing patients with additional services had many advantages, but this quality improvement project did not pay for itself through shorter LOS, or decreases in ED visits or readmissions.

While readmission rates and ED utilization are important patient outcomes, especially in the current healthcare climate, what determines readmissions and ED visits is likely complex and multifactorial. This study suggests that, in the nationwide effort to reduce readmissions, solely improving the discharge process for all general medical patients may not produce the hoped‐for financial savings. Improving the discharge process, however, is something valuable in its own right. Adding a DF to a resident team does improve some quality markers of the discharge process and decreases work hours for residents.

Recent studies have shown that a patient's discharge from the hospital is a vulnerable period for patient safety.14 With the reduction in length of stay (LOS) and the increase in patient acuity over the past decade, patients are discharged from acute care settings quicker and sicker, resulting in management of ongoing illness in a less‐monitored environment.5, 6 In addition, in teaching hospitals, residents are supervised by hospital‐based physicians who are rarely the primary care physician (PCP) for the residents' patients, which creates discontinuity of care.

One in 5 medical discharges is complicated by an adverse event believed, in part, to be due to poor communication between caregivers during this transition time.2 Discharge summaries, a key form of that communication, are not always done in a timely fashion and may lack key pieces of information.7, 8 For approximately 68% of patient discharges, the PCP will not have a discharge summary available for the patient's first follow‐up visit.911 In a survey of PCPs whose patients were in the hospital, only 23% reported direct communication with the hospital care team.12 This leaves PCPs unaware of pending test results or recommended follow‐up evaluations.10, 11, 13, 14 All of these factors are believed to contribute to adverse events, emergency department (ED) visits, and readmissions.

A recently published consensus statement on transitions of care by 6 major medical societies emphasizes the need for timely communication and transfer of information.15 These important processes are especially challenging to meet at academic medical centers, where discharge summaries and transition communication are done by residents in a hectic and challenging work environment, with multiple simultaneous and competing demands including outpatient clinic and required conferences.12 Residents have little formal training in how to write an effective discharge summary or how to systematically approach discharge planning. One study found higher error rates in discharge summaries written by residents compared with attending physicians.16 While the Accreditation Council for Graduate Medical Education (ACGME) limits the number of admissions per intern for both patient safety and educational reasons, the number of discharges per day is not limited despite the considerable amount of time required for appropriate discharge planning and communication.

Many interventions have been tried to improve the discharge process and reduce patient adverse events.17 Arranging early follow‐up appointments to reduce emergency department visits and readmissions has shown mixed results.13, 1820 Interventions that focus on specific populations, such as the elderly or patients with congestive heart failure, have been more successful.2123 Some interventions employed additional resources, such as a discharge form, transition coach, or discharge advocate, again with varying impact on results.18, 2427 A recent study by Jack et al. used nurse discharge advocates (DAs) to help with discharge planning and communication at an academic medical center.25 These DAs were independent of the care team, and focused on patient education and follow‐up plans, and reduced hospital reutilization in a selected population.

No studies have assessed the potential benefit of helping residents with the physician components of the discharge process. Prior studies have mainly focused on patient communication and follow‐up appointments, yet safe transitions also involve timely discharge summaries, physician‐to‐physician communication, physician‐to‐nurse communication, and medication reconciliation. Without support and time, these tasks can be very challenging for resident physicians with work‐hour limitations. We undertook a randomized, controlled trial to evaluate the impact on the discharge process of embedding a discharge facilitator in a resident medical team to help with the physician discharge process. We studied the effect for all the patients discharged from the resident team, rather than focusing on a select group or patients with a single diagnosis.

METHODS

RESULTS

Study Sample

During the 5‐month intervention (November 12, 2008 to April 14, 2009), a combined total of 999 patients were admitted to the intervention and control general medical teams. We excluded 96 patients who were not discharged but transferred to another service or intensive care units, and 24 patients who died. We also excluded 7 patients who were discharged from both teams the first day of the study, because the DF was not involved with the patients' discharge planning. That left 872 patients discharged to either home, a facility, or having left against medical advice (AMA) included in the study: 440 patients on the intervention team and 432 patients on the control team (Figure 1). Baseline patient demographic and clinical characteristics were similar across both teams with only gender being significantly different (Table 1). The mean age was 63 years (range, 1896) and the mean comorbidity score was 2.3 (range, 012). Of note, about a quarter of patients were discharged to facilities, about half were Medicare recipients, and approximately 80% had a PCP. The DF participated in the discharge process for nearly all of the intervention patients; she reported contributing approximately 50% of the content to the discharge summaries.

Figure 1

Table 1.Baseline Participant Characteristics

Characteristics	Intervention Team	Control Team
	n = 440	n = 432
Abbreviations: AMA, against medical advice; COPD, chronic obstructive pulmonary disease; PCP, primary care physician; SD, standard deviation. * P < 0.05; no other comparisons were statistically significant. Deyo Modification of the Charlson Comorbidity Index.
Mean age (SD), year	63 (18)	63 (18)
Women, n (%)*	181 (41)	207 (48)
Race, n (%)
White non‐Hispanic	267 (61)	243 (56)
Black non‐Hispanic	24 (5)	33 (8)
Hispanic	21 (5)	17 (4)
Unknown/other	128 (29)	139 (32)
Health insurance, n (%)
Medicare	213 (48)	226 (52)
Medicaid	85 (19)	81 (19)
Private	110 (25)	91 (21)
Other	32 (7)	34 (8)
PCP on admission, n (%)	370 (84)	356 (82)
Discharge disposition, n (%)
AMA	12 (3)	14 (3)
Home	305 (69)	315 (73)
Facility	123 (28)	103 (24)
Mean comorbidity index score (SD)	2.3 (2.4)	2.3 (2.4)
Diagnoses
Congestive heart failure	30 (6%)	27 (5%)
COPD/asthma	34 (7%)	47 (9%)
Cardiovascular disease	54 (11%)	50 (8%)
Alcohol/substance abuse	29 (6%)	34 (7%)
Gastrointestinal bleeds/ulcers	38 (8%)	41 (8%)
Hepatobiliary disease	30 (6%)	36 (7%)
Renal failure/kidney disease	33 (7%)	37 (7%)
Pneumonia	36 (7%)	22 (4%)
Musculoskeletal disease	26 (5%)	23 (5%)
Neurologic disease	22 (4%)	25 (5%)
Other	163 (33%)	172 (35%)

DISCUSSION

Our study embedded a nurse practitioner on a busy resident general medical team to help with all aspects of the discharge process for which physicians are responsible. Previous studies have been limited to patients with specific diagnoses, age, or disposition plans.1825 In this study, we included all general medical patients. Our intervention improved several important quality of care elements: the timeliness of completion of discharge summaries; and increased number of early follow‐up appointments, with more patients seen within 2 and 4 weeks after discharge. Patients reported better understanding of their follow‐up plans and more satisfaction with the discharge process. While not statistically significant, there was a trend towards better communication with nurses. For residents with work‐hour limitations, there was time savings with a trend towards finishing attending rounds on time and statistically significant earlier sign‐out rounds (46 minutes earlier). This intervention had no effect on patient length of stay, readmissions, or emergency department visits in the 30 days after discharge.

Despite improving many aspects of the discharge process and communication that have previously been raised as areas of concern for patient safety, there was no improvement in readmissions rates and ED utilization which are often used as the quality indicators for effective discharge planning. Similar types of interventions on general medical patients have generally also failed to show improvement in readmission rates.1820, 25 Weinberger et al. arranged follow‐up appointments within 1 week for patients discharged from a Veterans Administrative hospital; while patients were seen more often, the intervention actually increased readmission rates.20 Fitzgerald et al. had a case manager contact patients at home and encourage follow‐up, which increased follow‐up visits, but again had no effect on readmission.19 Einstadter et al. had a nurse case manager coordinate outpatient follow‐up on a resident team and also did not effect readmission rates or ED visits.18 Jack et al. in project reengineered discharge (RED) did show a significant reduction in combined hospital utilization measures. However, their study focused on a more limited patient population, and employed both a discharge advocate to arrange follow‐up and improve patient education, and a pharmacist to make postdischarge phone calls.25

So why did readmissions rates and ED visits not change in our study? It would be reasonable to think that having earlier follow‐up appointments, better and timely physician‐to‐physician communication, and a facilitator for patient questions should improve the quality of the discharge process. In a recent study, Jha et al. found there was no association between chart‐based measures of discharge quality and readmissions rates, and only a modest association for patient‐reported measures of discharge quality and readmission rates.28 The authors suggest readmission rates are driven by many factors beyond just improved discharge safety. Perhaps readmission rates are too complex a measure to use to assess discharge process improvement. For fiscal reasons, it is understandable that hospitals, insurance companies, and the Centers for Medicare and Medicaid want to reduce readmission rates and ED utilization. Jencks et al. noted the cost of readmissions in 2004 was 17.4 billion dollars.29 However, sweeping efforts to improve the discharge process for all general medical patients may not yield significant reductions in readmissions, as this study suggests. We may need to focus aggressive intervention on smaller target populations, as prior studies on focused groups suggest.2123

There are no evidence‐based studies to suggest when optimal follow‐up should occur after discharge.26 Several medical society guidelines recommend 2 weeks. More patients on the intervention team were seen within 2 weeks, but readmission rates were not affected. The University Health System Consortium recently reported that the majority of readmissions occurred within 6 days, with the average being about 2 to 3 days.30 In this study, the median days to readmit were 12 for the intervention team and 10 for the control. It is possible that even with our improved 2‐week follow‐up, this was not early enough to reduce readmissions. Follow‐up may need to be within 13 days of discharge for highly vulnerable patients, to significantly change readmission rates. Further studies focusing on this question would be helpful.

Finally, with ACGME limitation of work hours, many residency programs are looking for ways to reduce residents' workload and increase time for education. With a significant trend towards finishing attending rounds on time, it is likely that more residents on the intervention team were able to attend the noon‐time educational conferences. We speculate that this was due to fewer interruptions during rounds because the DF was available for nurses' questions. Sign‐out rounds occurred significantly earlier, possibly because of improved resident efficiency due to the DF's help with the discharge process. While residents may lose some educational experience from not performing all discharge tasks, they gain experience working in interdisciplinary teams, have increased time for education, and reduced work hours. Since the ACGME limits the number of residents per program and increasing the residency size is not an option, a DF should be considered as a possible solution to ACGME work‐hour restrictions.

This study had several limitations. First, the intervention team had 1 specific person embedded, and therefore the results of this study may have limited generalizability. Second, the limited number of residents working with the DF could have biased the intervention, as not all residents worked equally well with the DF. However, this may represent the real‐world experience on any teaching service, given variation in working styles and learning curves of residents over their training. Third, this study was done at 1 university‐affiliated urban Academic Medical Center, making it potentially less generalizable to resident teams in community hospitals. Fourth, we were not able to capture readmissions and ED visits at institutions outside the MGHPartners Healthcare System. However, given that patients were assigned at random to either team, this factor should have impacted both teams equally. Fifth, the study occurred during Massachusetts healthcare reform which requires everyone to have health insurance. This may have affected the rates of ED visits and readmission rates, especially with a shortage of primary care physicians and office visits. Finally, this intervention was not cost‐neutral. Paying for a nurse practitioner to help residents with the work of discharge and providing patients with additional services had many advantages, but this quality improvement project did not pay for itself through shorter LOS, or decreases in ED visits or readmissions.

While readmission rates and ED utilization are important patient outcomes, especially in the current healthcare climate, what determines readmissions and ED visits is likely complex and multifactorial. This study suggests that, in the nationwide effort to reduce readmissions, solely improving the discharge process for all general medical patients may not produce the hoped‐for financial savings. Improving the discharge process, however, is something valuable in its own right. Adding a DF to a resident team does improve some quality markers of the discharge process and decreases work hours for residents.

Recent studies have shown that a patient's discharge from the hospital is a vulnerable period for patient safety.14 With the reduction in length of stay (LOS) and the increase in patient acuity over the past decade, patients are discharged from acute care settings quicker and sicker, resulting in management of ongoing illness in a less‐monitored environment.5, 6 In addition, in teaching hospitals, residents are supervised by hospital‐based physicians who are rarely the primary care physician (PCP) for the residents' patients, which creates discontinuity of care.

One in 5 medical discharges is complicated by an adverse event believed, in part, to be due to poor communication between caregivers during this transition time.2 Discharge summaries, a key form of that communication, are not always done in a timely fashion and may lack key pieces of information.7, 8 For approximately 68% of patient discharges, the PCP will not have a discharge summary available for the patient's first follow‐up visit.911 In a survey of PCPs whose patients were in the hospital, only 23% reported direct communication with the hospital care team.12 This leaves PCPs unaware of pending test results or recommended follow‐up evaluations.10, 11, 13, 14 All of these factors are believed to contribute to adverse events, emergency department (ED) visits, and readmissions.

A recently published consensus statement on transitions of care by 6 major medical societies emphasizes the need for timely communication and transfer of information.15 These important processes are especially challenging to meet at academic medical centers, where discharge summaries and transition communication are done by residents in a hectic and challenging work environment, with multiple simultaneous and competing demands including outpatient clinic and required conferences.12 Residents have little formal training in how to write an effective discharge summary or how to systematically approach discharge planning. One study found higher error rates in discharge summaries written by residents compared with attending physicians.16 While the Accreditation Council for Graduate Medical Education (ACGME) limits the number of admissions per intern for both patient safety and educational reasons, the number of discharges per day is not limited despite the considerable amount of time required for appropriate discharge planning and communication.

Many interventions have been tried to improve the discharge process and reduce patient adverse events.17 Arranging early follow‐up appointments to reduce emergency department visits and readmissions has shown mixed results.13, 1820 Interventions that focus on specific populations, such as the elderly or patients with congestive heart failure, have been more successful.2123 Some interventions employed additional resources, such as a discharge form, transition coach, or discharge advocate, again with varying impact on results.18, 2427 A recent study by Jack et al. used nurse discharge advocates (DAs) to help with discharge planning and communication at an academic medical center.25 These DAs were independent of the care team, and focused on patient education and follow‐up plans, and reduced hospital reutilization in a selected population.

No studies have assessed the potential benefit of helping residents with the physician components of the discharge process. Prior studies have mainly focused on patient communication and follow‐up appointments, yet safe transitions also involve timely discharge summaries, physician‐to‐physician communication, physician‐to‐nurse communication, and medication reconciliation. Without support and time, these tasks can be very challenging for resident physicians with work‐hour limitations. We undertook a randomized, controlled trial to evaluate the impact on the discharge process of embedding a discharge facilitator in a resident medical team to help with the physician discharge process. We studied the effect for all the patients discharged from the resident team, rather than focusing on a select group or patients with a single diagnosis.

METHODS

RESULTS

Study Sample

During the 5‐month intervention (November 12, 2008 to April 14, 2009), a combined total of 999 patients were admitted to the intervention and control general medical teams. We excluded 96 patients who were not discharged but transferred to another service or intensive care units, and 24 patients who died. We also excluded 7 patients who were discharged from both teams the first day of the study, because the DF was not involved with the patients' discharge planning. That left 872 patients discharged to either home, a facility, or having left against medical advice (AMA) included in the study: 440 patients on the intervention team and 432 patients on the control team (Figure 1). Baseline patient demographic and clinical characteristics were similar across both teams with only gender being significantly different (Table 1). The mean age was 63 years (range, 1896) and the mean comorbidity score was 2.3 (range, 012). Of note, about a quarter of patients were discharged to facilities, about half were Medicare recipients, and approximately 80% had a PCP. The DF participated in the discharge process for nearly all of the intervention patients; she reported contributing approximately 50% of the content to the discharge summaries.

Figure 1

Table 1.Baseline Participant Characteristics

Characteristics	Intervention Team	Control Team
	n = 440	n = 432
Abbreviations: AMA, against medical advice; COPD, chronic obstructive pulmonary disease; PCP, primary care physician; SD, standard deviation. * P < 0.05; no other comparisons were statistically significant. Deyo Modification of the Charlson Comorbidity Index.
Mean age (SD), year	63 (18)	63 (18)
Women, n (%)*	181 (41)	207 (48)
Race, n (%)
White non‐Hispanic	267 (61)	243 (56)
Black non‐Hispanic	24 (5)	33 (8)
Hispanic	21 (5)	17 (4)
Unknown/other	128 (29)	139 (32)
Health insurance, n (%)
Medicare	213 (48)	226 (52)
Medicaid	85 (19)	81 (19)
Private	110 (25)	91 (21)
Other	32 (7)	34 (8)
PCP on admission, n (%)	370 (84)	356 (82)
Discharge disposition, n (%)
AMA	12 (3)	14 (3)
Home	305 (69)	315 (73)
Facility	123 (28)	103 (24)
Mean comorbidity index score (SD)	2.3 (2.4)	2.3 (2.4)
Diagnoses
Congestive heart failure	30 (6%)	27 (5%)
COPD/asthma	34 (7%)	47 (9%)
Cardiovascular disease	54 (11%)	50 (8%)
Alcohol/substance abuse	29 (6%)	34 (7%)
Gastrointestinal bleeds/ulcers	38 (8%)	41 (8%)
Hepatobiliary disease	30 (6%)	36 (7%)
Renal failure/kidney disease	33 (7%)	37 (7%)
Pneumonia	36 (7%)	22 (4%)
Musculoskeletal disease	26 (5%)	23 (5%)
Neurologic disease	22 (4%)	25 (5%)
Other	163 (33%)	172 (35%)

DISCUSSION

Our study embedded a nurse practitioner on a busy resident general medical team to help with all aspects of the discharge process for which physicians are responsible. Previous studies have been limited to patients with specific diagnoses, age, or disposition plans.1825 In this study, we included all general medical patients. Our intervention improved several important quality of care elements: the timeliness of completion of discharge summaries; and increased number of early follow‐up appointments, with more patients seen within 2 and 4 weeks after discharge. Patients reported better understanding of their follow‐up plans and more satisfaction with the discharge process. While not statistically significant, there was a trend towards better communication with nurses. For residents with work‐hour limitations, there was time savings with a trend towards finishing attending rounds on time and statistically significant earlier sign‐out rounds (46 minutes earlier). This intervention had no effect on patient length of stay, readmissions, or emergency department visits in the 30 days after discharge.

Despite improving many aspects of the discharge process and communication that have previously been raised as areas of concern for patient safety, there was no improvement in readmissions rates and ED utilization which are often used as the quality indicators for effective discharge planning. Similar types of interventions on general medical patients have generally also failed to show improvement in readmission rates.1820, 25 Weinberger et al. arranged follow‐up appointments within 1 week for patients discharged from a Veterans Administrative hospital; while patients were seen more often, the intervention actually increased readmission rates.20 Fitzgerald et al. had a case manager contact patients at home and encourage follow‐up, which increased follow‐up visits, but again had no effect on readmission.19 Einstadter et al. had a nurse case manager coordinate outpatient follow‐up on a resident team and also did not effect readmission rates or ED visits.18 Jack et al. in project reengineered discharge (RED) did show a significant reduction in combined hospital utilization measures. However, their study focused on a more limited patient population, and employed both a discharge advocate to arrange follow‐up and improve patient education, and a pharmacist to make postdischarge phone calls.25

So why did readmissions rates and ED visits not change in our study? It would be reasonable to think that having earlier follow‐up appointments, better and timely physician‐to‐physician communication, and a facilitator for patient questions should improve the quality of the discharge process. In a recent study, Jha et al. found there was no association between chart‐based measures of discharge quality and readmissions rates, and only a modest association for patient‐reported measures of discharge quality and readmission rates.28 The authors suggest readmission rates are driven by many factors beyond just improved discharge safety. Perhaps readmission rates are too complex a measure to use to assess discharge process improvement. For fiscal reasons, it is understandable that hospitals, insurance companies, and the Centers for Medicare and Medicaid want to reduce readmission rates and ED utilization. Jencks et al. noted the cost of readmissions in 2004 was 17.4 billion dollars.29 However, sweeping efforts to improve the discharge process for all general medical patients may not yield significant reductions in readmissions, as this study suggests. We may need to focus aggressive intervention on smaller target populations, as prior studies on focused groups suggest.2123

There are no evidence‐based studies to suggest when optimal follow‐up should occur after discharge.26 Several medical society guidelines recommend 2 weeks. More patients on the intervention team were seen within 2 weeks, but readmission rates were not affected. The University Health System Consortium recently reported that the majority of readmissions occurred within 6 days, with the average being about 2 to 3 days.30 In this study, the median days to readmit were 12 for the intervention team and 10 for the control. It is possible that even with our improved 2‐week follow‐up, this was not early enough to reduce readmissions. Follow‐up may need to be within 13 days of discharge for highly vulnerable patients, to significantly change readmission rates. Further studies focusing on this question would be helpful.

Finally, with ACGME limitation of work hours, many residency programs are looking for ways to reduce residents' workload and increase time for education. With a significant trend towards finishing attending rounds on time, it is likely that more residents on the intervention team were able to attend the noon‐time educational conferences. We speculate that this was due to fewer interruptions during rounds because the DF was available for nurses' questions. Sign‐out rounds occurred significantly earlier, possibly because of improved resident efficiency due to the DF's help with the discharge process. While residents may lose some educational experience from not performing all discharge tasks, they gain experience working in interdisciplinary teams, have increased time for education, and reduced work hours. Since the ACGME limits the number of residents per program and increasing the residency size is not an option, a DF should be considered as a possible solution to ACGME work‐hour restrictions.

This study had several limitations. First, the intervention team had 1 specific person embedded, and therefore the results of this study may have limited generalizability. Second, the limited number of residents working with the DF could have biased the intervention, as not all residents worked equally well with the DF. However, this may represent the real‐world experience on any teaching service, given variation in working styles and learning curves of residents over their training. Third, this study was done at 1 university‐affiliated urban Academic Medical Center, making it potentially less generalizable to resident teams in community hospitals. Fourth, we were not able to capture readmissions and ED visits at institutions outside the MGHPartners Healthcare System. However, given that patients were assigned at random to either team, this factor should have impacted both teams equally. Fifth, the study occurred during Massachusetts healthcare reform which requires everyone to have health insurance. This may have affected the rates of ED visits and readmission rates, especially with a shortage of primary care physicians and office visits. Finally, this intervention was not cost‐neutral. Paying for a nurse practitioner to help residents with the work of discharge and providing patients with additional services had many advantages, but this quality improvement project did not pay for itself through shorter LOS, or decreases in ED visits or readmissions.

While readmission rates and ED utilization are important patient outcomes, especially in the current healthcare climate, what determines readmissions and ED visits is likely complex and multifactorial. This study suggests that, in the nationwide effort to reduce readmissions, solely improving the discharge process for all general medical patients may not produce the hoped‐for financial savings. Improving the discharge process, however, is something valuable in its own right. Adding a DF to a resident team does improve some quality markers of the discharge process and decreases work hours for residents.

There is growing demand for safe and effective procedural sedation in pediatric facilities around the country. Multiple articles published in the last 10 years have addressed the shortage of pediatric anesthesiologists to meet this rising need.14 In 2005, Lalwani and Michel published results of a survey of North American children's hospitals that showed 87% of institutions reporting barriers to development of a pediatric sedation service, and that the most common barrier was shortage of anesthesiologists.5 In our hospital, the wait time for an outpatient sedated pediatric magnetic resonance imaging (MRI) grew to as long as 6 weeks. Many institutions have had to look for unique ways to solve this problem. Pediatric sedation programs have been developed which utilize intensivists, emergency medicine physicians, nurse anesthetists, or trained sedation nurses to provide safe pediatric sedation.611 Each of these programs has grown from the particular strengths and needs at each institution. In many institutions, hospitalists are the best candidates to meet this need because of their knowledge of patient needs and safety. They are accessible and receptive to obtaining additional training and, therefore, are a natural fit to provide this service.

As more non‐anesthesiologists are called upon to meet this growing need, the principles and practice of safe sedation must be followed. The Pediatric Sedation Research Consortium, a collaborative group of 37 locations that provide data on pediatric sedations, has published their findings on the safety of pediatric sedation/anesthesia outside of the operating room (OR) performed by anesthesiologists and non‐anesthesiologists.1213 This data has been very valuable, given that studies from single institutions will often lack the power to investigate the rare, but potentially devastating, adverse events which can occur in pediatric sedation/anesthesia.

Despite the widespread use of propofol by non‐anesthesiologists, the lack of substantial data regarding safety by these providers makes its use controversial. A search of the literature finds only 1 prior article that describes the use of propofol by general pediatricians. This was sedation for endoscopy, and the sedation was performed by specially trained pediatric residents in Italy.14 A recently published study from the Consortium regarding the use of propofol showed that the majority of propofol sedations were being performed by intensivists (49%), emergency medicine physicians (36%), or anesthesiologists (10%). General pediatricians or hospitalists performed just 2% of the cases in this series.13

In 2003, a large group of experienced pediatric hospitalists were already providing sedation in the Emergency Unit (EU) and Center for After‐hours Referrals for Emergency Services (CARES) at St Louis Children's Hospital. The Division of Hospital Medicine was approached to meet the demand for increased sedation services at our institution. The Division of Pediatric Anesthesia agreed to provide our physicians with the appropriate training to provide safe, effective, and efficient sedations for painful and non‐painful procedures outside of the OR. One of our sedation units, the Ambulatory Procedure Center (APC), has been described in detail in a prior publication by Strauser Sterni et al.15 Here, we will describe the operations of our sedation services, and specifically describe the training required for our hospitalists to provide sedation services.

METHODS

St Louis Children's Hospital is a 250‐bed tertiary‐care teaching hospital affiliated with Washington University School of Medicine. The Division of Hospitalist Medicine is today comprised of 43 physicians who provide care in the EU, CARES, inpatient units, Transport, and Sedation Services at St Louis Children's Hospital. Our division also provides pediatric care in the EU, inpatient units, newborn nursery, and labor and delivery at 3 affiliated hospitals. In 2003, we developed a dedicated program in our division to meet our institutional need for sedation, with training and oversight by the Division of Pediatric Anesthesia. We developed a structured 3‐tiered program of sedation providers to manage all of our sedation needs. We then designed a training program for these 3 tiers of sedation providers. The 3‐tired program is based on the level of sedation training of each member.

Current American Academy of Pediatrics (AAP) guidelines state:

The practitioner responsible for the treatment of the patient and/or the administration of drugs for sedation must be competent to use such techniques, provide the level of monitoring provided in these guidelines, and manage complications of these techniques (ie, to be able to rescue the patient). Because the level of intended sedation may be exceeded, the practitioner must be sufficiently skilled to provide rescue should the child progress to a level of deep sedation. The practitioner must be trained in, and capable of providing, at the minimum, bag‐valve‐mask ventilation to be able to oxygenate a child who develops airway obstruction or apnea. Training in, and maintenance of, advanced pediatric airway skills is required; regular skills reinforcement is strongly encouraged.16

Our first‐tier sedation providers are junior faculty who provide sedation in the EU and CARES, and in the EU at our community hospitals. The first tier completes sedation training as part of overall hospitalist orientation in order to provide this service. The second tier goes through an advanced sedation provider program to provide sedation in the APC, Pediatric Acute Wound Service (PAWS), inpatient units, and After Hours sedation call, as well as the locations from the first tier. The third tier completes a more complex advanced sedation training program, specifically using propofol, and provides propofol sedation in the APC only, as well as providing sedation in all of the units from the first and second tiers. The responsibilities of the hospitalist providing sedation are described in detail by tier below, including the specific training requirements necessary for each tier (Table 1).

RESULTS

Utilizing this design and training method, we have developed a successful pediatric hospitalist sedation program. Based on fiscal year 2009 billing data, the Division of Hospital Medicine performed 2471 sedations. There were 2069 sedations performed in APC or PAWS; of those, 1017 were performed on inpatients and 1052 were performed on outpatients. Hospitalists performed 402 sedations on patients in the EU. The EU numbers are likely much larger given that, for over half the year, billing data was not collected from the EU. Unfortunately, we did not have billing data regarding night and weekend sedations, but our best estimate is 1 to 2 per week. The wait time for an outpatient sedated pediatric MRI has gone from 6 weeks to 2 days or less. As of July 2010, we have trained 90 providers at Tier One, 32 at Tier Two, and 11 at Tier Three. We currently have 43 hospitalists providing Tier‐One sedation, 18 providing Tier‐Two, and 6 providing Tier‐Three. Average cumulative hospitalist experience is 1 year for Tier One, 5 years for Tier Two, and 10 years for Tier Three.

DISCUSSION

We believe this is the first description of a pediatric hospitalist training program for a sedation service. However, it is clear that many other pediatric hospitalists are performing sedation and developing similar training programs. When starting a program such as this, there are many things to consider. First, patient volume/demand must allow for each hospitalist to perform sedations on a regular basis, both for training and Maintenance of Certification. Second, Anesthesia must be willing to provide training and oversight. Third, the hospital or university must be willing to support the cost associated with the training period. Finally, negotiating with third party payers for reimbursement is critical to financial sustainability.

The success of our program hinged upon the ability to develop a strong and collaborative relationship with Anesthesiology. Many factors played into making this relationship work. Initially, Anesthesia approached us to help them meet an unmet clinical need. Because of this, we were viewed as helpful and as problem solvers, rather than as a threat. Additionally, each division had a sedation service champion that pushed for the development of a hospitalist sedation service. Lastly, regular meetings with Anesthesia, and the intense training program itself, helped to develop a sense of collegiality between the divisions.

We have faced many challenges and learned many lessons while developing this program. There is a significant cost to training sedation providers; 47 hospitalists trained to provide Tier‐One sedation have left the program. Of those, 16 hospitalists completed training for Tier‐Two sedation, and 5 completed Tier Three. The Tier‐Two training described earlier requires approximately 50 hours of dedicated time away from other hospitalist duties, while Tier Three requires an additional 125 hours. The majority of our turnover occurred in the first few years of the program. From a financial perspective, we have had to reserve sedation training beyond Tier One to hospitalists who are able to demonstrate evidence of a long‐term commitment to our division. Every person providing Tier‐Three sedation has been with the division over 6 years. From a broader perspective, we are providing hospitalists with an important and useful skill that may enhance their careerssafe and effective sedation.

Balancing the volume of cases is another issue to consider. Our goal is to provide safe and timely sedation, therefore we need to have enough scheduled cases to maintain competency and financial viability, but we must also leave adequate flexibility in the schedule for urgent cases.

In addition to the operating room training, we are beginning to incorporate pediatric simulation as an adjunct to our training. We have designed simulation scenarios which address issues of obstruction, apnea, hypotension, bronchospasm, and aspiration. However, OR training remains a mandatory requirement for sedation training and, at times, can be challenging to schedule.

We complete a post‐sedation assessment on all patients; we are currently performing a chart review of over 1600 patients sedated with propofol, to look at the rate of planned and unplanned interventions. We believe this data will show that our training has been successful, and that with analysis of our Quality Improvement data, we can improve the safety and efficacy of our sedation program even further.

CONCLUSIONS

A pediatric hospitalist sedation service, with proper training and oversight, can successfully augment sedation services provided by anesthesiologists. As has been stated in prior publications, a defined system, and the use of a dedicated well‐trained team makes a sedation service a success.1719 A collegial and mutually respectful relationship between Anesthesia and non‐Anesthesia sedation providers is critical in developing and maintaining a successful sedation program.

There is growing demand for safe and effective procedural sedation in pediatric facilities around the country. Multiple articles published in the last 10 years have addressed the shortage of pediatric anesthesiologists to meet this rising need.14 In 2005, Lalwani and Michel published results of a survey of North American children's hospitals that showed 87% of institutions reporting barriers to development of a pediatric sedation service, and that the most common barrier was shortage of anesthesiologists.5 In our hospital, the wait time for an outpatient sedated pediatric magnetic resonance imaging (MRI) grew to as long as 6 weeks. Many institutions have had to look for unique ways to solve this problem. Pediatric sedation programs have been developed which utilize intensivists, emergency medicine physicians, nurse anesthetists, or trained sedation nurses to provide safe pediatric sedation.611 Each of these programs has grown from the particular strengths and needs at each institution. In many institutions, hospitalists are the best candidates to meet this need because of their knowledge of patient needs and safety. They are accessible and receptive to obtaining additional training and, therefore, are a natural fit to provide this service.

As more non‐anesthesiologists are called upon to meet this growing need, the principles and practice of safe sedation must be followed. The Pediatric Sedation Research Consortium, a collaborative group of 37 locations that provide data on pediatric sedations, has published their findings on the safety of pediatric sedation/anesthesia outside of the operating room (OR) performed by anesthesiologists and non‐anesthesiologists.1213 This data has been very valuable, given that studies from single institutions will often lack the power to investigate the rare, but potentially devastating, adverse events which can occur in pediatric sedation/anesthesia.

Despite the widespread use of propofol by non‐anesthesiologists, the lack of substantial data regarding safety by these providers makes its use controversial. A search of the literature finds only 1 prior article that describes the use of propofol by general pediatricians. This was sedation for endoscopy, and the sedation was performed by specially trained pediatric residents in Italy.14 A recently published study from the Consortium regarding the use of propofol showed that the majority of propofol sedations were being performed by intensivists (49%), emergency medicine physicians (36%), or anesthesiologists (10%). General pediatricians or hospitalists performed just 2% of the cases in this series.13

In 2003, a large group of experienced pediatric hospitalists were already providing sedation in the Emergency Unit (EU) and Center for After‐hours Referrals for Emergency Services (CARES) at St Louis Children's Hospital. The Division of Hospital Medicine was approached to meet the demand for increased sedation services at our institution. The Division of Pediatric Anesthesia agreed to provide our physicians with the appropriate training to provide safe, effective, and efficient sedations for painful and non‐painful procedures outside of the OR. One of our sedation units, the Ambulatory Procedure Center (APC), has been described in detail in a prior publication by Strauser Sterni et al.15 Here, we will describe the operations of our sedation services, and specifically describe the training required for our hospitalists to provide sedation services.

METHODS

St Louis Children's Hospital is a 250‐bed tertiary‐care teaching hospital affiliated with Washington University School of Medicine. The Division of Hospitalist Medicine is today comprised of 43 physicians who provide care in the EU, CARES, inpatient units, Transport, and Sedation Services at St Louis Children's Hospital. Our division also provides pediatric care in the EU, inpatient units, newborn nursery, and labor and delivery at 3 affiliated hospitals. In 2003, we developed a dedicated program in our division to meet our institutional need for sedation, with training and oversight by the Division of Pediatric Anesthesia. We developed a structured 3‐tiered program of sedation providers to manage all of our sedation needs. We then designed a training program for these 3 tiers of sedation providers. The 3‐tired program is based on the level of sedation training of each member.

Current American Academy of Pediatrics (AAP) guidelines state:

The practitioner responsible for the treatment of the patient and/or the administration of drugs for sedation must be competent to use such techniques, provide the level of monitoring provided in these guidelines, and manage complications of these techniques (ie, to be able to rescue the patient). Because the level of intended sedation may be exceeded, the practitioner must be sufficiently skilled to provide rescue should the child progress to a level of deep sedation. The practitioner must be trained in, and capable of providing, at the minimum, bag‐valve‐mask ventilation to be able to oxygenate a child who develops airway obstruction or apnea. Training in, and maintenance of, advanced pediatric airway skills is required; regular skills reinforcement is strongly encouraged.16

Our first‐tier sedation providers are junior faculty who provide sedation in the EU and CARES, and in the EU at our community hospitals. The first tier completes sedation training as part of overall hospitalist orientation in order to provide this service. The second tier goes through an advanced sedation provider program to provide sedation in the APC, Pediatric Acute Wound Service (PAWS), inpatient units, and After Hours sedation call, as well as the locations from the first tier. The third tier completes a more complex advanced sedation training program, specifically using propofol, and provides propofol sedation in the APC only, as well as providing sedation in all of the units from the first and second tiers. The responsibilities of the hospitalist providing sedation are described in detail by tier below, including the specific training requirements necessary for each tier (Table 1).

RESULTS

Utilizing this design and training method, we have developed a successful pediatric hospitalist sedation program. Based on fiscal year 2009 billing data, the Division of Hospital Medicine performed 2471 sedations. There were 2069 sedations performed in APC or PAWS; of those, 1017 were performed on inpatients and 1052 were performed on outpatients. Hospitalists performed 402 sedations on patients in the EU. The EU numbers are likely much larger given that, for over half the year, billing data was not collected from the EU. Unfortunately, we did not have billing data regarding night and weekend sedations, but our best estimate is 1 to 2 per week. The wait time for an outpatient sedated pediatric MRI has gone from 6 weeks to 2 days or less. As of July 2010, we have trained 90 providers at Tier One, 32 at Tier Two, and 11 at Tier Three. We currently have 43 hospitalists providing Tier‐One sedation, 18 providing Tier‐Two, and 6 providing Tier‐Three. Average cumulative hospitalist experience is 1 year for Tier One, 5 years for Tier Two, and 10 years for Tier Three.

DISCUSSION

We believe this is the first description of a pediatric hospitalist training program for a sedation service. However, it is clear that many other pediatric hospitalists are performing sedation and developing similar training programs. When starting a program such as this, there are many things to consider. First, patient volume/demand must allow for each hospitalist to perform sedations on a regular basis, both for training and Maintenance of Certification. Second, Anesthesia must be willing to provide training and oversight. Third, the hospital or university must be willing to support the cost associated with the training period. Finally, negotiating with third party payers for reimbursement is critical to financial sustainability.

The success of our program hinged upon the ability to develop a strong and collaborative relationship with Anesthesiology. Many factors played into making this relationship work. Initially, Anesthesia approached us to help them meet an unmet clinical need. Because of this, we were viewed as helpful and as problem solvers, rather than as a threat. Additionally, each division had a sedation service champion that pushed for the development of a hospitalist sedation service. Lastly, regular meetings with Anesthesia, and the intense training program itself, helped to develop a sense of collegiality between the divisions.

We have faced many challenges and learned many lessons while developing this program. There is a significant cost to training sedation providers; 47 hospitalists trained to provide Tier‐One sedation have left the program. Of those, 16 hospitalists completed training for Tier‐Two sedation, and 5 completed Tier Three. The Tier‐Two training described earlier requires approximately 50 hours of dedicated time away from other hospitalist duties, while Tier Three requires an additional 125 hours. The majority of our turnover occurred in the first few years of the program. From a financial perspective, we have had to reserve sedation training beyond Tier One to hospitalists who are able to demonstrate evidence of a long‐term commitment to our division. Every person providing Tier‐Three sedation has been with the division over 6 years. From a broader perspective, we are providing hospitalists with an important and useful skill that may enhance their careerssafe and effective sedation.

Balancing the volume of cases is another issue to consider. Our goal is to provide safe and timely sedation, therefore we need to have enough scheduled cases to maintain competency and financial viability, but we must also leave adequate flexibility in the schedule for urgent cases.

In addition to the operating room training, we are beginning to incorporate pediatric simulation as an adjunct to our training. We have designed simulation scenarios which address issues of obstruction, apnea, hypotension, bronchospasm, and aspiration. However, OR training remains a mandatory requirement for sedation training and, at times, can be challenging to schedule.

We complete a post‐sedation assessment on all patients; we are currently performing a chart review of over 1600 patients sedated with propofol, to look at the rate of planned and unplanned interventions. We believe this data will show that our training has been successful, and that with analysis of our Quality Improvement data, we can improve the safety and efficacy of our sedation program even further.

CONCLUSIONS

A pediatric hospitalist sedation service, with proper training and oversight, can successfully augment sedation services provided by anesthesiologists. As has been stated in prior publications, a defined system, and the use of a dedicated well‐trained team makes a sedation service a success.1719 A collegial and mutually respectful relationship between Anesthesia and non‐Anesthesia sedation providers is critical in developing and maintaining a successful sedation program.

There is growing demand for safe and effective procedural sedation in pediatric facilities around the country. Multiple articles published in the last 10 years have addressed the shortage of pediatric anesthesiologists to meet this rising need.14 In 2005, Lalwani and Michel published results of a survey of North American children's hospitals that showed 87% of institutions reporting barriers to development of a pediatric sedation service, and that the most common barrier was shortage of anesthesiologists.5 In our hospital, the wait time for an outpatient sedated pediatric magnetic resonance imaging (MRI) grew to as long as 6 weeks. Many institutions have had to look for unique ways to solve this problem. Pediatric sedation programs have been developed which utilize intensivists, emergency medicine physicians, nurse anesthetists, or trained sedation nurses to provide safe pediatric sedation.611 Each of these programs has grown from the particular strengths and needs at each institution. In many institutions, hospitalists are the best candidates to meet this need because of their knowledge of patient needs and safety. They are accessible and receptive to obtaining additional training and, therefore, are a natural fit to provide this service.

As more non‐anesthesiologists are called upon to meet this growing need, the principles and practice of safe sedation must be followed. The Pediatric Sedation Research Consortium, a collaborative group of 37 locations that provide data on pediatric sedations, has published their findings on the safety of pediatric sedation/anesthesia outside of the operating room (OR) performed by anesthesiologists and non‐anesthesiologists.1213 This data has been very valuable, given that studies from single institutions will often lack the power to investigate the rare, but potentially devastating, adverse events which can occur in pediatric sedation/anesthesia.

Despite the widespread use of propofol by non‐anesthesiologists, the lack of substantial data regarding safety by these providers makes its use controversial. A search of the literature finds only 1 prior article that describes the use of propofol by general pediatricians. This was sedation for endoscopy, and the sedation was performed by specially trained pediatric residents in Italy.14 A recently published study from the Consortium regarding the use of propofol showed that the majority of propofol sedations were being performed by intensivists (49%), emergency medicine physicians (36%), or anesthesiologists (10%). General pediatricians or hospitalists performed just 2% of the cases in this series.13

In 2003, a large group of experienced pediatric hospitalists were already providing sedation in the Emergency Unit (EU) and Center for After‐hours Referrals for Emergency Services (CARES) at St Louis Children's Hospital. The Division of Hospital Medicine was approached to meet the demand for increased sedation services at our institution. The Division of Pediatric Anesthesia agreed to provide our physicians with the appropriate training to provide safe, effective, and efficient sedations for painful and non‐painful procedures outside of the OR. One of our sedation units, the Ambulatory Procedure Center (APC), has been described in detail in a prior publication by Strauser Sterni et al.15 Here, we will describe the operations of our sedation services, and specifically describe the training required for our hospitalists to provide sedation services.

METHODS

St Louis Children's Hospital is a 250‐bed tertiary‐care teaching hospital affiliated with Washington University School of Medicine. The Division of Hospitalist Medicine is today comprised of 43 physicians who provide care in the EU, CARES, inpatient units, Transport, and Sedation Services at St Louis Children's Hospital. Our division also provides pediatric care in the EU, inpatient units, newborn nursery, and labor and delivery at 3 affiliated hospitals. In 2003, we developed a dedicated program in our division to meet our institutional need for sedation, with training and oversight by the Division of Pediatric Anesthesia. We developed a structured 3‐tiered program of sedation providers to manage all of our sedation needs. We then designed a training program for these 3 tiers of sedation providers. The 3‐tired program is based on the level of sedation training of each member.

Current American Academy of Pediatrics (AAP) guidelines state:

The practitioner responsible for the treatment of the patient and/or the administration of drugs for sedation must be competent to use such techniques, provide the level of monitoring provided in these guidelines, and manage complications of these techniques (ie, to be able to rescue the patient). Because the level of intended sedation may be exceeded, the practitioner must be sufficiently skilled to provide rescue should the child progress to a level of deep sedation. The practitioner must be trained in, and capable of providing, at the minimum, bag‐valve‐mask ventilation to be able to oxygenate a child who develops airway obstruction or apnea. Training in, and maintenance of, advanced pediatric airway skills is required; regular skills reinforcement is strongly encouraged.16

Our first‐tier sedation providers are junior faculty who provide sedation in the EU and CARES, and in the EU at our community hospitals. The first tier completes sedation training as part of overall hospitalist orientation in order to provide this service. The second tier goes through an advanced sedation provider program to provide sedation in the APC, Pediatric Acute Wound Service (PAWS), inpatient units, and After Hours sedation call, as well as the locations from the first tier. The third tier completes a more complex advanced sedation training program, specifically using propofol, and provides propofol sedation in the APC only, as well as providing sedation in all of the units from the first and second tiers. The responsibilities of the hospitalist providing sedation are described in detail by tier below, including the specific training requirements necessary for each tier (Table 1).

RESULTS

Utilizing this design and training method, we have developed a successful pediatric hospitalist sedation program. Based on fiscal year 2009 billing data, the Division of Hospital Medicine performed 2471 sedations. There were 2069 sedations performed in APC or PAWS; of those, 1017 were performed on inpatients and 1052 were performed on outpatients. Hospitalists performed 402 sedations on patients in the EU. The EU numbers are likely much larger given that, for over half the year, billing data was not collected from the EU. Unfortunately, we did not have billing data regarding night and weekend sedations, but our best estimate is 1 to 2 per week. The wait time for an outpatient sedated pediatric MRI has gone from 6 weeks to 2 days or less. As of July 2010, we have trained 90 providers at Tier One, 32 at Tier Two, and 11 at Tier Three. We currently have 43 hospitalists providing Tier‐One sedation, 18 providing Tier‐Two, and 6 providing Tier‐Three. Average cumulative hospitalist experience is 1 year for Tier One, 5 years for Tier Two, and 10 years for Tier Three.

DISCUSSION

We believe this is the first description of a pediatric hospitalist training program for a sedation service. However, it is clear that many other pediatric hospitalists are performing sedation and developing similar training programs. When starting a program such as this, there are many things to consider. First, patient volume/demand must allow for each hospitalist to perform sedations on a regular basis, both for training and Maintenance of Certification. Second, Anesthesia must be willing to provide training and oversight. Third, the hospital or university must be willing to support the cost associated with the training period. Finally, negotiating with third party payers for reimbursement is critical to financial sustainability.

The success of our program hinged upon the ability to develop a strong and collaborative relationship with Anesthesiology. Many factors played into making this relationship work. Initially, Anesthesia approached us to help them meet an unmet clinical need. Because of this, we were viewed as helpful and as problem solvers, rather than as a threat. Additionally, each division had a sedation service champion that pushed for the development of a hospitalist sedation service. Lastly, regular meetings with Anesthesia, and the intense training program itself, helped to develop a sense of collegiality between the divisions.

We have faced many challenges and learned many lessons while developing this program. There is a significant cost to training sedation providers; 47 hospitalists trained to provide Tier‐One sedation have left the program. Of those, 16 hospitalists completed training for Tier‐Two sedation, and 5 completed Tier Three. The Tier‐Two training described earlier requires approximately 50 hours of dedicated time away from other hospitalist duties, while Tier Three requires an additional 125 hours. The majority of our turnover occurred in the first few years of the program. From a financial perspective, we have had to reserve sedation training beyond Tier One to hospitalists who are able to demonstrate evidence of a long‐term commitment to our division. Every person providing Tier‐Three sedation has been with the division over 6 years. From a broader perspective, we are providing hospitalists with an important and useful skill that may enhance their careerssafe and effective sedation.

Balancing the volume of cases is another issue to consider. Our goal is to provide safe and timely sedation, therefore we need to have enough scheduled cases to maintain competency and financial viability, but we must also leave adequate flexibility in the schedule for urgent cases.

In addition to the operating room training, we are beginning to incorporate pediatric simulation as an adjunct to our training. We have designed simulation scenarios which address issues of obstruction, apnea, hypotension, bronchospasm, and aspiration. However, OR training remains a mandatory requirement for sedation training and, at times, can be challenging to schedule.

We complete a post‐sedation assessment on all patients; we are currently performing a chart review of over 1600 patients sedated with propofol, to look at the rate of planned and unplanned interventions. We believe this data will show that our training has been successful, and that with analysis of our Quality Improvement data, we can improve the safety and efficacy of our sedation program even further.

CONCLUSIONS

A pediatric hospitalist sedation service, with proper training and oversight, can successfully augment sedation services provided by anesthesiologists. As has been stated in prior publications, a defined system, and the use of a dedicated well‐trained team makes a sedation service a success.1719 A collegial and mutually respectful relationship between Anesthesia and non‐Anesthesia sedation providers is critical in developing and maintaining a successful sedation program.

Teamwork is important in providing high‐quality hospital care. Despite tremendous efforts in the 10 years since publication of the Institute of Medicine's To Err is Human report,1 hospitalized patients remain at risk for adverse events (AEs).2 Although many AEs are not preventable, a large portion of those which are identified as preventable can be attributed to communication and teamwork failures.35 A Joint Commission study indicated that communication failures were the root cause for two‐thirds of the 3548 sentinel events reported from 1995 to 2005.6 Another study, involving interviews of resident physicians about recent medical mishaps, found that communication failures contributed to 91% of the AEs they reported.5

Teamwork also plays an important role in other aspects of hospital care delivery. Patients' ratings of nurse‐physician coordination correlate with their overall perception of the quality of care received.7, 8 A study of Veterans Health Administration (VHA) hospitals found that teamwork culture was significantly and positively associated with overall patient satisfaction.9 Another VHA study found that hospitals with higher teamwork culture ratings had lower nurse resignations rates.10 Furthermore, poor teamwork within hospitals may have an adverse effect on financial performance, as a result of inefficiencies in physician and nurse workflow.11

Some organizations are capable of operating in complex, hazardous environments while maintaining exceptional performance over long periods of time. These high reliability organizations (HRO) include aircraft carriers, air traffic control systems, and nuclear power plants, and are characterized by their preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise.12, 13 Preoccupation with failure is manifested by an organization's efforts to avoid complacency and persist in the search for additional risks. Reluctance to simplify interpretations is exemplified by an interest in pursuing a deep understanding of the issues that arise. Sensitivity to operations is the close attention paid to input from front‐line personnel and processes. Commitment to resilience relates to an organization's ability to contain errors once they occur and mitigate harm. Deference to expertise describes the practice of having authority migrate to the people with the most expertise, regardless of rank. Collectively, these qualities produce a state of mindfulness, allowing teams to anticipate and become aware of unexpected events, yet also quickly contain and learn from them. Recent publications have highlighted the need for hospitals to learn from HROs and the teams within them.14, 15

Recognizing the importance of teamwork in hospitals, senior leadership from the American College of Physician Executives (ACPE), the American Hospital Association (AHA), the American Organization of Nurse Executives (AONE), and the Society of Hospital Medicine (SHM) established the High Performance Teams and the Hospital of the Future project. This collaborative learning effort aims to redesign care delivery to provide optimal value to hospitalized patients. As an initial step, the High Performance Teams and the Hospital of the Future project team completed a literature review related to teamwork in hospitals. The purpose of this report is to summarize the current understanding of teamwork, describe interventions designed to improve teamwork, and make practical recommendations for hospitals to assess and improve teamwork‐related performance. We approach teamwork from the hospitalized patient's perspective, and restrict our discussion to interactions occurring among healthcare professionals within the hospital. We recognize the importance of teamwork at all points in the continuum of patient care. Highly functional inpatient teams should be integrated into an overall system of coordinated and collaborative care.

TEAMWORK: DEFINITION AND CONSTRUCTS

Physicians, nurses, and other healthcare professionals spend a great deal of their time on communication and coordination of care activities.1618 In spite of this and the patient safety concerns previously noted, interpersonal communication skills and teamwork have been historically underemphasized in professional training.1922 A team is defined as 2 or more individuals with specified roles interacting adaptively, interdependently, and dynamically toward a shared and common goal.23 Elements of effective teamwork have been identified through research conducted in aviation, the military, and more recently, healthcare. Salas and colleagues have synthesized this research into 5 core components: team leadership, mutual performance monitoring, backup behavior, adaptability, and team orientation (see Table 1).23 Additionally, 3 supporting and coordinating mechanisms are essential for effective teamwork: shared mental model, closed‐loop communication, and mutual trust (see Table 1).23 High‐performing teams use these elements to develop a culture for speaking up, and situational awareness among team members. Situational awareness refers to a person's perception and understanding of their dynamic environment, and human errors often result from a lack of such awareness.24 These teamwork constructs provide the foundational basis for understanding how hospitals can identify teamwork challenges, assess team performance, and design effective interventions.

CHALLENGES TO EFFECTIVE TEAMWORK

Several important and unique barriers to teamwork exist in hospitals. Teams are large and formed in an ad hoc fashion. On a given day, a patient's hospital team might include a hospitalist, a nurse, a case manager, a pharmacist, and 1 or more consulting physicians and therapists. Team members in each respective discipline care for multiple patients at the same time, yet few hospitals align team membership (ie, patient assignment). Therefore, a nurse caring for 4 patients may interact with 4 different hospitalists. Similarly, a hospitalist caring for 14 patients may interact with multiple nurses in a given day. Team membership is ever changing because hospital professionals work in shifts and rotations. Finally, team members are seldom in the same place at the same time because physicians often care for patients on multiple units and floors, while nurses and other team members are often unit‐based. Salas and others have noted that team size, instability, and geographic dispersion of membership serve as important barriers to improving teamwork.25, 26 As a result of these barriers, nurses and physicians do not communicate consistently, and often disagree on the daily plan of care for their patients.27, 28 When communication does occur, clinicians may overestimate how well their messages are understood by other team members, reflecting a phenomenon well known in communication psychology related to egocentric thought processes.29, 30

The traditionally steep hierarchy within medicine may also serve as a barrier to teamwork. Studies in intensive care units (ICUs), operating rooms, and general medical units reveal widely discrepant views on the quality of collaboration and communication between healthcare professionals.3133 Although physicians generally give high ratings to the quality of collaboration with nurses, nurses consistently rate the quality of collaboration with physicians as poor. Similarly, specialist physicians rate collaboration with hospitalists higher than hospitalists rate collaboration with specialists.33 Effective teams in other high‐risk industries, like aviation, strive to flatten hierarchy so that team members feel comfortable raising concerns and engaging in open and respectful communications.34

The effect of technology on communication practices and teamwork is complex and incompletely understood. The implementation of electronic heath records and computerized provider order entry systems fundamentally changes work‐flow, and may result in less synchronization and feedback during nurse‐physician collaboration.35 Similarly, the expanded use of text messages delivered via alphanumeric paging or mobile phone results in a transition toward asynchronous modes of communication. These asynchronous modes allow healthcare professionals to review and respond to messages at their convenience, and may reduce unnecessary interruptions. Research shows that these systems are popular among clinicians.3638 However, receipt and understanding of the intended message may not be confirmed with the use of asynchronous modes of communication. Moreover, important face‐to‐face communication elements (tone of voice, expression, gesture, eye contract)39, 40 are lacking. One promising approach is a system which sends low‐priority messages to a Web‐based task list for periodic review, while allowing higher priority messages to pass through to an alphanumeric pager and interrupt the intended recipient.41 Another common frustration in hospitals, despite advancing technology, is difficulty identifying the correct physician(s) and nurse(s) caring for a particular patient at a given point in time.33 Wong and colleagues found that 14% of pages in their hospital were initially sent to the wrong physician.42

ASSESSMENT OF TEAMWORK

One of the challenges in improving teamwork is the difficulty in measuring it. Teamwork assessment entails measuring the performance of teams composed of multiple individuals. Methods of teamwork assessment can be broadly categorized as self assessment, peer assessment, direct observation, survey of team climate or culture, and measurement of the outcome of effective teamwork. While self‐report tools are easy to administer and can capture affective components influencing team performance, they may not reflect actual skills on the part of individuals or teams. Peer assessment includes the use of 360‐degree evaluations or multisource feedback, and provides an evaluation of individual performance.4347

Direct observation provides a more accurate assessment of team‐related behaviors using trained observers. Observers use checklists and/or behaviorally anchored rating scales (BARS) to evaluate individual and team performance. A number of BARS have been developed and validated for the evaluation of team performance.4852 Of note, direct observation may be difficult in settings in which team members are not in the same place at the same time. An alternative method, which may be better suited for general medical units, is the use of survey instruments designed to assess attitudes and teamwork climate.5355 Importantly, higher survey ratings of collaboration and teamwork have been associated with better patient outcomes in observational studies.5658

The ultimate goal of teamwork efforts is to improve patient outcomes. Because patient outcomes are affected by a number of factors and because hospitals frequently engage in multiple, simultaneous efforts to improve care, it is often difficult to clearly link improved outcomes with teamwork interventions. Continued efforts to rigorously evaluate teamwork interventions should remain a priority, particularly as the cost of these interventions must be weighed against other interventions and investments.

EXAMPLES OF SUCCESSFUL INTERVENTIONS

A number of interventions have been used to improve teamwork in hospitals (see Table 2).

CONCLUSIONS

In summary, teamwork is critically important to provide safe and effective care. Important and unique barriers to teamwork exist in hospitals. We recommend the use of survey instruments, such as those mentioned earlier, as the most feasible method to assess teamwork in the general medical setting. Because each intervention addresses only a portion of the barriers to optimal teamwork, we encourage leaders to use a multifaceted approach. We recommend the implementation of a combination of interventions with adaptations to fit unique clinical settings and local culture.

Teamwork is important in providing high‐quality hospital care. Despite tremendous efforts in the 10 years since publication of the Institute of Medicine's To Err is Human report,1 hospitalized patients remain at risk for adverse events (AEs).2 Although many AEs are not preventable, a large portion of those which are identified as preventable can be attributed to communication and teamwork failures.35 A Joint Commission study indicated that communication failures were the root cause for two‐thirds of the 3548 sentinel events reported from 1995 to 2005.6 Another study, involving interviews of resident physicians about recent medical mishaps, found that communication failures contributed to 91% of the AEs they reported.5

Teamwork also plays an important role in other aspects of hospital care delivery. Patients' ratings of nurse‐physician coordination correlate with their overall perception of the quality of care received.7, 8 A study of Veterans Health Administration (VHA) hospitals found that teamwork culture was significantly and positively associated with overall patient satisfaction.9 Another VHA study found that hospitals with higher teamwork culture ratings had lower nurse resignations rates.10 Furthermore, poor teamwork within hospitals may have an adverse effect on financial performance, as a result of inefficiencies in physician and nurse workflow.11

Some organizations are capable of operating in complex, hazardous environments while maintaining exceptional performance over long periods of time. These high reliability organizations (HRO) include aircraft carriers, air traffic control systems, and nuclear power plants, and are characterized by their preoccupation with failure, reluctance to simplify interpretations, sensitivity to operations, commitment to resilience, and deference to expertise.12, 13 Preoccupation with failure is manifested by an organization's efforts to avoid complacency and persist in the search for additional risks. Reluctance to simplify interpretations is exemplified by an interest in pursuing a deep understanding of the issues that arise. Sensitivity to operations is the close attention paid to input from front‐line personnel and processes. Commitment to resilience relates to an organization's ability to contain errors once they occur and mitigate harm. Deference to expertise describes the practice of having authority migrate to the people with the most expertise, regardless of rank. Collectively, these qualities produce a state of mindfulness, allowing teams to anticipate and become aware of unexpected events, yet also quickly contain and learn from them. Recent publications have highlighted the need for hospitals to learn from HROs and the teams within them.14, 15

Recognizing the importance of teamwork in hospitals, senior leadership from the American College of Physician Executives (ACPE), the American Hospital Association (AHA), the American Organization of Nurse Executives (AONE), and the Society of Hospital Medicine (SHM) established the High Performance Teams and the Hospital of the Future project. This collaborative learning effort aims to redesign care delivery to provide optimal value to hospitalized patients. As an initial step, the High Performance Teams and the Hospital of the Future project team completed a literature review related to teamwork in hospitals. The purpose of this report is to summarize the current understanding of teamwork, describe interventions designed to improve teamwork, and make practical recommendations for hospitals to assess and improve teamwork‐related performance. We approach teamwork from the hospitalized patient's perspective, and restrict our discussion to interactions occurring among healthcare professionals within the hospital. We recognize the importance of teamwork at all points in the continuum of patient care. Highly functional inpatient teams should be integrated into an overall system of coordinated and collaborative care.

TEAMWORK: DEFINITION AND CONSTRUCTS

Physicians, nurses, and other healthcare professionals spend a great deal of their time on communication and coordination of care activities.1618 In spite of this and the patient safety concerns previously noted, interpersonal communication skills and teamwork have been historically underemphasized in professional training.1922 A team is defined as 2 or more individuals with specified roles interacting adaptively, interdependently, and dynamically toward a shared and common goal.23 Elements of effective teamwork have been identified through research conducted in aviation, the military, and more recently, healthcare. Salas and colleagues have synthesized this research into 5 core components: team leadership, mutual performance monitoring, backup behavior, adaptability, and team orientation (see Table 1).23 Additionally, 3 supporting and coordinating mechanisms are essential for effective teamwork: shared mental model, closed‐loop communication, and mutual trust (see Table 1).23 High‐performing teams use these elements to develop a culture for speaking up, and situational awareness among team members. Situational awareness refers to a person's perception and understanding of their dynamic environment, and human errors often result from a lack of such awareness.24 These teamwork constructs provide the foundational basis for understanding how hospitals can identify teamwork challenges, assess team performance, and design effective interventions.

CHALLENGES TO EFFECTIVE TEAMWORK

Several important and unique barriers to teamwork exist in hospitals. Teams are large and formed in an ad hoc fashion. On a given day, a patient's hospital team might include a hospitalist, a nurse, a case manager, a pharmacist, and 1 or more consulting physicians and therapists. Team members in each respective discipline care for multiple patients at the same time, yet few hospitals align team membership (ie, patient assignment). Therefore, a nurse caring for 4 patients may interact with 4 different hospitalists. Similarly, a hospitalist caring for 14 patients may interact with multiple nurses in a given day. Team membership is ever changing because hospital professionals work in shifts and rotations. Finally, team members are seldom in the same place at the same time because physicians often care for patients on multiple units and floors, while nurses and other team members are often unit‐based. Salas and others have noted that team size, instability, and geographic dispersion of membership serve as important barriers to improving teamwork.25, 26 As a result of these barriers, nurses and physicians do not communicate consistently, and often disagree on the daily plan of care for their patients.27, 28 When communication does occur, clinicians may overestimate how well their messages are understood by other team members, reflecting a phenomenon well known in communication psychology related to egocentric thought processes.29, 30

The traditionally steep hierarchy within medicine may also serve as a barrier to teamwork. Studies in intensive care units (ICUs), operating rooms, and general medical units reveal widely discrepant views on the quality of collaboration and communication between healthcare professionals.3133 Although physicians generally give high ratings to the quality of collaboration with nurses, nurses consistently rate the quality of collaboration with physicians as poor. Similarly, specialist physicians rate collaboration with hospitalists higher than hospitalists rate collaboration with specialists.33 Effective teams in other high‐risk industries, like aviation, strive to flatten hierarchy so that team members feel comfortable raising concerns and engaging in open and respectful communications.34

The effect of technology on communication practices and teamwork is complex and incompletely understood. The implementation of electronic heath records and computerized provider order entry systems fundamentally changes work‐flow, and may result in less synchronization and feedback during nurse‐physician collaboration.35 Similarly, the expanded use of text messages delivered via alphanumeric paging or mobile phone results in a transition toward asynchronous modes of communication. These asynchronous modes allow healthcare professionals to review and respond to messages at their convenience, and may reduce unnecessary interruptions. Research shows that these systems are popular among clinicians.3638 However, receipt and understanding of the intended message may not be confirmed with the use of asynchronous modes of communication. Moreover, important face‐to‐face communication elements (tone of voice, expression, gesture, eye contract)39, 40 are lacking. One promising approach is a system which sends low‐priority messages to a Web‐based task list for periodic review, while allowing higher priority messages to pass through to an alphanumeric pager and interrupt the intended recipient.41 Another common frustration in hospitals, despite advancing technology, is difficulty identifying the correct physician(s) and nurse(s) caring for a particular patient at a given point in time.33 Wong and colleagues found that 14% of pages in their hospital were initially sent to the wrong physician.42

ASSESSMENT OF TEAMWORK

One of the challenges in improving teamwork is the difficulty in measuring it. Teamwork assessment entails measuring the performance of teams composed of multiple individuals. Methods of teamwork assessment can be broadly categorized as self assessment, peer assessment, direct observation, survey of team climate or culture, and measurement of the outcome of effective teamwork. While self‐report tools are easy to administer and can capture affective components influencing team performance, they may not reflect actual skills on the part of individuals or teams. Peer assessment includes the use of 360‐degree evaluations or multisource feedback, and provides an evaluation of individual performance.4347

Direct observation provides a more accurate assessment of team‐related behaviors using trained observers. Observers use checklists and/or behaviorally anchored rating scales (BARS) to evaluate individual and team performance. A number of BARS have been developed and validated for the evaluation of team performance.4852 Of note, direct observation may be difficult in settings in which team members are not in the same place at the same time. An alternative method, which may be better suited for general medical units, is the use of survey instruments designed to assess attitudes and teamwork climate.5355 Importantly, higher survey ratings of collaboration and teamwork have been associated with better patient outcomes in observational studies.5658

The ultimate goal of teamwork efforts is to improve patient outcomes. Because patient outcomes are affected by a number of factors and because hospitals frequently engage in multiple, simultaneous efforts to improve care, it is often difficult to clearly link improved outcomes with teamwork interventions. Continued efforts to rigorously evaluate teamwork interventions should remain a priority, particularly as the cost of these interventions must be weighed against other interventions and investments.

EXAMPLES OF SUCCESSFUL INTERVENTIONS

A number of interventions have been used to improve teamwork in hospitals (see Table 2).